PHS63 Cost-Effectiveness Analysis Of A Pharmacist-Led Intervention On Improving Inhaler Adherence In Patients With Chronic Obstructive Pulmonary Disease

Objectives: The Belgian community pharmacist-led PHARMACOP intervention provided educational inhalation training sessions and motivational interviewing regarding medication use in patients with Chronic Obstructive Pulmonary Disease (COPD). The program significantly improved medication adherence and inhalation techniques compared with usual care. This study aimed to evaluate its costeffectiveness. Methods: An economic analysis was performed from the Belgian health care payer's perspective. A Markov model was constructed in which a cohort of 1,000 patients with COPD receiving the 3-month PHARMACOP-intervention or usual care, was followed. This cohort had a mean age of 70 years, 66% were male, 43% current smokers and patients had a mean Forced Expiratory Volume in 1 second of % predicted of 50. Three types of costs were calculated: intervention costs, medication costs and exacerbation costs. Outcome measures included the number of hospital-treated exacerbations, cost per prevented hospital-treated exacerbation and cost per Quality Adjusted Life-Year (QALY) gained. Follow-up was 1 year in the basecase analysis. Univariate-, probabilistic sensitivity- and scenario analyses (including long-term follow-up) were performed to assess uncertainty. Results: In the basecase analysis, the average overall costs per patient for the PHARMACOPintervention and usual care were € 2,221 and € 2,448, respectively within the 1-year time horizon. This reflects cost savings of € 227 for the PHARMACOP-intervention. The PHARMACOP-intervention resulted in the prevention of 71 hospital-treated exacerbations (167 for PHARMACOP versus 238 for usual care), i.e. 0.07 (95%CI: 0.04-0.10) incremental hospital-treated exacerbations per patient. In addition, a small (<0.001 QALYs) increase in QALYs was observed. Results showed robust costsavings in various sensitivity analyses. Conclusions: Optimization of current pharmacotherapy (e.g. close monitoring of inhalation technique and medication adherence) has been shown to be cost-saving and should be considered before adding new therapies

Downstaging of TURBT-Based Muscle-Invasive Bladder Cancer by Radical Cystectomy Predicts Better Survival

Differences between clinical (cT) and pathological tumor (pT) stage occur often after radical cystectomy (RC) for muscle-invasive bladder cancer. In order to evaluate the impact of downstaging on recurrence and survival, we selected patients from a large, contemporary, population-based series of 1,409 patients with MIBC. We included all patients who underwent RC (N=643) and excluded patients who received (neo)adjuvant therapy, those with known metastasis at time of diagnosis, and those with nonurothelial cell tumors. Disease outcomes were defined as recurrence-free survival (RFS) and relative survival (RS), as a good approximation of bladder cancer-specific survival. After applying the exclusion criteria, 375 patients were eligible for analysis. Tumor downstaging was found to be common after RC; in 99 patients (26.4%), tumor downstaging to non-muscle-invasive stages at RC occurred. Hydronephrosis at baseline and positive lymph nodes at RC occurred significantly less often in these patients. In 62 patients, no tumor was left in the cystectomy specimen. pT stage was pT1 in 20 patients and pTis in 17 patients. Patients with tumor downstaging have about a 30% higher RFS and RS compared to those without. Consequently, tumor downstaging is a favorable marker for prognosis after RC

Renal tubular damage and worsening renal function in chronic heart failure:Clinical determinants and relation to prognosis (Bio-SHiFT study)

Background It is uncertain that chronic heart failure (CHF) patients are susceptible to renal tubular damage with that of worsening renal function (WRF) preceding clinical outcomes. Hypothesis Changes in tubular damage biomarkers are stronger predictors of subsequent clinical events than changes in creatinine (Cr), and both have different clinical determinants. Methods During 2.2 years, we repeatedly simultaneously collected a median of 9 blood and 8 urine samples per patient in 263 CHF patients. We determined the slopes (rates of change) of the biomarker trajectories for plasma (Cr) and urinary tubular damage biomarkers N-acetyl-beta-d-glucosaminidase (NAG), and kidney-injury-molecule (KIM)-1. The degree of tubular injury was ranked according to NAG and KIM-1 slopes: increase in neither, increase in either, or increase in both; WRF was defined as increasing Cr slope. The composite endpoint comprised HF-hospitalization, cardiac death, left ventricular assist device placement, and heart transplantation. Results Higher baseline NT-proBNP and lower eGFR predicted more severe tubular damage (adjusted odds ratio, adj. OR [95%CI, 95% confidence interval] per doubling NT-proBNP: 1.26 [1.07-1.49]; per 10 mL/min/1.73 m(2) eGFR decrease 1.16 [1.03-1.31]). Higher loop diuretic doses, lower aldosterone antagonist doses, and higher eGFR predicted WRF (furosemide per 40 mg increase: 1.32 [1.08-1.62]; spironolactone per 25 mg decrease: 1.76 [1.07-2.89]; per 10 mL/min/1.73 m(2) eGFR increase: 1.40 [1.20-1.63]). WRF and higher rank of tubular injury individually entailed higher risk of the composite endpoint (adjusted hazard ratios, adj. HR [95%CI]: WRF 1.9 [1.1-3.4], tubular 8.4 [2.6-27.9]; when combined risk was highest 15.0 [2.0-111.0]). Conclusion Slopes of tubular damage and WRF biomarkers had different clinical determinants. Both predicted clinical outcome, but this association was stronger for tubular injury. Prognostic effects of both appeared independent and additive

Dementia incidence trend over 1992-2014 in the Netherlands: analysis of primary care data

$\textbf{Background:}$ Recent reports have suggested declining age-specific incidence rates of dementia in high-income countries over time. Improved education and cardiovascular health in early age have been suggested to bring about this effect. The aim of this study was to estimate the age- specific dementia-incidence trend in primary care records from a large population in the Netherlands. $\textbf{Methods and findings:}$ A dynamic cohort representative of the Dutch population was composed using primary care records from general practice registration networks (GPRN) across the country. Data regarding dementia incidence were obtained using general practitioner-recorded diagnosis of dementia within the electronic health records. Age-specific dementia incidence rates were calculated for all persons aged 60 years and over; negative binomial regression analysis was used to estimate the time trend. Nine out of eleven GPRNs provided data on more than 800,000 older people between 1992 and 2014, corresponding to over 4 million person- years and 23,186 incident dementia cases. The annual growth in dementia incidence rate was estimated to be 2.1% (95%CI 0.5 to 3.8%), and incidence rates were 1.08 (95%CI 1.04 to 1.13) times higher for women compared to men. There was no significant overall change since the start of a national dementia program in 2003. Despite their relatively low numbers of person years, the highest age groups contributed most to the increasing trend. Increased awareness of dementia by patients and doctors in more recent years may have influenced dementia diagnosis in GPs’ electronic health records, and needs to be taken into account when interpreting the data. $\textbf{Conclusions:}$ Within the clinical records of a large, representative sample of the Dutch population, we found no evidence for a declining incidence trend of dementia in the Netherlands. This could indicate true stability in incidence rates, or a balance between increased detection and a true reduction. Irrespective of the exact rates and mechanisms underlying these findings, they illustrate that the burden of work for physicians and nurses in general practice associated with newly diagnosed dementia has not been subject to substantial change in the past two decades. Hence, with the ageing of Western societies, we still need to anticipate on a dramatic absolute increase of dementia occurrence over the years to come

Long-term cost-effectiveness of digital inhaler adherence technologies in difficult-to-treat asthma

BACKGROUND: Digital inhalers can monitor inhaler usage, support difficult-to-treat asthma management and inform step-up treatment decisions yet their economic value is unknown, hampering wide-scale implementation.OBJECTIVE: We aimed to assess the long-term cost-effectiveness of digital inhaler-based medication adherence management in difficult-to-treat asthma.METHODS: A model-based cost-utility analysis was performed. The Markov model structure was determined by biological and clinical understanding of asthma and was further informed by guideline-based assessment of model development. Internal and external validation was performed using the AdViSHE tool. The INCA Sun randomized clinical trial data were incorporated into the model to evaluate the cost-effectiveness of digital inhalers. Several long-term clinical case scenarios were assessed (reduced number of exacerbations, increased asthma control, introduction of biosimilars [25% price-cut on biologics]).RESULTS: The long-term modelled cost-effectiveness based on a societal perspective indicated 1-year per-patient costs for digital inhalers and usual care (i.e., regular inhalers) of €7,546 and €10,752, respectively, reflecting cost savings of €3,207 for digital inhalers. Using a 10-year intervention duration and time horizon resulted incost savings of €26,309 for digital inhalers. In the first year, add-on biologic therapies accounted for 69% of the total costs in the usual care group, and for 49% in the digital inhaler group. Scenario analyses indicated consistent cost savings ranging from €2,287 (introduction biosimilars) to €4,581 (increased control, decreased exacerbations).CONCLUSION: In patients with difficult-to-treat asthma, digital inhaler based interventions can be cost-saving on the long-term by optimizing medication adherence and inhaler technique and reducing add-on biologic prescriptions.</p

Myelosuppression by sunitinib is flt-3 genotype dependent

Personalised Therapeutic