Real-world Medicare Healthcare Costs of Patients with Dupuytren's Contracture Treated with Collagenase or Fasciectomy.

Background: Our study aimed to compare real-world healthcare resource utilization (HRU) and healthcare cost (HC) of Medicare-insured patients (≥65 years old) with Dupuytren's contracture (DC) treated with Clostridium histolyticum (collagenase) or fasciectomy. Methods: DC patients treated with collagenase or fasciectomy between July 2011 and June 2017 were identified using the IBM MarketScan Medicare Supplemental Database. The index date was the date of the first procedure. Demographic characteristics were captured on the index date, and comorbidities were assessed during the 24-month preindex period. HRU and HC were analyzed throughout the 12-month postindex period. Patients were matched using propensity score weights. Gamma log-linked generalized linear models were used to evaluate HC drivers. Results: Out of 37,374 DC patients, 2911 received collagenase, while 6258 underwent fasciectomy. Postmatching, the total average annual HC was similar between collagenase and fasciectomy ($7271 versus $6220, P = 0.357). When HCs were stratified by the service provider, outpatient facility and physician office costs were lower in the collagenase cohort ($850 versus $1284, P = 0.047 and $546 versus $1001, P < 0.001). The costs of professional services were significantly higher than in the fasciectomy cohort due to the cost of collagenase injection ($1682 versus $629, P < 0.001). The HRU was similar between cohorts, except for more frequent outpatient facility visits in fasciectomy patients (12.3 versus 22.9, P < 0.001). Generalized linear model revealed Charlson comorbidity index, plan type, patients' residence region, sleep disorder, and hyperlipidemia as significant predictors of total HC. Conclusion: This study found comparable total annual HC and HRU between collagenase- and fasciectomy-treated Medicare patients.

Tracking Proactive Interference in Visual Memory.

The current contents of visual working memory can be disrupted by previously formed memories. This phenomenon is known as proactive interference, and it can be used to index the availability of old memories. However, there is uncertainty about the robustness and lifetime of proactive interference, which raises important questions about the role of temporal factors in forgetting. The present study assessed different factors that were expected to influence the persistence of proactive interference over an inter-trial interval in the visual recent probes task. In three experiments, participants encoded arrays of targets and then determined whether a single probe matched one of those targets. On some trials, the probe matched an item from the previous trial (a "recent negative"), whereas on other trials the probe matched a more distant item (a "non-recent negative"). Prior studies have found that recent negative probes can increase errors and slow response times in comparison to non-recent negative probes, and this offered a behavioral measure of proactive interference. In Experiment 1, factors of array size (the number of targets to be encoded) and inter-trial interval (300 ms vs. 8 s) were manipulated in the recent probes task. There was a reduction in proactive interference when a longer delay separated trials on one measure, but only when participants encoded two targets. When working memory capacity was strained by increasing the array size to four targets, proactive interference became stronger after the long delay. In Experiment 2, the inter-trial interval length was again manipulated, along with stimulus novelty (the number of stimuli used in the experiment). Proactive interference was modestly stronger when a smaller number of stimuli were used throughout the experiment, but proactive interference was minimally affected by the inter-trial interval. These findings are problematic for temporal models of forgetting, but Experiment 3 showed that proactive interference also resisted disruption produced by a secondary task presented within the inter-trial interval. Proactive interference was constantly present and generally resilient to the different manipulations. The combined data suggest a relatively durable, passive representation that can disrupt current working memory under a variety of different circumstances.

Healthcare Costs and Resource Use of Patients with Dupuytren Contracture Treated with Collagenase Clostridium Histolyticum or Fasciectomy: A Propensity Matching Analysis.

OBJECTIVE: Studies examining differences in US healthcare resource utilization (HCRU) and associated healthcare costs between collagenase clostridium histolyticum (CCH) and fasciectomy for Dupuytren contracture (DC) are limited. This study evaluated US HCRU and direct healthcare cost for the treatment of DC in privately insured patients using insurance claims. METHODS: This retrospective observational cohort study analyzed data from large nationwide insurance claims databases; it included individuals diagnosed with DC between July 1, 2011, and June 30, 2017, who were adults at index date (date of first treatment: CCH or fasciectomy). Participants had continuous health plan coverage 24 months pre-index and 12 months post-index date. All-cause and DC-related HCRU and healthcare costs from the payers' perspective were compared between propensity score-matched cohorts. Generalized linear models assessed factors associated with all-cause total healthcare costs. RESULTS: Of 83,983 patients diagnosed with DC, 1932 adults receiving fasciectomy and 953 adults receiving CCH were included. The mean ± standard deviation total all-cause healthcare cost was significantly lower with CCH than with fasciectomy (US$11,897 ± US$14,633 versus US$15,528 ± US$22,254, respectively; P<0.001). After propensity score matching, 702 and 999 patients remained in the CCH and fasciectomy cohorts, respectively. In this analysis, all-cause and DC-related total costs were significantly lower in the CCH cohort versus the fasciectomy cohort (all-cause: US$11,044 ± US$12,856 versus US$12,912 ± US$19,237, respectively, P=0.02; DC-specific: US$3417 ± US$3671 versus US$5800 ± US$4985, P<0.001), mainly due to the lower frequency of outpatient visits. CCH treatment and the use of a consumer-driven healthcare plan were associated with lower healthcare costs. CONCLUSION: Based on matched cohort data, adjusted 1-year healthcare costs for CCH-treated individuals were significantly lower compared with costs for fasciectomy-treated individuals.

Clinical characteristics and outcomes of SDHB-related pheochromocytoma and paraganglioma in children and adolescents.

PURPOSE: Pheochromocytomas/paragangliomas (PHEOs/PGLs) are rare in children with only a few SDHB mutation-related cases. Previous studies on children were conducted in small cohorts. This large set of pediatric patients provides robust data in the evaluation of clinical outcomes. METHODS: Sixty-four pediatric PHEO/PGL patients with SDHB germline mutations were included in the present study. The clinical presentation, disease course, and survival rate were evaluated. RESULTS: Thirty-eight males and 26 females were diagnosed with PHEO/PGL at a median age of 13 years. The majority of patients displayed norepinephrine hypersecretion and 73.44% initially presented with a solitary tumor. Metastases developed in 70% of patients at the median age of 16 years and were mostly diagnosed first 2 years and in years 12-18 post-diagnosis. The presence of metastases at the time of diagnosis had a strong negative impact on survival in males but not in females. The estimated 5-, 10-, and 20-year survival rates were 100%, 97.14%, and 77.71%, respectively. CONCLUSION: The present report has highlighted several important aspects in the management of pediatric patients with SDHB mutations associated-PHEO/PGL. Initial diagnostic evaluation of SDHB mutation carriers should be started at age of 5-6 years with initial work-up focusing on abdominal region. Thorough follow-up is crucial first 2 years post-diagnosis and more frequent follow-ups are needed in years 10-20 post-diagnosis due to the increased risk of metastases. Although this age group developed metastasis as early as 5 years from diagnosis, we have shown that the overall 20-year prognosis and survival are good.

Budgetary impact of the utilization of buprenorphine/naloxone sublingual film and tablet for Medicaid in the United States.

OBJECTIVES: The buprenorphine/naloxone combination for the treatment of opioid dependence is available in a film or tablet formulation. Recent retrospective studies demonstrated that treatment with the sublingual film formulation is associated with improved treatment retention and lower healthcare costs. In March 2013, generic buprenorphine/naloxone tablets were approved in the US. A budget impact model was built to compare healthcare expenditures for different market shares of sublingual film and tablet. METHODS: A Markov model was developed to track a cohort of opioid dependent patients treated with sublingual film or tablet through the following treatment phases: initiation, maintenance, discontinuation, off-treatment and reinitiation. Transition probabilities and costs for each phase were estimated from the MarketScan Medicaid database for the period between 1 March 2010 and 30 June 2012. The total expenditure for the plan and expenditure per plan member per month were predicted over 5 years. Two market share scenarios were considered: 1) sublingual film is progressively replaced by generic tablet (current situation) and 2) the sublingual film holds a market share of 100%. RESULTS: Predicted total costs over 5 years were $6400 million when the sublingual film holds a market share of 100% (as per Scenario 2) which is lower than when sublingual film is progressively replaced by generic tablet (current situation as per Scenario 1) by $64 million. These savings were mostly driven by inpatient care ($56 million saved over 5 years), followed by emergency room care ($27 million) and pharmaceutical costs ($24 million). Costs of outpatient care attenuated the difference as they were predicted to be higher by $44 million in Scenario 2. The reduction in total cost per member per month reached $0.027 in the fifth year. Results were most sensitive to price rebates and to the probability of non-psychiatric hospitalization. CONCLUSIONS: While using the sublingual film formulation for more patients treated with buprenorphine/naloxone is predicted to increase outpatient care costs, it would generate savings in emergency care and hospitalizations. In the treatment of opioid dependence, total direct medical costs for Medicaid would be lower for sublingual film treated patients, at current drug prices.

Analysis of buprenorphine/naloxone dosing impact on treatment duration, resource use and costs in the treatment of opioid-dependent adults: a retrospective study of US public and private health care claims.

OBJECTIVES: The buprenorphine/naloxone combination is used to treat the chronic relapsing disorder of opioid dependence. Adequate dosing levels are important to control cravings, prevent withdrawal syndrome, and maintain patients in treatment. The objective of this study was to estimate the impact of dosing on treatment persistence, resource utilization, and total direct health care costs. METHODS: A retrospective cohort analysis was performed using administrative claims extracted from the MarketScan and Clinformatics databases from January 2007 to June and November 2012. Patients initiating treatment with buprenorphine/naloxone were classified into 2 groups based on the prescribed average dose over the entire treatment period and matched by multiple criteria. The threshold for differentiating the dosing groups was set at 15 and 15.7 mg/day for publicly and privately insured patients, respectively. Resource utilization and related costs were calculated over the 12-month period after the treatment initiation. RESULTS: Patient characteristics at baseline were considerably different between the privately and publicly insured patients. Publicly insured patients were slightly younger (33.1 vs 34.3 years old for privately insured) and had a higher prevalence of mental disorders (70.9% vs 64.9%). In both groups, patients treated with higher doses (> 15 mg and > 15.7 mg per day for publicly and privately insured patients, respectively) had lower risk of discontinuation (public: 11% lower; private: 9% lower) and lower probability of a psychiatric hospitalization than patients treated with lower doses (public: 17% lower; private: 41% lower). Total costs were comparable between the 2 groups (public: $14 600; private: $21 000) despite the expected higher cost of pharmacy in the higher-dose group. CONCLUSIONS: Treatment with higher doses of buprenorphine/naloxone was associated with a longer time to treatment discontinuation, less resource use, and lower total medical costs despite higher pharmacy acquisition cost.

Persistence and healthcare utilization associated with the use of buprenorphine/naloxone film and tablet formulation therapy in adults with opioid dependence.

BACKGROUND: Buprenorphine/naloxone film was developed to improve retention in treatment and reduce public health risks over the tablet formulation for opioid dependence. OBJECTIVES: To compare patient persistence and resource utilization between formulations for the treatment of opioid dependence. METHODS: A longitudinal, retrospective cohort analysis was conducted to compare persistence and healthcare costs in a private US insurance claims database. Previously untreated patients, who initiated treatment with buprenorphine/naloxone following the introduction of the film, were classified in two groups according to the initial prescription. Persistence was defined as the proportion of patients continuing treatment for at least 6 months. Resource utilization and related costs were calculated over the 6- and 12-month periods after treatment initiation. RESULTS: Film and tablet groups included 2796 and 1510 patients enrolled over 9.76 and 13.76 months on average, respectively, from initiation of treatment. Patient characteristics were similar between groups. Mean prescribed doses were 14.62 and 14.26 mg/day in film and tablet groups. Among patients enrolled for at least 6 months from the initial treatment, persistence rates were 63.78% with film vs 58.13% with tablet. Time to treatment discontinuation was longer in the film group, with a hazard ratio of 0.818 (p = 0.0005, 95% CI = [0.730;0.916]) adjusted for baseline characteristics. Patients treated with film had significantly more outpatient visits (+4%, p = 0.0185) and lower probability to be hospitalized (-17%, p = 0.0158), resulting in lower total healthcare costs over the 12-month period after initiation (-27%, p < 0.0001). CONCLUSIONS: Patients treated with the film formulation of buprenorphine/naloxone appeared to stay longer on treatment, have a lower probability of hospital admission, and lower health care costs compared to patients treated with the tablet. This study, based on insurance claims data, has the advantage of reflecting real-world practice, but one cannot rule out the existence of bias due to differences in patient or prescriber profiles, despite adjustments made for observed characteristics at treatment initiation.

Clinical, surgical and histopathologic outcomes of Filipino patients with Micropapillary Thyroid Carcinoma in a Tertiary University Hospital in the Philippines / Journal of the ASEAN Federation of Endocrine Societies

Objective@#Micropapillary thyroid carcinoma (micro-PTC) has a good prognosis but a number of cases will present with aggressive behavior. This study aims to determine the clinical outcomes with surgical management and histopathologic characteristics of Filipino patients with micro-PTC at University of Santo Tomas Hospital. @*Methodology@#139 patients were diagnosed with micro-PTC from the year 2004-2011. Seventy five patients had complete data and were included in this retrospective study. Chi square test with Yates correction, T-test for tumor diameter, statistical means and percentages were used in data analysis.@*Results@#A total of 1,689 thyroid surgeries were done between 2004 and 2011. There were 1,054 patients (62.4%) diagnosed with benign thyroid tumor(s) and 635 patients (37.6%) with well-differentiated thyroid carcinoma. Of these, 139 (22%) patients have micro-PTC. The prevalence rate of micro-PTC was 22%, with a female predominance (86.6%). The patients’ ages ranged from 24-80 years old with a mean age of 47 years. Comparison of groups showed that having either incidental or non-incidental micro-PTC is independent of the clinical variables of the patient. Two (2.6%) patients initially presented with cranial and supraclavicular metastasis. This study had a low recurrence rate (5.3%) and a mortality rate of 1.3%. @*Conclusion@#Male gender is the only significant variable for lymph node and distant metastasis. The patient’s age, family history of cancer, number of foci, size and histological type of tumor have no prognostic value.