Decrease In Medication Use Research Articles

Radiofrequency Ablation of the Superior Cluneal Nerve: A Novel Minimally Invasive Approach Adopting Recent Anatomic and Neurosurgical Data.

Objectives/IntroductionSuperior cluneal neuralgia (SCN) is a distinct cause of lower back and/or leg pain related to pathology of the superior cluneal nerve (SCn). SCN has been termed pseudo-sciatica and is an overlooked differential diagnosis when patients are otherwise presenting with low back and/or radicular pain. Radiofrequency ablation (RFA) is commonly used for denervation of the medial branches of the dorsal root for facet joint syndrome for sacroiliac joint; however, RFA has not been described to ablate the SCn for SCN. Herein, we present a novel interventional minimally invasive approach using RFA of the SCn for SCN in a series of 46 patients.MethodsInstitutional review board approved retrospective chart review was used to collect data for all SCn RFA cases from January 1, 2018, to February 8, 2021. Fluoroscopically guided SCn ablations were performed for patients with a positive “iliac crest point sign,” reproductive of their back and leg pain during physical examination. Sensory stimulation was utilized to confirm RF cannula-probe placement adjacent to the SCn, and motor testing was used to confirm no distal motor response prior to monopolar RF ablation with a Halyard RF Generator (100 mm curved 22G 10 mm active tip RF cannulae). Charts were reviewed for time of analgesia follow-up, duration and degree of analgesia, improvements in patients’ functional capacity, and changes in medication.ResultsData were reviewed for 51 patients who underwent Scn RFA, 5 of which were lost to follow-up. The remaining 46 patients consisted of 29 women and 17 men with a mean age of 59.4 years; 78.3% (n = 36) had ongoing relief at a mean of 92.1 days follow-up, ranging from 13 to 308 days, with a mean of 92.3% analgesia (SD 15.0%). At a mean of 111.2 days of follow-up, ranging from 42–201 days, 21.7% (n = 10) of patients reported that their pain had returned and had 95% analgesia during that time period (SD 6.7%); 41.3% (n = 19) reported improved activity/gait, 17.4% reported improved mood (n = 8), and 8.7% reported decreased medication use (n = 4). Five patients had minor complications including bruising (1), 2–3 days of soreness on site (2), myofascial pain (1), and quadratus lumborus muscle spasm relieved with trigger point injection (1).ConclusionsThis is the first report of both technique and outcomes for radiofrequency ablation of superior cluneal neuralgia. This series suggests that RFA of the SCn is a suitable intervention for the treatment of SCN; 21.7% of patients reported a mean of 95% analgesia for a mean duration of 111.2 days, and the remaining 78.3% of patients reported ongoing relief with a mean of 92.3% analgesia at last follow-up (mean 92.1 days). There were no serious adverse events.

Controller Medication Use and Exacerbations for Children and Adults With Asthma in High-Deductible Health Plans

To examine the association between enrollment in high-deductible health plans (HDHPs) and asthma controller medication use and exacerbations.A longitudinal cohort of children (4–17 years old) and adults (18–64 years old) on employer-sponsored insurance, who had at least 24 months of continuous insurance enrollment.Identified from a national administrative claims database in the United States, patients with persistent asthma were selected, and their insurance was categorized as a HDHP, defined as an annual individual deductible of ≥$1000, or a traditional plan, with deductibles of $0–500. Enrollees in a HDHP were only those who switched from a traditional plan after 12 months to a HDHP for the following 12 months. A differences-in-differences analyses design was used to compare outcomes between patients who switched to a HDHP to that of controls, who remained in a traditional plan for the 24 months. Outcomes included controller medication fills, adherence, and asthma exacerbations.The study sample included 7275 children and 17 614 adults with HDHPs. In the differences-in-differences analyses among children, there were no differences in controller medical fill rates, except for a significant reduction in fills for inhaled corticosteroid (ICS) and long-acting beta-agonist (LABA) (−0.04; 95% confidence interval: −0.07 to −0.01). There were also no significant changes in the proportion of days covered by a controller medication (ie, adherence measure), steroid bursts, or asthma-related ED visits, comparing children with HDHPs to controls. Among adults with HDHPs, there were also no significant differences in outcomes.The findings are consistent with previous adult studies that revealed that enrollment in HDHPs have minimal to no decrease in medication use and without significant changes in health outcomes. The authors think this is partly due to HDHPs exempting medications, like asthma controller medications, from deductibles. These medications are instead paid in a copayment arrangement.This insurance policy approach reveals that HDHPs can be designed to support affordable coverage but also preserve necessary asthma care for patients.

Allergic Rhinitis: What Do We Know About Allergen-Specific Immunotherapy?

Allergic rhinitis (AR) is an IgE-mediated disease that is characterized by Th2 joint inflammation. Allergen-specific immunotherapy (AIT) is indicated for AR when symptoms remain uncontrolled despite medication and allergen avoidance. AIT is considered to have been effective if it alleviated allergic symptoms, decreased medication use, improved the quality of life even after treatment cessation, and prevented the progression of AR to asthma and the onset of new sensitization. AIT can be administered subcutaneously or sublingually, and novel routes are still being developed, such as intra-lymphatically and epicutaneously. AIT aims at inducing allergen tolerance through modification of innate and adaptive immunologic responses. The main mechanism of AIT is control of type 2 inflammatory cells through induction of various functional regulatory cells such as regulatory T cells (Tregs), follicular T cells (Tfr), B cells (Bregs), dendritic cells (DCregs), innate lymphoid cells (IL-10+ ILCs), and natural killer cells (NKregs). However, AIT has a number of disadvantages: the long treatment period required to achieve greater efficacy, high cost, systemic allergic reactions, and the absence of a biomarker for predicting treatment responders. Currently, adjunctive therapies, vaccine adjuvants, and novel vaccine technologies are being studied to overcome the problems associated with AIT. This review presents an updated overview of AIT, with a special focus on AR.

Trigger Site Deactivation Surgery for Headaches is Associated with Decreased Postoperative Medication Use.

Background:Patients with chronic headaches suffer debilitating pain, which often leads to the use of numerous medications. Trigger site deactivation surgery has emerged as an effective treatment for select headache patients. This study aims to describe the preoperative and postoperative medication use among patients undergoing trigger site deactivation.Methods:One-hundred sixty patients undergoing trigger site deactivation surgery between September 2012 and November 2017 were prospectively enrolled. Information on medication use, including type, dose, and frequency of use, was collected. Follow-up surveys were sent to all patients 12 months postoperatively.Results:One-hundred twenty-nine patients met the inclusion criteria. At the time of screening, 96% of patients described taking prescription medication for their headache pain. The type of medication varied among patients but included preventative in 55%, abortive in 52%, rescue in 54%, and antiemetic in 18%. Thirty-one percent of patients reported using opioid medication for their headache pain. At 12 months postoperatively, 68% of patients reported decreased prescription medication use. Patients reported a 67% decrease in the number of days they took medication. Twenty-three percent stopped medications altogether. Fifty percent of patients reported that their migraine medication helped them more compared with preoperatively.Conclusions:Trigger site deactivation surgery has been associated with improvements in headache symptoms. We now show that it is also associated with a significant decrease in medication use.

Music Intervention: Nonpharmacologic Method to Reduce Pain and Anxiety in Adult Patients Undergoing Bone Marrow Procedures.

Bone marrow procedures cause anxiety and pain in adult patients with cancer. Music is a safe, inexpensive, noninvasive intervention that is easy to implement and is well received by patients and providers. The purpose of this quality improvement project was to develop, implement, evaluate, and sustain a music protocol during bone marrow biopsy and aspiration procedures for adult patients with hematologic malignancies. In addition, this project sought to decrease pain, anxiety, heart rate, and blood pressure in patients undergoing bone marrow procedures. The project coordinator collected baseline data regarding toleration of bone marrow procedures and then implemented a music protocol during the procedures during a six-month intervention phase. Comparison variables included pain, anxiety, heart rate, blood pressure, and subjective impressions. The music protocol resulted in improved patient anxiety, decreased procedure time, and decreased medication use during bone marrow procedures. All patients who used the music intervention indicated they would use it again.

Controller Medication Use and Exacerbations for Children and Adults With Asthma in High-Deductible Health Plans

High-deductible health plans (HDHPs) are increasingly common and associated with decreased medication use in some adult populations. How children are affected is less certain. To examine the association between HDHP enrollment and asthma controller medication use and exacerbations. For this longitudinal cohort study with a difference-in-differences design, data were obtained from a large, national, commercial (and Medicare Advantage) administrative claims database between January 1, 2002, and December 31, 2014. Children aged 4 to 17 years and adults aged 18 to 64 years with persistent asthma who switched from traditional plans to HDHPs or remained in traditional plans (control group) by employer choice during a 24-month period were identified. A coarsened exact matching technique was used to balance the groups on characteristics including employer and enrollee propensity to have HDHPs. In most HDHPs, asthma medications were exempt from the deductible and subject to copayments. Statistical analyses were conducted from August 13, 2019, to January 19, 2021. Employer-mandated HDHP transition. Thirty-day fill rates and adherence (based on proportion of days covered [PDC]) were measured for asthma controller medications (inhaled corticosteroid [ICS], leukotriene inhibitors, and ICS long-acting β-agonists [ICS-LABAs]). Asthma exacerbations were measured by rates of oral corticosteroid bursts and asthma-related emergency department visits among controller medication users. The HDHP group included 7275 children (mean [SD] age, 10.8 [3.3] years; 4402 boys [60.5%]; and 5172 non-Hispanic White children [71.1%]) and 17 614 adults (mean [SD] age, 41.1 [13.4] years; 10 464 women [59.4%]; and 12 548 non-Hispanic White adults [71.2%]). The matched control group included 45 549 children and 114 141 adults. Compared with controls, children switching to HDHPs experienced significant absolute decreases in annual 30-day fills only for ICS-LABA medications (absolute change, -0.04; 95% CI, -0.07 to -0.01). Adults switching to HDHPs did not have significant reductions in 30-day fills for any controllers. There were no statistically significant differences in PDC, oral steroid bursts, or asthma-related emergency department visits for children or adults. For the 9.9% of HDHP enrollees with health savings account-eligible HDHPs that subjected medications to the deductible, there was a significant absolute decrease in PDC for ICS-LABA compared with controls (-4.8%; 95% CI, -7.7% to -1.9%). This cohort study found that in a population where medications were exempt from the deductible for most enrollees, HDHP enrollment was associated with minimal or no reductions in controller medication use for children and adults and no change in asthma exacerbations. These findings suggest a potential benefit from exempting asthma medications from the deductible in HDHPs.

Prenatal medication use in a prospective pregnancy cohort by pre-pregnancy obesity status

Background The association between obesity (body mass index (BMI) ≥ 30 kg/m2) and pattern of medication use during pregnancy in the United States is not well-studied. Higher pre-pregnancy BMI may be associated with increases or decreases in medication use across pregnancy as symptoms (e.g. reflux) or comorbidities (e.g. gestational diabetes) requiring treatment that may be associated with higher BMI could also change with advancing gestation. Objectives To determine whether prenatal medication use, by the number and types of medications, varies by pre-pregnancy obesity status. Methods In a secondary data analysis of a racially/ethnically diverse prospective cohort of pregnant women with low risk for fetal abnormalities enrolled in the first trimester of pregnancy and followed to delivery (singleton, 12 United States clinical sites), free text medication data were obtained at enrollment and up to five follow-up visits and abstracted from medical records at delivery. Results In 436 women with obesity and 1750 women without obesity (pre-pregnancy BMI, 19–29.9 kg/m2), more than 70% of pregnant women (77% of women with and 73% of women without obesity) reported taking at least one medication during pregnancy, respectively (adjusted risk ratio (aRR)=1.10, 95% confidence interval (CI)=1.01, 1.20), with 81% reporting two and 69% reporting three or more. A total of 17 classes of medications were identified. Among medication classes consumed by at least 5% of all women, the only class that differed between women with and without obesity was hormones and synthetic substitutes (including steroids, progesterone, diabetes, and thyroid medications) in which women with obesity took more medications (11 vs. 5%, aRR = 1.9, 95% CI = 1.38, 2.61) compared to women without obesity. Within this class, a higher percentage of women with obesity took diabetes medications (2.3 vs. 0.7%) and progesterone (3.4 vs. 1.3%) than their non-obese counterparts. Similar percentages of women with and without obesity reported consuming medications in the remaining medication classes including central nervous system agents (50 and 46%), gastrointestinal drugs (43 and 40%), anti-infective agents (23 and 21%), antihistamines (20 and 17%), autonomic drugs (10 and 9%), and respiratory tract agents (7 and 6%), respectively (p > 0.05 for all adjusted comparisons). There were no differences in medication use by obesity status across gestation. Since the study exclusion criteria limited the non-obese group to women without thyroid disease, in a sensitivity analysis we excluded all women who reported thyroid medication intake and still a higher proportion of women with obesity took the hormones and synthetic substitutes class compared to women without obesity. Conclusion Our findings suggest that pre-pregnancy obesity in otherwise healthy women is associated with a higher use of only selected medications (such as diabetes medications and progesterone) during pregnancy, while the intake of other more common medication types such as analgesics, antibiotics, and antacids does not vary by pre-pregnancy obesity status. As medication safety information for prenatal consumption is insufficient for many medications, these findings highlight the need for a more in-depth examination of factors associated with prenatal medication use.

Treatment Effectiveness and Medication Use Reduction for Older Adults in Interdisciplinary Pain Rehabilitation.

ObjectiveTo examine the effectiveness of an interdisciplinary pain rehabilitation program (IPRP) that incorporates medication tapering on improving pain-related and performance-based outcomes for older adults with chronic noncancer pain and determine the proportion who demonstrated reliable improvement in outcome.Patients and MethodsThis 2-year retrospective clinical cohort study examined treatment outcomes of 134 older adult patients 65 years or older with chronic noncancer pain who completed a 3-week IPRP with physician-supervised medication tapering between January 1, 2015, and December 31, 2017. Pain, pain catastrophizing, depressive symptoms, and quality of life were assessed at pretreatment, posttreatment, and follow-up. Physical performance and medication use were assessed pre- and posttreatment. Outcomes were examined using a series of repeated-measures analyses of variance, examining effect size and reliable change.ResultsSignificant treatment effects (P<.001) with large effect sizes were observed for all self-report and physical performance outcome measures at posttreatment and 6-month follow-up (42.5% response rate). There were no significant differences in outcome based on opioid use status at admission. Reliable change analyses revealed that 76.9% (n=103 of 134) evidenced improvement in at least 1 pain-related outcome measure at posttreatment, and 87.7% (n=50 of 57), at follow-up. Patients also had significant reductions (P<.01) in medications at posttreatment (opioids, benzodiazepines, sedative-hypnotics, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and anticonvulsants).ConclusionOlder adults with chronic noncancer pain demonstrated improved pain-related outcomes, physical performance, and decreased medication use following IPRP treatment. Results support the effectiveness of IPRPs in enhancing the physical and emotional functioning of older adults with chronic pain while also facilitating the reduction of medications that place them at risk for adverse events.

Disparities in Childhood Attention Deficit Hyperactivity Disorder Symptom Severity by Neighborhood Poverty.

To determine the association between neighborhood poverty and Attention Deficit Hyperactivity Disorder (ADHD) severity among children in a large metropolitan area. This is a secondary analysis of data collected April 2016 to July 2017 at the Children's Hospital of Philadelphia Care Network. We attributed 2015 American Community Survey census tract poverty, defined as percent of individuals with income below poverty level, to each child's residential address. Tracts were grouped from low to high poverty. ADHD severity was determined by Vanderbilt Parent Rating Scale (VPRS) symptom score. We also recorded parent-reported child ADHD medication use. A total of 286 children were linked to 203 unique census tracts. The majority of children from high poverty tracts were black and from disadvantaged households. Higher neighborhood poverty was associated with higher VPRS scores and decreased medication use in bivariate analysis. Poverty was no longer associated with VPRS scores in multivariate analysis, but medication use still had a significant negative association with VPRS score. Post hoc stratification by medication use revealed that neighborhood poverty and VPRS score were significantly associated for children on medication, but not for those off medication. Neighborhood poverty was not associated with ADHD severity in multivariate analysis. This suggests other factors, including medication use, confound the relationship between neighborhood poverty and ADHD severity. Lack of medication treatment was significantly associated with higher symptom burdens for children with access to primary care. Decreased medication use in higher poverty communities warrants exploration and public health interventions to ensure adequate ADHD management for all children.

P147 Systematic review: diverting loop ileostomy as treatment option in severe inflammatory bowel disease

Abstract Background Severe colitis in the setting of inflammatory bowel disease (IBD), refractory to medical treatment, has traditionally been treated with an emergent colectomy, typically consisting of a two-step approach with a loop diversion in a setting of acute colitis, followed by a colectomy when inflammation has decreased as to minimise the risk of post-operative complications. More recently, several studies have questioned the need for secondary colectomy or have considered stoma reversal a viable option after diversion. We conducted a literature search primarily looking at the incidence of successful reversal or acute colectomy during follow-up. Secondary outcomes were post-surgical complications and clinical improvement after diversion. Methods We identified articles using a literature search using six medical databases. Articles were selected on the following criteria; severe colitis (either Crohn’s disease (CD) or ulcerative colitis (UC)), refractory to medical treatment, treated using a temporary loop ileostoma instead of an acute setting colectomy and scoring of clinical improvement parameters, such as decreased medication use and improvement of nutritional state. Results Seven studies, of which one was an extension and one was paediatric, were included. All were small studies with 13 to 33 participants, resulting in a total of 145 patients. A range of 16–60% underwent stoma reversal of the diversion based on mucosa and clinical remission with a follow-up rate varying from 4 to 33 months. In six studies, 15–29% of patients undergoing stoma reversal were symptom free during follow-up. Two studies showed partial remission in 55.2% and 69% of participants. Total colectomy in the diverted group, described in 5 studies, was seen in 9–53%. Complication rates ranged from 12–29%. Overall clinical improvement was seen in &amp;gt;80% % of diverted patients. Only 2 studies made subgroup analyses of CD and UC, which showed a better result in CD patients regarding clinical improvement (&amp;gt;90% improvement vs. &amp;gt;80% improvement in UC patients) and rates of successful diversion, which was seen in 3/14 (21%) CD patients and 3/19 (16%) UC patients. Conclusion Diverting loop ileostomy in severe IBD is an effective treatment to avoid acute setting colectomy, with improvement in clinical status in &amp;gt;80% of patients and a chance of 15–29% of successful stoma reversal without symptoms of IBD.

Role of Breathing Exercises and Yoga/Pranayama in Childhood Asthma: A Systematic Review.

Various complementary or alternative medicines (including breathing exercises and yoga/pranayama) have been tried as an attractive option to pharmacotherapy in childhood asthma. To evaluate the role of breathing exercise and yoga/pranayama as add on therapy to the "pharmacologically recommended treatment" of childhood asthma. We searched the published literature in the major databases: Medline via Ovid, PubMed, CENTRAL, Embase, and Google Scholar till June 2018. Randomized trials comparing breathing exercises and yoga/ pranayama versus control or as part of a composite intervention versus control were included. The primary outcome measures were quality of life and change in asthma symptoms. Secondary outcomes were: decrease in medication use, number of exacerbations, change in lung function and immunological parameters, school absenteeism and adverse events. A total of 10 trials (466 children, 6-14 years age) were included. The severity of asthma varied among the trials. The data for primary outcome measures could not be pooled, there were mixed results for both primary and secondary outcomes. No significant benefit was obtained in acute asthma and the lung function tests [except PEFR % at 4-6 weeks, PEF absolute at 3 months, and FVC absolute at 3 months] in chronic asthma. One trial compared breathing exercise versus yoga and found no difference. Adverse events were not significant. Breathing exercise and yoga/ pranayama may have some additive role in the treatment of childhood asthma. However, at present, it cannot be recommended as a standard of care due to insufficient data.

Retrospective Evaluation of an Online Diabetes Health Coaching Program: A Pilot Study.

An estimated one third of American adults have prediabetes; over 30 million have type 2 diabetes mellitus. Health and wellness coaching is an emerging tool for preventing and treating chronic disease. Mastering Diabetes (MD) promotes a low-fat, plant-based, whole-food diet, utilizing online education, day-to-day accountability and support, and video conferencing. This pilot study provides a retrospective view of the effectiveness of MD to treat diabetes. Current and former clients of MD were invited to participate in a survey. On completion of the online consent, subjects were asked a series of questions in a REDCap-based survey: age, gender, enrollment date in MD, changes in weight, HbA1c, medication use, overall health, and current level of adherence to achieved changes. Overall, 253 (8.9%) participants responded to the survey; 80.6% were females, mean age was 56 years. Most of those responding (78.4%, P < .001) reported weight loss; 68.8% (P < .001) reported decreased HbA1c; 52.4% reported decreased medication use; 86.8% reported continued health improvement since having participated in MD; and 83.5% found the online program very helpful. This study demonstrated improvement in HbA1c and weight in participants in an online health and wellness coaching. Study limitations prevent drawing generalizable conclusions; further prospective evaluation is needed.

Successful Implementation of the Eat Sleep Console Model of Care for Infants With NAS in a Community Hospital.

Opioid use across the United States is increasing. The concomitant rise in the incidence of neonatal abstinence syndrome (NAS) has made care of infants with this disease process a top priority for pediatric centers across the country. There is growing evidence that the Eat Sleep Console (ESC) model of care is superior to the established Finnegan Neonatal Abstinence Scoring System model. We aimed to improve the care of infants with NAS by transitioning from the Finnegan Neonatal Abstinence Scoring System model to the ESC model of care. Our goal was to decrease the average length of stay from 11.77 to 5.94 days without having an increase in readmissions. A multidisciplinary team was created. Education about NAS and ESC was created and distributed. Patients were admitted to the inpatient unit, and outcomes were observed. Standard quality improvement methodology was used for this intervention. After implementation of the ESC care model, average length of stay decreased to 5.94 days, with 0 patients readmitted or transferred for NAS-related complications. We saw a 48% reduction in average variable cost per patient. In addition to these reductions and savings, total per patient morphine exposure was reduced from 2.25 to 0.45 mg/kg, a 79% reduction in use. The ESC model of care was successfully implemented at our institution with resultant cost savings, decreased length of stay, and decreased medication use. Our work further supports the adoption of this new model of care for infants with NAS.

Abstract 132: Does Migraine Surgery Affect Medication Use?

PURPOSE: Patients with migraine headaches (MH) suffer debilitating pain that often leads to the use of numerous medications. MH surgery has emerged as an effective treatment in select patients. The aim of this study was to describe preoperative and postoperative medication use among patients undergoing MH surgery. METHODS: 160 patients undergoing MH surgery between 2013 and 2018 were prospectively enrolled. Information on medication use, including type, dose, and frequency of use was collected. Follow up surveys were sent to all patients twelve months postoperatively. RESULTS: 109 patients met inclusion criteria. Preoperatively, 95% of patients described taking prescription medication for their MH pain. Type of medication varied among patients but included abortive in 46%, preventative in 54%, rescue in 62%, and antiemetic in 18%. At twelve months postoperatively, 64% of patients reported using less prescription medication. Patients reported a 67% decrease in the number of days they took medication. Twenty percent stopped medications altogether. Fifty-two percent of patients reported that their migraine medication helped them more compared to preoperatively. CONCLUSION: MH surgery has been shown to improve symptoms in up to 90% of patients. We now show that it is also associated with a significant decrease in medication use. It is important for surgeons to be aware of this data as we continue to counsel future patients.

PMD13 - A Canadian Cost-Utility Analysis of two Trabecular Micro-Bypass Stents in Patients with Mild-to-Moderate Open-Angle Glaucoma

To estimate the cost-utility of two micro-bypass trabecular stents (MBTS) implantation versus standard of care (SOC) in the Canadian healthcare setting. A Markov model was designed to track progression of glaucoma through health states defined using Hodapp-Parrish-Anderson stages and death: mild, moderate, advanced, severe/blind glaucoma over a 15 year time horizon. Reduction in intraocular pressure (IOP) and medication use due to MBTS and SOC were identified from MBTS randomized clinical trials and meta-analyzed. Transition probabilities were estimated using IOP-adjusted rate of decline in visual field (VF) loss. A 10% decline in relative treatment effect per year was conservatively assumed for extrapolation of efficacy beyond trial follow-up. Unit costs and utilization of healthcare resources, and progression-related utility scores for the general Canadian population were obtained by literature review and reflect 2017 Canadian costs. IMS Brogan PharmaStat was used to estimate medication costs with wastage. Probabilistic and 1-way sensitivity analyses were conducted to estimate the impact of parameter and methodological uncertainty on costs and quality-adjusted life years (QALYs). The meta-analysis showed a relative reduction of 1.13 medications/patient and an IOP change of -1.10 mmHg at 36 months favoring MBTS. The model estimated MBTS therapy was the dominant strategy as it was associated with an incremental improvement in quality of life (0.071 QALYs), and a decrease in healthcare costs of $2,995 per patient over a lifetime. Sensitivity analyses showed that results were robust to variations in model assumptions. The costs of the MBTS procedure are expected to be recouped over a few years due to decreased medication use and downstream procedures avoided. Together with the quality of life gains expected with MBTS, it becomes increasingly cost-effective with longer time horizons as it dominates SOC after 2.9 years.

EGD First in Bi-directional Endoscopy Is Associated with Decreased Medication Use and Time: A Quality Improvement Initiative

EGD First in Bi-directional Endoscopy Is Associated with Decreased Medication Use and Time: A Quality Improvement Initiative

Outcomes after combined phacoemulsification and trabecular microbypass stent implantation in controlled open-angle glaucoma

To study the effect of combined phacoemulsification cataract surgery and iStent (trabecular microbypass stent) implantation on intraocular pressure (IOP) and medication use in open-angle glaucoma (OAG) patients with a low mean preoperative IOP. University of Colorado Health Eye Center, Aurora, Colorado, USA. Retrospective case series. Treatment outcomes analyzed included IOP, medication use, and corrected distance visual acuity (CDVA). Treatment success was defined as a 20% or more IOP reduction or discontinuation of at least 1medication. Sixty-four eyes of 45 patients were included in the analysis. At 1year, the mean IOP was significantly reduced from 14.7±3.2 mm Hg (SD) to 13.2±2.8mm Hg (P<.01) and the mean medication use decreased from 1.81±1.13 to 1.41±1.48 (P=.0001). The estimated IOP reduction at 1, 3, 6, and 12months was 3.5% (P=.23), 7.9% (P=.04), 9.7% (P=.01), and 12.2% (P=.002), respectively. Treatment success at 1year was achieved in 76.1% of patients, and 41% of patients were medication free at 1year. The CDVA was significantly improved from 0.4±0.38 logMAR at baseline to 0.17±0.35 at 1year (P<.0001). Combined cataract surgery and trabecular microbypass stent implantation was statistically effective in reducing IOP and/or medication burden in OAG patients with a low preoperative IOP. During the informed surgical consent process, the physician and patient should consider the clinical benefit of modest IOP lowering and/or a decrease in medication use. Drs. Seibold, SooHoo, Pantcheva, and Kahook have received grant support from Glaukos Corp. No other author has a financial or proprietary interest in any material or method mentioned.

Evaluation of the Effectiveness of Percutaneous Octapolar Leads in Pain Treatment with Spinal Cord Stimulation of Patients with Failed Back Surgery Syndrome During a 1-Year Follow-Up: A Prospective Multicenter International Study.

To evaluate the effectiveness and safety of percutaneous octapolar (8-contact) leads in spinal cord stimulation (SCS) treatment of failed back surgery syndrome (FBSS) patients who have not reached their therapy goals with other treatment interventions. Our prospective, multicenter, open-label, nonrandomized study included 93 patients ≥18years of age suffering from chronic (≥6months), intractable pain predominantly in the legs. Patients implanted with octapolar lead(s) and a neurostimulator after a successful test trial were followed for 12months. Patients provided self-reported data on change in visual analog scale (VAS) score for leg pain (primary outcome) and low back pain, quality of life (EuroQol 5 dimensions [EQ-5D] index), sleep, medication use, and paresthesia coverage (secondary outcomes). Adverse events and preferred stimulation settings were documented. Eighty-one (87%) patients had a successful SCS trial. Patients reported significantly improved leg pain relief; average VAS score was 72±17 prior to SCS treatment and 32±24 at 12 months (P<0.001). Significant decrease in back pain (P<0.001), improvement in quality of life (P<0.001), and improvement in sleep (P<0.05) was observed. Sixty-three percent and 40% of patients were responders (≥50% pain reduction) on leg and back pain, respectively, after 12months. A decrease in medication use was seen for antidepressants and anticonvulsants. Eighty-eight percent of the patients managed with 1 or 2 programs for optimal effect and paresthesia coverage. Twenty-five SCS-related adverse events were registered in 22 patients (24%). Surgical revision due to lead displacement or dysfunction was needed in 6 (6%) of the patients. Use of percutaneous octapolar SCS leads gives significant long-term pain relief and improvement in quality of life and sleep in FBSS patients. The outcomes are better than reported on 4-contact leads and indicate that the progress in SCS technology that has taken place during the past decade correlates with therapy improvements.

Protocol-driven adjustment of ocular hypotensive medication in patients at low risk of conversion to glaucoma

To investigate the safety and potential savings of decreasing medication use in low-risk patients with ocular hypertension (OH). Patients with OH receiving pressure-lowering medication identified by medical record review at a university hospital underwent examination by a glaucoma specialist with assessment of visual field (VF), vertical cup-to-disc ratio (vCDR), central corneal thickness and intraocular pressure (IOP). Subjects with estimated 5-year risk of glaucoma conversion <15% were asked to discontinue ≥1 medication, IOP was remeasured 1 month later and risk was re-evaluated at 1 year. Among 212 eyes of 126 patients, 44 (20.8%) had 5-year risk >15% and 14 (6.6%) had unreliable baseline VF. At 1 month, 15 patients (29 eyes, 13.7%) defaulted follow-up or refused to discontinue medication and 11 eyes (5.2%) had risk >15%. The remaining 69 patients (107 eyes, 50.7%) successfully discontinued 141 medications and completed 1-year follow-up. Mean IOP (20.5±2.65 mm Hg vs 20.3±3.40, p=0.397) did not change, though mean VF pattern SD (1.58±0.41 dB vs 1.75±0.56 dB, p=0.001) and glaucoma conversion risk (7.31±3.74% vs 8.76±6.28%, p=0.001) increased at 1 year. Mean defect decreased (-1.42±1.60 vs -1.07±1.52, p=0.022). One eye (0.47%) developed a repeatable VF defect and 13 eyes (6.1%) had 5-year risk >15% at 1 year. The total 1-year cost of medications saved was US$4596. Nearly half (43.9%) of low-risk OH eyes in this setting could safely reduce medications over 1 year, realising substantial savings.

Analgesic use in older adults with back pain: the BACE study.

Older patients with back pain are more likely to visit their general practitioner (GP) and are more likely to be prescribed analgesics. To assess analgesic use in older adults with back pain in general practice. The BACE study in the Netherlands is a prospective cohort study. Patients (aged >55 years) with back complaints were recruited when consulting their GP or shortly thereafter. Measurements took place at baseline and at 3- and 6-month follow-up. For medication use, patients were asked if they had used any medication for their back pain in the previous 3 months and, if so, to specify the medication name, dosage used, frequency of usage, and whether the medication was prescribed or purchased over the counter. Of the 1,402 patients who were approached to enter the study, 675 were included. Of these patients, 484 (72%) reported medication use at baseline. Nonsteroidal anti-inflammatory drugs (NSAIDs) (57%) were more often used than paracetamol (49%). Paracetamol was mostly obtained over the counter (69%), and NSAIDs were mostly obtained by prescription (85%). At baseline, patients with severe pain (numerical rating scale score ≥7) used more paracetamol, opioids, and muscle relaxants. Patients with chronic pain (back pain >3 months) used more paracetamol, while patients with a shorter duration of pain used more NSAIDs. During follow-up there was an overall decline in medication use; however, at 3- and 6-month follow-up, 36% and 30% of the patients, respectively, still used analgesics. In these older adults consulting their GP with back pain, 72% used analgesics at baseline. Despite a decrease in medication use during follow-up, at 3 and 6 months a considerable proportion still used analgesics.