Gaps in antihypertensive and statin treatments and benefits of optimisation: a modelling study in a 1 million ethnically diverse urban population in UK

ObjectivesTo characterise gaps in antihypertensive treatment in people with hypertension and statin treatment in people with cardiovascular diseases (CVD) in a large urban population and quantify the health and economic impacts of their optimisation.DesignA cross-sectional population study and a long-term CVD decision model.SettingPrimary care, UK.ParticipantsAll adults with diagnosed hypertension or CVD in a population of about 1 million people, served by 123 primary care practices in London, UK in 2019.InterventionsFollowing UK clinical guidelines, all adults with diagnosed hypertension were categorised into optimal, suboptimal and untreated groups with respect to their antihypertensive treatment, and all adults with diagnosed CVD were categorised in the same manner with respect to their statin treatment.OutcomesProportion of patients suboptimally treated or untreated. Projected cardiovascular events avoided, years and quality-adjusted life years (QALYs) gained and healthcare costs saved with optimised treatments.Results21 954 of the 91 828 adults with hypertension (24%; mean age 59 years; 49% women) and 9062 of the 23 723 adults with CVD (38%; mean age 69 years; 43% women) were not optimally treated with antihypertensive or statin treatment, respectively. Per 1000 additional patients optimised over 5 years, hypertension treatment is projected to prevent 25 (95% CI 16 to 32) major vascular events (MVEs) and 7 (3 to 10) vascular deaths, statin treatment, 28 (22 to 33) MVEs and 6 (4 to 7) vascular deaths. Over their lifespan, a patient with uncontrolled hypertension aged 60–69 years is projected to gain 0.64 (95% CI 0.36 to 0.87) QALYs with optimised hypertension treatment, and a similarly aged patient with previous CVD not optimally treated with statin is projected to gain 0.3 (0.24 to 0.37) QALYs with optimised statin treatment. In both cases, the hospital cost savings minus extra medication costs were about £1100 per person over remaining lifespan.ConclusionsOptimising cardiovascular treatments can cost-effectively reduce cardiovascular risk and improve life expectancy.

Diabetes Prevalence Among Underserved Older Adults in the US: The Case of Native Hawaiians and Pacific Islanders

The effects of chronic diabetes among older adults in the United States represent ongoing challenges in diagnosis, treatment, comorbidities, amputations, and the increased risk of death. These challenges are made more complicated among underserved populations due to limited access to healthcare, medication costs, and later diagnosis of the condition. These issues are particularly true for the NHPI population, which has high rates of lifetime diabetes, greater levels of poverty, and inadequate health insurance. Useful statistics about diabetes among the NHPI have been difficult to obtain due to their small population size and lack of inclusion in federal health surveys. While early work by Panapasa examined prevalence among NHPI males in California, no reliable measures of diabetes among older NHPI’s existed at the national level. Released in 2017, the 2014 Native Hawaiian Pacific Islander National Health Interview Survey represents the first representative survey of the health and socio-economic correlates for this population, allowing the examination of health conditions such as diabetes at the national level. This presentation will examine the prevalence of diabetes among NHPI’s aged 60 and older and the impacts of this disease on overall health and quality of life. The paper will use the NHPI-NHIS to examine the use and access to diabetic medications and overall access to affordable health care. The paper will examine differences by age group, gender, immigration status, and ethnicity. While we know the overall prevalence of diabetes is high, this paper will offer new information on differentials within the older NHPI population.

Fidaxomicin as first line: What will it cost in the USA and Canada?

Importance: Recent changes in the Infectious Diseases and Healthcare Epidemiology Societies of America (IDSA-SHEA) guidelines for managing Clostridioides difficile infections (CDI) have placed fidaxomicin as first-line treatment for CDI. Objective: To estimate the net cost of first line fidaxomicin as compared to vancomycin in the American and Canadian healthcare systems and to estimate the price points at which fidaxomicin would become cost saving. Data sources: We identified all randomized controlled trials comparing fidaxomicin with vancomycin through the 2021 IDSA-SHEA guideline update. Medication costs were obtained from wholesale prices (US) and the Quebec drug formulary (Canada). The average cost of a CDI recurrence was established through two systematic reviews using PubMed. Study selection: For fidaxomicin efficacy, we included double-blind and placebo-controlled trials. For the systematic review of recurrence costs, studies were included if they were primary research articles, had a cost-analysis of CDI, included cases of recurrent CDI, and were calculated with cost parameters from American or Canadian healthcare systems. Studies were excluded if the population was solely pediatric or hospitalized. Data extraction and Synthesis: For the efficacy meta-analysis, data was pooled using a random effects model. For the costs review, literature screening was performed by 2 independent reviewers. The mean cost across identified studies was adjusted to 2021 dollars. Main Outcomes and Measures: The primary outcome of the meta-analysis was CDI recurrence at day 40. The primary outcome of the systematic review was the average cost of a CDI recurrence in the American and Canadian healthcare systems. The objective was to estimate the net cost per recurrence prevented and the price point below which fidaxomicin would be cost saving. Results: At current drug pricing, the estimated additional cost of a 10-day course of fidaxomicin compared to vancomycin in order to prevent one recurrence was $46,178USD (95%CI $36,942-$69,267) and $13,760CAD (95%CI $11,008-$20,640), respectively. The estimated mean systemic cost of a CDI recurrence was $14,506USD and $8,588CAD, respectively. When priced below $1550USD and $800CAD, fidaxomicin was likely to become cost saving. Conclusions and Relevance: The increased drug expenditure on fidaxomicin will not be offset through recurrence prevention unless fidaxomicin price is re-negotiated.

Clinical and economic outcomes attributable to carbapenem-resistant Enterobacterales and delayed appropriate antibiotic therapy in hospitalized patients

Objective: To assess the impact of carbapenem resistance and delayed appropriate antibiotic therapy (DAAT) on clinical and economic outcomes among patients with Enterobacterales infection. Methods: This retrospective cohort study was conducted in a tertiary-care medical center in Thailand. Hospitalized patients with Enterobacterales infection were included. Infections were classified as carbapenem-resistant Enterobacterales (CRE) or carbapenem-susceptible Enterobacterales (CSE). Multivariate Cox proportional hazard modeling was used to examine the association between CRE with DAAT and 30-day mortality. Generalized linear models were used to examine length of stay (LOS) and in-hospital costs. Results: In total, 4,509 patients with Enterobacterales infection (age, mean 65.2 ±18.7 years; 43.3% male) were included; 627 patients (13.9%) had CRE infection. Among these CRE patients, 88.2% received DAAT. CRE was associated with additional medication costs of $177 (95% confidence interval [CI], 114–239; P < .001) and additional in-hospital costs of $725 (95% CI, 448–1,002; P < .001). Patients with CRE infections had significantly longer LOS and higher mortality rates than patients with CSE infections: attributable LOS, 7.3 days (95% CI, 5.4–9.1; P < .001) and adjusted hazard ratios (aHR), 1.55 (95% CI, 1.26–1.89; P < .001). CRE with DAAT were associated with significantly longer LOS, higher mortality rates, and in-hospital costs. Conclusion: CRE and DAAT are associated with worse clinical outcomes and higher in-hospital costs among hospitalized patients in a tertiary-care hospital in Thailand.

59. Impact of Pharmacist-Led De-Escalation of MRSA Therapy Using MRSA Nasal PCR

Background Experts suggest that a highly sensitive MRSA nasal PCR can be used to rule out MRSA pneumonia with a negative predictive value greater than 95%. At Adventist Health Glendale (AHGL), the MRSA nasal PCR had a 97% negative predictive value. Pharmacist-led de-escalation of MRSA therapy using MRSA nasal PCR may reduce unnecessary MRSA coverage, patient adverse events, and medication costs. The purpose of this study was to assess the impact on duration of antimicrobial therapy of pharmacist-driven de-escalation of MRSA-targeted antibiotics in pneumonia using MRSA nasal PCR. Methods This was a prospective quasi-experimental study (Oct 2018 – Mar 2019 vs. Oct 2019 – Mar 2020) at AHGL, a 515-bed acute care community hospital in Los Angeles, CA, which included adults on MRSA pneumonia agents (either IV vancomycin or IV/PO linezolid). Upon receiving CPOE orders of these MRSA-targeted therapies for pneumonia, the pharmacist ordered a MRSA nasal PCR per protocol for eligible patients, followed up with the results of the MRSA nasal PCR, and recommended to discontinue MRSA therapy if the MRSA nasal PCR was negative. This study received an exemption determination from AHGL IRB. Results The total number of patients in the pre-protocol group was 97, and 155 in the post-protocol group. There was a statistically significant decrease in the median duration of MRSA pneumonia agents from the pre-protocol group compared to the post-protocol group (3 days vs. 2 days, P-value = 0.0004). Additionally, there was a statistically significant decrease in the median hospital length of stay from the pre-protocol group compared to the post-protocol group (9 days vs. 7 days, P-value = 0.02). Conclusion Implementation of a protocol involving pharmacist-led de-escalation of MRSA-targeted antibiotics for pneumonia utilizing MRSA nasal PCR led to significant decreases in both duration of therapy of MRSA-targeted antibiotics and length of hospital stay. Disclosures All Authors: No reported disclosures

Association between depression and antibiotic use: analysis of population-based National Health Insurance claims data

Background Frequent exposure to antibiotic treatments may increase the risk of antibiotic resistance, which may threaten the effectiveness of future antibiotic treatments. Thus, it is important to identify the preventable risks in terms of antibiotic use. This study assessed the association between major depressive disorder (MDD) and antibiotic use by comparing the likelihood and extent of antibiotic use between patients with and without MDD. Methods This retrospective cross-sectional study utilized the National Patients Sample data from the 2017 Health Insurance Review and Assessment Service. We analyzed 16,950 patients with MDD, defined as those with at least two claims records stating a primary diagnosis of MDD (International Classification of Diseases, 10th revision codes F32–33) and 67,800 patients without MDD (1:4 propensity-score matched control group). Antibiotic use was compared between the patients with and without MDD based on three variables: the presence of antibiotic prescriptions, total prescription days of antibiotics per year, and total medication costs of antibiotics per year. Results The adjusted odds ratio obtained by multivariate regression analysis for the presence of prescription of antibiotics was 1.31 (95% confidence interval [CI]: 1.25–1.36). In the negative binomial model, the number of prescription days was 1.25 times (95% CI: 1.23–1.28) higher in patients with MDD than in those without MDD. Generalized linear model analysis showed a 1.39-fold (95% CI: 1.36–1.43) higher cost of antibiotic prescription in patients with MDD than in those without MDD. Conclusions Our results suggest a potential association between MDD and the prescription of antibiotics, implying that patients with MDD are relatively vulnerable to infections. It is important to prevent as well as closely monitor the occurrence of infections when managing patients with MDD.

Impact of Intervention by an Antimicrobial Stewardship Team on Rational Use of Antibiotics

Background: An antimicrobial stewardship program can be defined as the set of actions performed in hospitals for the rational use of antibiotics. Early conversion from intravenous to oral antibiotics plays an important role in reducing the cost of treatment, shortening the length of hospital stay, and decreasing the workload of nurses. The purpose of this study was to evaluate the impact of the implementation of antimicrobial stewardship program on duration of hospitalization and medication costs. Methods: We performed an interventional study in Razi teaching hospital. All hospitalized patients aged 18 and older who met the inclusion criteria were included. This study comprised two groups. The interventional prospective group to assess the impact of intravenous to oral antibiotic conversion, and a retrospective group in which the intervention had not been applied, used as the comparator. Results: A total of 260 cases were enrolled; 47 in the interventional group and 213 in the retrospective one. The length of hospitalization was significantly shorter in the intervention group compared to the retrospective one (5.2 vs7.9 days, p<0.001). The cost of intravenous antibiotics and total medication costs significantly decreased in the intervention group. Conclusion: Our findings suggest that conversion from intravenous to oral antibiotics is effective for reducing the length of hospital stay, antibiotic cost, and excess use of intravenous antibiotics.

The benefit of an ambulant psychiatric rehabilitation program in Vienna, Austria: an uncontrolled repeated measures study

We investigated the benefit of a 6-week ambulant psychiatric rehabilitation program in an ambulant psychiatric rehabilitation clinic in Vienna, Austria, from January 2014 to December 2016 by an uncontrolled repeated measures study. The potential of this intervention program was assessed by effectiveness and cost measures using suitable statistical analyses. We compared the effectiveness and cost measures of this ambulant psychiatric rehabilitation program on patients for the period of up to 12 months after discharge to the period of 12 months before admission to the intervention program based on self-reported catamnesis questionnaires. For the program’s effectiveness measures, we accounted for both psychological indices for measuring depression severity, symptom burden, and functioning to document the health improvement of patients and economy-related indices such as the number of sick leave days for patients. For the program’s cost measures, both direct tangible treatment and medication costs and indirect tangible costs based on the productivity loss measured in non-working days of the patients were considered. The results significantly demonstrated that all psychological effectiveness measures for the patients highly improved by the 6-weeks rehabilitation program and remained rather stable 12 months after discharge. We found that costs for the 6-week ambulant psychiatric rehabilitation program could be easily covered within 12 months after discharge once a total societal cost perspective was considered. Even additional total cost savings of up to over 5000 Euro could be achieved which were highest for employed patients, followed by unemployed patients receiving rehabilitation allowance due to both their high direct medication and treatment costs as well as high indirect costs for productivity loss. The most important finding was that this treatment program was especially beneficial for rehabilitation patients in earlier stages of psychiatric diseases who were still employed, indicating the need for early intervention in mental disorder.

The economic cost and sustainability of the precision oncology promise.

7 Background: Despite the promise of precision oncology, the cost-effectiveness of targeted treatments is debated. Until now, the increase in price of oral targeted anti-cancer treatments used in common malignancies has not been evaluated. Here, we report patterns in price changes from 2015-2019 for multiple oral anti-cancer medications for common solid tumor malignancies. Methods: We utilized the publicly available Medicare Part D provider utilization and payment database from 2015 to 2019. We extracted drug prices (using generic names) for commonly used targeted oral anticancer agents for lung, breast, and prostate cancer. The primary outcome was the correlation of average change in Medicare spending per dosage unit among the multiple brand-name medications within each class available. We additionally calculated compound annual growth rates (CAGRs) [i.e. mean annual growth rates over a specified period of time] for medication costs within each class, and compared it with the consumer price index (a measure of the average change over time in the prices of consumer items). Results: The study included 6 EGFR inhibitors (1 generic), 5 ALK inhibitors, 2 BRAF inhibitors, 3 hormonal agents (1 generic), 3 CDK4/6 inhibitors, 2 PARP inhibitors, and 7 anti-androgen agents (2 generic). The median (range) Pearson correlation coefficient values for drugs within each class were 0.967 (0.915-0.978) for EGFRi, 0.981 (0.966-0.989) for ALKi, 0.996 for BRAFi, 0.994 (0.992-0.999) for CDK4/6i, 0.855 for PARPi, and 0.442 (-0.522-0.962) for anti-androgens. Except for anti-androgens, all other drug classes showed strong linear association in price increase between two drugs within the same-class. A coefficient could not be calculated for therapies with 2 or fewer data points ( i.e., generic erlotinib, dacomitinib, generic abiraterone, apalutamide, and darolutamide). There was no significant correlation between expenditure for anti-estrogen agents. The median (range) CAGRs in costs over this 5-year period were: were 4.56% for EGFRi, 6.40% for ALKi, 2.58% for BRAFi, 5.48% for hormonal agents, 5.21% for CDK4/6i, 27.29% for PARPi, and 34.8% for anti-androgen agents. Conclusions: The median CAGR in costs for modern oral precision driven cancer therapeutic classes mostly outpaced CPI (2.26%/year), and the average inflation rate (1.90%/year). Increase in cost within the same class should be weighed against incremental clinical benefit for the patients. For most classes despite there being multiple agents, the rise in drug expenditures correlated closely, calling into question the true value of within class competition. There is an urgent need for drug pricing reform given the average expenditure of Medicare part D, and ultimately out of pocket costs for our patients with cancer continues to trend upwards. Increased advocacy efforts are needed to ensure precision therapeutics remains an attainable and sustainable goal.