Medication adherence star ratings measures, health care resource utilization, and cost.

OBJECTIVE: To examine the association between missed CMS Star Ratings quality measures for medication adherence over 3 years for diabetes, hypertension, and hyperlipidemia medications (9 measures) and health care utilization and relative costs. STUDY DESIGN: Retrospective cohort study. METHODS: The study examined eligible patients who qualified for the diabetes, statin, and renin-angiotensin system antagonist medication adherence measures in 2018, 2019, and 2020 and were continuously enrolled in a Medicare Advantage prescription drug plan from 2017 through 2021. A total of 103,900 patients were divided into 4 groups based on the number of adherence measures missed (3 medication classes over 3 years): (1) missed 0 measures, (2) missed 1 measure, (3) missed 2 or 3 measures, and (4) missed 4 or more measures. To achieve a quality measure, patients had to meet the Pharmacy Quality Alliance 80% threshold of proportion of days covered during the calendar year. RESULTS: The mean age of the cohort was 71.1 years, and 49.9% were female. Compared with patients who missed 0 of 9 adherence measures, those who missed 1 measure, 2 or 3 measures, and 4 or more measures experienced 12% to 26%, 22% to 42%, and 24% to 50% increased risks, respectively, of all-cause and diabetes-related inpatient stays and all-cause and diabetes-related emergency department visits (all  P  values < .01). Additionally, patients who missed 1, 2 or 3, and 4 or more adherence measures experienced 14%, 19%, and 20% higher monthly medical costs, respectively. CONCLUSIONS: Missing Star Ratings quality measures for medication adherence was associated with an increased likelihood of health care resource utilization and increased costs for patients taking medications to treat diabetes, hypertension, and hyperlipidemia.

Managing comorbidities in chronic kidney disease reduces utilization and costs.

BACKGROUND: Effective management of comorbid diabetes and hypertension in patients with chronic kidney disease (CKD) is important for optimal outcomes. However, little is known about this relationship from a health plan perspective. The objective of this study was to evaluate the association of effective management of comorbid diabetes and/or hypertension with healthcare resource utilization (HCRU) in patients with chronic kidney disease (CKD). METHODS: This retrospective cohort study used the Humana Research Database to identify patients with CKD Stage ≥ 3a in 2017. Eligible patients were enrolled in a Medicare Advantage Prescription Drug plan for ≥ 12 months before and after the index date (first observed evidence of CKD). Patients with end-stage renal disease, kidney transplant, or hospice election preindex were excluded. Recommended comorbid disease management included hemoglobin A1c monitoring; adherence to glucose-lowering, cardiovascular, and angiotensin-converting enzyme inhibitors/angiotensin receptor blocker medications; and nephrologist/primary care provider (PCP) visits. HCRU was evaluated for 12 months postindex. RESULTS: The final cohort of 241,628 patients was 55% female and 77% White, with an average age of 75 years. Approximately 90% of patients had Stage 3 CKD. Half had both diabetes and hypertension, and most of the remaining half had hypertension without diabetes. Patients meeting the criteria for good disease management, compared with patients not meeting those criteria, were less likely to experience an inpatient hospitalization, by as much as 40% depending on the criterion and the comorbidities present, or an emergency department visit, by as much as 30%. Total monthly healthcare costs were as much as 17% lower. CONCLUSIONS: Management of comorbid diabetes and hypertension in patients with CKD was associated with lower HCRU and costs. Care coordination programs targeting patients with CKD must give careful attention to glucose and blood pressure control. TRIAL REGISTRATION: Not applicable.

Home versus outpatient hospital intravenous immunoglobulin infusion and health care resource utilization.

BACKGROUND: Home health care delivery is projected to increase. Intravenous immunoglobulin (IVIG) therapy has high potential to move from the outpatient hospital (OPH) setting to home delivery. OBJECTIVE: This study examined the relationship between home and OPH IVIG infusions and health care utilization. METHODS: We used a retrospective cohort study design and the Humana Research Database to identify patients with 1 or more medical or pharmacy claims for an IVIG infusion agent from January 1, 2017, to December 31, 2018. Eligible patients were enrolled in a Medicare Advantage Prescription Drug (MAPD) or commercial health plan, with at least 12 months of continuous enrollment before and after their first infusion (i.e., index date) received in the home or OPH setting. We measured the odds of experiencing an inpatient (IP) stay or emergency department (ED) visit, adjusted for baseline differences in age, sex, race, region, population density, low-income, and dual eligibility status, MAPD or commercial health plan, plan type, treatment-naïve status, home health use, RxRisk-V comorbidity burden score, and indications for IVIG use. RESULTS: A total of 208 and 1079 patients received IVIG infusions in the home and OPH setting, respectively. The odds for an IP stay (odds ratio [OR] 0.56 [95% CI 0.38-0.82]) and ED visit (OR 0.62 [95% CI 0.41-0.93]) were significantly lower in patients who received IVIG infusion in the home than patients receiving infusion in the OPH setting. CONCLUSIONS: Our findings suggest there may be value to increasing referrals for IVIG home infusion. Decreased health care utilization provides value to the system in cost savings and to patients and families owing to less disruption and improved clinical outcomes. Further study can help inform health policy designed to maximize the benefits of IVIG home infusion while minimizing potential risks.

Anticholinergic exposure and its association with dementia/Alzheimer's disease and mortality in older adults.

BACKGROUND: Use of anticholinergic (ACH) medications is associated with increased risk of cognitive decline in the elderly. However, little is known about this association from a health plan perspective. METHODS: This retrospective cohort study used the Humana Research Database to identify individuals with at least one ACH medication dispensed in 2015. Patients were followed until incidence of dementia/Alzheimer's disease, death, disenrollment or end of December 2019. Multivariate Cox regression models were used to assess the association between ACH exposure and study outcomes, adjusting for demographics and clinical characteristics. RESULTS: A total of 12,209 individuals with no prior ACH use or dementia/Alzheimer's disease diagnosis were included. As ACH polypharmacy increased (i.e., from no ACH exposure, to one, two, three, and four or more ACH medications), there was a stair-step increase in the incidence rate of dementia/Alzheimer's disease (15, 30, 46, 56 and 77 per 1,000 person-years of follow-up) and in the incidence of mortality (19, 37, 80, 115 and 159 per 1,000 person-years of follow-up). After adjusting for confounders, ACH exposure to one, two, three and four or more ACH medications was associated with a 1.6 (95% CI 1.4-1.9), 2.1 (95% CI 1.7-2.8), 2.6 (95% CI 1.5-4.4), and 2.6 (95% CI 1.1-6.3) times, respectively, increased risk of a dementia/Alzheimer's disease diagnosis compared to periods of no ACH exposure. ACH exposure to one, two, three and four or more medications was associated with a 1.4 (95% CI 1.2-1.6), 2.6 (95% CI 2.1-3.3), 3.8 (95% CI 2.6-5.4), and 3.4 (95% CI 1.8-6.4) times, respectively, increased risk of mortality compared to periods of no ACH exposure. CONCLUSIONS: Reducing ACH exposure may potentially minimize long-term adverse effects in older adults. Results suggest populations which may benefit from targeted interventions to reduce ACH polypharmacy.

Early vs late filling of new heart failure prescription and its association with avoidable hospital admissions.

BACKGROUND: Individuals with heart failure (HF) are at increased risk for hospitalization and readmission after discharge. The impact of timing to new prescription filling on avoidable HF hospitalization is understudied in HF management. The Agency of Healthcare Research and Quality identifies HF-related inpatient admissions as potentially avoidable if they could be managed successfully in outpatient settings. OBJECTIVE: To compare avoidable HF hospitalization rate and all-cause and HF-related costs in patients who were early fillers (≤30 days) vs late fillers (>30 days) of newly prescribed HF medications following an HF-related inpatient stay or emergency department visit. METHODS: This retrospective cohort study used the Humana Research Database to identify patients with at least 1 claim for a new HF medication from January 1, 2018, to June 30, 2019. Eligible patients were enrolled in a Medicare Advantage Prescription Drug plan for at least 12 months pre-index and 6-months post-index (ie, first new HF prescription). Individuals who were early (n = 794) vs late fillers (n = 397) were propensity-score matched in a 2:1 ratio to balance baseline characteristics. A logistic regression model was fitted to compare avoidable HF hospitalization in those who were late fillers vs early fillers. Mean cost differences were compared using paired t-test. Outcomes were measured 6-months post-index. RESULTS: Late fillers had greater odds of experiencing an avoidable HF hospitalization compared with early fillers (odds ratio = 1.65; P = 0.001). Late filling was associated with a 49.5% increase in average all-cause medical costs (P < 0.0001), a 13.6% decrease in average all-cause pharmacy costs (P = 0.0929), and a 39.4% increase in average all-cause total costs (P < 0.0001). HF-related costs showed similar trends. CONCLUSION: Compared with patients who filled their prescription within 30 days of discharge following an HF admission, those who delayed the filling of a new HF prescription experienced increased likelihood of an avoidable readmission, and late filling was associated with increased 6-month total and medical costs. DISCLOSURES: Humana Healthcare Research, Inc., funded the research and article development. No external funds were used in the creation of this work. All authors are/were employees of Humana Inc. and/or Humana Healthcare Research, Inc., at the time of the work.

Transition-to-dialysis planning, health care use, and mortality in end-stage renal disease.

OBJECTIVES: To evaluate the association of dialysis transition planning factors (eg, nephrologist care, vascular access placement, place of dialysis) with inpatient (IP) stays, emergency department (ED) visits, and mortality. STUDY DESIGN: Retrospective cohort study. METHODS: We used the Humana Research Database to identify 7026 patients with a diagnosis of end-stage renal disease (ESRD) in 2017 who were enrolled in a Medicare Advantage Prescription Drug plan with at least 12 months preindex enrollment, with first ESRD evidence as the index date. Patients with kidney transplant, hospice election, or dialysis preindex were excluded. Transition-to-dialysis planning was defined as optimal (vascular access placed), suboptimal (nephrologist care, but no vascular access), or unplanned (first dialysis in IP stay or ED visit). RESULTS: The cohort was 41% female and 66% White, with a mean age of 70 years. Optimally planned, suboptimally planned, and unplanned transition to dialysis occurred for 15%, 34%, and 44% of the cohort, respectively. Among patients with preindex chronic kidney disease (CKD) stages 3a and 3b, 64% and 55%, respectively, had an unplanned dialysis transition. For patients with preindex CKD stages 4 and 5, 68% and 84%, respectively, had a planned transition. In adjusted models, patients with a suboptimally or optimally planned transition were 57% to 72% less likely to die, 20% to 37% less likely to experience an IP stay, and 80% to 100% more likely to experience an ED visit than patients with an unplanned dialysis transition. CONCLUSIONS: A planned transition to dialysis was associated with reduced odds of IP stays and lower mortality.

Association of medication adherence quality measures for diabetes, hypertension, and hyperlipidemia with cognitive decline.

Background: While diabetes, hypertension, and hyperlipidemia each are associated with increased risk of cognitive decline, little is known regarding how nonadherence to medications for these conditions is associated with cognitive decline risk. Methods: We identified patients enrolled in a Medicare Advantage Prescription Drug plan who were eligible for inclusion in the CMS Star Medication Adherence quality measures for diabetes, hypertension, and hyperlipidemia in 2018, 2019, and 2020. To achieve an adherence quality measure, patients had to meet 80% of the proportion of days for the medication. We used propensity score with inverse probability of treatment weighting to balance outcomes for baseline characteristics and logistic regression models to compare odds of cognitive decline outcomes across patient groups. Results: The study population of 99,774 individuals had a mean age of 71.0 years and was 49.1% female, 73.9% White, and 17.8% Black, with 62.0% living in an urban setting. Compared with patients who missed zero adherence measures, those who missed one measure had 23%-33% increased odds of cognitive decline (any decline OR = 1.23; dementia OR = 1.33; Alzheimer's disease OR = 1.27; all P values <0.01). Patients who missed 2-3 measures had 37%-96% increased odds of cognitive decline (any decline OR = 1.37; dementia OR = 1.58; Alzheimer's disease OR = 1.96; all P values <0.01). Patients who missed ≥4 adherence measures had the greatest odds of cognitive decline (any decline OR = 1.64; dementia OR = 2.05; Alzheimer's disease OR = 2.48; all P values <0.01). Conclusion: Not achieving CMS Star Medication Adherence quality measures for diabetes, hypertension, and hyperlipidemia therapies was associated with increased risk of cognitive decline outcomes.

A real-world comparison of cardiovascular, medical and costs outcomes in new users of SGLT2 inhibitors versus GLP-1 agonists.

AIMS: To compare SGLT2 inhibitors and GLP-1 agonists on cardiovascular (CV) outcomes, treatment persistence/discontinuation, healthcare utilization and costs. METHODS: This retrospective cohort study utilized medical and pharmacy claims to identify new SGLT2 inhibitor or GLP-1 agonist users from January 2015 to June 2017. A total of 5,507 patients were included in each treatment group after 1:1 propensity score matching. Cox proportional hazards models were used to compare CV outcomes and treatment discontinuation. Healthcare utilization and costs were compared using Wilcoxon signed rank test. RESULTS: No differences in the primary composite CV outcome or secondary CV outcome were observed. Patients using GLP-1 agonists were more likely to discontinue treatment (hazard ratio 1.15, 95% confidence interval 1.10-1.21) and more likely to have an inpatient hospitalization (14.4% vs. 11.9%, P < 0.001) or emergency department visit (27.4% vs. 23.5%, P < 0.001) compared to patients on SGLT2 inhibitors. The average per-person per-month cost difference was +$179 for total cost (P < 0.001), +$70 for medical cost (P < 0.001) and +$108 for pharmacy cost (P < 0.001) for GLP-1 agonists compared to SGLT2 inhibitors. CONCLUSIONS: Differences in composite CV outcomes were not established. However, other findings that favored SGLT2 inhibitors should be weighed against the known risks associated with this therapeutic class.

Comparing Medical Utilization and Cost Outcomes in Oral Versus Injectable Immunotherapy Users with Chronic Inflammatory Joint and Skin Diseases.

BACKGROUND: Rheumatoid arthritis (RA), psoriatic arthritis (PsA), and psoriasis (PSO) are immune-mediated systemic, chronic inflammatory conditions. Moderate to severe disease is treated with conventional disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, sulfasalazine, or leflunomide. If a patient does not respond to these firstline treatments, then tumor necrosis factor inhibitor (TNFi) or non-TNFi immunotherapy agents are administered via infusion, injection, or taken orally. Although the effectiveness of established infusion, injection, and newer oral therapies are known, the relative effectiveness among the routes of administration is not well understood. OBJECTIVE: To compare drug use, health care resource utilization, and costs among patients who are treatment-naive to oral immunotherapy and injectable biologic immunotherapy. METHODS: This retrospective observational study used claims data from a large U.S. health plan to identify new users of oral and injectable immunotherapy, diagnosed with a joint (RA or PsA), skin (PSO), or joint and skin condition from July 1, 2014, to June 30, 2017. The index date was the first claim for an oral or injectable medication. Medicaid, Medicare Advantage, and commercial plan patients aged 19-89 years with continuous enrollment 6 months before and 12 months after the index date were included in the study. Outcomes were adjusted using propensity score by inverse probability of treatment weighting. Treatment discontinuation, switching, health care resource utilization, and costs were measured during the post-index period. RESULTS: Oral versus injectable users with joint (n = 458 vs. 3,875), skin (n = 265 vs. 951), or joint and skin (n = 171 vs. 805) conditions were identified. For drug utilization outcomes, no differences in discontinuation rates were observed between oral and injectable groups for any of the cohorts. However, those in skin and joint and skin cohorts had higher rates of switching to other immunotherapies in patients initiated on orals compared with injectables. Health care resource utilization outcomes were mixed. While mean outpatient and physician office visits were significantly higher in oral compared with injectable groups across all 3 cohorts, no differences were observed for inpatient stays. Total costs (medical plus pharmacy) were lower for oral groups across all 3 cohorts. Pharmacy costs were lower for oral groups, but medical costs were higher for oral groups across all 3 cohorts. CONCLUSIONS: This is the first population-level study at a route-of-administration level, which compared switching, health care resource utilization, and costs across several conditions. Switching drugs was more likely in the oral group, which may indicate lower effectiveness or tolerability of oral immunotherapies relative to injectables. Health care resource utilization was higher in the oral group, but total costs were lower, which was likely driven by the lower costs of oral drugs. DISCLOSURES: This study was a Humana internal study, and all authors were at the time employees of Humana and used Humana resources. The authors have no conflicts of interest or financial interests to disclose that relate to the research described in this study. This study was presented as a podium and poster presentation at the AMCP Managed Care & Specialty Pharmacy Annual Meeting; April 23-26, 2018; Boston, MA.

Daily nicotine patch wear time predicts smoking abstinence in socioeconomically disadvantaged adults: An analysis of ecological momentary assessment data.

INTRODUCTION: Individuals who use the nicotine patch are more likely to quit smoking than those who receive placebo or no medication. However, studies have not yet examined the association between actual daily nicotine patch wear time during the early phase of a smoking cessation attempt and later smoking abstinence. The purpose of this study was to address this gap in the literature. METHODS: Participants who enrolled in a safety-net hospital smoking cessation program were followed for 13 weeks (i.e., 1 week pre-quit through 12 weeks post-quit). Participants completed in-person assessments and daily ecological momentary assessments on study provided smartphones. Multivariate logistic regressions were used to determine if daily patch wear time during the first week post-quit predicted 7-day biochemically verified point prevalence smoking abstinence 4 and 12 weeks following the scheduled quit date. Demographic characteristics and smoking behaviors were adjusted as covariates. RESULTS: Participants (N=74) were primarily non-White (78.7%) and most (86%) had an annual household income of <$20,000. Greater average hours of daily nicotine patch wear time during the first week post-quit was associated with a greater likelihood of abstinence at the 4 and 12 week post-quit visits (aOR=2.22, 95% CI:1.17-4.23; aOR=2.24, 95% CI:1.00-5.03). Furthermore, more days of wearing the patch for ≥19h was associated with a greater likelihood of abstinence at the 4 and 12 week post-quit visits (aOR=1.81, 95% CI:1.01-3.22; aOR=2.18, 95% CI:1.03-4.63). CONCLUSIONS: Greater adherence to the nicotine patch early in a quit attempt may increase the likelihood of smoking cessation among socioeconomically disadvantaged adults.

Use of Hematopoietic Growth Factors and Risk of Thromboembolic and Pulmonary Toxicities in Elderly Patients with Advanced Ovarian Cancer.

OBJECTIVE: To evaluate the risk of thromboembolic and pulmonary toxicities associated with hematopoietic growth factor (HGF) use (i.e., erythropoietin-stimulating agent [ESA] and/or colony-stimulating factor [CSF]) in a community-dwelling cohort of elderly patients with advanced ovarian cancer. METHODS: We studied 8,188 women, 65 years and older from the Surveillance, Epidemiology and End Results-Medicare linked database, diagnosed from January 1, 2000 to December 31, 2009. Patients were categorized into five groups: no chemotherapy and no ESA/CSF (n = 2,616), chemotherapy but no ESA/CSF (n = 1,854), ESA only (n = 1,313), CSF only (n = 743), and ESA + CSF (n = 1,662). We reported the cumulative incidence of toxicities for 2, 6, and greater than 6 months, and the incidence density for the overall follow-up. Cox-proportional hazards regression was performed to determine risk of toxicities. RESULTS: Of the 5,572 patients receiving chemotherapy, 66.7% (n = 3,718) received HGF supportive treatment, 29.8% received ESA + CSF, 23.6% received ESA only, and 13.3% received CSF only. Patients who received chemotherapy and also ESA + CSF had a 14.1% cumulative incidence of thromboembolic event (TEE) at 6 months of follow-up compared with 8.0% in those who received chemotherapy without growth factor and 3.2% in those with neither chemotherapy nor growth factor. Those with chemotherapy who received ESA + CSF had a significantly higher risk of TEE (adjusted hazard ratio, 1.22; 95% confidence interval, 1.01-1.47) as compared with patients with chemotherapy and no ESA/CSF, although patients aged 85 years and older may experience up to a five-fold increased risk. The risk of pulmonary toxicities did not significantly differ by HGF use. CONCLUSIONS: An increased risk of TEEs was observed in elderly patients with ovarian cancer who received ESA + CSF. The risk-benefit ratio for administering HGF should be carefully evaluated, especially among those 85 years and older.

Impact of a Mobile Phone Intervention to Reduce Sedentary Behavior in a Community Sample of Adults: A Quasi-Experimental Evaluation.

BACKGROUND: Greater time spent sedentary is linked with increased risk of breast, colorectal, ovarian, endometrial, and prostate cancers. Given steadily increasing rates of mobile phone ownership, mobile phone interventions may have the potential to broadly influence sedentary behavior across settings. OBJECTIVE: The purpose of this study was to examine the short-term impact of a mobile phone intervention that targeted sedentary time in a diverse community sample. METHODS: Adults participated in a quasi-experimental evaluation of a mobile phone intervention designed to reduce sedentary time through prompts to interrupt periods of sitting. Participants carried mobile phones and wore accelerometers for 7 consecutive days. Intervention participants additionally received mobile phone prompts during self-reported sitting and information about the negative health impact of prolonged sedentariness. The study was conducted from December 2012 to November 2013 in Dallas, Texas. Linear mixed model regression analyses were conducted to evaluate the influence of the intervention on daily accelerometer-determined estimates of sedentary and active time. RESULTS: Participants (N=215) were predominantly female (67.9%, 146/215) and nonwhite (black: 50.7%, 109/215; Latino: 12.1%, 26/215; other: 5.6%, 12/215). Analyses revealed that participants who received the mobile phone intervention had significantly fewer daily minutes of sedentary time (B=-22.09, P=.045) and more daily active minutes (B=23.01, P=.04) than control participants. CONCLUSIONS: A simple mobile phone intervention was associated with engaging in less sedentary time and more physical activity. Findings underscore the potential impact of mobile phone interventions to positively influence sedentary behavior and physical activity.

Impact of Hematopoietic Growth Factors on Blood Transfusion Needs, Incidence of Neutropenia, and Overall Survival Among Elderly Advanced Ovarian Cancer Patients Treated With Chemotherapy.

OBJECTIVE: To determine the effectiveness of erythropoietin-stimulating agent (ESA) and granulocyte colony-stimulating factor (CSF) in reducing blood transfusion needs and neutropenia incidence in community-dwelling elderly ovarian cancer patients. METHODS: The SEER (Surveillance Epidemiology and End Results)-Medicare database was used to identify 5572 women with stage III/IV ovarian cancer who received chemotherapy. To assess clinical effectiveness, we categorized patients based on the number of administrations of ESA (ie, epoetin-alfa and darbepoetin-alfa) and CSF (ie, filgrastim and pegfilgrastim). To evaluate effect on survival, patients were categorized as receiving ESA only, CSF only, ESA + CSF, and no ESA/CSF. RESULTS: Two thirds of patients received growth factor support (24% ESA only, 13% CSF only, 30% ESA + CSF). Depending on the number of epoetin-alfa administrations, ESA was associated with 48% to 56% lower need for blood transfusion compared with no ESA (hazard ratio for 1-3 claims, 0.47; 4-6 claims, 0.52; 7-10 claims, 0.48; ≥11 claims, 0.44). Patients who received at least 3 prophylactic filgrastim administrations had 71% to 98% lower risk of developing neutropenia (hazard ratio for 3-4 claims, 0.29; ≥5 claims, 0.02) compared with those without CSF. Effectiveness was comparable for darbepoetin-alfa and pegfilgrastim use. Overall survival was longer in those who received CSF only; however, the risk of mortality after 24 months was higher in those who received ESA (P = 0.0005). All models were adjusted for relevant covariates. CONCLUSIONS: Erythropoietin-stimulating agents were effective in reducing blood transfusion need. Granulocyte colony-stimulating factors were effective in lowering neutropenia incidence and also were associated with improved survival in elderly ovarian cancer patients. Findings are consistent with clinical trials and clinical guidelines.

Cost Effectiveness of Chemotherapeutic Agents and Targeted Biologics in Ovarian Cancer: A Systematic Review.

BACKGROUND: Adjuvant chemotherapy is a key component of advanced ovarian cancer treatment, when surgery alone is not sufficient. Recurrence is common in ovarian cancer patients and most women require prolonged second-line and higher-line chemotherapy. With newer targeted therapies, modest improvements in survival and quality of life may be attained at substantial cost, but the relative economic efficiency of these newer agents remains unknown. OBJECTIVE: We undertook this systematic review to comprehensively evaluate the cost-effectiveness of various chemotherapeutic and targeted therapy alternatives for ovarian cancer. METHODS: We searched Medline, PubMed, and Embase databases to identify economic evaluations published over the last 18 years (1996-2014). From the 2513 unique papers retrieved, 74 full texts were selected for full-text review based on a priori eligibility criteria. Two authors independently reviewed these articles to determine eligibility for final review. The quality of the included studies was assessed using the Quality of Health Economic Studies (QHES). RESULTS: A total of 28 studies were included for reporting. Administration of intravenous cisplatin-paclitaxel combination chemotherapy for first-line treatment was the most cost-effective alternative (2014 US dollars [USD] equivalent incremental cost-effectiveness ratio [ICER] ~US$17,000-US$27,000 per life year gained [LYG]), while the use of bevacizumab did not demonstrate similar value for money (2014 USD equivalent ICER was greater than US$200,000 per quality-adjusted life-year [QALY]). For second-line treatment, the use of platinum-paclitaxel combination or platinum monotherapy was cost-effective compared with platinum monotherapy or best supportive care, respectively, in women with recurrent platinum-sensitive disease. For patients with partial platinum sensitivity, pegylated liposomal doxorubicin (PLD) plus trabectedin may be cost-effective (2014 USD equivalent ICER was ~US$57,000-US$62,000 per QALY) compared with PLD alone. For recurrent platinum-resistant cases, there was limited evidence to conclude the most valuable treatment; though one study showed that best supportive care was most cost-effective, while second-line monotherapy with doxorubicin (2014 USD equivalent ICER was ~US$90,000 per LYG) may also be cost-effective compared with best supportive care. CONCLUSIONS: Despite varying methodological approaches and multiple sources for cost and effectiveness inputs, this systematic review demonstrated that standard platinum-taxane combination chemotherapy for first-line treatment was most cost-effective. There was unanimous agreement that bevacizumab was not a cost-effective front-line therapy compared with platinum-taxane combination for the overall ovarian cancer population, though its use in the high-use population may yield better value. For second-line treatment, platinum-based chemotherapy remained cost-effective among patients with recurrent platinum-sensitive disease, while there was limited evidence to conclude the most valuable treatment alternative among patients with recurrent platinum-resistant disease. Future research incorporating real-world data is essential to corroborate findings from trial-based economic evaluations. In addition, for improving consistency in reporting and quality of studies, incorporating QALYs in this population is important, especially since chemotherapy is administered for lengthy periods of time.

Cost-Effectiveness of Neoadjuvant Chemotherapy versus Primary Surgery in Elderly Patients with Advanced Ovarian Cancer.

BACKGROUND: The use of neoadjuvant chemotherapy (NAC) in the treatment of advanced ovarian cancer has increased in recent years. There is uncertainty about NAC's effectiveness and no study of its cost-effectiveness compared with that of standard primary debulking surgery (PDS). OBJECTIVES: To seek answers to three important questions: 1) What is the lifetime cost of treating elderly patients with advanced ovarian cancer, based on the primary treatment received? 2) Are the extra costs expended by the NAC group worth any extra survival advantage? 3) Would NAC potentially benefit a particular subgroup and serve as a cost-effective first-line treatment approach? METHODS: A cohort of elderly women (≥65 years) with stage III/IV ovarian cancer was identified from the Surveillance, Epidemiology and End Results-Medicare linked database from January 1, 2000, to December 31, 2009. Cost analysis was conducted from a payer perspective, and direct medical costs incurred by Medicare were integrated for each patient. Cumulative treatment costs were estimated with a phase-of-care approach, and effectiveness was measured as years of survival. Incremental cost-effectiveness ratio (ICER) and propensity-score-adjusted net monetary benefit regression was used to estimate the cost-effectiveness of NAC per life-year gained. Analyses were further stratified by risk group categorization on the basis of tumor stage, patient age, and comorbidity score. RESULTS: Average lifetime cost for treatment with NAC was $17,417 more than with PDS. With only 0.1 incremental life-year gained, the ICER estimate was $174,173. Stratification, however, helped to delineate the treatment effect. Patients in the high-risk subgroup incurred $34,390 and 0.8 life-years more than did patients in the PDS subgroup, with a corresponding ICER of $42,987. In the non-high-risk subgroup, NAC use was dominated by PDS (more costly, less effective). CONCLUSIONS: Administering NAC before surgery to patients in the high-risk subgroup was cost-effective at "normal" levels of willingness to pay, but not for the overall sample or for patients in the non-high-risk subgroup.

Smoking policy change at a homeless shelter: attitudes and effects.

Homeless adults are exposed to more smokers and smoke in response to environmental tobacco cues more than other socioeconomically disadvantaged groups. Addressing the culture of smoking in homeless shelters through policy initiatives may support cessation and improve health in this vulnerable and understudied population. This study examined support for and expected/actual effects of a smoking ban at a homeless shelter. A 2-wave cross-sectional study with an embedded cohort was conducted in the summer of 2013 two weeks before (wave 1) and two months after (wave 2) a partial outdoor smoking ban was implemented. A total of 394 homeless adults were surveyed (i.e., wave 1 [n=155]; wave 2 [n=150]; and 89 additional participants completed both waves). On average, participants were 43 years old, primarily African American (63%), male (72%), and had been homeless for the previous 12 months (median). Most participants were smokers (76%) smoking 12 cigarettes per day on average. Most participants supported the creation of a large smoke-free zone on the shelter campus, but there was less support for a shelter-wide smoking ban. Average cigarettes smoked per day did not differ between study waves. However, participants who completed both study waves experienced a reduction in expired carbon monoxide at wave 2 (W1=18.2 vs. W2=15.8 parts per million, p=.02). Expected effects of the partial ban were similar to actual effects. Partial outdoor smoking bans may be well supported by homeless shelter residents and may have a positive impact on shelter resident health.

Financial incentives for abstinence among socioeconomically disadvantaged individuals in smoking cessation treatment.

OBJECTIVES: We evaluated the effectiveness of offering adjunctive financial incentives for abstinence (contingency management [CM]) within a safety net hospital smoking cessation program. METHODS: We randomized participants (n = 146) from a Dallas County, Texas, Tobacco Cessation Clinic from 2011 to 2013 to usual care (UC; cessation program; n = 71) or CM (UC + 4 weeks of financial incentives; n = 75), and followed from 1 week before the quit date through 4 weeks after the quit date. A subset (n = 128) was asked to attend a visit 12 weeks after the scheduled quit date. RESULTS: Participants were primarily Black (62.3%) or White (28.1%) and female (57.5%). Most participants were uninsured (52.1%) and had an annual household income of less than $12 000 (55.5%). Abstinence rates were significantly higher for those assigned to CM than UC at all visits following the quit date (all Ps < .05). Point prevalence abstinence rates in the CM and UC groups were 49.3% versus 25.4% at 4 weeks after the quit date and 32.8% versus 14.1% at 12 weeks after the quit date. CM participants earned an average of $63.40 ($150 possible) for abstinence during the first 4 weeks after the scheduled quit date. CONCLUSIONS: Offering small financial incentives for abstinence might be an effective means to improve abstinence rates among socioeconomically disadvantaged individuals participating in smoking cessation treatment.

Attitudes of South Asian women to breast health and breast cancer screening: findings from a community based sample in the United States.

BACKGROUND: Breast cancer incidence is increasing among South Asian migrants to the United States (US). However, their utilization of cancer screening services is poor. This study characterizes attitudes of South Asians towards breast health and screening in a community sample. MATERIALS AND METHODS: A cross-sectional survey based on the Health Belief Model (HBM) was conducted among South Asians (n=124) in New Jersey and Chicago. The following beliefs and attitudes towards breast cancer screening were assessed-health motivation, breast self-examination confidence, breast cancer susceptibility and fear, and mammogram benefits and barriers. Descriptive statistics and Spearman rank correlation coefficients were computed for HBM subscales. FINDINGS: Mean age of participants was 36 years with an average 10 years stay in the US. Most women strived to care for their health (3.82±1.18) and perceived high benefits of screening mammography (3.94±0.95). However, they perceived lower susceptibility to breast cancer in the future (2.30±0.94). CONCLUSIONS: Increasing awareness of breast cancer risk for South Asian women may have a beneficial effect on cancer incidence because of their positive attitudes towards health and breast cancer screening. This is especially relevant because South Asians now constitute one of the largest minority populations in the US and their incidence of breast cancer is steadily increasing.

Family income trajectory during childhood is associated with adolescent cigarette smoking and alcohol use.

BACKGROUND: Although childhood socioeconomic disadvantage has been linked with adolescent tobacco and alcohol use in cross-sectional research, less is known about the influence of changes in socioeconomic status during childhood. Upward socioeconomic mobility may attenuate the negative influence of earlier socioeconomic disadvantage on health, while downward mobility may counter the health benefits of earlier socioeconomic advantage. This study evaluated the influence of common trajectories of family income during childhood on smoking and alcohol use during adolescence. METHODS: Data utilized were part of the 15-year longitudinal Study of Early Child Care and Youth Development. A 5-class trajectory model (two stable, one downward, and two upward income trajectories) was developed previously with this sample (N=1356). Logistic regression analyses were conducted to determine whether children of the more disadvantaged income trajectories were more likely to engage in tobacco and alcohol use at age 15 relative to those of the most advantaged trajectory. RESULTS: Family income trajectory was significantly associated with ever-smoking (p=.02) and past-year alcohol use at age 15years (p=.008). Children from the less advantaged trajectories were more likely to have ever-smoked than children of the most advantaged trajectory (all p's<.05). Children of the downwardly mobile trajectory were more likely to have used alcohol within the past year than children of the most advantaged trajectories as well as the most disadvantaged trajectory (all p's<.05). CONCLUSIONS: Findings indicate that childhood socioeconomic disadvantage influences adolescent smoking, while downward socioeconomic mobility influences adolescent alcohol use.

Small financial incentives increase smoking cessation in homeless smokers: a pilot study.

Although over 70% of homeless individuals smoke, few studies have examined the effectiveness of smoking cessation interventions in this vulnerable population. The purpose of this pilot study was to compare the effectiveness of shelter-based smoking cessation clinic usual care (UC) to an adjunctive contingency management (CM) treatment that offered UC plus small financial incentives for smoking abstinence. Sixty-eight homeless individuals in Dallas, Texas (recruited in 2012) were assigned to UC (n=58) or UC plus financial incentives (CM; n=10) groups and were followed for 5 consecutive weeks (1 week pre-quit through 4 weeks post-quit). A generalized linear mixed model regression analysis was conducted to compare biochemically-verified abstinence rates between groups. An additional model examined the interaction between time and treatment group. The participants were primarily male (61.8%) and African American (58.8%), and were 49 years of age on average. There was a significant effect of treatment group on abstinence overall, and effects varied over time. Follow-up logistic regression analyses indicated that CM participants were significantly more likely than UC participants to be abstinent on the quit date (50% vs. 19% abstinent) and at 4 weeks post-quit (30% vs. 1.7% abstinent). Offering small financial incentives for smoking abstinence may be an effective way to facilitate smoking cessation in homeless individuals.