Value and Cost of Myeloma Therapy-We Can Afford It.

A national conversation regarding the price and affordability of drugs exists, where concern for value and benefits of medications is challenged by the increasing price of both injectable and oral medications, including the cost of care of myeloma. At the same time, we have seen unprecedented improvements in the overall survival of patients with myeloma, mostly because of the availability of these new drugs. Here, we present data to assert that these medications and associated expenses are of direct benefit to patients and society. The entrepreneurial reward for drug development in the United States has fueled vigorous drug development efforts that have culminated in the approval of 11 new drugs for the treatment of myeloma by the U.S. Food and Drug Administration (FDA) since 1999. These patented drugs are available to patients in the United States usually at a higher price than in the rest of the world. Nevertheless, the majority of patients, via direct copay assistance or through indirect support via third parties, have access to these drugs irrespective of their socioeconomic status. One of the major regulatory hurdles that prevents access to these drugs is the legal impossibility that pharmaceutical companies have in directly supporting copay assistance for patients with government-funded health care. Moreover, assessments of value should include formal pharmacoeconomic analyses performed by experts. Interference with market forces and coercive action, such as price controls, or exercising eminent domain in the quest for cheaper medications will stymie innovation and rob us of the cures of the future.

A randomized trial of individual peer support for adults with psychiatric disabilities undergoing civil commitment.

OBJECTIVE: Given the proliferation of peer-delivered services and its growing but insufficient empirical base, we undertook a randomized trial to examine the effects of such services on individuals with severe psychiatric disabilities undergoing a civil commitment. METHOD: We recruited n = 113 individuals who were civilly committed for inpatient treatment. Randomly assigned experimental participants were paired with a trained peer specialist to receive intensive 1-on-1 support to assist them with both their recovery and the conditions of their mandated court-ordered services. Individuals in the control group were invited to receive other supportive, peer-delivered services, such as social and group educational activities, but excluding individual peer support. We assessed a variety of outcomes including social supports, quality of life, recovery, symptoms, and functioning. RESULTS: Mounting a randomized trial in this setting and with participants who were court-ordered for inpatient treatment proved challenging in terms of recruitment, service provision, retention in the intervention, and attrition from the research. Intent-to-treat analyses revealed no significant differences in outcomes by study condition. As-treated analyses comparing high- and low-use peer support groups with control group participants found significant differences favoring peer support recipients in quality of life and functioning but no differences in other study outcomes. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Difficulties with ensuring the quality of the peer support in this study may be in part responsible for our failure to see more-definitive and -positive results. As the peer support specialist profession evolves, an understanding of its effective ingredients and mechanisms must be elucidated to allow for more-rigorous studies. (PsycINFO Database Record

Individual peer support: a qualitative study of mechanisms of its effectiveness.

Peer-delivered services for individuals with psychiatric conditions have proliferated over the past three decades. The values and principles underlying peer support have been explored, but we lack an understanding of its mechanisms of action. To shed light on the processes of peer support, we conducted a study with individuals who had received substantial individual peer support. We completed individual interviews, audiotaped, transcribed, and examined them using a thematic analysis approach. Our analyses suggest that individual peer support provided various practical, emotional, and social supports which were perceived as beneficial. Participants valued having someone to rely on, a friend, and someone to socialize with. We, however, found that individuals' expectations of peer support did not always comport with available services. Participants viewed peer support as especially valuable because of the opportunity for a non-treatment based, normalizing relationship. We conclude that peer support complements rather than supplants needed traditional mental health services.

Influential factors for post-fellowship career decision-making: an NCCN survey.

Insight into factors important to fellows' decision-making about their career paths is critical to successfully developing program curricula, making capacity projections, and recruiting oncology physicians. This study was performed to determine the factors associated with post-fellowship career decision-making. Program evaluation surveys were administered to oncology fellows who attended the Fellows Recognition Program at the 2009 NCCN Annual Conference. A total of 125 (75%) fellows completed the initial survey. Overall, 73% of fellows reported participating in clinical research and 58% received formal training as part of their fellowship program. Receipt of formal training was correlated with greater program satisfaction (r(s) = 0.20; P = .03), feeling more prepared for a post-fellowship career (r(s) = 0.30; P < .001), and greater interest in clinical research post fellowship (r(s) = 0.32; P < .001). Interest in post-fellowship clinical research (r(s) = 0.49; P < .001) and importance of protected academic time (r(s) = 0.57; P < .001) were strongly correlated with interest in practicing in an academic environment, whereas institutional reputation (r(s) = 0.18; P = .04) and a multidisciplinary practice environment (r(s) = 0.22; P = .02) were moderately associated with interest. Location, salary, multidisciplinary environment, and flexible scheduling were the most important controllable lifestyle (CL) factors. These results suggest that fellowship programs may be able to foster a desire to participate in research and subsequent interest in practicing in an academic institution through providing opportunities for formal training in clinical research skills. However, even in an academic setting, CL factors are important to attracting and retaining faculty.

Practice and productivity of physician assistants and nurse practitioners in outpatient oncology clinics at national comprehensive cancer network institutions.

PURPOSE: It is expected that over the next 10 to 15 years, demand for oncology services will increase, potentially surpassing the supply of available oncologists. Physician assistants (PAs) and nurse practitioners (NPs) have the potential to address the anticipated shortage in physician supply. The two objectives of this study were to define how National Cancer Institute (NCI) -designated comprehensive cancer centers use PAs/NPs and to pilot a self-reported PA/NP productivity tool. METHODS: An online survey addressing practice patterns and productivity in 4-hour outpatient oncology clinics was administered to PAs/NPs practicing at 15 National Comprehensive Cancer Network member institutions. RESULTS: A total of 206 PAs/NPs were included in the final analysis. NPs and PAs reported similar clinical activities, with the following exceptions: NPs reported spending more time on telephone triage, and PAs reported spending more time on procedures. Overall, PAs/NPs reported seeing more follow-up (mean, 6.1; standard deviation [SD], 3.5) than new patients (mean, 1.2; SD, 1.3) per clinic. NPs with a medical oncology specialty reported a marginally greater productivity among follow-up patients than did PAs. Otherwise, NPs and PAs saw a similar number of patients regardless of specialty. CONCLUSION: To our knowledge, this is the first study attempting to characterize PA/NP clinical activities and define productivity benchmarks at NCI-designated comprehensive cancer centers. Given the increasing complexity of oncologic care and the increased population of patients with cancer and cancer survivors requiring that care, PAs/NPs have the potential to fill important roles in both outpatient and inpatient care settings.

Insights and perspectives in the clinical and operational management of cancer-related anemia.

Management of anemia in patients with cancer presents challenges from clinical, operational, and economic perspectives. Clinically, anemia in these patients may result from treatment (chemotherapy, radiation therapy, or surgical interventions) or from the malignancy itself. Anemia not only contributes to cancer-related fatigue and other quality of life issues, but also affects prognosis. From the operational perspective, a patient with cancer who is also anemic may consume more laboratory, pharmacy, and clinical resources than other patients with cancer.

NCCN Task Force Report: Specialty Pharmacy.

The use of specialty pharmacies is expanding in oncology pharmacy practice. Specialty pharmacies provide a channel for distributing drugs that, from the payor perspective, creates economies of scale and streamlines the delivery of expensive drugs. Proposed goals of specialty pharmacy include optimization of pharmaceutical care outcomes through ensuring appropriate medication use and maximizing adherence, and optimization of economic outcomes through avoiding unwarranted drug expenditure. In oncology practice, specialty pharmacies have become a distribution channel for various agents. The use of a specialty pharmacy, and the addition of the pharmacist from the specialty pharmacy to the health care team, may not only provide benefits for care but also present challenges in oncology practice. The NCCN Specialty Pharmacy Task Force met to identify and examine the impact of specialty pharmacy practice on the care of people with cancer, and to provide recommendations regarding issues discussed. This report provides recommendations within the following categories: education and training of specialty pharmacy practitioners who care for individuals with cancer, coordination of care, and patient safety. Areas for further evaluation are also identified.

Report on the NCCN Third Annual Patient Safety Summit.

The issues of patient safety and preventing medical errors routinely make headlines, with reports of thousands of preventable deaths and costs in the billions of dollars per year. Far less noticeable, but potentially more important, is the work taking place on a daily basis to develop new systems and processes of safety and use of technology in the effort to reduce preventable adverse events. The NCCN Third Annual Patient Safety Summit examined 3 processes central to maintaining patient safety in the oncology setting: medication reconciliation, communication during patient hand-offs, and reporting of events, including "near-miss" events that do not reach a patient or result in harm. The NCCN Patient Safety Summit included a multidisciplinary audience of safety experts, clinicians, and hospital administrators from NCCN member institutions, with speakers from member institutions sharing clinical and practical experiences in implementing safety improvements. Common themes included transitions from paper to electronic systems, education and training for individuals and teams as new methods are put into place, and the need for all members of the multidisciplinary care team to recognize their impact on patient safety.