Substantial Reduction In Use Research Articles

Impact of Oncology Drug Shortages on Chemotherapy Treatment.

Prescription drug shortages began to increase markedly in the mid-2000s, including sterile injectable products such as chemotherapy drugs. Using Medicare claims linked to Surveillance Epidemiology and End Results (SEER), we examined outpatient chemotherapy use during shortage periods relative to the months before and after a shortage for newly diagnosed patients with breast, colorectal, leukemia, lung, lymphoma, ovarian, or pancreatic cancer (N=182,470). For most drugs, we found little impact of shortages on either the fraction of patients receiving that drug or the quantity provided. In some cases, we found declines in utilization: 4% for doxorubicin and fluorouracil; 2.9% for oxaliplatin; and about 1% for cytarabine, dacarbazine, and leuprolide. Although shortages for a few drugs resulted in substantial reductions in use, in most cases, they resulted in little to no reduction. We discuss potential explanations for these counterintuitive findings, including potential limitations of current drug shortage reporting methods.

The institution of a white cell growth factor appropriate non-use policy for incurable metastatic solid tumors within a community oncology practice.

33 Background: Texas Oncology (TO) is a community-based practice. with over 250 physicians (MD) who order chemotherapy. In 2015, pegfilgrastim (pgcsf) was the highest individual drug in billed claims. Concurrently, TO was participating in the United Healthcare (UHC) Episode of Care (EOC) program and anticipating the Oncology Care Model. Patient and program expense dictated understanding pgcsf utilization. Methods: Data were obtained in 9/2015 from EOC claims to identify overall and individual pgcsf use in solid tumor metastatic disease (MDx). Chart review was done for the top prescribers. In 3/16, ASCO pgcsf guidelines and TO education materials were emailed to all physicians. In 3/17 appropriate non-use recommendations were communicated and a real-time internal approval process begun. On 10/1/2017, UHC instituted a pgcsf prior authorization (PA) program. Retrospective data from the iKnowMed EHR system was collected in 3-month intervals from April 2016 through March 2018 and evaluated for number of pgcsf administrations at TO for MDx, as well as, administrations/provider/quarter for TO and The US Oncology Network. MDx was defined by any of the following criteria: stage IV at diagnosis (with certain disease exceptions); TNM M value of “1” or “+”; a metastatic line of therapy; evidence of metastatic disease documented within the EHR. Results: Initial survey of EOC claims indicated 16% of patients received pgcsf for MDx. Rates per MD ranged from 0 to 57%. Review of the top users indicated 90% of uses could have been addressed with dose reduction. In the first measured quarter of April to June 2016 to the last, October to December 2017, pgcsf use dropped by 50%. Changes for some diseases were dramatic: Use in colon cancer fell from 132 uses/quarter to a low of 46, and for non-small lung cancer – 80 to 23 respectively. Conclusions: The deadopting of low value care can be challenging. In the case of pgcsf substantial reductions in use were achieved using data and guidelines for education in the setting of value based contracts. Ultimately, the most change was achieved by an internal real time approval process. This was reinforced by a payer PA requirement.

A Typology of Substance Use Among Pregnant Teens in the United States.

Previous research suggests that, in general, youth who become pregnant during their teenage years tend to report elevated levels of substance use prior to conception and substantial reductions in use during pregnancy. While such studies provide insight into aggregate patterns of adolescent substance use in relation to pregnancy, they may have the unintended effect of masking the behavioral heterogeneity of pregnant teens. The present study employs data from a large, population-based study of adolescents in the United States. We employ latent class analysis to identify subgroups of pregnant adolescents (ages 12-17; n = 810) on the basis of variables measuring the past 12-month and past 30-day use of an extensive array of substances. Results revealed a four class solution. Classes were identified as Class 1: Abstainers (n = 344, 42.47 %), Class 2: Drinkers (n = 303, 37.41 %), Class 3: Alcohol and Cannabis Users (n = 77, 9.51 %), and Class 4: Polydrug Users (n = 86, 10.62 %). The Abstainers class had the highest proportion of Hispanic youth (34.3 %) as well as the highest proportion of youth residing in households earning less than $20,000 per year (44.2 %). The Polydrug Users class had the highest proportion of youth who were in late adolescence (75.58 %), non-Hispanic white (54.65 %), high-income (13.95 %), and in their first trimester of pregnancy (58.33 %). Findings point to an important degree of heterogeneity among pregnant teens and may have implications for the development of interventions designed for youth exhibiting disconcerting patterns of substance use prior to pregnancy.

STYLING CHARACTERISTICS OF BUSINESS CORRESPONDENCE IN GERMAN & UKRAINIAN LANGUAGES

The article compares the structure of business correspondence between German and Ukrainian languages. Business correspondence is instrumental in establishing official, business and partner contacts between government institutions and private companies alike. It is also a major factor in building relationships between individuals. Business correspondence in Germany is defined by German Industry Standards (DIN 5008, 676) and has more requisite elements than it does in Ukraine. The differences lie in the format and placement of the date, the main text of German letter being divided into three parts versus two parts in Ukrainian, the signature in German letter is placed above the name of the author while Ukrainian letter has it across from author's name. Ukrainian business letter does not call for specify its subject before the salutation. Common to both German and Ukrainian business letters is the use of a certain minimum of set expressions and stock phrases predicated upon a limited number of standard aspects of business writing which tend to be highly repetitive (letter of notification, request, proposal, demand, refusal, agreement). Covered herein are main types of German business letters (corporate partnership request letter, inquiry letter, business proposal letter, marketing letter, repeat offer letter, order letter, refusal letter, complaint letter, reminder letter), their characteristic features and typical stock phrases and set expressions. A grammatical analysis shows that business correspondence is marked by prevalence of present tense, more frequent use of active voice over passive, rather frequent occurrence of infinitive constructs with "zu" and imperative mood, rather infrequent occurrence of subordinate clauses - mainly noun, adjective and conditional clauses. Recent times are marked by a substantial reduction in use of subjunctive mood Konjunktiv II.

Implementation of a Heparin-Induced Thrombocytopenia Management Program Reduces the Cost of Diagnostic Testing and Pharmacologic Treatment in an Academic Medical Center

Abstract Hematologists that are expert in benign hematology are needed to promote safe and cost-effective diagnosis of bleeding and thrombotic disorders in the hospital setting. The Joint Commission has identified anticoagulation as an area that has a high frequency of adverse drug outcomes and needs close supervision. The purpose of this study is to demonstrate the clinical utility of benign hematology expertise to guide use of direct thrombin inhibitors (DTIs) in the setting of heparin-induced thrombocytopenia. Heparin-induced thrombocytopenia represents a serious complication of heparin therapy and requires accurate diagnostic testing and safe and effective anticoagulation to prevent adverse outcomes. In recent years, serologic tests for the presence of heparin–platelet factor 4 antibodies has led to widespread testing and increased use of DTIs to manage thrombocytopenic patients. Patients that have a positive ELISA assay are tested by the serotonin release assay to confirm the presence of the antibody that can trigger thrombosis. The antibody can trigger platelet activation, arterial thrombosis and/or venous thrombosis. The risk of a thrombotic event is high and anticoagulation is recommended to reduce thrombosis that can lead to amputation, stroke, or loss of life. Treatment is recommended with a DTI followed by warfarin therapy. The American Society of Hematology and several expert panels have published guidelines regarding management of heparin-induced thrombocytopenia. Despite these guidelines, medical centers are challenged by regulating the diagnosis and management of this clinical problem. The Medical University of South Carolina Hospital, a 750 bed academic medical center, established an Anticoagulation and Bleeding Management Service led by hematologists and a multidisciplinary team to evaluate the use of diagnostic testing and use of DTIs. In phase one, a review of the testing in the intensive care units at our medical center was retrospectively analyzed. Results demonstrated a high frequency of serologic testing in cases that had low to intermediate 4T score results. In contrast, a very low percentage of ELISA-positive cases were confirmed to be serotonin release assay-positive. Often times DTIs were administered for several days until the SRA assay results were available. In collaboration with nursing, pharmacy, pathology and hematology, a specific set of guidelines were implemented. Prior to submitting an ELISA measurement clinicians were required to perform a 4T score. All positive ELISA assays were reported to the Anticoagulation and Bleeding Management Consult Service and specific treatment guidelines were provided in accordance with published ASH guidelines. We collected and reviewed baseline data regarding the frequency of testing and use of DTIs prior to implementing the protocol. We found that an average of 5.5 cases per month were given DTIs prior to implementation of the protocol. The average number of patients treated with DTI after the implementation of the protocol averaged 1.2 per month . This represented a 78% drop in DTI use. Over the same time period we saw ELISA testing and SRA testing both decline, with ELISA testing reduced by 20% and Serotonin Release Assay testing reduced by 70%. In conclusion, the implantation of a centralized hospital-wide protocol that coordinates testing and treatment of patients suspected of having heparin-induced thrombocytopenia has led to a substantial reduction in use of DTIs and improved management of patients suspect of having this clinical disorder. An Anticoagulation and Bleeding Management Service led by expert benign hematologists can play a major role in developing safe and cost-effective approaches for the diagnosis and treatment of complicated bleeding and thrombotic disorders. Disclosures No relevant conflicts of interest to declare.

Economic return from the Women's Health Initiative estrogen plus progestin clinical trial: a modeling study.

The findings of the Women's Health Initiative (WHI) estrogen plus progestin (E+P) trial led to a substantial reduction in use of combined hormone therapy (cHT) among postmenopausal women in the United States. The economic effect of this shift has not been evaluated relative to the trial's $260 million cost (2012 U.S. dollars). To estimate the economic return from the WHI E+P trial. Decision model to simulate health outcomes for a "WHI scenario" with observed cHT use and a "no-WHI scenario" with cHT use extrapolated from the pretrial period. Primary analyses of WHI outcomes, peer-reviewed literature, and government sources. Postmenopausal women in the United States, aged 50 to 79 years, who did not have a hysterectomy. 2003 to 2012. Payer. Combined hormone therapy. Disease incidence, expenditure, quality-adjusted life-years, and net economic return. The WHI scenario resulted in 4.3 million fewer cHT users, 126,000 fewer breast cancer cases, 76,000 fewer cardiovascular disease cases, 263,000 more fractures, 145,000 more quality-adjusted life-years, and expenditure savings of $35.2 billion. The corresponding net economic return of the trial was $37.1 billion ($140 per dollar invested in the trial) at a willingness-to-pay level of $100,000 per quality-adjusted life-year. The 95% CI for the net economic return of the trial was $23.1 to $51.2 billion. No evaluation of indirect costs or outcomes beyond 2012. The WHI E+P trial made high-value use of public funds with a substantial return on investment. These results can contribute to discussions about the role of public funding for large, prospective trials with high potential for public health effects. National Heart, Lung, and Blood Institute.

Belt Restraint Reduction in Nursing Homes: Effects of a Multicomponent Intervention Program

To test the effects of a multicomponent intervention program to reduce the use of belt restraints in psychogeriatric nursing homes. A quasi-experimental longitudinal design. Study duration was 8 months. Twenty-six psychogeriatric nursing home wards in 13 Dutch nursing homes were assigned to intervention or control groups. Seven hundred fourteen residents were selected for participation. Legal representatives of 520 residents agreed on participation; complete data are available for 405 residents. The intervention program included four major components: promotion of institutional policy change that discourages use of belt restraint, nursing home staff education, consultation by a nurse specialist aimed at nursing home staff, and availability of alternative interventions. The primary outcome measure was the frequency of belt restraint use. Secondary outcomes included other types of physical restraints, psychoactive drug use, falls, and fall-related injuries. These data were collected at baseline and after 4 and 8 months. A trained, blinded observer measured the use of belts and other physical restraints types four times during a 24-hour period. The intervention resulted in a 50% decrease in belt use (odds ratio = 0.48, 95% confidence interval = 0.28-0.81; P = .005). No increase occurred in the use of other types of restraints. No marked differences between the groups were found regarding psychoactive drugs, falls, and fall-related injuries. A multicomponent intervention program led to a substantial reduction in use of belts, full-enclosure bedrails, and sleep suits without increasing the use of other physical restraints, psychoactive drugs, or falls and fall-related injuries.

Systematic Investigation of Initiatives to Reduce Seclusion and Restraint in a State Psychiatric Hospital

This study used an experimental design to examine the effect of systematic implementation of behavioral interventions on the rate of seclusion and restraint in an inpatient psychiatric hospital. With a variant of the multiple-baseline design, a model designed to reduce seclusion and restraint was implemented at a large state-funded hospital in the southeastern United States. The implementation schedule was established such that each of five inpatient units was randomly assigned to implement the intervention components in a different order, and each unit served as its own control. Participants were patients and staff, for a total of 89,783 patient-days over a 3.5-year period from January 2005 through June 2008. The components included trauma-informed care training, changes to unit rules and language, changes to the physical characteristics of the therapeutic environment, and involvement of patients in treatment planning. The rate of inpatient psychiatric seclusion and restraint (per patient day) was tracked continuously during the 3.5-year period. A significant reduction of 82.3% (p=.008) in the rate of seclusion and restraint was observed between the baseline phase (January 2005 through February 2006) and the follow-up, postintervention phase (April 2008 through June 2008). After control for illness severity and nonspecific effects associated with an observation-only phase, changes to the physical environment were uniquely associated with a significant reduction in rate of seclusion and restraint during the intervention rollout period. These data suggest that substantial reductions in use of seclusion and restraint are possible in inpatient psychiatric settings and that changes to the physical characteristics of the therapeutic environment may have a significant effect on use of seclusion and restraint.

Systematic Investigation of Initiatives to Reduce Seclusion and Restraint in a State Psychiatric Hospital

Objectives: This study used an experimental design to examine the effect of systematic implementation of behavioral interventions on the rate of seclusion and restraint in an inpatient psychiatric hospital. Methods: With a variant of the multiple-baseline design, a model designed to reduce seclusion and restraint was implemented at a large state-funded hospital in the southeastern United States. The implementation schedule was established such that each of five inpatient units was randomly assigned to implement the intervention components in a different order, and each unit served as its own control. Participants were patients and staff, for a total of 89,783 patient-days over a 3.5-year period from January 2005 through June 2008. The components included trauma-informed care training, changes to unit rules and language, changes to the physical characteristics of the therapeutic environment, and involvement of patients in treatment planning. The rate of inpatient psychiatric seclusion and restraint (per patient day) was tracked continuously during the 3.5-year period. Results: A significant reduction of 82.3% (p=.008) in the rate of seclusion and restraint was observed between the baseline phase (January 2005 through February 2006) and the follow-up, postintervention phase (April 2008 through June 2008). After control for illness severity and nonspecific effects associated with an observation-only phase, changes to the physical environment were uniquely associated with a significant reduction in rate of seclusion and restraint during the intervention rollout period. Conclusions: These data suggest that substantial reductions in use of seclusion and restraint are possible in inpatient psychiatric settings and that changes to the physical characteristics of the therapeutic environment may have a significant effect on use of seclusion and restraint. (Psychiatric Services 62:477–483, 2011)

Treatment Populations, Services, and Outcomes for Cocaine and Crack-Cocaine Dependence

This paper analyzes demographic and other pretreatment characteristics, measures of treatment services received, and treatment outcomes of participantsin the National Treatment Improvement Evaluation Study (NTIES), a large-scale longitudinal study of substance abuse treatment (D. R. Gerstein et al., 1997; R. A. Johnson & D. R. Gerstein, 2000). The focus here is those treated primarily for cocaine powder or crack-cocaine dependence, compared with those in treatment for other substances, particularly heroin. Crack-dependent users tend to be female and black, older than primary marijuana or alcohol users but younger than those in treatment for heroin. Primary cocaine powder or crack users are likely to have entered treatment under pressure from the criminal justice system. After treatment there are substantial reductions in use of cocaine powder and crack, especially among participants with fewer prior treatment episodes and lower pretreatment intensity of use. Longer duration and intensity of treatment result in greater reductions in cocaine and crack use.

How does case management for long-term mentally ill individuals affect their use of health care services? An 18-month follow-up of 10 Swedish case management services

As part of an evaluation of 10 Swedish case management services, outcome in terms of changes in use of health care services was explored. The sample consisted of 176 long-term mentally ill individuals. Changes in use of psychiatric inpatient and outpatient services, primary health care services, and somatic inpatient and outpatient services during an 18-month follow-up were investigated. The results showed a marked and significant decrease in use of psychiatric inpatient services, which were on average reduced by 43% in terms of bed days used. There was no significant change in use of compulsory psychiatric care. The reduction in psychiatric inpatient care was largest for individuals with a diagnosis of schizophrenia. Case manager interventions directed towards the client's finances and coordination of care and support was related to less use of psychiatric inpatient services. To have more contacts with the case manager was related to fewer visits in psychiatric outpatient care. The use of primary health care and other somatic health care was unaffected. It is concluded that admission to a case management service resulted in a substantial reduction in use of psychiatric inpatient care, which to some extent was related to specific activities of the case manager.

Meditation Subculture and Drug Use

The present study reports into the effectiveness of an organized meditation program in controlling drug use among its members. Subjects were 230 young men and women from Canada. A ten-page self-report questionnaire *was used and only the data relating to drug use are presented here. It is seen that within 3 months of joining this group, 82% of cannabis users and 61% of psychedelic users stopped taking drugs. Very substantial reduction in use of alcohol and tobacco also took place. It has been hypothesized that the group meditation program, which possesses characteristics of a subculture rather than meditation practice per se, is responsible for this reduction in drug use.

Treatment outcome in a chronic pain rehabilitation program.

One hundred patients were selected who had completed an outpatient rehabilitation program designed to teach competent coping with chronic pain. Data at follow-up periods averaging 21 months posttreatment indicated statistically significant decreases in subjective pain intensity and increases in activities of daily living with substantial reductions in use of medications for pain. Changes from pretreatment to follow-up were not significantly different among groups of patients with pending, current, or no disability. Eight of 19 unemployed persons who had pending disability claims had returned to work at follow-up. It was concluded that considerable changes in function can occur with relatively brief outpatient pain rehabilitation and that pending or current disability is not necessarily an indication of likely treatment failure.