Development of a novel shared decision making aid for primary immunodeficiency diseases

Aim: To describe development of a shared decision making (SDM) aid in treating primary immunodeficiency diseases (PID) with immunoglobulin replacement therapy (IGRT). Materials & methods: Expert engagement and qualitative formative research informed development. IGRT administration features were prioritized using object-case best-worst scaling (BWS) methodology. The aid was assessed by US adults self-reporting PID and revised following interviews/mock treatment-choice discussions with immunologists. Results: Patients participating in interviews (n = 19) and mock treatment-choice discussions (n = 5) deemed the aid useful/accessible and supported the utility of BWS, with content and BWS exercises refined following participant feedback. Conclusion: Formative research led to an improved SDM aid/BWS exercise, and illustrated how the aid may improve treatment decision making. The aid may help less-experienced patients and facilitate efficient SDM.

Infusion parameters of 20% subcutaneous immunoglobulin for primary immunodeficiency diseases among patient support program participants

BACKGROUND

The safety and efficacy of subcutaneous immune globulin 20% (human) solution (Cuvitru; Ig20Gly) for primary immunodeficiency disease (PID) have been demonstrated in 2 pivotal trials.

OBJECTIVE

To describe patient characteristics and infusion parameters of patients with PID initiating Ig20Gly outside of a clinical trial setting.

METHODS

This retrospective, observational study analyzed records of patients participating in the HelloCuvitru program, a patient support program in the United States providing Ig20Gly free of charge for the first 4 infusions to patients aged 2 years or older who had PID and no previous experience of Ig20Gly. Data were collected retrospectively from patient records and during nurse visits.

RESULTS

A total of 817 patients (88% of 931 enrolled) completed 4 infusions. At the fourth Ig20Gly infusion, the median (interquartile range) dose was 0.55 (0.46-0.69) g/kg/mo, infusion rate/site was 40 (30.0-50.0) mL, and infusion rate per site was 47 (42.5-53.3) mL/h/site. By the fourth infusion, most patients (58%) received Ig20Gly at 2 infusion sites every 7 (30%) or 14 (25%) days. Median prescribed Ig20Gly dose per month was similar across age groups; median infusion volume per site increased with age. Most patients younger than 18 years received infusions every 14 days; patients aged 18 years or older were more likely to receive infusions weekly. Infusion parameters were similar regardless of whether patients received previous immunoglobulin subcutaneously or intravenously.

CONCLUSION

In this large, real-world population of patients with PID, most Ig20Gly infusions were administered for less than 1 hour and required fewer than 2 infusion sites, consistent with the pivotal trials. Infusion rate per site was similar regardless of age, previous immunoglobulin treatment, or infusion frequency.

Patient experience with subcutaneous immunoglobulin 20%, Ig20Gly, for primary immunodeficiency diseases: a prespecified post hoc analysis of combined data from 2 pivotal trials

BACKGROUND

Often, patients with primary immunodeficiency diseases (PID), which are marked by the absence or loss of functional antibodies, require lifelong treatment with immunoglobulin (IG) replacement therapy administered either intravenously (intravenous immunoglobulin [IVIG]) or subcutaneously (subcutaneous immunoglobulin [SCIG]). In patients with PID, the 20% SCIG product, Ig20Gly, was shown to be efficacious and well tolerated in 2 phase 2/3 trials conducted in North America and Europe. This analysis evaluated patient satisfaction with Ig20Gly therapy and treatment preferences.

METHODS

This prespecified post hoc analysis showed combined data from 2 Ig20Gly pivotal trials. Treatment satisfaction was assessed in the pre-Ig20Gly period and after ≥11 months of Ig20Gly treatment using the Life Quality Index (LQI; both studies) and the Treatment Satisfaction Questionnaire for Medication-9 (TSQM-9; North American study only). Treatment preference was assessed using a survey at the end of the European study. Median within-patient differences in LQI and TSQM-9 scores between the pre-Ig20Gly period and the end of the Ig20Gly treatment period were assessed using the Wilcoxon signed-rank test.

RESULTS

A total of 113 patients (n = 68 [North American]; n = 45 [Europe]) with PID were included in the analysis. In the combined LQI analysis (n = 110), significant improvements were observed in the treatment interference (median ∆: + 2.8; P = 0.006) and therapy setting (median ∆: + 5.6; P < 0.0001) domains, and in the item-level scores for convenience (median ∆: + 1.0; P < 0.0001) and interference with work/school (median ∆: + 1.0; P = 0.0001) categories. In the subgroup analyses, significant improvements in the treatment interference and therapy setting domains and the convenience and interference with work/school items were observed for those who had previously received treatment outside the home, those who had previously received IVIG, and those in the North American study. Significant improvements were observed in the TSQM-9 treatment convenience domain (median ∆: + 11.1; P < 0.0001) and selected item-level scores in the North American study. In the European study, most (88.9%) patients preferred to continue Ig20Gly versus other IG treatments.

CONCLUSIONS

After ≥11 months of taking Ig20Gly, patients reported high levels of treatment satisfaction, convenience, and preference for Ig20Gly, with consistent results across studies and use of multiple patient-reported outcome measures.

An evaluation of the budget impact of a new 20% subcutaneous immunoglobulin (Ig20Gly) for the management of primary immunodeficiency diseases in Switzerland

Introduction

While most individual primary immunodeficiency diseases (PID) are rare, the collective prevalence of PID results in a substantial economic and clinical burden. The aim of this study was to evaluate the budgetary implications of Ig20Gly (Immune Globulin Subcutaneous [human] 20% solution; CUVITRU^®, Baxalta US Inc, now part of Shire Plc, Westlake Village, CA, USA) as a treatment for PID relative to intravenous immunoglobulin (IVIG) and other subcutaneous immunoglobulin (SCIG) formulations in the Swiss health care setting.

Materials and methods

A budget impact model was developed in Microsoft Excel to capture the estimated prevalence of PID in Switzerland, the proportion of patients treated in different health care settings, and the costs of administering SCIG and IVIG in each setting. Unit costs were based on a recent cost-minimization analysis of SCIG in Lausanne, and drug costs were taken from the Spezialitätenliste. All costs were reported in 2016 Swiss Francs (CHF), and future costs were not discounted.

Results

The total cost of treating PID in Switzerland was estimated to be CHF 11.16 m over 3 years, comprising CHF 9.28 m of drug costs and CHF 1.87 m of ancillary costs, including health care professional time and other administration costs, such as pumps and needle sets. The analysis showed that using Ig20Gly in place of other SCIG formulations would be cost neutral, while using Ig20Gly in place of IVIG would result in savings of 4.0%.

Conclusion

Ig20Gly would be cost neutral relative to existing SCIG products and would result in cost savings relative to IVIG in patients with PID in Switzerland, even with modest uptake.

An analysis of the relative effects of VKORC1 and CYP2C9 variants on anticoagulation related outcomes in warfarin-treated patients

The objective of this study was to assess the relative influence of VKORC1 and CYP2C9 genetic variants on several clinical outcomes related to warfarin treatment. We conducted a retrospective cohort analysis of 172 anticoagulation clinic patients followed from warfarin initiation. We assessed the following clinical outcomes: time to stable dose; time in, above, and below therapeutic range; the probability of overanticoagulation (international normalized ratio [INR] >5); frequency of anticoagulation clinic visits; and the contribution of genetics to maintenance dose. Patients with CYP2C9 variants, compared to those without, achieved stable dose 48% later (p<0.01),spent a higher proportion of time above range in the first month of therapy (14% vs. 25%, p=0.07), and had a higher odds ratio (OR) of an INR >5 (OR: 4.15, p=0.03). In contrast, the only statistically significant effect withVKORC1 was a higher odds of an INR >5 (OR: 4.47,p=0.03) for patients homozygous for theVKORC1 low-dose haplotype (AA) compared to heterozygotes. We did not detect an influence of CYP2C9 norVKORC1 on the frequency of clinic visits. CYP2C9 alone,VKORC1 alone, and a combination of genetic and clinical factors explained 12%, 27%, and 50%,respectively, of the variation in warfarin maintenance dose. In conclusion, genetic variation in VKORC1 appears to have a different influence than CYP2C9 on anticoagulation-related outcomes such as bleeding events and time in therapeutic range. This difference may be due, in part, to pharmacokinetics factors (e.g. drug half-life), which are influenced primarily by CYP2C9; these findings should be confirmed in additional studies.

Burden of illness for super-refractory status epilepticus patients

OBJECTIVE

To provide an estimate of the annual number of super-refractory status epilepticus (SRSE) cases in the US and to evaluate utilization of hospital resources by these patients.

METHODS

The Premier Hospital Database was utilized to estimate the number of SRSE cases based on hospital discharges during 2012. Discharges were classified as SRSE cases based on an algorithm using seizure-related International Classification of Diseases-9 (ICD-9) codes, Intensive Care Unit (ICU) length of stay (LOS), and treatment protocols (e.g. benzodiazepines, anti-epileptic drugs (AEDs), and ventilator use). Secondary analyses were conducted using more restrictive algorithms for SRSE.

RESULTS

A total of 6,325 hospital discharges were classified as SRSE cases from a total of 5,300,000 hospital discharges. Applying a weighting based on hospital characteristics and 2012 US demographics, this projected to an estimated 41,156 cases of SRSE in the US during 2012, an estimated incidence rate of ∼13/100,000 annually for SRSE in the US. Secondary analyses using stricter SRSE algorithms resulted in estimated incidence rates of ∼11/100,000 and 8/100,000 annually. The mean LOS for SRSE hospitalizations was 16.5 days (median =11; interquartile range [IQR] = 6-20), and the mean ICU LOS was 9.3 days (median =6; IQR =3-12). The mean cost of an SRSE hospitalization was $51,247 (median = $33,294; 95% CI = $49,634-$52,861).

LIMITATIONS

The analysis uses ICD-9 diagnostic codes and claims information, and there are inherent limitations in any methodology based on treatment protocol, which created challenges in distinguishing with complete accuracy between SRSE, RSE, and SE on the basis of care patterns in the database.

CONCLUSION

SRSE is associated with high mortality and morbidity, which place a high burden on healthcare resources. Projections based upon the findings of this study suggest an estimated 25,821-41,959 cases of SRSE may occur in the US each year, but more in-depth studies are required.

Variation in hospital resource use and cost among surgical procedures using topical absorbable hemostats

Background

Adjunctive hemostats are used to assist with the control of intraoperative bleeding. The most common types are flowables, gelatins, thrombins, and oxidized regenerated celluloses (ORCs). In the US, Surgicel^® products are the only US Food and Drug Administration-approved ORCs.

Objective

To compare the outcomes of health care resource utilization (HRU) and costs associated with using ORCs compared to other adjunctive hemostats (OAHs are defined as flowables, gelatins, and topical thrombins) for surgical procedures in the US inpatient setting.

Patients and methods

A retrospective, US-based cohort study was conducted using hospital inpatient discharges from the 2011–2012 calendar years in the Premier Healthcare Database. Patients with either an ORC or an OAH who underwent a cardiovascular procedure (valve surgery and/or coronary artery bypass graft surgery), carotid endarterectomy, cholecystectomy, or hysterectomy were included. Propensity score matching was used to create comparable groups of ORC and OAH patients. Clinical, economic, and HRU outcomes were compared.

Results

The propensity score matching created balanced patient cohorts for cardiovascular procedure (22,718 patients), carotid endarterectomy (10,890 patients), cholecystectomy (6,090 patients), and hysterectomy (9,348 patients). In all procedures, hemostatic agent costs were 28%–56% lower for ORCs, and mean hemostat units per discharge were 16%–41% lower for ORCs compared to OAHs. Length of stay and total procedure costs for patients treated with ORCs were lower for carotid endarterectomy patients (0.3 days and US$700) and for cholecystectomy patients (1 day and US$3,350) (all P<0.001).

Conclusion

Costs and HRU for patients treated with ORCs were lower than or similar to patients treated with OAHs. Proper selection of the appropriate hemostatic agents has the potential to influence clinical outcomes and treatment costs.

An observational study of glycemic control in canagliflozin treated patients

OBJECTIVE

To evaluate changes in glycemic control following the initial canagliflozin pharmacy claim in a real-world population.

RESEARCH DESIGN AND METHODS

A retrospective cohort analysis of adult patients with type 2 diabetes mellitus (T2DM) was conducted using 2013 medical, pharmacy and laboratory claims from the Inovalon MORE 2 Registry. Patients with T2DM aged ≥18 years with ≥60 days of canagliflozin supply and HbA1c test results within 120 days before and ≥60 days after initial canagliflozin claim (defined as index date) were included. The differences between HbA1c levels pre- and post-index were assessed. Changes pre- and post-index in Healthcare Effectiveness Data and Information Set (HEDIS) glycemic control criteria of HbA1c <7% and <8% and poor control of HbA1c >9% were evaluated. Subgroup analyses of patients with HbA1c >7% at baseline and patients aged ≥65 were also conducted.

RESULTS

Among the 268 patients meeting the study criteria, mean HbA1c pre-index was 8.3% and post-index was 7.6%; the mean reduction in HbA1c pre-post index was 0.7% (95% CI: 0.6%, 0.9%). The proportions of patients meeting the HEDIS glycemic control measures (HbA1c <7%, <8% and poor control of >9%) improved and was significantly different pre- and post-index (all p < 0.001). Of the patients with an HbA1c >7% prior to index (81% of the cohort; mean pre-index HbA1c = 8.8%), HbA1c was reduced by 0.9% (95% CI: 0.8%, 1.1%). The aged ≥65 subgroup consisted of 15% of the cohort, with a pre-index HbA1c of 8.3%. The mean reduction in HbA1c test results pre- and post-canagliflozin index was 0.6% (95% CI: 0.4%, 0.9%). This analysis did not adjust for changes in antihyperglycemic agents during the study period.

CONCLUSION

Patients with T2DM were observed to have improved glycemic control following initial canagliflozin pharmacy claim as measured by HbA1c change and attainment of specific glycemic control criteria.

Reduction in hospital costs and resource consumption associated with the use of advanced topical hemostats during inpatient procedures

OBJECTIVE

The use of hemostatic agents has increased over time for all surgical procedures. The purpose of this study was to evaluate the newer topical absorbable hemostat products Surgicel * Fibrillar † and Surgicel SNoW ‡ (Surgicel advanced products, abbreviated as SAPs) compared to the older product Surgicel Original (SO) with respect to healthcare resource use and costs in procedures where these hemostats are most commonly used.

RESEARCH DESIGN AND METHODS

A retrospective analysis of the Premier hospital database was used to identify adults who underwent brain/cerebral (BC), cardiovascular (CV: valve surgery and coronary artery bypass graft) and carotid endarterectomy (CEA) between January 2011-December 2012. Among these patients, those treated with SAPs were compared to those treated with SO. Propensity score matching (PSM) was used to create comparable groups to evaluate differences between SAPs and SO.

MAIN OUTCOME MEASURES

The primary end-points for this study were length of stay (LOS), all-cause total cost, number of intensive care unit (ICU) days, ICU cost, transfusion costs and units, and SO/SAP product units per discharge.

RESULTS

Matched PSM created patient cohorts for SO and SAPs were created for BC (n = 758 for both groups), CV (n = 3388 for both groups), and CEA (n = 2041 for both groups) procedures. Patients that received SAPs had a 14-16% lower mean LOS for each procedure compared to SO, as well as 12-18% lower total mean cost per discharge for each procedure (p < 0.02 for all results). Mean ICU costs for SAPs were also lower, with a reduction of 20% for BC and 19% for CV compared to SO (p < 0.01). However, for CEA, there was no statistically significant difference in ICU costs for SAPs compared to SO.

CONCLUSIONS

In a retrospective hospital database analysis, the use of SAPs were associated with lower healthcare resource utilization and costs compared to SO.

Cost-effectiveness of bronchial thermoplasty in commercially-insured patients with poorly controlled, severe, persistent asthma

OBJECTIVES

We examined the cost-effectiveness of treating poorly controlled, severe, persistent asthma patients with bronchial thermoplasty (BT), a novel technology that uses thermal energy to reduce airway smooth muscle mass, with 5-year outcome data demonstrating a durable reduction in asthma exacerbations.

STUDY DESIGN

We conducted a model-based cost-effectiveness analysis assessing 5-year healthcare utilization, patient quality of life and adverse events.

METHODS

We utilized Markov modeling to estimate the costs and quality-of-life impact of BT compared with high-dose combination therapy among poorly controlled, severe, persistent asthma patients: those requiring high-dose combination therapy and having experienced an asthma exacerbation-related ER visit in the past year.

RESULTS

The cost-effectiveness of BT was US$5495 per quality-adjusted life year; and approximately 22% of sensitivity analysis iterations estimated BT to reduce costs and increase quality of life.

CONCLUSIONS

BT is a cost-effective treatment option for patients with poorly controlled, severe, persistent asthma.

Management patterns of medicare patients undergoing treatment for upper urinary tract calculi

PURPOSE

We conducted this study to identify differences in the re-treatment rates and ancillary procedures for the two most commonly utilized stone treatment procedures in the Medicare population: ureteroscopy (URS) and shock wave lithotripsy (SWL).

MATERIALS AND METHODS

A retrospective claims analysis of the Medicare standard analytical file 5% sample was conducted to identify patients with a new diagnosis of urolithiasis undergoing treatment with URS or SWL from 2009-2010. Outcomes evaluated: (1) repeat stone removal procedures within 120 days post index procedure, (2) stent placement procedures on the index date, 30 days prior to and 120 days post index date, and (3) use of general anesthesia.

RESULTS

We identified 3885 eligible patients, of which 2165 (56%) underwent SWL and 1720 (44%) underwent URS. Overall, SWL patients were 1.73 times more likely to undergo at least one repeat procedure than URS patients, and twice as likely to require multiple re-treatments compared to URS. Among those with ureteral stones, SWL patients were 2.27 times more likely to undergo repeat procedures. The difference was not statistically significant in renal stone patients. Overall, SWL patients were 1.41 times more likely than URS patients to have a stent placed prior to index procedure, and 1.33 times more likely to have a stent placed subsequent to the index procedure. The majority of URS patients (77.8%) had a stent placed at the time of index procedure. There was no significant difference in anesthetic approaches between SWL and URS.

CONCLUSIONS

Patients undergoing SWL are significantly more likely to require re-treatments than URS patients. SWL patients are also significantly more likely to require ureteral stent placement as a separate event. SWL and URS patients have similar rates of general anesthesia.

Cost-effectiveness of metal stents in pancreatic cancer

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Background: American Society for Gastrointestinal Endoscopy guidelines recommend endoscopic metal stent placement for pancreatic carcinoma patients with biliary obstruction and estimated life expectancy of >6 months. Because life expectancy of many such patients has until now been <6 months, plastic stents are frequently placed. Recent phase III trials demonstrated that compared with current standards of care, treatment with chemotherapy regimens FOLFIRINOX and gemcitabine/nab-paclitaxel significantly prolonged overall survival (OS) well beyond the 6-month range. Given this prolonged survival, we evaluated the cost effectiveness of initial metal versus plastic stent placement in pancreatic adenocarcinoma patients with biliary obstruction. Methods: A Markov cohort model was developed to project lifetime health-related outcomes, costs, quality-adjusted life years (QALYs), and cost effectiveness of metal compared with plastic stents. Patients entered the model with locally advanced cancer and underwent endoscopic retrograde cholangiopancreatography with metal or plastic stent placement. Patients were at risk of complications, stent migration or occlusion with subsequent stent placement, progression to metastatic cancer, and death. Published sources were used to estimate clinical, cost, utility, and event rate inputs, and results were presented from the 3rd party payer perspective in 2012 U.S. dollars/QALY. In sensitivity analyses, overall survival was varied from 6-24 months to assess the impact of uncertainty in estimates on model outcomes. Results: Patients with metal stents had lower costs and greater overall and quality-adjusted survival. Placement of metal stents saved approximately $1,500 per patient over a lifetime, improving OS by 0.07 months and quality-adjusted survival by 0.10 months. These findings were robust in sensitivity analyses varying the length of survival for patients with pancreatic cancer. Conclusions: This model demonstrates that placement of metal biliary stents at initial onset of obstructive jaundice in patients with stage III/IV pancreatic adenocarcinoma is cost saving and improves survival when compared with use of plastic stents.

Risk-sharing arrangements that link payment for drugs to health outcomes are proving hard to implement

Risk-sharing agreements, under which payers and pharmaceutical manufacturers agree to link payment for drugs to health outcomes achieved, rather than the volume of products used, offer an appealing payment model for pharmaceuticals. Although such agreements have been widely touted, the experience to date mainly demonstrates how hard they are to implement. Barriers include high implementation costs, measurement challenges, and the absence of a suitable data infrastructure. Risk-sharing arrangements could gain traction in the United States as payers and product manufacturers acquire experience with the concept and as measurement techniques and information systems improve. For the foreseeable future, they are likely to remain the exception as drug companies pursue payment models unconnected to data collection or performance assessment.

Health-care referrals from direct-to-consumer genetic testing

BACKGROUND

direct-to-consumer genetic testing (DTC-GT) provides personalized genetic risk information directly to consumers. Little is known about how and why consumers then communicate the results of this testing to health-care professionals.

AIM

to query specialists in clinical genetics about their experience with individuals who consulted them after DTC-GT.

METHODS

invitations to participate in a questionnaire were sent to three different groups of genetic professionals, totaling 4047 invitations, asking questions about individuals who consulted them after DTC-GT. For each case reported, respondents were asked to describe how the case was referred to them, the patient's rationale for DTC-GT, and the type of DTC-GT performed. Respondents were also queried about the consequences of the consultations in terms of additional testing ordered. The costs associated with each consultation were estimated. A clinical case series was compiled based upon clinician responses.

RESULTS

the invitation resulted in 133 responses describing 22 cases of clinical interactions following DTC-GT. Most consultations (59.1%) were self-referred to genetics professionals, but 31.8% were physician referred. Among respondents, 52.3% deemed the DTC-GT to be "clinically useful." BRCA1/2 testing was considered clinically useful in 85.7% of cases; 35.7% of other tests were considered clinically useful. Subsequent referrals from genetics professionals to specialists and/or additional diagnostic testing were common, generating individual downstream costs estimated to range from $40 to $20,600.

CONCLUSIONS

this clinical case series suggests that approximately half of clinical geneticists who saw patients after DTC-GT judged that testing was clinically useful, especially the BRCA1/2 testing. Further studies are needed in larger and more diverse populations to better understand the interactions between DTC-GT and the health-care system.

A policy model to evaluate the benefits, risks and costs of warfarin pharmacogenomic testing

BACKGROUND

In 2007, the US FDA added information about pharmacogenomics to the warfarin label based on the influence of the CYP2C9 and VKORC1 genes on anticoagulation-related outcomes. Payers will be facing increasing demand for coverage decisions regarding this technology, but the potential clinical and economic impacts of testing are not clear.

OBJECTIVE

To develop a policy model to evaluate the potential outcomes of warfarin pharmacogenomic testing based on the most recently available data.

METHODS

A decision-analytic Markov model was developed to assess the addition of genetic testing to anticoagulation clinic standard care for a hypothetical cohort of warfarin patients. The model was based on anticoagulation status (international normalized ratio), a common outcome measure in clinical trials that captures both the benefits and risks of warfarin therapy. Initial estimates of testing effects were derived from a recently completed randomized controlled trial (n = 200). Healthcare cost ($US, year 2007 values) and health-state utility data were obtained from the literature. The perspective was that of a US third-party payer. Probabilistic and one-way sensitivity analyses were performed to explore the range of plausible results.

RESULTS

The policy model included thromboembolic events (TEs) and bleeding events and was populated by data from the COUMAGEN trial. The rate of bleeding calculated for standard care approximated bleeding rates found in an independent cohort of warfarin patients. According to our model, pharmacogenomic testing provided an absolute reduction in the incidence of bleeds of 0.17%, but an absolute increase in the incidence of TEs of 0.03%. The improvement in QALYs was small, 0.003, with an increase in total cost of $US162 (year 2007 values). The incremental cost-effectiveness ratio (ICER) ranged from testing dominating to standard care dominating, and the ICER was <$US50,000 per QALY in 46% of simulations. Results were most sensitive to the cost of genotyping and the effect of genotyping.

CONCLUSION

Our model, based on initial clinical studies to date, suggests that warfarin pharmacogenomic testing may provide a small clinical benefit with significant uncertainty in economic value. Given the uncertainty in the analysis, further updates will be important as additional clinical data become available.

The Adoption of Cost-Effectiveness Acceptability Curves in Cost-Utility Analyses

Background. Cost-effectiveness acceptability curves (CEACs) plot the probability that one health intervention is more cost-effective than alternatives, as a function of societal willingness to pay for additional units of health (e.g., life-years or quality-adjusted life-years gained). Objectives. To quantify the adoption of CEACs in published cost-utility analyses (CUAs), and to identify factors associated with CEAC use. Methods. Data from the Tufts Medical Center Cost-Effectiveness Analysis Registry (www.cearegistry.org), a database with detailed information on approximately 1,400 CUAs published in the peer reviewed literature through 2006, was analyzed. The registry includes data on study origin, study methodology, reporting of results, whether CEACs were presented, and a subjective quality score. Univariate and multivariate logistic regression analyses were used to identify factors predicting CEAC use, from their introduction in 1994 through 2006. Results. Approximately 15% of CUAs published since 1994 present a CEAC. The use of CEACs has increased rapidly in recent years, from 2.1% of published CUAs in 2001 to 32.6% in 2006 (P < 0.0001). The most significant predictors of CEAC use were study quality (odds ratio [OR]: 2.26; 95% confidence interval [CI]: 1.80, 2.85), recent publication (OR: 1.99; 95% CI: 1.73, 2.29), and whether studies pertain to the UK (OR: 5.66; 95% CI: 3.67, 8.72) or Sweden (OR: 3.76; 95% CI: 1.67, 8.44). Conclusions. CEAC use is increasing in the published cost-effectiveness literature, especially in UK-based studies.

An analysis of the relative effects of VKORC1 and CYP2C9 variants on anticoagulation related outcomes in warfarin-treated patients

The objective of this study was to assess the relative influence of VKORC1 and CYP2C9 genetic variants on several clinical outcomes related to warfarin treatment. We conducted a retrospective cohort analysis of 172 anticoagulation clinic patients followed from warfarin initiation. We assessed the following clinical outcomes: time to stable dose; time in, above, and below therapeutic range; the probability of overanticoagulation (international normalized ratio [INR] >5); frequency of anticoagulation clinic visits; and the contribution of genetics to maintenance dose. Patients with CYP2C9 variants, compared to those without, achieved stable dose 48% later (p < 0.01), spent a higher proportion of time above range in the first month of therapy (14% vs. 25%, p = 0.07), and had a higher odds ratio (OR) of an INR >5 (OR: 4.15, p = 0.03). In contrast, the only statistically significant effect with VKORC1 was a higher odds of an INR >5 (OR: 4.47, p = 0.03) for patients homozygous for the VKORC1 low-dose haplotype (AA) compared to heterozygotes. We did not detect an influence of CYP2C9 nor VKORC1 on the frequency of clinic visits. CYP2C9 alone, VKORC1 alone, and a combination of genetic and clinical factors explained 12%, 27%, and 50%, respectively, of the variation in warfarin maintenance dose. In conclusion, genetic variation in VKORC1 appears to have a different influence than CYP2C9 on anticoagulation-related outcomes such as bleeding events and time in therapeutic range. This difference may be due, in part, to pharmacokinetics factors (e.g. drug half-life), which are influenced primarily by CYP2C9; these findings should be confirmed in additional studies.

A review of public policy issues in promoting the development and commercialization of pharmacogenomic applications: challenges and implications

This article reviews the regulatory, social, policy, and other issues that will shape the development of pharmacogenomics applications. We identify and analyze 19 key public policy issues, ranging from the economic incentives for linked diagnostic-drug development, to the regulation of tests and drugs, and to privacy and informed consent. Challenging technical, business, and policy-related issues might either hinder progress in the field of pharmacogenomics or potentially accelerate it, depending on how they are addressed and resolved. How well the numerous important stakeholders - both private and public - address these issues will be critical for pharmacogenomics to deliver on its promise.

Modelling costs and outcomes of expanded availability of emergency contraceptive use in British Columbia

BACKGROUND

Emergency contraception (EC) can potentially reduce unwanted pregnancies and abortions. However, these agents are underused due to lack of awareness and barriers to utilization. While earlier economic evaluations have indicated that use of EC is potentially cost-effective, recent evidence of a lower risk of pregnancy following unprotected intercourse than previously reported suggest prior studies may have over-estimated cost savings.

OBJECTIVES

To model cost savings and pregnancy-related outcomes associated with the policy change authorizing pharmacist provision of EC in British Columbia, and to estimate the costs of initiatives to further women's awareness and utilization of EC that would result.

METHODS

Three decision analytic models were developed evaluating current EC utilization (physician-only), EC utilization following pharmacist provision and potential expanded EC awareness and utilization following a public awareness initiative. Models were developed from the Ministry of Health perspective for 2001 using cost and event data from the Ministry supplemented by data from the literature.

RESULTS

Current EC utilization saved the Ministry $2.20 million (95% CR: $0.15 million, $4.90 million) in medical costs the first year, and incremental savings from pharmacist provision was $0.64 million (95% CR: $0.24 million, $1.28 million). A public awareness initiative costing less than $2.57 million (95% CR: $0.22 million, $5.75 million) annually is potentially cost saving.

CONCLUSIONS

Pharmacist provision of EC was cost saving to the Ministry, even when the estimated risk of pregnancy in the population is less than assumed in previous studies. Increasing EC availability directly from pharmacists and increasing EC awareness have the potential to reduce health care costs.

Screening for the alpha-adducin Gly460Trp variant in hypertensive patients: a cost-effectiveness analysis

BACKGROUND

Studies have shown that approximately 80% of hypertensive patients do not take diuretics despite their recommendation as a first-line therapy. A recent study reported that hypertensive patients with the Gly460Trp variant in the alpha-adducin gene are more likely to benefit from diuretic therapy. The objective of this study was to evaluate the potential cost effectiveness of screening for the alpha-adducin Gly460Trp variant among hypertensive patients.

METHODS

A decision analytic Markov model was developed to estimate the clinical and economic outcomes comparing screening for the Gly460Trp variant to identify patients for addition of a diuretic compared to no screening and no addition of diuretic (usual care) in a hypothetical cohort of treated hypertensive patients not receiving diuretic therapy. We used a lifetime horizon and payer perspective. Cost, utility and epidemiological data were obtained from the literature. One-way, probabilistic, and scenario sensitivity analyses were conducted to evaluate the uncertainty in the results.

RESULTS

The screening strategy increased quality adjusted life years (QALYs) by 0.14 (95% confidence range [CR]: 0.05, 0.36) and saved dollar 1834 (dollar 505, dollar 5174) compared to usual care. The most influential input was the strength of the interaction between the alpha-adducin gene variant and diuretic effect.

CONCLUSIONS

Our results suggest that screening for the alpha-adducin gene variant may be a useful mechanism to identify patients most likely to benefit from diuretic therapy and improve compliance with current treatment guidelines.