High costs, low quality of life, reduced survival, and room for improving treatment: an analysis of burden and unmet needs in glioma

Gliomas are a group of heterogeneous tumors that account for substantial morbidity, mortality, and costs to patients and healthcare systems globally. Survival varies considerably by grade, histology, biomarkers, and genetic alterations such as IDH mutations and MGMT promoter methylation, and treatment, but is poor for some grades and histologies, with many patients with glioblastoma surviving less than a year from diagnosis. The present review provides an introduction to glioma, including its classification, epidemiology, economic and humanistic burden, as well as treatment options. Another focus is on treatment recommendations for IDH-mutant astrocytoma, IDH-mutant oligodendroglioma, and glioblastoma, which were synthesized from recent guidelines. While recommendations are nuanced and reflect the complexity of the disease, maximum safe resection is typically the first step in treatment, followed by radiotherapy and/or chemotherapy using temozolomide or procarbazine, lomustine, and vincristine. Immunotherapies and targeted therapies currently have only a limited role due to disappointing clinical trial results, including in recurrent glioblastoma, for which the nitrosourea lomustine remains the de facto standard of care. The lack of treatment options is compounded by frequently suboptimal clinical practice, in which patients do not receive adequate therapy after resection, including delayed, shortened, or discontinued radiotherapy and chemotherapy courses due to treatment side effects. These unmet needs will require significant efforts to address, including a continued search for novel treatment options, increased awareness of clinical guidelines, improved toxicity management for chemotherapy, and the generation of additional and more robust clinical and health economic evidence.

MO800: A Systematic Literature Review on the Costs and Healthcare Resource Utilization Associated With Dialysis And Anemia Management by Dialysis Modality in Patients With End-Stage Kidney Disease

BACKGROUND AND AIMS

End-stage kidney disease (ESKD) is associated with a high clinical and economic burden. Dialysis modalities include in-center hemodialysis (ICHD) and home dialysis [home hemodialysis (HHD) or peritoneal dialysis (PD)]. The prevalence of anemia in ESKD is estimated to be > 50% and is associated with an increased risk of comorbidities and a lower quality of life [1]. Understanding the economic consequences of dialysis by modality of care, in the general ESKD population and the anemia-related ESKD population, is an essential aspect of the value of home dialysis. This study assessed the extent to which the economic burden of dialysis in ESKD and the management of anemia in ESKD have been characterized in the literature based on modality of care (HHD versus PD versus ICHD).

METHOD

A systematic literature review (SLR) was conducted to characterize costs and healthcare resource use (HCRU) in patients receiving ICHD, HHD or PD, and to further assess the impact of anemia. Data extracted included, but were not limited to, the cost of dialysis, hospitalizations, erythropoiesis-stimulating agents (ESAs) and other drug costs. Database searches were conducted in Embase, Medline, EconLit, Cochrane Library and University of York Center for Reviews and Dissemination (2011–21).

RESULTS

Searches identified 1105 records, of which 43 met the inclusion criteria (costs = 26, HCRU = 8, costs and HCRU = 9). Studies were conducted in Europe (n = 18), North America (n = 14), Asia (n = 7), Australia (n = 2), South America (n = 1) and mixed continents (n = 1). A total of 15 studies were observational/database analyses, and 28 were economic evaluations. Most studies compared costs, including direct (medical and pharmacy) and indirect, and/or HCRU for ICHD, HHD and PD (n = 22), while 11 compared ICHD and HHD and 10 compared ICHD and PD. A summary of results is reported in the Table 1. A total of 14 primary cost studies reported total dialysis costs and showed that ICHD was more expensive than HHD/PD per patient per year. A total of 16 economic models presented relevant outputs in the form of total dialysis costs. The majority of these (n = 13) reported that ICHD is more costly than HHD/PD, with 11 studies concluding that HHD/PD is cost-effective or even dominant compared with ICHD. HCRU was presented in 17 studies, with hospitalizations the most frequently reported (n = 12). Some studies reported that ICHD patients incurred more all-cause hospitalizations than HHD/PD patients, while others reported the opposite (especially for high-dose or frequent modalities). Four studies reported that patients receiving HHD/PD had more in-hospital days than ICHD. There was limited evidence for anemia-related outcomes, with only 11 studies showing either costs and/or HCRU relating to ESA or iron use (Table 1). Five studies reported that the use and dose of epoetin alfa or general ESAs were higher in ICHD patients than in HHD/PD patients (Fig. 1). Of these, one study reported the same trend for IV iron use but the opposite for darbepoetin alfa using baseline data. Four studies reported the same ESA costs for different modalities. An additional four studies reported a higher ESA cost for ICHD patients compared with HHD/PD, with three of the studies indicating that this is related to differences in dosage and use of ESAs. One economic evaluation modeled that ESA and iron costs were higher for HHD than ICHD, though not statistically significant (Table 1).

CONCLUSION

Most studies reported a higher total dialysis cost for ICHD compared with home dialysis, with evidence that home dialysis is cost-effective. There was a paucity of evidence characterizing anemia in ESKD. In this SLR, more ICHD patients used ESAs and at higher doses than HHD/PD patients, thus incurring a higher cost. Global interests highlight increasing home dialysis penetration; therefore, it is important to understand the cost differences and drivers of these differences in ESKD patients with anemia.

Does deep neuromuscular blockade during laparoscopy procedures change patient, surgical, and healthcare resource outcomes? A systematic review and meta-analysis of randomized controlled trials

Background

Deep neuromuscular blockade may facilitate the use of reduced insufflation pressure without compromising the surgical field of vision. The current evidence, which suggests improved surgical conditions compared with other levels of block during laparoscopic surgery, features significant heterogeneity. We examined surgical patient- and healthcare resource use-related outcomes of deep neuromuscular blockade compared with moderate neuromuscular blockade in adults undergoing laparoscopic surgery.

Methods

We conducted a systematic literature review according to the quality standards recommended by the Cochrane Handbook for Systematic Reviews. Randomized controlled trials comparing outcomes of deep neuromuscular blockade and moderate neuromuscular blockade among adults undergoing laparoscopic surgeries were included. A random-effects model was used to conduct pair-wise meta-analyses.

Results

The systematic literature review included 15 studies—only 13 were analyzable in the meta-analysis and none were judged to be at high risk of bias. Compared with moderate neuromuscular blockade, deep neuromuscular blockade was associated with improved surgical field of vision and higher vision quality scores. Also, deep neuromuscular blockade was associated with a reduction in the post-operative pain scores in the post-anesthesia care unit compared with moderate neuromuscular blockade, and there was no need for an increase in intra-abdominal pressure during the surgical procedures. There were minor savings on resource utilization, but no differences were seen in recovery in the post-anesthesia care unit or overall length of hospital stay with deep neuromuscular blockade.

Conclusions

Deep neuromuscular blockade may aid the patient and physician surgical experience by improving certain patient outcomes, such as post-operative pain and improved surgical ratings, compared with moderate neuromuscular blockade. Heterogeneity in the pooled estimates suggests the need for better designed randomized controlled trials.

The impact of intra-abdominal pressure on perioperative outcomes in laparoscopic cholecystectomy: a systematic review and network meta-analysis of randomized controlled trials

Background

Laparoscopic cholecystectomy involves using intra-abdominal pressure (IAP) to facilitate adequate surgical conditions. However, there is no consensus on optimal IAP levels to improve surgical outcomes. Therefore, we conducted a systematic literature review (SLR) to examine outcomes of low, standard, and high IAP among adults undergoing laparoscopic cholecystectomy.

Methods

An electronic database search was performed to identify randomized controlled trials (RCTs) that compared outcomes of low, standard, and high IAP among adults undergoing laparoscopic cholecystectomy. A Bayesian network meta-analysis (NMA) was used to conduct pairwise meta-analyses and indirect treatment comparisons of the levels of IAP assessed across trials.

Results

The SLR and NMA included 22 studies. Compared with standard IAP, on a scale of 0 (no pain at all) to 10 (worst imaginable pain), low IAP was associated with significantly lower overall pain scores at 24 h (mean difference [MD]: − 0.70; 95% credible interval [CrI]: − 1.26, − 0.13) and reduced risk of shoulder pain 24 h (odds ratio [OR] 0.24; 95% CrI 0.12, 0.48) and 72 h post-surgery (OR 0.22; 95% CrI 0.07, 0.65). Hospital stay was shorter with low IAP (MD: − 0.14 days; 95% CrI − 0.30, − 0.01). High IAP was not associated with a significant difference for these outcomes when compared with standard or low IAP. No significant differences were found between the IAP levels regarding need for conversion to open surgery; post-operative acute bleeding, pain at 72 h, nausea, and vomiting; and duration of surgery.

Conclusions

Our study of published trials indicates that using low, as opposed to standard, IAP during laparoscopic cholecystectomy may reduce patients’ post-operative pain, including shoulder pain, and length of hospital stay. Heterogeneity in the pooled estimates and high risk of bias of the included trials suggest the need for high-quality, adequately powered RCTs to confirm these findings.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-07527-2) contains supplementary material, which is available to authorized users.