Tale of Two Erythropoiesis-Stimulating Agents: Utilization, Dosing, Litigation, and Costs of Darbepoetin and Epoetin Among South Carolina Medicaid-Covered Patients With Cancer and Chemotherapy-Induced Anemia

PURPOSE

The US Food and Drug Administration (FDA) has approved epoetin and darbepoetin for chemotherapy-induced anemia (CIA). Approved epoetin and darbepoetin dosing schedules were three times per week and weekly, respectively, although off-label, less frequent scheduling was common. In 2004, 2007, and 2008, a US Food and Drug Administration Advisory Committees warned of risks associated with erythropoiesis-stimulating agents. During this period, lawsuits alleging illegal darbepoetin marketing practices have concluded, resulting in $1.1 billion in fines and settlements and one criminal conviction. No prior study, to our knowledge, has reported on the use of darbepoetin versus epoetin for CIA.

METHODS

We evaluated the dosing, utilization, and costs of erythropoiesis-stimulating agents among 3,761 South Carolina Medicaid patients with CIA.

RESULTS

Epoetin and darbepoetin utilization rates were 22% and 28% in 2003, 10% and 33% in 2007, and 3% and 7% in 2010, respectively. Mean per-patient per-administration epoetin and darbepoetin doses were 40,983 IU and 191 µg, respectively, in 2003 and 47,753 IU and 369 µg, respectively, in 2010. Mean monthly patient costs for epoetin and darbepoetin were $1,030 and $981, respectively, in 2003 and $932 and $1,352, respectively, in 2010. Epoetin use decreased steadily between 2002 and 2010; darbepoetin use increased steadily between 2003 and 2007 and then decreased steadily thereafter. Per-patient dosing of darbepoetin, but not epoetin, increased steadily between 2003 and 2010, and monthly per-patient epoetin costs decreased 3% while the per-patients costs of darbepoetin increased 30% between 2003 and 2010.

CONCLUSION

To our knowledge, our findings are the first data reporting on epoetin versus darbepoetin use for CIA and support recently concluded lawsuits involving allegations of illegal marketing practices of the manufacturer of darbepoetin.

Patient Copayments, Provider Incentives and Income Effects: Theory and Evidence from the Essential Medications List under China's 2009 Healthcare Reform

Expanding access through insurance expansion can increase healthcare utilization through moral hazard. Reforming provider incentives to introduce more supply-side cost sharing is increasingly viewed as crucial for affordable, sustainable access. Using both difference-in-differences and segmented regression analyses on a panel of 1,466 hypertensive and diabetic patients, we empirically examine Shandong province's initial implementation of China's 2009 Essential Medications List policy. The policy reduced drug sale markups to providers but also increased drug coverage benefits for patients. We find that providers appeared to compensate for lost drug revenues by increasing office visits, for which no fee reduction occurred. At the same time, physician agency (yielding to patient demand for pharmaceuticals) may have tempered provider incentives to reduce drug expenditures at the visit level. Taken together, the policy may have increased total spending or total out-of-pocket expenditures. Mandating payment reductions in a service that comprises a large portion of provider income may have unintended consequences.

The Association Between Electronic Bullying and School Absenteeism Among High School Students in the United States

BACKGROUND

We examined the relationship between exposure to electronic bullying and absenteeism as a result of being afraid.

METHODS

This multivariate, multinomial regression analysis of the 2013 Youth Risk Behavior Survey data assessed the association between experiencing electronic bullying in the past year and how often students were absent in the last month due to feeling unsafe at/in transit to school. The model controlled for other predictors of school absence including demographics, physical/behavioral health, and risk factors. Missing data were multiply imputed.

RESULTS

Electronic bullying was significantly associated with absences. Controlling for model covariates, the relative risk of missing 1 day of school was 1.77 times higher, the relative risk of missing 2 to 3 days of school per month increased by a factor of 2.08, and the relative risk of missing 4 or more days of school per month increased by a factor of 1.77 for those who experienced electronic bullying in the past year compared with those who were not electronically bullied.

CONCLUSIONS

Electronic bullying's association with absenteeism places it among already recognized negative influences such as depression and binge drinking, necessitating schools to implement policies to mediate the resulting harmful effects.

Zika virus: A call to action for physicians in the era of climate change

In February 2016, the World Health Organization declared the mosquito-borne Zika virus to be a "public health emergency of international concern" as the disease linked to thousands of birth defects in Brazil spreads rapidly. The distribution of the Aedes mosquitos has drastically increased over the past few decades, which have been the hottest decades on Earth in more than 1000 years based on climate proxy measures. Although a combination of factors explains the current Zika virus outbreak, it's highly likely that the changes in the climate contribute to the spread of Aedes vector carrying the Zika virus, the pathogen causing serious birth defects. Physicians, both individually and collectively, as trusted and educated members of society have critical roles to play. In addition to clinical management and prevention of Zika, physicians should communicate about the health benefits of addressing climate change in straightforward evidence-based language to their local communities and policymakers, and make clear their support for policies mitigating climate change.

Variation in Vaccination Data Available at School Entry Across the United States

OBJECTIVES

To compile substate-level data on US school-age children's vaccination rates.

METHODS

For states that did not have suitable data online, in 2015 we submitted information requests to the state health department and followed up with the state's Freedom of Information Act when necessary.

RESULTS

The accessibility, scale, and types of vaccination data varied considerably. Whereas 26 states provided data online, 14 released data only after a Freedom of Information Act request. School or school-district data were available for 24 states, 19 at the county level, 2 at the health department level, and 6 provided no substate-level data.

CONCLUSIONS

Effective vaccination policy requires a robust understanding of vaccination behavior. Some states make it difficult to access data or provide low-resolution data of limited value for identifying vaccination behavior.

A spatiotemporal analysis of non-medical exemptions from vaccination: California schools before and after SB277

Childhood vaccination programs are considered one of the most beneficial public health programs in modern history. In the United States, the increasing use of non-medical exemptions (NMEs) from school entry vaccination requirements has garnered attention and scrutiny in the popular press, academic literature, and policy forums. In 2016, California law SB277 goes into effect, eliminating the NME option for students attending the state's public and private schools. Whereas SB277 is a strong move to increase vaccination coverage within California's schools, the new law contains an important caveat - students already having a valid NME (obtained prior to the 2016 school year) are "grandfathered" in until their next grade checkpoint (seventh grade). Although no new students will enter the California school system with a NME after 2016, the law's grandfather clause will allow NMEs to persist within the state school system until 2022. This analysis demonstrates how the past "build up" of students with pre-SB277 NMEs and the law's grandfather clause will act in combination to affect NME rates across the state after the implementation of SB277. We construct spatially explicit, yearly models of all students (K-12) enrolled in the California school system from 2011 to 2022. Our analysis finds that, although all regions of the state will eventually reach an NME rate of 0% by 2022, SB277's effect will be highly spatially and temporally variable. Some school districts will continue to experience elevated NME rates and increased risk of disease outbreak for years after SB277 is implemented. Our analysis highlights the potential spatially variant consequences of SB277's grandfather clause, providing important information for other states considering similar policy initiatives.

Murder Liability for Prescribing Opioids: A Way Forward?

In February 2016, Dr. Hsiu-Ying Tseng was sentenced to 30-years to life in prison after a jury found her guilty of second-degree murder for three patient drug overdose deaths in California. For the first time in American history, a physician was held criminally liable for the murder of a patient by means of extreme recklessness in opioid prescribing. Although Dr. Tseng’s unique conviction reflects her outlier prescribing practices, the conviction and sentencing has sent ripples through the medical community, causing concerns for many physicians who now worry they will be held criminally liable when their patients abuse and misuse opioid prescriptions. However, physicians—particularly the majority that prescribe opioids in an earnest attempt to alleviate legitimate patient pain—may take comfort that the legal risks can be managed. Prescribers can take a number of steps to minimize criminal liability concerns, including following available guidelines, such as those recently issued on opioid prescribing for chronic pain by the Centers for Disease Control and Prevention. While outlier physicians like Dr. Tseng may meet the standards for criminal liability, criminal prosecution may do little to curb prescription opioid abuse—an epidemic that calls for more upstream prevention measures.