Change In Treatment Policy Research Articles

North Carolina Medicaid System Perspectives on Substance Use Disorder Treatment Policy Changes During the COVID-19 Pandemic.

This study aimed to describe perspectives from stakeholders involved in the Medicaid system in North Carolina regarding substance use disorder (SUD) treatment policy changes during the coronavirus disease 2019 pandemic. We conducted semistructured interviews in early 2022 with state agency representatives, Medicaid managed care organizations, and Medicaid providers (n = 22) as well as 3 focus groups of Medicaid beneficiaries with SUD (n = 14). Interviews and focus groups focused on 4 topics: policies, meeting needs during COVID, demand for SUD services, and staffing. Overall, policy changes, such as telehealth and take-home methadone, were considered beneficial, with participants displaying substantial support for both policies. Shifting demand for services, staffing shortages, and technology barriers presented significant challenges. Innovative benefits and services were used to adapt to these challenges, including the provision of digital devices and data plans to improve access to telehealth. Perspectives from Medicaid stakeholders, including state organizations to beneficiaries, support the continuation of SUD policy changes that occurred. Staffing shortages remain a substantial barrier. Based on the participants' positive responses to the SUD policy changes made during the coronavirus disease 2019 pandemic, such as take-home methadone and telehealth initiation of buprenorphine, these changes should be continued. Additional steps are needed to ensure payment parity for telehealth services.

Low Prevalence of Antimalarial Resistance Mutations in India During 2014-2015: Impact of Combining First-line Therapy With Primaquine.

Antimalarial drug resistance surveillance and containment are crucial for countries aiming to eliminate malaria. Monitoring resistance evolution through studies before and after treatment policy changes is essential. A total of 939 Plasmodium falciparum-positive blood samples were collected between 2014 and 2015 across 10 sites in India, categorized into 4 geographic clusters. Polymerase chain reaction-amplified products were sequenced to identify point mutations at drug resistance-conferring genes (Pfdhfr, Pfdhps, Pfmdr1, and Pfk13). Triple Pfdhfr mutants were found only in northeast India bordering Myanmar, while the wild type (WT) was dominant in central India. Pfdhps WTs were prevalent in all areas, and no double mutants were found. Except in northwest India, Pfmdr1 WT was dominant in all clusters. Nonsynonymous double mutations were only found in northwest India. Only synonymous mutations occurred in Pfk13. These were found in central India at a low frequency. The pattern of linkage disequilibrium and principal component analysis reflects low pressure for drug resistance and heterogeneity between the geographic clusters. Resistance levels were highest in northeast India, close to the Myanmar border, where resistance is common. Primaquine has been widely used as a gametocidal and schizonticidal drug, likely contributing to maintaining low drug resistance levels and preventing strong selection for resistance.

Hypertension Control Status Among Patients Receiving Treatment From Selected Primary Health Centres in Puducherry: A Cohort-Analysis Approach.

High blood pressure (hypertension) is a major risk factor contributing to 60% of premature deaths caused by non-communicable diseases. In India, a mere 15% of the hypertensive population achieves optimal blood pressure control. Effective monitoring of hypertension is crucial for mitigating the morbidity and mortality associated with cardiovascular diseases. This study employed a cohort analysis approach to determine the control status of hypertension and identify factors associated with hypertension among individuals seeking care at selected primary health centres (PHCs) in Puducherry from January 2019 to December 2022. We assessed treatment records of 1127 patients with hypertension registered at PHCs in both urban and rural areas between 2019 and 2022. Information on socio-demographic details and blood pressure readings was collected to assess the control status of hypertension on a quarterly and six-monthly basis. Additionally, 436 patients were interviewed to identify factors associated with uncontrolled hypertension. Control rates of hypertension varied among PHCs on a quarterly and six-monthly basis. The rural PHC achieved the highest quarterly control rate of 80% in Q4 2020, while the urban PHC had the lowest rate of 44% in Q1 2020. Similarly, the highest six-monthly control rate of 78% was observed in Q3 2019 at both rural and urban PHCs, with the lowest rate of 44% in Q1 2020 at the urban PHC. Conclusion:Analysing data obtained from regular monitoring of hypertension control status allows healthcare providers to identify patterns, trends, and correlations. It assists providers in making informed decisions regarding treatment adjustments, medication choices, lifestyle recommendations, and policy changes. This approach is expected to improve control status for hypertension, leading to the ultimate goal of better health outcomes for patients.

Experiencing and treating ‘madness’ in the United States circa 1967–2022: Critical counter-histories

Over the past 55 years, in the United States, we have witnessed shifts and changes in mental health treatment practice and policy focused on ‘psychosis.’ Alarmingly, in this same period, neither in its social location nor its clinical outcomes, has psychosis, particularly multi-episode psychosis, shown much substantive improvement (Hansen et al., 2022; Huxley et al., 2021). Epidemiological studies of stigma have documented the worsening of perceived dangerousness and desired social distance (Pescosolido et al., 2010, 2019), while long-term trajectories include extraordinarily high rates of incarceration, homelessness, and unemployment (Lin et al., 2022; Ramsay et al., 2012; Wildeman and Wang, 2017). Disengagement from “services” viewed by users as unresponsive to the user's actual needs and values is thought to be part of the problem, although it is not clear that those who do engage do better (Hansen et al., 2022). Written from the first-person perspectives of current/former “users”—people who have experienced psychosis and “used” services—this paper leverages critical counter-history, conceptual analysis, and autoethnography to ask how and why treatment policies and practices continue to fail so many persons labelled with psychosis in the United States. Outcome, we argue, hangs on much more than clinical effort. We thus explain widespread “treatment failure” as a consequence of interpersonal misunderstanding and misrecognition as well as entrenched structural and institutional ableism, racism, and classism—factors to which clinical services and individualizing narratives alike consistently fail to adequately respond. On a more hopeful note, we trace histories of activist (user/survivor) resistance. This includes efforts that may appear fledgling or transient, but that have nevertheless sustained a distinctly different vision of what might be possible.

Malaria outbreak in Laos caused by formerly rare artemisinin resistant strains of Plasmodium falciparum

In The Lancet Infectious Diseases, Varanya Wasakul and colleagues1 employed genomic analysis to characterise an outbreak of Plasmodium falciparum infections in Laos. They show that the outbreak was driven by an artemisinin resistant lineage that infiltrated the community in southern Laos during the 2020–21 malaria season, coinciding with a change in treatment policy in neighbouring countries.

Medicaid Hepatitis C Virus Treatment Policies: Impact on Testing and Treatment in the Commercially Insured

A total of 23 state Medicaid programs continue to restrict hepatitis C virus (HCV) medication access by liver disease or substance-use criteria, creating obstacles to HCV elimination and significant care disparities. Because public insurers often set precedents for private insurer coverage and clinician practice patterns, this study sought to analyze whether spillover occurs from state Medicaid HCV treatment restrictions to HCV screening and treatment rates in commercially insured individuals. Investigators analyzed 2014‒2017 commercial claims data across 48 U.S. states (721,961,965 person-months) and used an interrupted times series design to compare hepatitis C virus screening and treatment rates before and after state Medicaid HCV treatment policy changes, adjusting for state-level random effects, Medicaid expansion status, and state drug overdose incidence rates, in states that relaxed Medicaid policy over the study period. Analysis occurred during 2019‒2021. Hepatitis C virus screening rates among commercially insured individuals increased after the corresponding state Medicaid program relaxed HCV treatment policy. Among states that changed Medicaid policy, those that reduced fibrosis or both fibrosis and abstinence restrictions experienced increased HCV screening rates by the study end compared with states that changed only abstinence restrictions (rate ratio=1.29; 95% CI=1.15, 1.44; and rate ratio=1.32; 95% CI=1.17, 1.50, respectively). Similar patterns did not occur in HCV treatment rates, which declined after 2015 across groups. These data show that HCV screening rates increased among commercially insured individuals after the removal of Medicaid HCV treatment restrictions in the same state. This suggests that Medicaid treatment policies can spill over to affect health outcomes among commercially insured populations.

Additional clinical value of routine CT imaging in fragility fractures of the pelvis: a prospective cohort study (ARTIFACT).

Additional CT imaging for fragility fractures of the pelvis (FFP) has a high detection rate for concomitant posterior ring fractures (cPRFs). However, the clinical value of routine additional CT imaging is unknown. This study aimed to determine the additional clinical value of routine CT imaging by changes in treatment policy and to establish the predictive value of pain localized around the sacroiliac joint (SIJ) for cPRFs. A prospective cohort study was conducted in a single teaching hospital in the Netherlands between November 2019 and November 2020. Patients were included if they were ≥ 65years and had a (suspected) FFP on the pelvic radiograph. All patients underwent additional CT imaging. Changes in treatment policies ((possible) surgery, restrictive weight-bearing, hospital admission and outpatient follow-up) after CT imaging were registered. Fifty-one patients (44 female) were included with a mean age of 80.6years. Routine CT imaging revealed an additional cPRF in 27 patients (53%). A change in treatment occurred in 29 patients (57%), of which 7 (12%) were managed either surgical or with restrictive weight-bearing. The presence of pain around the SIJ had a sensitivity of 89% and specificity of 61% for detecting a cPRF. Routine additional CT imaging has few direct therapeutic consequences with regards to surgical management or restrictive weight-bearing. These findings may be altered when considering a lower threshold for surgical intervention. The presence of pain around the SIJ was highly predictive for a clinically relevant cPRF. NL8011 on 02-09-2019.

Modelling Botswana's HIV/AIDS response and treatment policy changes: Insights from a cascade of mathematical models.

The management of HIV/AIDS has evolved ever since advent of the disease in the past three decades. Many countries have had to revise their policies as new information on the virus, and its transmission dynamics emerged. In this paper, we track the changes in Botswana's HIV/AIDS response and treatment policies using a piece-wise system of differential equations. The policy changes are easily tracked in three epochs. Models for each era are formulated from a "grand model" that can be linked to all the epochs. The grand model's steady states are determined and analysed in terms of the model reproduction number, $ R_{0}. $ The model exhibits a backward bifurcation, where a stable disease-free equilibrium coexists with a stable endemic equilibrium when $ R_{0} < 1. $ The stability of the models for the other epochs can be derived from that of the grand model by setting some parameters to zero. The models are fitted to HIV/AIDS prevalence data from Botswana for the past three decades. The changes in the populations in each compartment are tracked as the response to the disease and treatment policy changed over time. Finally, projections are made to determine the possible trajectory of HIV/AIDS in Botswana. The implications of the policy changes are easily seen, and a discussion on how these changes impacted the epidemic are articulated. The results presented have crucial impact on how policy changes affected and continue to influence the trajectory of the HIV/AIDS epidemic in Botswana.

Current guidelines for malaria treatment in Somalia: evidence-based recommendations

Case management – rapid diagnosis and prompt administration of artemisinin-based combination therapy (ACT) – is a fundamental pillar of recommended malaria interventions in Somalia. Unfortunately, the emergence and spread of drug resistant falciparum parasites continues to pose a considerable threat to effective case management. With technical and financial support from WHO, the efficacy of recommended ACTs has been regularly monitored in sentinel sites since 2003. These studies provided evidence that supported the adoption of artesunate-sulfadoxine/pyrimethamine as first-line treatment in 2005 and artemether-lumefantrine as second-line treatment in 2011. Efficacy studies conducted between 2011 and 2015 showed high artesunate-sulfadoxine/pyrimethamine treatment failure rates of 12.3% - 22.2%, above the threshold (10%) for a change of treatment policy as recommended by WHO. This was also associated with high prevalence of quadruple and quintuple mutations in the dihydrofolate reductase (Pfdhfr) and dihydropteroate synthase (Pfdhps) genes, which are associated with sulfadoxine/pyrimethamine resistance. Based on these findings, national malaria treatment guidelines were updated in 2016, with artesunate-sulfadoxine/pyrimethamine replaced by artemether-lumefantrine as first-line treatment and dihydroartemisinin-piperaquine recommended as second-line treatment. Subsequent efficacy studies in 2016 and 2017 confirmed that both the current first- and second-line treatments remain highly efficacious (cure rate above 97%). Technical and financial support from WHO has been instrumental in generating evidence that informs malaria treatment policy and should therefore continue to ensure that effective treatments are available to malaria patients in the country.

Usefulness and safety of midline incision for right-sided hepatectomy: Cohort study

BackgroundWhile the adoption rates of laparoscopic hepatectomy are increasing, most patients still undergo open hepatectomy. Open hepatectomies use inverted L-shaped or Mercedes incisions for right-sided liver tumor. To decrease procedural invasiveness, we performed midline incisions in such cases, excluding those of laparoscopic hepatectomy. This retrospective study examined the effects of this change in treatment policy on overall patient surgical outcomes. Materials and methodsFrom 2012 to 2018, 374 patients who underwent hepatectomy for right-sided hepatocellular carcinoma were enrolled, and short-term patient outcomes were compared following stratification into the 1st (n = 157) or 2nd (n = 217) Era group based on whether procedures occurred before or after the policy change, respectively. ResultsShort-term outcomes were mostly comparable between the two groups, with significantly increased postoperative aspartate aminotransferase maximum values found in the 2nd Era group relative to the 1st Era group (median: 393 vs. 331, p < 0.05). Pain scores at rest during postoperative day 1 and while moving on postoperative days 1, 2, and 3 were significantly lower in the 2nd Era group than in the 1st Era group (p < 0.05, <0.01, <0.05, <0.01, respectively). ConclusionsUtilization of midline incisions may provide some benefits in postoperative outcomes for right-sided open hepatectomy cases.

Malaria prevention and treatment awareness and practice among patent medicine vendors (PMVs) in Gombe Metropolis, Nigeria

The ravaging consequences of Malaria in Sub-Saharan Africa (SSA) have been a subject of serious concern to every stakeholder. Literature and anecdotal evidence shows that around 60% of Nigerians seek fever treatment from Patent Medicine Vendors (PMVs) despite the limited formal dispensing knowledge most possess. This study attempts to establish a base line of knowledge, attitude and practices of Malaria control among PMVs in Gombe Metropolis, North Eastern Nigeria. The study was a descriptive cross sectional survey based on structured questionnaires used to collect relevant information from 109 PMVs selected by purposive sampling technique. The result show that 85.3% of the participants in this study correctly identified fever or high body temperature as the common sign of uncomplicated (UC) Malaria, while 70.6% recognized convulsion as one of the main symptoms of severe Malaria. Furthermore, 86.2% of the PMVs also knew that sleeping inside treated nets constitute one of the best ways to prevent Malaria. In the same vein, awareness of change in Malaria treatment policy from monotherapy to Artemisinin based combination therapy (ACT) was high (73.3%) among them. However, those PMVs that had ever undergone some degree of drug dispensing training exhibited a significantly higher level of awareness of change in malaria treatment policy (X2 =17.903, P = 0.000). Although 85.3% of PMVs frequently recommend Arthemeter Lumefantrine (AL) as treatment of uncomplicated Malaria, only 39.4% of the participants would refer severe malaria cases. Even though most Malaria control awareness and practice variables were found to be fairly good among the participants, it is clear from the study that there is the need for enhanced training, monitoring and supervision by the relevant authorities so as to fully harness the vast potential in PMVs.

Electron beam intraoperative radiotherapy for metastatic epidural spinal cord compression: a prospective observational study.

To assess the additional effects of intraoperative radiotherapy (IORT) with decompression surgery and adjuvant external beam radiotherapy (EBRT) for metastatic epidural spinal cord compression (MESCC).This single-arm institutional prospective observational study recruited patients between June 2017 and March 2020 and included those with symptoms of spinal cord compression owing to metastases, who were diagnosed using MRI. Patients with radiation-sensitive primary tumors and those who could not tolerate surgery were excluded. The treatment protocol comprised decompression surgery and electron beam IORT of 20 Gy in a single fraction followed by EBRT of 30 Gy in 10 fractions. The primary endpoints included the 1-year local failure rate and ambulatory functions.The study was closed in May 2019 owing to changes in treatment policies at our institution. Twenty patients were registered between June 2017 and May 2019. Although all patients completed surgery and IORT, 2 did not receive postoperative EBRT. Patients most commonly had colorectal cancer (4 patients), followed by thyroid cancer, renal cell carcinoma, lung cancer, breast cancer, sarcomas, and other cancers (3, 3, 2, 2, 2, and 4 patients, respectively). The median follow-up duration was 16 months (range 2-30 months); the 1-year local failure rate was 16%. On comparing ambulatory functions pre-treatment and at 1 year after treatment, improvement, no change, and worsening were observed in 3, 9, and 0 patients, respectively.This study's findings suggest that decompression surgery and IORT followed by EBRT are effective in achieving local control and maintaining ambulation in patients with MESCC.

Co-use of methamphetamine and opioids among people in treatment in Oregon: A qualitative examination of interrelated structural, community, and individual-level factors

BackgroundRates of methamphetamine use and methamphetamine-related deaths have increased steadily in the United States in recent years. Methamphetamine is increasingly present in opioid-related deaths. An initial study of de-identified urine specimens (n = 102) collected at a drug treatment program between 2017 and 2018 indicated that 61% of specimens contained methamphetamine; of the specimens containing methamphetamine, people were, on average, five years younger than those who tested negative for methamphetamine; and non-fentanyl opioids were more than three times as common in methamphetamine positive specimens. The National Drug Early Warning System (NDEWS) Coordinating Center initiated a HotSpot Study to assess whether there was an emerging dynamic in the area, or if enhanced data collection could give insights into the co-use of methamphetamine and opioids. MethodsA qualitative study, grounded in principles of rapid ethnographic assessment and a social science/anthropological framework was conducted and used methodological complementarity to contextualize results from the initial urinalysis study. Targeted sampling was conducted at two treatment sites. Program staff and patients were recruited to participate in focus groups and semi-structured interviews to assess structural, community, and individual-level factors impacting methamphetamine and opioid co-use. ResultsWithin our broader framework of structural, community, and individual-level factors intersecting co-use, our data yielded three sub-themes: 1) the circulation of stigma regarding methamphetamine use was consistently described by both patients and staff and this intersected structural changes in treatment policy and suggested compounded stigma; 2) community-level factors and temporality were important for understanding patterns of methamphetamine use and for further interpreting the initial urinalysis; 3) patient rationales regarding the co-use of methamphetamine and opioids included strategies to mitigate the harms of heroin, as well as to detox or titrate the effects of heroin. Conclusion and implicationsUsing an ethnographically-oriented and social science/anthropological approach and methodological complementarity to contextualize the prior urinalysis study demonstrates how behavioral variables cannot be abstracted from larger socio-structural and community contexts which impact people's decision-making process regarding co-use of methamphetamine and opioids. Further, by grounding our analysis in the meaning-centered and experiential narratives of people who use drugs, our research demonstrates the importance of considering the expertise of people who co-use opioids and methamphetamine as central for informing future sustainable program planning to address co-use that also accounts for the interrelationship between structural, community, and individual-level factors.

Compulsory and voluntary drug treatment models in China: A need for improved evidence-based policy and practice to reduce the loaded burden of substance use disorders

In China, the majority of people who use drugs (PWUD) identified by authorities are admitted to compulsory isolated detoxification centers in which their treatment is administered by administrative and judicial systems that restrict their freedom. China's compulsory isolated detoxification centers have been criticized as an abuse of human rights. The two other primary models of drug treatment in China include community-based treatment and medically-oriented voluntary treatment. This article presents an overview of the three primary treatment models for PWUD currently practiced in China. The existing compulsory and voluntary treatment models predominantly operate separately from each other, and lack evidence-based guidelines. A drug treatment system that embraces social support, psychosocial interventions and well-qualified health-based workforce is currently lacking. We propose that China needs to employ a localized model that is composed of well-facilitated and evidence-based treatment methods for both compulsory and voluntary treatment for PWUD to reduce the burden of illicit drug use. The implementation of these models of care, however, need to be tailored to the country's historical background, large population of PWUD and cultural settings in order to succeed. Urgent changes in drug treatment policies and practices are needed by the Chinese governments at different levels, organizations and front-line practitioners if we are to see a reduction in the incidence and impact of harms related to substance use in China.

Adoption of evidence-based global policies at the national level: intermittent preventive treatment for malaria in pregnancy and first trimester treatment in Kenya, Malawi, Mali and The Gambia.

In 2012, the World Health Organization (WHO) updated its policy on intermittent preventive treatment in pregnancy with sulphadoxine–pyrimethamine (IPTp-SP). A global recommendation to revise the WHO policy on the treatment of malaria in the first trimester is under review. We conducted a retrospective study of the national policy adoption process for revised IPTp-SP dosing in four sub-Saharan African countries. Alongside this retrospective study, we conducted a prospective policy adoption study of treatment of first trimester malaria with artemisinin combination therapies (ACTs). A document review informed development and interpretation of stakeholder interviews. An analytical framework was used to analyse data exploring stakeholder perceptions of the policies from 47 in-depth interviews with a purposively selected range of national level stakeholders. National policy adoption processes were categorized into four stages: (1) identify policy need; (2) review the evidence; (3) consult stakeholders and (4) endorse and draft policy. Actors at each stage were identified with the roles of evidence generation; technical advice; consultative and statutory endorsement. Adoption of the revised IPTp-SP policy was perceived to be based on strong evidence, support from WHO, consensus from stakeholders; and followed these stages. Poor tolerability of quinine was highlighted as a strong reason for a potential change in treatment policy. However, the evidence on safety of ACTs in the first trimester was considered weak. For some, trust in WHO was such that the anticipated announcement on the change in policy would allay these fears. For others, local evidence would first need to be generated to support a change in treatment policy. A national policy change from quinine to ACTs for the treatment of first trimester malaria will be less straightforward than experienced with increasing the IPTp dosing regimen despite following the same policy processes. Strong leadership will be needed for consultation and consensus building at national level.

Health systems readiness and quality of inpatient malaria case-management in Kano State, Nigeria

BackgroundNigeria was among the first African countries to adopt and implement change of treatment policy for severe malaria from quinine to artesunate. Seven years after the policy change health systems readiness and quality of inpatient malaria case-management practices were evaluated in Kano State of Nigeria.MethodsA cross-sectional survey was undertaken in May 2019 at all public hospitals. Data collection comprised hospital assessments, interviews with inpatient health workers and data extraction from medical files for all suspected malaria patients admitted to the paediatric and medical wards in April 2019. Descriptive analyses included 22 hospitals, 154 health workers and 1,807 suspected malaria admissions analysed from malaria test and treat case-management perspective.Results73% of hospitals provided malaria microscopy, 27% had rapid diagnostic tests and 23% were unable to perform any parasitological malaria diagnosis. Artemisinin-based combination therapy (ACT) was available at 96% of hospitals, artemether vials at 68% while injectable quinine and artesunate were equally stocked at 59% of hospitals. 32%, 21% and 15% of health workers had been exposed to relevant trainings, guidelines and supervision respectively. 47% of suspected malaria patients were tested while repeat testing was rare (7%). 60% of confirmed severe malaria patients were prescribed artesunate. Only 4% of admitted non-severe test positive cases were treated with ACT, while 76% of test negative patients were prescribed an anti-malarial. Artemether was the most common anti-malarial treatment for non-severe test positive (55%), test negative (43%) and patients not tested for malaria (45%). In all categories of the patients, except for confirmed severe cases, artemether was more commonly prescribed for adults compared to children. 44% of artesunate-treated patients were prescribed ACT follow-on treatment. Overall compliance with test and treat policy for malaria was 13%.ConclusionsTranslation of new treatment policy for severe malaria into inpatient practice is compromised by lack of malaria diagnostics, stock-outs of artesunate and suboptimal health workers’ practices. Establishment of the effective supply chain and on-going supportive interventions for health workers accompanied with regular monitoring of the systems readiness and clinical practices are urgently needed.

Cancer Patient Satisfaction and Perception of Chemotherapy Services During COVID-19 Pandemic in Central Java, Indonesia

Background: The COVID-19 pandemic affects all healthcare services, including cancer care. Consequently, our institution implemented several changes in accordance with the National guidelines for managing COVID-19 transmission. However, the patients’ perception of such changes is unknown. The objective of this study is to explore the knowledge of cancer patients on COVID-19, their perceptions towards the changes in oncology service, and to identify key elements that contribute to their level of anxiety or comfort. Methods: Written questionnaires were given out to cancer patients indicated or undergoing chemotherapy between 23rd June and 3rd July 2020 in a tertiary referral hospital. Data collection was performed 75 days after the implementation of hospital and oncology services changes in response to COVID-19. Results: A total of 221 cancer patients participated in this study. The majority of patients possess adequate knowledge and practice appropriate preventive actions. They expressed a positive attitude towards the changes in hospital policies and contented with the consistency of chemotherapy services. The television and internet (social media, communication apps) were the main sources of information for the patient.Conclusion: Our institution managed to maintain the consistency of chemotherapy services, despite the implementation of several changes in hospital and treatment policies. With adequate education, patients can remain content and express a positive attitude towards the changes in their treatment experience. Both health care personnel and policymakers should consistently be updated with the continuous surge of publications regarding COVID-19 and adjust their decisions with the best evidence-based practice.

Nested g-computation: A causal approach to analysis of censored medical costs in the presence of time-varying treatment.

Rising medical costs are an emerging challenge in policy decisions and resource allocation planning. When cumulative medical cost is the outcome, right-censoring induces informative missingness due to heterogeneity in cost accumulation rates across subjects. Inverse-weighting approaches have been developed to address the challenge of informative cost trajectories in mean cost estimation, though these approaches generally ignore post-baseline treatment changes. In post-hysterectomy endometrial cancer patients, data from a linked database of Medicare records and the Surveillance, Epidemiology, and End Results program of the National Cancer Institute reveal substantial within-subject variation in treatment over time. In such a setting, the utility of existing intent-to-treat approaches is generally limited. Estimates of population mean cost under a hypothetical time-varying treatment regime can better assist with resource allocation when planning for a treatment policy change; such estimates must inherently take time-dependent treatment and confounding into account. In this paper, we develop a nested g-computation approach to cost analysis to address this challenge, while accounting for censoring. We develop a procedure to evaluate sensitivity to departures from baseline treatment ignorability. We further conduct a variety of simulations and apply our nested g-computation procedure to two-year costs from endometrial cancer patients.

Predicting the future distribution of antibiotic resistance using time series forecasting and geospatial modelling

Background: Increasing antibiotic resistance in a location may be mitigated by changes in treatment policy, or interventions to limit transmission of resistant bacteria. Therefore, accurate forecasting of the distribution of antibiotic resistance could be advantageous. Two previously published studies addressed this, but neither study compared alternative forecasting algorithms or considered spatial patterns of resistance spread. Methods: We analysed data describing the annual prevalence of antibiotic resistance per country in Europe from 2012 – 2016, and the quarterly prevalence of antibiotic resistance per clinical commissioning group in England from 2015 – 2018. We combined these with data on rates of possible covariates of resistance. These data were used to compare the previously published forecasting models, with other commonly used forecasting models, including one geospatial model. Covariates were incorporated into the geospatial model to assess their relationship with antibiotic resistance. Results: For the European data, which was recorded on a coarse spatiotemporal scale, a naïve forecasting model was consistently the most accurate of any of the forecasting models tested. The geospatial model did not improve on this accuracy. However, it did provide some evidence that antibiotic consumption can partially explain the distribution of resistance. The English data were aggregated at a finer scale, and expected-trend-seasonal (ETS) forecasts were the most accurate. The geospatial model did not significantly improve upon the median accuracy of the ETS model, but it appeared to be less sensitive to noise in the data, and provided evidence that rates of antibiotic prescription and bacteraemia are correlated with resistance. Conclusion: Annual, national-level surveillance data appears to be insufficient for fitting accurate antibiotic resistance forecasting models, but there is evidence that data collected at a finer spatiotemporal scale could be used to improve forecast accuracy. Additionally, incorporating antibiotic prescription or consumption data into the model could improve the predictive accuracy.

OR34-04 Efficiency of Adrenal Venous Sampling in the Treatment Choice of Primary Aldosteronism (AVSTAT Study)

BACKGROUND: Adrenal venous sampling (AVS) is strongly recommended for a subtype diagnosis of primary aldosteronism (PA) if adrenalectomy (ADX) is desired by the patient. Given various issues related to AVS such as technical demand, invasive nature, expensive cost and radiation exposure, AVS is expected to lead efficiently to the subtype diagnosis and ADX. Aim: Primary objective was to assess the performance of AVS to determine treatment of PA by investigating the ratio of unilateral disease and rate of ADX following AVS in patients with unilateral disease. Methods: Sixteen major referral centers in ENS@T (n=10) and Japan (n=6) participated in the study. Study period was from 2006 to 2018. Data on total number of PA patients, AVS (total number and number of successful procedures), number of patients with unilateral diseases, and number of patients that underwent ADX were collected by a questionnaire-based survey. In addition, reasons for not proceeding to ADX in patients with a unilateral diagnosis were investigated. The diagnosis of PA was based on the positive case detection and at least one positive result in confirmatory testing. Results: Total number of confirmed PA patients and conducted AVS showed a dramatic increase during the past decade (PA: 1061 pts/ 2006–2011 to 3718 pts/ 2012–2018; AVS: 720/ 2006–2011 to 2448/ 2012–2018). Success rate of AVS was improved from 79.0% (2006–2011) to 92.5% (2012–2018). Both rate of unilateral PA and ADX of successful procedures decreased from 42.7% (2006–2011) to 37.3% (2012–2018) and from 40.8% (2006–2011) to 34.9% (2012–2018), respectively. Of the patients with successful AVS, bilateral disease was diagnosed in 63.5% (1812/2854 pts). Of the unilateral PA patients, 11.9% (125/ 1054 pts) were not subjected to ADX. The rate of the patients not subjected to ADX was significantly higher in Japan than in ENS@T centers both in patients with successful AVS (75.8% vs. 53.4%) and with unilateral disease (19.9% vs. 8.6%). Clinical decision against ADX in unilateral disease was made by the physicians in 33.3%, the patients in 33.3%, and both in 33.3%. Medical factors for Dr.’s decision against ADX in unilateral disease included good blood pressure control, normokalemia, comorbidities (e.g. DM, CKD), non-lateralized CT findings (e.g. no tumor, contralateral tumor), and discordant results among different criteria of AVS.Conclusions: High prevalence of bilateral disease and change of treatment policy after implementation affected the efficiency of AVS as an essential diagnostic procedure prior to ADX. Development of non-invasive procedures to exclude bilateral PA and more strict indication of AVS are warranted.