101
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Thourani VH, Brennan JM, Edelman JJ, Chen Q, Boero IJ, Sarkar RR, Murphy SM, Leon MB, Kodali SK. Treatment Patterns, Disparities, and Management Strategies Impact Clinical Outcomes in Patients with Symptomatic Severe Aortic Regurgitation. STRUCTURAL HEART 2021. [DOI: 10.1080/24748706.2021.1988779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Brito JP, Ross JS, El Kawkgi OM, Maraka S, Deng Y, Shah ND, Lipska KJ. Levothyroxine Use in the United States, 2008-2018. JAMA Intern Med 2021; 181:1402-1405. [PMID: 34152370 PMCID: PMC8218227 DOI: 10.1001/jamainternmed.2021.2686] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This cross-sectional study assesses national data for commercially insured and Medicare Advantage enrollees to analyze the use of levothyroxine in the US over time.
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Affiliation(s)
- Juan P Brito
- Division of Endocrinology, Diabetes, Metabolism, & Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Joseph S Ross
- Section of General Internal Medicine and the National Clinician Scholars Program, Yale School of Medicine, New Haven, Connecticut.,Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut.,Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Omar M El Kawkgi
- Division of Endocrinology, Diabetes, Metabolism, & Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Spyridoula Maraka
- Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, Little Rock.,Central Arkansas Veterans Healthcare System, Little Rock
| | - Yihong Deng
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Nilay D Shah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.,Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
| | - Kasia J Lipska
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut.,Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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103
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Wallach JD, Deng Y, McCoy RG, Dhruva SS, Herrin J, Berkowitz A, Polley EC, Quinto K, Gandotra C, Crown W, Noseworthy P, Yao X, Shah ND, Ross JS, Lyon TD. Real-world Cardiovascular Outcomes Associated With Degarelix vs Leuprolide for Prostate Cancer Treatment. JAMA Netw Open 2021; 4:e2130587. [PMID: 34677594 PMCID: PMC8536955 DOI: 10.1001/jamanetworkopen.2021.30587] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE With a growing interest in the use of real-world evidence for regulatory decision-making, it is important to understand whether real-world data can be used to emulate the results of randomized clinical trials. OBJECTIVE To use electronic health record and administrative claims data to emulate the ongoing PRONOUNCE trial (A Trial Comparing Cardiovascular Safety of Degarelix Versus Leuprolide in Patients With Advanced Prostate Cancer and Cardiovascular Disease). DESIGN, SETTING, AND PARTICIPANTS This retrospective, propensity-matched cohort study included adult men with a diagnosis of prostate cancer and cardiovascular disease who initiated either degarelix or leuprolide between December 24, 2008, and June 30, 2019. Participants were commercially insured individuals and Medicare Advantage beneficiaries included in a large US administrative claims database. EXPOSURES Degarelix or leuprolide. MAIN OUTCOMES AND MEASURES The primary end point was time to first occurrence of a major adverse cardiovascular event (MACE), defined as death due to any cause, myocardial infarction, or stroke, analogous to the PRONOUNCE trial. Secondary end points were time to death due to any cause, myocardial infarction, stroke, and angina. Cox proportional hazards regression was used to evaluate primary and secondary end points. RESULTS A total of 32 172 men initiated degarelix or leuprolide for prostate cancer; of them, 9490 (29.5%) had cardiovascular disease, and 7800 (24.2%) met the PRONOUNCE trial eligibility criteria and were included in this study. Overall, 165 participants (2.1%) were Asian, 1390 (17.8%) were Black, 663 (8.5%) were Hispanic, and 5258 (67.4%) were White. The mean (SD) age was 74.4 (7.4) years. Among 2226 propensity score-matched patients, no significant difference was observed in the risk of MACE for patients taking degarelix vs those taking leuprolide (10.18 vs 8.60 events per 100 person-years; hazard ratio [HR], 1.18; 95% CI, 0.86-1.61). Degarelix was associated with a higher risk of death from any cause (HR, 1.48; 95% CI, 1.01-2.18) but not of myocardial infarction (HR, 1.16; 95% CI, 0.60-2.25), stroke (HR, 0.92; 95% CI, 0.45-1.85), or angina (HR, 1.36; 95% CI, 0.43-4.27). CONCLUSIONS AND RELEVANCE In this emulation of a clinical trial of men with cardiovascular disease undergoing treatment for prostate cancer, degarelix was not associated with a lower risk of cardiovascular events than leuprolide. Comparison of these data with PRONOUNCE trial results, when published, will help enhance our understanding of the appropriate role of using real-world data to emulate clinical trials.
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Affiliation(s)
- Joshua D. Wallach
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Yihong Deng
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Rozalina G. McCoy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Sanket S. Dhruva
- Section of Cardiology, San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Medicine, UCSF School of Medicine, San Francisco, California
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
- Flying Buttress Associates, Charlottesville, Virginia
| | - Alyssa Berkowitz
- Center for Outcomes Research and Evaluation, Yale–New Haven Health, New Haven, Connecticut
| | - Eric C. Polley
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Kenneth Quinto
- Office of Medical Policy, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Springs, Maryland
| | - Charu Gandotra
- Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Springs, Maryland
| | - William Crown
- Florence Heller Graduate School, Brandeis University, Waltham, Massachusetts
| | - Peter Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Nilay D. Shah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Joseph S. Ross
- Flying Buttress Associates, Charlottesville, Virginia
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
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104
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Blayney DW, Seto T, Hoang N, Lindquist C, Kurian AW. Benchmark Method for Cost Computations Across Health Care Systems: Cost of Care per Patient per Day in Breast Cancer Care. JCO Oncol Pract 2021; 17:e1403-e1412. [PMID: 33646822 PMCID: PMC8791822 DOI: 10.1200/op.20.00462] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 12/08/2020] [Accepted: 01/19/2021] [Indexed: 01/07/2023] Open
Abstract
PURPOSE To estimate the value of cancer care and to compare value among episodes of care, a transparent, reproducible, and standardized cost computation methodology is needed. Charges, claims, and reimbursements are related to cost but are nontransparent and proprietary. We developed a method to measure the cost of the following phases of care: (1) initial treatment with curative intent, (2) surveillance and survivorship care, and (3) relapse and end-of-life care. METHODS We combined clinical data from our electronic health record, the state cancer registry, and the Social Security Death Index. We analyzed the care of patients with breast cancer and mapped Common Procedural Terminology (CPT) codes to the corresponding cost conversion factor and date in the CMS Medicare fee schedule. To account for varying duration of episodes of care, we computed a cost of care per day (CCPD) for each patient. RESULTS Median CCPD for initial treatment was $29.45 in US dollars (USD), the CCPD for surveillance and survivorship care was $2.45 USD, and the CCPD for relapse care was $13.80 USD. Among the three breast cancer types (hormone receptor-positive or human epidermal growth factor receptor 2 [HER2]-negative, HER2-positive, and triple-negative), there was no difference in CCPD. Relapsed patients in the most expensive surveillance CCPD group had significantly shorter survival. CONCLUSION We developed a method to identify high-value oncology care-cost of care per patient per day (CCPD)-in episodes of initial, survivorship, and relapse care. The methodology can help identify positive deviants (who have developed best practices) delivering high-value care. Merging our data with claims data from third-party payers can increase the accuracy and validity of the CCPD.
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Affiliation(s)
- Douglas W. Blayney
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, CA
| | - Tina Seto
- Technology and Digital Solutions, Stanford HealthCare and School of Medicine, Stanford, CA
| | - Nhat Hoang
- Technology and Digital Solutions, Stanford HealthCare and School of Medicine, Stanford, CA
| | - Craig Lindquist
- Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, CA
| | - Allison W. Kurian
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
- Division of Medical Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
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105
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Shi Y, Dykhoff HJ, Guevara LRH, Sangaralingham LR, Schroeder DR, Flick RP, Zaccariello MJ, Warner DO. Moderators of the association between attention-deficit/hyperactivity disorder and exposure to anaesthesia and surgery in children. Br J Anaesth 2021; 127:722-728. [PMID: 34503832 DOI: 10.1016/j.bja.2021.07.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/23/2021] [Accepted: 07/09/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Children's exposure to anaesthesia has been associated with risk of developing attention-deficit/hyperactivity disorder (ADHD). The goal of this study was to determine if selected patient characteristics moderate the association between exposure to anaesthesia and ADHD. METHODS In a cohort of children born in between 2006 and 2012, exposure to anaesthesia before the age of 5 yr was categorised into unexposed, singly, or multiply exposed. Weighted proportional hazard regression was performed to evaluate the hazard ratios (HRs) of ADHD diagnosis related to anaesthesia exposure. Interaction analyses were performed to evaluate potential moderators. RESULTS Among 185 002 children in the cohort, 9179 were diagnosed with ADHD. Compared with unexposed children, a single exposure to anaesthesia was associated with a HR of 1.39, (95% confidence interval [CI], 1.32-1.47) for ADHD. Multiple exposures were associated with a HR of 1.75 (95% CI, 1.62-1.87). In the analyses evaluating moderators of the association between exposure and ADHD, only the interaction for race was statistically significant (P=0.006); exposure increased the incidence of ADHD to a greater extent in non-White compared with White children. Among children with a single exposure, the age at exposure did not affect the relationship between exposure and incidence of ADHD (P=0.78). CONCLUSIONS Exposure of young children to anaesthesia and surgery is associated with an increased incidence of ADHD, with more exposures associated with greater risk. Compared with White children, non-White children are at greater risk for reasons that are unknown but need to be further explored.
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Affiliation(s)
- Yu Shi
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Hayley J Dykhoff
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Lindsay R H Guevara
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lindsey R Sangaralingham
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA; OptumLabs, Cambridge, MA, USA
| | | | - Randall P Flick
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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Adoption of the Antifibrotic Medications Pirfenidone and Nintedanib for Patients with Idiopathic Pulmonary Fibrosis. Ann Am Thorac Soc 2021; 18:1121-1128. [PMID: 33465323 DOI: 10.1513/annalsats.202007-901oc] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: In October 2014, the antifibrotic medications pirfenidone and nintedanib became the first medications approved by the U.S. Food and Drug Administration for use in patients with idiopathic pulmonary fibrosis (IPF). Since approval, there has been no nonregistry analysis of the real-world adoption of these medications in everyday clinical practice. Objectives: To evaluate the adoption, persistence, and out-of-pocket (OOP) costs of pirfenidone and nintedanib since their approval in the United States in 2014. Methods: A retrospective cohort analysis was performed by identifying privately insured and Medicare Advantage beneficiaries with IPF. We then split the patients into three cohorts: those who were untreated and those who filled a prescription for either pirfenidone or nintedanib between October 1, 2014, and July 31, 2019. The primary outcome was adoption of the medications. Secondary outcomes included medication persistence and prescription drug costs. Results: A total of 10,996 patients with IPF were identified in the data set. A minority of patients (26.4%) with IPF identified in the cohort had started either medication since approval in 2014, with the adoption of both medications being comparable at around 13.2%. Those receiving the medications were younger (72 vs. 73.9 yr; P < 0.0001) and healthier (3.9 vs. 4.9 comorbidities; P < 0.0001) than those not receiving treatment. Men were significantly more likely to receive treatment than woman (30.0% vs. 21.9%; P < 0.0001). Among treated patients, 42.8% discontinued the medications during the study period. Patients' OOP expenses per month were high for both drugs (mean, $397.51 for nintedanib; mean, $394.49 for pirfenidone). Conclusions: The adoption of both the antifibrotic medications in the United States in everyday practice has been low since approval and may be associated with the high OOP cost.
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107
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Yang KC, Lee B, Ahn YY, Perry BL. Use of and Comorbidities Associated With Diagnostic Codes for COVID-19 in US Health Insurance Claims. JAMA Netw Open 2021; 4:e2124643. [PMID: 34495342 PMCID: PMC8427377 DOI: 10.1001/jamanetworkopen.2021.24643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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 quality improvement study assesses the comorbidities associated with COVID-19 diagnostic codes in US health insurance claims.
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Affiliation(s)
- Kai-Cheng Yang
- Luddy School of Informatics, Computing, and Engineering, Indiana University-Bloomington, Bloomington
| | - Byungkyu Lee
- Department of Sociology, Indiana University-Bloomington, Bloomington
| | - Yong-Yeol Ahn
- Luddy School of Informatics, Computing, and Engineering, Indiana University-Bloomington, Bloomington
| | - Brea L. Perry
- Department of Sociology, Indiana University-Bloomington, Bloomington
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108
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Chu CD, Powe NR, McCulloch CE, Crews DC, Han Y, Bragg-Gresham JL, Saran R, Koyama A, Burrows NR, Tuot DS. Trends in Chronic Kidney Disease Care in the US by Race and Ethnicity, 2012-2019. JAMA Netw Open 2021; 4:e2127014. [PMID: 34570204 PMCID: PMC8477264 DOI: 10.1001/jamanetworkopen.2021.27014] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 07/25/2021] [Indexed: 12/13/2022] Open
Abstract
Importance Significant racial and ethnic disparities in chronic kidney disease (CKD) progression and outcomes are well documented, as is low use of guideline-recommended CKD care. Objective To examine guideline-recommended CKD care delivery by race and ethnicity in a large, diverse population. Design, Setting, and Participants In this serial cross-sectional study, adult patients with CKD that did not require dialysis, defined as a persistent estimated glomerular filtration rate less than 60 mL/min/1.73 m2 or a urine albumin-creatinine ratio of 30 mg/g or higher for at least 90 days, were identified in 2-year cross-sections from January 1, 2012, to December 31, 2019. Data from the OptumLabs Data Warehouse, a national data set of administrative and electronic health record data for commercially insured and Medicare Advantage patients, were used. Exposures The independent variables were race and ethnicity, as reported in linked electronic health records. Main Outcomes and Measures On the basis of guideline-recommended CKD care, the study examined care delivery process measures (angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker prescription for albuminuria, statin prescription, albuminuria testing, nephrology care for CKD stage 4 or higher, and avoidance of chronic nonsteroidal anti-inflammatory drug prescription) and care delivery outcome measures (blood pressure and diabetes control). Results A total of 452 238 patients met the inclusion criteria (mean [SD] age, 74.0 [10.2] years; 262 089 [58.0%] female; a total of 7573 [1.7%] Asian, 49 970 [11.0%] Black, 15 540 [3.4%] Hispanic, and 379 155 [83.8%] White). Performance on process measures was higher among Asian, Black, and Hispanic patients compared with White patients for angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker use (79.8% for Asian patients, 76.7% for Black patients, and 79.9% for Hispanic patients compared with 72.3% for White patients in 2018-2019), statin use (72.6% for Asian patients, 69.1% for Black patients, and 74.1% for Hispanic patients compared with 61.5% for White patients), nephrology care (64.8% for Asian patients, 72.9% for Black patients, and 69.4% for Hispanic patients compared with 58.3% for White patients), and albuminuria testing (53.9% for Asian patients, 41.0% for Black patients, and 52.6% for Hispanic patients compared with 30.7% for White patients). Achievement of blood pressure control to less than 140/90 mm Hg was similar or lower among Asian (71.8%), Black (63.3%), and Hispanic (69.8%) patients compared with White patients (72.9%). Achievement of diabetes control with hemoglobin A1c less than 7.0% was 50.1% in Asian patients, 49.3% in Black patients, and 46.0% in Hispanic patients compared with 50.3% for White patients. Conclusions and Relevance Higher performance on CKD care process measures among Asian, Black, and Hispanic patients suggests that differences in medication prescription and diagnostic testing are unlikely to fully explain known disparities in CKD progression and kidney failure. Improving care delivery processes alone may be inadequate for reducing these disparities.
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Affiliation(s)
- Chi D. Chu
- Division of Nephrology, University of California, San Francisco
- OptumLabs Visiting Fellow, OptumLabs, Eden Prairie, Minnesota
| | - Neil R. Powe
- Department of Medicine, University of California, San Francisco
- Department of Medicine, Mark Zuckerberg and Priscilla Chan San Francisco General Hospital, San Francisco, California
- Center for Vulnerable Populations, University of California, San Francisco
| | - Charles E. McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Deidra C. Crews
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Center for Health Equity, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Yun Han
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
| | | | - Rajiv Saran
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
| | - Alain Koyama
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nilka R. Burrows
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Delphine S. Tuot
- Division of Nephrology, University of California, San Francisco
- Department of Medicine, University of California, San Francisco
- Department of Medicine, Mark Zuckerberg and Priscilla Chan San Francisco General Hospital, San Francisco, California
- Center for Vulnerable Populations, University of California, San Francisco
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McCoy RG, Galindo RJ, Swarna KS, Van Houten HK, O’Connor PJ, Umpierrez GE, Shah ND. Sociodemographic, Clinical, and Treatment-Related Factors Associated With Hyperglycemic Crises Among Adults With Type 1 or Type 2 Diabetes in the US From 2014 to 2020. JAMA Netw Open 2021; 4:e2123471. [PMID: 34468753 PMCID: PMC8411297 DOI: 10.1001/jamanetworkopen.2021.23471] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE Hyperglycemic crises (ie, diabetic ketoacidosis [DKA] and hyperglycemic hyperosmolar state [HHS]) are life-threatening acute complications of diabetes. Efforts to prevent these events at the population level have been hindered by scarce granular data and difficulty in identifying individuals at highest risk. OBJECTIVE To assess sociodemographic, clinical, and treatment-related factors associated with hyperglycemic crises in adults with type 1 or type 2 diabetes in the US from 2014 to 2020. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study analyzed administrative claims and laboratory results for adults (aged ≥18 years) with type 1 or type 2 diabetes from the OptumLabs Data Warehouse from January 1, 2014, through December 31, 2020. MAIN OUTCOMES AND MEASURES Rates of emergency department or hospital visits with a primary diagnosis of DKA or HHS (adjusted for age, sex, race/ethnicity, and region, and for year when calculating annualized rates) were calculated separately for patients with type 1 diabetes and type 2 diabetes. The associations of sociodemographic factors (age, sex, race/ethnicity, region, and income), clinical factors (comorbidities), and treatment factors (glucose-lowering medications, hemoglobin A1c) with DKA or HHS in patients with type 1 or type 2 diabetes were assessed using negative binomial regression. RESULTS Among 20 156 adults with type 1 diabetes (mean [SD] age, 46.6 [16.5] years; 51.2% male; 72.6% White race/ethnicity) and 796 382 with type 2 diabetes (mean [SD] age, 65.6 [11.8] years; 50.3% female; 54.4% White race/ethnicity), adjusted rates of hyperglycemic crises were 52.69 per 1000 person-years (95% CI, 48.26-57.12 per 1000 person-years) for type 1 diabetes and 4.04 per 1000 person-years (95% CI, 3.88-4.21 per 1000 person-years) for type 2 diabetes. In both groups, factors associated with the greatest hyperglycemic crisis risk were low income (≥$200 000 vs <$40 000: type 1 diabetes incidence risk ratio [IRR], 0.61 [95% CI, 0.46-0.81]; type 2 diabetes IRR, 0.69 [95% CI, 0.56-0.86]), Black race/ethnicity (vs White race/ethnicity: type 1 diabetes IRR, 1.33 [95% CI, 1.01-1.74]; type 2 diabetes IRR, 1.18 [95% CI, 1.09-1.27]), high hemoglobin A1c level (≥10% vs 6.5%-6.9%: type 1 diabetes IRR, 7.81 [95% CI, 5.78-10.54]; type 2 diabetes IRR, 7.06 [95% CI, 6.26-7.96]), history of hyperglycemic crises (type 1 diabetes IRR, 7.88 [95% CI, 6.06-9.99]; type 2 diabetes IRR, 17.51 [95% CI, 15.07-20.34]), severe hypoglycemia (type 1 diabetes IRR, 2.77 [95% CI, 2.15-3.56]; type 2 diabetes IRR, 4.18 [95% CI, 3.58-4.87]), depression (type 1 diabetes IRR, 1.62 [95% CI, 1.37-1.92]; type 2 diabetes IRR, 1.46 [95% CI, 1.34-1.59]), neuropathy (type 1 diabetes IRR, 1.64 [95% CI, 1.39-1.93]; type 2 diabetes IRR, 1.25 [95% CI, 1.17-1.34]), and nephropathy (type 1 diabetes IRR, 1.22 [95% CI, 1.01-1.48]; type 2 diabetes IRR, 1.23 [95% CI, 1.14-1.33]). Age had a U-shaped association with hyperglycemic crisis risk in patients with type 1 diabetes (compared with patients aged 18-44 years: 45-64 years IRR, 0.72 [95% CI, 0.59-0.87]; 65-74 years IRR, 0.62 [95% CI, 0.47-0.80]; ≥75 years IRR, 0.96 [95% CI, 0.66-1.38]). In type 2 diabetes, risk of hyperglycemic crises decreased progressively with age (45-64 years IRR, 0.57 [95% CI, 0.51-0.63]; 65-74 years IRR, 0.44 [95% CI, .39-0.49]; ≥75 years IRR, 0.41 [95% CI, 0.36-0.47]). In patients with type 2 diabetes, higher risk was associated with sodium-glucose cotransporter 2 inhibitor therapy (IRR, 1.30; 95% CI, 1.14-1.49) and insulin dependency (compared with regimens with bolus insulin: regimens with basal insulin only, IRR, 0.69 [95% CI, 0.63-0.75]; and without any insulin, IRR, 0.36 [95% CI, 0.33-0.40]). CONCLUSIONS AND RELEVANCE In this cohort study, younger age, Black race/ethnicity, low income, and poor glycemic control were associated with an increased risk of hyperglycemic crises. The findings suggest that multidisciplinary interventions focusing on groups at high risk for hyperglycemic crises are needed to prevent these dangerous events.
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Affiliation(s)
- Rozalina G. McCoy
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - Rodolfo J. Galindo
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Kavya Sindhu Swarna
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - Holly K. Van Houten
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
- HealthPartners Institute Center for Chronic Care Innovation, Minneapolis, Minnesota
| | - Patrick J. O’Connor
- HealthPartners Institute Center for Chronic Care Innovation, Minneapolis, Minnesota
| | - Guillermo E. Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Nilay D. Shah
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
- OptumLabs, Eden Prairie, Minnesota
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Chen Q, Cherry DR, Nalawade V, Qiao EM, Kumar A, Lowy AM, Simpson DR, Murphy JD. Clinical Data Prediction Model to Identify Patients With Early-Stage Pancreatic Cancer. JCO Clin Cancer Inform 2021; 5:279-287. [PMID: 33739856 DOI: 10.1200/cci.20.00137] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Pancreatic cancer is an aggressive malignancy with patients often experiencing nonspecific symptoms before diagnosis. This study evaluates a machine learning approach to help identify patients with early-stage pancreatic cancer from clinical data within electronic health records (EHRs). MATERIALS AND METHODS From the Optum deidentified EHR data set, we identified early-stage (n = 3,322) and late-stage (n = 25,908) pancreatic cancer cases over 40 years of age diagnosed between 2009 and 2017. Patients with early-stage pancreatic cancer were matched to noncancer controls (1:16 match). We constructed a prediction model using eXtreme Gradient Boosting (XGBoost) to identify early-stage patients on the basis of 18,220 features within the EHR including diagnoses, procedures, information within clinical notes, and medications. Model accuracy was assessed with sensitivity, specificity, positive predictive value, and the area under the curve. RESULTS The final predictive model included 582 predictive features from the EHR, including 248 (42.5%) physician note elements, 146 (25.0%) procedure codes, 91 (15.6%) diagnosis codes, 89 (15.3%) medications, and 9 (1.5%) demographic features. The final model area under the curve was 0.84. Choosing a model cut point with a sensitivity of 60% and specificity of 90% would enable early detection of 58% late-stage patients with a median of 24 months before their actual diagnosis. CONCLUSION Prediction models using EHR data show promise in the early detection of pancreatic cancer. Although widespread use of this approach on an unselected population would produce high rates of false-positive tests, this technique may be rapidly impactful if deployed among high-risk patients or paired with other imaging or biomarker screening tools.
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Affiliation(s)
- Qinyu Chen
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Daniel R Cherry
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA.,School of Medicine, University of California San Diego, La Jolla, CA
| | - Vinit Nalawade
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Edmund M Qiao
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA.,School of Medicine, University of California San Diego, La Jolla, CA
| | - Abhishek Kumar
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA.,School of Medicine, University of California San Diego, La Jolla, CA
| | - Andrew M Lowy
- Department of Surgery, University of California San Diego, La Jolla, CA
| | - Daniel R Simpson
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA.,School of Medicine, University of California San Diego, La Jolla, CA
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Zhang H, Wen J, Alexander GC, Curtis JR. Comparative effectiveness of biologics and targeted therapies for psoriatic arthritis. RMD Open 2021; 7:rmdopen-2020-001399. [PMID: 33863840 PMCID: PMC8055145 DOI: 10.1136/rmdopen-2020-001399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To quantify comparative effectiveness of interleukin (IL)-12/23 antagonist (ustekinumab), IL-17A antagonists (secukinumab and ixekizumab), PDE4 inhibitor (apremilast) and tumour necrosis factor-alpha (TNF-α) inhibitors (infliximab, etanercept, adalimumab, certolizumab pegol and golimumab) for psoriatic arthritis (PsA). METHODS We adapted a deidentified claims-based algorithm validated for inflammatory arthritis treatments to compare treatments among a retrospective cohort of commercially insured and Medicare Advantage beneficiaries with PsA from October 2013 to April 2019 in the OptumLabs Data Warehouse. Main outcomes include (1) treatment effectiveness, based on: adherence, adding or switching biologic or PDE4, addition of new non-biologic disease-modifying antirheumatic drug, increase in biologic or PDE4 dose or frequency and glucocorticoid use and (2) percentage of each group fulfilling the effectiveness algorithm. We used Poisson regression with robust variance stratified by prior PsA biologic exposure and adjusted for potential confounders. RESULTS Of 2730 individuals with PsA, 327 received IL-12/23, 138 IL-17A's, 624 PDE4 and 1641 TNF-α's. Effectiveness criteria were fulfilled among 63 (19.3%) IL-12/23 recipients, 40 (29.0%) IL-17A recipients, 160 (25.6%) PDE4 recipients and 530 (32.3%) TNF-α recipients. Among biologic-naïve individuals, IL-12/23 was less effective than TNF-α's with fully adjusted relative risk (aRR) compared with TNF-α's of 0.63 (95% CI 0.45 to 0.89). Among biologic-experienced individuals, PDE4 recipients were less effective than TNF-α's (aRR 0.67, 95% CI 0.46 to 0.96). CONCLUSIONS TNF-α's appeared more effective than IL-12/23's for biologic-naïve individuals, and PDE4's for biologic-experienced individuals. These results may help inform treatment choice for individuals with PsA.
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Affiliation(s)
- Hanzhe Zhang
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jiajun Wen
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.,OptumLabs Visiting Fellow, OptumLabs, Eden Prairie, Minnesota, USA
| | - G Caleb Alexander
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.,Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA .,Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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112
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Abstract
Rationale: Many lung transplant centers prescribe antifungal medications after transplantation to prevent invasive fungal infections (IFIs); however, the effectiveness of antifungal prophylaxis at reducing the risk of all-cause mortality or IFI has not been established.Objectives: We aimed to evaluate the effect of antifungal prophylaxis on all-cause mortality and IFI in lung transplant patients.Methods: Using administrative claims data, we identified adult patients who underwent lung transplantation between January 1, 2005, and December 31, 2018. Propensity score analysis using inverse probability treatment-weighting approach was used to balance the differences in baseline characteristics between those receiving antifungal prophylaxis and those not receiving antifungal prophylaxis. Cox proportional hazards regression was used to compare rates of all-cause mortality and IFI in both groups.Results: We identified 662 lung transplant recipients (LTRs) (387 received prophylaxis and 275 did not). All-cause mortality was significantly lower in those receiving antifungal prophylaxis compared with those not receiving antifungal prophylaxis (event rate per 100 person-years, 8.36 vs. 19.49; hazard ratio, 0.43; 95% confidence interval, 0.26-0.71; P = 0.003). Patients receiving antifungal prophylaxis had a lower rate of IFI compared with those not receiving prophylaxis (event rate per 100 person-years, 14.94 vs. 22.37; hazard ratio, 0.68; 95% confidence interval, 0.44-1.05; P = 0.079), but did not reach statistical significance.Conclusions: In this real-world analysis, antifungal prophylaxis in LTRs was associated with reduced all-cause mortality compared with those not receiving antifungal prophylaxis. Rates of IFI were also lower in those receiving prophylaxis, but this was not statistically significant in our primary analysis.
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Brennan JM, Lowenstern A, Sheridan P, Boero IJ, Thourani VH, Vemulapalli S, Wang TY, Liska O, Gander S, Jager J, Leon MB, Peterson ED. Association Between Patient Survival and Clinician Variability in Treatment Rates for Aortic Valve Stenosis. J Am Heart Assoc 2021; 10:e020490. [PMID: 34387116 PMCID: PMC8475044 DOI: 10.1161/jaha.120.020490] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Patients with symptomatic severe aortic stenosis (ssAS) have a high mortality risk and compromised quality of life. Surgical/transcatheter aortic valve replacement (AVR) is a Class I recommendation, but it is unclear if this recommendation is uniformly applied. We determined the impact of managing cardiologists on the likelihood of ssAS treatment. Methods and Results Using natural language processing of Optum electronic health records, we identified 26 438 patients with newly diagnosed ssAS (2011-2016). Multilevel, multivariable Fine-Gray competing risk models clustered by cardiologists were used to determine the impact of cardiologists on the likelihood of 1-year AVR treatment. Within 1 year of diagnosis, 35.6% of patients with ssAS received an AVR; however, rates varied widely among managing cardiologists (0%, lowest quartile; 100%, highest quartile [median, 29.6%; 25th-75th percentiles, 13.3%-47.0%]). The odds of receiving AVR varied >2-fold depending on the cardiologist (median odds ratio for AVR, 2.25; 95% CI, 2.14-2.36). Compared with patients with ssAS of cardiologists with the highest treatment rates, those treated by cardiologists with the lowest AVR rates experienced significantly higher 1-year mortality (lowest quartile, adjusted hazard ratio, 1.22, 95% CI, 1.13-1.33). Conclusions Overall AVR rates for ssAS were low, highlighting a potential challenge for ssAS management in the United States. Cardiologist AVR use varied substantially; patients treated by cardiologists with lower AVR rates had higher mortality rates than those treated by cardiologists with higher AVR rates.
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Affiliation(s)
- J Matthew Brennan
- Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | - Angela Lowenstern
- Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | - Paige Sheridan
- Department of Family Medicine and Public Health University of California, San Diego School of Medicine San Diego CA.,Boston Consulting Group Boston MA
| | | | - Vinod H Thourani
- Department of Cardiovascular Surgery Piedmont Heart Institute Atlanta GA
| | | | - Tracy Y Wang
- Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | | | | | | | - Martin B Leon
- Columbia University Irving Medical Center and New York Presbyterian Hospital New York NY
| | - Eric D Peterson
- Duke Clinical Research Institute Duke University School of Medicine Durham NC
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Mukherjee M, Cresswell K, Sheikh A. Identifying strategies to overcome roadblocks to utilising near real-time healthcare and administrative data to create a Scotland-wide learning health system. Health Informatics J 2021; 27:1460458220977579. [PMID: 33446033 DOI: 10.1177/1460458220977579] [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] [Indexed: 01/13/2023]
Abstract
Creating a learning health system could help reduce variations in quality of care. Success is dependent on timely access to health data. To explore the barriers and facilitators to timely access to patients' data, we conducted in-depth semi-structured interviews with 37 purposively sampled participants from government, the NHS and academia across Scotland. Interviews were analysed using the framework approach. Participants were of the view that Scotland could play a leading role in the exploitation of routine data to drive forward service improvements, but highlighted major impediments: (i) persistence of paper-based records and a variety of information systems; (ii) the need for a proportionate approach to managing information governance; and (iii) the need for support structures to facilitate accrual, processing, linking, analysis and timely use and reuse of data for patient benefit. There is a pressing need to digitise and integrate existing health information infrastructures, guided by a nationwide proportionate information governance approach and the need to enhance technological and human capabilities to support these efforts.
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Affiliation(s)
- Mome Mukherjee
- The University of Edinburgh, UK.,Health Data Research, UK
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115
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McCoy RG, Van Houten HK, Karaca-Mandic P, Ross JS, Montori VM, Shah ND. Second-Line Therapy for Type 2 Diabetes Management: The Treatment/Benefit Paradox of Cardiovascular and Kidney Comorbidities. Diabetes Care 2021; 44:dc202977. [PMID: 34348996 PMCID: PMC8929191 DOI: 10.2337/dc20-2977] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 06/24/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine whether glucagon-like peptide 1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2i) are preferentially initiated among patients with cardiovascular disease, heart failure (HF), or nephropathy, where these drug classes have established benefit, compared with dipeptidyl peptidase 4 inhibitors (DPP-4i), for which corresponding benefits have not been demonstrated. RESEARCH DESIGN AND METHODS We retrospectively analyzed claims of adults with type 2 diabetes included in OptumLabs Data Warehouse, a deidentified database of commercially insured and Medicare Advantage beneficiaries, who first started GLP-1RA, SGLT2i, or DPP-4i therapy between 2016 and 2019. Using multinomial logistic regression, we examined the relative risk ratios (RRR) of starting GLP-1RA and SGLT2i compared with DPP-4i for those with a history of myocardial infarction (MI), cerebrovascular disease, HF, and nephropathy after adjusting for demographic and other clinical factors. RESULTS We identified 75,395 patients who started GLP-1RA, 58,234 who started SGLT2i, and 91,884 who started DPP-4i. Patients with prior MI, cerebrovascular disease, or nephropathy were less likely to start GLP-1RA rather than DPP-4i compared with patients without these conditions (RRR 0.83 [95% CI 0.78-0.88] for MI, RRR 0.77 [0.74-0.81] for cerebrovascular disease, and RRR 0.87 [0.84-0.91] for nephropathy). Patients with HF or nephropathy were less likely to start SGLT2i (RRR 0.83 [0.80-0.87] for HF and RRR 0.57 [0.55-0.60] for nephropathy). Both medication classes were less likely to be started by non-White and older patients. CONCLUSIONS Patients with cardiovascular disease, HF, and nephropathy, for whom evidence suggests a greater likelihood of benefiting from GLP-1RA and/or SGLT2i therapy, were less likely to start these drugs. Addressing this treatment/benefit paradox, which was most pronounced in non-White and older patients, may help reduce the morbidity associated with these conditions.
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Affiliation(s)
- Rozalina G McCoy
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN
| | - Holly K Van Houten
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN
- OptumLabs, Eden Prairie, MN
| | - Pinar Karaca-Mandic
- Department of Finance and Medical Industry Leadership Institute, Carlson School of Management, University of Minnesota, Minneapolis, MN
- National Bureau of Economic Research, Cambridge, MA
| | - Joseph S Ross
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
| | - Victor M Montori
- Division of Endocrinology, Diabetes, Metabolism, & Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Nilay D Shah
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN
- OptumLabs, Eden Prairie, MN
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116
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McCoy RG, Van Houten HK, Dunlay SM, Yao X, Dempsey T, Noseworthy PA, Sangaralingham LR, Limper AH, Shah ND. Race and sex differences in the initiation of diabetes drugs by privately insured US adults. Endocrine 2021; 73:480-484. [PMID: 33830439 PMCID: PMC8273106 DOI: 10.1007/s12020-021-02710-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/23/2021] [Indexed: 12/18/2022]
Affiliation(s)
- Rozalina G McCoy
- Department of Medicine, Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA.
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA.
| | - Holly K Van Houten
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
- OptumLabs, Cambridge, MA, USA
| | - Shannon M Dunlay
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Xiaoxi Yao
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Timothy Dempsey
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Peter A Noseworthy
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lindsey R Sangaralingham
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Andrew H Limper
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nilay D Shah
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
- OptumLabs, Cambridge, MA, USA
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Chang CY, Kam L, Dang N, Cheung R, Nguyen MH. ALT Levels in Treatment-Naive, Chronic Hepatitis B Patients with Concurrent Fatty Liver Disease: A US Nationwide Study. Dig Dis 2021; 40:497-505. [PMID: 34348281 DOI: 10.1159/000518645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/21/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Treatment criteria for chronic hepatitis B (CHB) relies on ALT, which can be impacted by concurrent nonalcoholic fatty liver disease (NAFLD), but ALT data on patients with CHB and NAFLD are limited. We aimed to characterize ALT distribution in untreated CHB patients with NAFLD. METHODS We retrospectively analyzed untreated US adults with CHB (533 with NAFLD, 3,172 without NAFLD) using the Clinformatics™ Data Mart Database (2003-2019). The main outcome was ALT elevation (>1× upper limit of normal, 35/25 U/L for men/women, respectively). Secondary outcomes were advanced fibrosis (via FIB-4 index) and factors associated with fibrosis. RESULTS The majority of patients were Asian (61.0%) and hepatitis B e-antigen (HBeAg)-negative (90.4%). Patients with CHB and NAFLD were older (57.2 vs. 49.5 years, p < 0.001), more likely male (59.3% vs. 46.2%, p < 0.001), with higher percentages of advanced fibrosis (3.6% vs. 2.6%, p < 0.001) than those with CHB alone. CHB-NAFLD patients were more likely to have elevated ALT than those with CHB only, but this difference was only significant among those with low hepatitis B virus (HBV) DNA (38.1% vs. 25.6%, p < 0.001), not those with higher HBV DNA (>2,000 IU/mL). After adjusting for HBeAg, HBV DNA, and diabetes, NAFLD was not independently associated with advanced fibrosis (odds ratio 1.18, 95% confidence interval: 0.30-4.59, p = 0.81). DISCUSSION CHB-NAFLD patients with HBV DNA below treatment threshold were more likely to have elevated ALT but not those with higher HBV DNA, suggesting that ALT threshold does not need to be raised for antiviral eligibility for CHB with NAFLD.
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Affiliation(s)
- Christine Y Chang
- Department of Medicine, Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA.,Department of Medicine, California Pacific Medical Center, San Francisco, California, USA
| | - Leslie Kam
- Department of Medicine, Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
| | - Nolan Dang
- Department of Medicine, Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
| | - Ramsey Cheung
- Department of Medicine, Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA.,Department of Medicine, Gastroenterology and Hepatology, Palo Alto Veterans Administration Medical Center, Palo Alto, California, USA
| | - Mindie H Nguyen
- Department of Medicine, Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA.,Department of Epidemiology and Population Health, Stanford University Medical Center, Palo Alto, California, USA
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Sarakbi D, Mensah-Abrampah N, Kleine-Bingham M, Syed SB. Aiming for quality: a global compass for national learning systems. Health Res Policy Syst 2021; 19:102. [PMID: 34281534 PMCID: PMC8287697 DOI: 10.1186/s12961-021-00746-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 06/23/2021] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Transforming a health system into a learning one is increasingly recognized as necessary to support the implementation of a national strategic direction on quality with a focus on frontline experience. The approach to a learning system that bridges the gap between practice and policy requires active exploration. METHODS This scoping review adapted the methodological framework for scoping studies from Arksey and O'Malley. The central research question focused on common themes for learning to improve the quality of health services at all levels of the national health system, from government policy to point-of-care delivery. RESULTS A total of 3507 records were screened, resulting in 101 articles on strategic learning across the health system: health professional level (19%), health organizational level (15%), subnational/national level (26%), multiple levels (35%), and global level (6%). Thirty-five of these articles focused on learning systems at multiple levels of the health system. A national learning system requires attention at the organizational, subnational, and national levels guided by the needs of patients, families, and the community. The compass of the national learning system is centred on four cross-cutting themes across the health system: alignment of priorities, systemwide collaboration, transparency and accountability, and knowledge sharing of real-world evidence generated at the point of care. CONCLUSION This paper proposes an approach for building a national learning system to improve the quality of health services. Future research is needed to validate the application of these guiding principles and make improvements based on the findings.
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Affiliation(s)
- Diana Sarakbi
- Health Quality Programs, Queen's University, Kingston, Canada.
- Health Quality Programs, Queen's University, Cataraqui Building, 92 Barrie Street, Kingston, ON, K7L 3N6, Canada.
| | | | | | - Shams B Syed
- Integrated Health Services, World Health Organization, Geneva, Switzerland
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Kelly BT, Thao V, Dempsey TM, Sangaralingham LR, Payne SR, Teague TT, Moua T, Shah ND, Limper AH. Outcomes for hospitalized patients with idiopathic pulmonary fibrosis treated with antifibrotic medications. BMC Pulm Med 2021; 21:239. [PMID: 34273943 PMCID: PMC8286036 DOI: 10.1186/s12890-021-01607-2] [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: 03/20/2021] [Accepted: 07/04/2021] [Indexed: 11/10/2022] Open
Abstract
Background Idiopathic Pulmonary Fibrosis is a chronic, progressive interstitial lung disease for which there is no cure. However, lung function decline, hospitalizations, and mortality may be reduced with the use of the antifibrotic medications, nintedanib and pirfenidone. Historical outcomes for hospitalized patients with Idiopathic Pulmonary Fibrosis are grim; however there is a paucity of data since the approval of nintedanib and pirfenidone for treatment. In this study, we aimed to determine the effect of nintedanib and pirfenidone on mortality following respiratory-related hospitalizations, intensive care unit (ICU) admission, and mechanical ventilation. Methods Using a large U.S. insurance database, we created a one-to-one propensity score matched cohort of patients with idiopathic pulmonary fibrosis treated and untreated with an antifibrotic who underwent respiratory-related hospitalization between January 1, 2015 and December 31, 2018. Mortality was evaluated at 30 days and end of follow-up (up to 2 years). Subgroup analyses were performed for all patients receiving treatment in an ICU and those receiving invasive and non-invasive mechanical ventilation during the index hospitalization. Results Antifibrotics were not observed to effect utilization of mechanical ventilation or ICU treatment during the index admission or effect mortality at 30-days. If patients survived hospitalization, mortality was reduced in the treated cohort compared to the untreated cohort when followed up to two years (20.1% vs 47.8%). Conclusions Treatment with antifibrotic medications does not appear to directly improve 30-day mortality during or after respiratory-related hospitalizations. Post-hospital discharge, however, ongoing antifibrotic treatment was associated with improved long-term survival.
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Affiliation(s)
- Bryan T Kelly
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Gonda 18-South, 200 1st St SW, Rochester, MN, 55905, USA
| | - Viengneesee Thao
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA.,OptumLabs, Cambridge, MA, USA
| | - Timothy M Dempsey
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Gonda 18-South, 200 1st St SW, Rochester, MN, 55905, USA
| | - Lindsey R Sangaralingham
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA.,OptumLabs, Cambridge, MA, USA
| | - Stephanie R Payne
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA.,OptumLabs, Cambridge, MA, USA
| | - Taylor T Teague
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Gonda 18-South, 200 1st St SW, Rochester, MN, 55905, USA
| | - Teng Moua
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Gonda 18-South, 200 1st St SW, Rochester, MN, 55905, USA
| | - Nilay D Shah
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA.,Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | - Andrew H Limper
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Gonda 18-South, 200 1st St SW, Rochester, MN, 55905, USA. .,Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA.
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Benning TJ, Shah ND, Inselman JW, Van Houten HK, Ross JS, Wyatt KD. Drug labeling changes and pediatric hematology/oncology prescribing: Measuring the impact of U.S. legislation. Clin Trials 2021; 18:732-740. [PMID: 34269090 PMCID: PMC10119689 DOI: 10.1177/17407745211030683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND/AIMS The Pediatric Research Equity Act and Best Pharmaceuticals for Children Act are intended to promote the conduct of clinical trials that generate pediatric-specific evidence about drug safety and efficacy. This study assesses the quality of evidence generated through Pediatric Research Equity Act-mandated and Best Pharmaceuticals for Children Act-incentivized clinical trials of hematology/oncology drugs and characterizes subsequent changes in pediatric drug utilization rates. METHODS Trial characteristics (blinding, randomization, and comparator group) were determined for clinical trials that supported pediatric label changes. Using data from OptumLabs® Data Warehouse, a de-identified administrative claims database, we calculated pediatric utilization rates for each drug. We calculated monthly utilization rates from January 2003 (or from the first month in which data were available) to December 2018. RESULTS We identified 11 hematology/oncology drugs that underwent pediatric label changes under the Pediatric Research Equity Act Pediatric Research Equity Act and/or Best Pharmaceuticals for Children Act, and we identified 15 trials supporting these changes. Of these trials, 36% (5/14) were randomized, 31% (4/13) were blinded, and 36% (5/14) used a comparator group. A median of 49 children (interquartile range 29.5) received the drug under investigation across these trials. Pediatric label changes were not associated with subsequent changes in pediatric drug utilization. Although some drugs saw increased pediatric use after gaining new pediatric indications, this pattern was not consistently observed. In addition, there was no evidence to suggest that drugs were utilized less frequently after they failed to receive pediatric indications. CONCLUSIONS Clinical trials of hematology/oncology drugs conducted under the Pediatric Research Equity Act Pediatric Research Equity Act and Best Pharmaceuticals for Children Act generally have low methodological rigor, and the resulting label changes are not consistently associated with changes in pediatric utilization. Alternative regulatory strategies and study designs may be necessary to maximize the impact of newly generated knowledge on drug utilization.
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Affiliation(s)
| | - Nilay D Shah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,OptumLabs, Eden Prairie, MN, USA.,Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | - Jonathan W Inselman
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | - Holly K Van Houten
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,OptumLabs, Eden Prairie, MN, USA
| | - Joseph S Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA.,Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA.,Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA.,National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Kirk D Wyatt
- Division of Pediatric Hematology/Oncology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Pediatric Hematology/Oncology, Roger Maris Cancer Center, Sanford Health, Fargo, ND, USA
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Singh S, Heien HC, Sangaralingham L, Shah ND, Sandborn WJ. Obesity Is Not Associated With an Increased Risk of Serious Infections in Biologic-Treated Patients With Inflammatory Bowel Diseases. Clin Transl Gastroenterol 2021; 12:e00380. [PMID: 34228004 PMCID: PMC8260899 DOI: 10.14309/ctg.0000000000000380] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 05/28/2021] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Obesity has been associated with adverse disease-related outcomes and inferior treatment response to biologic agents in patients with inflammatory bowel diseases (IBDs), but its impact on the risk of treatment-related complications is unknown. We performed a cohort study examining the association between obesity and risk of serious infections in biologic-treated patients with IBD. METHODS Using an administrative claims database, in a cohort of biologic-treated patients with IBD between 2014 and 2018 with follow-up 1 year before and after treatment initiation, we compared the risk of serious infections (infections requiring hospitalization) between obese vs nonobese patients (based on validated administrative claims) using Cox proportional hazard analysis. RESULTS We included 5,987 biologic-treated patients with IBD (4,881 on tumor necrosis factor-α antagonists and 1,106 on vedolizumab), of whom 524 (8.8%) were classified as obese. Of the 7,115 person-year follow-up, 520 patients developed serious infection. Risk of serious infection was comparable in obese vs nonobese patients (8.8% vs 8.5%; unadjusted hazard ratio, 1.15; 95% confidence interval, 0.86-1.54). After adjusting for age, comorbidities, disease characteristics, health care utilization, use of corticosteroids, immunomodulators, and opiates, obesity was not associated with an increased risk of serious infection (adjusted hazard ratio, 0.74 [95% confidence interval, 0.55-1.01]). Similar results were seen on stratified analysis by disease phenotype (Crohn's disease and ulcerative colitis) and index biologic therapy (tumor necrosis factor-α antagonists and vedolizumab). DISCUSSION After adjusting for comorbid conditions and disease characteristics, obesity is not independently associated with an increased risk of serious infections in biologic-treated patients with IBD.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Herbert C. Heien
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Lindsey Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nilay D. Shah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
- Division of Health Care Policy and Research, Department of Health Services Research, Mayo Clinic, Rochester, Minnesota, USA
| | - William J. Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
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Lowenstern A, Sheridan P, Wang TY, Boero I, Vemulapalli S, Thourani VH, Leon MB, Peterson ED, Brennan JM. Sex disparities in patients with symptomatic severe aortic stenosis. Am Heart J 2021; 237:116-126. [PMID: 33722584 DOI: 10.1016/j.ahj.2021.01.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 01/28/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND We evaluated whether there is equitable distribution across sexes of treatment and outcomes for aortic valve replacement (AVR), via surgical (SAVR) or transcatheter (TAVR) methods, in symptomatic severe aortic stenosis (ssAS) patients. METHODS Using de-identified data, we identified 43,822 patients with ssAS (2008-2016). Multivariate competing risk models were used to determine the likelihood of any AVR, while accounting for the competing risk of death. Association between sex and 1-year mortality, stratified by AVR status, was evaluated using multivariate Cox regression models with AVR as a time-dependent variable. RESULTS Among patients with ssAS, 20,986 (47.9%) were female. Females were older (median age 81 vs. 78, P<0.001), more likely to have body mass index <20 (8.5% vs. 3.5%), and home oxygen use (4.4% vs. 3.4%, P<0001 for all). Overall, 12,129 (27.7%) patients underwent AVR for ssAS. Females were less likely to undergo AVR compared with males (24.1% vs. 31.0%, adjusted hazard ratio [HR] 0.80, 95% confidence interval [CI] 0.77-0.83), but when treated, were more likely to undergo TAVR (37.9% vs. 30.9%, adjusted HR 1.21, 95% CI 1.15-1.27). Untreated females and males had similarly high rates of mortality at 1 year (31.1% vs. 31.3%, adjusted HR 0.98, 95% CI 0.94-1.03). Among those undergoing AVR, females had significantly higher mortality (10.2% vs. 9.4%, adjusted HR 1.24, 95% CI 1.10-1.41), driven by increased SAVR-associated mortality (9.0% vs. 7.6%, adjusted HR 1.43, 95% CI 1.21-1.69). CONCLUSIONS Treatment rates for ssAS patients remain suboptimal with disparities in female treatment.
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Affiliation(s)
- Angela Lowenstern
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Paige Sheridan
- Department of Family Medicine and Public Health, University of San Diego, San Diego, CA; Boston Consulting Group, Boston, MA
| | - Tracy Y Wang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, GA
| | - Martin B Leon
- Columbia University Medical Center and New York Presbyterian Hospital, New York, NY
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - J Matthew Brennan
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
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123
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Chaisson CE, Ameli O, Paterson VJ, Weiseth A, Genen L, Thayer S. Using a Claims-Based Framework to Identify Severe Maternal Morbidities in a Commercially Insured US Population. J Perinat Neonatal Nurs 2021; 35:237-246. [PMID: 34171882 DOI: 10.1097/jpn.0000000000000580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Many severe maternal morbidities (SMMs) are preventable, and understanding circumstances in which complications occur is crucial. The objective was to evaluate a framework for SMM benchmarking and quality improvement opportunities. Building upon metrics defined by the Centers for Disease Control and Prevention on the basis of an inpatient sample, analysis included indicators across 5 domains (Hemorrhage/Transfusion, Preeclampsia/Eclampsia, Cardiovascular, Sepsis, and Thromboembolism/Cerebrovascular). Morbidity rates per 10 000 deliveries were calculated using de-identified administrative claims in commercially insured women in the United States. Longitudinal data linked inpatient delivery episodes and 6-week postpartum period, and SMMs were assessed for present on admission and geographic variation. This retrospective analysis of 356 838 deliveries identified geographic variation in SMMs. For example, hemorrhage rates per 10 000 varied 3-fold across states from 279.7 in Alabama to 964.69 in Oregon. Administrative claims can be used to calculate SMM rates, identify geographic variations, and assess problems locally, nationally, and across payers. Identifying conditions present on admission and a postpartum window is valuable in differentiating events occurring during preadmission, inpatient stay, and postpartum periods. Targeting preventable SMMs through local and hospital-level interventions and limiting SMM progression through postdischarge monitoring may reduce the prevalence of SMM and postpartum complications.
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Affiliation(s)
- Christine E Chaisson
- OptumLabs, Eden Prairie, Minnesota (Ms Chaisson and Drs Ameli and Thayer); Ariadne Labs, Boston, Massachusetts (Ms Paterson and Dr Weiseth); and ProgenyHealth, Plymouth Meeting, Pennsylvania (Dr Genen)
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Nash DM, Bhimani Z, Rayner J, Zwarenstein M. Learning health systems in primary care: a systematic scoping review. BMC FAMILY PRACTICE 2021; 22:126. [PMID: 34162336 PMCID: PMC8223335 DOI: 10.1186/s12875-021-01483-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 05/10/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Learning health systems have been gaining traction over the past decade. The purpose of this study was to understand the spread of learning health systems in primary care, including where they have been implemented, how they are operating, and potential challenges and solutions. METHODS We completed a scoping review by systematically searching OVID Medline®, Embase®, IEEE Xplore®, and reviewing specific journals from 2007 to 2020. We also completed a Google search to identify gray literature. RESULTS We reviewed 1924 articles through our database search and 51 articles from other sources, from which we identified 21 unique learning health systems based on 62 data sources. Only one of these learning health systems was implemented exclusively in a primary care setting, where all others were integrated health systems or networks that also included other care settings. Eighteen of the 21 were in the United States. Examples of how these learning health systems were being used included real-time clinical surveillance, quality improvement initiatives, pragmatic trials at the point of care, and decision support. Many challenges and potential solutions were identified regarding data, sustainability, promoting a learning culture, prioritization processes, involvement of community, and balancing quality improvement versus research. CONCLUSIONS We identified 21 learning health systems, which all appear at an early stage of development, and only one was primary care only. We summarized and provided examples of integrated health systems and data networks that can be considered early models in the growing global movement to advance learning health systems in primary care.
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Affiliation(s)
- Danielle M Nash
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada. .,ICES, London, ON, Canada.
| | - Zohra Bhimani
- Department of Medicine, London Health Sciences Centre, London, ON, Canada
| | - Jennifer Rayner
- Centre for Studies in Family Medicine, Western University, London, ON, Canada.,Department of Research and Evaluation, Alliance for Healthier Communities, Toronto, ON, Canada
| | - Merrick Zwarenstein
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.,Centre for Studies in Family Medicine, Western University, London, ON, Canada.,ICES, Toronto, ON, Canada
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Goyal A, Payne S, Sangaralingham LR, Jeffery MM, Naessens JM, Gazelka HM, Habermann EB, Krauss WE, Spinner RJ, Bydon M. Variations in Postoperative Opioid Prescription Practices and Impact on Refill Prescriptions Following Lumbar Spine Surgery. World Neurosurg 2021; 153:e112-e130. [PMID: 34153486 DOI: 10.1016/j.wneu.2021.06.060] [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: 02/08/2021] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Understanding postsurgical prescribing patterns and their impact on persistent opioid use is important for establishing reasonable opioid prescribing protocols. We aimed to determine national variation in postoperative opioid prescription practices following elective lumbar spine surgery and their impact on short-term refill prescriptions. METHODS The OptumLabs Data Warehouse was queried from 2016 to 2017 for adults undergoing anterior lumbar fusion, posterior lumbar fusion, circumferential lumbar fusion, and lumbar decompression/discectomy for degenerative spine disease. Discharge opioid prescription fills were obtained and converted to morphine milligram equivalents (MMEs). Age- and sex-adjusted MMEs and frequency of discharge prescriptions >200 MMEs were determined for each U.S. census division and procedure type. RESULTS The study included 43,572 patients with 37,894 postdischarge opioid prescription fills. There was wide variation in mean filled MMEs across all census divisions (anterior lumbar fusion: 774-1147 MMEs; posterior lumbar fusion: 717-1280 MMEs; circumferential lumbar fusion: 817-1271 MMEs; lumbar decompression/discectomy: 619-787 MMEs). A significant proportion of cases were found to have filled discharge prescriptions >200 MMEs (posterior lumbar fusion: 78.6%-95%; anterior lumbar fusion: 87.5%-95.6%; circumferential lumbar fusion: 81.4%-96.5%; lumbar decompression/discectomy: 80.5%-91%). Multivariable logistic regression showed that female sex and inpatient surgery were associated with a top-quartile discharge prescription and a short-term second opioid prescription fill, while the opposite was noted for elderly and opioid-naïve patients (all P ≤ 0.05). Prescriptions with long-acting opioids were associated with higher odds of a second opioid prescription fill (reference: nontramadol short-acting opioid). CONCLUSIONS In analysis of filled opioid prescriptions, we observed a significant proportion of prescriptions >200 MMEs and wide regional variation in postdischarge opioid prescribing patterns following elective lumbar spine surgery.
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Affiliation(s)
- Anshit Goyal
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Stephanie Payne
- Department of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Molly M Jeffery
- Department of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA
| | - James M Naessens
- Department of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Halena M Gazelka
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - William E Krauss
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert J Spinner
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Huang Y, Yuan W, Kohane IS, Beaulieu-Jones BK. Illustrating potential effects of alternate control populations on real-world evidence-based statistical analyses. JAMIA Open 2021; 4:ooab045. [PMID: 34142018 PMCID: PMC8206406 DOI: 10.1093/jamiaopen/ooab045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/06/2021] [Indexed: 11/14/2022] Open
Abstract
Objective Case-control study designs are commonly used in retrospective analyses of real-world evidence (RWE). Due to the increasingly wide availability of RWE, it can be difficult to determine whether findings are robust or the result of testing multiple hypotheses. Materials and Methods We investigate the potential effects of modifying cohort definitions in a case-control association study between depression and type 2 diabetes mellitus. We used a large (>75 million individuals) de-identified administrative claims database to observe the effects of minor changes to the requirements of glucose and hemoglobin A1c tests in the control group. Results We found that small permutations to the criteria used to define the control population result in significant shifts in both the demographic structure of the identified cohort as well as the odds ratio of association. These differences remain present when testing against age- and sex-matched controls. Discussion Analyses of RWE need to be carefully designed to avoid issues of multiple testing. Minor changes to control cohorts can lead to significantly different results and have the potential to alter even prospective studies through selection bias. Conclusion We believe this work offers strong support for the need for robust guidelines, best practices, and regulations around the use of observational RWE for clinical or regulatory decision-making.
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Affiliation(s)
- Yidi Huang
- Department of Biomedical Informatics, Harvard Medical School, Countway Library, Boston, Massachusetts, USA
| | - William Yuan
- Department of Biomedical Informatics, Harvard Medical School, Countway Library, Boston, Massachusetts, USA
| | - Isaac S Kohane
- Department of Biomedical Informatics, Harvard Medical School, Countway Library, Boston, Massachusetts, USA
| | - Brett K Beaulieu-Jones
- Department of Biomedical Informatics, Harvard Medical School, Countway Library, Boston, Massachusetts, USA
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127
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Li X, Ostropolets A, Makadia R, Shoaibi A, Rao G, Sena AG, Martinez-Hernandez E, Delmestri A, Verhamme K, Rijnbeek PR, Duarte-Salles T, Suchard MA, Ryan PB, Hripcsak G, Prieto-Alhambra D. Characterising the background incidence rates of adverse events of special interest for covid-19 vaccines in eight countries: multinational network cohort study. BMJ 2021; 373:n1435. [PMID: 35727911 PMCID: PMC8193077 DOI: 10.1136/bmj.n1435] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To quantify the background incidence rates of 15 prespecified adverse events of special interest (AESIs) associated with covid-19 vaccines. DESIGN Multinational network cohort study. SETTING Electronic health records and health claims data from eight countries: Australia, France, Germany, Japan, the Netherlands, Spain, the United Kingdom, and the United States, mapped to a common data model. PARTICIPANTS 126 661 070 people observed for at least 365 days before 1 January 2017, 2018, or 2019 from 13 databases. MAIN OUTCOME MEASURES Events of interests were 15 prespecified AESIs (non-haemorrhagic and haemorrhagic stroke, acute myocardial infarction, deep vein thrombosis, pulmonary embolism, anaphylaxis, Bell's palsy, myocarditis or pericarditis, narcolepsy, appendicitis, immune thrombocytopenia, disseminated intravascular coagulation, encephalomyelitis (including acute disseminated encephalomyelitis), Guillain-Barré syndrome, and transverse myelitis). Incidence rates of AESIs were stratified by age, sex, and database. Rates were pooled across databases using random effects meta-analyses and classified according to the frequency categories of the Council for International Organizations of Medical Sciences. RESULTS Background rates varied greatly between databases. Deep vein thrombosis ranged from 387 (95% confidence interval 370 to 404) per 100 000 person years in UK CPRD GOLD data to 1443 (1416 to 1470) per 100 000 person years in US IBM MarketScan Multi-State Medicaid data among women aged 65 to 74 years. Some AESIs increased with age. For example, myocardial infarction rates in men increased from 28 (27 to 29) per 100 000 person years among those aged 18-34 years to 1400 (1374 to 1427) per 100 000 person years in those older than 85 years in US Optum electronic health record data. Other AESIs were more common in young people. For example, rates of anaphylaxis among boys and men were 78 (75 to 80) per 100 000 person years in those aged 6-17 years and 8 (6 to 10) per 100 000 person years in those older than 85 years in Optum electronic health record data. Meta-analytic estimates of AESI rates were classified according to age and sex. CONCLUSION This study found large variations in the observed rates of AESIs by age group and sex, showing the need for stratification or standardisation before using background rates for safety surveillance. Considerable population level heterogeneity in AESI rates was found between databases.
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Affiliation(s)
- Xintong Li
- Centre for Statistics in Medicine, NDORMS, University of Oxford, Oxford, UK
| | - Anna Ostropolets
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, NY, USA
| | - Rupa Makadia
- Janssen Research and Development, Titusville, NJ, USA
| | - Azza Shoaibi
- Janssen Research and Development, Titusville, NJ, USA
| | - Gowtham Rao
- Janssen Research and Development, Titusville, NJ, USA
| | - Anthony G Sena
- Janssen Research and Development, Titusville, NJ, USA
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | | | - Katia Verhamme
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Bio-Analysis, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg, Gent, Belgium
| | - Peter R Rijnbeek
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Talita Duarte-Salles
- Fundacio Institut Universitari per a la recerca a l'Atencio Primaria de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Marc A Suchard
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Human Genetics, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA, USA
| | - Patrick B Ryan
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, NY, USA
- Janssen Research and Development, Titusville, NJ, USA
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, NY, USA
| | - Daniel Prieto-Alhambra
- Centre for Statistics in Medicine, NDORMS, University of Oxford, Oxford, UK
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, Netherlands
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128
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Winestone LE, Hochman LL, Sharpe JE, Alvarez E, Becker L, Chow EJ, Reiter JG, Ginsberg JP, Silber JH. Impact of Dependent Coverage Provision of the Affordable Care Act on Insurance Continuity for Adolescents and Young Adults With Cancer. JCO Oncol Pract 2021; 17:e882-e890. [PMID: 33090897 PMCID: PMC8258053 DOI: 10.1200/op.20.00330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2020] [Indexed: 12/27/2022] Open
Abstract
PURPOSE The 2010 Dependent Coverage Provision (DCP) of the Affordable Care Act (ACA) allowed enrollees to remain on their parents' health insurance until 26 years of age. We compared rates of insurance disenrollment among patients with cancer who were DCP-eligible at age 19 to those who were not eligible at age 19. METHODS Using OptumLabs Data Warehouse, which contains longitudinal, real-world, de-identified administrative claims for commercial enrollees, we examined patients born between 1982 and 1993 and diagnosed with cancer between 2000 and 2015. In the recent cohort, patients who turned 19 in 2010-2012 (DCP-eligible to stay on parents' insurance) were matched to patients who turned 19 in 2007-2009 (not DCP-eligible when turning 19). In an earlier control cohort, patients who turned 19 between 2004 and 2006 (not DCP-eligible) were matched to patients who turned 19 between 2001 and 2003 (not DCP-eligible). Patients were matched on cancer type, diagnosis date, demographics, and treatment characteristics. The time to loss of coverage was estimated using Cox models. Difference-in-difference between the recent and earlier cohorts was also evaluated. RESULTS A total of 2,829 patients who turned 19 years of age in 2010-2012 were matched to patients who turned 19 in 2007-2009. Median time to disenrollment was 26 months for younger patients versus 22 months for older patients (hazard ratio [HR], 0.85; 95% CI, 0.80 to 0.90; P = .001). In 8,978 patients who turned 19 between 2001 and 2006, median time to disenrollment was 20 months among both younger and older patients (HR, 0.99; 95% CI, 0.94 to 1.03; P = .59). The difference between the recent cohort and the earlier control cohort was a 15% greater reduction in coverage loss (P < .0001), favoring those turning 19 after the DCP went into effect. CONCLUSION In the vulnerable population of adolescent and young adult cancer survivors, the ACA may have lowered the insurance dropout rate.
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Affiliation(s)
- Lena E. Winestone
- Division of Allergy, Immunology, and Blood & Marrow Transplant, Department of Pediatrics, University of California San Francisco (UCSF) Benioff Children's Hospital; and UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | - Lauren L. Hochman
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - James E. Sharpe
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Elysia Alvarez
- Department of Pediatrics, University of California Davis, Sacramento, CA
| | | | - Eric J. Chow
- Department of Pediatrics, University of Washington, Seattle Children’s Hospital; and Fred Hutchinson Cancer Research Institute, Seattle, WA
| | - Joseph G. Reiter
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Jill P. Ginsberg
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine; and Division of Pediatric Oncology, The Children’s Hospital of Philadelphia, Philadelphia, PA
- Cancer Survivorship Program, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Jeffrey H. Silber
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine; and Division of Pediatric Oncology, The Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Health Care Management, The Wharton School; and Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA
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Metabolic acidosis is associated with increased risk of adverse kidney outcomes and mortality in patients with non-dialysis dependent chronic kidney disease: an observational cohort study. BMC Nephrol 2021; 22:185. [PMID: 34011303 PMCID: PMC8136202 DOI: 10.1186/s12882-021-02385-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Management of chronic kidney disease (CKD) requires the management of risk factors, such as hypertension and albuminuria, that affect CKD progression. Identification of additional modifiable risk factors is necessary to develop new treatment strategies for CKD. We sought to quantify the association of metabolic acidosis with CKD progression and mortality in a large U.S. community-based cohort. METHODS In this longitudinal, retrospective cohort study we identified non-dialysis-dependent patients with stage 3‒5 CKD from Optum's de-identified integrated electronic health records. We selected cohorts of patients with confirmed metabolic acidosis or normal serum bicarbonate levels based on 2 consecutive serum bicarbonate values: 12 to < 22 mEq/L or 22-29 mEq/L, respectively, 28‒365 days apart. The primary composite outcome was ≥ 40 % decline in estimated glomerular filtration rate (eGFR), renal replacement therapy (chronic dialysis or kidney transplant), or all-cause mortality (DD40). Secondary outcomes included each component of the composite outcome. Cox proportional hazards models were used for the DD40 outcome and secondary outcomes, while logistic regression models were used for the DD40 outcome at 2 years. RESULTS A total of 51,558 patients qualified for the study. The unadjusted 2-year incidence of adverse renal and fatal outcomes was significantly worse among patients in the metabolic acidosis group vs. those who had normal serum bicarbonate levels: 48 % vs. 17 % for DD40, 10 % vs. 4 % for ≥ 40 % decline in eGFR, 20 % vs. 6 % for renal replacement therapy, and 31 % vs. 10 % for all-cause mortality (all P < 0.001). Over a ≤ 10-year period, for each 1-mEq/L increase in serum bicarbonate, the adjusted hazard ratio for DD40 was 0.926 (95 % confidence interval [CI], 0.922-0.930; P < 0.001); over a ≤ 2-year period, the adjusted odds ratio for DD40 was 0.873 (95 % CI, 0.866-0.879; P < 0.001). CONCLUSIONS In this large community cohort of patients with stage 3‒5 CKD, the presence of metabolic acidosis was a significant, independent risk factor for the composite adverse outcome of CKD progression, renal replacement therapy, and all-cause mortality (DD40).
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Real-world comparative effectiveness of triplets containing bortezomib (B), carfilzomib (C), daratumumab (D), or ixazomib (I) in relapsed/refractory multiple myeloma (RRMM) in the US. Ann Hematol 2021; 100:2325-2337. [PMID: 33970288 PMCID: PMC8357697 DOI: 10.1007/s00277-021-04534-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/22/2021] [Indexed: 10/30/2022]
Abstract
Multiple available combinations of proteasome inhibitors, immunomodulators (IMIDs), and monoclonal antibodies are shifting the relapsed/refractory multiple myeloma (RRMM) treatment landscape. Lack of head-to-head trials of triplet regimens highlights the need for real-world (RW) evidence. We conducted an RW comparative effectiveness analysis of bortezomib (V), carfilzomib (K), ixazomib (I), and daratumumab (D) combined with either lenalidomide or pomalidomide plus dexamethasone (Rd or Pd) in RRMM. A retrospective cohort of patients initiating triplet regimens in line of therapy (LOT) ≥ 2 on/after 1/1/2014 was followed between 1/2007 and 3/2018 in Optum's deidentified US electronic health records database. Time to next treatment (TTNT) was estimated using Kaplan-Meier methods; regimens were compared using covariate-adjusted Cox proportional hazard models. Seven hundred forty-one patients (820 patient LOTs) with an Rd backbone (VRd, n = 349; KRd, n = 218; DRd, n = 99; IRd, n = 154) and 348 patients (392 patient LOTs) with a Pd backbone (VPd, n = 52; KPd, n = 146; DPd, n = 149; IPd, n = 45) in LOTs ≥2 were identified. More patients ≥75 years received IRd (39.6%), IPd (37.8%), and VRd (36.7%) than other triplets. More patients receiving VRd/VPd were in LOT2 vs other triplets. Unadjusted median TTNT in LOT ≥ 2: VRd, 13.9; KRd, 8.7; IRd, 11.4; DRd, not estimable (NE); and VPd, 12.0; KPd, 6.7; IPd, 9.5 months; DPd, NE. In covariate-adjusted analysis, only KRd vs DRd was associated with a significantly higher risk of next LOT initiation/death (HR 1.72; P = 0.0142); no Pd triplet was significantly different vs DPd in LOT ≥ 2. Our data highlight important efficacy/effectiveness gaps between results observed in phase 3 clinical trials and those realized in the RW.
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131
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Maddux JT, Inselman JW, Jeffery MM, Lam RW, Shah ND, Rank MA. Persistence of asthma biologic use in a US claims database. Ann Allergy Asthma Immunol 2021; 127:648-654. [PMID: 33971361 DOI: 10.1016/j.anai.2021.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 04/20/2021] [Accepted: 04/28/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little is known on the persistence of asthma biologic use in clinical practice. OBJECTIVE To evaluate the persistence of asthma biologic use and time to clinical response in clinical practice. METHODS A cohort of people with asthma who used at least 1 asthma biologic was constructed using data from 2003 to 2019 in the OptumLabs Data Warehouse. Treatment persistence was defined by the length of time that a person continuously used an asthma biologic, allowing for a lapse in use up to 4 months before confirming that a person stopped. Clinical response to treatment (defined as a decline in asthma exacerbations of at least 50% compared with the 6 months before starting an asthma biologic) was described over time and in relation to biologic persistence. RESULTS There were 9575 people who had at least 1 episode of asthma biologic use. There were 5319 people (64%, 95% confidence interval, 63%-65%) who completed 6 months or more on an asthma biologic and 3284 (45%, 95% confidence interval, 44%-46%) who completed 12 months or more. Of people with 1 or more asthma exacerbation 6 months before index biologic use, 63%, 76%, 80%, and 81% realized a 50% or more reduction in postindex asthma exacerbations in the first 6 months, 6 to 12 months, 12 to 18 months, and 18 to 24 months, respectively. CONCLUSION Between 48% and 64% of people remained on an asthma biologic for 6 months or more after first use. Most people who achieved a reduction in asthma exacerbations did so in the first 6 months of treatment.
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Affiliation(s)
- Jacob T Maddux
- Department of Medicine, Mayo Clinic, Phoenix, Arizona; Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona.
| | - Jonathan W Inselman
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Molly M Jeffery
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Regina W Lam
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona
| | - Nilay D Shah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota; OptumLabs, Cambridge, Massachusetts
| | - Matthew A Rank
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona; Division of Pulmonology, Phoenix Children's Hospital, Phoenix, Arizona
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132
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Ross JS. Covid-19, open science, and the CVD-COVID-UK initiative. BMJ 2021; 373:n898. [PMID: 33827892 DOI: 10.1136/bmj.n898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Joseph S Ross
- Section of General Medicine Department of Internal Medicine, Yale University School of Medicine, PO box 208093, New Haven, CT 06520-8093, USA
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Abstract
Given the high prevalence and associated cost of chronic pain, it has a significant impact on individuals and society. Improvements in the treatment and management of chronic pain may increase patients’ quality of life and reduce societal costs. In this paper, we evaluate state-of-the-art machine learning approaches in chronic pain research. A literature search was conducted using the PubMed, IEEE Xplore, and the Association of Computing Machinery (ACM) Digital Library databases. Relevant studies were identified by screening titles and abstracts for keywords related to chronic pain and machine learning, followed by analysing full texts. Two hundred and eighty-seven publications were identified in the literature search. In total, fifty-three papers on chronic pain research and machine learning were reviewed. The review showed that while many studies have emphasised machine learning-based classification for the diagnosis of chronic pain, far less attention has been paid to the treatment and management of chronic pain. More research is needed on machine learning approaches to the treatment, rehabilitation, and self-management of chronic pain. As with other chronic conditions, patient involvement and self-management are crucial. In order to achieve this, patients with chronic pain need digital tools that can help them make decisions about their own treatment and care.
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Vallabhajosyula S, Payne SR, Jentzer JC, Sangaralingham LR, Kashani K, Shah ND, Prasad A, Dunlay SM. Use of Post-Acute Care Services and Readmissions After Acute Myocardial Infarction Complicated by Cardiac Arrest and Cardiogenic Shock. Mayo Clin Proc Innov Qual Outcomes 2021; 5:320-329. [PMID: 33997631 PMCID: PMC8105498 DOI: 10.1016/j.mayocpiqo.2020.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023] Open
Abstract
OBJECTIVE To evaluate post-acute care utilization and readmissions after cardiac arrest (CA) and cardiogenic shock (CS) complicating acute myocardial infarction (AMI). METHODS With use of an administrative claims database, AMI patients from January 1, 2010, to May 31, 2018, were stratified into CA+CS, CA only, CS only, and AMI alone. Outcomes included 90-day post-acute care (inpatient rehabilitation or skilled nursing facility) utilization and 1-year emergency department visits and readmissions. RESULTS Of 163,071 AMI patients, CA+CS, CA only, and CS only were noted in 3965 (2.4%), 8221 (5.0%), and 6559 (4.0%), respectively. In-hospital mortality was noted in 10,686 (6.6%) patients: CA+CS, 1935 (48.8%); CA only, 2948 (35.9%); CS only, 1578 (24.1%); and AMI alone, 4225 (2.9%) (P<.001). Among survivors, post-acute care services were used in 67,799 (44.5%), with higher use in the CS+CA cohort (1310 [64.6%]; hazard ratio [HR], 1.19; 95% CI, 1.06 to 1.33; P=.003) and CA cohort (2738 [51.9%]; HR, 1.27; 95% CI, 1.20 to 1.35; P<.001) but not in the CS cohort (3048 [61.2%]; HR, 1.03; 95% CI, 0.97 to 1.11; P=.35) compared with the AMI cohort (60,703 [43.3%]). Compared with the AMI cohort (48,990 [35.0%]), patients with CS only (2,085 [41.9%]; HR, 1.16; 95% CI, 1.10 to 1.22; P<.001) but not those with CA+CS (724 [35.7%]; HR, 1.07; 95% CI, 0.98 to 1.17; P=.14) had higher rates of readmissions (P=.03). Readmissions were lower in those with CA (1,590 [30.2%]; HR, 0.94; 95% CI, 0.89 to 0.99). Repeated AMI, coronary artery disease, and heart failure were the most common readmission reasons. There were no differences for emergency department visits. CONCLUSION CA is associated with increased post-acute care use, whereas CS is associated with increased readmission risk in AMI survivors.
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Key Words
- AMI, acute myocardial infarction
- CA, cardiac arrest
- CS, cardiogenic shock
- ED, emergency department
- HR, hazard ratio
- ICD-10-CM, International Classification of Diseases, Tenth Revision, Clinical Modification
- ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification
- MCS, mechanical circulatory support
- PCI, percutaneous coronary intervention
- SNF, skilled nursing facility
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
- Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN
| | - Stephanie R. Payne
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN
| | - Jacob C. Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Lindsey R. Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN
| | - Kianoush Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Nilay D. Shah
- Department of Health Services Research, Mayo Clinic, Rochester, MN
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN
- OptumLabs, Cambridge, MA
| | - Abhiram Prasad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Shannon M. Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
- Department of Health Services Research, Mayo Clinic, Rochester, MN
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Anderson KE, Alexander GC, Niles L, Scholle SH, Saloner B, Dy SM. Quality of Preventive and Chronic Illness Care for Insured Adults With Opioid Use Disorder. JAMA Netw Open 2021; 4:e214925. [PMID: 33830229 PMCID: PMC8033422 DOI: 10.1001/jamanetworkopen.2021.4925] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Nearly all initiatives to improve care for individuals with opioid use disorder (OUD) have focused on improving OUD identification and treatment. Whether individuals with OUD have lower quality of care than individuals without OUD remains unclear. OBJECTIVE To measure quality of non-OUD preventive and chronic illness care and care coordination for individuals with OUD compared with individuals without OUD. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study of deidentified data on outpatients throughout the US was conducted. Claims for 79 372 commercially insured and Medicare Advantage enrollees aged 18 years or older with diagnosis codes for OUD between January 1, 2018, and December 31, 2019, and 46 601 individuals without OUD were included in the analysis. EXPOSURE Diagnosis of OUD. MAIN OUTCOMES AND MEASURES Quality indicator performance was calculated, using claims for individuals with OUD and matched comparators without OUD. Within 3 domains of outpatient care quality (preventive care, chronic illness care, and care coordination), 6 indicators used in accountability programs were selected. Performance for individuals with and without OUD was compared, and logistic regression was used to analyze sociodemographic and comorbidity characteristics associated with higher quality of health care. RESULTS The study included 125 973 individuals, including 69 466 (55.1%) women and 78 225 (62.1%) White individuals, with a mean (SD) age of 59.0 (16.1) years. For the preventive care measure examining breast cancer screening, performance for the OUD cohort was 55.4% (95% CI, 54.7%-56.0%) compared with 65.6% (95% CI, 64.4%-66.7%) for individuals without OUD (P < .001). Quality of care for adherence to statin therapy was lower for individuals with OUD (70.4%; 95% CI, 68.7%-72.1%) compared with individuals without OUD (76.7%; 95% CI, 74.4%-78.7%) (P < .001) and for the hemoglobin A1c testing indicator (OUD: 80.9%; 95% CI, 80.4%-81.5%; comparator: 85.8%; 95% CI, 84.9%-86.8%; P < .001). Care coordination quality also was lower for individuals with OUD compared with those without OUD for mental health follow-up (OUD: 45.3%; 95% CI, 44.6%-46.0%; comparator: 52.5%; 95% CI, 50.0%-55.0%; P < .001) and for potentially avoidable hospitalizations for chronic conditions (OUD: 11.4%; 95% CI, 11.2%-11.7%; comparator: 8.8%; 95% CI, 8.3%-9.2%; P < .001) and diabetes, where a lower score indicates higher quality (OUD: 2.4%; 95% CI, 2.3%-2.5%; comparator: 1.9%; 95% CI, 1.7%-2.1%; P = .001). CONCLUSIONS AND RELEVANCE These findings suggest that individuals with OUD have moderately lower quality of care across preventive and chronic illness care and care coordination for non-OUD care compared with individuals without OUD. More attention to measurement and improvement of non-OUD care for these individuals is needed.
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Affiliation(s)
- Kelly E. Anderson
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - G. Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
- OptumLabs Visiting Fellow, OptumLabs, Eden Prairie, Minnesota
| | - Lauren Niles
- National Committee for Quality Assurance, Washington, DC
| | | | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sydney M. Dy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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Beaulieu-Jones BK, Yuan W, Brat GA, Beam AL, Weber G, Ruffin M, Kohane IS. Machine learning for patient risk stratification: standing on, or looking over, the shoulders of clinicians? NPJ Digit Med 2021; 4:62. [PMID: 33785839 PMCID: PMC8010071 DOI: 10.1038/s41746-021-00426-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 02/08/2021] [Indexed: 01/03/2023] Open
Abstract
Machine learning can help clinicians to make individualized patient predictions only if researchers demonstrate models that contribute novel insights, rather than learning the most likely next step in a set of actions a clinician will take. We trained deep learning models using only clinician-initiated, administrative data for 42.9 million admissions using three subsets of data: demographic data only, demographic data and information available at admission, and the previous data plus charges recorded during the first day of admission. Models trained on charges during the first day of admission achieve performance close to published full EMR-based benchmarks for inpatient outcomes: inhospital mortality (0.89 AUC), prolonged length of stay (0.82 AUC), and 30-day readmission rate (0.71 AUC). Similar performance between models trained with only clinician-initiated data and those trained with full EMR data purporting to include information about patient state and physiology should raise concern in the deployment of these models. Furthermore, these models exhibited significant declines in performance when evaluated over only myocardial infarction (MI) patients relative to models trained over MI patients alone, highlighting the importance of physician diagnosis in the prognostic performance of these models. These results provide a benchmark for predictive accuracy trained only on prior clinical actions and indicate that models with similar performance may derive their signal by looking over clinician's shoulders-using clinical behavior as the expression of preexisting intuition and suspicion to generate a prediction. For models to guide clinicians in individual decisions, performance exceeding these benchmarks is necessary.
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Affiliation(s)
| | | | - Gabriel A Brat
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - Andrew L Beam
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Griffin Weber
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | | | - Isaac S Kohane
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA.
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Jeffery MM, Cummins NW, Dempsey TM, Limper AH, Shah ND, Bellolio F. Association of outpatient ACE inhibitors and angiotensin receptor blockers and outcomes of acute respiratory illness: a retrospective cohort study. BMJ Open 2021; 11:e044010. [PMID: 33737435 PMCID: PMC7978099 DOI: 10.1136/bmjopen-2020-044010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES Evaluate associations between ACE inhibitors (ACEis) and angiotensin receptor blockers (ARBs) and clinical outcomes in acute viral respiratory illness (AVRI). DESIGN Retrospective cohort analysis of claims data. SETTING The USA; 2018-2019 influenza season. PARTICIPANTS Main cohort: people with hypertension (HTN) taking an ACEi, ARB or other HTN medications, and experiencing AVRI. Falsification cohort: parallel cohort receiving elective knee or hip replacement. MAIN OUTCOME MEASURES Main cohort: hospital admission, intensive care unit, acute respiratory distress (ARD), ARD syndrome and all-cause mortality. Falsification cohort: complications after surgery and all-cause mortality. RESULTS The main cohort included 236 843 episodes of AVRI contributed by 202 629 unique individuals. Most episodes were in women (58.9%), 81.4% in people with Medicare Advantage and 40.3% in people aged 75+ years. Odds of mortality were lower in the ACEi (0.78 (0.74 to 0.83)) and ARB (0.64 (0.61 to 0.68)) cohorts compared with other HTN medications. On all other outcomes, people taking ARBs (but not ACEis) had a >10% reduction in odds of inpatient stays compared with other HTN medications.In the falsification analysis (N=103 353), both ACEis (0.89 (0.80 to 0.98)) and ARBs (0.82 (0.74 to 0.91)) were associated with decreased odds of complications compared with other HTN medications; ARBs (0.64 (0.47 to 0.87)) but not ACEis (0.79 (0.60 to 1.05)) were associated with lower odds of death compared with other HTN medications. CONCLUSIONS Outpatient use of ARBs was associated with better outcomes with AVRI compared with other medications for HTN. ACEis were associated with reduced risk of death, but with minimal or no reduction in risk of other complications. A falsification analysis conducted to provide context on the possible causal implications of these findings did not provide a clear answer. Further analysis using observational data will benefit from additional approaches to assess causal relationships between these drugs and outcomes in AVRI.
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Affiliation(s)
- Molly Moore Jeffery
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota, USA
- Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nathan W Cummins
- Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Timothy M Dempsey
- Pulmonary Critical Care Medicine, David Grant Medical Center, Travis AFB, California, USA
| | - Andrew H Limper
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Robert D and Patricia E Kern Center for the Sciences of the Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nilay D Shah
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota, USA
- Robert D and Patricia E Kern Center for the Sciences of the Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
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Enticott J, Johnson A, Teede H. Learning health systems using data to drive healthcare improvement and impact: a systematic review. BMC Health Serv Res 2021; 21:200. [PMID: 33663508 PMCID: PMC7932903 DOI: 10.1186/s12913-021-06215-8] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 01/18/2021] [Indexed: 11/15/2022] Open
Abstract
Background The transition to electronic health records offers the potential for big data to drive the next frontier in healthcare improvement. Yet there are multiple barriers to harnessing the power of data. The Learning Health System (LHS) has emerged as a model to overcome these barriers, yet there remains limited evidence of impact on delivery or outcomes of healthcare. Objective To gather evidence on the effects of LHS data hubs or aligned models that use data to deliver healthcare improvement and impact. Any reported impact on the process, delivery or outcomes of healthcare was captured. Methods Systematic review from CINAHL, EMBASE, MEDLINE, Medline in-process and Web of Science PubMed databases, using learning health system, data hub, data-driven, ehealth, informatics, collaborations, partnerships, and translation terms. English-language, peer-reviewed literature published between January 2014 and Sept 2019 was captured, supplemented by a grey literature search. Eligibility criteria included studies of LHS data hubs that reported research translation leading to health impact. Results Overall, 1076 titles were identified, with 43 eligible studies, across 23 LHS environments. Most LHS environments were in the United States (n = 18) with others in Canada, UK, Sweden and Australia/NZ. Five (21.7%) produced medium-high level of evidence, which were peer-reviewed publications. Conclusions LHS environments are producing impact across multiple continents and settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06215-8.
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Affiliation(s)
- Joanne Enticott
- Monash Centre for Health Research and Implementation, Monash University, 43-51 Kanooka Grove, Clayton, VIC, 3168, Australia. .,Monash Partners Academic Health Science Centre, 43-51 Kanooka Grove, Clayton, VIC, 3168, Australia.
| | - Alison Johnson
- Monash Partners Academic Health Science Centre, 43-51 Kanooka Grove, Clayton, VIC, 3168, Australia
| | - Helena Teede
- Monash Centre for Health Research and Implementation, Monash University, 43-51 Kanooka Grove, Clayton, VIC, 3168, Australia. .,Monash Partners Academic Health Science Centre, 43-51 Kanooka Grove, Clayton, VIC, 3168, Australia.
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Inselman JW, Rank MA, Zawada SK, Jeffery MM. Which people with asthma are most likely to be hospitalized with COVID-19 in the United States? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2080-2082. [PMID: 33684636 PMCID: PMC7934792 DOI: 10.1016/j.jaip.2021.02.050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Jonathan W Inselman
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Matthew A Rank
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn; Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Ariz; Division of Pulmonology, Phoenix Children's Hospital, Phoenix, Ariz.
| | - Stephanie K Zawada
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, Minn
| | - Molly M Jeffery
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minn
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140
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Eckert AJ, Zhou FL, Grimsmann JM, Pettus JH, Kerner W, Miller KM, Stechemesser L, Edelman SV, Spies C, Holl RW, Ibald-Mulli AM. Demographic characteristics and acute complications among adults with type 1 diabetes: Comparison of two multicentre databases from Germany and the United States. J Diabetes Complications 2021; 35:107812. [PMID: 33280985 DOI: 10.1016/j.jdiacomp.2020.107812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/27/2020] [Accepted: 11/11/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Studies on acute complications in adult T1D were previously reported from the United States (U.S.) and from Germany. The aim was to compare demographic characteristics and patterns of severe hypoglycaemia (SH) and diabetic ketoacidosis (DKA) between Germany and the U.S. METHODS Descriptive comparison on individuals aged ≥18 years, with T1D duration ≥2 years were made between the German diabetes-patient registry (DPV) and the U.S. electronic-health-record database (T1PCO). Individuals in both databases were divided into patients with haemoglobin A1c (HbA1c) <7% and HbA1c ≥7%. RESULTS 5190 (DPV) and 31,430 individuals (T1PCO) fulfilled the inclusion criteria. DPV patients were younger, more often male and had lower body-mass index. In both databases, more males than females had HbA1c <7%. Individuals had higher HbA1c in T1PCO compared to DPV. The relationship between HbA1c and DKA was similar in both databases. SH revealed a U-shaped curve in T1PCO, but no clear pattern was present in DPV. SH events increased with higher age in DPV, but not in T1PCO. CONCLUSION Patterns of SH differ between Germany and U.S. Differences in capture of SH among the databases cannot be excluded, but differences in health care including patient education and level of care by specialists are likely.
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Affiliation(s)
- Alexander J Eckert
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany; German Centre for Diabetes Research (DZD), Neuherberg, Germany.
| | | | - Julia M Grimsmann
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany; German Centre for Diabetes Research (DZD), Neuherberg, Germany
| | | | | | | | - Lars Stechemesser
- First Department of Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Steven V Edelman
- Veterans Affairs Medical Center, University of California San Diego, San Diego, CA, USA
| | - Carsten Spies
- Department of Gastroenterology, Hepatology, Diabetology and emergency medicine, St. Vincent Hospital Limburg, Limburg, Germany
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany; German Centre for Diabetes Research (DZD), Neuherberg, Germany
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141
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Jackson CL, Deng Y, Yao X, Van Houten H, Shah ND, Kopecky S. Proprotein convertase subtilisin/kexin type 9 inhibitor utilization and low-density lipoprotein-cholesterol control in familial hypercholesterolemia. J Clin Lipidol 2021; 15:339-346. [PMID: 33419720 DOI: 10.1016/j.jacl.2020.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/15/2020] [Accepted: 12/23/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors were approved in August 2015 as an adjunct to maximally tolerated statin treatment in those with familial hypercholesterolemia (FH). OBJECTIVE To assess PCSK9 inhibitor utilization patterns and cholesterol control in the high-risk FH population. METHODS This study was a retrospective analysis of a large administrative database that includes privately insured and Medicare Advantage patients. Individuals with diagnosis codes for FH from October 2016-September 2019 were identified. Differences in PCSK9 inhibitor utilization between various groups were evaluated using multivariable logistic regression. RESULTS During the study period, 1:371 people enrolled in medical/pharmacy plans had a diagnosis of FH. While 62.5% (n = 33,649) had medication fills for statins (without PCSK9 inhibitors), only 2.0% (n = 1062) had medication fills for PCSK9 inhibitors (with or without other medications). Compared to men, women were more likely to be untreated (OR 1.23, 95% confidence interval (CI):1.18-1.28, p < 0.01) but more likely to be treated with PCSK9 inhibitors (OR 2.18, 95%CI:1.90-2.49, p < 0.01). Compared to those younger than 55 years of age, older individuals were more likely to be treated (OR 1.64, 95%CI:1.56-1.72, p < 0.01) but less likely to be treated with PCSK9 inhibitors (OR 0.40, 95%CI:0.34-0.47, p < 0.01). Lastly, those with household incomes ≥$40,000 were more likely to be treated with PCSK9 inhibitors than those with lower household incomes (OR 1.69, 95%CI:1.41-2.02, p < 0.01). CONCLUSION PCSK9 inhibitor utilization in FH remains low. Significant differences exist based on demographic factors. Female sex, higher household incomes, and younger age were associated with increased PCSK9 inhibitor utilization.
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Affiliation(s)
| | - Yihong Deng
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA; Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Holly Van Houten
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Nilay D Shah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA; Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA; OptumLabs, Cambridge, MA, USA
| | - Stephen Kopecky
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
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142
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Tan NY, Deng Y, Yao X, Sangaralingham LR, Shah ND, Rule AD, Burnett JC, Dunlay SM, Sangaralingham SJ. Renal Outcomes in Patients with Systolic Heart Failure Treated With Sacubitril-Valsartan or Angiotensin Converting Enzyme Inhibitor/Angiotensin Receptor Blocker. Mayo Clin Proc Innov Qual Outcomes 2021; 5:286-297. [PMID: 33997628 PMCID: PMC8105557 DOI: 10.1016/j.mayocpiqo.2020.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective To assess 4 adverse renal outcomes in a heterogeneous cohort of patients with systolic heart failure (HF) who were prescribed sacubitril-valsartan vs angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARB). Patients and Methods The OptumLabs Database Warehouse, which contains linked administrative claims and laboratory results, was used to identify patients with systolic HF who were prescribed sacubitril-valsartan or ACEi/ARB between July 1, 2015, and September 30, 2019. One-to-one propensity score matching and inverse probability of treatment weighting was used to balance baseline variables. Cox proportional hazards modeling was performed to compare renal outcomes in both medication groups, including 30% or more decline in estimated glomerular filtration rate (eGFR), doubling of serum creatinine, acute kidney injury (AKI), and kidney failure (eGFR < 15 mL/min per 1.73 m2, kidney transplant, or dialysis initiation). Results A total of 4667 matched pairs receiving sacubitril-valsartan or ACEi/ARB were included; the mean follow-up period was 7.8±7.8 months. The mean age was 69.4±11 years; 35% were female, 19% black, and 15% Hispanic. The cumulative risk at 1 year was 6% for 30% or more decline in eGFR, 2% for doubling of serum creatinine, 3% for AKI, and 2% to 3% for kidney failure. Furthermore, no significant differences in risk were observed with sacubitril-valsartan compared with ACEi/ARB for a 30% or more decline in eGFR (hazard ratio [HR], 0.96; 95% CI, 0.79 to 1.10), doubling of serum creatinine (HR, 0.94; 95% CI, 0.69 to 1.27); AKI (HR, 0.80; 95% CI, 0.63 to 1.03), and kidney failure (HR 0.80; 95% CI, 0.59 to 1.08). Conclusion Among patients with systolic HF, the risk of adverse renal outcomes was similar between patients prescribed sacubitril-valsartan and those prescribed ACEi/ARB.
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Key Words
- ACEi, angiotensin-converting enzyme inhibitor
- AKI, acute kidney injury
- ARB, angiotensin receptor blocker
- HF, heart failure
- HFrEF, heart failure with reduced ejection fraction
- HR, hazard ratio
- ICD-10, International Classification of Diseases, Tenth Revision
- ICD-9, International Classification of Diseases, Ninth Revision
- IPTW, inverse probability of treatment weighting
- NP, natriuretic peptide
- RAAS, renin-angiotensin-aldosterone system
- RCT, randomized controlled trial
- eGFR, estimated glomerular filtration rate
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Affiliation(s)
- Nicholas Y Tan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Yihong Deng
- The Robert and Patricia E. Kern Center for the Sciences of Healthcare Delivery, Mayo Clinic, Rochester, MN
| | - Xiaoxi Yao
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.,The Robert and Patricia E. Kern Center for the Sciences of Healthcare Delivery, Mayo Clinic, Rochester, MN.,Division of Health Care Policy and Research, Department of Health Services Research, Mayo Clinic, Rochester, MN
| | - Lindsey R Sangaralingham
- The Robert and Patricia E. Kern Center for the Sciences of Healthcare Delivery, Mayo Clinic, Rochester, MN
| | - Nilay D Shah
- The Robert and Patricia E. Kern Center for the Sciences of Healthcare Delivery, Mayo Clinic, Rochester, MN.,Division of Health Care Policy and Research, Department of Health Services Research, Mayo Clinic, Rochester, MN.,OptumLabs, Cambridge, MA
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - John C Burnett
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.,Cardiorenal Research Laboratory, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Shannon M Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.,Division of Health Care Policy and Research, Department of Health Services Research, Mayo Clinic, Rochester, MN
| | - S Jeson Sangaralingham
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.,Cardiorenal Research Laboratory, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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143
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DeGeorge BR, Van Houten HK, Mwangi R, R Sangaralingham L, Kakar S. Outcomes and complications of operative versus non-operative management of distal radius fractures in adults under 65 years of age. J Hand Surg Eur Vol 2021; 46:159-166. [PMID: 32752977 DOI: 10.1177/1753193420941310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
To compare the outcomes of non-operative versus operative treatment for distal radius fractures in patients aged from 18 to 64 years, we performed a retrospective analysis using the OptumLabs® Data Warehouse using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes of distal radius fracture. Of the 34,184 distal radius fractures analysed, 11,731 (34%) underwent operative management. Short-term complications within 90 days of fracture identified an overall complication rate of 16.6 per 1000 fractures and the 1-year upper extremity-specific complication rate was 287 per 1000 fractures. Overall, post-injury stiffness was the most common 1-year upper extremity-specific complication and was associated with operative management (202.8 vs. 123.4 per 1000 fractures, operative vs. non-operative, p < 0.01). Secondary procedures were significantly more common following non-operative management (8.7% vs. 43%, operative vs. non-operative, p < 0.01) with carpal tunnel release representing the most common secondary procedure. Operative management of distal radius fractures resulted in significantly fewer secondary procedures at the expense of increased overall 1-year complication rates, specifically stiffness.Level of evidence: III.
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Affiliation(s)
- Brent R DeGeorge
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Holly K Van Houten
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,OptumLabs, Cambridge, MA, USA
| | - Raphael Mwangi
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,OptumLabs, Cambridge, MA, USA
| | - Sanjeev Kakar
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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144
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National Patterns of Filled Prescriptions and Third-Line Treatment Utilization for Privately Insured Women With Overactive Bladder. Female Pelvic Med Reconstr Surg 2021; 27:e261-e266. [PMID: 31157717 DOI: 10.1097/spv.0000000000000744] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate national patterns of care for women with overactive bladder (OAB) in an administrative data set and identify potential areas for improvement. METHODS We performed an analysis using the OptumLabs Data Warehouse, which contains deidentified administrative claims data from a large national US health insurance plan. The study included women, older than 18 years, with a new OAB diagnosis from January 1, 2007, to June 30, 2017. We excluded those with an underlying neurologic etiology, with interstitial cystitis/painful bladder syndrome, were pregnant, or did not have continuous enrollment for 12 months before and after OAB diagnosis. Trends in management were assessed via the Cochran-Armitage test. Time to discontinuation among medications was compared using t test. RESULTS Of 1.4 million women in the database during the study time frame, 60,246 (4%) were included in the study. Median age was 61 years [interquartile range (IQR), 50-73], and median follow-up was 2.6 years (IQR, 1.6-4.2). Overall, 37% were treated with anticholinergics, 5% with beta-3 agonists, 7% with topical estrogen, and 2% with pelvic floor physical therapy; 26% saw a specialist; and 2% underwent third-line therapy. Median time to cessation of prescription filling was longer for beta-3 agonists versus anticholinergics [median, 4.1 months (IQR, 1-15) vs 3.6 months (IQR, 1-10); P < 0.0001]. Use of third-line therapies significantly increased over the study time frame, from 1.1% to 2.2% (P < 0.0001). CONCLUSIONS Most of the patients do not continue filling prescriptions for OAB medications, and a minority of patients were referred for specialty evaluation. Although third-line therapy use is increasing, it is used in a small proportion of women with OAB. Given these patterns, there may be underutilization of specialist referral and other OAB therapies.
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145
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McCoy RG, Van Houten HK, Deng Y, Mandic PK, Ross JS, Montori VM, Shah ND. Comparison of Diabetes Medications Used by Adults With Commercial Insurance vs Medicare Advantage, 2016 to 2019. JAMA Netw Open 2021; 4:e2035792. [PMID: 33523188 PMCID: PMC7851726 DOI: 10.1001/jamanetworkopen.2020.35792] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
IMPORTANCE Glucagonlike peptide-1 receptor agonists (GLP-1RA), sodium-glucose cotransporter-2 inhibitors (SGLT2i), and dipeptidyl peptidase-4 inhibitors (DPP-4i) are associated with low rates of hypoglycemia, and postmarketing trials of GLP-1RA and SGLT2i demonstrated that these medications improved cardiovascular and kidney outcomes. OBJECTIVE To compare trends in initiation of treatment with GLP-1RA, SGLT2i, and DPP-4i by older adults with type 2 diabetes insured by Medicare Advantage vs commercial health plans. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used administrative claims data from a deidentified database of commercially insured and Medicare Advantage beneficiaries. Adults aged 58 to 66 years with type 2 diabetes who filled any medication prescription to lower glucose levels from January 1, 2016, to December 31, 2019, were compared between groups. EXPOSURE Enrollment in a Medicare Advantage or commercial health insurance plan. MAIN OUTCOMES AND MEASURES The odds of initiating GLP-1RA, SGLT2i, and DPP-4i treatment were examined for Medicare Advantage vs commercial insurance beneficiaries using 3 separate logistic regression models adjusted for year and demographic and clinical factors. These models were used to calculate adjusted annual rates of medication initiation by health plan. RESULTS A total of 382 574 adults with pharmacologically treated type 2 diabetes (52.9% men; mean [SD] age, 62.4 [2.7] years) were identified, including 172 180 Medicare Advantage and 210 394 commercial beneficiaries. From 2016 to 2019, adjusted rates of initiation of GLP-1RA, SGLT2i, and DPP-4i treatment increased among all beneficiaries, from 2.14% to 20.02% for GLP-1RA among commercial insurance beneficiaries and from 1.50% to 11.44% among Medicare Advantage beneficiaries; from 2.74% to 18.15% for SGLT2i among commercial insurance beneficiaries and from 1.57% to 8.51% among Medicare Advantage beneficiaries; and from 3.30% to 11.71% for DPP-4i among commercial insurance beneficiaries and from 2.44% to 7.68% among Medicare Advantage beneficiaries. Initiation rates for all 3 drug classes were consistently lower among Medicare Advantage than among commercial insurance beneficiaries. Within each calendar year, the odds of initiating GLP-1RA treatment ranged from 0.28 (95% CI, 0.26-0.29) to 0.70 (95% CI, 0.65-0.75) for Medicare Advantage and commercial insurance beneficiaries, respectively; SGLT2i, from 0.21 (95% CI, 0.20-0.22) to 0.57 (95% CI, 0.53-0.61), respectively; and DPP-4i, from 0.37 (95% CI, 0.34-0.39) to 0.73 (95% CI, 0.69-0.78), respectively (P < .001 for all). The odds of starting GLP-1RA and SGLT2i increased with income; for an income of $200 000 and higher vs less than $40 000, the odds ratio for GLP-1RA was 1.23 (95% CI, 1.15-1.32) and for SGLT2i was 1.16 (95% CI, 1.09-1.24). CONCLUSIONS AND RELEVANCE These findings suggest that Medicare Advantage beneficiaries may be less likely than commercially insured beneficiaries to be treated with newer medications to lower glucose levels, with greater disparities among lower-income patients. Better understanding of nonclinical factors contributing to treatment decisions and efforts to promote greater equity in diabetes management appear to be needed.
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Affiliation(s)
- Rozalina G. McCoy
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - Holly K. Van Houten
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - Yihong Deng
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - Pinar Karaca Mandic
- Department of Finance and Medical Industry Leadership Institute, Carlson School of Management, University of Minnesota, Minneapolis
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Joseph S. Ross
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
| | - Victor M. Montori
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- Knowledge Evaluation Research Unit, Rochester, Minnesota
| | - Nilay D. Shah
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
- OptumLabs, Cambridge, Massachusetts
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146
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Lee B, Zhao W, Yang KC, Ahn YY, Perry BL. Systematic Evaluation of State Policy Interventions Targeting the US Opioid Epidemic, 2007-2018. JAMA Netw Open 2021; 4:e2036687. [PMID: 33576816 PMCID: PMC7881356 DOI: 10.1001/jamanetworkopen.2020.36687] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 12/19/2020] [Indexed: 01/17/2023] Open
Abstract
Importance In response to the increase in opioid overdose deaths in the United States, many states recently have implemented supply-controlling and harm-reduction policy measures. To date, an updated policy evaluation that considers the full policy landscape has not been conducted. Objective To evaluate 6 US state-level drug policies to ascertain whether they are associated with a reduction in indicators of prescription opioid abuse, the prevalence of opioid use disorder and overdose, the prescription of medication-assisted treatment (MAT), and drug overdose deaths. Design, Setting, and Participants This cross-sectional study used drug overdose mortality data from 50 states obtained from the National Vital Statistics System and claims data from 23 million commercially insured patients in the US between 2007 and 2018. Difference-in-differences analysis using panel matching was conducted to evaluate the prevalence of indicators of prescription opioid abuse, opioid use disorder and overdose diagnosis, the prescription of MAT, and drug overdose deaths before and after implementation of 6 state-level policies targeting the opioid epidemic. A random-effects meta-analysis model was used to summarize associations over time for each policy and outcome pair. The data analysis was conducted July 12, 2020. Exposures State-level drug policy changes to address the increase of opioid-related overdose deaths included prescription drug monitoring program (PDMP) access, mandatory PDMPs, pain clinic laws, prescription limit laws, naloxone access laws, and Good Samaritan laws. Main Outcomes and Measures The outcomes of interests were quarterly state-level mortality from drug overdoses, known indicators for prescription opioid abuse and doctor shopping, MAT, and prevalence of drug overdose and opioid use disorder. Results This cross-sectional study of drug overdose mortality data and insurance claims data from 23 million commercially insured patients (12 582 378 female patients [55.1%]; mean [SD] age, 45.9 [19.9] years) in the US between 2007 and 2018 found that mandatory PDMPs were associated with decreases in the proportion of patients taking opioids (-0.729%; 95% CI, -1.011% to -0.447%), with overlapping opioid claims (-0.027%; 95% CI, -0.038% to -0.017%), with daily morphine milligram equivalent greater than 90 (-0.095%; 95% CI, -0.150% to -0.041%), and who engaged in drug seeking (-0.002%; 95% CI, -0.003% to -0.001%). The proportion of patients receiving MAT increased after the enactment of mandatory PDMPs (0.015%; 95% CI, 0.002% to 0.028%), pain clinic laws (0.013%, 95% CI, 0.005%-0.021%), and prescription limit laws (0.034%, 95% CI, 0.020% to 0.049%). Mandatory PDMPs were associated with a decrease in the number of overdose deaths due to natural opioids (-518.5 [95% CI, -728.5 to -308.5] per 300 million people) and methadone (-122.7 [95% CI, -207.5 to -37.8] per 300 million people). Prescription drug monitoring program access policies showed similar results, although these policies were also associated with increases in overdose deaths due to synthetic opioids (380.3 [95% CI, 149.6-610.8] per 300 million people) and cocaine (103.7 [95% CI, 28.0-179.5] per 300 million people). Except for the negative association between prescription limit laws and synthetic opioid deaths (-723.9 [95% CI, -1419.7 to -28.1] per 300 million people), other policies were associated with increasing overdose deaths, especially those attributed to non-prescription opioids such as synthetic opioids and heroin. This includes a positive association between naloxone access laws and the number of deaths attributed to synthetic opioids (1338.2 [95% CI, 662.5 to 2014.0] per 300 million people). Conclusions and Relevance Although this study found that existing state policies were associated with reduced misuse of prescription opioids, they may have the unintended consequence of motivating those with opioid use disorders to access the illicit drug market, potentially increasing overdose mortality. This finding suggests that there is no easy policy solution to reverse the epidemic of opioid dependence and mortality in the US.
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Affiliation(s)
- Byungkyu Lee
- Department of Sociology, Indiana University-Bloomington, Bloomington
| | - Wanying Zhao
- Luddy School of Informatics, Computing, and Engineering, Indiana University-Bloomington, Bloomington
| | - Kai-Cheng Yang
- Luddy School of Informatics, Computing, and Engineering, Indiana University-Bloomington, Bloomington
| | - Yong-Yeol Ahn
- Luddy School of Informatics, Computing, and Engineering, Indiana University-Bloomington, Bloomington
| | - Brea L. Perry
- Network Science Institute, Department of Sociology, Indiana University-Bloomington, Bloomington
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147
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Grass F, Merchea A, Mathis KL, Mishra N, Heien H, Sangaralingham LR, Larson DW. Cost drivers of locally advanced rectal cancer treatment-An analysis of a leading healthcare insurer. J Surg Oncol 2021; 123:1023-1029. [PMID: 33497477 DOI: 10.1002/jso.26390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/01/2021] [Accepted: 01/10/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND To evaluate the economic burden of locally advanced rectal cancer (LARC) treatment from a society perspective through analysis of health insurance-derived data of commercially insured and Medicare Advantage (MA) patients. METHODS Retrospective cost analysis of patients undergoing rectal resection within a multimodal (neoadjuvant chemoradiation + adjuvant chemotherapy) treatment strategy between January 1, 2010 and October 31, 2018, using the claims OptumLabs Data Warehouse database. RESULTS In total, 1738 (935 commercial and 803 MA) patients were included. Overall treatment costs totaled $230,881,746 (on average $183 653 ± 82 384 per commercially insured and $73 681 ± 32 917 per MA patient). Cost distribution according to category (commercially insured patients) was: 29.92% related to outpatient care (follow-up visits/diagnostics), radiotherapy: 21.83%, index resection: 20.62%, chemotherapy: 17.44%, surgical inpatient: 6.32%, medical inpatient: 3.28%, emergency room: 0.58%. Relative cost distribution of the index resection itself differed marginally between the three approaches and was 21.49% for open, 19.30% for laparoscopic, and 20.93% for robotic surgery. Relative cost distributions of neoadjuvant, adjuvant, and outpatient treatments remained unchanged, independently of the surgical approach. This representation was similar in MA patients. CONCLUSION Index-surgery related costs were outweighed by costs related to oncological and outpatient workup/follow-up treatments independently of both surgical approach and insurance type.
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Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, Switzerland
| | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nitin Mishra
- Division of Colon and Rectal Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Herbert Heien
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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148
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Akar JG, Hummel JP, Yao X, Sangaralingham L, Dhruva S, Dong J, Ward R, Shah ND, Ross J, Noseworthy PA. Catheter-related complications and mortality of atrial fibrillation ablation following introduction of contact force-sensing technology. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2020; 2:e000058. [PMID: 35047796 PMCID: PMC8647613 DOI: 10.1136/bmjsit-2020-000058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/10/2020] [Accepted: 12/14/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Contact force-sensing catheters allow real-time catheter-tissue contact force monitoring during atrial fibrillation. These catheters were rapidly adopted into clinical practice following market introduction in 2014, but concerns have been raised regarding collateral damage such as esophageal injury. We sought to examine whether the introduction of force-sensing catheters was associated with a change in short-term and intermediate-term acute care use, complications and mortality following atrial fibrillation ablation. DESIGN Retrospective cohort analysis. We used inverse probability treatment weight matching to account for the differences in baseline characteristics between groups. SETTING We examined patients included in the OptumLabs Data Warehouse who underwent ablation for atrial fibrillation before (2011-2013) and after (2015-2017) the market introduction of contact force-sensing catheters. MAIN OUTCOME MEASURES We examined 30-day and 90-day rates of all-cause acute care use, including hospitalizations and emergency department visits, as well as death and hospitalization for catheter-related complications, including atrioesophageal fistula, pericarditis, cardiac tamponade/perforation and stroke/transient ischemic attack. RESULTS Our sample included 3470 and 5772 patients who underwent atrial fibrillation (AF) ablation before and after market introduction of contact force-sensing catheters, respectively. Complication rates were low and did not differ between the two periods (p>0.10 for each outcome). The 30-day and 90-day mortality was 0.1% and 0.3%, respectively after market introduction and unchanged from prior to 2014. The 90-day rates of all-cause acute care use decreased, from 27.0% in 2011-2013 to 23.9% in 2015-2017 (p<0.001). CONCLUSIONS AF ablation-related catheter complications and mortality are low and there has been no significant change following the introduction of force-sensing catheters.
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Affiliation(s)
- Joseph G Akar
- Department of Internal Medicine, Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - James P Hummel
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Xiaoxi Yao
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Lindsey Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sanket Dhruva
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Jun Dong
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rebecca Ward
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Nilay D Shah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph Ross
- Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Peter A Noseworthy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
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149
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Lee S, Li B, Martin EA, D'Souza AG, Jiang J, Doktorchik C, Southern DA, Lee J, Wiebe N, Quan H, Eastwood CA. CREATE: A New Data Resource to Support Cardiac Precision Health. CJC Open 2020; 3:639-645. [PMID: 34036259 PMCID: PMC8134941 DOI: 10.1016/j.cjco.2020.12.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 12/08/2020] [Indexed: 11/27/2022] Open
Abstract
Background The initiatives of precision medicine and learning health systems require databases with rich and accurately captured data on patient characteristics. We introduce the Clinical Registry, AdminisTrative Data and Electronic Medical Records (CREATE) database, which includes linked data from 4 population databases: Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH; a national clinical registry), Sunrise Clinical Manager (SCM) electronic medical record (city-wide), the Discharge Abstract Database (DAD), and the National Ambulatory Care Reporting System (NACRS). The intent of this work is to introduce a cardiovascular-specific database for pursuing precision health activities using big data analytics. Methods We used deterministic data linkage to link SCM electronic medical record data to APPROACH clinical registry data using patient identifier variables. The APPROACH-SCM data set was subsequently linked to DAD and NACRS to obtain inpatient and outpatient cohort data. We further validated the quality of the linkage, where applicable, in these databases by comparing against the Alberta Health Insurance Care Plan registry database. Results We achieved 99.96% linkage across these 4 databases. Currently, there are 30,984 patients with 35,753 catheterizations in the CREATE database. The inpatient cohort contained 65.75% (20,373/30,984) of the patient sample, whereas the outpatient cohort contained 29.78% (9226/30,984). The infrastructure and the process to update and expand the database has been established. Conclusions CREATE is intended to serve as a database for supporting big data analytics activities surrounding cardiac precision health. The CREATE database will be managed by the Centre for Health Informatics at the University of Calgary, and housed in a secure high-performance computing environment.
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Affiliation(s)
- Seungwon Lee
- Centre for Health Informatics, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Calgary, Alberta, Canada.,Data Intelligence for Health Lab, University of Calgary, Calgary, Alberta, Canada
| | - Bing Li
- Centre for Health Informatics, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Calgary, Alberta, Canada
| | - Elliot A Martin
- Centre for Health Informatics, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Calgary, Alberta, Canada
| | - Adam G D'Souza
- Centre for Health Informatics, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Calgary, Alberta, Canada
| | - Jason Jiang
- Centre for Health Informatics, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Calgary, Alberta, Canada
| | - Chelsea Doktorchik
- Centre for Health Informatics, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Danielle A Southern
- Centre for Health Informatics, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Joon Lee
- Centre for Health Informatics, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Data Intelligence for Health Lab, University of Calgary, Calgary, Alberta, Canada.,Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Natalie Wiebe
- Centre for Health Informatics, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Hude Quan
- Centre for Health Informatics, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Cathy A Eastwood
- Centre for Health Informatics, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Singh S, Heien HC, Sangaralingham L, Shah ND, Lai JC, Sandborn WJ, Moore AA. Frailty and Risk of Serious Infections in Biologic-treated Patients With Inflammatory Bowel Diseases. Inflamm Bowel Dis 2020; 27:1626-1633. [PMID: 33325507 PMCID: PMC8522787 DOI: 10.1093/ibd/izaa327] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Identifying biologic-treated patients with inflammatory bowel diseases (IBDs) at higher risk of serious infections is a priority. We conducted a retrospective cohort study evaluating frailty and risk of serious infections in biologic-treated patients with IBD. METHODS Using an administrative claims database, we identified biologic-treated patients with IBD between 2014 and 2018 with follow-up 1 year before and after treatment initiation. Using a validated claims-based hospital frailty risk scoring system, patients were classified as frail and nonfrail. We compared the risk of serious infections (infections requiring hospitalization) between frail and nonfrail patients using Cox proportional hazard analysis adjusting for age, comorbidities, disease characteristics, health care utilization, use of corticosteroids, immunomodulators, and opiates. RESULTS We included 5987 biologic-treated patients with IBD (4881 on TNFα antagonists, 1106 on vedolizumab), of whom 2350 (39.3%) were classified as frail; over 7115 person-years of follow-up was included, and 520 patients developed serious infection. Frailty was not associated with increased risk of serious infection (adjusted hazard ratio [aHR], 1.12; 95% CI, 0.93-1.36), whereas advanced age (older than 60 years), high comorbidity burden, corticosteroid use, opiate use, and prior serious infection were associated with increased risk of serious infection. On stratified analysis, frailty was associated with increased risk of serious infections in vedolizumab-treated patients (aHR, 1.69; 95% CI, 1.03-2.79) but not in TNFα antagonist-treated patients (aHR, 1.03; 95% CI, 0.83-1.27). CONCLUSIONS In biologic-treated patients with IBD, frailty assessed using a claims-based frailty index was not independently associated with increased risk of serious infections. Future studies evaluating objective and biological measures of frailty are warranted to risk-stratify older patients with IBD.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology and Department of Medicine, University of California San Diego, La Jolla, California, USA
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California, USA
- Address correspondence to: Siddharth Singh, MD, MS, Division of Gastroenterology, and Division of Biomedical Informatics, Department of Medicine, University of California San Diego, 9452 Medical Center Drive, ACTRI 1W501, La Jolla, CA 92037, USA. E-mail:
| | - Herbert C Heien
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Lindsey Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nilay D Shah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
- Division of Health Care Policy and Research, Department of Health Services Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology Department of Medicine University of California San Francisco, San Francisco, California, USA
| | - William J Sandborn
- Division of Gastroenterology and Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Alison A Moore
- Division of Geriatrics and Gerontology, Department of Medicine, University of California San Diego, La Jolla, California, USA
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