ISPOR Fourth Annual European Congress Contributed Presentation Abstracts Contributed Podium Presentations
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Volume 4 Number 6 2001VALUE IN HEALTH
ISPOR 1098-3015/01/$15.00/401 401420
ISPOR Fourth Annual European CongressContributed Presentation Abstracts
Contributed Podium Presentations
HEALTH POLICY I
VALIDITY OF THE MINIMUM-DATA-SET-BASED QUALITY INDICATOR FOR DETERMINING THE PREVALENCE OF ANTIPSYCHOTIC MEDICATION USAGE AMONG LOW RISK NURSING HOME RESIDENTS: A STATEWIDE ASSESSMENT
, Cortes LL
, Fouladi R
The University of Texas at Austin, Austin, TX, USA;
Texas Department of Human Services, Austin, TX, USA;
The University of Texas at MD Anderson Cancer Center, Houston, TX, USA
The Minimum Data Set (MDS) is an inter-national facility-reported database used to standardizethe assessment process and improve the quality of care innursing homes. Specific MDS assessments are used asquality indicators to determine the prevalence of antipsy-chotic prescribing as well as potentially inappropriate anti-psychotic usage. MDS classifies low-risk residents as receiv-ing an antipsychotic medication but having no documentedpsychotic or related condition and no cognitive impairmentwith behavioral symptoms. Without an audit of residentrecords, it is impossible to determine if the MDS accuratelyreports the prevalence of antipsychotic medications andwhether all low-risk residents represent inappropriateprescribing. The purpose of this study was to deter-mine MDS validity for identifying low-risk residents inTexas.
Facility-based MDS assessments were com-pared to independent on-site assessments. A team ofpharmacists reviewed the chart records of low risk resi-dents and determined whether a resident received an an-tipsychotic medication and the presence or absence of avalid indication. These findings were compared to thestatewide MDS quality indicator prevalence rate.
Based on MDS assessments, 10,163 residentsfrom 1021 nursing homes were identified as low risk.The chart records revealed that 12.4% of these residentswere not receiving antipsychotic medication. Of the 8904residents who were receiving an antipsychotic, 48.2%had a valid diagnosis or indication and were mistakenlyidentified as low-risk by the MDS database. Of the re-maining 4610 residents, 84.4% were missing a diagnosisand 15.6% had an inappropriate indication.
For this population of residents, a lackof accurate essential diagnostic information in MDS as-sessments and a high prevalence of inappropriate antipsy-chotic prescribing was found to be a widespread prob-lem. These findings indicate that nursing facilities wereinaccurate in their responses to MDS assessment itemsand therefore, the MDS had poor validity as a quality in-dicator for antipsychotic use.
TRANSLATING EVIDENCE TO PRACTICE IN BREAST CANCER
, Jayadevappa R
, de Pouvourville N
, Chartre S
University of Pennsylvania, Philadelphia, PA, USA;
University of Paris Medical School, Paris, France
Practice guidelines are being implementedfor many diseases to improve outcomes, increase use ofevidence-based medicine, and to reduce medical errors.Rarely are these efforts systematically evaluated in clini-cal care. We chose breast cancer in women as one diseasethat has excellent scientific evidence on treatment efficacybut almost no data on actual use in physician practice.
We studied use of breast conserving sur-gery, breast reconstruction, adjuvant chemotherapy, radi-ation, taxoids, tamoxifen, and aromatase inhibitors in el-igible women. The population was diagnosed between1995 and 2000 in six surgical oncology practices in theeight counties around Philadelphia with nearly seven mil-lion people. Four thousand three hundred ninety fivewomen were enrolled and followed retrospectively up tofive years after diagnosis. We abstracted each patientscomplete clinical record.
Lumpectomy was provided to 51.0% ofwomen, among whom 2.3% also had reconstruction.Forty nine percent of women (49.0%) had mastectomywith 18.0% having breast reconstruction, 56.8% re-ceived radiation therapy and 32.3% received adjuvantchemotherapy. Among eligible women, 0.6% had aro-matase inhibitors and 12.3% were prescribed taxoids.Among estrogen and/or progesterone-receptor-positivewomen, 72.4% got tamoxifen, while 35.1% with nega-tive estrogen and progesterone receptors got tamoxifen.One woman refused all treatment, one refused any breastsurgery, five refused adjuvant chemotherapy, two refusedradiation. Eight percent of eligible women refused tamox-ifen, mainly because of elevated risk of adverse side effects,and one had an autologous bone marrow transplant. Lo-gistic regression found that breast reconstruction was in-
versely related to patient age (p
.0029), tamoxifen var-ied directly with patient age (p
.0002) but inverselywith physician age (p
.02), and adjuvant chemotherapyand taxoids varied inversely with patient age (p
Two decades of multiple randomizedcontrol trials and meta-analyses have led to only modestsuccess in the use of highly beneficial treatments forbreast cancer in these specific oncology practices, al-though non-beneficial treatments are almost never used.
REGIONAL VARIATION IN PRESCRIPTION USE IN THE UNITED STATES
Motheral BR, Cox ER, Mager D, Henderson R
Express-Scripts, Maryland Heights, MO, USA
To evaluate the factors influencing the utiliza-tion of prescribed medications across the United States.
Prescription claims data for a random sam-ple of commercially insured Express Scripts members, 18to 64 years of age and continuously eligible for at leasttwo months in 1999 (N
1,467,699), were geo-coded atthe block group level. Key independent variables includedage, gender, family size, median income, education, ur-ban/rural location, client type, and pharmacy benefit de-sign. Outcome measures included any use of prescrip-tions. Hierarchical modeling (HLM) was used to controlfor clustering of patients within health plans.
Results from HLM indicate that after control-ling for demographics, client type, and pharmacy benefitdesign, variation in the probability of using a prescribedmedication was found across regions of the country.Members in the South have a greater likelihood of useand members in the Northeast and West having a lowerprobability of use than members in the Midwest. Agreater probability of use was associated with older age,female gender, higher income, family size
1, and enroll-ment in a managed care plan. Factors associated withlower probability of prescription use included presence ofa deductible, living in an urban area and having a manda-tory generic policy.
While patient age and gender remainkey factors driving prescription utilization, socioeconom-ics, pharmacy benefit design, and where a person lives arealso predictors of prescription use. Future research isneeded to better understand the causative roles of diseaseburden, physician practice style, and consumer preferencesin prescription drug use variation across the United States.
BRIEF ASSESSMENT OF PRIORITY SYMPTOMS IN HORMONE REFRACTORY PROSTATE CANCER (HRPCA)
, Banik D
, Singh A
, Ashraf T
, Padley RJ
, Dalal M
, Cella D
Evanston Northwestern Healthcare, Evanston, IL, USA;
Abbott Laboratories, Abbott Park, IL, USA
The objective of this study was to derive abrief, clinically relevant symptom index for men withHRPCa.
An international sample of 44 medical on-cologists, radiation oncologists, and urologists were pre-sented with 29 disease-related symptoms derived fromthe Functional Assessment of Cancer Therapy-Prostate(FACT-P) quality of life (QOL) instrument and asked toselect the five most important symptoms in assessing thetreatment response for men with HRPCa. Symptoms en-dorsed at a frequency greater than chance were retainedfor the index. Retrospective validation of the index wasaccomplished using data from a multi-national, random-ized, double-blind, placebo-controlled clinical trial ofatrasentan, a selective, oral ET-A receptor antagonist.The FACT-P and European Organization for Researchand Treatment of Cancer (EORTC) QLQ-C30 adminis-tered at baseline, six weeks and final visit were used toevaluate QOL responses to treatment of 288 men withHRPCa.
Experts initially selected eight priority symp-toms. Item-Response Theory analysis identified one mis-fitting item (worry), lending support for a seven-item in-dex (FPSI-7). Internal consistency was high for the seven-item index (0.75). Concurrent validity was establishedthrough correlations (
0.05) between the FPSI-7 andthe FACT-General (FACT-G;
0.56); FACT-P (
0.73); FACT Prostate Cancer Subscale (PCS;
0.88);Trial Outcome Index (TOI;
0.83); and QLQ-C30global score (
.56), symptom domain scores (
0.76), and generic domain scores (
0.36 to0.60). The FPSI-7 successfully differentiated patients byfunctional status, measured by the Eastern CooperativeOncology Group (ECOG) performance status rating(PSR,
.001), and clinical outcome, measured by dis-ease progression status (
.001). PSR and disease pro-gression are important outcomes for patients and clin