Comparing Diagnosis and Treatment of Pulmonary Hypertension Patients at a Pulmonary Hypertension Center versus Community Centers

Once patients are diagnosed with pulmonary hypertension it is important to identify the correct diagnostic group as it will have implications on the disease state management. Pulmonary hypertension is increasingly diagnosed and treated in general medical practices; however, evidence-based guidelines recommend evaluation and treatment in pulmonary hypertension centers for accurate diagnosis and appropriate treatment recommendations. We conducted a retrospective cohort study of 509 random patients 18 years and older who were evaluated in our pulmonary hypertension clinic from January 2005 to December 2018. 68.4% (n = 348) had their diagnostic group clarified or changed. Pulmonary hypertension was deemed an incorrect diagnosis in 12.4% (n = 63). A total of 114 patients (22.4%) had been initiated on pulmonary hypertension specific treatment prior to presentation. Pulmonary hypertension specific medication was stopped in 57 (50.0%) cases. The estimated monthly saving of the stopped medication based on wholesale acquisition costs was USD 396,988.05–419,641.05, a monthly saving of USD 6964.70–7362.12 per patient. Evaluation outside of a pulmonary hypertension center may lead to misdiagnosis and inappropriate or inadequate treatment. Pulmonary arterial hypertension directed therapy improves median survival, but inappropriate therapy may cause harm; therefore, patients benefit from a specialized center with multiple resources to secure an accurate diagnosis and tailored treatment for their condition.

Fotogrammetrie jako optimální technika pro 3D digitalizaci v muzejních institucích

One of the challenges that museums often face is how to present their ‚treasures‘ in a form that is both comprehensive and relevant to today‘s audiences. Digital content alone is not enough in this context and 3D content is increasingly gaining importance. One of the most accessible and at the same time most effective 3D digitisation methods is photogrammetry. The result, if procedures are followed correctly, is not only high-quality content with a wide range of uses, but also potential stepping stones for effective business models. This can reduce acquisition costs quite significantly and make 3D digitisation accessible to a wider range of institutions.

Mid-Term Monitoring of Glacier’s Variations with UAVs: The Example of the Belvedere Glacier

Recently, Unmanned Aerial Vehicles (UAV) have opened up unparalleled opportunities for alpine glacier monitoring, as they allow for reconstructing extensive and high-resolution 3D models. In order to evaluate annual ice flow velocities and volume variations, six yearly measurements were carried out between 2015 and 2020 on the debris-covered Belvedere Glacier (Anzasca Valley, Italian Alps) with low-cost fixed-wing UAVs and quadcopters. Every year, ground control points and check points were measured with GNSS. Images acquired from UAV were processed with Structure-from-Motion and Multi-View Stereo algorithms to build photogrammetric models, orthophotos and digital surface models, with decimetric accuracy. Annual glacier velocities were derived by combining manually-tracked features on orthophotos with GNSS measurements. Velocities ranging between 17 m y−1 and 22 my−1 were found in the central part of the glacier, whereas values between 2 m y−1 and 7 my−1 were found in the accumulation area and at the glacier terminus. Between 2 × 106 m3 and 3.5 × 106m3 of ice volume were lost every year. A pair of intra-year measurements (October 2017–July 2018) highlighted that winter and spring volume reduction was ∼1/4 of the average annual ice loss. The Belvedere monitoring activity proved that decimetric-accurate glacier models can be derived with low-cost UAVs and photogrammetry, limiting in-situ operations. Moreover, UAVs require minimal data acquisition costs and allow for great surveying flexibility, compared to traditional techniques. Information about annual flow velocities and ice volume variations of the Belvedere Glacier may have great value for further understanding glacier dynamics, compute mass balances, or it might be used as input for glacier flow modelling.

Sustained reductions in unnecessary antimicrobial administration and hospital Clostridioides difficile rates via stewardship in a nonacademic setting

A large community hospital sought to reduce its burden of hospital-acquired Clostridioides difficile infection (CDI). We implemented an antimicrobial stewardship program (ASP), resulting in marked reductions in unnecessary antimicrobial use, CDI rates, antimicrobial acquisition costs, with preservation of gram-negative susceptibilities. ASP programs are effective in a community setting.

Price versus clinical guidelines in primary care statin prescribing: a retrospective cohort study and cost simulation model

Objective To investigate the relative impact of generic entry and National Institute for Health and Care Excellence clinical guidelines on prescribing using statins as an exemplar. Design Retrospective analysis of statin prescribing in primary care and cost simulation model. Setting Royal College of General Practitioners Research and Surveillance Centre (RCGP R&SC) database and Prescription Cost Analysis (PCA) database. Participants New patients prescribed statins for the first time between July 2003 and September 2018. Results General trends of statin’ prescriptions were largely driven by a decrease in acquisition costs triggered by patent expiration, preceding NICE guidelines which themselves did not seem to affect prescription trends. Significant heterogeneity is observed in the prescription of the most cost-effective statin across GPs. A cost simulation shows that, between 2004 and 2018, the NHS could have saved £2.8bn (around 40% of the £6.3bn spent on statins during this time) if all GP practices had prescribed only the most cost-effective treatment. Conclusions There is potential for large savings for the NHS if new and, whenever possible, ongoing patients are promptly switched to the first medicine that becomes available as generic within a therapeutic class as long as it has similar efficacy to still-patented medicines.

Financial Analysis of Habitat Conservation Banking in California

Habitat conservation banking is a policy instrument for conserving endangered species by providing financial incentives for the landowners in the United States. This policy instrument aims to protect habitat, but little or no thought has been given to its financial performance. A financial analysis of habitat conservation banks (HCB) informs policymakers and conservation biologists of the long-term success of this policy and the future of HCBs. This paper evaluates 26 habitat conservation banks (HCB) in California by calculating their Net Present Values (NPV). We do so by compiling the cost and revenue data for habitat conservation banks. The average annual cost of operating HCBs was $42.78/acre (median: $22.58/acre), and the average credit price or revenue from credit sale was $6014.72/acre (median: $553.65/acre). The average NPV for 26 HCBs was $4205.90/acre at a 4% rate of return, indicating an overall positive return from such an easement instrument. However, only 14 HCBs out of 26 produced a positive return. With the inclusion of land acquisition costs, three of eight HCBs performed financially well. On the brighter side, the number of HCBs has increased with time. But there is not enough evidence to ascertain financial certainty from their revenues. A right selection of space (land acquisition costs can make or break finances for HCB) and species could encourage landowners to establish HCBs. This could build confidence on those who may have been discouraged from lack of knowledge and fear of losing revenue due to regulatory compliance to conserve endangered species habitat in their land. The findings are helpful in identifying lands and prioritizing investments to generate conservation credits.

Residential Construction with a Focus on Evaluation of the Life Cycle of Buildings

The article focuses on highlighting the role of life cycle costing (LCC) in the preparatory and implementation phase of residential projects. It involves the evaluation of several investment scenarios in the pre-investment phase, the choice between variants of the design of the entire building or its parts, and the choice of variants of structures and equipment with acceptable parameters. An innovative method of evaluating the life cycle of buildings is described in the article. This method was tested in selected residential projects realized by Skanska in the Czech Republic. Experience from construction practice shows that the choice of variants, constructions, or equipment of buildings only on the basis of the lowest acquisition costs (lowest bid prices) is wrong. The LCC calculation tool has been designed to model life cycle costs of individual variants of construction designs with different input parameters. It is possible to analyze the components or equipment that have the greatest impact on total life cycle costs. The article presents a tool that evaluates the long-term economic efficiency of the proposed residential buildings in terms of analysis of life cycle costs. The article will also expand the knowledge of the professional and general public about the importance of examining investment and operating costs already in the phase of construction preparation.

Total Car-T Cost of Care Beyond the Price of Car-T Cell Therapy in Patients with Multiple Myeloma

Background: Chimeric antigen receptor T (CAR-T) cell therapy is a recent treatment option for triple-class exposed relapsed refractory multiple myeloma (RRMM) patients, who have previously received proteasome inhibitors, immunomodulatory agents, and monoclonal antibodies. In addition to CAR-T cell therapy acquisition costs, there are expected CAR-T healthcare costs separate from the cost of the CAR-T cell therapy itself. Identification and quantification of these costs have not previously been fully investigated. Healthcare payers, hospitals, and physicians need this important cost information in order to make informed healthcare decisions. Objective: The objective of this study was to quantify CAR-T therapy associated healthcare costs, i.e., costs aside from CAR-T therapy acquisition costs, associated with use of CAR-T therapy in RRMM patients. Methods: RRMM CAR-T clinical trial data and published literature, including peer-reviewed publications and conference presentations, were used for identification of these additional healthcare cost components. Inclusion/exclusion of additional cost components was based on previously published oncology pharmacoeconomic studies and input from key opinion leaders (KOLs) with expertise in the treatment of RRMM patients. The study categorized costs for RRMM patients who receive the CAR-T infusion. Costs were categorized as pre-infusion, peri-infusion (excluding CAR-T therapy acquisition costs), and post-infusion costs. Pre-infusion costs included evaluation costs, apheresis costs, bridging therapy costs, and conditioning therapy costs. Peri-infusion costs included either inpatient or outpatient infusion costs. Post-infusion costs included 100-day post-infusion monitoring costs, additional infusion monitoring costs in the first year, and management of serious adverse event (AE) costs associated with the CAR-T therapy. Serious AEs included AEs that require or prolong hospitalization or result in death. CAR-T acquisition costs are known and readily accessible, but this is not the case for other costs associated with CAR-T therapy, i.e., the pre-, peri-, and post-infusion costs. The costs must be individually calculated utilizing CAR-T clinical trial data, medical resource costs and utilization, and AE costs and rates. Based on a targeted literature review, there are sufficient data in the public domain to quantify the component additional costs, however there are no publications quantifying the entirety of these costs specifically in RRMM patients receiving CAR-T. Methodology was developed for derivation of these costs, which comprise an important and consequential portion of the total CAR-T therapy costs. Results: The RRMM patient pre- and peri-infusion CAR-T healthcare cost, aside from CAR-T therapy acquisition costs, was estimated to be $15,478. The components of this cost were apheresis ($112), bridging therapy ($8,570), conditioning therapy ($3,435), and a single day of inpatient infusion ($3,362). The post-infusion costs (including additional inpatient hospital days, AE management, and monitoring costs) are dependent on the types and rates of AEs associated with CAR-T therapy. These results will be presented at the ASH 2021 meeting. Conclusions: This study developed a methodology for the categorization, quantification, and calculation of the important healthcare costs, aside from CAR-T therapy acquisition costs, associated with the use of CAR-T in triple-class exposed RRMM patients. This information has been lacking in the literature and the analysis provides valuable, holistic information that key stakeholders require to make informed decisions. Disclosures Jagannath: Bristol Myers Squibb: Consultancy; Janssen Pharmaceuticals: Consultancy; Karyopharm Therapeutics: Consultancy; Legend Biotech: Consultancy; Takeda: Consultancy; Sanofi: Consultancy. Joseph: Johnson and Johnson: Current Employment, Current equity holder in publicly-traded company. Crivera: Johnson & Johnson: Current Employment, Current equity holder in publicly-traded company. Jackson: Janssen: Current Employment; Memorial Sloan Kettering Cancer Center: Consultancy. Valluri: Janssen: Current Employment, Current equity holder in publicly-traded company. Cost: Johnson & Johnson: Current Employment, Current equity holder in publicly-traded company. Phelps: Johnson & Johnson: Current Employment, Current equity holder in publicly-traded company. Slowik: Johnson & Johnson: Current Employment, Current equity holder in publicly-traded company. Klein: Medical Decision Modeling Inc.: Current Employment. Yu: Medical Decision Modeling Inc.: Current Employment. Smolen: Medical Decision Modeling Inc.: Current Employment. Cohen: GlaxoSmithKline: Consultancy, Research Funding; Janssen: Consultancy; Takeda: Consultancy; Oncopeptides: Consultancy; BMS/Celgene: Consultancy; AstraZeneca: Consultancy; Genentech/Roche: Consultancy; Novartis: Research Funding.

Cost per Responder Analysis for Pegcetacoplan and Eculizumab in the Treatment of Adults with Paroxysmal Nocturnal Hemoglobinuria

Background: In the absence of clinical guidelines for paroxysmal nocturnal hemoglobinuria (PNH), the European Society for Blood and Marrow Transplantation (EBMT) developed categories for classifying hematological response to complement inhibitor treatment (per Risitano AM, et al. Front Immunol. 2019;10:1157). These categories are: complete (no transfusions, normal stable Hb, and no evidence of hemolysis); major (no transfusions, normal Hb, but evidence of residual intravascular/extravascular hemolysis); good (no transfusions, but persistent chronic mild anemia); partial (persistent chronic moderate anemia and/or occasional red blood cell transfusions); minor (3-6 transfusions every 6 months); no response (>6 transfusions every 6 months). In the phase 3 PEGASUS trial (NCT03500549), 41 and 39 patients previously treated with C5 inhibitors with Hb<10.5 were randomized for treatment with pegcetacoplan or eculizumab, respectively. In a post hoc analysis of the 16-week PEGASUS data, patients were classified by EBMT category to compare hematologic responses of each treatment (per Risitano AM, et al. Blood. 2020; 136(Suppl1):44-5). Objectives: The objective of this study was to evaluate the number needed to treat (NNT) and treatment costs of pegcetacoplan and eculizumab using EBMT response criteria. Methods: The analysis used a United States payer perspective and included drug acquisition costs and associated intravenous or subcutaneous administration costs. Drug costs were calculated using dosages for each treatment as given in the PEGASUS trial, including dosage and frequency escalations. Weekly dosages were multiplied by each drug's wholesale acquisition costs from RedBook (2020 United States dollars). We calculated the following outcomes over 16 weeks and by treatment: NNT to achieve each level of response, mean cost per treated patient, total costs, mean cost per treated patient per week, cost per complete responder, cost per good responder, and cost spent on patients with partial/minor/no response. Additional analyses were conducted to calculate outcomes for treatment-naïve patients treated with pegcetacoplan using similar post hoc analyses of combined 16-week data from the phase 1b-2a PADDOCK/PALOMINO (NCT02588833 and NCT03593200) trials. Results: Results are summarized in Table 1. Based on response rates, patients with PNH treated with pegcetacoplan had a lower NNT (1.4) to achieve good-to-complete response compared with eculizumab (19.5). NNT to achieve complete response was 2.6 for pegcetacoplan; no patients treated with eculizumab achieved complete response at 16 weeks. For the PEGASUS trial, mean cost per treated patient was $182,762 (with C5 inhibitor loading dose) and $176,504 over 16 weeks for pegcetacoplan and eculizumab, respectively. Among the 41 pegcetacoplan-treated patients, the total costs were $7,493,256 over 16 weeks. Of 41 pegcetacoplan patients, 16 achieved a complete response, and their total costs were $2.9 million over the 16-week period ($468,328 per complete responder). The total 16-week costs were $2.6 million for 14 patients with good response ($535,233 per good responder). For the 39 eculizumab-treated patients, total 16-week costs were $6,883,637. Two of 39 patients achieved a good response, and their total costs were $353,007 ($3,441,818 per good responder). Of the 39 patients, 37 achieved partial, minor, or no response or discontinued treatment, for a total cost of $6.5 million. This resulted in 95% of total treatment costs being spent on inadequate or no response in the eculizumab arm compared with 27% in the pegcetacoplan arm. For treatment-naïve patients treated with pegcetacoplan, the mean cost per complete responder ($347,339) and per good responder ($496,198) over 16 weeks were both lower than the cost per responder for patients treated with either pegcetacoplan or eculizumab after previous C5 inhibitor treatment. Conclusion: Based on the treatment response observed in PEGASUS, the NNT and cost to achieve good or good-to-complete response was lower for pegcetacoplan-treated patients than eculizumab-treated patients, according to EBMT consensus-based hematological response categories. PNH treatment with pegcetacoplan allowed more patients to achieve EBMT defined good-to-complete response and better overall response and is a more efficient use of spending with lower cost per responder in all response categories. Figure 1 Figure 1. Disclosures Anderson: Apellis: Consultancy, Research Funding. Talbird: Apellis: Consultancy, Research Funding. Fishman: Apellis: Current Employment, Current equity holder in publicly-traded company.

Skill Acquisition and Data Sales

We develop a data-sales model to study the implications of alternative data for financial markets. Investors acquire skills to process the purchased raw data, and developing such skills is costly and involves considerable uncertainty. The data vendor controls the size of the data sample to influence the precision of the information investors can extract from the purchased data. Price informativeness is hump-shaped in skill-acquisition costs although the cost of capital and return volatility are U-shaped in skill-acquisition costs. Similar patterns can arise for skill mean and volatility. Our analysis suggests that the funds and data industries foster each other. This paper was accepted by Agostino Capponi, finance.