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Mitchell AP, Kinlaw AC, Peacock-Hinton S, Dusetzina SB, Winn AN, Sanoff HK, Lund JL. Commercial Versus Medicaid Insurance and Use of High-Priced Anticancer Treatments. Oncologist 2024; 29:527-533. [PMID: 38484395 PMCID: PMC11144993 DOI: 10.1093/oncolo/oyae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/16/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Because the markups on cancer drugs vary by payor, providers' financial incentive to use high-price drugs is differential according to each patient's insurance type. We evaluated the association between patient insurer (commercial vs Medicaid) and the use of high-priced cancer treatments. MATERIALS AND METHODS We linked cancer registry, administrative claims, and demographic data for individuals diagnosed with cancer in North Carolina from 2004 to 2011, with either commercial or Medicaid insurance. We selected cancers with multiple FDA-approved, guideline-recommended chemotherapy options and large price differences between treatment options: advanced colorectal, lung, and head and neck cancer. The outcome was a receipt of a higher-priced option, and the exposure was insurer: commercial versus Medicaid. We estimated risk ratios (RRs) for the association between insurer and higher-priced treatment using log-binomial models with inverse probability of exposure weights. RESULTS Of 812 patients, 209 (26%) had Medicaid. The unadjusted risk of receiving higher-priced treatment was 36% (215/603) for commercially insured and 27% (57/209) for Medicaid insured (RR: 1.31, 95% CI: 1.02-1.67). After adjustment for confounders the association was attenuated (RR: 1.15, 95% CI: 0.81-1.65). Exploratory subgroup analysis suggested that commercial insurance was associated with increased receipt of higher-priced treatment among patients treated by non-NCI-designated providers (RR: 1.53, 95% CI: 1.14-2.04). CONCLUSIONS Individuals with Medicaid and commercial insurance received high-priced treatments in similar proportion, after accounting for differences in case mix. However, modification by provider characteristics suggests that insurance type may influence treatment selection for some patient groups. Further work is needed to determine the relationship between insurance status and newer, high-price drugs such as immune-oncology agents.
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Luebke MC, Davidson ERW, Crotty BH, Fergestrom N, O'Connor RC, Schmitt E, Winn AN, Flynn KE, Neuner JM. Referral and Prescription Patterns for Female Patients With Urinary Incontinence. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024; 30:489-497. [PMID: 37881958 PMCID: PMC11002977 DOI: 10.1097/spv.0000000000001423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
IMPORTANCE Although behavioral modifications, medications, and other interventions can improve urinary incontinence (UI), many women never receive them. OBJECTIVES To better characterize UI treatment patterns in primary care, we examined prescriptions and referrals to pelvic floor physical therapy (PFPT) and specialist physicians within a large Midwestern academic health system. STUDY DESIGN Electronic health records were queried to identify a cohort of adult female patients receiving a new UI diagnosis during outpatient primary care visits from 2016 to 2020. Urinary incontinence referrals and referral completion were examined for the overall cohort, and medication prescriptions were examined for women with urgency or mixed UI. Logistic regression was used to assess the association of prescriptions and/or referrals with patient demographics, comorbidities, and UI diagnosis dates. RESULTS In the year after primary care UI diagnosis, 37.2% of patients in the overall cohort (n = 4,382) received guideline-concordant care. This included 20.6% of women who were referred for further management: 17.7% to urology/urogynecology and 3.2% to PFPT. Most women who were referred attended an initial appointment. Among those with urgency (n = 2,398) or mixed UI (n = 552), 17.1% were prescribed medication. Women with stress (odds ratio [OR], 3.10; 95% CI, 2.53-3.79) and mixed UI (OR, 6.17; 95% CI, 4.03-9.66) were more likely to be referred for further management, and women diagnosed during the COVID-19 pandemic were less likely to be referred for further care (OR, 0.39; 95% CI, 0.29, 0.48). CONCLUSION Only slightly above 1 in 3 women with a new diagnosis of UI in primary care received guideline-based medications or referrals within 1 year, suggesting missed opportunities for timely care.
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Basu A, Winn AN, Johnson KM, Jiao B, Devine B, Hankins JS, Arnold SD, Bender MA, Ramsey SD. Gene Therapy Versus Common Care for Eligible Individuals With Sickle Cell Disease in the United States : A Cost-Effectiveness Analysis. Ann Intern Med 2024; 177:155-164. [PMID: 38252942 DOI: 10.7326/m23-1520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Sickle cell disease (SCD) and its complications contribute to high rates of morbidity and early mortality and high cost in the United States and African heritage community. OBJECTIVE To evaluate the cost-effectiveness of gene therapy for SCD and its value-based prices (VBPs). DESIGN Comparative modeling analysis across 2 independently developed simulation models (University of Washington Model for Economic Analysis of Sickle Cell Cure [UW-MEASURE] and Fred Hutchinson Institute Sickle Cell Disease Outcomes Research and Economics Model [FH-HISCORE]) using the same databases. DATA SOURCES Centers for Medicare & Medicaid Services claims data, 2008 to 2016; published literature. TARGET POPULATION Persons eligible for gene therapy. TIME HORIZON Lifetime. PERSPECTIVE U.S. health care sector and societal. INTERVENTION Gene therapy versus common care. OUTCOME MEASURES Incremental cost-effectiveness ratios (ICERs), equity-informed VBPs, and price acceptability curves. RESULTS OF BASE-CASE ANALYSIS At an assumed $2 million price for gene therapy, UW-MEASURE and FH-HISCORE estimated ICERs of $193 000 per QALY and $427 000 per QALY, respectively, under the health care sector perspective. Corresponding estimates from the societal perspective were $126 000 per QALY and $281 000 per QALY. The difference in results between models stemmed primarily from considering a slightly different target population and incorporating the quality-of-life (QOL) effects of splenic sequestration, priapism, and acute chest syndrome in the UW model. From a societal perspective, acceptable (>90% confidence) VBPs ranged from $1 million to $2.5 million depending on the use of alternative effective metrics or equity-informed threshold values. RESULTS OF SENSITIVITY ANALYSIS Results were sensitive to the costs of myeloablative conditioning before gene therapy, effect on caregiver QOL, and effect of gene therapy on long-term survival. LIMITATION The short-term effects of gene therapy on vaso-occlusive events were extrapolated from 1 study. CONCLUSION Gene therapy for SCD below a $2 million price tag is likely to be cost-effective when applying a societal perspective at an equity-informed threshold for cost-effectiveness analysis. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute.
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Mitchell AP, Winn AN. Authors' reply to Laurent. BMJ 2023; 383:p2832. [PMID: 38049172 DOI: 10.1136/bmj.p2832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
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Lin M, Estrada-Merly N, Eapen M, Zamora AE, Pezzin LE, Winn AN, Philip J, Schinke C, Drobyski WR, Anderson LD, D'Souza A. Widening demographic gaps in CAR-T therapy utilization for multiple myeloma in the United States. Bone Marrow Transplant 2023; 58:1400-1402. [PMID: 37673983 DOI: 10.1038/s41409-023-02102-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 08/17/2023] [Accepted: 08/30/2023] [Indexed: 09/08/2023]
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Winn AN, Atallah E, Cortes J, Deininger MWN, Kota V, Larson RA, Moore JO, Mauro MJ, Oehler VG, Pinilla-Ibarz J, Radich JP, Shah NP, Thompson JE, Flynn KE. Estimated Savings After Stopping Tyrosine Kinase Inhibitor Treatment Among Patients With Chronic Myeloid Leukemia. JAMA Netw Open 2023; 6:e2347950. [PMID: 38109114 PMCID: PMC10728762 DOI: 10.1001/jamanetworkopen.2023.47950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/02/2023] [Indexed: 12/19/2023] Open
Abstract
Importance Patients with chronic myeloid leukemia (CML) who have a sustained deep molecular response using tyrosine kinase inhibitors (TKIs) can safely attempt to stop their use. As these medications are very costly, this change in treatment protocols may result in large savings. Objective To estimate future savings from attempting to stop TKI use among patients with CML who have deep molecular response. Design, Setting, and Participants A microsimulation model was developed for this decision analytical modeling study to estimate costs for US adults moving from using a TKI, to attempting discontinuation and then reinitiating TKI therapy, if clinically appropriate. Estimates were calculated for US patients who currently have CML and simulated newly diagnosed cohorts of patients over the next 30 years. Exposure Attempting to stop using a TKI. Main Outcomes and Measures Estimated savings after attempted discontinuation of TKI use. Results A simulated population of individuals with CML in 2018 and future populations were created using estimates from the SEER*Explorer website. The median age at diagnosis was 66 years for men and 65 years for women. Between 2022 and 2052, the savings associated with eligible patients attempting discontinuation of TKI therapy was estimated at more than $30 billion among those currently diagnosed and over $15 billion among those who will develop CML in the future, for a total savings of over $54 billion by 2052 for drug treatment and polymerase chain reaction testing. The estimate is conservative as it does not account for complications and other health care-associated costs for patients continuing TKI therapy. Conclusions and Relevance The findings of this decision analytical modeling study of patients with CML suggest that attempting discontinuation of TKI therapy could save over $54 billion during the next 30 years. Further education for patients and physicians is needed to safely increase the number of patients who can successfully attain treatment-free remission.
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Mitchell AP, Dusetzina SB, Mishra Meza A, Trivedi NU, Bach PB, Winn AN. Pharmaceutical industry payments and delivery of non-recommended and low value cancer drugs: population based cohort study. BMJ 2023; 383:e075512. [PMID: 37879723 PMCID: PMC10599253 DOI: 10.1136/bmj-2023-075512] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE To estimate the association between oncologists' receipt of payments from the pharmaceutical industry and delivery of non-recommended or low value interventions among their patients. DESIGN Cohort study. SETTING Fee-for-service Medicare claims. PARTICIPANTS Medicare beneficiaries with a diagnosis of incident cancer (new occurrence of a cancer diagnosis code in proximity to claims for cancer treatment, and no such diagnosis codes during a ≥1 year washout period) during 2014-19, who met additional requirements identifying them as at risk for one of four non-recommended or low value interventions: denosumab for castration sensitive prostate cancer, granulocyte colony stimulating factors (GCSF) for patients at low risk for neutropenic fever, nab-paclitaxel for cancers with no evidence of superiority over paclitaxel, and a branded drug in settings where a generic or biosimilar version was available. MAIN OUTCOME MEASURES Receipt of the non-recommended or low value drug for which the patient was at risk. The primary association of interest was the assigned oncologist's receipt of any general payments from the manufacturer of the corresponding non-recommended or low value drug (measured in Open Payments) within 365 days before the patient's index cancer date. The two modeling approaches used were general linear model controlling for patients' characteristics and calendar year, and general linear model with physician level indicator variables. RESULTS Oncologists were in receipt of industry payments for 2962 of 9799 patients (30.2%) at risk for non-recommended denosumab (median $63), 76 747 of 271 485 patients (28.3%) at risk for GCSF (median $60); 18 491 of 86 394 patients (21.4%) at risk for nab-paclitaxel (median $89), and 4170 of 13 386 patients (31.2%) at risk for branded drugs (median $156). The unadjusted proportion of patients who received non-recommended denosumab was 31.4% for those whose oncologist had not received payment and 49.5% for those whose oncologist had (prevalence difference 18.0%); the corresponding values for GCSF were 26.6% v 32.1% (5.5%), for nab-paclitaxel were 7.3% v 15.1% (7.8%), and for branded drugs were 88.3% v 83.5% (-4.8%). Controlling for patients' characteristics and calendar year, payments from industry were associated with increased use of denosumab (17.5% (95% confidence interval 15.3% to 19.7%)), GCSF (5.8% (5.4% to 6.1%)), and nab-paclitaxel (7.6% (7.1% to 8.1%)), but lower use of branded drugs (-4.6% (-5.8% to -3.3%)). In physician level indicator models, payments from industry were associated with increased use of denosumab (7.4% (2.5% to 12.2%)) and nab-paclitaxel (1.7% (0.9% to 2.5%)), but not with GCSF (0.4% (-0.3% to 1.1%)) or branded drugs (1.2% (-6.0 to 8.5%)). CONCLUSIONS Within some clinical scenarios, industry payments to physicians are associated with non-recommended and low value drugs. These findings raise quality of care concerns about the financial relationships between physicians and industry.
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Laiteerapong N, Alexander J, Philipson L, Winn AN, Huang ES. First-Line Therapy for Type 2 Diabetes With Sodium-Glucose Cotransporter-2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists. Ann Intern Med 2023; 176:eL230007. [PMID: 37068291 DOI: 10.7326/l23-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
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Gopalan A, Winn AN, Karter AJ, Laiteerapong N. Racial and Ethnic Differences in Medication Initiation Among Adults Newly Diagnosed with Type 2 Diabetes. J Gen Intern Med 2023; 38:994-1000. [PMID: 35927604 PMCID: PMC10039131 DOI: 10.1007/s11606-022-07746-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/13/2022] [Indexed: 10/16/2022]
Abstract
OBJECTIVE Given persistent racial/ethnic differences in type 2 diabetes outcomes and the lasting benefits conferred by early glycemic control, we examined racial/ethnic differences in diabetes medication initiation during the year following diagnosis. METHODS Among adults newly diagnosed with type 2 diabetes (2005-2016), we examined how glucose-lowering medication initiation differed by race/ethnicity during the year following diagnosis. We specified modified Poisson regression models to estimate the association between race/ethnicity and medication initiation in the entire cohort and within subpopulations defined by HbA1c, BMI, age at diagnosis, comorbidity, and neighborhood deprivation index (a census tract-level socioeconomic indicator). RESULTS Among the 77,199 newly diagnosed individuals, 47% started a diabetes medication within 12 months of diagnosis. The prevalence of medication initiation ranged from 32% among Chinese individuals to 58% among individuals of Other/Unknown races/ethnicities. Compared to White individuals, medication initiation was less likely among Chinese (relative risk: 0.78 (95% confidence interval 0.72, 0.84)) and Japanese (0.82 (0.75, 0.90)) individuals, but was more likely among Hispanic/Latinx (1.27 (1.24, 1.30)), African American (1.14 (1.11, 1.17)), other Asian (1.13 (1.08, 1.18)), South Asian (1.10 (1.04, 1.17)), Other/Unknown (1.31 (1.24, 1.39)), American Indian or Alaska Native (1.11 (1.04, 1.18)), and Native Hawaiian/Pacific Islander (1.28 (1.19, 1.37)) individuals. Racial/ethnic differences dissipated among individuals with higher HbA1c values. CONCLUSIONS Initiation of glucose-lowering treatment during the year following type 2 diabetes diagnosis differed markedly by race/ethnicity, particularly for those with lower HbA1c values. Future research should examine how patient preferences, provider implicit bias, and shared decision-making contribute to these early treatment differences.
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Centor RM, Laiteerapong N, Winn AN. Web Exclusive. Annals On Call - First-Line Drug Therapy for Type 2 Diabetes. Ann Intern Med 2023; 176:eA220004. [PMID: 36802895 DOI: 10.7326/a22-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
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Neuner JM, Fergestrom N, Pezzin LE, Laud PW, Ruddy KJ, Winn AN. Medication delivery factors and adjuvant endocrine therapy adherence in breast cancer. Breast Cancer Res Treat 2023; 197:223-233. [PMID: 36357711 DOI: 10.1007/s10549-022-06704-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/31/2022] [Indexed: 11/12/2022]
Abstract
PURPOSE Over 50% of breast cancer patients prescribed a 5-year course of daily oral adjuvant endocrine therapy (ET) are nonadherent. We investigated the role of costs and cancer medication delivery mode and other medication delivery factors on adherence. METHODS We conducted a retrospective cohort study of commercially insured and Medicare advantage patients with newly diagnosed breast cancer in 2007-2015 who initiated ET. We examined the association between 12-month ET adherence (proportion of days covered by fills ≥ 0.80) and ET copayments, 90-day prescription refill use, mail order pharmacy use, number of pharmacies, and synchronization of medications. We used regression models to estimate nonadherence risk ratios adjusted for demographics (age, income, race, urbanicity), comorbidities, total medications, primary cancer treatments, and generic AI availability. Sensitivity analyses were conducted using alternative specifications for independent variables. RESULTS Mail order users had higher adherence in both commercial and Medicare-insured cohorts. Commercially insured patients who used mail order were more likely to be adherent if they had low copayments (< $5) and 90-day prescription refills. For commercially insured patients who used local pharmacies, use of one pharmacy and better synchronized refills were also associated with adherence. Among Medicare patients who used mail order pharmacies, only low copayments were associated with adherence, while among Medicare patients using local pharmacies both low copayments and 90-day prescriptions were associated with ET adherence. CONCLUSION Out-of-pocket costs, medication delivery mode, and other pharmacy-related medication delivery factors are associated with adherence to breast cancer ET. Future work should investigate whether interventions aimed at streamlining medication delivery could improve adherence for breast cancer patients.
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Holt JM, Cusatis R, Mortensen N, Wolfrath N, Hyun N, Winn AN, Brown SA, Somai MM, Crotty BH. Twenty-first century house calls: a survey of ambulatory care providers to inform organisational telehealth strategy. BMJ Health Care Inform 2022; 29:bmjhci-2022-100626. [PMID: 36564094 PMCID: PMC9791455 DOI: 10.1136/bmjhci-2022-100626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 11/13/2022] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES While patient interest in telehealth increases, clinicians' perspectives may influence longer-term adoption. We sought to identify facilitators and barriers to continued clinician incorporation of telehealth into practice. METHODS A cross-sectional 24-item web-based survey was emailed to 491 providers with ≥50 video visits (VVs) within an academic health system between 1 March 2020 and 31 December 2020. We quantitatively summarised the characteristics and perceptions of respondents by using descriptive and test statistics. We used systematic content analysis to qualitatively code open-ended responses, double coding at least 25%. RESULTS 247 providers (50.3%) responded to the survey. Seventy-nine per cent were confident in their ability to deliver excellent clinical care through VV. In comparison, 48% were confident in their ability to troubleshoot technical issues. Most clinicians (87%) expressed various concerns about VV. Providers across specialties generally agreed that VV reduced infection risk (71%) and transportation barriers (71%). Three overarching themes in the qualitative data included infrastructure and training, usefulness and expectation setting for patients and providers. DISCUSSION As healthcare systems plan for future delivery directions, they must address the tension between patients' and providers' expectations of care within the digital space. Telehealth creates new friction, one where the healthcare system must fit into the patient's life rather than the usual dynamic of the patient fitting into the healthcare system. CONCLUSION Telehealth infrastructure and patient and clinician technological acumen continue to evolve. Clinicians in this survey offered valuable insights into the directions healthcare organisations can take to right-size this healthcare delivery modality.
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Choi JG, Winn AN, Skandari MR, Franco MI, Staab EM, Alexander J, Wan W, Zhu M, Huang ES, Philipson L, Laiteerapong N. First-Line Therapy for Type 2 Diabetes With Sodium-Glucose Cotransporter-2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists : A Cost-Effectiveness Study. Ann Intern Med 2022; 175:1392-1400. [PMID: 36191315 PMCID: PMC10155215 DOI: 10.7326/m21-2941] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Guidelines recommend sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP1) receptor agonists as second-line therapy for patients with type 2 diabetes. Expanding their use as first-line therapy has been proposed but the clinical benefits may not outweigh their costs. OBJECTIVE To evaluate the lifetime cost-effectiveness of a strategy of first-line SGLT2 inhibitors or GLP1 receptor agonists. DESIGN Individual-level Monte Carlo-based Markov model. DATA SOURCES Randomized trials, Centers for Disease Control and Prevention databases, RED BOOK, and the National Health and Nutrition Examination Survey. TARGET POPULATION Drug-naive U.S. patients with type 2 diabetes. TIME HORIZON Lifetime. PERSPECTIVE Health care sector. INTERVENTION First-line SGLT2 inhibitors or GLP1 receptor agonists. OUTCOME MEASURES Life expectancy, lifetime costs, incremental cost-effectiveness ratios (ICERs). RESULTS OF BASE-CASE ANALYSIS First-line SGLT2 inhibitors and GLP1 receptor agonists had lower lifetime rates of congestive heart failure, ischemic heart disease, myocardial infarction, and stroke compared with metformin. First-line SGLT2 inhibitors cost $43 000 more and added 1.8 quality-adjusted months versus first-line metformin ($478 000 per quality-adjusted life-year [QALY]). First-line injectable GLP1 receptor agonists cost more and reduced QALYs compared with metformin. RESULTS OF SENSITIVITY ANALYSIS By removing injection disutility, first-line GLP1 receptor agonists were no longer dominated (ICER, $327 000 per QALY). Oral GLP1 receptor agonists were not cost-effective (ICER, $823 000 per QALY). To be cost-effective at under $150 000 per QALY, costs for SGLT2 inhibitors would need to be under $5 per day and under $6 per day for oral GLP1 receptor agonists. LIMITATION U.S. population and costs not generalizable internationally. CONCLUSION As first-line agents, SGLT2 inhibitors and GLP1 receptor agonists would improve type 2 diabetes outcomes, but their costs would need to fall by at least 70% to be cost-effective. PRIMARY FUNDING SOURCE American Diabetes Association.
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Holt JM, Spanbauer C, Cusatis R, Winn AN, Talsma A, Asan O, Somai M, Hanson R, Moore J, Makoul G, Crotty BH. Real-world implementation evaluation of an electronic health record-integrated consumer informatics tool that collects patient-generated contextual data. Int J Med Inform 2022; 165:104810. [PMID: 35714549 DOI: 10.1016/j.ijmedinf.2022.104810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 05/09/2022] [Accepted: 06/05/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Use the RE-AIM framework to examine the implementation of a patient contextual data (PCD) Tool designed to share patients' needs, values, and preferences with care teams ahead of clinical encounters. MATERIALS & METHODS Observational study that follows initial PCD Tool scaling across primary care at a Midwestern academic health network. Program invitations, enrollment, patient submissions, and clinician views were tracked over a 1-year study period. Logistic regression modeled the likelihood of using the PCD Tool, accounting for patient covariates. RESULTS Of 58,874 patients who could be contacted by email, 9,183 (15.6%) became PCD Tool users. Overall, 76% of primary care providers had patients who used the PCD Tool. Older age, female gender, non-minority race, patient portal activation, and Medicare coverage were significantly associated with increased likelihood of use. Number of office visits, medical issues, and behavioral health conditions also associated with use. Primary care staff viewed 18.7% of available PCD Tool summaries, 1.1% to 57.6% per clinic. DISCUSSION The intervention mainly reached non-minority patients and patients who used more health services. Given the requirement for an email address on file, some patients may have been underrepresented. Overall, patient reach and adoption and clinician adoption, implementation, and maintenance of this Tool were modest but stable, consistent with a non-directive approach to fostering adoption by introducing the Tool in the absence of clear expectations for use. CONCLUSION Healthcare organizations must implement effective methods to increase the reach, adoption, implementation, and maintenance of PCD tools across all patient populations. Assisting people, particularly racial minorities, with PCD Tool registration and actively supporting clinician use are critical steps in implementing technology that facilitates care.
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Alexander JT, Staab EM, Wan W, Franco M, Knitter A, Skandari MR, Bolen S, Maruthur NM, Huang ES, Philipson LH, Winn AN, Thomas CC, Zeytinoglu M, Press VG, Tung EL, Gunter K, Bindon B, Jumani S, Laiteerapong N. Longer-term Benefits and Risks of Sodium-Glucose Cotransporter-2 Inhibitors in Type 2 Diabetes: a Systematic Review and Meta-analysis. J Gen Intern Med 2022; 37:439-448. [PMID: 34850334 PMCID: PMC8811049 DOI: 10.1007/s11606-021-07227-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 10/19/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter-2 inhibitors (SGLT2Is) are a recent class of medication approved for the treatment of type 2 diabetes (T2D). Previous meta-analyses have quantified the benefits and harms of SGLT2Is; however, these analyses have been limited to specific outcomes and comparisons and included trials of short duration. We comprehensively reviewed the longer-term benefits and harms of SGLT2Is compared to placebo or other anti-hyperglycemic medications. METHODS We searched PubMed, Scopus, and clinicaltrials.gov from inception to July 2019 for randomized controlled trials of minimum 52 weeks' duration that enrolled adults with T2D, compared an SGLT2I to either placebo or other anti-hyperglycemic medications, and reported at least one outcome of interest including cardiovascular risk factors, microvascular and macrovascular complications, mortality, and adverse events. We conducted random effects meta-analyses to provide summary estimates using weighted mean differences (MD) and pooled relative risks (RR). The study was registered a priori with PROSPERO (CRD42018090506). RESULTS Fifty articles describing 39 trials (vs. placebo, n = 28; vs. other anti-hyperglycemic medication, n = 12; vs. both, n = 1) and 112,128 patients were included in our analyses. Compared to placebo, SGLT2Is reduced cardiovascular risk factors (e.g., hemoglobin A1c, MD - 0.55%, 95% CI - 0.62, - 0.49), macrovascular outcomes (e.g., hospitalization for heart failure, RR 0.70, 95% CI 0.62, 0.78), and mortality (RR 0.87, 95% CI 0.80, 0.94). Compared to other anti-hyperglycemic medications, SGLT2Is reduced cardiovascular risk factors, but insufficient data existed for other outcomes. About a fourfold increased risk of genital yeast infections for both genders was observed for comparisons vs. placebo and other anti-hyperglycemic medications. DISCUSSION We found that SGLT2Is led to durable reductions in cardiovascular risk factors compared to both placebo and other anti-hyperglycemic medications. Reductions in macrovascular complications and mortality were only observed in comparisons with placebo, although trials comparing SGLT2Is vs. other anti-hyperglycemic medications were not designed to assess longer-term outcomes.
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Alexander JT, Staab EM, Wan W, Franco M, Knitter A, Skandari MR, Bolen S, Maruthur NM, Huang ES, Philipson LH, Winn AN, Thomas CC, Zeytinoglu M, Press VG, Tung EL, Gunter K, Bindon B, Jumani S, Laiteerapong N. The Longer-Term Benefits and Harms of Glucagon-Like Peptide-1 Receptor Agonists: a Systematic Review and Meta-Analysis. J Gen Intern Med 2022; 37:415-438. [PMID: 34508290 PMCID: PMC8810987 DOI: 10.1007/s11606-021-07105-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/19/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Previous meta-analyses of the benefits and harms of glucagon-like peptide-1 receptor agonists (GLP1RAs) have been limited to specific outcomes and comparisons and often included short-term results. We aimed to estimate the longer-term effects of GLP1RAs on cardiovascular risk factors, microvascular and macrovascular complications, mortality, and adverse events in patients with type 2 diabetes, compared to placebo and other anti-hyperglycemic medications. METHODS We searched PubMed, Scopus, and clinicaltrials.gov (inception-July 2019) for randomized controlled trials ≥ 52 weeks' duration that compared a GLP1RA to placebo or other anti-hyperglycemic medication and included at least one outcome of interest. Outcomes included cardiovascular risk factors, microvascular and macrovascular complications, all-cause mortality, and treatment-related adverse events. We performed random effects meta-analyses to give summary estimates using weighted mean differences (MD) and pooled relative risks (RR). Risk of bias was assessed using the Cochrane Collaboration risk of bias in randomized trials tool. Quality of evidence was summarized using the Grading of Recommendations, Assessment, Development, and Evaluation approach. The study was registered a priori with PROSPERO (CRD42018090506). RESULTS Forty-five trials with a mean duration of 1.7 years comprising 71,517 patients were included. Compared to placebo, GLP1RAs reduced cardiovascular risk factors, microvascular complications (including renal events, RR 0.85, 0.80-0.90), macrovascular complications (including stroke, RR 0.86, 0.78-0.95), and mortality (RR 0.89, 0.84-0.94). Compared to other anti-hyperglycemic medications, GLP1RAs only reduced cardiovascular risk factors. Increased gastrointestinal events causing treatment discontinuation were observed in both comparisons. DISCUSSION GLP1RAs reduced cardiovascular risk factors and increased gastrointestinal events compared to placebo and other anti-hyperglycemic medications. GLP1RAs also reduced MACE, stroke, renal events, and mortality in comparisons with placebo; however, analyses were inconclusive for comparisons with other anti-hyperglycemic medications. Given the high costs of GLP1RAs, the lack of long-term evidence comparing GLP1RAs to other anti-hyperglycemic medications has significant policy and clinical practice implications.
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Crotty BH, Hyun N, Polovneff A, Dong Y, Decker MC, Mortensen N, Holt JM, Winn AN, Laud PW, Somai MM. Analysis of Clinician and Patient Factors and Completion of Telemedicine Appointments Using Video. JAMA Netw Open 2021; 4:e2132917. [PMID: 34735013 PMCID: PMC8569484 DOI: 10.1001/jamanetworkopen.2021.32917] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
IMPORTANCE Telemedicine provides patients access to episodic and longitudinal care. Policy discussions surrounding future support for telemedicine require an understanding of factors associated with successful video visits. OBJECTIVE To assess patient and clinician factors associated with successful and with failed video visits. DESIGN, SETTING, AND PARTICIPANTS This was a quality improvement study of 137 846 scheduled video visits at a single academic health system in southeastern Wisconsin between March 1 and December 31, 2020, supplemented with patient experience survey data. Patient information was gathered using demographic information abstracted from the electronic health record and linked with block-level socioeconomic data from the US Census Bureau. Data on perceived clinician experience with technology was obtained using the survey. MAIN OUTCOMES AND MEASURES The primary outcome of interest was the successful completion of a scheduled video visit or the conversion of the video visit to a telephone-based service. Visit types and administrative data were used to categorize visits. Mixed-effects modeling with pseudo R2 values was performed to compare the relative associations of patient and clinician factors with video visit failures. RESULTS In total, 75 947 patients and 1155 clinicians participated in 137 846 scheduled video encounters, 17 190 patients (23%) were 65 years or older, and 61 223 (81%) patients were of White race and ethnicity. Of the scheduled video encounters, 123 473 (90%) were successful, and 14 373 (10%) were converted to telephone services. A total of 16 776 patients (22%) completed a patient experience survey. Lower clinician comfort with technology (odds ratio [OR], 0.15; 95% CI, 0.08-0.28), advanced patient age (66-80 years: OR, 0.28; 95% CI, 0.26-0.30), lower patient socioeconomic status (including low high-speed internet availability) (OR, 0.85; 95% CI, 0.77-0.92), and patient racial and ethnic minority group status (Black or African American: OR, 0.75; 95% CI, 0.69-0.81) were associated with conversion to telephone visits. Patient characteristics accounted for systematic components for success; marginal pseudo R2 values decreased from 23% (95% CI, 21.1%-26.1%) to 7.8% (95% CI, 6.3%-9.4%) with exclusion of patient factors. CONCLUSIONS AND RELEVANCE As policy makers consider expanding telehealth coverage and hospital systems focus on investments, consideration of patient support, equity, and friction should guide decisions. In particular, this quality improvement study suggests that underserved patients may become disproportionately vulnerable by cuts in coverage for telephone-based services.
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Mitchell AP, Mishra A, Dey P, Curry MA, Trivedi NU, Haddadin M, Rahman MW, Winn AN, Dusetzina SB, Bach PB. Personal Payments from Pharmaceutical Companies to Authors of Oncology Clinical Practice Guidelines. Oncologist 2021; 26:e1897. [PMID: 34546620 DOI: 10.1002/onco.13983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Mitchell AP, Mishra A, Dey P, Curry MA, Trivedi NU, Haddadin M, Rahman MW, Winn AN, Dusetzina SB, Bach PB. Personal Payments from Pharmaceutical Companies to Authors of Oncology Clinical Practice Guidelines. Oncologist 2021; 26:771-778. [PMID: 33982829 PMCID: PMC8417859 DOI: 10.1002/onco.13823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/30/2021] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Oncologists who author clinical practice guidelines frequently have financial relationships with the pharmaceutical industry. It is unknown whether participation on clinical practice guideline committees is associated with differences in the amounts of industry money received. MATERIALS AND METHODS We conducted a nested case-control study from August 2013 to December 2018. We manually abstracted membership records of National Comprehensive Cancer Network (NCCN) Guidelines committees for the 20 most common cancers and linked to Open Payments. The study sample included medical oncologists selected to join an NCCN Guidelines committee ("joiners") during the study period. Joiners were matched 1:2 to medical oncologists who had no participation on NCCN committees (controls) by gender, NCCN institution, and medical school graduation year. We performed difference-in-differences (DiD) estimation to assess whether selection to an NCCN committee was associated with the dollar value of payments received from industry, using generalized estimating equations to address correlation between matched pairs and between repeated observations of the same pair. RESULTS During the study period, 54 physicians joined an NCCN Guidelines committee. These physicians received more payments than matched controls in the year prior to joining ($11,259 vs. $3,427; p = .02); this difference did not increase in the year after joining (DiD = $731; p = .45). CONCLUSION Medical oncologists selected to NCCN Guidelines committees had greater financial ties to industry than their peers. The potential influence of industry in oncology clinical practice guidelines may be reduced through the selection of committee members with fewer ties to industry. IMPLICATIONS FOR PRACTICE Oncologists who author clinical practice guidelines frequently have financial conflicts of interest with the pharmaceutical industry. This creates concern about the potential for industry influence on guidelines. However, it is unknown whether oncologists who author guidelines have greater industry relationships than their peers. This study compared medical oncologists who were newly selected to join a National Comprehensive Cancer Network (NCCN) Guidelines panel with medical oncologists at the same institutions and at similar career stages. At the time they joined, oncologists joining NCCN Guidelines panels had received more than three times the dollar value of industry payments than their peers. The potential for industry influence may be reduced by the selection of less-conflicted panel members.
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Winn AN, Mitchell AP, Fergestrom N, Neuner JM, Trogdon JG. The Role of Physician Professional Networks in Physicians' Receipt of Pharmaceutical and Medical Device Industries' Payments. J Gen Intern Med 2021; 36:1858-1866. [PMID: 33904046 PMCID: PMC8298740 DOI: 10.1007/s11606-021-06802-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/03/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Financial relationships between physicians and the pharmaceutical and medical device industries are common, but the factors associated with physicians receiving payments are unknown. OBJECTIVE The objective of this study is to evaluate the influence of physicians' professional networks' characteristics on the receipt of payments among physicians. DESIGN Network analysis of cross-sectional data PARTICIPANTS: US physicians who shared Medicare patients with other physicians in 2015 (N=357,813). EXPOSURE (INTERVENTION) Proportion of a physician's professional network that received industry payments and other network characteristics including number of physician connections, how central the physician is within the network, and the tightness of the referral network in which a physician is located. MAIN OUTCOME MEASURES Relative risk of receiving industry payments. We used modified Poisson regression to control for confounding by gender, time since graduation, practice size, and practice setting (teaching hospital vs. not). We included dummy variables for specialty and hospital referral region level. KEY RESULTS The proportion of a physician's peers in their professional network that received payments was strongly associated with receipt of pharmaceutical or device industry payments by the physician (top vs bottom quartile aRR=1.28, 95%CI=1.25-1.31). Physician's centrality within a network had a small positive effect on receiving payment (top vs bottom quartile aRR=1.02, 95%CI=1.01-1.04). Network density also had a small negative association with receipt of payment (top vs bottom quartile aRR=0.97, 95%CI=0.96-0.98). CONCLUSIONS Network characteristics, particularly the receipt of payments among physicians one shares patients with, are associated with whether a physician receives payments. This finding has implications for institutional regulation of industry payments to physicians and demonstrates how institutional policy may impact not only the physicians within the institution but also physicians outside of the institution.
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Winn AN, Kelly M, Ciprut S, Walter D, Gold HT, Zeliadt SB, Sherman SE, Makarov DV. The cost, survival, and quality-of-life implications of guideline-discordant imaging for prostate cancer. Cancer Rep (Hoboken) 2021; 5:e1468. [PMID: 34137520 PMCID: PMC8842701 DOI: 10.1002/cnr2.1468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 11/16/2022] Open
Abstract
Background National Comprehensive Cancer Network (NCCN) guidelines for incident prostate cancer staging imaging have been widely circulated and accepted as best practice since 1996. Despite these clear guidelines, wasteful and potentially harmful inappropriate imaging of men with prostate cancer remains prevalent. Aim To understand changing population‐level patterns of imaging among men with incident prostate cancer, we created a state‐transition microsimulation model based on existing literature and incident prostate cancer cases. Methods To create a cohort of patients, we identified incident prostate cancer cases from 2004 to 2009 that were diagnosed in men ages 65 and older from SEER. A microsimulation model allowed us to explore how this cohort's survival, quality of life, and Medicare costs would be impacted by making imaging consistent with guidelines. We conducted a probabilistic analysis as well as one‐way sensitivity analysis. Results When only imaging high‐risk men compared to the status quo, we found that the population rate of imaging dropped from 53 to 38% and average per‐person spending on imaging dropped from $236 to $157. The discounted and undiscounted incremental cost‐effectiveness ratios indicated that ideal upfront imaging reduced costs and slightly improved health outcomes compared with current practice patterns, that is, guideline‐concordant imaging was less costly and slightly more effective. Conclusion This study demonstrates the potential reduction in cost through the correction of inappropriate imaging practices. These findings highlight an opportunity within the healthcare system to reduce unnecessary costs and overtreatment through guideline adherence.
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Dusetzina SB, Huskamp HA, Jazowski SA, Winn AN, Basch E, Keating NL. Comparison of Anticancer Medication Use and Spending Under US Oncology Parity Laws With and Without Out-of-Pocket Spending Caps. JAMA HEALTH FORUM 2021; 2:e210673. [PMID: 35977314 PMCID: PMC8796987 DOI: 10.1001/jamahealthforum.2021.0673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/29/2021] [Indexed: 11/14/2022] Open
Abstract
Question How does orally administered anticancer medication (OAM) use and spending differ among states that adopted parity with vs without out-of-pocket spending caps? Findings In this cohort study of 23 states and 207 579 OAM prescription fills, out-of-pocket spending caps were associated with higher OAM use and lower out-of-pocket spending by $831 per OAM prescription fill among the highest spenders. Savings were larger for enrollees in states with caps that applied predeductible and postdeductible vs those that applied postdeductible only. Meaning Caps may offer improved financial protection for the highest spenders without increasing mean health plan spending on OAMs. Importance By 2020, nearly all states had adopted oncology parity laws in the US, ensuring that patients in fully insured private health plans pay no more for orally administered anticancer medications (OAMs) than infused therapies. Between 2013 and mid-2017, 11 states implemented parity with out-of-pocket spending caps, which may further reduce patient out-of-pocket spending. Objective To compare OAM uptake and out-of-pocket and health plan spending on OAMs in states with parity with and without spending caps, as well as to assess out-of-pocket spending for caps that apply predeductible vs postdeductible. Design, Setting, and Participants This cohort study analyzed OAM users enrolled in commercial health plans offered by Aetna, Humana, and United Healthcare in the US from 2011 to 2017, aggregated by the Health Care Cost Institute, using difference-in-difference-in-differences (DDD) analysis. Data analysis was conducted between June and August 2020. Exposures Time (before vs after parity), whether the state parity law included an out-of-pocket spending cap, and whether the plan was fully insured (subject to parity) or self-funded (not subject to parity). Among states with caps, out-of-pocket spending was also compared by whether the cap was applied predeductible and postdeductible vs only postdeductible. Main Outcomes and Measures Monthly OAM prescription fills per 100 000 enrollees, per-OAM prescription-fill out-of-pocket spending, and annual per-user health plan spending on OAMs. Results In this study of 23 states (11 with caps and 12 without) and 207 579 OAM prescription fills, caps were associated with a modest increase in OAM use (DDD, 7.40 [95% CI, 3.41-11.39] per 100 000 enrollees). There was no difference in mean out-of-pocket spending comparing fully insured and self-funded enrollees in states with vs without caps (DDD, −$17 [95% CI, −$57 to $24), but caps were associated with lower spending among OAM users in the 95th percentile of out-of-pocket spending by $831 (95% CI, −$871 to −$791) per OAM prescription fill. Caps applied predeductible were associated with greater out-of-pocket savings relative to caps applied only postdeductible. This included per-OAM prescription-fill savings at the 75th, 90th, and 95th percentiles. Postparity, mean annual spending on OAMs among users was $113 589 in states without caps and $102 252 in states with caps, with no differences between groups (DDD, $9799 [95% CI, −$4230 to $23 829). Conclusions and Relevance In this cohort study, among states adopting oncology parity laws between 2013 and 2017, mean out-of-pocket spending per OAM prescription fill and mean health plan spending among OAM users was similar in states with and without caps. However, enrollees in states with parity plus out-of-pocket caps had greater reductions in out-of-pocket spending among the highest spenders. Caps may offer improved financial protection for the highest spenders without increasing mean health plan spending on OAMs.
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Kim NH, Look KA, Dague L, Winn AN. Financial burden and medication adherence among near-poor older adults in a pharmaceutical assistance program. Res Social Adm Pharm 2021; 18:2517-2523. [PMID: 34030976 DOI: 10.1016/j.sapharm.2021.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 04/20/2021] [Accepted: 04/20/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND With increasing drug prices in the past decade, affordability and medication adherence are a growing concern for near-poor older adults, especially for those who are not receiving Low-Income Subsidy in Medicare Part D. SeniorCare is a pharmaceutical assistance program in Wisconsin for near-poor older adults, providing comprehensive prescription coverage with flat copayments. OBJECTIVES To evaluate five-year trends in financial hardship and medication adherence and to examine factors associated with these outcomes in SeniorCare members. METHODS SeniorCare program enrollment and pharmacy claims data from 2014 to 2018 were used. The study population was near-poor older adults in SeniorCare with annual family income ≤200% of the federal poverty level. Financial burden was assessed using the proportion of total annual out-of-pocket costs to total annual income. Medication adherence was assessed by adapting the measures endorsed by the Pharmacy Quality Alliance and National Quality Forum. Descriptive statistics and independent t-tests were used to evaluate the trends, and multivariate logistic regressions were conducted to examine factors associated with financial burden and medication adherence. RESULTS From 2014 to 2018, mean annual out-of-pocket costs per member declined by 3.7% (p < 0.001) for all drugs, while those for specialty drugs increased by 31.2% (p < 0.05). Around 3.3% spent more than 5% of their income for prescription drugs in 2014, which decreased to 2.4% in 2018 (p < 0.001). The proportions of adherent patients increased from 78.1% to 81.2% (p < 0.001) for diabetes medications (excluding insulins), from 77.3% to 79.5% (p < 0.001) for statins, and from 79.8% to 80.8% (p < 0.05) for RASA. Members subject to a $500 annual deductible were more likely to experience high financial burden (adjusted odds ratio (AOR) = 1.677, p < 0.001) and less likely to be adherent to diabetes medications (AOR = 0.484, p < 0.001). CONCLUSIONS The near-poor older adults enrolled in Wisconsin SeniorCare program had low financial burden and good medication adherence within the program.
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Bakken BK, Winn AN. Clinician burnout during the COVID-19 pandemic before vaccine administration. J Am Pharm Assoc (2003) 2021; 61:e71-e77. [PMID: 33962895 PMCID: PMC8056845 DOI: 10.1016/j.japh.2021.04.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/31/2021] [Accepted: 04/08/2021] [Indexed: 11/24/2022]
Abstract
Background Coronavirus disease 2019 (COVID-19) has disrupted pharmacy practice. Little research has been done to assess how COVID-19 has affected pharmacists’ employment, workload, and feelings of burnout. Objectives The objectives of this study were to characterize the impact of COVID-19 on pharmacists’ employment status, workload, and feelings of burnout, as well as to examine emotional health concerns related to COVID-19. Methods Wisconsin pharmacists were surveyed using an online instrument between August 25, 2020, and September 22, 2020. The data analysis, performed in December 2020, examined employment status, 3 common burnout risk factors (workload, rewards, and social depersonalization), and emotional health concerns related to COVID-19. Results Of the 1300 pharmacists, 439 completed the survey (33.8%). The study analysis included pharmacists in community (n = 127) and hospital or health system (n = 107) settings. With regard to employment changes and workload, hospital pharmacists (36%) were more likely to have their hours reduced than community pharmacists (13%) (P < 0.01), and, conversely, community pharmacists (19%) were more likely to have their hours increased than hospital pharmacists (8%) (P = 0.01). For the burnout domain of workload, 45% of the pharmacists reported increased feelings of physical exhaustion at work, and 53% reported increased feelings of emotional exhaustion at work, with no difference between settings. Regarding the burnout domain of rewards, 6% of the hospital pharmacists and 1% of the community pharmacists experienced a reduction in hourly wages or salaries as a result of COVID-19. For the burnout domain of depersonalization, 25% of the pharmacists reported that their ability to connect with colleagues and patients decreased during the COVID-19 pandemic. Additional emotional health concerns reported by the pharmacists included 40% experiencing more anxiety and 25% experiencing more sadness or depression during the COVID-19 pandemic, with no difference between settings. Conclusion This study found that the burnout domains related to workload, rewards, and depersonalization were negatively affected by COVID-19. Pharmacy managers need to proactively combat burnout as well as be reactive when employees show signs of burnout to maintain their workforce and meet the COVID-19–associated challenges.
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Dusetzina SB, Huskamp HA, Jazowski SA, Winn AN, Wood WA, Olszewski A, Basch E, Keating NL. Oral Oncology Parity Laws, Medication Use, and Out-of-Pocket Spending for Patients With Blood Cancers. J Natl Cancer Inst 2021; 112:1055-1062. [PMID: 31883008 DOI: 10.1093/jnci/djz243] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/16/2019] [Accepted: 12/24/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In this study, we sought to estimate the association between oral oncology parity law adoption and anticancer medication use for patients with chronic myeloid leukemia or multiple myeloma. METHODS This was an observational study of administrative claims from 2008 to 2017. Among individuals initiating tyrosine kinase inhibitors (TKIs) for chronic myeloid leukemia or immunomodulatory drugs for multiple myeloma, we compared out-of-pocket spending, adherence, and discontinuation before and after parity among individuals in fully insured plans (subject to parity) vs self-funded plans (exempt from parity) using propensity-score weighted difference-in-differences regression models. RESULTS Among patients initiating TKIs (N = 2082) or immunomodulatory drugs (N = 3326) there were no statistically significant differences in adherence or discontinuation associated with parity. The proportion of patients with initial out-of-pocket payments of $0 increased in fully insured plans after parity from 5.7% to 46.1% for TKIs and from 10.9% to 48.8% for immunomodulatory drugs. Relative to changes in self-funded plans, those in fully insured plans were 4.27 (95% CI = 2.20 to 8.27) times as likely to pay nothing for TKIs and 1.96 (95% CI = 1.40 to 2.73) times as likely to pay nothing for immunomodulatory drugs after parity. Similarly, the proportion paying more than $100 decreased from 30.3% to 24.7% for TKIs and 30.6% to 27.5% for immunomodulatory drugs in fully insured plans after parity. Relative to changes in self-funded plans, those in fully insured plans were 0.74 (95% CI = 0.54 to 1.01) times as likely to pay more than $100 for TKIs and 0.85 (95% CI = 0.68 to 1.06) times as likely to pay more than $100 for immunomodulatory drugs after parity. CONCLUSIONS Among patients initiating TKIs or immunomodulatory drugs, parity was not associated with better adherence or less discontinuation of therapy but yielded decreased patient out-of-pocket payments for some patients.
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