Basic Life Support Guidance for Caregivers of NICU Graduates: Evaluation of Skill Transfer after Training

Background Intensivists indeed discharge neonatal intensive care unit (NICU) graduates after a period of physiological stability. There is, however, a real risk of life-threatening events at home. Survival after such episodes depends on time from arrest to initiation of basic life support (BLS). It is rational to train parents who would be first responders. We sought to measure objectively and prospectively, effect of BLS training on parents of NICU graduates on the psychomotor, cognitive, and affective domains of human learning.

Methods After face-to-face training sessions, proportion of home caregivers who obtained 100% marks on a pretested performance checklist for psychomotor skills of BLS on a mannequin were measured. Two other domains of learning and number of attempts required to obtain desirable results were also analyzed.

Results Median (interquartile range [IQR]) birth weight of the high-risk neonates was 1,050 g (930, 1570) and median gestational age was 29 (IQR 28, 33) weeks. More than 75% of parents had no prior exposure to BLS training. Among 46 trained caregivers, 80.4% achieved the desired score of 5 in the psychomotor performance checklist on the first attempt. A maximum of two attempts was required to reeducate and achieve score of 5 in the remaining caregivers. Forty-two (91.3%) caregivers obtained full marks on cognitive domain test. All caregivers responded positively toward affective domain questionnaire.

Conclusion It is possible to train parents in BLS measures and demonstrate their psychomotor skills on a mannequin effectively. No parents who were approached refused training or indicated anxiety in learning the skills required.

Economic evaluation of sunitinib versus other new targeted therapies as first-line treatment of metastatic renal cell carcinoma (mRCC) in the United States

e17556

Background: RCC, the most prevalent kidney cancer, is a relatively rare malignancy that carries a poor prognosis. New targeted therapies, such as sunitinib, sorafenib, temsirolimus, and bevacizumab + interferon-alfa (IFN-α), are now available in the US for the treatment of mRCC. In the absence of head-to-head trials, the aim of this analysis was to assess the economic value of these therapies as first-line treatment of mRCC from a U.S. third-party payer perspective, using an indirect comparison based on reported survival data. Methods: An economic model was built to simulate progression-free and overall survival based on each treatment's hazard ratio against IFN-α as reported from phase II and III clinical trials. Clinical model parameters were also derived from these trials and complemented with clinical experts’ opinions. Costs of drugs, routine follow-up, treatment-related adverse events, disease progression, and best supportive care of terminally-ill patients were included in the model. Results, expressed as life-years (LY), progression-free LY (PFLY), and quality adjusted LY (QALY) gained, treatment costs (applied in 2008 USD), and incremental cost-effectiveness ratios (ICER), were obtained through probabilistic analysis over a 10-year time horizon. Since the phase III clinical trial of temsirolimus included the MSKCC (modified) poor risk group patients only, two separate evaluations were carried out: (1) comparison of sunitinib, sorafenib, and bevacizumab + IFN-α in all patients and (2) a similar comparison of sunitinib and temsirolimus in the poor-risk group patients only. Results: In the first comparison model, sunitinib was both more effective (with gains of 0.52 and 0.19 PFLY, and 0.17 and 0.03 QALY) and less costly (by $13,675 and $84,260) than sorafenib and bevacizumab + IFN-α, respectively, over 10 years. Similarly, sunitinib was both more effective (with gains of 0.12 PFLY and 0.07 QALY) and less costly (saving $9,605 over ten years) than temsirolimus in patients in the poor risk group. Conclusions: These model results suggest that sunitinib is a cost-effective alternative to sorafenib, bevacizumab + IFN-α, and temsirolimus as a first-line treatment of mRCC.

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Cost-effectiveness of anastrozole versus tamoxifen as adjuvant therapy in early breast cancer (EBC) – a German health economic analysis

Abstract #6109

Background: The non-steroidal aromatase inhibitor (AI) anastrozole is superior to tamoxifen in terms of efficacy and safety in the adjuvant treatment of postmenopausal patients with hormone receptor-positive (HR+) early breast cancer (EBC). The aim of the current study was to evaluate the cost-effectiveness of anastrozole versus tamoxifen from the German health care perspective.
 Methods: A probabilistic Markov model was developed using data from the published literature and expert opinion to project trial outcomes to 25 years based on a cohort of 1000 postmenopausal women with HR+ EBC. Resource use data and costs were obtained from standard sources and expert opinion. Utility scores for the different heath states were obtained from a patient-based utility study using the standard gamble technique. Results were expressed as incremental cost-effectiveness ratios (ICERs) per quality adjusted life-years (QALYs) gained. Costs and benefits were discounted at 5% annually.
 Results: Total costs over the 25 year period for anastrozole and tamoxifen were €12,422 and €6,757, respectively. The cost per life year (LY) for anastrozole compared to tamoxifen was €24,822/LY gained. The ICER of anastrozole compared to tamoxifen was €21,050/QALY gained (95% CI €9,841 - €62,344). The result remained robust to all parameters tested in the sensitivity analysis. Cost-effectiveness probability curves indicated a >90% probability that the cost per QALY gained with anastrozole would be <€42,000.
 Conclusions: In this model, five years of adjuvant anastrozole is a cost-effective treatment alternative to tamoxifen in postmenopausal women with HR+ EBC from the German health care perspective.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6109.

Weight loss, dietary advice and statin therapy in non-alcoholic fatty liver disease: a retrospective study

BACKGROUND

Studies have shown that weight loss can have a favourable effect upon non-alcoholic fatty liver disease (NAFLD). However, the most effective means of achieving weight loss and safety profile of lipid-lowering drugs in the presence of NAFLD is unknown.

AIM

To investigate the effect of dietary advice and lipid-lowering drugs, particularly statins, on patients with NAFLD and dyslipidaemia.

DESIGN

Observational records based study.

METHODS

We studied 71 patients with NAFLD and dyslipidaemia diagnosed and treated between 1996 and 2002 at University Hospital Lewisham. Some were referred to a dietician for weight loss advice as part of their management. After treatment all patients were assessed for changes in weight, serum alanine transaminase (ALT) and serum lipids including serum cholesterol, serum high density lipoprotein (HDL) and serum triglycerides.

RESULTS

Thirty-seven male and 34 female patients with NAFLD and dyslipidaemia were followed up for a mean period of 440 +/- 374 days (median 335). Regression analysis revealed a significant association between changes in weight and changes in serum ALT (p < 0.039). Dietary advice failed to reduce body weight but significantly lowered the serum cholesterol to HDL ratio (p = 0.05). Only 15.4% of patients taking statins experienced a rise in serum ALT > or = 40 U/l, and in each case the rise was transient, returning near baseline or below without discontinuation of statin treatment.

CONCLUSIONS

Weight loss appears to improve NAFLD, and dietary advice and lipid-lowering drugs may be beneficial for patients with NAFLD and dyslipidaemia even if weight loss is not achieved. Statins appear to be safe and efficacious in this group.

The economic consequences of noncompliance in cardiovascular disease and related conditions: a literature review

OBJECTIVES

To review studies on the cost consequences of compliance and/or persistence in cardiovascular disease (CVD) and related conditions (hypertension, dyslipidaemia, diabetes and heart failure) published since 1995, and to evaluate the effects of noncompliance on healthcare expenditure and the cost-effectiveness of pharmaceutical interventions.

METHODS

English language papers published between January 1995 and February 2007 that examined compliance/persistence with medication for CVD or related conditions, provided an economic evaluation of pharmacological interventions or cost analysis, and quantified the cost consequences of noncompliance, were identified through database searches. The cost consequences of noncompliance were compared across studies descriptively.

RESULTS

Of the 23 studies identified, 10 focused on hypertension, seven on diabetes, one on dyslipidaemia, one on coronary heart disease, one on heart failure and three covered multiple diseases. In studies assessing drug costs only, increased compliance/persistence led to increased drug costs. However, increased compliance/persistence increased the effectiveness of treatment, leading to a decrease in medical events and non-drug costs. This offset the higher drug costs, leading to savings in overall treatment costs. In studies evaluating the effect of compliance/persistence on the cost-effectiveness of pharmacological interventions, increased compliance/persistence appeared to reduce cost-effectiveness ratios, but the extent of this effect was not quantified.

CONCLUSIONS

Noncompliance with cardiovascular and antidiabetic medication is a significant problem. Increased compliance/persistence leads to increased drug costs, but these are offset by reduced non-drug costs, leading to overall cost savings. The effect of noncompliance on the cost-effectiveness of pharmacological interventions is inconclusive and further research is needed to resolve the issue.

The significance of compliance and persistence in the treatment of diabetes, hypertension and dyslipidaemia: a review

OBJECTIVES

To review studies of patient compliance/persistence with cardiovascular or antidiabetic medication published since the year 2000; to compare the methods used to measure compliance/persistence across studies; to compare reported compliance/persistence rates across therapeutic classes and to assess whether compliance/persistence correlates with clinical outcomes.

METHODS

English language papers published between January 2000 and November 2005 investigating patient compliance/persistence with cardiovascular or antidiabetic medication were identified through searches of the MEDLINE and EMBASE databases. Definitions and measurements of compliance/persistence were compared across therapeutic areas using contingency tables.

RESULTS

Of the 139 studies analysed, 32% focused on hypertension, 27% on diabetes and 13% on dyslipidaemia. The remainder covered coronary heart disease and cardiovascular disease (CVD) in general. The most frequently reported measure of compliance was the 12-month medication possession ratio (MPR). The overall mean MPR was 72%, and the MPR did not differ significantly between treatment classes (range: 67-76%). The average proportion of patients with an MPR of >80% was 59% overall, 64% for antihypertensives, 58% for oral antidiabetics, 51% for lipid-lowering agents and 69% in studies of multiple treatments, again with no significant difference between treatment classes. The average 12-month persistence rate was 63% and was similar across therapeutic classes. Good compliance had a positive effect on outcome in 73% of the studies examining clinical outcomes.

CONCLUSIONS

Non-compliance with cardiovascular and antidiabetic medication is a significant problem, with around 30% of days 'on therapy' not covered by medication and only 59% of patients taking medication for more than 80% of their days 'on therapy' in a year. Good compliance has a positive effect on clinical outcome, suggesting that the management of CVD may be improved by improving patient compliance.

Cost-effectiveness analysis of anastrozole vs tamoxifen in adjuvant therapy for early stage breast cancer in the United Kingdom: the 5-year completed treatment analysis of the ATAC ('Arimidex', Tamoxifen alone or in combination) trial

Results from the completed treatment analysis of the ATAC (Arimidex, Tamoxifen alone or in combination) trial indicated that anastrozole was significantly superior to tamoxifen in terms of efficacy and safety in the adjuvant treatment of postmenopausal women with hormone receptor-positive (HR+) early breast cancer. On the basis of these results, this study estimated the cost-effectiveness of anastrozole vs tamoxifen, from the perspective of the UK National Health Service (NHS). A Markov model was developed using the 5-year completed treatment analysis from the ATAC trial (ISRCTN18233230), as well as data obtained from published literature and expert opinion. Resource utilisation data and associated costs (2003-4 UK pound) were compiled from standard sources and expert opinion. Utility scores for a number of health states were obtained from a cross-sectional study of 26 representative patients using the standard gamble technique. The utility scores were then inserted into the model to obtain cost per quality adjusted life-year (QALY) gained. Costs and benefits were discounted at recommended annual rates of the UK Treasury (3.5%). Modelled for 25 years, anastrozole, relative to generic tamoxifen, was estimated to result in 0.244 QALYs gained per patient at an additional cost of pound4315 per patient). The estimated incremental cost-effectiveness of anastrozole compared with tamoxifen was pound17 656 per QALY gained. There was a greater than 90% probability that the cost-effectiveness of anastrozole was below pound30 000 per QALY gained and of the order of 65% that it was below pound20 000 per QALY gained. The results were robust to all parameters tested in sensitivity analysis. Compared with commonly accepted thresholds, anastrozole is a cost-effective alternative to generic tamoxifen in adjuvant treatment of postmenopausal women with HR+ early breast cancer from the UK NHS perspective.

Cost-effectiveness of docetaxel compared to paclitaxel in metastatic breast cancer: A UK health economic analysis

1081

Background: Docetaxel was shown to be superior to paclitaxel in OS and TTP (median OS: 1.28 vs 1.06 yr, HR=1.41; median TTP: 0.47 vs 0.30 yr, HR= 1.64) for the treatment of patients with metastatic breast cancer progressing after an anthracycline-based regimen (Jones et al. J Clin Oncol. 2005;23:5542). A cost-effectiveness analysis based on this head-to-head comparison was performed considering clinical effectiveness, quality-adjusted life-years, and direct medical costs in the UK. Methods: A probabilistic Markov model was developed to examine results over a 10-yr long time-horizon. Patient level data were available on PFS and OS, treatment cycles and doses, number of cycles affected by adverse events, G-CSF use and post-failure treatment. Generalized gamma regression, fitting patient-level data best were used to model baseline PFS and OS in the paclitaxel arm. HRs adjusting for all covariates were applied to the baseline hazards to generate the docetaxel arm. Resource use and utility values for health states were obtained from published literature and practicing UK oncologists. Unit costs came from 2005 NHS reference costs; drug costs from the British National Formulary 2006 without hospital discount. Costs and benefits were discounted at 3.5%. A Monte-Carlo simulation and extensive 1-way sensitivity analyses were conducted. Results: Docetaxel is more costly (£13,500 vs £10,600), but yields higher health benefits than paclitaxel (2.01 vs 1.48 LYs and 1.18 vs 0.85 QALYs for docetaxel and paclitaxel, respectively) over a 10-yr time horizon. The discounted Incremental Cost-Effectivness Ratio (ICER) of docetaxel vs paclitaxel 3-weekly was estimated to be £5,532/LY gained (95% CI 2,250–12,700) and £8,741/QALY gained (95% CI 3,400–17,300). The ICER was most sensitive to the HR for PFS, OS and the cost of docetaxel and paclitaxel. However, ICERs remained below £20,000/QALY at extreme values of the parameters. Conclusions: Compared with paclitaxel 3-weekly, over a 10-yr time horizon docetaxel provides survival and quality-adjusted survival benefit to metastatic breast cancer patients failing anthracycline regimens at an acceptable cost in a UK setting. Docetaxel is cost-effective compared to paclitaxel.

No significant financial relationships to disclose.

College students' perceptions of psychiatrists, psychologists, and social workers: a comparison

The present study compared perceptions held by 180 college students of psychiatrists, psychologists, and social workers. The students viewed social workers as warm and easy to relate to but not particularly intelligent. Psychiatrists were viewed as bright but cold and reserved. The students indicated that they would most likely consult psychologists for help with the majority of their problems.