Real-world evaluation of TNF-inhibitor utilization in rheumatoid arthritis.

OBJECTIVES: To evaluate 12-month treatment patterns, healthcare resource use (HCRU), and costs for patients with rheumatoid arthritis (RA), following initiation of index TNF inhibitors (TNFi) and subsequent biologic DMARDs (bDMARDs). METHODS: This was a retrospective cohort analysis of adults with RA newly initiating TNFi in the Truven Marketscan Commercial Claims and Encounters and Medicare Supplemental Databases during 2010-2013. A sub-group of patients who switched to a bDMARD within 12 months post-index and within 180 days of last index TNFi were subsequently evaluated over 12 months. TNFi/bDMARD treatment patterns were characterized as: continuers, no gap >180 days in prescription/administration of index TNFi; discontinuers, gap >180 days; switchers, initiated new bDMARD. Concomitant conventional synthetic DMARD use, co-morbid chronic illnesses, and RA severity were assessed. All-cause/RA-related HCRU and costs were evaluated 12 months post-index. RESULTS: Of 9567 identified patients, 67.2%, 17.3%, and 15.4% were continuers, discontinuers, and switchers, respectively. Switchers had the highest 12-month unadjusted mean all-cause costs of $34,585 vs $33,051 for continuers (p = 0.1158) and $24,915 for discontinuers (p < 0.0001; discontinuers vs continuers, p < 0.0001). RA-related costs comprised 82.8%, 31.4%, and 85.7% of total costs for continuers, discontinuers, and switchers, respectively. Of 764 switchers, 68.2% switched to alternative TNFi (cyclers), the rest to non-TNFi bDMARDs; 36.7% of patients who switched to TNFi switched again (to third-line bDMARD) vs 27.6% (p = 0.0313) of those who switched to non-TNFi bDMARDs. Switchers to non-TNFi bDMARDs had higher mean 12-month all-cause costs of $76,580 compared with $50,689 for switchers to alternative TNFi (p < 0.0001); biologic-administration visits comprised 78.8% of the greater total RA-related costs of switchers to non-TNFi bDMARDs. CONCLUSIONS: Real-world TNFi discontinuation/switching rates correspond to randomized controlled trial non-response rates. TNFi cycling is common and associated with an increased likelihood of switching to third-line bDMARD. Switching to non-TNFi bDMARDs was associated with higher costs, mostly attributed to in-office administrations.

An application of the matching law to evaluate the allocation of two- and three-point shots by college basketball players.

We applied the matching equation to evaluate the allocation of two- and three-point shots by male and female college basketball players from a large Division 1 university. The matching law predicts that the proportion of shots taken from three-point range should match the proportional reinforcement rate produced by such shots. Thus, we compared the proportion of three-point shots taken relative to all shots to the proportion of three-point shots scored relative to all shots scored. However, the matching equation was adjusted to account for the greater reinforcer magnitude of the three-point basket (i.e., 1.5 times greater than the two-point basket reinforcer magnitude). For players with substantial playing time, results showed that the overall distribution of two- and three-point shots was predicted by the matching equation. Game-by-game shot distribution was variable, but the cumulative proportion of shots taken from three-point range as the season progressed was predicted almost perfectly on a player-by-player basis for both male and female basketball players.

Medication use review process and information systems utilized for oncology chemotherapy quality improvement.

Fatal chemotherapy overdoses at prestigious institutions have prompted extensive reviews of policies and procedures in medical centers throughout the country. Improving medication use systems for chemotherapy requires a comprehensive multidisciplinary approach. A process to develop a medical center policy on chemotherapy based on the medication use model adopted by the Joint Commission on Accreditation of Healthcare Organizations will be discussed. This will include the prescribing, preparing, dispensing, administering, and monitoring process as well as quality improvement systems. Pharmacy information systems enhancements that safeguard patients are also discussed including maximum dose checks and specific dosing algorithms for bone marrow transplant patients.

Involving physicians in efforts to control pharmaceutical expenditures.

Managed care methods of influencing physician prescribing behavior work as well in hospital settings as they do in the ambulatory environment. The authors studied the effect of pharmacist interventions in certain diagnostic areas and found that these efforts do result in significant cost savings.

Job characteristics and satisfaction of pharmacy technicians.

Perceptions of job characteristics and job satisfaction of central-area technicians and drug-administration technicians at The Ohio State University Hospitals were analyzed. A questionnaire was administered to 79 pharmacy drug-administration technicians; 44 central-area technicians; 10 pharmacy residents, who served as objective raters (5 in the central area and 5 in the decentral area); 13 central-area pharmacists; and 17 decentral-area pharmacists. Perceived job characteristics were measured with the Job Characteristics Inventory; job satisfaction was measured by the Minnesota Job Satisfaction Questionnaire. The two groups of technicians differed significantly in their perceptions of task identity, task significance, and dealing with others. Significantly greater autonomy in technicians' jobs was perceived to exist by pharmacists and raters in both areas than by technicians. Significantly greater task identity was perceived by the central-area technicians than by their raters, and significantly greater task importance was perceived by both groups of technicians than by their pharmacists and raters. Friendship opportunities were perceived to exist to a significantly greater degree by decentral pharmacists and raters than by the drug-administration technicians. In the institution studied, both central-area and drug-administration technicians tended to be dissatisfied with their jobs. Central-area technicians' satisfaction was influenced most by the technicians' relationships with their supervisors and the feelings of accomplishment they gained. Drug-administration technicians were most satisfied if they believed they had opportunities to use their abilities. Efforts to increase job satisfaction among pharmacy technicians should focus on increasing feedback and task identity.

Costs of training drug-administration technicians.

The costs associated with training drug-administration pharmacy technicians in a 1000-bed university teaching hospital were determined. Data were collected between January 1 and December 31, 1983, for the personnel acquisition phase and four training phases of the technician training program. The study phases were further divided into direct and indirect costs. The pharmacy department interviewed 56 applicants for the training program, of which 19 were accepted; 15 of the 19 (79%) trainees successfully completed the program and were hired. Four nine-week training sessions were conducted. The cost per training hour was $15.69, the cost per trainee was $5,683, and the total training cost of the program was $85,245. Although these cost data are specific to this hospital, they may assist other hospitals in the financial management of pharmacy technician training programs.

Activity analysis of pharmacy-directed drug-administration technicians.

The percentage of time required by drug-administration technicians to perform predefined activities was determined using a work-sampling technique. Two trained pharmacists used random-sampling techniques to estimate the amount of time technicians spent performing activities in each of four major work categories. These categories, which included drug administration and related activities, clerical, communication, and "other," were divided into 24 activity elements, and technicians were randomly observed during the first or second work shift (8 1/2 hours) for 20 days in a one-month period. Drug-administration technicians spent the most time in the drug administration and related activities category (40.4 +/- 2.5%), followed by "other" (24.1 +/- 2.2%), communication (17.9 +/- 2.0%), and clerical (17.6 +/- 2.0%) activities. In the "other" category, technicians were not observed 11.6 +/- 1.7% of the time, but this was expected since the technicians were granted a 30-minute lunch period and two 15-minute breaks. A work-sampling technique was effective in quantifying activities performed by drug-administration technicians.

[Problems posed by massive hemorrhages of colorectal origin. Apropos of 12 case reports]. / Problèmes posés par les hémorragies massives d'origine colo-rectale. A propos de 12 observations.

Urgent surgical operation to treat massive hemmorrhage of colorectal origin was necessary in 12 patients: --colon diverticulosis: 7 cases, --cecal angiodysplasia: 1 case, --pancreatocolic fistula: 1 case, --ischemic colitis: 2 cases, --post-radiation therapy rectitis: 1 case. Lesions exclused from discussion in this report and provoking hemorrhage were colorectal tumors, chronic inflammatsry colitis, rectosigmoid angiomatosis, and post-traumatic or iatrogenic lesions. After a definition of massive hemmorrhage based on pre-operative transfusional requirements, the exploratory procedures necessary for localization of the site of the hemorrhage or for detecting a right colon angiodysplasia are discussed. Bimesenteric arteriography represents the exploration of choice, but its usefulness is limited in patients with several risk factors and an average age of 70 years. The respective values of a barium enema and peroperative endoscopy in this particular context are also discussed. Elective surgery should be performed only when the exact site of bleeding has been determined or when an angiodysplasia is present. Particular problems arise when treating diffuse colon diverticulosis hemorrhage, and that provoked by the association of an angiodysplasia and a diverticulosis, as well as hemorrhagic lesions that may require emergency therapy in much rarer affections: ischemic colitis, pancreatocolic fistula, iliosigmoidal fistula, colorectal varices, colon and rectal ulcers, and colorectal radiolesions.

Life expectancy following spinal cord injury: a ten-years survey in the Rhône-Alpes Region, France, 1969-1980.

A ten years survey of 848 patients having sustained traumatic spinal cord injury between 1969 and 1979 was conducted in the Rhône-Alpes Region, France. All patients had been referred to the spinal cord injury unit, Hôpital Henry Gabrielle. 48 deaths were recorded: 36 patients admitted early to the Unit, and 12 patients injured before 1969 but followed-up in the Unit. The deceased patients were older and more frequently male and tetraplegic than the rest of the group. In 75 per cent of the deceased patients, the survival time was less than 1/5 of the theoretical life expectancy. In 59 per cent, it was less than 1/10. Twenty tetraplegics died of respiratory complications. Three patients committed suicide, the rest died of urinary complications. The results appear to determine a secondary period with high mortality rate, after the initial high mortality of these patients. About one year post-injury, the life expectancy in our series appears to tend towards the values observed in the French population.

Cost justifying a pharmacy residency program.

Cost justification of a pharmacy residency training program was prepared. The contributions of the pharmacy residents were tabulated and compared with the cost of the program to the hospital. Contributions were determined by identifying the activities performed by residents that could be quantified in financial terms. The residents' activities that benefited the hospital included administrative support, completion of special projects, scheduling staff assignments, and coordinating education programs. Costs were derived from salaries, fringe benefits, and training expense. An output value analysis was performed by comparing the contributions of the residents to the institution with the cost of the training program. The contributions of the residents exceeded the costs of the training program by a ratio of 1.3 to 1.

The technical aids of tetraplegic patients.

A twenty-minute film shows how tetraplegic patients can compensate their disability thanks to very simple means. The independence of tetraplegic patients is considered with non-sophisticated equipment that are to be used every day in every department of occupational therapy.

Epidemiology of spinal cord injury in the Rhône-Alpes Region, France, 1970-75.

Three hundred and fifty-one cases of traumatic spinal cord injuries concerning only inhabitants of the Rhône-Alpes region have been collected at Henry Gabrielle Hospital. Incidence and prevalence are discussed, as well as male/female ratio, causes of accidents, and their relationship to sex, race, age, vertebral level, associated injuries and profession.

Semiological value of painful sensitivity of the testis in spinal cord injuries [proceedings].

About 85 cases of spinal cord male injured patients; the authors bring their experience of the painful sensitivity of the testis by squeezing the gland. This sign has a semiological value about the topography and the level of complete and incomplete cord syndromes. It is of no value for the testicular fertility. The rehabilitation of neurological bladders must take this sign into account so as to appreciate the type of micturition.

[Immobilisation hypercalcaemia (author's transl)]. / L'hypercalcémie d'immobilisation.

Hypercalcaemia would seem to be rare during immobilisation, whilst osteoporosis and hypercalciuria are constant. In fact, it often goes unnoticed. The case presented here confirms its predominance in the adolescent male. The reason for immobilisation seems to be irrelevant. The clinical symptoms are very variable: polydipsia, nausea, headache, apathy, anorexia. Blood calcium levels are raised, up to 14 mg%. This hypercalcaemia is due to very marked bone loss in adolescents, secondary to hyper-resorption and a temporary stoppage in osseous formation. The differential diagnosis from primary hyperparathyroidism is sometimes difficult but is aided by laboratory and histological findings. The essential is to consider the possibility of immobilisation hypercalcaemia in the presence of any suggestive symptoms in an immobilised adolescent. Treatment includes a return to weight bearing, adequate water intake and the administration of phosphorus, calcitonin, furosemide, and corticosteroids.

Histological and hormonal testicular changes in spinal cord patients.

Hormonal dosages and testicular biopsy are discussed in paraplegic patients of several neurological levels. There are no absolute biological criteria but histology showed slowing of spermatogenesis.

Results of rehabilitation in central cord syndromes.

Out of 180 cervical cord syndromes (traumatic, neoplastic and vascular) studied we examined the prognosis of rehabilitation in 31 central cord syndromes dating back from 6 months at the least or 6 years at the most.