Burden of breast cancer with brain metastasis: a French national hospital database analysis

Abstract

Objective:

Incidence of breast cancer with brain metastases (BCBM) is increasing, especially among patients over-expressing HER2. Epidemiology on this sub-type of cancer is scarce, since cancer registries carry no information on the HER2 status. A retrospective database analysis was conducted to estimate the burden of BCBM, especially among HER2-positive patients in a secondary objective.

Methods:

Patients with a new diagnosis of BCBM carried out between January and December 2008 were identified from the national hospital database using the International Disease Classification. Patients receiving a targeted anti-HER2 therapy were identified from the national pharmacy database. Hospital and pharmacy claims were linked to estimate the burden of HER2-positive patients. Data on hospitalizations were extracted to describe treatment patterns and healthcare costs during a 1-year follow-up. Predictors of treatment cost were analyzed through multi-linear regression analysis.

Results:

Two thousand and ninety-nine BCBM patients were identified (mean age (SD)?=?57.8 (13.6)), of whom 12.2% received a targeted anti-HER2 therapy; 79% of patients had brain metastases associated with extracranial metastases, and the attrition rate reached 82%. Patients received mostly palliative care (47.4%), general medical care (40.6%), and chemotherapy (35.0%). The total annual hospital cost of treatment was 8,426,392€, representing a mean cost of 22,591€ (±14,726) per patient, mainly influenced by extracranial metastases, surgical acts, and HER2-overexpression (p?<?0.0001).

Conclusions:

The database linkage of hospital and pharmacy claims is a relevant approach to identify sub-type of cancer. Chemotherapy was widely used as a systemic treatment for breast cancer rather than for local treatment of brain metastases whose morbi-mortality remains high. The variability of treatment costs suggests clinical heterogeneity and, thus, extensive individualization of protocols.     

Derivation of severity index for rheumatoid arthritis and its association with healthcare outcomes

Abstract

Objectives:

To develop a claims-based severity index for rheumatoid arthritis (RA) using the Veterans Health Administration (VHA) database.

Methods:

Adult patients with at least two RA diagnoses 2 months apart were identified between 10/1/2008–09/30/2009. Patients were required to have at least 12 months continuous health plan enrollment before and after the index date (first RA diagnosis date) for an overall study period of 10/1/2007–09/30/2010. A severity index for rheumatoid arthritis (SIFRA, a proprietary algorithm of SIMR, Inc. [STATinMED Research]) was developed by calculating a weighted sum of 34 RA-related indicators assessed by an expert Delphi panel of six rheumatologists, including laboratory, clinical, and functional status, extra-articular manifestations, surgical history, and medications, during a 1-year pre-index period. Separate SIFRA versions were derived for patients with and without laboratory information. Correlations between SIFRA and previously validated claims-based indexes for RA severity (CIRAS), and other traditional comorbidity indexes were calculated during the pre-index period. The relationship between SIFRA and follow-up healthcare outcomes was also examined using histograms.

Results:

The Spearman’s rank correlations between SIFRA and CIRAS were 0.525 for SIFRA without and 0.539 with laboratory data. The correlations between SIFRA and the Charlson Comorbidity Index (CCI) (0.1503 without, 0.1135 with laboratory data), Elixhauser Index (ELIX) (0.105 without, 0.079 with laboratory data), and Chronic Disease Score (CDS) (0.255 without, 0.239 with laboratory data) were low. Histograms showed that patients in the upper tercile of SIFRA incurred $9123 more all-cause and $1326 more RA-related healthcare costs during the 1-year post-index period than patients in the lower tercile. Using SIFRA in combination with CCI, CDS, or ELIX significantly increased the percentage of variation explained in outcomes measures.

Limitations:

Patients in the VHA database may not represent typical RA patients since the database generally contains older, economically disadvantaged men with a high disease burden. Validity of the score is indirectly based on disease activity score 28 (DAS28), which measures disease activity rather than severity.

Conclusions:

SIFRA was found to have moderate correlations with the previously validated CIRAS score, and demonstrated evidence of being a significant determinant of total and RA-related healthcare costs for RA patients. This study suggests that SIFRA could be an important methodological tool to control for severity in RA-related outcomes research. The algorithm can be applied to any claims dataset.     

Utilization and cost comparison of erythropoiesis-stimulating agents in inpatient and outpatient hospital settings

Abstract

Objective:

To compare utilization and associated costs of epoetin alfa (EPO) and darbepoetin alfa (DARB), two erythropoiesis-stimulating agents (ESAs), in patients with cancer undergoing chemotherapy and patients with chronic kidney disease (CKD) not on dialysis in inpatient and outpatient hospital settings.

Methods:

An analysis of medical claims recorded between January 2006 and December 2009 was conducted using the Premier Perspective Comparative Hospital database. Patients included were ≥18 years old with cancer and chemotherapy or with pre-dialysis CKD and with ≥1 claim for EPO or DARB during a hospital inpatient or outpatient treatment episode. Patients treated with both ESAs or who were receiving dialysis were excluded. Mean cumulative drug costs and dose ratios (units EPO: mcg DARB) were calculated using cumulative dose and April 2010 wholesale acquisition costs.

Results:

Cancer chemotherapy: 13,832 inpatient stays (EPO: 10,454; DARB: 3378) and 5590 outpatient treatment episodes (EPO: 2856; DARB: 2734) were identified. The inpatient and outpatient populations reported ESA dose ratios of 230:1 and 238:1 with DARB cost premiums of 42% (EPO: $948; DARB: $1348) and 38% (EPO: $3358; DARB: $4627), respectively. CKD: 148,746 hospital stays (EPO: 116,017; DARB: 32,729) and 11,012 outpatient treatment episodes (EPO: 6921; DARB 4091) were identified. The inpatient and outpatient populations reported ESA dose ratios of 251:1 and 257:1 with DARB cost premiums of 30% (EPO: $566; DARB: $738) and 27% (EPO: $2077; DARB: $2642), respectively.

Limitations:

The lack of randomization may have led to confounding by indication. In addition, statistical significance must be interpreted with caution in studies involving large samples.

Conclusions:

This study of 19,422 patients with cancer receiving chemotherapy and 159,758 patients with pre-dialysis CKD reported ESA dose ratios ranging from 230:1–257:1 (units EPO: mcg DARB) and associated cost premiums of 27–42% for DARB.     

Initial treatment failure in non-ICU community-acquired pneumonia: risk factors and association with length of stay,total hospital charges,and mortality

Abstract

Objectives:

To identify risk factors for initial treatment failure in patients with community-acquired pneumonia (CAP) in non-intensive care unit (non-ICU) settings, and to characterize the association between initial treatment failure and length of stay, total hospital charges, and mortality.

Methods:

Retrospective cohort study. Using data from >100 US hospitals, this study identified all adults (age ≥18 years) hospitalized for pneumonia between January 1, 2000 and June 30, 2009 who began antibiotic therapy within 24?h of admission and were treated for at least 48?h if alive; patients admitted to intensive care within the first 24?h in hospital were excluded. Initial therapy was defined as all parenteral antibiotics administered within the first 24?h in hospital. Treatment failure was assessed based on subsequent receipt of new antibiotic(s), excluding agents of similar/narrower spectrum and those begun at discharge. Multivariate logistic regression was used to identify risk factors for treatment failure, and multivariate linear and logistic regression to compare length of stay, total hospital charges, and in-hospital mortality between patients experiencing initial treatment failure and those who did not.

Results:

Among 32,324 patients with non-ICU CAP, 4695 (14.6%) experienced initial treatment failure, most often within 72?h of hospital admission. Significant predictors of initial treatment failure included malnourishment (OR?=?1.87; 95% CI?=?1.60–2.18), receipt of vasoactive medications within 24?h of admission (1.51 [1.17–1.94]), and renal failure (1.45 [1.32–1.59]). Treatment failure was associated with higher case fatality (8.5% vs 3.3%), longer hospital stays (mean [SD]?=?10.1 [8.1] days vs 4.9 [3.3] days), and higher total hospital charges ($37,602 [$71,876] vs $14,371 [$21,633]) (all comparisons, p?<?0.01). Study limitations include possible inclusion of patients with healthcare-associated pneumonia (HCAP) in the study sample, our focus on the 40 most commonly used antibiotic regimens, and indirect measurement of treatment failure.

Conclusions:

Approximately one in seven non-ICU CAP patients experience failure of initial antibiotic therapy. Risk of failure is higher for patients with significant comorbidities and/or severe infections. Non-ICU patients who experience initial treatment failure have significantly longer hospital stays, higher total hospital charges, and higher rates of mortality.     

论我国企业年金筹资模式的选择

通过对待遇确定型和缴费确定型两种企业年金筹资模式的研究比较,并结合我国具体经济发展状况,我国应同时出台DB型和DC型两种模式企业年金制度,优先鼓励待遇确定型企业年金筹资模式（DB）,同时辅之以缴费确定型企业年金筹资模式（DC）。     

Hybrid input-output analysis of wastewater treatment and environmental impacts: A case study for the Tokyo Metropolis

This paper proposes a new hybrid input-output model designed to analyze both the generation and treatment of wastewater. This model, named wastewater treatment input-output model (WWIO), can be regarded as an extension of the waste input-output model (WIO) (Nakamura, S. and Kondo, Y., 2002. Input-output analysis of waste management. Journal of Industry Ecology, 6(1): 39-63.). As an application, I compiled the Tokyo Metropolitan WWIO table for 2000, which comprises 482 economic sectors, 11 wastewater treatment sectors, 12 types of wastewater-related waste and 6 types of environmental load. The model was applied to different scenarios to compare alternative wastewater treatment systems. The results indicate that replacing the simple treatment with the high-class treatment improves the quality of treated water while increasing CO₂-equivalent emissions. Meanwhile, when the dewatered sludge is incinerated instead of landfilling, both CO₂-equivalent emissions and landfill volume decrease.     

略论高职思政课教学内容的构建与处理

高职院校思想政治理论课所用的教材与普通高校本科一致,都属国家教育部统编教材,但是高职院校的人才培养目标和高职院校学生自身特点（如心理特征、知识结构、能力偏向等）却不同于本科类院校。由此,在具体教学实践活动中,高职思政课教师应根据高职院校实际、学生实际,重新构建高职思政课的教学内容,并对其妥善处理,从而提高高职思政课的教学实效。     

经皮冠状动脉介入治疗术后术肢血肿护理研究进展

经皮冠状动脉介入诊疗技术作为冠状动脉粥样硬化性心脏病一种重要的有创诊疗手段,不可避免会发生各种并发症,其中术后术肢血肿是临床上常见的外周血管并发症之一,导致术肢的疼痛、肿胀、瘀斑等,严重者甚至可引起筋膜间隔区综合征,若不及时处理容易造成肢体功能障碍,加重患者经济负担和心理负担。其预后有利于提高患者的生命质量及促进患者身心健康发展,选择有效的护理方法是改善术后血肿、促进肢体康复的关键,本研究综合分析了经皮冠状动脉介入治疗术后术肢血肿的形成原因、防治和护理的临床新进展,以期为临床护理工作提供参考和依据。     

A contribution on the nature and treatment of missing data in large market surveys

Nonresponse (or missing data) is often encountered in large-scale surveys. To enable the behavioural analysis of these data sets, statistical treatments are commonly applied to complete or remove these data. However, the correctness of such procedures critically depends on the nature of the underlying missingness generation process. Clearly, the efficacy of applying either case deletion or imputation procedures rests on the unknown missingness generation mechanism. The contribution of this article is twofold. The study is the first to propose a simple sequential method to attempt to identify the form of missingness. Second, the effectiveness of the tests is assessed by generating (experimentally) nine missing data sets by imposed missing completely at random, missing at random and not missing at random processes, with data removed.     

商誉会计处理的几点思考

商誉是由于得天独厚的地理位置、悠久的经营历史、高水平的管理、优质的服务、良好的信誉、融洽的社会和企业关系,使一个企业的获利水平高于同行业平均获利水平的特殊资产,商誉可分为自创和外购两部分.本文就自创商誉和外购商誉的会计处理以及外购商誉的推销等问题进行了阐述,并提出了自己的理解和想法.