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1.  Most Americans Do Not Believe That There Is An Association Between Health Care Prices And Quality Of Care 
Health affairs (Project Hope)  2016;35(4):647-653.
Many organizations are developing health care price information tools for consumers. However, consumers may avoid low-price care if they perceive price to be associated with quality. We conducted a nationally representative survey to examine whether consumers perceive that price and quality are associated and whether the way in which questions are framed affects consumers’ responses. Most Americans (58–71 percent, depending on question framing) did not think that price and quality are associated, but a substantial minority did perceive an association (21–24 percent) or were unsure if there was one (8–16 percent). Responses to questions framed in terms of high price and high quality differed from responses to questions framed in terms of low price and low quality. People who had compared prices were more likely than those who have not compared prices to perceive that price and quality were associated. We explore implications of these findings, including how behavioral economics can inform approaches to helping consumers use price and quality information.
doi:10.1377/hlthaff.2015.1334
PMCID: PMC5029784  PMID: 27044965
2.  Value of genetic testing for hereditary colorectal cancer in a probability-based US online sample 
Background
While choices about genetic testing are increasingly common for patients and families, and public opinion surveys suggest public interest in genomics, it is not known how adults from the general population value genetic testing for heritable conditions. We sought to understand in a US sample the relative value of the characteristics of genetic tests to identify risk of hereditary colorectal cancer, among the first genomic applications with evidence to support its translation to clinical settings.
Methods
A Web-enabled choice-format conjoint survey was conducted with adults age 50 and older from a probability-based US panel. Participants were asked to make a series of choices between two hypothetical blood tests that differed in risk of false negative test, privacy, and cost. Random parameters logit models were used to estimate preferences, the dollar value of genetic information, and intent to have genetic testing.
Results
A total of 355 individuals completed choice-format questions. Cost and privacy were more highly valued than reducing the chance of a false negative result. Most (97%, 95% Confidence Interval (CI): 95% to 99%) would have genetic testing to reduce the risk of dying from colorectal cancer in the best scenario (no false negatives, results disclosed to primary care physician). Only 41% (95% CI: 25% to 57%) would have genetic testing in the worst case (20% false negatives, results disclosed to insurance company).
Conclusions
Given the characteristics and levels included in the choice, if false negative test results are unlikely and results are shared with a primary care physician, the majority would have genetic testing. As genomic services become widely available, primary care professionals will need to be increasingly knowledgeable about genetic testing decisions.
doi:10.1177/0272989X14565820
PMCID: PMC4501912  PMID: 25589525
3.  “Economic Evidence on Identifying Clinically Actionable Findings with Whole Genome Sequencing: A Scoping Review” 
Background
The American College of Medical Genetics (ACMG) recommends that mutations in 56 genes for 24 conditions are clinically actionable, and should be reported as secondary findings after whole genome sequencing (WGS). Our aim was to identify published economic evaluations of detecting mutations in the general population or in targeted/high-risk populations in these genes and conditions and identify gaps in knowledge.
Methods
A targeted PUBMED search from 1994 through November 2014 was performed and we included original articles reporting cost-effectiveness or cost-utility ratio or net benefits/benefit-cost focused on screening (not treatment) for ACMG listed conditions and genes in English. Articles were screened, classified as targeting a high-risk or general population, and abstracted by two reviewers. General population studies were evaluated for actual cost-effectiveness measures (e.g. ICER) while targeted populations studies were evaluated for whether at least one scenario proposed was cost-effective (e.g. ICER of ≤ $100,000 per life-year (LY) or quality-adjusted life-year (QALY) gained).
Results
A total of 607 studies were identified and 32 relevant studies were included. Identified studies addressed less than one third (7 of 24, 29%) of the AMCG conditions. The cost-effectiveness of screening in the general population was examined in only 2 of 24 (8%) conditions.
Conclusion
The cost-effectiveness of most genetic findings that the ACMG recommends for return has not been evaluated in economic studies or in the context of screening in the general population. The individual studies do not directly address the cost-effectiveness of WGS.
doi:10.1038/gim.2015.69
PMCID: PMC4654986  PMID: 25996638
Review; Economics; AMCG; Incidental Findings; “Whole Genome Sequencing”
4.  Consumer familiarity, perspectives and expected value of personalized medicine with a focus on applications in oncology 
Personalized medicine  2015;12(1):13-22.
Aims
Knowledge of consumer perspectives of personalized medicine (PM) is limited. Our study assessed consumer perspectives of PM, with a focus on oncology care, to inform industry, clinician and payer stakeholders' programs and policy.
Materials & Methods
A nationally representative survey of 602 US consumers' ≥30 years old explored familiarity, perspectives and expected value of PM.
Results
Most (73%) respondents have not heard of ‘personalized medicine,’ though after understanding the term most (95%) expect PM to have a positive beneft. Consumer's willingness to pay is associated with products' impact on survival, rather than predicting disease risk. If testing indicates consumers are not candidates for oncology therapies, most (84%) would seek a second opinion or want therapy anyway.
Conclusions
Understanding heterogeneity in consumer perspectives of PM can inform program and policy development.
doi:10.2217/pme.14.74
PMCID: PMC4303575  PMID: 25620993
consumers; education; knowledge; oncology; personalized medicine; perspectives; value
7.  Eligibility criteria in private and public coverage policies for BRCA genetic testing and genetic counseling 
Purpose
Coverage policies for genetic services for hereditary cancers are of interest because the services influence cancer risk reduction for both persons with cancer as well as their family members. We compared coverage policies for BRCA genetic testing and genetic counseling among selected payers in the US to illuminate eligibility criteria variation that may explain differential access by insurance type. We compared these policies to policies for breast cancer screening with MRI to consider whether payers apply a unique policy approach to genetic services.
Methods
We conducted a case study of large private and public payers selected on number of covered lives. We examined coverage policies for BRCA genetic testing, genetic counseling, and screening with MRI and the eligibility criteria for each. We compared eligibility criteria against National Comprehensive Cancer Network guidelines.
Results
Eligibility criteria for BRCA testing were related to personal history and family history of cancer. Although private payers covered BRCA testing for persons with and without cancer, the local Medicare carrier in our study only covered testing for persons with cancer. In contrast, Arizona's Medicaid program did not cover BRCA testing at all. Few payers had detailed eligibility criteria for genetic counseling. Private payers have more detailed coverage policies for both genetic services and screening with MRI in comparison to public payers.
Conclusion
Despite clinical guidelines establishing standards for BRCA testing, we found differences in coverage policies particularly between private and public payers. Future research and policy discussions can consider how differences in private and public payer policies influence access to genetic technologies and health outcomes.
doi:10.1097/GIM.0b013e31822a8113
PMCID: PMC4537294  PMID: 21844812
BRCA testing; coverage policy; family history; genetic counseling; hereditary breast and ovarian cancer; payer
8.  Binge Eating and Weight Loss Behaviors of Overweight and Obese College Students 
Purpose
To investigate binge eating (BE) and weight related behaviors in overweight and obese college students.
Data Sources
This was a secondary analysis of data from 487 overweight and obese college age students from a private university in the northeastern US.
Conclusions
BE was reported by 34.9% of students. Only 6.2% of participants reported the use of compensatory behaviors (i.e., self-induced vomiting, laxative, or diuretic use) to prevent weight gain. BE was associated with smoking and exercising to lose weight. Gender differences emerged from the data as women were more likely to report being obese, the use of compensatory behaviors, and to perceive themselves as moderately or extremely overweight.
Implications for Practice
Binge eating is a significant problem on college campuses and is associated with the development of obesity and eating disorders. Nurse practitioners (NPs) are in an excellent position to effect change in this population through their frequent contact with young adults in community and school-based venues. Nurse practitioners are well-prepared to identify at-risk college students and provide them with individualized care, education, and support.
doi:10.1002/2327-6924.12070
PMCID: PMC3937296  PMID: 24170676
9.  Genomic Sequencing: Assessing The Health Care System, Policy, And Big-Data Implications 
Health affairs (Project Hope)  2014;33(7):1246-1253.
New genomic sequencing technologies enable the high-speed analysis of multiple genes simultaneously, including all of those in a person's genome. Sequencing is a prominent example of a “big data” technology because of the massive amount of information it produces and its complexity, diversity, and timeliness. Our objective in this article is to provide a policy primer on sequencing and illustrate how it can affect health care system and policy issues. Toward this end, we developed an easily applied classification of sequencing based on inputs, methods, and outputs. We used it to examine the implications of sequencing for three health care system and policy issues: making care more patient-centered, developing coverage and reimbursement policies, and assessing economic value. We conclude that sequencing has great promise but that policy challenges include how to optimize patient engagement as well as privacy, develop coverage policies that distinguish research from clinical uses and account for bioinformatics costs, and determine the economic value of sequencing through complex economic models that take into account multiple findings and downstream costs.
doi:10.1377/hlthaff.2014.0020
PMCID: PMC4113721  PMID: 25006153
12.  Challenges of Coverage Policy Development for Next-Generation Tumor Sequencing Panels: Experts and Payers Weigh In 
Background
Next-generation tumor sequencing (NGTS) panels, which include multiple established and novel targets across cancers, are emerging in oncology practice, but lack formal positive coverage by US payers. Lack of coverage may impact access and adoption. This study identified challenges of NGTS coverage by private payers.
Methods
We conducted semi-structured interviews with 14 NGTS experts on potential NGTS benefits, and with 10 major payers, representing more than 125,000,000 enrollees, on NGTS coverage considerations. We used the framework approach of qualitative research for study design and thematic analyses and simple frequencies to further describe findings.
Results
All interviewed payers see potential NGTS benefits, but all noted challenges to formal coverage: 80% state that inherent features of NGTS do not fit the medical necessity definition required for coverage, 70% view NGTS as a bundle of targets versus comprehensive tumor characterization and may evaluate each target individually, and 70% express skepticism regarding new evidence methods proposed for NGTS. Fifty percent of payers expressed sufficient concerns about NGTS adoption and implementation that will preclude their ability to issue positive coverage policies.
Conclusions
Payers perceive that NGTS holds significant promise but, in its current form, poses disruptive challenges to coverage policy frameworks. Proactive multidisciplinary efforts to define the direction for NGTS development, evidence generation, and incorporation into coverage policy are necessary to realize its promise and provide patient access. This study contributes to current literature, as possibly the first study to directly interview US payers on NGTS coverage and reimbursement.
PMCID: PMC4372087  PMID: 25736008
13.  Using the Coronary Artery Calcium Score to Guide Statin Therapy 
Background
The coronary artery calcium score (CAC) predicts future coronary heart disease (CHD) events and could be used to guide primary prevention interventions, but CAC measurement has costs and exposes patients to low-dose radiation.
Methods and Results
We estimated the cost-effectiveness of measuring CAC and prescribing statin therapy based on the resulting score under a range of assumptions using an established model enhanced with CAC distribution and risk estimates from the Multi-Ethnic Study of Atherosclerosis (MESA). Ten years of statin treatment for 10,000 55-year-old women with high cholesterol (10-year CHD risk=7.5%) was projected to prevent 32 myocardial infarctions, cause 70 cases of statin-induced myopathy, and add 1,108 years to total life-expectancy. Measuring CAC and targeting statin treatment to the 2,500 women with CAC>0 would provide 45% of the benefit (+501 life-years), but CAC measurement would cost $2.25 million and cause 9 radiation-induced cancers. Treat All was preferable to CAC screening in this scenario and across a broad range of other scenarios (CHD risk=2.5-15%) when statin assumptions were favorable ($0.13/pill and no quality of life penalty). When statin assumptions were less favorable ($1.00/pill and disutility=0.00384), CAC screening with statin treatment for persons with CAC>0 was cost-effective (<$50,000/quality-adjusted life-year) in this scenario, in 55-year old men with CHD risk=7.5%, and in other intermediate risk scenarios (CHD risk=5-10%). Our results were critically sensitive to statin cost and disutility, and relatively robust to other assumptions. Alternate CAC treatment thresholds (>100 or >300) were generally not cost-effective.
Conclusions
CAC testing in intermediate risk patients can be cost-effective, but only if statins are costly or significantly impact quality of life.
doi:10.1161/CIRCOUTCOMES.113.000799
PMCID: PMC4156513  PMID: 24619318
coronary; atherosclerosis; economics; calcium; statins
14.  Prostatitis, Steatitis, and Diarrhea in a Dog following Presumptive Flea-Borne Transmission of Bartonella henselae 
Journal of Clinical Microbiology  2014;52(9):3447-3452.
Bartonella henselae is increasingly associated with a variety of pathological entities, which are often similar in dogs and human patients. Following an acute flea infestation, a dog developed an unusual clinical presentation for canine bartonellosis. Comprehensive medical, microbiological, and surgical interventions were required for diagnosis and to achieve a full recovery.
doi:10.1128/JCM.00942-14
PMCID: PMC4313127  PMID: 24920774
15.  Private Companies Providing Health Care Price Data: Who Are They and What Information do They Provide? 
Summary
There is interest in making health care price information more transparent given the increase in enrollment in high-deductible and consumer-directed health plans, and as policy efforts intensify to engage consumers to obtain high value care. We examine the role of private companies that market price transparency tools, primarily to self-insured employers – an important yet understudied topic. What companies exist? How did they emerge? What information do they provide? Where do they get that information? How does the price and quality information provided compare across companies?
PMCID: PMC4323083  PMID: 25678764
16.  Assessing Progress toward Becoming a Patient-Centered Medical Home: An Assessment Tool for Practice Transformation 
Health Services Research  2013;48(6 Pt 1):1879-1897.
Objective. To describe the properties of the Patient-Centered Medical Home Assessment (PCMH-A) as a tool to stimulate and monitor progress among primary care practices interested in transforming to patient-centered medical homes (PCMHs).
Study Setting. Sixty-five safety net practices from five states participating in a national demonstration program for PCMH transformation.
Study Design. Longitudinal analyses of PCMH-A scores were performed. Scores were reviewed for agreement and sites were categorized over time into one of five categories by external facilitators. Comparisons to key activity completion rates and NCQA PCMH recognition status were completed.
Data Collection/Extraction Methods. Multidisciplinary teams at each practice completed the 33-item self-assessment tool every 6 months between March 2010 and September 2012.
Principal Findings. Mean overall PCMH-A scores increased (7.2, March 2010, to 9.1, September 2012; [p < .01]). Increases were statistically significant for each of the change concepts (p < .05). Facilitators agreed with scores 82% of the time. NCQA-recognized sites had higher PCMH-A scores than sites that were not yet recognized. Sites that completed more transformation activities and progressed over defined tiers reported higher PCMH-A scores. Scores improved most in areas where technical assistance was provided.
Conclusions. The PCMH-A was sensitive to change over time and provided an accurate reflection of practice transformation.
doi:10.1111/1475-6773.12111
PMCID: PMC3876398  PMID: 24138593
Process assessment; patient-centered care; primary health care
17.  How do physician assessments of patient preferences for colorectal cancer screening tests differ from actual preferences? A comparison in Canada and the United States using a stated-choice survey 
Health economics  2009;18(12):1420-1439.
Background
Patient preferences can affect colorectal cancer screening test use. We compared utility-based preferences for alternative CRC screening tests from a stated-preference discrete-choice survey of the general population and physicians in Canada and the United States.
Methods
General population respondents (Canada, n=501; US, n=1087) participated in a survey with twelve choice scenarios and nine CRC screening test attributes. Physicians (n=100, both Canada and US) reported expected patient preferences. We estimated relative importance of attributes using bivariate probit regression analysis and calculated willingness-to-pay for various CRC screening tests.
Results
In 28% and 31% of scenarios, Canadian and US respondents, respectively, chose no screening over a hypothetical test. Canadian (45%) and US (46%) physicians expected patients to choose no screening more often.
For all groups the most important attribute was sensitivity, but physicians’ perception of patients’ preferences are significantly different from actual preferences. Other key attributes are those related to test performance or the testing process. Fecal DNA, colonoscopy, and virtual colonoscopy were the most preferred tests by all groups, but respondents were willing-to-pay more than physicians predicted.
Conclusion
Physicians’ perception of patients’ preferences are quite different from those of the general population. However, among general population and physicians, Canadian and US preferences were similar.
doi:10.1002/hec.1437
PMCID: PMC3964796  PMID: 19191268
colorectal cancer; screening; willingness-to-pay; discrete-choice; stated-preference
18.  The economic value of personalized medicine tests: what we know and what we need to know 
Purpose
There is uncertainty about when personalized medicine tests provide economic value. We assessed evidence on the economic value of personalized medicine tests and gaps in the evidence base.
Methods
We created a unique evidence base by linking data on published cost–utility analyses from the Tufts Cost-Effectiveness Analysis Registry with data measuring test characteristics and reflecting where value analyses may be most needed: (i) tests currently available or in advanced development, (ii) tests for drugs with Food and Drug Administration labels with genetic information, (iii) tests with demonstrated or likely clinical utility, (iv) tests for conditions with high mortality, and (v) tests for conditions with high expenditures.
Results
We identified 59 cost–utility analyses studies that examined personalized medicine tests (1998–2011). A majority (72%) of the cost/quality-adjusted life year ratios indicate that testing provides better health although at higher cost, with almost half of the ratios falling below $50,000 per quality-adjusted life year gained. One-fifth of the results indicate that tests may save money.
Conclusion
Many personalized medicine tests have been found to be relatively cost-effective, although fewer have been found to be cost saving, and many available or emerging medicine tests have not been evaluated. More evidence on value will be needed to inform decision making and assessment of genomic priorities.
doi:10.1038/gim.2013.122
PMCID: PMC3949119  PMID: 24232413
cost-effectiveness; economic value; ethical/legal/social implications (ELSI); genetic tests; personalized medicine
19.  HOW DOES COST MATTER IN HEALTH-CARE DISCRETE-CHOICE EXPERIMENTS? 
Health economics  2011;20(3):323-330.
SUMMARY
Willingness-to-pay (WTP) estimates derived from discrete-choice experiments (DCEs) generally assume that the marginal utility of income is constant. This assumption is consistent with theoretical expectations when costs are a small fraction of total income. We analyze the results of five DCEs that allow direct tests of this assumption. Tests indicate that marginal utility often violates theoretical expectations. We suggest that this result is an artifact of a cognitive heuristic that recodes cost levels from a numerical scale to qualitative categories. Instead of evaluating nominal costs in the context of a budget constraint, subjects may recode costs into categories such as ‘low’, ‘medium’, and ‘high’ and choose as if the differences between categories were equal. This simplifies the choice task, but undermines the validity of WTP estimates as welfare measures. Recoding may be a common heuristic in healthcare applications when insurance coverage distorts subjects’ perception of the nominal costs presented in the DCE instrument. Recoding may also distort estimates of marginal rates of substitution for other attributes with numeric levels. Incorporating ‘cheap talk’ or graphic representation of attribute levels may encourage subjects to be more attentive to absolute attribute levels.
doi:10.1002/hec.1591
PMCID: PMC3918954  PMID: 20217834
willingness to pay; discrete-choice experiments; decision heuristics; treatment cost
20.  Strategies to Identify the Lynch Syndrome Among Patients With Colorectal Cancer 
Annals of internal medicine  2011;155(2):69-79.
Background
Testing has been advocated for all persons with newly diagnosed colorectal cancer to identify families with the Lynch syndrome, an autosomal dominant cancer-predisposition syndrome that is a paradigm for personalized medicine.
Objective
To estimate the effectiveness and cost-effectiveness of strategies to identify the Lynch syndrome, with attention to sex, age at screening, and differential effects for probands and relatives.
Design
Markov model that incorporated risk for colorectal, endometrial, and ovarian cancers.
Data Sources
Published literature.
Target Population
All persons with newly diagnosed colorectal cancer and their relatives.
Time Horizon
Lifetime.
Perspective
Third-party payer.
Intervention
Strategies based on clinical criteria, prediction algorithms, tumor testing, or up-front germline mutation testing, followed by tailored screening and risk-reducing surgery.
Outcome Measures
Life-years, cancer cases and deaths, costs, and incremental cost-effectiveness ratios.
Results of Base-Case Analysis
The benefit of all strategies accrued primarily to relatives with a mutation associated with the Lynch syndrome, particularly women, whose life expectancy could increase by approximately 4 years with hysterectomy and salpingo-oophorectomy and adherence to colorectal cancer screening recommendations. At current rates of germline testing, screening, and prophylactic surgery, the strategies reduced deaths from colorectal cancer by 7% to 42% and deaths from endometrial and ovarian cancer by 1% to 6%. Among tumor-testing strategies, immunohistochemistry followed by BRAF mutation testing was preferred, with an incremental cost-effectiveness ratio of $36 200 per life-year gained.
Results of Sensitivity Analysis
The number of relatives tested per proband was a critical determinant of both effectiveness and cost-effectiveness, with testing of 3 to 4 relatives required for most strategies to meet a threshold of $50 000 per life-year gained. Immunohistochemistry followed by BRAF mutation testing was preferred in 59% of iterations in probabilistic sensitivity analysis at a threshold of $100 000 per life-year gained. Screening for the Lynch syndrome with immunohistochemistry followed by BRAF mutation testing only up to age 70 years cost $44 000 per incremental life-year gained compared with screening only up to age 60 years, and screening without an upper age limit cost $88 700 per incremental life-year gained compared with screening only up to age 70 years.
Limitation
Other types of cancer, uncertain family pedigrees, and genetic variants of unknown significance were not considered.
Conclusion
Widespread colorectal tumor testing to identify families with the Lynch syndrome could yield substantial benefits at acceptable costs, particularly for women with a mutation associated with the Lynch syndrome who begin regular screening and have risk-reducing surgery. The cost-effectiveness of such testing depends on the participation rate among relatives at risk for the Lynch syndrome.
Primary Funding Source
National Institutes of Health.
doi:10.7326/0003-4819-155-2-201107190-00002
PMCID: PMC3793257  PMID: 21768580
21.  Economic Evaluation of Targeted Cancer Interventions: Critical Review and Recommendations 
Scientific advances have improved our ability to target cancer interventions to individuals who will benefit most, and spare the risks and costs to those who will derive little benefit or even be harmed. Several approaches are currently used for targeting interventions for cancer risk reduction, screening and treatment, including risk prediction algorithms for identifying high-risk subgroups and diagnostic tests for tumor markers and germline genetic mutations. Economic evaluation can inform decisions about the use of targeted interventions, which may be more costly than traditional strategies. However, assessing the impact of a targeted intervention on costs and health outcomes requires explicit consideration of the method of targeting. Here we describe the importance of this principle by reviewing published cost-effectiveness analyses (CEAs) of targeted interventions in breast cancer. Few studies we identified explicitly evaluated the relationship between the method of targeting, the accuracy of the targeting test and outcomes of the targeted intervention. Those that did found that characteristics of targeting tests had a substantial impact on outcomes. We posit that the method of targeting and the outcomes of a targeted intervention are inextricably linked and recommend that CEAs of targeted interventions explicitly consider costs and outcomes of the method of targeting.
doi:10.1097/GIM.0b013e31821f3e64
PMCID: PMC3774033  PMID: 21637102
breast cancer; economic analysis; cost-effectiveness analysis; targeted therapy; personalized medicine; BRCA; trastuzumab; gene expression profiling
22.  Personalized Medicine and Oncology Practice Guidelines: A Case Study of Contemporary Biomarkers in Colorectal Cancer 
Predictive and prognostic biomarkers offer a potential means to personalize cancer medicine, although many reach the marketplace before they have been validated, and their adoption is often hindered by variable clinical evidence. Because of this variability in supporting evidence, clinical practice guidelines formulated by panels of subspecialty experts may be particularly important in guiding stakeholders’ acceptance and use of new personalized medicine biomarker tests and other nascent technologies. This article provides a structured review of the clinical evidence supporting 4 contemporary biomarker tests in colorectal cancer: K-ras and B-raf mutation analyses, mismatch repair protein testing, and the Oncotype DX Colon Cancer Assay. All 4 tests have been evaluated for guideline inclusion by the NCCN Guidelines Panel for Colon Cancer. This case study shows significant variability in the level of clinical evidence associated with these tests. In the cases of B-raf and mismatch repair protein testing, the available evidence is also inconsistent as it pertains to the specific NCCN guideline recommendation. Based on this uncertainty in the evidence base, the authors conclude that expert clinical judgment, experience, and consensus may be more heavily weighted than published clinical trial data in the evaluation of new personalized medicine biomarker tests. Potential implications of this conclusion and future directions for research are discussed.
PMCID: PMC3695822  PMID: 21233242
Biomarker; personalized medicine; guidelines; KRAS; BRAF; microsatellite instability; Oncotype DX Colon Cancer Assay
23.  Gene Expression Profile Testing for Breast Cancer and the Use of Chemotherapy, Serious Adverse Effects, and Costs of Care 
Background
As gene expression profile (GEP) testing for breast cancer may provide additional prognostic information to guide the use of adjuvant chemotherapy, we examined the association between GEP testing and use of chemotherapy, serious chemotherapy-related adverse effects, and total charges during the 12 months following diagnosis.
Methods
Medical record review was conducted for women age 30 to 64 years, with incident, non-metastatic, invasive breast cancer diagnosed 2006–2008 in a large, national health plan.
Results
Of 534 patients, 25.8% received GEP testing, 68.2% received chemotherapy, and 10.5% experienced a serious chemotherapy-related adverse effect. GEP testing was most commonly used in women at moderate clinical risk of recurrence (52.0% vs. 25.0% of low-risk women and 5.5% of high-risk). Controlling for the propensity to receive GEP testing, women who had GEP were less likely to receive chemotherapy (propensity adjusted odds ratio, 95% confidence interval 0.62, 0.39 – 0.99). Use of GEP was associated with more chemotherapy use among women at low risk based on clinical characteristics (OR = 42.19; CI 2.50 – 711.82), but less use among women with a high risk based on clinical characteristics (OR = 0.12 CI 0.03 – 0.47). Use of GEP was not associated with chemotherapy for the moderate risk group. There was no significant relationship between GEP use and either serious chemotherapy-associated adverse effects or total charges.
Conclusions
While GEP testing was associated with an overall decrease in adjuvant chemotherapy, we did not find differences in serious chemotherapy-associated adverse events or charges during the 12 months following diagnosis.
doi:10.1007/s10549-011-1628-6
PMCID: PMC3590013  PMID: 21681446
breast cancer; utilization; genomics
24.  Effectiveness of public health programs for decreasing alcohol consumption 
Patient intelligence  2011;2011(3):29-38.
Excessive alcohol consumption and the associated negative consequences are a major public health concern in the United States and throughout the world. Historically, there have been numerous attempts to develop policies and prevention programs aimed at decreasing high-risk alcohol use. Policy initiatives have demonstrated considerable effectiveness and include changes in the minimum legal drinking age, reductions in acceptable legal limits for blood alcohol concentration while operating a motor vehicle, as well as decreasing availability and access to alcohol for underage individuals. Primary prevention programs that have used exclusively educational approaches have received mixed results. Increasing effectiveness has been associated with prevention programs that have utilized a multi-component approach and have included educational initiatives with environmental changes.
doi:10.2147/PI.S12431
PMCID: PMC3505028  PMID: 23180975
alcohol abuse; underage; public health; programs; binge drinking
25.  Influence of Patient Preferences on the Cost-Effectiveness of Screening for Lynch Syndrome 
Journal of Oncology Practice  2012;8(3 Suppl):e24s-e30s.
This cost-utility analysis reports on the effect of quality of life on the value of screening all new patients with colorectal cancer for Lynch syndrome.
Purpose:
Patients and relatives have varying preferences for genetic testing and interventions related to hereditary cancer syndromes. We examined how the impact of these services on quality of life (QoL) affects the cost-effectiveness of screening for Lynch syndrome among probands newly diagnosed with colorectal cancer and their relatives.
Methods:
We constructed a state-transition model comparing screening strategies (clinical criteria, prediction algorithms, tumor testing, and upfront germline testing) with no screening to identify Lynch syndrome. The model incorporated individuals' health state utilities after screening, germline testing, and risk-reducing surgeries, with utilities persisting for 12 months in the base case. Outcomes consisted of quality-adjusted life-years (QALYs), costs, and cost per QALY gained. Sensitivity analyses assessed how the duration and magnitude of changes in QoL influenced results.
Results:
Multiple screening strategies yielded gains in QALYs at acceptable costs compared with no screening. The preferred strategy—immunohistochemistry of tumors followed by BRAF mutation testing (IHC/BRAF)—cost $59,700 per QALY gained in the base case. The duration and magnitude of decreases in QoL after decisions related to germline testing and surgeries were key determinants of the cost-effectiveness of screening. IHC/BRAF cost > $100,000 per QALY gained when decrements to QoL persisted for 21 months.
Conclusion:
Screening for Lynch syndrome in the population is likely to yield long-term gains in life expectancy that outweigh any short-term decreases in QoL, at acceptable costs. Counseling for individuals should aim to mitigate potential negative impact of genetic testing and risk-reducing interventions on QoL.
doi:10.1200/JOP.2011.000535
PMCID: PMC3348599  PMID: 22942831

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