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Mitchell AP, Kinlaw AC, Peacock-Hinton S, Dusetzina SB, Winn AN, Sanoff HK, Lund JL. Commercial Versus Medicaid Insurance and Use of High-Priced Anticancer Treatments. Oncologist 2024; 29:527-533. [PMID: 38484395 PMCID: PMC11144993 DOI: 10.1093/oncolo/oyae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/16/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Because the markups on cancer drugs vary by payor, providers' financial incentive to use high-price drugs is differential according to each patient's insurance type. We evaluated the association between patient insurer (commercial vs Medicaid) and the use of high-priced cancer treatments. MATERIALS AND METHODS We linked cancer registry, administrative claims, and demographic data for individuals diagnosed with cancer in North Carolina from 2004 to 2011, with either commercial or Medicaid insurance. We selected cancers with multiple FDA-approved, guideline-recommended chemotherapy options and large price differences between treatment options: advanced colorectal, lung, and head and neck cancer. The outcome was a receipt of a higher-priced option, and the exposure was insurer: commercial versus Medicaid. We estimated risk ratios (RRs) for the association between insurer and higher-priced treatment using log-binomial models with inverse probability of exposure weights. RESULTS Of 812 patients, 209 (26%) had Medicaid. The unadjusted risk of receiving higher-priced treatment was 36% (215/603) for commercially insured and 27% (57/209) for Medicaid insured (RR: 1.31, 95% CI: 1.02-1.67). After adjustment for confounders the association was attenuated (RR: 1.15, 95% CI: 0.81-1.65). Exploratory subgroup analysis suggested that commercial insurance was associated with increased receipt of higher-priced treatment among patients treated by non-NCI-designated providers (RR: 1.53, 95% CI: 1.14-2.04). CONCLUSIONS Individuals with Medicaid and commercial insurance received high-priced treatments in similar proportion, after accounting for differences in case mix. However, modification by provider characteristics suggests that insurance type may influence treatment selection for some patient groups. Further work is needed to determine the relationship between insurance status and newer, high-price drugs such as immune-oncology agents.
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Affiliation(s)
- Aaron P Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Alan C Kinlaw
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Sharon Peacock-Hinton
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, United States
- Vanderbilt-Ingram Cancer Center, Nashville, TN, United States
| | - Aaron N Winn
- University of Illinois at Chicago, Chicago, IL, United States
| | - Hanna K Sanoff
- Department of Hematology/ Oncology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Jennifer L Lund
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Roberts TJ, Kehl KL, Brooks GA, Sholl L, Wright AA, Landrum MB, Keating NL. Practice-Level Variation in Molecular Testing and Use of Targeted Therapy for Patients With Non-Small Cell Lung Cancer and Colorectal Cancer. JAMA Netw Open 2023; 6:e2310809. [PMID: 37115543 PMCID: PMC10148196 DOI: 10.1001/jamanetworkopen.2023.10809] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/15/2023] [Indexed: 04/29/2023] Open
Abstract
Importance All patients with newly diagnosed non-small cell lung cancer (NSCLC) and colorectal cancer (CRC) should receive molecular testing to identify those who can benefit from targeted therapies. However, many patients do not receive recommended testing and targeted therapies. Objective To compare rates of molecular testing and targeted therapy use by practice type and across practices. Design, Setting, and Participants This cross-sectional study used 100% Medicare fee-for-service data from 2015 through 2019 to identify beneficiaries with new metastatic NSCLC or CRC diagnoses receiving systemic therapy and to assign patients to oncology practices. Hierarchical linear models were used to characterize variation by practice type and across practices. Data analysis was conducted from June 2019 to October 2022. Exposures Oncology practice providing care. Outcomes Primary outcomes were rates of molecular testing and targeted therapy use for patients with NSCLC and CRC. Secondary outcomes were rates of multigene testing for NSCLC and CRC. Results There were 106 228 Medicare beneficiaries with incident NSCLC (31 521 [29.7%] aged 65-69 years; 50 348 [47.4%] female patients; 2269 [2.1%] Asian, 8282 [7.8%] Black, and 91 215 [85.9%] White patients) and 39 512 beneficiaries with incident CRC (14 045 [35.5%] aged 65-69 years; 17 518 [44.3%] female patients; 896 [2.3%] Asian, 3521 [8.9%] Black, and 32 753 [82.9%] White patients) between 2015 and 2019. Among these beneficiaries, 18 435 (12.9%) were treated at National Cancer Institute (NCI)-designated centers, 8187 (5.6%) were treated at other academic centers, and 94 329 (64.7%) were treated at independent oncology practices. Molecular testing rates increased from 74% to 85% for NSCLC and 45% to 65% for CRC. First-line targeted therapy use decreased from 12% to 8% among patients with NSCLC and was constant at 5% for patients with CRC. For NSCLC, molecular testing rates were similar across practice types while rates of multigene panel use (13.2%) and targeted therapy use (16.6%) were highest at NCI-designated cancer centers. For CRC, molecular testing rates were 3.8 (95% CI: 1.2-6.5), 3.3 (95% CI, 0.4-6.1), and 12.2 (95% CI, 9.1-15.3) percentage points lower at hospital-owned practices, large independent practices, and small independent practices, respectively. Rates of targeted therapy use for CRC were similar across practice types. After adjusting for patient characteristics, there was moderate variation in molecular testing and targeted therapy use across oncology practices. Conclusions and Relevance In this cross-sectional study of Medicare beneficiaries, molecular testing rates for NSCLC and CRC increased in recent years but remained lower than recommended levels. Rates of targeted therapy use decreased for NSCLC and remained stable for CRC. Variation across practices suggests that where a patient was treated may have affected access to recommended testing and efficacious treatments.
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Affiliation(s)
- Thomas J. Roberts
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Kenneth L. Kehl
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gabriel A. Brooks
- Section of Medical Oncology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Lynette Sholl
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Alexi A. Wright
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Nancy L. Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Carroll CE, Landrum MB, Wright AA, Keating NL. Adoption of Innovative Therapies Across Oncology Practices-Evidence From Immunotherapy. JAMA Oncol 2023; 9:324-333. [PMID: 36602811 PMCID: PMC9857528 DOI: 10.1001/jamaoncol.2022.6296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 10/03/2022] [Indexed: 01/06/2023]
Abstract
Importance Immunotherapies reflect an important breakthrough in cancer treatment, substantially improving outcomes for patients with a variety of cancer types, yet little is known about which practices have adopted this novel therapy or the pace of adoption. Objective To assess adoption of immunotherapies across US oncology practices and examine variation in adoption by practice type. Design, Setting, and Participants This cohort study used data from Medicare fee-for-service beneficiaries undergoing 6-month chemotherapy episodes between 2010 and 2017. Data were analyzed January 19, 2021, to September 28, 2022, for patients with cancer types for which immunotherapy was approved by the US Food and Drug Administration (FDA) during the study period: melanoma, kidney cancer, lung cancer, and head and neck cancer. Exposures Oncology practice location (rural vs urban), affiliation type (academic system, nonacademic system, independent), and size (1 to 5 physicians vs 6 or more physicians). Main Outcomes and Measures The primary outcome was whether a practice adopted immunotherapy. Adoption rates for each practice type were estimated using multivariate linear models that adjusted for patient characteristics (age, sex, race and ethnicity, cancer type, Charlson Comorbidity Index, and median household income). Results Data included 71 659 episodes at 1732 oncology practices. Of these, 264 practices (15%) were rural, 900 (52%) were independent, and 492 (28%) had 1 to 5 physicians. Most practices adopted immunotherapy within 2 years of FDA approval, but there was substantial variation in adoption rates across practice types. After FDA approval, adoption of immunotherapy was 11 (95% CI, -16 to -6) percentage points lower at rural practices than urban practices and 27 (95% CI, -32 to -22) percentage points lower at practices with 1 to 5 physicians than practices with 6 or more physicians. Adoption rates were similar at independent practices and nonacademic systems; however, both practice types had lower adoption than academic systems (independent practice difference, -6 [95% CI, -9 to -3] percentage points; nonacademic systems difference, -9 [95% CI, -11 to -6] percentage points). Conclusions and Relevance In this cohort study of Medicare claims, practice characteristics, especially practice size and rural location, were associated with adoption of immunotherapy. These findings suggest that there may be geographic disparities in access to important innovations for treating patients with cancer.
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Affiliation(s)
- Caitlin E. Carroll
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Alexi A. Wright
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Nancy L. Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
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Watanabe T, Sugiyama T, Imai K, Higashi T. How are new drugs disseminated in Japan? Analysis using the National Database of Health Insurance Claims of Japan. Cancer Sci 2022; 113:1771-1778. [PMID: 35266252 PMCID: PMC9128186 DOI: 10.1111/cas.15322] [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: 10/07/2021] [Revised: 02/07/2022] [Accepted: 02/28/2022] [Indexed: 11/28/2022] Open
Abstract
Drug lag refers to the difference in the time of a new drug's approval in different countries; the dissemination of the new drug after approval within the countries is another problem. We examined the nationwide dissemination of 11 cancer drugs approved in Japan between 2011 and 2015 using the National Database of Health Insurance Claims data. We extracted data on the number of cancer drug prescriptions from 47 prefectures and associated demographic information, such as age and sex. Eight diabetes drugs were also examined for comparison. We observed a lag between the marketing approval date of the drugs and their first use. To further explore the rise and pattern of each drug’s dissemination, we analyzed the trend of the cumulative number and total of new prescriptions for each prefecture. The results showed that the first month of new cancer drug prescriptions varied across prefectures. On average, they lagged by up to 2 months in the slowest prefectures, whereas the variation was almost nonexistent for diabetes drugs. The patterns of dissemination varied more among cancer drugs across the seven Japanese geographical regions. After the initial prescription, the number of prescriptions showed a steep rise for most cancer drugs, whereas the increase was gradual for diabetes drugs. In conclusion, the dissemination of cancer drugs had a greater lag time than that of diabetes drugs. Further research is needed to explore the causative factors to ensure that all effective drugs are equally accessible for those who need them.
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Affiliation(s)
- Tomone Watanabe
- Division of Health Services Research, National Cancer Center Japan, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.,Department of Cancer Health Services Research, Graduate School of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Takehiro Sugiyama
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan.,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Kenjiro Imai
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Takahiro Higashi
- Division of Health Services Research, National Cancer Center Japan, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.,Department of Cancer Health Services Research, Graduate School of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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Keating NL, Jhatakia S, Brooks GA, Tripp AS, Cintina I, Landrum MB, Zheng Q, Christian TJ, Glass R, Hsu VD, Kummet CM, Woodman S, Simon C, Hassol A. Association of Participation in the Oncology Care Model With Medicare Payments, Utilization, Care Delivery, and Quality Outcomes. JAMA 2021; 326:1829-1839. [PMID: 34751709 PMCID: PMC8579232 DOI: 10.1001/jama.2021.17642] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
IMPORTANCE In 2016, the US Centers for Medicare & Medicaid Services initiated the Oncology Care Model (OCM), an alternative payment model designed to improve the value of care delivered to Medicare beneficiaries with cancer. OBJECTIVE To assess the association of the OCM with changes in Medicare spending, utilization, quality, and patient experience during the OCM's first 3 years. DESIGN, SETTING, AND PARTICIPANTS Exploratory difference-in-differences study comparing care during 6-month chemotherapy episodes in OCM participating practices and propensity-matched comparison practices initiated before (January 2014 through June 2015) and after (July 2016 through December 2018) the start of the OCM. Participants included Medicare fee-for-service beneficiaries with cancer treated at these practices through June 2019. EXPOSURES OCM participation. MAIN OUTCOMES AND MEASURES Total episode payments (Medicare spending for Parts A, B, and D, not including monthly payments for enhanced oncology services); utilization and payments for hospitalizations, emergency department (ED) visits, office visits, chemotherapy, supportive care, and imaging; quality (chemotherapy-associated hospitalizations and ED visits, timely chemotherapy, end-of-life care, and survival); and patient experiences. RESULTS Among Medicare fee-for-service beneficiaries with cancer undergoing chemotherapy, 483 319 beneficiaries (mean age, 73.0 [SD, 8.7] years; 60.1% women; 987 332 episodes) were treated at 201 OCM participating practices, and 557 354 beneficiaries (mean age, 72.9 [SD, 9.0] years; 57.4% women; 1 122 597 episodes) were treated at 534 comparison practices. From the baseline period, total episode payments increased from $28 681 for OCM episodes and $28 421 for comparison episodes to $33 211 for OCM episodes and $33 249 for comparison episodes during the intervention period (difference in differences, -$297; 90% CI, -$504 to -$91), less than the mean $704 Monthly Enhanced Oncology Services payments. Relative decreases in total episode payments were primarily for Part B nonchemotherapy drug payments (difference in differences, -$145; 90% CI, -$218 to -$72), especially supportive care drugs (difference in differences, -$150; 90% CI, -$216 to -$84). The OCM was associated with statistically significant relative reductions in total episode payments among higher-risk episodes (difference in differences, -$503; 90% CI, -$802 to -$204) and statistically significant relative increases in total episode payments among lower-risk episodes (difference in differences, $151; 90% CI, $39-$264). The OCM was not significantly associated with differences in hospitalizations, ED visits, or survival. Of 22 measures of utilization, 10 measures of quality, and 7 measures of care experiences, only 5 were significantly different. CONCLUSIONS AND RELEVANCE In this exploratory analysis, the OCM was significantly associated with modest payment reductions during 6-month episodes for Medicare beneficiaries receiving chemotherapy for cancer in the first 3 years of the OCM that did not offset the monthly payments for enhanced oncology services. There were no statistically significant differences for most utilization, quality, and patient experience outcomes.
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Affiliation(s)
- Nancy L. Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | | | | | | | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Qing Zheng
- Abt Associates, Cambridge, Massachusetts
| | | | | | - Van Doren Hsu
- General Dynamics Information Technology, Falls Church, Virginia
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Medlinskiene K, Tomlinson J, Marques I, Richardson S, Stirling K, Petty D. Barriers and facilitators to the uptake of new medicines into clinical practice: a systematic review. BMC Health Serv Res 2021; 21:1198. [PMID: 34740338 PMCID: PMC8570007 DOI: 10.1186/s12913-021-07196-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 10/19/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Implementation and uptake of novel and cost-effective medicines can improve patient health outcomes and healthcare efficiency. However, the uptake of new medicines into practice faces a wide range of obstacles. Earlier reviews provided insights into determinants for new medicine uptake (such as medicine, prescriber, patient, organization, and external environment factors). However, the methodological approaches used had limitations (e.g., single author, narrative review, narrow search, no quality assessment of reviewed evidence). This systematic review aims to identify barriers and facilitators affecting the uptake of new medicines into clinical practice and identify areas for future research. METHOD A systematic search of literature was undertaken within seven databases: Medline, EMBASE, Web of Science, CINAHL, Cochrane Library, SCOPUS, and PsychINFO. Included in the review were qualitative, quantitative, and mixed-methods studies focused on adult participants (18 years and older) requiring or taking new medicine(s) for any condition, in the context of healthcare organizations and which identified factors affecting the uptake of new medicines. The methodological quality was assessed using QATSDD tool. A narrative synthesis of reported factors was conducted using framework analysis and a conceptual framework was utilised to group them. RESULTS A total of 66 studies were included. Most studies (n = 62) were quantitative and used secondary data (n = 46) from various databases, e.g., insurance databases. The identified factors had a varied impact on the uptake of the different studied new medicines. Differently from earlier reviews, patient factors (patient education, engagement with treatment, therapy preferences), cost of new medicine, reimbursement and formulary conditions, and guidelines were suggested to influence the uptake. Also, the review highlighted that health economics, wider organizational factors, and underlying behaviours of adopters were not or under explored. CONCLUSION This systematic review has identified a broad range of factors affecting the uptake of new medicines within healthcare organizations, which were grouped into patient, prescriber, medicine, organizational, and external environment factors. This systematic review also identifies additional factors affecting new medicine use not reported in earlier reviews, which included patient influence and education level, cost of new medicines, formulary and reimbursement restrictions, and guidelines. REGISTRATION PROSPERO database (CRD42018108536).
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Affiliation(s)
- Kristina Medlinskiene
- Medicine Optimisation Research Group, School of Pharmacy and Medical Sciences, University of Bradford, Richmond Road, Bradford, BD7 1DP UK
- Medicine Management and Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Justine Tomlinson
- Medicine Optimisation Research Group, School of Pharmacy and Medical Sciences, University of Bradford, Richmond Road, Bradford, BD7 1DP UK
- Medicine Management and Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Iuri Marques
- Medicine Optimisation Research Group, School of Pharmacy and Medical Sciences, University of Bradford, Richmond Road, Bradford, BD7 1DP UK
| | - Sue Richardson
- Department of Management, Huddersfield Business School, University of Huddersfield, Huddersfield, HD1 3DH UK
| | - Katherine Stirling
- Medicine Management and Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Duncan Petty
- Medicine Optimisation Research Group, School of Pharmacy and Medical Sciences, University of Bradford, Richmond Road, Bradford, BD7 1DP UK
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Gilstrap LG, Blair RA, Huskamp HA, Zelevinsky K, Normand SL. Assessment of Second-Generation Diabetes Medication Initiation Among Medicare Enrollees From 2007 to 2015. JAMA Netw Open 2020; 3:e205411. [PMID: 32442290 PMCID: PMC7244990 DOI: 10.1001/jamanetworkopen.2020.5411] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Little is known about how new and expensive drugs diffuse into practice affects health care costs. OBJECTIVE To describe the variation in second-generation diabetes drug use among Medicare enrollees between 2007 and 2015. DESIGN, SETTING, AND PARTICIPANTS This population-based, cross-sectional study included data from 100% of Medicare Parts A, B, and D enrollees who first received diabetes drug therapy from January 1, 2007, to December 31, 2015. Patients with type 1 diabetes were excluded. Data were analyzed beginning in the spring of 2018, and revisions were completed in 2019. EXPOSURES For each patient, the initial diabetes drug choice was determined; drugs were classified as first generation (ie, approved before 2000) or second generation (ie, approved after 2000, including dipeptidyl peptidase 4 [DPP-4] inhibitors, glucagon-like peptide-1 [GLP-1] receptor agonists, and sodium-glucose cotransporter-2 [SGLT-2] inhibitors). MAIN OUTCOMES AND MEASURES The primary outcome was the between-practice variation in use of second-generation diabetes drugs between 2007 and 2015. Practices with use rates of second-generation diabetes drugs more than 1 SD above the mean were considered high prescribing, while those with use rates more than 1 SD below the mean were considered low prescribing. RESULTS Among 1 182 233 patients who initiated diabetes drug therapy at 42 977 practices between 2007 and 2015, 1 104 718 (93.4%) were prescribed a first-generation drug (mean [SD] age, 75.4 [6.7] years; 627 134 [56.8%] women) and 77 515 (6.6%) were prescribed a second-generation drug (mean [SD] age, 76.5 [7.2] years; 44 697 [57.7%] women). By December 2015, 22 457 practices (52.2%) had used DPP-4 inhibitors once, compared with 3593 practices (8.4%) that had used a GLP-1 receptor agonist once. Furthermore, 17 452 practices (40.6%) were using DPP-4 inhibitors in 10% of eligible patients, while 1286 practices (3.0%) were using GLP-1 receptor agonists in 10% of eligible patients, and SGLT-2 inhibitors, available after March 2013, were used at least once by 1716 practices (4.0%) and used in 10% of eligible patients by 872 practices (2.0%) by December 2015. According to Poisson random-effect regression models, beneficiaries in high-prescribing practices were more than 3-fold more likely to receive DPP-4 inhibitors (relative risk, 3.55 [95% CI, 3.42-3.68]), 24-fold more likely to receive GLP-1 receptor agonists (relative risk, 24.06 [95% CI, 14.14-40.94]) and 60-fold more likely to receive SGLT-2 inhibitors (relative risk, 60.41 [95% CI, 15.99-228.22]) compared with beneficiaries in low-prescribing practices. CONCLUSIONS AND RELEVANCE These findings suggest that there was substantial between-practice variation in the use of second-generation diabetes drugs between 2007 and 2015, with a concentration of use among a few prescribers and practices responsible for much of the early diffusion.
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Affiliation(s)
- Lauren G. Gilstrap
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Rachel A. Blair
- Division of Endocrinology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Haiden A. Huskamp
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Katya Zelevinsky
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Sharon-Lise Normand
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Keating NL, O’Malley AJ, Onnela JP, Gray SW, Landon BE. Association of Physician Peer Influence With Subsequent Physician Adoption and Use of Bevacizumab. JAMA Netw Open 2020; 3:e1918586. [PMID: 31899533 PMCID: PMC6991243 DOI: 10.1001/jamanetworkopen.2019.18586] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
IMPORTANCE Understanding adoption of new cancer therapies may help identify opportunities to increase use for high-value indications. OBJECTIVE To determine whether use of bevacizumab in 2005 to 2006 by oncologists' peers was associated with greater bevacizumab use among oncologists in 2007 to 2010. DESIGN, SETTING, AND PARTICIPANTS This cohort study of physicians and their patients took place in 51 randomly selected hospital referral regions in the United States. Participants were 44 012 fee-for-service Medicare beneficiaries aged 65 years or older with cancers of the colorectum, lung, breast, kidney, brain, or ovary treated by 3261 oncologists in 2005 to 2010 and assigned to one of 252 communities. Data were analyzed in 2017 to 2018. EXPOSURES Among patients treated with chemotherapy during 2007 to 2010 by an oncologist who had not treated patients with bevacizumab in 2005 to 2006, models assessed the association of bevacizumab use with rates of bevacizumab use in their physician's community of connected physicians in 2005 to 2006. Models adjusted for patient and physician characteristics and physician, practice, and community random effects. MAIN OUTCOMES AND MEASURES Receipt of bevacizumab. RESULTS A total of 34 750 patients (14 126 [40.6%] aged ≥75 years; 21 321 [61.4%] female) with cancers of the colorectum, lung, breast, kidney, brain, and ovary were treated with chemotherapy in 2005 to 2006 in the 51 hospital referral regions. Among 9262 patients treated in 2007 to 2010 by 829 physicians whose patients did not use bevacizumab in 2005 to 2006, 3654 (39.5%) were aged 75 years or older and 6227 (67.2%) were female. The rate of bevacizumab use relative to other chemotherapy in 2007 to 2010 by tertile of use (bevacizumab for <4.4%, 4.4%-6.2%, and >6.2% of all patients receiving chemotherapy) among their physician's peers in 2005 to 2006 was 10.0%, 9.5%, and 13.6%, respectively. After adjustment, use of bevacizumab in 2007 to 2010 was greater among physicians in communities with the highest rates of bevacizumab use in 2005 to 2006 compared with those whose peers were in the lowest tertile of bevacizumab use in 2005 to 2006 (adjusted odds ratio, 1.64; 95% CI, 1.20-2.25). CONCLUSIONS AND RELEVANCE This study found that an increase in oncologists' adoption and use of bevacizumab in the years after its approval was associated with their peer physicians being earlier adopters. As organizations seek to provide better care at lower costs, interventions that leverage physician ties may help to promote adoption of high-value use of new cancer treatments and deimplementation of low-value therapies.
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Affiliation(s)
- Nancy L. Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - A. James O’Malley
- Department of Biomedical Data Science and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Hanover, New Hampshire
| | - Jukka-Pekka Onnela
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Stacy W. Gray
- Department of Population Sciences and Medical Oncology, City of Hope Medical Center, Duarte, California
| | - Bruce E. Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Krimphove MJ, Tully KH, Friedlander DF, Marchese M, Ravi P, Lipsitz SR, Kilbridge KL, Kibel AS, Kluth LA, Ott PA, Choueiri TK, Trinh QD. Adoption of immunotherapy in the community for patients diagnosed with metastatic melanoma. J Immunother Cancer 2019; 7:289. [PMID: 31699149 PMCID: PMC6836520 DOI: 10.1186/s40425-019-0782-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 10/22/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The introduction of immune checkpoint inhibitors has led to a survival benefit in patients with advanced melanoma; however data on the adoption of immunotherapy in the community are scarce. METHODS Using the National Cancer Database, we identified 4725 patients aged ≥20 diagnosed with metastatic melanoma in the United States between 2011 and 2015. Multinomial regression was used to identify factors associated with the receipt of treatment at a low vs. high immunotherapy prescribing hospital, defined as the bottom and top quintile of hospitals according to their proportion of treating metastatic melanoma patients with immunotherapy. RESULTS We identified 246 unique hospitals treating patients with metastatic melanoma. Between 2011 and 2015, the proportion of hospitals treating at least 20% of melanoma patients with immunotherapy within 90 days of diagnosis increased from 14.5 to 37.7%. The mean proportion of patients receiving immunotherapy was 7.8% (95% Confidence Interval [CI] 7.47-8.08) and 50.9% (95%-CI 47.6-54.3) in low and high prescribing hospitals, respectively. Predictors of receiving care in a low prescribing hospital included underinsurance (no insurance: relative risk ratio [RRR] 2.44, 95%-CI 1.28-4.67, p = 0.007; Medicaid: RRR 2.10, 95%-CI 1.12-3.92, p = 0.020), care in urban areas (RRR 2.58, 95%-CI 1.34-4.96, p = 0.005) and care at non-academic facilities (RRR 5.18, 95%CI 1.69-15.88, p = 0.004). CONCLUSION While the use of immunotherapy for metastatic melanoma has increased over time, adoption varies widely across hospitals. Underinsured patients were more likely to receive treatment at low immunotherapy prescribing hospitals. The variation suggests inequity in access to these potentially life-saving drugs.
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Affiliation(s)
- Marieke J. Krimphove
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Karl H. Tully
- Department of Urology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - David F. Friedlander
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Maya Marchese
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Praful Ravi
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Stuart R. Lipsitz
- Department of General Internal Medicine and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Kerry L. Kilbridge
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA USA
| | - Adam S. Kibel
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Luis A. Kluth
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Patrick A. Ott
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA USA
| | - Toni K. Choueiri
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA USA
| | - Quoc-Dien Trinh
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
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Kim H, Keating NL, Perloff JN, Hodgkin D, Liu X, Bishop CE. Aggressive Care near the End of Life for Cancer Patients in Medicare Accountable Care Organizations. J Am Geriatr Soc 2019; 67:961-968. [DOI: 10.1111/jgs.15914] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/14/2018] [Accepted: 02/06/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Hyosin Kim
- The Heller School for Social Policy and ManagementBrandeis University Waltham Massachusetts
| | - Nancy L. Keating
- Department of Health Care PolicyHarvard Medical School Boston Massachusetts
- Division of General Internal MedicineBrigham and Women's Hospital Boston Massachusetts
| | - Jennifer N. Perloff
- The Heller School for Social Policy and ManagementBrandeis University Waltham Massachusetts
| | - Dominic Hodgkin
- The Heller School for Social Policy and ManagementBrandeis University Waltham Massachusetts
| | - Xiaodong Liu
- Department of PsychologyBrandeis University Waltham Massachusetts
| | - Christine E. Bishop
- The Heller School for Social Policy and ManagementBrandeis University Waltham Massachusetts
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