A Budget Impact Analysis of the VENTANA PD-L1 SP142 Immunohistochemistry Assay Versus the Dako PD-L1 IHC 22C3 Assay in Patients With Advanced or Metastatic Triple-Negative Breast Cancer Treated With Atezolizumab in Combination With Nab-Paclitaxel

OBJECTIVE: To estimate the budget impact determined by the adoption of two different diagnostic strategies, SP142 assay or 22C3 assay, in the identification (in terms of PD-L1 status) of patients with mTNBC eligible for treatment with atezolizumab in combination with nab-paclitaxel.METHODS: The budget impact analysis (BIA) was conducted using a budget impact model (BIM) considering the Italian National Health Service’s (iNHS) perspective. The analysis assessed only the direct medical cost (tissue biopsy, PD-L1 assay, specialist visit, pharmacological treatment with atezolizumab in combination with nab-paclitaxel) of patients with PD-L1 positive mTNBC, and management of the adverse events associated with the pharmacological treatment administered. The BIM also considered the clinical benefits (progression free survival, PFS) resulting from the drug therapy administered on the basis of the results of the post-hoc analysis of the IMpassion130 clinical trial. The BIA was conducted over a 1-year time horizon. The median cost per patient in the progression-free state was also calculated. The costs were calculated using the net ex-factory prices (cancer drugs) and regional or national tariffs (tissue biopsy, PD-L1 assay, specialist visit and adverse events management). A sensitivity analysis was conducted to evaluate the base case result.RESULTS: The SP142 assay diagnostic pathway would result in a reduction of the iNHS expenditure of approximately 5.6 million euros (-12%). Almost all of the reduction in iNHS expenditure would be determined by the lower number of patients treated (SP142: 689 patients vs 22C3: 786 patients) with immunotherapy (-€ 5,530,871). Compared with 22C3 assay, the SP142 assay shows a cost per PFS month reduction of € 736 (€ 7,010 vs € 7,746).CONCLUSIONS: The use of the SP142 assay proved to be cost-effective compared to the 22C3 assay; the SP142 assay can support the choice of the most appropriate cancer drug, maximizing the effectiveness and minimizing the waste of healthcare resources.

A Multidisciplinary Spine Clinic Model Significantly Reduces Lead Times for Appropriate Specialist Visit and Appropriate Intervention in an Underserved Population: A Case Control Pilot Study

INTRODUCTION Spinal disorders are a leading cause of disability and lost productivity. Streamlining the route to specialist consultation and/or intervention can mitigate healthcare costs and improve patient outcomes and satisfaction. We instituted a multidisciplinary spine clinic (MSC) with physicians from neurosurgery, orthopaedics, pain medicine, and physiatry, where patients are simultaneously seen by providers from all these specialties, as appropriate. We hypothesized that patients from an underserved population initially seen in the MSC would experience reduced lead times to specialist visits and appropriate interventions compared to similar patients seen in a traditional unidisciplinary neurosurgery clinic (UDC). METHODS Records from 150 consecutive outpatients seen by a spine-specialized neurosurgeon either in the MSC or UDC from April 2018 July 2018 were abstracted. Multiple linear regression was used to determine if utilization of a MSC led to shorter lead times from initial visit with a spine surgeon (IV) to pain specialist visit (SV) and/or intervention. RESULTS The analytic sample consisted of 150 patients (n = 49 UDC, n = 101 MSC). Median time to SV and intervention in the UDC were 49 d (IQR 32–111) and 63 d (IQR 42–172), respectively. In the MSC, median time to SV was 20 d (IQR 0-38) and median time to intervention was 43 d (IQR 22–79). After controlling for differences between the two groups, multivariate analysis showed that the time to SV was reduced by 45 d (coef. −45.9, 95% CI [−69.5, −22.2], P < .001) and time to intervention was reduced by 60 d (coef. −55.0, 95% CI [−94.1, −15.8], P = .007) for patients seen in the MSC. CONCLUSION By centralizing providers in a MSC, outpatients with degenerative spinal conditions experienced shorter lead times to specialist consultation and intervention. As the direct and indirect costs of caring for spinal diseases balloon, implementation of MSCs can improve care coordination for patients. This model can be implemented successfully for socioeconomically disadvantaged populations.

Analysis of an electronic consultation program at an academic medical centre: Primary care provider questions, specialist responses, and primary care provider actions

Introduction Electronic consultations (eConsults) increase access to specialty care, but little is known about the types of questions primary care providers (PCPs) ask through eConsults, and how they respond to specialist recommendations. Methods This is a retrospective descriptive analysis of the first 200 eConsults completed in the UCSF eConsult program. Participating PCPs were from eight adult primary care sites at the University of California, San Francisco (UCSF), USA. Medicine subspecialties participating were Cardiology, Endocrinology, Gastroenterology/hepatology, Hematology, Infectious diseases, Nephrology, Pulmonary medicine, Rheumatology, and Sleep medicine. We categorized eConsult questions into “diagnosis,” “treatment,” and/or “monitoring.” We performed medical record reviews to determine the percentage of specialist recommendations PCPs implemented, and the proportion of patients with a specialist visit in the same specialty as the eConsult, emergency department visit, or hospital admission during the subsequent six months. Results PCP questions related to diagnosis in 71% of cases, treatment in 46%, and monitoring in 21%. Specialist responses related to diagnosis in 76% of cases, treatment in 64%, and monitoring in 40%. PCPs ordered 79% of all recommended laboratory tests, 86% of recommended imaging tests and procedures, 65% of recommended new medications, and 73% of recommended medication changes. In the six months after the eConsult, 14% of patients had a specialist visit within the UCSF system in the same specialty as the eConsult. Discussion eConsults provide guidance to PCPs across the spectrum of patient care. PCPs implement specialists’ recommendations in the large majority of cases, and few patients subsequently require in-person specialty care related to the reason for the eConsult.

Use of Physician Services by Older Adults: 1991/1992 to 2000/2001

ABSTRACTCanadians have expressed concern that access to family physicians (FP) has declined. Anonymized physician services data for 1991/1992 to 2000/2001 were used to evaluate changes in supply and age-specific rates of use of FPs and specialists in Winnipeg, Manitoba. Physician-to-population ratios declined 7.5 per cent, FP-to-population ratios declined 4.8 per cent, and specialist-to-population ratios declined 10.0 per cent. Among the general population, FP visit rates declined 3 per cent. Among older adults, physician visit rates increased 2.3 per cent, FP visit rates increased 10.9 per cent, and specialist visit rates declined 15.7 per cent. By comparison, we document declines in FP use by those younger than 5 years (25.5%) and those 6 to 19 years of age (18.6%). Increases in FP and declines in specialist use occurred primarily among those aged 65 to 84 years. By 2000/2001 older adults accounted for 25 per cent of all FP encounters. Gains in FP use among older adults was less attributable to the presence of more seniors and more related to the fact that a higher proportion of them are visiting a FP each year and, potentially, substituting primary for secondary care.