Annals for Educators - 5 March 2019

Inpatient Management of Patients With Cirrhosis

Cirrhosis affects millions of U.S. adults and costs the U.S. health care system upward of $6 billion annually. Cirrhosis is underrecognized, and the only cure is transplantation. Complications, including bleeding, infection, ascites, and renal injury, contribute to high rates of hospitalization, readmission, and mortality in this population. Evidence-based practices and guidelines offer quality recommendations for clinicians, but many of these guidelines have changed recently. This article provides an update on the current guidelines for the inpatient management of cirrhosis.

Core Performance Measures for Migraine Headache: A Review by the American College of Physicians

Migraine is a chronic condition that affects about 15% of the population in the United States and is characterized by recurrent, debilitating headache that lasts somewhere between 4 and 72 hours. Only 1 performance measure for migraine is currently in use in pay-for-performance programs. Although the American College of Physicians (ACP) broadly supports the role of performance measurement in performance improvement, this support is based on the principle that only measures that are evidence-based and meet high standards of methodological soundness are appropriate given their potential impact on patient care. ACP’s Performance Measurement Committee reviews performance measures using a rigorous process to recognize high-quality performance measures, address gaps and areas for improvement in performance measures, and help reduce reporting burden. This article presents a review of 1 performance measure that includes migraine and considers a potential core performance measure using ACP’s process to inform physicians, payers, and policymakers.

The Misplaced Push to Restrict Access to Gabapentin

Dying Healthy: Public Health Priorities for Fixed Population Life Expectancies

Death at Home or Hospice Among Physicians

Progress in Chronic Disease: Self-management for Patients With Epilepsy

Why Opioids Stop Working for Pain: No Free Ride in the Brain

Prophylactic Weekly Efanesoctocog Alfa Versus Standard-Care Factor VIII in People Living With Severe Hemophilia A: A Cost-Effectiveness Analysis: Annals of Internal Medicine: Vol 178, No 6

Background: Prophylaxis goals for patients with severe hemophilia A encompass advancement toward the hemophilia-free mind (freedom from bleeding, pain, arthropathy, and treatment burden). Efanesoctocog alfa, the first ultra-long half-life factor VIII agent that enables once-weekly prophylaxis, shows a 77% improvement in annualized bleeding rate compared with standard-care factor VIII prophylaxis. Objective: To evaluate the conventional and distributional cost-effectiveness of prophylaxis with efanesoctocog alfa versus standard-care factor VIII (standard half-life and extended half-life) in the United States. Design: Markov model. Data Sources: XTEND-1 study and other published sources. Target Population: Patients with severe hemophilia A. Time Horizon: Lifetime. Perspective: U.S. health system and societal. Intervention: Prophylaxis with efanesoctocog alfa versus standard-care factor VIII. Outcome Measures: Incremental cost-effectiveness ratio (ICER; cost per quality-adjusted life-year [QALY]) and threshold inequality aversion parameter (equity weight). Results of Base-Case Analysis: Efanesoctocog alfa and standard-care factor VIII accrued 19.7 and 14.6 discounted lifetime QALYs at costs of $22.1 million and $11.2 million, respectively, with an ICER of $2.13 million per QALY. The distributional cost-effectiveness analysis (DCEA)–derived threshold equity weight was 6.9, exceeding commonly used U.S. equity standards. Results were consistent across all scenario analyses. Results of Sensitivity Analysis: Only the price of efanesoctocog alfa could change the conclusion. Efanesoctocog alfa needs to be priced at less than 53% of its current price for conventional cost-effectiveness and less than 59% for distributional cost-effectiveness. Standard-care factor VIII was favored in 100% of 10 000 probabilistic iterations. Limitation: Benchmark equity weights (as opposed to hemophilia-specific weights) to interpret DCEA results. Conclusion: Prophylaxis with efanesoctocog alfa is not conventionally or distributionally cost-effective for severe hemophilia A in the United States at current pricing and equity weight thresholds. Primary Funding Source: National Institutes of Health; National Heart, Lung, and Blood Institute.

Review: Weak evidence of benefits of cannabis for chronic neuropathic pain; moderate to weak evidence of adverse effects

Source Citation Nugent SM, Morasco BJ, O’Neil ME, et al. The effects of cannabis among adults with chronic pain and an overview of general harms: a systematic review. Ann Intern Med. 2017;167:319-31. 28806817