Ebere Onukwugha

Effect of Age on Survival Benefit of Adjuvant Chemotherapy in Elderly Patients with Stage III Colon Cancer

OBJECTIVES: To estimate the modifying effect of age on the survival benefit associated with adjuvant chemotherapy receipt in elderly patients with a diagnosis of Stage III colon cancer.

Trends in Disparities in Receipt of Adjuvant Therapy for Elderly Stage Iii Colon Cancer Patients: The Role of the Medical Oncologist Evaluation

Background:Race disparities in adjuvant chemotherapy for stage III colon cancer patients have been documented, and medical oncologist evaluation is a critical step in the treatment process. Recent healthcare system and environmental changes may have reduced treatment gaps. Objectives:To examine differential rates of oncologist evaluation and conditional treatment, by race, and to determine whether changing evaluation and treatment patterns reduced disparities. Research Design:Retrospective analysis of Surveillance Epidemiology and End Results-Medicare registry, enrollment, and claims data. Subjects:Patients age >65, white or African American race, diagnosed with American Joint Committee on Cancer stage III colon cancer between 1997 and 2002. N = 7176. Key Measures:Oncology specialty evaluation and management visit or chemotherapy claim; receipt of 5-fluorouracil based chemotherapy. Time periods are grouped into early (1997–1998), middle (1999–2000), and late (2001–2002). Results:Initial adjusted oncologist evaluation rates were higher for whites compared with African American patients (58.7% vs. 42.9%), but changes over time reduced the race gap substantially. We did not find significant race-time trends in treatment rates conditional on oncologist evaluation. Conclusions:Race disparities in medical oncologist evaluations diminished over time, possibly in response to increased provider supply or changing patient and provider attitudes, but there was no parallel reduction in disparities in conditional treatment rates. Projected decreases in oncologist supply suggest the need for further research on this relationship. Research on the role of supplemental medical insurance on disparities in treatment is needed, particularly as the cost of recommended adjuvant therapy increases.

Using Cost-Effectiveness Analysis to Sharpen Formulary Decision-Making: The Example of Tiotropium at the Veterans Affairs Health Care System

OBJECTIVE To identify a cost-saving subset of criteria for the use of tiotropium at a Veterans Affairs Medical Center based on a cost-effectiveness analysis with ipratropium as the comparator. METHODS Retrospective analysis of electronic medical records for the calendar year 2004 was conducted. The sample was drawn from a population at the Baltimore Veterans Affairs Medical Center that had a confirmed diagnosis of chronic obstructive pulmonary disease (COPD) and had filled prescriptions for ipratropium. The tiotropium sample was based on a modeled cohort of COPD patients who had received tiotropium. The analysis was conducted from the perspective of the Veterans Affairs Health Care System. The outcome was the incremental cost-effectiveness of tiotropium versus ipratropium. RESULTS The incremental cost-effectiveness ratio (ICER) was

Racial differences in hospital discharge disposition among stroke patients in Maryland.

2360 per avoided exacerbation. Tiotropium cost-effectiveness increased with COPD severity and was cost-saving in patients with very severe disease (ICER =

Determinants of quality of care and treatment initiation in Medicare disabled patients with chronic hepatitis C

-1818) and in patients with a previous COPD-related hospitalization (ICER =

The impact of comorbidity on costs and effects of second-line treatment among elderly metastatic colon cancer patients.

-4472). The ICER was most sensitive to the relative effectiveness and price of tiotropium. Results identified the levels of treatment effectiveness and price beyond which tiotropium would become cost-saving relative to ipratropium. CONCLUSIONS The results support the existing Veterans Affairs practice of offering tiotropium to patients with COPD-related hospitalizations. Periodic review of the effectiveness data to determine whether tiotropium would be cost-saving in patients with very severe COPD is suggested. Cost-effectiveness analyses that identify practical criteria-for-use should become an integral part of the formulary process.

Heterogeneity of treatment effects (HTE) in stage IV prostate cancer (S4PC).

Objective. The objective of this retrospective study was to assess the evidence for racial differences in discharge disposition among patients hospitalized for stroke. Data. Hospital discharge data from the Maryland Health Services Cost Review Commission were used in the analysis. The data covered the period from January 2000 to September 2003. Study design. Discharge-disposition categories were ordered such that higher numbers corresponded to less desirable outcomes: 1 = discharge to home; 2 = discharge to any medical care facility; 3 = death. We analyzed the influence of black race on the discharge disposition by estimating a partial proportional odds logit regression model that included demographic and clinical covariates. Data extraction. The study inclusion criteria were 1) stroke (ICD9 431—434; 436—438) as a primary admission diagnosis and 2) patient race identified as black or white. Patients discharged against medical advice were excluded. The sample contained 51,564 stroke hospitalizations. Principal findings. Based on the relative odds ratios (OR; 95% confidence interval [CI]), black males were more likely to be discharged to higher ranked (i.e., less desirable) discharge categories (OR = 1.66; CI 1.55—1.77) compared to white males. Black females were more likely to die (OR = 1.14; CI 1.02—1.28) and more likely either to die or to be discharged to medical care (OR = 1.38; CI 1.24—1.54) compared to white males. Conclusions. Blacks are at greater mortality risk following stroke hospitalizations and face less desirable discharge dispositions if they survive. These results are consistent with prior reports of lower survival rates among blacks and are robust to adjustments for various confounding factors. Key words: patient discharge; African Americans; cerebrovascular stroke; in-hospital mortality. (Med Decis Making 2007;27:233—242)

Comparative Effectiveness of Proton Pump Inhibitors vs. Histamine type-2 receptors blockers for preventing Clinically Important Gastrointestinal Bleeding during Intensive Care: A population-based study.

Background: Aligning with a national priority to bridge health disparities in disadvantaged populations, we explored contextual determinants of pretreatment quality of care and treatment receipt of Medicare disabled patients with hepatitis C virus (HCV) infection. Methods: We used Medicare claims (2006–2009) linked to the Area Health Resource Files. Ordinal partial proportional odds and weighted modified Poisson regressions were used to model the determinants of quality care receipt and interferon-based treatment, respectively. Results: We identified 1936 Medicare disabled HCV patients, of whom 10.4% were treated with peg-interferon. Despite the high comorbidity burden among HCV disabled patients, greater engagement in care correlated with greater likelihood of quality care and treatment receipt. Conclusion: Our study highlights the need for process and linkage to care in Medicare disabled HCV patients, but future research relevant to novel interferon-free agents is needed to assess patterns of quality of care and treatment receipt in this vulnerable population.

Does first-line treatment impact the cost-effectiveness of second-line treatment for elderly metastatic colon cancer patients?

536 Background: The Charleston Co-morbidity Index (CCI) was developed as in hospital mortality indicatory and subsequently has been used to both predict and adjust survival differences in cancer patients. We therefore sought to examine how the incremental cost effectiveness of treating elderly metastatic colon cancer (mCC) patients with second-line treatment (Tx2) will vary based upon their baseline CCI. Methods: We identified 2,897 elderly (age 66+) mCC patients who received NCCN recommended first-line treatment (Tx1) between 2003 and 2009 in the SEER-Medicare dataset. Approximately 6% and 1% of patients with missing CCI and outlier costs, respectively, were excluded. We categorized patients by their CCI for 12 months prior to diagnosis into three categories: low (CCI = 0), medium (CCI = 1) and high (CCI = 2+). We calculated 5-years cost-effectiveness of Tx2. Patients enrolled in HMOs, lost part A and/or B, and died of causes other than colon cancer are censored. Costs are inflation adjusted to January 2...

Impact of physician visits on bone density testing in men with prostate cancer who receive androgen deprivation therapy.

180 Background: HTE occurs when individual patient factors modify a treatments effect on health outcomes in a non-random and predictable manner. HTE results in specific subgroups of patients in the same study having different responses to the same treatment due to interactions between their individual factors and the treatment. METHODS A systematic literature review was conducted of articles published between 1946 and 2011. Inclusion criteria required that articles examine the impact of HTE factors on survival outcomes (OS, TTP, PFS) or QOL among S4PC patients, in the context of a specific treatment. The quality of evidence was graded as good, fair or poor, per AHRQ guidelines. RESULTS The search identified 2,659 articles of which 92 met study inclusion criteria. Most articles (46%) were post-hoc analyses of randomized clinical trials. PC treatments included chemotherapy, radiation, hormonal therapy (74%) and bone-modifying agents. HTE in S4PC was identified for both biologic and non-biologic factors. Factors related to clinical signs/symptoms, laboratory tests and disease severity have been extensively studied in the literature (Table). Age and race seldom showed any correlation with PC outcomes. CONCLUSIONS Current evidence reveals diverse factors contributing to HTE in S4PC. Ultimately, such knowledge can help oncologists prescribe more personalized medicine, help patients make more informed treatment choices, and inform policy making and treatment coverage decisions. [Table: see text].