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Zhou Y, Beyer KMM, Laud PW, Winn AN, Pezzin LE, Nattinger AB, Neuner J. An adapted two-step floating catchment area method accounting for urban-rural differences in spatial access to pharmacies. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2021; 12:69-77. [PMID: 33717229 DOI: 10.1093/jphsr/rmaa022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 11/03/2020] [Indexed: 11/12/2022]
Abstract
Objective To adapt the two-step floating catchment area approach to account for urban-rural differences in pharmacy access in the United States. Methods The urban-rural two-step floating catchment area method was described mathematically. To calculate urban-rural-two-step floating catchment area measure, census tracts and pharmacies within the study area (Southeastern Wisconsin) were classified as urban, suburban or rural, and then different catchment area sizes (2, 5 and 15 miles) were applied, based on the Centers for Medicare & Medicaid Services (CMS)' criteria for Medicare Part D service access within urban, suburban and rural areas. The urban-rural-two-step floating catchment area measures were compared to traditional two-step floating catchment area measures computed using three fixed catchment area sizes (2, 5, and 15 miles) by visually examining their spatial distributions. Associations between the four pharmacy accessibility measures and selected socio-demographics are calculated using Spearman's rank-order correlation and further compared. Key findings The urban-rural two-step floating catchment area measure outperforms all the fixed catchment size measures and has the strongest Spearman correlations with the selected census variables. It also reduces the number of census tracts characterized as 'no access' when compared to the original measures. The spatial distribution of urban-rural two-step floating catchment area pharmacy access exhibits a more granular variation across the study area. Conclusions The results support our hypothesis that spatial access to pharmacies should account for urbanicity/rurality patterns within a region.
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Check DK, Winn AN, Fergestrom N, Reeder-Hayes KE, Neuner JM, Roberts AW. Response to Strassels and Durham. J Natl Cancer Inst 2020; 112:1280. [DOI: 10.1093/jnci/djaa146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 09/04/2020] [Indexed: 11/12/2022] Open
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Seymour EK, Ruterbusch JJ, Winn AN, George JA, Beebe-Dimmer JL, Schiffer CA. The costs of treating and not treating patients with chronic myeloid leukemia with tyrosine kinase inhibitors among Medicare patients in the United States. Cancer 2020; 127:93-102. [PMID: 33119175 DOI: 10.1002/cncr.33267] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/21/2020] [Accepted: 09/04/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with high cost-sharing of tyrosine kinase inhibitors (TKIs) experience delays in treatment for chronic myeloid leukemia (CML). To the authors' knowledge, the clinical outcomes among and costs for patients not receiving TKIs are not well defined. METHODS Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, the authors evaluated differences in TKI initiation, health care use, cost, and survival among patients with CML with continuous Medicare Parts A and B and Part D coverage who were diagnosed between 2007 and 2015. RESULTS A total of 941 patients were included. Approximately 29% of all patients did not initiate treatment with TKIs within 6 months (non-TKI users), and had lower rates of BCR-ABL testing and more hospitalizations compared with TKI users. Approximately 21% were not found to have any TKI claims at any time. TKI initiation rates within 6 months of diagnosis increased for all patients over time (61% to 85%), with greater improvements observed in patients receiving subsidies (55% to 90%). Total Medicare costs were greater in patients treated with TKIs, with approximately 50% because of TKI costs. Non-TKI users had more inpatient costs compared with TKI users. Trends in cost remained significant when adjusting for age and comorbidities. The median overall survival was 40 months (95% confidence interval [95% CI], 34-48 months) compared with 86 months (95% CI, 73 months to not reached), respectively, for non-TKI users versus TKI users, a finding that remained consistent when adjusting for age, comorbidities, and subsidy status (hazard ratio, 2.23; 95% CI, 1.77-2.81). CONCLUSIONS Approximately 21% of all patients with CML did not receive TKIs at any time. Cost-sharing subsidies consistently are found to be associated with higher initiation rates. Non-TKI users had higher inpatient costs and poorer survival outcomes. Interventions to lower TKI costs for all patients are desirable.
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Winn AN, Check DK, Farkas A, Fergestrom NM, Neuner JM, Roberts AW. Association of Current Opioid Use With Serious Adverse Events Among Older Adult Survivors of Breast Cancer. JAMA Netw Open 2020; 3:e2016858. [PMID: 32930779 PMCID: PMC7492912 DOI: 10.1001/jamanetworkopen.2020.16858] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
IMPORTANCE National efforts to improve safe opioid prescribing focus on preventing misuse, overdose, and opioid use disorder. This approach overlooks opportunities to better prevent other serious opioid-related harms in complex populations, such as older adult survivors of cancer. Little is known about the rates and risk factors for comprehensive opioid-related harms in this population. OBJECTIVE To determine rates of multiple opioid-related adverse drug events among older adults who survived breast cancer and estimate the risk of these events associated with opioid use in the year after completing cancer treatment. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used 2007 to 2016 Surveillance, Epidemiology and End Results-Medicare data from fee-for-service Medicare beneficiaries with first cancer diagnosis of stage 0 to III breast cancer at age 66 to 90 years from January 1, 2008, through December 31, 2015, who completed active breast cancer treatment. Data were analyzed from October 31, 2019, to June 10, 2020. EXPOSURES Repeated daily measure indicating possession of any prescription opioid supply in Medicare Part D prescription claims. MAIN OUTCOMES AND MEASURES Adjusted risk ratios (aRRs), estimated using modified Poisson generalized estimating equation models, for adverse drug events related to substance misuse (ie, diagnosed opioid abuse, dependence, or poisoning), other adverse drug events associated with opioid use (ie, gastrointestinal events, infections, falls and fractures, or cardiovascular events), and all-cause hospitalization associated with opioid supply the prior day, controlling for patient characteristics. RESULTS Among 38 310 women included in the study (mean [SD] age, 74.3 [6.3] years), there were 0.010 (95% CI, 0.008-0.011) adverse drug events related to substance misuse per 1000 person-days, 0.237 (95% CI, 0.229-0.245) other adverse drug events associated with opioid use per 1000 person-days, and 0.675 (95% CI, 0.662-0.689) all-cause hospitalizations per 1000 person-days. Opioid use was associated with increased risk of adverse drug events related to substance misuse (aRR, 14.62; 95% CI, 9.69-22.05; P < .001), other adverse drug events related to opioid use (aRR, 2.50; 95% CI, 2.11-2.96; P < .001), and all-cause hospitalization (aRR, 2.77; 95% CI, 2.55-3.02; P < .001). In a dose-response effect, individuals with high daily opioid doses had consistently higher risks of all study outcomes compared with individuals who had low opioid doses. Compared with days with no opioid exposure, the risk of any adverse drug event related to substance misuse was 3.4-fold higher for individuals with a current opioid supply ≥50 mg morphine equivalent dose per day (aRR, 3.40; 95% CI, 2.47-4.68; P < .001), while the risk was 2.3-fold higher for individuals with 1 to 49 mg morphine equivalent dose per day (aRR, 2.29; 95% CI, 1.89-2.77; P < .001). CONCLUSIONS AND RELEVANCE These findings suggest that among older adults who survived breast cancer, continued prescription opioid use in the year after completing active cancer treatment was associated with an immediate increased risk of a broad range of serious adverse drug events related to substance misuse and other adverse drug events associated with opioid use. Clinicians should consider the comprehensive risks of managing cancer pain with long-term opioid therapy.
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Check DK, Winn AN, Fergestrom N, Reeder-Hayes KE, Neuner JM, Roberts AW. Concurrent Opioid and Benzodiazepine Prescriptions Among Older Women Diagnosed With Breast Cancer. J Natl Cancer Inst 2020; 112:765-768. [PMID: 31605134 PMCID: PMC7357325 DOI: 10.1093/jnci/djz201] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/18/2019] [Accepted: 10/02/2019] [Indexed: 11/13/2022] Open
Abstract
Guidelines recommend using caution in co-prescribing opioids with benzodiazepines, yet, in practice, the extent of concurrent prescribing is poorly understood. Notably, no population-based studies, to our knowledge, have investigated concurrent prescribing among patients with cancer. We conducted a retrospective cohort study using data from the Surveillance, Epidemiology, and End Results (SEER) database linked with Medicare claims (2012-2016) for women diagnosed with breast cancer. We used modified Poisson regression to examine predictors of any concurrent prescriptions in the year post-diagnosis and Poisson regression to examine predictors of the number of overlapping days. We found that 13.0% of the 19 267 women in our sample had concurrent prescriptions. Women who underwent more extensive treatment and those with previous use of opioids or benzodiazepines were at increased risk for concurrent prescriptions (adjusted risk ratio of previous benzodiazepine use vs no previous use = 15.05, 95% confidence interval = 13.19 to 17.19). Among women with concurrent prescriptions, overlap was most pronounced among low-income, rural, and Hispanic women (adjusted incidence rate ratio of Hispanic vs non-Hispanic white = 1.25, 95% confidence interval = 1.20 to 1.30). Our results highlight opportunities to reduce patients' unnecessary exposure to this combination.
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Winn AN, Check D, Fergestrom N, Neuner JM, Roberts A. The impact of the use of opioids among older breast cancer survivors and adverse events. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.12098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12098 Background: Older adults and cancer survivors are underrepresented in the literature underpinning recent opioid prescribing guidelines. As prevention of unnecessary persistent opioid use and inadvertent opioid-related harms gains importance in clinical practice, it is necessary to fully capture the risks of opioid related adverse events among patients with cancer pain. The objective of this study was to determine the association between opioid use after cancer diagnosis and comprehensive opioid-related adverse events among older adult breast cancer survivors. Methods: We conducted a retrospective cohort study using Surveillance, Epidemiology, and End Results tumor registry data linked with Medicare administrative claims data from 2007-2016 of women with newly diagnosed non-metastatic breast cancer. The study observation period was the year following a patient’s end of active cancer treatment. The primary exposure was a daily measure of opioid exposure based on Part D prescription claims. The primary outcomes were daily indicators of all-cause hospitalization, substance use event and a composite of other opioid-related adverse events (infections, gastrointestinal events, falls/fractures, cardiovascular events) and each component of the composite adverse event. We estimated the association of current opioid use and the immediate risk of an outcome event the following day using modified Poisson generalized estimating equation models. We adjusted for patient demographics, cancer characteristics and cancer treatments received. Results: We found that opioid exposure more than doubled the immediate risk of all-cause hospitalization (aRR = 2.77; 95%CI = 2.57, 2.99; p < 0.001) and having a composite adverse event (aRR = 2.50; 95%CI = 2.18, 2.87; p < 0.001) and dramatically increases the immediate risk of a substance use event (aRR = 14.26; 95%CI = 7.11, 28.59; p < 0.001). We find consistent results when looking at individual components of the composite adverse event measure. Conclusions: Older adult breast cancer survivors with continued prescription opioid use in the year after completing active cancer treatment experienced an immediate increased risk of all-cause hospitalization, substance use events, and myriad opioid-related adverse effects.
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Mitchell AP, Mishra AA, Dey P, Curry MA, Trivedi NA, Haddadin M, Rahman M, Winn AN, Dusetzina S, Bach P. The association between drug industry payments and NCCN guideline panel membership. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.2068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
2068 Background: The high frequency of financial relationships between the pharmaceutical industry and influential oncologists who author clinical practice guidelines may influence guideline recommendations. Therefore, we assessed the financial relationships held by NCCN Guidelines panelists before and after joining the panel, compared to those held by a matched set of oncologists. Methods: Membership of NCCN Guidelines panels for the 20 most common cancers was obtained from archival guidelines and linked manually to Open Payments records of industry payments. We identified physicians who newly joined an NCCN panel during the August 2013-December 2018 study period, and we included medical oncologists who had at least 1 year of Open Payments data before and after joining. These medical oncologists who joined an NCCN panel (panelists) were matched 1:2 to medical oncologists with the same gender, institutional affiliation, and medical school graduation year, who did not join an NCCN panel (non-panelists). The dollar value of industry payments was then calculated over the 1 year before (pre-join) and after (post-join) the date that each panelist joined. We used generalized linear models to assess differences in industry payments between the panelists and matched non-panelists in the pre-join period. We used difference-in-difference estimation (DiD) to assess whether joining an NCCN panel was associated with increased payments in the post-join period. Results: There were 54 panelists and 108 non-panelists (matched from 1447 eligible oncologists at NCCN institutions). Mean per-oncologist payments among panelists were greater than non-panelists in the pre-join period ($11,259 vs $3,427, p = 0.02). From the pre-join to post-join period there was a similar increase in mean per-oncologist payments among panelists and non-panelists ($2,236 vs. $1,569, DiD estimate +$667, p = 0.77). Conclusions: Medical oncologists who were selected to an NCCN Guidelines panel had greater financial ties to industry compared to peer oncologists who were not selected. This difference was present prior to joining; oncologists did not experience a greater increase in financial payments from industry in the 1-year period after joining an NCCN panel. These results suggest an opportunity to reduce the potential influence of industry in oncology clinical practice guidelines through the selection of guideline panelists with fewer ties to industry.
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Neuner JM, Winn AN, Pezzin LE, Laud PW, Nattinger AB, Fergestrom N. Factors associated with adjuvant endocrine therapy adherence in non-metastatic breast cancer. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
533 Background: Over 50% of breast cancer patients prescribed adjuvant endocrine therapy (ET) are nonadherent during the recommended 5-year course of therapy. We investigated the role of cancer medication delivery on adherence, including mail order pharmacy use, number of pharmacies and copays. Methods: We conducted a retrospective cohort study of 15,769 commercially insured breast cancer patients age 18-64 with newly diagnosed breast cancer in 2007-2015 that initiated ET. Incident breast cancer was identified by a validated algorithm which identifies mainly non-metastatic breast cancer. We examined the association between 12-month AET adherence (proportion of days covered by fills ≥0.80) and mail order pharmacy use, number of pharmacies, and AET copays. We used Poisson regression to estimate nonadherence risk ratios and adjusted for demographics (age, income, race, urbanicity), comorbidities, total medications, primary cancer treatments (surgery, radiation, chemo, and ET initiated), and generic AI availability. Sensitivity analyses were conducted using alternate specifications for independent variables. To test whether any observed differences were due to self-selection, we also conducted a negative control analysis. Results: Most patients were white (74.4%) and age 55-64 (43.3%). Only 16% of patients used a mail order pharmacy for ET fills, most patients only used one pharmacy (58.8%) and 25.2% had a co-pay of $20 or more. In the primary analysis, mail order patients were more likely to be adherent to their ET (aRR 1.21; 95% CI 1.18-1.24), patients using one pharmacy were more likely to be adherent (1 vs 3+: aRR 1.09; 95% CI 1.06-1.13), and patients with lower copays were more likely to be adherent (quartile 1 vs 4: aRR 1.04; 95% CI 1.01-1.08). Results were consistent across sensitivity analyses, and there was no association between mail order and copays and the negative control outcome of any pneumonia diagnoses. Conclusions: Medication delivery factors are associated with adherence to breast cancer AET. Future work should investigate whether interventions to streamline medication delivery could improve adherence for this population.
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Winn AN, Fergestrom NM, Pezzin LE, Laud PW, Neuner JM. The impact of generic aromatase inhibitors on initiation, adherence, and persistence among women with breast cancer: Applying multi-state models to understand the dynamics of adherence. Pharmacoepidemiol Drug Saf 2020; 29:550-557. [PMID: 32196839 DOI: 10.1002/pds.4995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 02/13/2020] [Accepted: 02/26/2020] [Indexed: 01/30/2023]
Abstract
PURPOSE Clinical trials have clearly documented the survival benefit of aromatase inhibitors (AIs); however, many women fail to initiate (primary nonadherence) or remain adherent to AIs (secondary nonadherence). Prior studies have found that costs impact secondary nonadherence to medications but have failed to examine primary nonadherence. The purpose of this study is to examine primary and secondary adherence following the reduction in copays due to the introduction of generic AIs. METHODS Using Surveillance, Epidemiology, and End Results-Medicare data, we identified 50 054 women diagnosed with incident breast cancer between 2008 and 2013. We compare women whose copays would change and those whose would not, due to the receipt of cost-sharing subsidies before and after generics were introduced using a difference-in-difference (DinD) analysis. To examine primary and secondary nonadherence, we rely on a multistate model with four states (Not yet initiated, User, Not Using, and Death). We adjusted for baseline factors using inverse probability treatment weights and then simulated adherence for 36 months following diagnosis. RESULTS The generic introduction of AIs resulted in patients initiating AIs faster (DinD = -4.7%, 95%CI = -7.0, -2.3; patients not yet initiating treatment at 6-months), being more adherent (DinD ranging in absolute increase of 8.1%-10.4%) and being less likely to not be using the therapy (DinD range in absolute decrease of 1.2% at 6 months to 8.8% at 24 months) for women that do not receive a subsidy after generics were available. CONCLUSIONS Introduction of generic alternatives to AIs significantly reduced primary and secondary nonadherence.
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Roberts AW, Fergestrom N, Neuner JM, Winn AN. New-onset persistent opioid use following breast cancer treatment in older adult women. Cancer 2019; 126:814-822. [PMID: 31846054 DOI: 10.1002/cncr.32593] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/08/2019] [Accepted: 05/13/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Patients with cancer-related pain are underrepresented in the opioid literature despite high opioid exposure and numerous risk factors for adverse opioid outcomes, including unnecessary persistent opioid use. The objective of this study was to determine the extent, historical trends, and predictors of new-onset persistent opioid use among older adult women after active breast cancer treatment. METHODS Using Surveillance, Epidemiology, and End Results-Medicare data for opioid-naive women diagnosed with stage 0 to III breast cancer at the age of 66 to 90 years between 2008 and 2013, this study estimated overall and quarterly adjusted probabilities of new-onset persistent opioid use, which was defined as receiving ≥90 days' supply of opioids in the year after active breast cancer treatment. Sensitivity analyses were conducted with an alternative definition of persistent opioid use: any opioid fill 90 to 180 days after active cancer treatment. RESULTS Nearly two-thirds of the subjects received prescription opioid therapy during cancer treatment. Quarterly probabilities of new-onset persistent opioid use after active treatment ranged from 2% to 4%; in sensitivity analyses, the alternative outcome definition resulted in predicted probabilities ranging from 11.4% to 14.7%. Subjects with more advanced disease, a higher comorbidity burden, a low-income status, and greater opioid exposure during active cancer treatment were more likely to develop persistent opioid use. CONCLUSIONS Persistent opioid use was an infrequent occurrence among older adult patients with breast cancer completing cancer treatment between 2008 and 2013. This finding was encouraging because of the concerning opioid trends seen in noncancer populations. However, opportunities to further mitigate unsafe opioid use as a complication of cancer care, including standardization of persistent opioid use definitions, should be explored.
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Winn AN, Somai M, Fergestrom N, Crotty BH. Association of Use of Online Symptom Checkers With Patients' Plans for Seeking Care. JAMA Netw Open 2019; 2:e1918561. [PMID: 31880791 PMCID: PMC6991310 DOI: 10.1001/jamanetworkopen.2019.18561] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This cross-sectional study examines the association of patient use of a free online symptom checker tool with patient plans for seeking medical care.
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Crotty BH, Winn AN, Asan O, Nagavally S, Walker RJ, Egede LE. Clinician Encouragement and Online Health Record Usage. J Gen Intern Med 2019; 34:2345-2347. [PMID: 31313113 PMCID: PMC6848784 DOI: 10.1007/s11606-019-05162-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Check D, Winn AN, Fergestrom N, Neuner JM, Roberts A. Concurrent opioid and benzodiazepine use after breast cancer diagnosis. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.27_suppl.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
28 Background: Benzodiazepines contribute to one-third of opioid overdose deaths in the U.S. Guidelines caution against co-prescribing these two drug classes. Although patients with cancer commonly experience pain and anxiety, no studies have assessed trends in concurrent opioid/benzodiazepine use after cancer diagnosis. Our study examined trends in, and predictors of concurrent opioid/benzodiazepine use in older women diagnosed with breast cancer. Methods: We conducted a retrospective cohort analysis using 2012-2016 SEER-Medicare data for women diagnosed with stage 0-III breast cancer who had no concurrent opioid/benzodiazepine use in the 3 months prior to diagnosis. Using modified Poisson regression, we estimated the adjusted probability of concurrent use (≥1 day of overlapping opioid/benzodiazepine supply) in the 12 months post-diagnosis for patients diagnosed in each calendar quarter from Q2:2013 to Q4:2015. We also estimated the overall relative risk (RR) of concurrent use associated with patient demographic and clinical characteristics. Results: Among the 19, 267 women in our cohort, the quarterly adjusted probabilities of concurrent use were stable over time, ranging from 12% to 15%. Risk of concurrent use decreased with age but increased with cancer stage. Prior opioid use and prior benzodiazepine use increased the risk of concurrent use in the 12 months post-diagnosis (RR prior vs. no prior opioids = 2.57, 95% CI = 2.27-2.92; RR prior vs. no prior benzodiazepines = 15.05, 95% CI = 13.19-17.19). Women who underwent mastectomy (vs. no or minimal surgery) were 71% more likely to have concurrent use (RR = 1.71, 95% CI = 1.40-2.10). Similarly, women who received chemotherapy (vs. no chemotherapy) were 28% more likely to have concurrent use (RR = 1.28, 95% CI = 1.07-1.54). Finally, Black women (vs. White women) were 38% less likely to have concurrent use (RR = 0.62, 95% CI = 0.50-0.76). Conclusions: Up to 1 in 8 older women diagnosed with breast cancer exhibited concurrent opioid/benzodiazepine use in the 12 months after diagnosis. Clinicians must be mindful of exposing patients to this high-risk combination during cancer and survivorship care, particularly among patients with more intensive cancer treatment or prior use of either drug.
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Winn AN, Keating NL, Trogdon JG, Basch EM, Dusetzina SB. Spending by Commercial Insurers on Chemotherapy Based on Site of Care, 2004-2014. JAMA Oncol 2019; 4:580-581. [PMID: 29470578 DOI: 10.1001/jamaoncol.2017.5544] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Wan W, Skandari MR, Minc A, Nathan AG, Zarei P, Winn AN, O'Grady M, Huang ES. Cost-effectiveness of Initiating an Insulin Pump in T1D Adults Using Continuous Glucose Monitoring Compared with Multiple Daily Insulin Injections: The DIAMOND Randomized Trial. Med Decis Making 2019; 38:942-953. [PMID: 30403576 DOI: 10.1177/0272989x18803109] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The economic impact of both continuous glucose monitoring (CGM) and insulin pumps (continuous subcutaneous insulin infusion [CSII]) in type 1 diabetes (T1D) have been evaluated separately. However, the cost-effectiveness of adding CSII to existing CGM users has not yet been assessed. OBJECTIVE The aim of this study was to evaluate the societal cost-effectiveness of CSII versus continuing multiple daily injections (MDI) in adults with T1D already using CGM. METHODS In the second phase of the DIAMOND trial, 75 adults using CGM were randomized to either CGM+CSII or CGM+MDI (control) and surveyed at baseline and 28 weeks. We performed within-trial and lifetime cost-effectiveness analyses (CEAs) and estimated lifetime costs and quality-adjusted life-years (QALYs) via a modified Sheffield T1D model. RESULTS Within the trial, the CGM+CSII group had a significant reduction in quality of life from baseline (-0.02 ± 0.05 difference in difference [DiD]) compared with controls. Total per-person 28-week costs were $8,272 (CGM+CSII) versus $5,623 (CGM+MDI); the difference in costs was primarily attributable to pump use ($2,644). Pump users reduced insulin intake (-12.8 units DiD) but increased the use of daily number of test strips (+1.2 DiD). Pump users also increased time with glucose in range of 70 to 180 mg/dL but had a higher HbA1c (+0.13 DiD) and more nonsevere hypoglycemic events. In the lifetime CEA, CGM+CSII would increase total costs by $112,045 DiD, decrease QALYs by 0.71, and decrease life expectancy by 0.48 years. CONCLUSIONS Based on this single trial, initiating an insulin pump in adults with T1D already using CGM was associated with higher costs and reduced quality of life. Additional evidence regarding the clinical effects of adopting combinations of new technologies from trials and real-world populations is needed to confirm these findings.
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Winn AN, Maciejewski ML, Dusetzina SB. Identifying Heterogeneous Treatment Effects of Drug Policy in Quasi-experimental Settings. CURR EPIDEMIOL REP 2019. [DOI: 10.1007/s40471-019-00213-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Winn AN, Neuner JM. Making Sure We Don't Forget the Basics When Using Machine Learning. J Natl Cancer Inst 2019; 111:529-530. [PMID: 30346555 DOI: 10.1093/jnci/djy179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 09/06/2018] [Indexed: 11/13/2022] Open
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Winn AN, Knueppel P, Neuner JM. The impact of ACA on medical financial hardship among cancer survivors. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.e18160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18160 Background: Prior research has documented that privately insured cancer patients are exposed to significant financial burdens which can result in bankruptcy. A key provision of the Affordable Care Act (ACA) was to set limits on patients out-of-pocket (OOP) spending, which was implemented in 2014. This study aims to assess if OOP limits reduces financial hardship. Methods: Using the 2000-2017 National Health Interview Survey we identified cancer survivors under age 65. We performed a difference in difference analysis which compared financial hardship for low- or moderate-income individuals (LMII), family income under $50,000, to those with higher incomes before and after OOP limits were implemented for privately insured patients. Financial hardship was measured in the following ways: delayed medical care due to cost and the number of family members delayed medical care due to costs, could not afford a prescription, medical care or seeing a specialist, and problems paying medical bills. We used multivariate regression models adjusting for age, race, marital status, gender and size of family. All analyses accounted for the complex survey design and weights. Results: We identified 20,879 privately insured, cancer survivors age 65 or younger. The impact of the ACA resulted in lower financial hardships for LMII compared to higher income persons for most outcomes. The impact of the OOP limits on financial hardship for LMII was seen in any family member delaying care due to costs (difference-in-difference (DiD) = -3.6%; 95% CI = -5.9%, -1.5%; p-value = 0.002), number of family members delaying care due to costs (DiD = -0.048; 95% CI = -0.082, -0.135; p-value = 0.002), had problems paying medical bills (DiD = -3.3%; 95% CI = -6.3%, -0.4%; p-value = 0.028), could not afford prescription medication (DiD = -2.3%; 95% CI = -4.2%, -0.3%; p-value = 0.023), could not afford medical care (DiD = -1.9%; 95% CI = -3.5%, -0.3%; p-value = 0.021), but there was no statistically significant difference in the ability to afford seeing a specialist (DiD = -1.1%; 95% CI = -2.6%, -0.5%; p-value = 0.002). Conclusions: Little research has examined the impact of the ACA’s OOP spending limits. In this study we find that after the introduction of OOP spending limits, financial hardship measured in a variety of ways significantly decreased for LMII.
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Mitchell AP, Winn AN, Lund JL, Dusetzina SB. Evaluating the Strength of the Association Between Industry Payments and Prescribing Practices in Oncology. Oncologist 2019; 24:632-639. [PMID: 30728276 DOI: 10.1634/theoncologist.2018-0423] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/30/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Financial relationships between physicians and the pharmaceutical industry are common, but factors that may determine whether such relationships result in physician practice changes are unknown. MATERIALS AND METHODS We evaluated physician use of orally administered cancer drugs for four cancers: prostate (abiraterone, enzalutamide), renal cell (axitinib, everolimus, pazopanib, sorafenib, sunitinib), lung (afatinib, erlotinib), and chronic myeloid leukemia (CML; dasatinib, imatinib, nilotinib). Separate physician cohorts were defined for each cancer type by prescribing history. The primary exposure was the number of calendar years during 2013-2015 in which a physician received payments from the manufacturer of one of the studied drugs; the outcome was relative prescribing of that drug in 2015, compared with the other drugs for that cancer. We evaluated whether practice setting at a National Cancer Institute (NCI)-designated Comprehensive Cancer Center, receipt of payments for purposes other than education or research (compensation payments), maximum annual dollar value received, and institutional conflict-of-interest policies were associated with the strength of the payment-prescribing association. We used modified Poisson regression to control confounding by other physician characteristics. RESULTS Physicians who received payments for a drug in all 3 years had increased prescribing of that drug (compared with 0 years), for renal cell (relative risk [RR] 1.81, 95% confidence interval [CI] 1.58-2.07), CML (RR 1.22, 95% CI 1.08-1.39), and lung (RR 1.69, 95% CI 1.58-1.82), but not prostate (RR 0.97, 95% CI 0.93-1.02). Physicians who received compensation payments or >$100 annually had increased prescribing compared with those who did not, but NCI setting and institutional conflict-of-interest policies were not consistently associated with the direction of prescribing change. CONCLUSION The association between industry payments and cancer drug prescribing was greatest among physicians who received payments consistently (within each calendar year). Receipt of payments for compensation purposes, such as for consulting or travel, and higher dollar value of payments were also associated with increased prescribing. IMPLICATIONS FOR PRACTICE Financial payments from pharmaceutical companies are common among oncologists. It is known from prior work that oncologists tend to prescribe more of the drugs made by companies that have given them money. By combining records of industry gifts with prescribing records, this study identifies the consistency of payments over time, the dollar value of payments, and payments for compensation as factors that may strengthen the association between receiving payments and increased prescribing of that company's drug.
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Winn AN, Dusetzina SB. More evidence on the limited impact of state oral oncology parity laws. Cancer 2018; 125:335-336. [DOI: 10.1002/cncr.31904] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 11/09/2018] [Indexed: 01/09/2023]
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Drangsholt S, Walter D, Ciprut S, Lepor A, Sedlander E, Curnyn C, Loeb S, Malloy P, Winn AN, Makarov DV. Quantifying downstream impact of inappropriate staging imaging in a cohort of veterans with low- and intermediate-risk incident prostate cancer. Urol Oncol 2018; 37:145-149. [PMID: 30578160 DOI: 10.1016/j.urolonc.2018.11.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 11/12/2018] [Accepted: 11/21/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION According to current National Comprehensive Cancer Network guidelines, routine imagining for staging low-risk prostate cancer is not recommended. However, extensive overuse of guideline-discordant imaging continues to persist. Incidental findings are common on imaging and little is known about the optimal management. Rates of incidental findings vs. false positive diagnosis from inappropriate imaging are poorly understood and have yet to be quantified for low- and intermediate-risk prostate cancer patients. OBJECTIVE To determine the frequency of positive radiologic findings in patients with low- and intermediate-risk prostate cancer during initial staging at VA New York Harbor Healthcare System. METHODS We retrospectively reviewed all low- and intermediate-risk prostate cancer patients' medical records from the VA New York Harbor Healthcare System for diagnosis from 2005 to 2015. We reviewed each individual's prebiopsy prostate specific antigen (PSA), Gleason score, and clinical stage. We also determined if imaging obtained yielded a false positive, incidental finding, or if metastatic disease occurred within the 6 months following initial diagnosis. RESULTS There were 414 men, who were classified as low- to intermediate-risk prostate cancer and underwent inappropriate staging imaging of 4,306 men diagnosed with prostate cancer. Of these 414 men, 178 (43%) had additional follow-up imaging for positive findings. We calculated an incidental finding rate of 10% and a false positive rate of 38% for patients. Five (1%) patients had metastatic disease. CONCLUSION Despite guideline recommendations, imaging overuse remains an issue for low-intermediate-risk prostate cancer patients. The false positive rate found in this analysis is alarmingly high at 38%. This use of scans is burdensome to the healthcare system and patient. This study highlights the frequency of inappropriate imaging and its negative consequences.
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Dusetzina SB, Huskamp HA, Winn AN, Basch E, Keating NL. Out-of-Pocket and Health Care Spending Changes for Patients Using Orally Administered Anticancer Therapy After Adoption of State Parity Laws. JAMA Oncol 2018; 4:e173598. [PMID: 29121177 DOI: 10.1001/jamaoncol.2017.3598] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Oral anticancer medications are increasingly important but costly treatment options for patients with cancer. By early 2017, 43 states and Washington, DC, had passed laws to ensure patients with private insurance enrolled in fully insured health plans pay no more for anticancer medications administered by mouth than anticancer medications administered by infusion. Federal legislation regarding this issue is currently pending. Despite their rapid acceptance, the changes associated with state adoption of oral chemotherapy parity laws have not been described. Objective To estimate changes in oral anticancer medication use, out-of-pocket spending, and health plan spending associated with oral chemotherapy parity law adoption. Design, Setting, and Participants Analysis of administrative health plan claims data from 2008-2012 for 3 large nationwide insurers aggregated by the Health Care Cost Institute. Data analysis was first completed in 2015 and updated in 2017. The study population included 63 780 adults living in 1 of 16 states that passed parity laws during the study period and who received anticancer drug treatment for which orally administered treatment options were available. Study analysis used a difference-in-differences approach. Exposures Time period before and after adoption of state parity laws, controlling for whether the patient was enrolled in a plan subject to parity (fully insured) or not (self-funded, exempt via the Employee Retirement Income Security Act). Main Outcomes and Measures Oral anticancer medication use, out-of-pocket spending, and total health care spending. Results Of the 63 780 adults aged 18 through 64 years, 51.4% participated in fully insured plans and 48.6% in self-funded plans (57.2% were women; 76.8% were aged 45 to 64 years). The use of oral anticancer medication treatment as a proportion of all anticancer treatment increased from 18% to 22% (adjusted difference-in-differences risk ratio [aDDRR], 1.04; 95% CI, 0.96-1.13; P = .34) comparing months before vs after parity. In plans subject to parity laws, the proportion of prescription fills for orally administered therapy without copayment increased from 15.0% to 53.0%, more than double the increase (12.3%-18.0%) in plans not subject to parity (P < .001). The proportion of patients with out-of-pocket spending of more than $100 per month increased from 8.4% to 11.1% compared with a slight decline from 12.0% to 11.7% in plans not subject to parity (P = .004). In plans subject to parity laws, estimated monthly out-of-pocket spending decreased by $19.44 at the 25th percentile, by $32.13 at the 50th percentile, and by $10.83 at the 75th percentile but increased at the 90th ($37.19) and 95th ($143.25) percentiles after parity (all P < .001, controlling for changes in plans not subject to parity). Parity laws did not increase 6-month total spending for users of any anticancer therapy or for users of oral anticancer therapy alone. Conclusions and Relevance While oral chemotherapy parity laws modestly improved financial protection for many patients without increasing total health care spending, these laws alone may be insufficient to ensure that patients are protected from high out-of-pocket medication costs.
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Mitchell AP, Winn AN, Dusetzina SB. Pharmaceutical Industry Payments and Oncologists' Selection of Targeted Cancer Therapies in Medicare Beneficiaries. JAMA Intern Med 2018; 178:854-856. [PMID: 29630687 PMCID: PMC6145757 DOI: 10.1001/jamainternmed.2018.0776] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study examines the association between oncologists’ receipt of payments from pharmaceutical manufacturers and drug selection in 2 situations where there are multiple treatment options.
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Laiteerapong N, Cooper JM, Skandari MR, Clarke PM, Winn AN, Naylor RN, Huang ES. Individualized Glycemic Control for U.S. Adults With Type 2 Diabetes: A Cost-Effectiveness Analysis. Ann Intern Med 2018; 168:170-178. [PMID: 29230472 PMCID: PMC5989575 DOI: 10.7326/m17-0537] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Intensive glycemic control in type 2 diabetes (glycated hemoglobin [HbA1c] level <7%) is an established, cost-effective standard of care. However, guidelines recommend individualizing goals on the basis of age, comorbidity, diabetes duration, and complications. OBJECTIVE To estimate the cost-effectiveness of individualized control versus uniform intensive control (HbA1c level <7%) for the U.S. population with type 2 diabetes. DESIGN Patient-level Monte Carlo-based Markov model. DATA SOURCES National Health and Nutrition Examination Survey 2011-2012. TARGET POPULATION The approximately 17.3 million persons in the United States with diabetes diagnosed at age 30 years or older. TIME HORIZON Lifetime. PERSPECTIVE Health care sector. INTERVENTION Individualized versus uniform intensive glycemic control. OUTCOME MEASURES Average lifetime costs, life-years, and quality-adjusted life-years (QALYs). RESULTS OF BASE-CASE ANALYSIS Individualized control saved $13 547 per patient compared with uniform intensive control ($105 307 vs. $118 854), primarily due to lower medication costs ($34 521 vs. $48 763). Individualized control decreased life expectancy (20.63 vs. 20.73 years) due to an increase in complications but produced more QALYs (16.68 vs. 16.58) due to fewer hypoglycemic events and fewer medications. RESULTS OF SENSITIVITY ANALYSIS Individualized control was cost-saving and generated more QALYs compared with uniform intensive control, except in analyses where the disutility associated with receiving diabetes medications was decreased by at least 60%. LIMITATION The model did not account for effects of early versus later intensive glycemic control. CONCLUSION Health policies and clinical programs that encourage an individualized approach to glycemic control for U.S. adults with type 2 diabetes reduce costs and increase quality of life compared with uniform intensive control. Additional research is needed to confirm the risks and benefits of this strategy. PRIMARY FUNDING SOURCE National Institute of Diabetes and Digestive and Kidney Diseases.
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Anderson C, Winn AN, Dusetzina SB, Nichols HB. Endocrine Therapy Initiation among Older Women with Ductal Carcinoma In Situ. J Cancer Epidemiol 2017; 2017:6091709. [PMID: 29056966 PMCID: PMC5615957 DOI: 10.1155/2017/6091709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 08/14/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Although treatment of ductal carcinoma in situ (DCIS) is controversial, national guidelines recommend considering endocrine therapy for women with estrogen receptor- (ER-) positive DCIS or those undergoing breast conserving surgery (BCS) without radiation. We evaluated uptake and predictors of endocrine therapy use among older women with DCIS. METHODS In the SEER-Medicare database, we identified women aged 65+ years diagnosed with DCIS during 2007-2011. We evaluated demographic, tumor, and treatment characteristics associated with endocrine therapy initiation. RESULTS Among 2,945 women with DCIS, 41% initiated endocrine therapy (66% tamoxifen, 34% aromatase inhibitors). Initiation was more common among women with ER-positive than ER-negative DCIS (48% versus 16%; HR = 3.75, 95% CI: 2.91-4.83); 28% of women with unknown ER status initiated endocrine therapy. Initiation was less common after BCS alone compared to BCS with radiation (32% versus 50%; HR = 0.69, 95% CI: 0.59-0.80). CONCLUSIONS Less than half of older women with DCIS initiate endocrine therapy to prevent second breast cancers. Our findings suggest use was more common, but not exclusive, among women with ER-positive DCIS, but not among women who underwent BCS alone. Endocrine therapy should be targeted toward patients most likely to benefit from its use.
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