Person: Tan, Sally
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Tan, Sally
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Publication Phase II study of tivantinib (ARQ 197) in patients with metastatic triple-negative breast cancer(Springer US, 2015) Tolaney, Sara M.; Tan, Sally; Guo, Hao; Barry, William; Van Allen, Eliezer; Wagle, Nikhil; Brock, Jane; Larrabee, Katherine; Paweletz, Cloud; Ivanova, Elena; Janne, Pasi; Overmoyer, Beth; Wright, John J.; Shapiro, Geoffrey I.; Winer, Eric P.; Krop, Ian E.Summary Background: MET expression and activation appear to be important for initiation and progression of triple-negative breast cancer. Tivantinib (ARQ 197) is an orally administered agent that targets MET, although recent preclinical data suggests the agent may have mechanisms of action that are independent of MET signaling. We conducted a phase 2 study of tivantinib monotherapy in patients with metastatic triple-negative breast cancer. Methods: Patients with metastatic triple-negative breast cancer who had received 1 to 3 prior lines of chemotherapy in the metastatic setting were enrolled into this two-stage, single arm phase 2 study. Treatment consisted of twice daily oral dosing of tivantinib (360 mg po bid) during a 21-day cycle. Patients underwent restaging scans at 6 weeks, and then every 9 weeks. Tumor biomarkers that might predict response to tivantinib were explored. Results: 22 patients were enrolled. The overall response rate was 5 % (95 % CI 0–25 %) and the 6-month progression-free survival (PFS) was 5 % (95 % CI 0–25 %), with one patient achieving a partial response (PR). Toxicity was minimal with only 5 grade ≥3 adverse events (one grade 3 anemia, one grade 3 fatigue, and 3 patients with grade 3/4 neutropenia). Conclusion: This study represents the first evaluation of tivantinib for the treatment of metastatic triple-negative breast cancer. These results suggest that single agent tivantinib is well tolerated, but did not meet prespecified statistical targets for efficacy.Publication Association of Dermatologist Density With the Volume and Costs of Dermatology Procedures Among Medicare Beneficiaries(American Medical Association (AMA), 2018) Tan, Sally; Tsoucas, Daphne; Mostaghimi, ArashImportance The persistent shortage of dermatologists in the United States affects access to care and patient outcomes. Objective To characterize the effect of geographic variations in dermatologist density on the provision of dermatology procedures within Medicare. Design, Setting, and Participants This was a cross-sectional study using the 2013 Medicare Provider Utilization and Payment Database. Dermatology-related procedures were defined by the top 50 billing codes accounting for more than 95% of procedures billed by dermatologists. Billing codes corresponding to evaluation and monitoring visits and dermatopathology were excluded. Total costs were estimated from the Centers for Medicare & Medicaid Services physician fee schedule, based on the nonfacility national payment amount with no modifiers. Nationally representative administrative database that includes 100% of charges billed by noninstitutional clinicians covered under Medicare Part B. A total of 10 391 dermatologists practicing within the 50 states and Washington, DC, were included. The Medicare-eligible population was defined as all persons 65 years or older. Exposures Density of dermatologists, categorized into first (5.3 per 100 000 persons ≥65 years) through fifth (54.8 per 100 000 persons ≥65 years) quintiles. Main Outcomes and Measures Utilization of dermatology procedures (mean volume per 100 000 persons ≥65 years) and total cost (mean amount billed per person ≥65 years) by clinician type across quintiles of dermatologist density. Results In 2013, dermatologists billed Medicare for 28 million procedures costing $2.21 billion. Mean billed amount by dermatologists per person 65 years or older was $15.87 in the lowest-density quintile vs $92.02 in the highest-density quintile. This trend suggests that each interval increase of 10 dermatologists per 100 000 persons 65 years or older is correlated with a $14.81 increase in Medicare spending on dermatology procedures (95% CI, 8.28-21.34; P = .005). Utilization of these procedures differed among clinician types, with dermatologists largely performing destruction of premalignant lesions and PCPs primarily doing injections. Conclusions and Relevance There is evidence of supply-sensitive variation in the provision of dermatology procedures for the Medicare-eligible population; higher dermatologist density is correlated with increased utilization of dermatology procedures and subsequent billed charges to Medicare. Further research is needed to determine the effect of such variations on outcomes and whether incentives can better align dermatologists with areas of clinical need.Publication National Readmission Rates and Outcomes for Patients Discharged Against Medical Advice(2018-05-15) Tan, SallyPurpose: Reducing non-elective readmissions is a strategic priority for hospitals. Individuals discharged against medical advice (AMA) are at high risk for readmissions. Previous studies on readmission outcomes after AMA discharge have been limited in their generalizability. This study sought to determine the likelihood of readmissions after AMA discharge, to identify factors associated with readmissions, and to assess in-hospital mortality, inpatient charges and length of stay for these readmissions. Methods: Using the Agency for Healthcare Research and Quality (AHRQ) all-payer Nationwide Readmissions Database, we conducted a retrospective cohort analysis of 19,882,317 (95% CI: 12,232,775 - 20,535,955) weighted index admissions for patients ≥18 years admitted from January - November 2014. We calculated 30-day non-elective readmission rates, 30-day in-hospital mortality, lengths of stay, and hospital charges by discharge disposition. To assess differences in readmission rates by discharge disposition, we estimated multivariable logistic regression models and adjusted for patient, clinical, and hospital characteristics. Results: Patients discharged AMA had a 30-day all-cause readmission rate of 21.0% (95% CI: 20.6 - 21.3) versus 10.4% (95% CI: 10.2 - 10.5%) for routine discharge to home or self-care. The difference remained significant (p<0.001) after adjusting for clinical, sociodemographic and hospital characteristics. Younger age, increased number of chronic comorbidities, low household income, and having public insurance were associated with higher readmission rates. Adjusted odds of 30-day in-hospital mortality was estimated to be 10% higher for patients discharged AMA versus routine discharge to home or self-care (aOR 1.10, 95% CI: 1.01 - 1.20). Leaving AMA resulted in the lowest hospital utilization (p<0.001), with a median 30-day total LOS of 5.8 days (IQR: 3.1 - 10.9) and total charges of $48,499 (IQR: $26,494 - $92,488). Conclusions: The 30-day readmission rate was significantly higher for patients discharged AMA than for routine discharge to home or self-care. While patients discharged AMA had lower overall hospital utilization, in aggregate they had slightly higher adjusted in-hospital mortality. There is potential opportunity to both lower healthcare spending for lower-risk AMA patients and improve outcomes for higher-risk AMA patients. Future research should focus on better risk stratification of this patient population so that such targeted interventions may be implemented.