1
|
Shin JI, Xu Y, Chang AR, Carrero JJ, Flaherty CM, Mukhopadhyay A, Inker LA, Blecker SB, Horwitz LI, Grams ME. Prescription Patterns for Sodium-Glucose Cotransporter 2 Inhibitors in U.S. Health Systems. J Am Coll Cardiol 2024; 84:683-693. [PMID: 39142721 DOI: 10.1016/j.jacc.2024.05.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 05/23/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce heart failure (HF) hospitalizations, recurrent cardiovascular events, and chronic kidney disease (CKD) progression, and thus constitute a Class 1a recommendation in people with diabetes and atherosclerotic cardiovascular disease, HF, or CKD and in people with severe albuminuria or HF, regardless of diabetes status. OBJECTIVES The purpose of this study was to comprehensibly characterize the rate of SGLT2 inhibitor prescriptions among people with a Class 1a recommendation for SGLT2 inhibitor use. METHODS Among 3,189,827 adults from 28 U.S. health systems within Optum Labs Data Warehouse between April 1, 2022, and March 31, 2023, we assessed SGLT2 inhibitor prescription rates, stratified by presence of diabetes and Class 1a recommendation. RESULTS Among 716,387 adults with diabetes, 63.4% had a Class 1a recommendation for SGLT2 inhibitor therapy. There was little difference by Class 1a recommendation status (present: 11.9%; 95% CI: 11.9%-12.0% vs absent: 11.4%; 95% CI: 11.3%-11.6%; standardized mean difference: 1.3%). Among 2,473,440 adults without diabetes, 6.2% had a Class 1a recommendation for SGLT2 inhibitor therapy, and 3.1% (3.0%-3.2%) of those received a prescription. Internists/family practitioners initiated SGLT2 inhibitor prescriptions most commonly among people with diabetes, whereas specialists initiated SGLT2 inhibitor prescriptions most commonly among people without diabetes. No health system had >25% SGLT2 inhibitor prescription rate among people with a Class 1a recommendation. Health systems with higher proportions of patients with commercial insurance and lower proportions with Medicare had higher SGLT2 inhibitor prescription rates. CONCLUSIONS In this analysis of U.S. data from 2022 to 2023, SGLT2 inhibitor prescription among people with a Class 1a recommendation is low. Interventions are needed to increase uptake of guideline-recommended SGLT2 inhibitor use.
Collapse
Affiliation(s)
- Jung-Im Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - Yunwen Xu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Alexander R Chang
- Departments of Nephrology and Population Health Sciences, Geisinger, Danville, Pennsylvania, USA
| | - Juan J Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Carina M Flaherty
- Division of Precision Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Amrita Mukhopadhyay
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA; Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Lesley A Inker
- Division of Nephrology, Department of Internal Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Saul B Blecker
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA; Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Leora I Horwitz
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA; Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Morgan E Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Division of Precision Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA; Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| |
Collapse
|
2
|
Xu Y, Ballew SH, Chang AR, Inker LA, Grams ME, Shin JI. Risk of Major Bleeding, Stroke/Systemic Embolism, and Death Associated With Different Oral Anticoagulants in Patients With Atrial Fibrillation and Severe Chronic Kidney Disease. J Am Heart Assoc 2024:e034641. [PMID: 39119973 DOI: 10.1161/jaha.123.034641] [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: 02/14/2024] [Accepted: 06/20/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Patients with atrial fibrillation and severe chronic kidney disease have higher risks of bleeding, thromboembolism, and mortality. However, optimal anticoagulant choice in these high-risk patients remains unclear. METHODS AND RESULTS Using deidentified electronic health records from the Optum Labs Data Warehouse, adults with atrial fibrillation and severe chronic kidney disease (estimated glomerular filtration rate <30 mL/min per 1.73 m2) initiating warfarin, apixaban, or rivaroxaban between 2011 and 2021 were included. Using inverse probability of treatment weighting, adjusted risks of major bleeding, stroke/systemic embolism, and death were compared among agents. A total of 6794 patients were included (mean age, 78.5 years; mean estimated glomerular filtration rate, 24.7 mL/min per 1.73 m2; 51% women). Apixaban versus warfarin was associated with a lower risk of major bleeding (incidence rate, 1.5 versus 2.9 per 100 person-years; subdistribution hazard ratio [sub-HR], 0.53 [95% CI, 0.39-0.70]), and similar risks for stroke/systemic embolism (incidence rate, 1.9 versus 2.4 per 100 person-years; sub-HR, 0.80 [95% CI, 0.59-1.09]) and death (incidence rate, 4.6 versus 4.5 per 100 person-years; HR, 1.03 [95% CI, 0.82-1.29]). Rivaroxaban versus warfarin was associated with a higher risk of major bleeding (incidence rate, 4.9 versus 2.9 per 100 person-years; sub-HR, 1.65 [95% CI, 1.10-2.48]), with no difference in risks for stroke/systemic embolism and death. Apixaban versus rivaroxaban was associated with a lower risk of major bleeding (sub-HR, 0.53 [95% CI, 0.36-0.78]). CONCLUSIONS These real-world findings are consistent with potential safety advantages of apixaban over warfarin and rivaroxaban for patients with atrial fibrillation and severe chronic kidney disease. Further randomized trials comparing individual oral anticoagulants are warranted.
Collapse
Affiliation(s)
- Yunwen Xu
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD USA
| | - Shoshana H Ballew
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD USA
- Optimal Aging Institute, New York University Grossman School of Medicine and Langone Health New York NY USA
- Department of Population Health New York University Grossman School of Medicine and Langone Health New York NY USA
| | | | - Lesley A Inker
- Division of Nephrology, Department of Internal Medicine Tufts Medical Center Boston MA USA
| | - Morgan E Grams
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD USA
- Department of Population Health New York University Grossman School of Medicine and Langone Health New York NY USA
- Department of Medicine New York University Grossman School of Medicine and Langone Health New York NY USA
| | - Jung-Im Shin
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD USA
| |
Collapse
|
3
|
Moffett AT, Halpern SD, Weissman GE. The Effect of a Post-Bronchodilator FEV 1 /FVC < 0.7 on COPD Diagnosis and Treatment: A Regression Discontinuity Design. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.08.05.24311519. [PMID: 39148856 PMCID: PMC11326314 DOI: 10.1101/2024.08.05.24311519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
Background Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend the diagnosis of chronic obstructive pulmonary disease (COPD) only in patients with a post-bronchodilator forced expiratory volume in 1 second to forced vital capacity ratio (FEV 1 /FVC) less than 0.7. However the impact of this recommendation on clinical practice is unknown. Research Question What is the effect of a documented post-bronchodilator FEV 1 /FVC < 0.7 on the diagnosis and treatment of COPD? Study Design and Methods We used a national electronic health record database to identify clinical encounters between 2007 to 2022 with patients 18 years of age and older in which a post-bronchodilator FEV 1 /FVC value was documented. An encounter was associated with a COPD diagnosis if a diagnostic code for COPD was assigned, and was associated with COPD treatment if a prescription for a medication commonly used to treat COPD was filled within 90 days. We used a regression discontinuity design to measure the effect of a post-bronchodilator FEV 1 /FVC < 0.7 on COPD diagnosis and treatment. Results Among 27 817 clinical encounters, involving 18 991 patients, a post-bronchodilator FEV 1 /FVC < 0.7 was present in 14 876 (53.4%). The presence of a documented post-bronchodilator FEV 1 /FVC < 0.7 had a small effect on the probability of a COPD diagnosis, increasing by 6.0% (95% confidence interval [CI] 1.1% to 10.9%) from 38.0% just above the 0.7 cutoff to 44.0% just below this cutoff. The presence of a documented post-bronchodilator FEV 1 /FVC had no effect on the probability of COPD treatment ( - 2.1%, 95% CI - 7.2% to 3.0%). Interpretation The presence of a documented post-bronchodilator FEV 1 /FVC < 0.7 has only a small effect on the probability that a clinician will make a guideline-concordant diagnosis of COPD and has no effect on corresponding treatment decisions.
Collapse
|
4
|
Shi Y, Heien HC, Orvidas LJ, Sangaralingham LR, Halbauer M, Warner DO, Phelan S. Racial and Ethnic Disparities in Otolaryngology Office Visit and Tympanostomy Tube Placement in Children with Otitis Media. Laryngoscope 2024; 134:3846-3852. [PMID: 38450789 DOI: 10.1002/lary.31380] [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: 11/13/2023] [Revised: 01/22/2024] [Accepted: 02/22/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVES Racial disparities are pervasive in access to pediatric surgery. The goal of this study was to test the hypotheses that, compared with White children, non-White and Hispanic children: (1) were less likely to attend evaluations by otolaryngologists after a diagnosis of otitis media (OM) eligible for surgical referral, and (2) these children were less likely to receive tympanostomy tube (TT) after surgical consultation. METHODS The OptumLabs Data Warehouse is a de-identified claims database of privately insured enrollees. Guidelines on the management of OMs suggest that children should be evaluated for surgery if they have recurrent acute OM or chronic OM with effusion. A cohort of children who were diagnosed with OM were constructed. For Hypothesis 1, the primary outcome was otolaryngology office visit within 6 months of a diagnosis of recurrent or chronic OM. For Hypothesis 2, the outcome was TT placement within 6 months following the otolaryngology office visit. Cox regression models were used to determine the relationship between race/ethnicity and the primary outcomes. RESULTS Among 187,776 children with OMs, 72,774 (38.8%) had otolaryngology visits. In a multivariate Cox model, the hazard ratios of attending otolaryngology visit for Black, Hispanic, and Asian children were 0.93 (95% CI,0.90, 0.96), 0.86 (0.83, 0.88), and 0.74 (0.71, 0.77), compared with White children. Among the children evaluated by otolaryngologists, 46,554 (63.97%) received TT. Black, Hispanic, and Asian children with recurrent acute OM had lower likelihood of receiving TT. CONCLUSIONS Racial disparities in attending otolaryngology office visit contributed to the disparities in receiving TT. QUALITY OF EVIDENCE Level 3 Laryngoscope, 134:3846-3852, 2024.
Collapse
Affiliation(s)
- Yu Shi
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Herbert C Heien
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Laura J Orvidas
- Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Lindsey R Sangaralingham
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, U.S.A
- OptumLabs, Cambridge, Massachusetts, U.S.A
| | - Moira Halbauer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Sean Phelan
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, U.S.A
| |
Collapse
|
5
|
Thao V, Helfinstine DA, Sangaralingham LR, Yonekawa Y, Starr MR. Hospitalization, Overdose, and Mortality After Opioid Prescriptions Tied to Ophthalmic Surgery. Ophthalmology 2024; 131:943-949. [PMID: 38280654 DOI: 10.1016/j.ophtha.2024.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/18/2024] [Accepted: 01/19/2024] [Indexed: 01/29/2024] Open
Abstract
PURPOSE Opioid prescriptions continue to carry significant short- and long-term systemic risks, even after ophthalmic surgery. The goal of this study was to identify any association of opioid prescription, after ophthalmic surgery, with postoperative hospitalization, opioid overdose, opioid dependence, and all-cause mortality. DESIGN Retrospective, cross-sectional analysis. PARTICIPANTS Patients undergoing an ophthalmic surgery in the OptumLabs Data Warehouse. METHODS We used deidentified administrative claims data from the OptumLabs Data Warehouse to create 3 cohorts of patients for analysis from January 1, 2016, to June 30, 2022. The first cohort consisted of 1-to-1 propensity score-matched patients who had undergone ophthalmic surgery and had filled a prescription for an opioid and not filled a prescription for an opioid. The second cohort consisted of patients who were considered opioid naïve and had filled a prescription for an opioid matched to patients who had not filled a prescription for an opioid. The last cohort consisted of opioid-naïve patients matched across the following morphine milligram equivalents (MME) groups: ≤ 40, 41-80, and > 80. MAIN OUTCOME MEASURES Short- and long-term risks of hospitalization, opioid overdose, opioid dependency/abuse, and death were compared between the cohorts. RESULTS We identified 1 577 692 patients who had undergone an ophthalmic surgery, with 312 580 (20%) filling an opioid prescription. Among all patients, filling an opioid prescription after an ophthalmic surgery was associated with increased mortality (hazard rate [HR], 1.28; 95% confidence interval [CI], 1.25-1.31; P < 0.001), hospitalization (HR, 1.51; 95% CI, 1.49-1.53; P < 0.001), opioid overdose (HR, 7.31; 95% CI, 6.20-8.61, P < 0.001), and opioid dependency (HR, 13.05; 95% CI, 11.48-14.84; P < 0.001) compared with no opioid prescription. Furthermore, we found that higher MME doses of opioids were associated with higher rates of mortality, hospitalization, and abuse/dependence. CONCLUSIONS Patients who filled an opioid prescription after an ophthalmic surgery experienced higher rates of mortality, hospitalization, episodes of opioid overdose, and opioid dependence compared with patients who did not fill an opioid prescription. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.
Collapse
Affiliation(s)
- Viengneesee Thao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - David A Helfinstine
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Yoshihiro Yonekawa
- The Retina Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Matthew R Starr
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
6
|
Yao X, Van Houten HK, Siontis KC, Friedman PA, McBane RD, Gersh BJ, Noseworthy PA. Ten-Year Trend of Oral Anticoagulation Use in Postoperative and Nonpostoperative Atrial Fibrillation in Routine Clinical Practice. J Am Heart Assoc 2024; 13:e035708. [PMID: 38934887 PMCID: PMC11255709 DOI: 10.1161/jaha.124.035708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 05/31/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND The study aimed to describe the patterns and trends of initiation, discontinuation, and adherence of oral anticoagulation (OAC) in patients with new-onset postoperative atrial fibrillation (POAF), and compare with patients newly diagnosed with non-POAF. METHODS AND RESULTS This retrospective cohort study identified patients newly diagnosed with atrial fibrillation or flutter between 2012 and 2021 using administrative claims data from OptumLabs Data Warehouse. The POAF cohort included 118 366 patients newly diagnosed with atrial fibrillation or flutter within 30 days after surgery. The non-POAF cohort included the remaining 315 832 patients who were newly diagnosed with atrial fibrillation or flutter but not within 30 days after a surgery. OAC initiation increased from 28.9% to 44.0% from 2012 to 2021 in POAF, and 37.8% to 59.9% in non-POAF; 12-month medication adherence increased from 47.0% to 61.8% in POAF, and 59.7% to 70.4% in non-POAF. The median time to OAC discontinuation was 177 days for POAF, and 242 days for non-POAF. Patients who saw a cardiologist within 90 days of the first atrial fibrillation or flutter diagnosis, regardless of POAF or non-POAF, were more likely to initiate OAC (odds ratio, 2.92 [95% CI, 2.87-2.98]; P <0.0001), adhere to OAC (odds ratio, 1.08 [95% CI, 1.04-1.13]; P <0.0001), and less likely to discontinue (odds ratio, 0.83 [95% CI, 0.82-0.85]; P <0.0001) than patients who saw a surgeon or other specialties. CONCLUSIONS The use of and adherence to OAC were higher in non-POAF patients than in POAF patients, but they increased over time in both groups. Patients managed by cardiologists were more likely to use and adhere to OAC, regardless of POAF or non-POAF.
Collapse
Affiliation(s)
- Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMN
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
- OptumLabsMinnetonkaMN
| | - Holly K. Van Houten
- Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMN
- OptumLabsMinnetonkaMN
| | | | | | | | | | | |
Collapse
|
7
|
Kim SH, Kim Y. Big Data Research on Severe Asthma. Tuberc Respir Dis (Seoul) 2024; 87:213-220. [PMID: 38443148 PMCID: PMC11222096 DOI: 10.4046/trd.2023.0186] [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: 11/18/2023] [Revised: 01/11/2024] [Accepted: 02/29/2024] [Indexed: 03/07/2024] Open
Abstract
The continuously increasing prevalence of severe asthma has imposed an increasing burden worldwide. Despite the emergence of novel therapeutic agents, management of severe asthma remains challenging. Insights garnered from big data may be helpful in the effort to determine the complex nature of severe asthma. In the field of asthma research, a vast amount of big data from various sources, including electronic health records, national claims data, and international cohorts, is now available. However, understanding of the strengths and limitations is required for proper utilization of specific datasets. Use of big data, along with advancements in artificial intelligence techniques, could potentially facilitate the practice of precision medicine in management of severe asthma.
Collapse
Affiliation(s)
- Sang Hyuk Kim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine, Gyeongju, Republic of Korea
| | - Youlim Kim
- Division of Pulmonary and Allergy, Department of Internal Medicine, Konkuk University Hospital, Konkuk University School of Medicine, Seoul, Republic of Korea
| |
Collapse
|
8
|
Green I, Briggs M, Encalada Soto D, Cole K, Wygant J, Burnett T, Zhu X, Chen I, Sangaralingam LR, Thao V. Health Care Utilization by Patients With Chronic Pelvic Pain. Obstet Gynecol 2024; 144:4-11. [PMID: 38696811 DOI: 10.1097/aog.0000000000005595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/21/2024] [Indexed: 05/04/2024]
Abstract
OBJECTIVE To describe the patterns of health care utilization among patients with chronic pelvic pain. METHODS Deidentified administrative claims data from the OptumLabs Data Warehouse were used. Adult female patients who had their first medical claim for chronic pelvic pain between January 1, 2016, and December 31, 2019, were included. Utilization was examined for 12 months after the index diagnosis. The greedy nearest neighbor matching method was used to identify a control group of individuals without chronic pelvic pain. Comparisons were made between those with and those without chronic pelvic pain using χ 2 tests for categorical data and Wilcoxon rank-sum tests for continuous data. RESULTS In total, 18,400 patients were analyzed in the chronic pelvic pain cohort. Patients with chronic pelvic pain had a higher rate of chronic overlapping pain conditions. Patients with chronic pelvic pain had higher rates of health care utilization across all queried indices. They had more outpatient office visits; 55.5% had 10 or more office visits. Patients with chronic pelvic pain showed higher utilization of the emergency department (ED) (6.3 visits vs 1.9 visits; P <.001). Urine culture and pelvic ultrasonography were the most utilized tests. One-third of patients with chronic pelvic pain utilized physical therapy (PT), and 13% utilized psychological or behavioral therapy. Patients with chronic pelvic pain had higher rates of hysterectomy (8.9% vs 0.6%). The average total health care costs per patient with chronic pelvic pain per year was $12,254. CONCLUSION Patients with chronic pelvic pain have higher rates of chronic overlapping pain conditions and undergo more ED visits, imaging tests, and hysterectomies than patients without chronic pelvic pain. Improving access to multidisciplinary care, increasing utilization of interventions such as PT and psychological or behavioral therapy, and reducing ED utilization may be possible targets to help reduce overall health care costs and improve patient care.
Collapse
Affiliation(s)
- Isabel Green
- Department of Obstetrics and Gynecology, Mayo Clinic, and Health Care Policy and Research and the Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine and Science, Rochester, Minnesota; the Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin; Minimally Invasive Gynecologic Surgery, University of South Florida, Tampa, Florida; and the University of Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Zhou B, Kwan B, Desai MJ, Nalawade V, Henk J, Viravalli N, Murphy JD, Nathan PC, Ruddy KJ, Shliakhtsitsava K, Su HI, Whitcomb BW. Association of platinum-based chemotherapy with live birth and infertility in female survivors of adolescent and young adult cancer. Fertil Steril 2024; 121:1020-1030. [PMID: 38316209 PMCID: PMC11128346 DOI: 10.1016/j.fertnstert.2024.01.039] [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: 09/21/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVE To estimate the effect of platinum-based chemotherapy on live birth (LB) and infertility after cancer, in order to address a lack of treatment-specific fertility risks for female survivors of adolescent and young adult cancer, which limits counseling on fertility preservation decisions. DESIGN Retrospective cohort study. SETTING US administrative database. PATIENTS We identified incident breast, colorectal, and ovarian cancer cases in females aged 15-39 years who received platinum-based chemotherapy or no chemotherapy and matched them to females without cancer. INTERVENTION Platinum-based chemotherapy. MAIN OUTCOME MEASURES We estimated the effect of chemotherapy on the incidence of LB and infertility after cancer, overall, and after accounting for competing events (recurrence, death, and sterilizing surgeries). RESULTS There were 1,287 survivors in the chemotherapy group, 3,192 in the no chemotherapy group, and 34,147 women in the no cancer group, with a mean age of 33 years. Accounting for competing events, the overall 5-year LB incidence was lower in the chemotherapy group (3.9%) vs. the no chemotherapy group (6.4%). Adjusted relative risks vs. no chemotherapy and no cancer groups were 0.61 (95% confidence interval [CI] 0.42-0.82) and 0.70 (95% CI 0.51-0.93), respectively. The overall 5-year infertility incidence was similar in the chemotherapy group (21.8%) compared with the no chemotherapy group (20.7%). The adjusted relative risks vs. no chemotherapy and no cancer groups were 1.05 (95% CI 0.97-1.15) and 1.42 (95% CI 1.31-1.53), respectively. CONCLUSIONS Cancer survivors treated with platinum-based chemotherapy experienced modestly increased adverse fertility outcomes. The estimated effects of platinum-based chemotherapy were affected by competing events, suggesting the importance of this analytic approach for interpretations that ultimately inform clinical fertility preservation decisions.
Collapse
Affiliation(s)
- Beth Zhou
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, San Diego, California
| | - Brian Kwan
- Division of Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health, University of California San Diego, San Diego, California; Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, California
| | - Milli J Desai
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, San Diego, California
| | - Vinit Nalawade
- Moores Cancer Center, University of California San Diego, San Diego, California; Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California
| | - Joe Henk
- OptumLabs, Eden Prarie, Minnesota
| | | | - James D Murphy
- Moores Cancer Center, University of California San Diego, San Diego, California; Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California
| | - Paul C Nathan
- Department of Paediatrics, Division of Haematology/Oncology, the Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Ksenya Shliakhtsitsava
- Division of Hematology-Oncology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - H Irene Su
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, San Diego, California; Moores Cancer Center, University of California San Diego, San Diego, California
| | - Brian W Whitcomb
- Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts, Amherst, Massachusetts.
| |
Collapse
|
10
|
Savitz ST, Stevens MA, Nath B, D’Onofrio G, Melnick ER, Jeffery MM. Trends in the Prescribing of Buprenorphine for Opioid Use Disorder, 2019-2023. Mayo Clin Proc Innov Qual Outcomes 2024; 8:308-320. [PMID: 38841599 PMCID: PMC11152959 DOI: 10.1016/j.mayocpiqo.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
Objective To evaluate whether access to buprenorphine to treat opioid use disorder (OUD) was associated with the coronavirus disease pandemic, the relaxation of training requirements to obtain an X-Waiver to prescribe buprenorphine (April 2021), and the removal of the X-Waiver (December 2022). Patients and Methods The OptumLabs Data Warehouse, which includes claims from Commercial and Medicare Advantage enrollees, was used to evaluate trends in prescription fills from January 1, 2019, to June 30, 2023. We compared fill patterns of buprenorphine for OUD with acamprosate to treat alcohol use disorder and naltrexone to treat alcohol use disorder or OUD. We evaluated trends in the rate ratio (RR) of overall fills; RR by days supply; distribution of fills by daily dose; and distribution of fills by prescriber type. Results Coronavirus disease (RR, 1.06; 95% CI, 1.01-1.11) was associated with a slightly increased rate of fills for Commercial enrollees but not overall or for Medicare Advantage enrollees. There were also no significant increases (P>0.05) associated with the change in training requirements or removal of the X-Waiver. Over the study period, there was an increasing share of fills for 16+ mg for Commercial enrollees, and buprenorphine prescribers were more likely to be advanced practice nurses or physician assistants. Conclusion We did not find meaningful improvement in access in response to coronavirus disease or the changes in the X-Waiver. These findings suggest that interventions beyond removing the X-Waiver may be needed to improve buprenorphine access.
Collapse
Affiliation(s)
- Samuel T. Savitz
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
| | - Maria A. Stevens
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
| | - Bidisha Nath
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Gail D’Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Edward R. Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
- Department of Biostatistics, Yale School of Public Health, New Haven, CT
| | - Molly M. Jeffery
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
11
|
Cross MR, Savitz ST, Sangaralingham LR, So EL, Ackerman MJ, Noseworthy PA. Sudden Cardiac Death or Ventricular Arrythmia in Patients Taking Levetiracetam or Oxcarbazepine. Neurology 2024; 102:e209177. [PMID: 38560823 DOI: 10.1212/wnl.0000000000209177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 01/05/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Levetiracetam is a widely used antiseizure medication. Recent concerns have been raised regarding the potential prolongation of the QT interval by levetiracetam and increased risk of sudden cardiac death. This could have profound implications for patient safety and for prescribing practice. This study assessed the potential association of levetiracetam with cardiac outcomes related to QT interval prolongation. We compared outcomes of patients taking levetiracetam with those taking oxcarbazepine as a comparator medication that has not been associated with prolongation of the QT interval. METHODS The sample included patients who were newly prescribed levetiracetam or oxcarbazepine from January 31, 2010, to December 31, 2019, using administrative claims data from the OptumLabs Data Warehouse (OLDW). The analysis focused on a combined endpoint of sudden cardiac death or ventricular arrythmia, which are both linked to QT interval prolongation. We used a new user design and selected oxcarbazepine as an active comparator with levetiracetam to minimize bias. We used propensity score weighting to balance the levetiracetam and oxcarbazepine cohorts and then performed weighted Cox regressions to evaluate the association of levetiracetam with the combined endpoint. RESULTS We identified 104,655 enrollees taking levetiracetam and 39,596 enrollees taking oxcarbazepine. At baseline, enrollees taking levetiracetam were older, more likely to have diagnosed epilepsy, and more likely to have diagnosed comorbidities including hypertension, cerebrovascular disease, and coronary artery disease. In the main analysis, we found no significant difference between levetiracetam and oxcarbazepine in the rate of the combined endpoint for the Cox proportional hazards model (hazard ratio [HR] 0.79, 95% CI 0.42-1.47) or Cox regression with time-varying characteristics (HR 0.78, 95% CI 0.41-1.50). DISCUSSION When compared with oxcarbazepine, levetiracetam does not correlate with increased risk of ventricular arrythmia and sudden cardiac death. Our finding does not support the concern for cardiac risk to indicate restriction of levetiracetam use nor the requirement of cardiac monitoring when using it. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that sudden cardiac death and ventricular arrythmia are not more frequent in patients older than 17 years newly prescribed levetiracetam, compared with those prescribed oxcarbazepine.
Collapse
Affiliation(s)
- Madeline R Cross
- From the Department of Neurology (M.R.C.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (S.T.S.), Division of Health Care Delivery Research (L.R.S., P.A.N.), Division of Epilepsy, Department of Neurology (E.L.S.), and Department of Cardiovascular Diseases (M.J.A., P.A.N.), Mayo Clinic, Rochester, MN
| | - Samuel T Savitz
- From the Department of Neurology (M.R.C.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (S.T.S.), Division of Health Care Delivery Research (L.R.S., P.A.N.), Division of Epilepsy, Department of Neurology (E.L.S.), and Department of Cardiovascular Diseases (M.J.A., P.A.N.), Mayo Clinic, Rochester, MN
| | - Lindsey R Sangaralingham
- From the Department of Neurology (M.R.C.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (S.T.S.), Division of Health Care Delivery Research (L.R.S., P.A.N.), Division of Epilepsy, Department of Neurology (E.L.S.), and Department of Cardiovascular Diseases (M.J.A., P.A.N.), Mayo Clinic, Rochester, MN
| | - Elson L So
- From the Department of Neurology (M.R.C.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (S.T.S.), Division of Health Care Delivery Research (L.R.S., P.A.N.), Division of Epilepsy, Department of Neurology (E.L.S.), and Department of Cardiovascular Diseases (M.J.A., P.A.N.), Mayo Clinic, Rochester, MN
| | - Michael J Ackerman
- From the Department of Neurology (M.R.C.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (S.T.S.), Division of Health Care Delivery Research (L.R.S., P.A.N.), Division of Epilepsy, Department of Neurology (E.L.S.), and Department of Cardiovascular Diseases (M.J.A., P.A.N.), Mayo Clinic, Rochester, MN
| | - Peter A Noseworthy
- From the Department of Neurology (M.R.C.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (S.T.S.), Division of Health Care Delivery Research (L.R.S., P.A.N.), Division of Epilepsy, Department of Neurology (E.L.S.), and Department of Cardiovascular Diseases (M.J.A., P.A.N.), Mayo Clinic, Rochester, MN
| |
Collapse
|
12
|
Barkmeier AJ, Herrin J, Swarna KS, Deng Y, Polley EC, Umpierrez GE, Galindo RJ, Ross JS, Mickelson MM, McCoy RG. Comparative Effectiveness of Glucagon-Like Peptide-1 Receptor Agonists, Sodium-Glucose Cotransporter 2 Inhibitors, Dipeptidyl Peptidase-4 Inhibitors, and Sulfonylureas for Sight-Threatening Diabetic Retinopathy. Ophthalmol Retina 2024:S2468-6530(24)00229-X. [PMID: 38735641 DOI: 10.1016/j.oret.2024.05.003] [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: 03/28/2024] [Revised: 04/24/2024] [Accepted: 05/06/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVE To investigate whether the choice of glucose-lowering agent for type 2 diabetes (T2D) impacts a patient's risk of developing sight-threatening diabetic retinopathy complications. DESIGN Retrospective observational database study emulating an idealized target trial. SUBJECTS Adult (≥21 years) enrollees in United States commercial, Medicare Advantage, and Medicare fee-for-service plans from January 1, 2014, to December 31, 2021, with T2D and moderate cardiovascular disease (CVD) risk who had no baseline history of advanced diabetic retinal complications, initiating treatment with glucagon-like peptide-1 receptor agonists (GLP-1 RA), sodium-glucose cotransporter 2 inhibitors (SGLT2i), dipeptidyl peptidase-4 inhibitors (DPP-4i), and sulfonylureas. METHODS We used inverse propensity scoring weights in time-to-event Cox proportional hazards models. MAIN OUTCOME MEASURES Treatment for either diabetic macular edema or proliferative diabetic retinopathy. RESULTS The final study population included 371 698 patients, of whom 42 265 initiated GLP-1 RA, 53 476 initiated SGLT2i, 78 444 initiated DPP-4i, and 197 513 initiated sulfonylurea agents. The probability of treatment for sight-threatening retinopathy within 2 and 5 years was 0.3% and 0.7% for patients initiating SGLT2i (median follow-up 830 [interquartile range (IQR), 343-1401] days), 0.4% and 1.0% for GLP-1 RA (669 [IQR, 256-1167] days), 0.4% and 0.9% for DPP-4i (1263 [IQR, 688-1938] days), and 0.5% and 1.2% for sulfonylurea (1223 [IQR, 662-1879] days). Sodium-glucose cotransporter 2 inhibitors use was associated with a lower risk of treatment for sight-threatening retinopathy compared with all other medication classes, including GLP-1 RA (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.55-0.97), DPP-4i (HR, 0.79; 95% CI, 0.64-0.97), and sulfonylurea (HR, 0.61; 95% CI, 0.50-0.74). Glucagon-like peptide-1 receptor agonists use was associated with a similar risk of sight-threatening retinopathy as DPP-4i (HR, 1.07; 95% CI, 0.85-1.35) and sulfonylurea (HR, 0.83; 95% CI, 0.67-1.03). CONCLUSIONS Sodium-glucose cotransporter 2 inhibitors use was associated with a lower risk of sight-threatening diabetic retinopathy among adults with T2D and moderate CVD risk compared with other glucose-lowering therapies. Glucagon-like peptide-1 receptor agonists do not confer increased retinal risk, relative to DPP-4i and sulfonylurea medications. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
Collapse
Affiliation(s)
| | - Jeph Herrin
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Kavya Sindhu Swarna
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota; OptumLabs, Eden Prairie, Minnesota
| | - Yihong Deng
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota; OptumLabs, Eden Prairie, Minnesota
| | - Eric C Polley
- Department of Public Health Sciences, the University of Chicago, Chicago, Illinois
| | - Guillermo E Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rodolfo J Galindo
- Division of Endocrinology, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Joseph S Ross
- 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
| | - Mindy M Mickelson
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - Rozalina G McCoy
- OptumLabs, Eden Prairie, Minnesota; Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland; University of Maryland Institute for Health Computing, Bethesda, Maryland
| |
Collapse
|
13
|
Yew PY, Loth M, Adam TJ, Wolfson J, Liang Y, Tonellato PJ, Chi CL. Potential impact of blood cholesterol guidelines on statin treatment in the U.S. population using interrupted time series analysis. BMC Cardiovasc Disord 2024; 24:245. [PMID: 38730371 PMCID: PMC11088177 DOI: 10.1186/s12872-024-03921-z] [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: 09/29/2023] [Accepted: 05/03/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND The 2013 ACC/AHA Guideline was a paradigm shift in lipid management and identified the four statin-benefit groups. Many have studied the guideline's potential impact, but few have investigated its potential long-term impact on MACE. Furthermore, most studies also ignored the confounding effect from the earlier release of generic atorvastatin in Dec 2011. METHODS To evaluate the potential (long-term) impact of the 2013 ACC/AHA Guideline release in Nov 2013 in the U.S., we investigated the association of the 2013 ACC/AHA Guideline with the trend changes in 5-Year MACE survival and three other statin-related outcomes (statin use, optimal statin use, and statin adherence) while controlling for generic atorvastatin availability using interrupted time series analysis, called the Chow's test. Specifically, we conducted a retrospective study using U.S. nationwide de-identified claims and electronic health records from Optum Labs Database Warehouse (OLDW) to follow the trends of 5-Year MACE survival and statin-related outcomes among four statin-benefit groups that were identified in the 2013 ACC/AHA Guideline. Then, Chow's test was used to discern trend changes between generic atorvastatin availability and guideline potential impact. RESULTS 197,021 patients were included (ASCVD: 19,060; High-LDL: 33,907; Diabetes: 138,159; High-ASCVD-Risk: 5,895). After the guideline release, the long-term trend (slope) of 5-Year MACE Survival for the Diabetes group improved significantly (P = 0.002). Optimal statin use for the ASCVD group also showed immediate improvement (intercept) and long-term positive changes (slope) after the release (P < 0.001). Statin uses did not have significant trend changes and statin adherence remained unchanged in all statin-benefit groups. Although no other statistically significant trend changes were found, overall positive trend change or no changes were observed after the 2013 ACC/AHA Guideline release. CONCLUSIONS The 2013 ACA/AHA Guideline release is associated with trend improvements in the long-term MACE Survival for Diabetes group and optimal statin use for ASCVD group. These significant associations might indicate a potential positive long-term impact of the 2013 ACA/AHA Guideline on better health outcomes for primary prevention groups and an immediate potential impact on statin prescribing behaviors in higher-at-risk groups. However, further investigation is required to confirm the causal effect of the 2013 ACA/AHA Guideline.
Collapse
Affiliation(s)
- Pui Ying Yew
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA
| | - Matt Loth
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA
- School of Nursing, University of Minnesota, Minneapolis, MN, USA
| | - Terrence J Adam
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA
- Department of Pharmaceutical Care & Health Systems, University of Minnesota, Minneapolis, MN, USA
| | - Julian Wolfson
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Yue Liang
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA
| | - Peter J Tonellato
- Department of Health Management and Informatics, University of Missouri School of Medicine, Columbia, MO, USA
| | - Chih-Lin Chi
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA.
- School of Nursing, University of Minnesota, Minneapolis, MN, USA.
- University of Minnesota Institute for Health Informatics, 8-102 Phillips-Wangensteen Building 516 Delaware St. SE, Minneapolis, MN, 55455, USA.
| |
Collapse
|
14
|
Dhruva SS, Murillo J, Ameli O, Chaisson CE, Redberg RF, Cohen K. Effectiveness, utilisation and cost associated with implantable loop recorders versus external monitors after ischaemic or cryptogenic stroke. Open Heart 2024; 11:e002714. [PMID: 38719499 PMCID: PMC11086550 DOI: 10.1136/openhrt-2024-002714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 04/23/2024] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVE Implantable loop recorders (ILRs) are increasingly used for long-term rhythm monitoring after ischaemic and cryptogenic stroke, with the goal of detecting atrial fibrillation (AF) and subsequent initiation of oral anticoagulation to reduce risk of adverse clinical outcomes. There is a need to determine the effectiveness of different rhythm monitoring strategies in this context. METHODS We conducted a retrospective cohort analysis of individuals with commercial and Medicare Advantage insurance in Optum Labs Data Warehouse who had incident ischaemic or cryptogenic stroke and no prior cardiovascular implantable electronic device from 1 January 2016 to 30 June 2021. Patients were stratified by rhythm monitoring strategy: ILR, long-term continuous external cardiac monitor (>48 hours to 30 days) or Holter monitor (≤48 hours). The primary outcome was risk-adjusted all-cause mortality at 12 months. Secondary outcomes included new diagnosis of AF and oral anticoagulation, bleeding, and costs. RESULTS Among 48 901 patients with ischaemic or cryptogenic stroke, 9235 received an ILR, 29 103 long-term continuous external monitor and 10 563 Holter monitor only. Mean age was 69.9 (SD 11.9) years and 53.5% were female. During the 12-month follow-up period, patients who received ILRs compared with those who received long-term continuous external monitors had a higher odds of new diagnosis of AF and oral anticoagulant initiation (adjusted OR 2.27, 95% CI 2.09 to 2.48). Compared with patients who received long-term continuous external monitors, those who received ILRs had similar 12-month mortality (HR 1.00; 95% CI 0.89 to 1.12), with approximately $13 000 higher costs at baseline (including monitor cost) and $2500 higher costs during 12-month follow-up. CONCLUSIONS In this large real-world study of patients with ischaemic or cryptogenic stroke, ILR placement resulted in more diagnosis of AF and initiation of oral anticoagulation, but no difference in mortality compared with long-term continuous external monitors.
Collapse
Affiliation(s)
- Sanket S Dhruva
- University of California San Francisco School of Medicine, San Francisco, California, USA
- Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Philip R Lee Institute for Health Policy Studies, San Francisco, California, USA
| | - Jaime Murillo
- Medical Affairs UnitedHealth Group, Minnetonka, Minnesota, USA
| | - Omid Ameli
- Optum Center for Research and Innovation, Minnetonka, Minnesota, USA
| | | | - Rita F Redberg
- University of California San Francisco School of Medicine, San Francisco, California, USA
- Philip R Lee Institute for Health Policy Studies, San Francisco, California, USA
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Ken Cohen
- Optum Center for Research and Innovation, Minnetonka, Minnesota, USA
| |
Collapse
|
15
|
Stevens MA, Dykhoff HJ, Kronzer VL, Myasoedova E, Davis JM, Duarte-García A, Crowson CS. Disparities in multimorbidity and comorbidities in rheumatoid arthritis by sex across the lifespan. Rheumatology (Oxford) 2024; 63:1639-1648. [PMID: 37651451 PMCID: PMC11147539 DOI: 10.1093/rheumatology/kead454] [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: 05/18/2023] [Revised: 08/04/2023] [Accepted: 08/09/2023] [Indexed: 09/02/2023] Open
Abstract
OBJECTIVES Multimorbidity is burdensome for people with RA. We investigated differences in multimorbidity and comorbidities by sex and age in the RA population. METHODS This cross-sectional analysis used national administrative claims (OptumLabs® Data Warehouse) from people with RA and non-RA comparators (matched on age, sex, race, census region, index year and length of baseline insurance coverage) from 2010-2019. RA was determined using a validated algorithm. Multimorbidity was defined as ≥2 (MM2+) or ≥5 (MM5+) comorbidities from a validated set of 44 chronic conditions. We used logistic regression to assess associations between characteristics and multimorbidity. RESULTS The sample included 154 391 RA patients and 154 391 non-RA comparators. For people aged 18-50 years, RA women (vs RA men) had 7.5 and 4.4 (vs 3.2 and 0.9 in non-RA women vs non-RA men) percentage point increases for MM2+ and MM5+, respectively. For people aged 51+ years, RA women (vs RA men) had 2.1 and 2.5 (vs 1.2 and 0.3 in non-RA women vs non-RA men) percentage point increases for MM2+ and MM5+, respectively. Interactions revealed that differences in multimorbidity between women and men were exacerbated by RA (vs non-RA) (P < 0.05), with more pronounced effects in people aged 18-50. Men had more cardiovascular-related conditions, whereas RA women had more psychological, neurological and general musculoskeletal conditions. Other comorbidities varied by sex and age. CONCLUSION Multimorbidity disproportionately impacts women with RA. Research, clinical and policy agendas for rheumatic diseases should acknowledge and support the variation in care needs by sex and gender across the lifespan.
Collapse
Affiliation(s)
- Maria A Stevens
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
- OptumLabs, Eden Prairie, MN, USA
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hayley J Dykhoff
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Vanessa L Kronzer
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Elena Myasoedova
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - John M Davis
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alí Duarte-García
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Cynthia S Crowson
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
16
|
Steiger K, Herrin J, Swarna KS, Davis EM, McCoy RG. Disparities in Acute and Chronic Complications of Diabetes Along the U.S. Rural-Urban Continuum. Diabetes Care 2024; 47:818-825. [PMID: 38387066 PMCID: PMC11043221 DOI: 10.2337/dc23-1552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 01/24/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVE To determine the relative hazards of acute and chronic diabetes complications among people with diabetes across the U.S. rural-urban continuum. RESEARCH DESIGN AND METHODS This retrospective cohort study used the OptumLabs Data Warehouse, a deidentified data set of U.S. commercial and Medicare Advantage beneficiaries, to follow 2,901,563 adults (age ≥18 years) with diabetes between 1 January 2012 and 31 December 2021. We compared adjusted hazard ratios (HRs) of diabetes complications in remote areas (population <2,500), small towns (population 2,500-50,000), and cities (population >50,000). RESULTS Compared with residents of cities, residents of remote areas had greater hazards of myocardial infarction (HR 1.06 [95% CI 1.02-1.10]) and revascularization (HR 1.04 [1.02-1.06]) but lower hazards of hyperglycemia (HR 0.90 [0.83-0.98]) and stroke (HR 0.91 [0.88-0.95]). Compared with cities, residents of small towns had greater hazards of hyperglycemia (HR 1.06 [1.02-1.10]), hypoglycemia (HR 1.15 [1.12-1.18]), end-stage kidney disease (HR 1.04 [1.03-1.06]), myocardial infarction (HR 1.10 [1.08-1.12]), heart failure (HR 1.05 [1.03-1.06]), amputation (HR 1.05 [1.02-1.09]), other lower-extremity complications (HR 1.02 [1.01-1.03]), and revascularization (HR 1.05 [1.04-1.06]) but a smaller hazard of stroke (HR 0.95 [0.94-0.97]). Compared with small towns, residents of remote areas had lower hazards of hyperglycemia (HR 0.85 [0.78-0.93]), hypoglycemia (HR 0.92 [0.87-0.97]), and heart failure (HR 0.94 [0.91-0.97]). Hazards of retinopathy and atrial fibrillation/flutter did not vary geographically. CONCLUSIONS Adults in small towns are disproportionately impacted by complications of diabetes. Future studies should probe for the reasons underlying these disparities.
Collapse
Affiliation(s)
- Kyle Steiger
- Internal Medicine Residency, Mayo Clinic, Rochester, MN
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Kavya Sindhu Swarna
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- OptumLabs, Eden Prairie, MN
| | - Esa M. Davis
- Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore, MD
- Institute for Health Computing, University of Maryland, Bethesda, MD
| | - Rozalina G. McCoy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- OptumLabs, Eden Prairie, MN
- Institute for Health Computing, University of Maryland, Bethesda, MD
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| |
Collapse
|
17
|
Saber W, Bansal A, Li L, Scott BL, Sangaralingham LR, Thao V, Roth JA, Wright W, Steuten LMG, Pidala JA, Mishra A, Maziarz RT, Westervelt P, McGuirk JP, Cutler C, Nakamura R, Ramsey SD. Cost-Effectiveness of Reduced-Intensity Allogeneic Hematopoietic Cell Transplantation for Older Patients With High-Risk Myelodysplastic Syndrome: Analysis of BMT CTN 1102. JCO Oncol Pract 2024; 20:572-580. [PMID: 38261970 DOI: 10.1200/op.23.00413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/07/2023] [Accepted: 10/25/2023] [Indexed: 01/25/2024] Open
Abstract
PURPOSE BMT CTN 1102 was a phase III trial comparing reduced-intensity allogeneic hematopoietic cell transplantation (RIC alloHCT) to standard of care for persons with intermediate- or high-risk myelodysplastic syndrome (MDS). We report results of a cost-effectiveness analysis conducted alongside the clinical trial. METHODS Three hundred eighty-four patients received HCT (n = 260) or standard of care (n = 124) according to availability of a human leukocyte antigen-matched donor. Cost-effectiveness was calculated from US commercial and Medicare perspectives over a 20-year time horizon. Health care utilization and costs were estimated using propensity score-matched cohorts of HCT recipients in the OptumLabs Data Warehouse (age 50-64 years) and Medicare (age 65 years and older). EuroQol 5 Dimension (EQ-5D) surveys of trial participants were used to derive health state utilities. RESULTS Extrapolated 20-year overall survival for those age 50-64 years was 29% for HCT (n = 105) versus 13% for usual care (n = 44) and 31% for HCT (n = 155) versus 12% for non-HCT (n = 80) for those age 65 years and older. HCT was more effective (+2.36 quality-adjusted life-years [QALYs] for age 50-64 years and +2.92 QALYs for age 65 years and older) and more costly (+$452,242 in US dollars (USD) for age 50-64 years and +$233,214 USD for age 65 years and older) than usual care, with incremental cost-effectiveness ratios of $191,487 (USD)/QALY and $79,834 (USD)/QALY, respectively. For persons age 50-64 years, there was a 29% chance that HCT was cost-effective using a willingness-to-pay (WTP) threshold of $150K (USD)/QALY and 51% at a $200K (USD)/QALY. For persons age 65 years and older, the probability was 100% at a WTP >$150K (USD)/QALY. CONCLUSION Among patients age 65 years and older with high-risk MDS, RIC HCT is a high-value strategy. For those age 50-64 years, HCT is a lower-value strategy but has similar cost-effectiveness to other therapies commonly used in oncology.
Collapse
Affiliation(s)
- Wael Saber
- Medical College of Wisconsin, Milwaukee, WI
| | - Aasthaa Bansal
- Fred Hutchinson Cancer Center, Seattle, WA
- University of Washington, Seattle, WA
| | - Lily Li
- Fred Hutchinson Cancer Center, Seattle, WA
| | | | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Department of Health Sciences Research, Division of Health Care Policy and Research (X.Y., N.D.S.), Mayo Clinic, Rochester, MN
| | - Viengneesee Thao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Department of Health Sciences Research, Division of Health Care Policy and Research (X.Y., N.D.S.), Mayo Clinic, Rochester, MN
| | - Joshua A Roth
- University of Washington, Seattle, WA
- Pfizer Inc, New York, NY
| | | | | | | | | | - Richard T Maziarz
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR
| | | | | | | | | | - Scott D Ramsey
- Fred Hutchinson Cancer Center, Seattle, WA
- University of Washington, Seattle, WA
| |
Collapse
|
18
|
McCoy RG, Herrin J, Swarna KS, Deng Y, Kent DM, Ross JS, Umpierrez GE, Galindo RJ, Crown WH, Borah BJ, Montori VM, Brito JP, Neumiller JJ, Mickelson MM, Polley EC. Effectiveness of glucose-lowering medications on cardiovascular outcomes in patients with type 2 diabetes at moderate cardiovascular risk. NATURE CARDIOVASCULAR RESEARCH 2024; 3:431-440. [PMID: 38846711 PMCID: PMC11156225 DOI: 10.1038/s44161-024-00453-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 02/22/2024] [Indexed: 06/09/2024]
Abstract
Cardiovascular disease (CVD) is the leading cause of death among people with type 2 diabetes1-5, most of whom are at moderate CVD risk6, yet there is limited evidence on the preferred choice of glucose-lowering medication for CVD risk reduction in this population. Here, we report the results of a retrospective cohort study where data for US adults with type 2 diabetes and moderate risk for CVD are used to compare the risks of experiencing a major adverse cardiovascular event with initiation of glucagon-like peptide-1 receptor agonists (GLP-1RA; n = 44,188), sodium-glucose cotransporter 2 inhibitors (SGLT2i; n = 47,094), dipeptidyl peptidase-4 inhibitors (DPP4i; n = 84,315) and sulfonylureas (n = 210,679). Compared to DPP4i, GLP-1RA (hazard ratio (HR) 0.87; 95% confidence interval (CI) 0.82-0.93) and SGLT2i (HR 0.85; 95% CI 0.81-0.90) were associated with a lower risk of a major adverse cardiovascular event, whereas sulfonylureas were associated with a higher risk (HR 1.19; 95% CI 1.16-1.22). Thus, GLP-1RA and SGLT2i may be the preferred glucose-lowering agents for cardiovascular risk reduction in patients at moderate baseline risk for CVD. ClinicalTrials.gov registration: NCT05214573.
Collapse
Affiliation(s)
- Rozalina G McCoy
- Division of Endocrinology, Diabetes, & Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland Institute for Health Computing, Bethesda, MD, USA
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
- OptumLabs, Eden Prairie, MN, USA
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Kavya Sindhu Swarna
- OptumLabs, Eden Prairie, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Yihong Deng
- OptumLabs, Eden Prairie, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Joseph S Ross
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Guillermo E Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Rodolfo J Galindo
- Division of Endocrinology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - William H Crown
- Florence Heller Graduate School, Brandeis University, Waltham, MA, USA
| | - Bijan J Borah
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Victor M Montori
- Division of Endocrinology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Juan P Brito
- Division of Endocrinology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Joshua J Neumiller
- Department of Pharmacotherapy, Washington State University, Spokane, WA, USA
- Providence Medical Research Center, Spokane, WA, USA
| | - Mindy M Mickelson
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Eric C Polley
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA
| |
Collapse
|
19
|
McCoy RG, Swarna KS, Deng Y, Herrin JS, Ross JS, Kent DM, Borah BJ, Crown WH, Montori VM, Umpierrez GE, Galindo RJ, Brito JP, Mickelson MM, Polley EC. Derivation of an Annualized Claims-Based Major Adverse Cardiovascular Event Estimator in Type 2 Diabetes. JACC. ADVANCES 2024; 3:100852. [PMID: 38939660 PMCID: PMC11198625 DOI: 10.1016/j.jacadv.2024.100852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 11/07/2023] [Accepted: 11/07/2023] [Indexed: 06/29/2024]
Abstract
Background Major adverse cardiovascular events (MACE) are a leading cause of morbidity and mortality among adults with type 2 diabetes. Currently, available MACE prediction models have important limitations, including reliance on data that may not be routinely available, narrow focus on primary prevention, limited patient populations, and longtime horizons for risk prediction. Objectives The purpose of this study was to derive and internally validate a claims-based prediction model for 1-year risk of MACE in type 2 diabetes. Methods Using medical and pharmacy claims for adults with type 2 diabetes enrolled in commercial, Medicare Advantage, and Medicare fee-for-service plans between 2014 and 2021, we derived and internally validated the annualized claims-based MACE estimator (ACME) model to predict the risk of MACE (nonfatal acute myocardial infarction, nonfatal stroke, and all-cause mortality). The Cox proportional hazards model was composed of 30 covariates, including patient age, sex, comorbidities, and medications. Results The study cohort comprised 6,623,526 adults with type 2 diabetes, mean age 68.1 ± 10.6 years, 49.8% women, and 73.0% Non-Hispanic White. ACME had a concordance index of 0.74 (validation index range: 0.739-0.741). The predicted 1-year risk of the study cohort ranged from 0.4% to 99.9%, with a median risk of 3.4% (IQR: 2.3%-6.5%). Conclusions ACME was derived in a large usual care population, relies on routinely available data, and estimates short-term MACE risk. It can support population risk stratification at the health system and payer levels, participant identification for decentralized clinical trials of cardiovascular disease, and risk-stratified observational studies using real-world data.
Collapse
Affiliation(s)
- Rozalina G. McCoy
- Division of Endocrinology, Diabetes, & Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- University of Maryland Institute for Health Computing, Bethesda, Maryland, USA
- Division of Gerontology, Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
- OptumLabs, Eden Prairie, Minnesota, USA
| | - Kavya Sindhu Swarna
- OptumLabs, Eden Prairie, Minnesota, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
| | - Yihong Deng
- OptumLabs, Eden Prairie, Minnesota, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
| | - Jeph S. Herrin
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Joseph S. Ross
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
| | - David M. Kent
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
| | - Bijan J. Borah
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
| | - William H. Crown
- Florence Heller Graduate School, Brandeis University, Waltham, Massachusetts, USA
| | - Victor M. Montori
- Division of Endocrinology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Guillermo E. Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rodolfo J. Galindo
- Division of Endocrinology, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Juan P. Brito
- Division of Endocrinology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Mindy M. Mickelson
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
| | - Eric C. Polley
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, USA
| |
Collapse
|
20
|
Cliff BQ, Eddelbuettel JCP, Meiselbach MK, Eisenberg MD. Deductible imputation in administrative medical claims datasets. Health Serv Res 2024; 59:e14278. [PMID: 38233373 PMCID: PMC11248712 DOI: 10.1111/1475-6773.14278] [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] [Indexed: 01/19/2024] Open
Abstract
OBJECTIVE To validate imputation methods used to infer plan-level deductibles and determine which enrollees are in high-deductible health plans (HDHPs) in administrative claims datasets. DATA SOURCES AND STUDY SETTING 2017 medical and pharmaceutical claims from OptumLabs Data Warehouse for US individuals <65 continuously enrolled in an employer-sponsored plan. Data include enrollee and plan characteristics, deductible spending, plan spending, and actual plan-level deductibles. STUDY DESIGN We impute plan deductibles using four methods: (1) parametric prediction using individual-level spending; (2) parametric prediction with imputation and plan characteristics; (3) highest plan-specific mode of individual annual deductible spending; and (4) deductible spending at the 80th percentile among individuals meeting their deductible. We compare deductibles' levels and categories for imputed versus actual deductibles. DATA COLLECTION/EXTRACTION METHODS Not applicable. PRINCIPAL FINDINGS All methods had a positive predictive value (PPV) for determining high- versus low-deductible plans of ≥87%; negative predictive values (NPV) were lower. The method imputing plan-specific deductible spending modes was most accurate and least computationally intensive (PPV: 95%; NPV: 91%). This method also best correlated with actual deductible levels; 69% of imputed deductibles were within $250 of the true deductible. CONCLUSIONS In the absence of plan structure data, imputing plan-specific modes of individual annual deductible spending best correlates with true deductibles and best predicts enrollees in HDHPs.
Collapse
Affiliation(s)
- Betsy Q. Cliff
- Department of Public Health SciencesUniversity of ChicagoChicagoIllinoisUSA
| | | | - Mark K. Meiselbach
- Health Policy and ManagementJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Matthew D. Eisenberg
- Health Policy and ManagementJohns Hopkins UniversityBaltimoreMarylandUSA
- Johns Hopkins UniversityBaltimoreMarylandUSA
| |
Collapse
|
21
|
Beaulieu-Jones BK, Frau F, Bozzi S, Chandross KJ, Peterschmitt MJ, Cohen C, Coulovrat C, Kumar D, Kruger MJ, Lipnick SL, Fitzsimmons L, Kohane IS, Scherzer CR. Disease progression strikingly differs in research and real-world Parkinson's populations. NPJ Parkinsons Dis 2024; 10:58. [PMID: 38480700 PMCID: PMC10937726 DOI: 10.1038/s41531-024-00667-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 02/23/2024] [Indexed: 03/17/2024] Open
Abstract
Characterization of Parkinson's disease (PD) progression using real-world evidence could guide clinical trial design and identify subpopulations. Efforts to curate research populations, the increasing availability of real-world data, and advances in natural language processing, particularly large language models, allow for a more granular comparison of populations than previously possible. This study includes two research populations and two real-world data-derived (RWD) populations. The research populations are the Harvard Biomarkers Study (HBS, N = 935), a longitudinal biomarkers cohort study with in-person structured study visits; and Fox Insights (N = 36,660), an online self-survey-based research study of the Michael J. Fox Foundation. Real-world cohorts are the Optum Integrated Claims-electronic health records (N = 157,475), representing wide-scale linked medical and claims data and de-identified data from Mass General Brigham (MGB, N = 22,949), an academic hospital system. Structured, de-identified electronic health records data at MGB are supplemented using a manually validated natural language processing with a large language model to extract measurements of PD progression. Motor and cognitive progression scores change more rapidly in MGB than HBS (median survival until H&Y 3: 5.6 years vs. >10, p < 0.001; mini-mental state exam median decline 0.28 vs. 0.11, p < 0.001; and clinically recognized cognitive decline, p = 0.001). In real-world populations, patients are diagnosed more than eleven years later (RWD mean of 72.2 vs. research mean of 60.4, p < 0.001). After diagnosis, in real-world cohorts, treatment with PD medications has initiated an average of 2.3 years later (95% CI: [2.1-2.4]; p < 0.001). This study provides a detailed characterization of Parkinson's progression in diverse populations. It delineates systemic divergences in the patient populations enrolled in research settings vs. patients in the real-world. These divergences are likely due to a combination of selection bias and real population differences, but exact attribution of the causes is challenging. This study emphasizes a need to utilize multiple data sources and to diligently consider potential biases when planning, choosing data sources, and performing downstream tasks and analyses.
Collapse
Affiliation(s)
- Brett K Beaulieu-Jones
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, 02115, USA.
- APDA Center for Advanced Parkinson Research of Harvard Medical School and Brigham and Women's Hospital, Boston, MA, 02115, USA.
- Precision Neurology Program of Brigham & Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.
- Department of Medicine, University of Chicago, Chicago, IL, 60615, USA.
- Aligning Science Across Parkinson's (ASAP) Collaborative Research Network, Chevy Chase, MD, 20815, USA.
| | | | - Sylvie Bozzi
- Sanofi Health Economics and Value Assessment, Sanofi, Paris, France
| | | | | | | | | | - Dinesh Kumar
- Sanofi Translational Sciences, Framingham, MA, 01701, USA
| | - Mark J Kruger
- Sanofi Genzyme, Clinical Development Neurology, Cambridge, MA, USA
| | - Scott L Lipnick
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, 02115, USA
| | - Lane Fitzsimmons
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, 02115, USA
| | - Isaac S Kohane
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, 02115, USA
| | - Clemens R Scherzer
- APDA Center for Advanced Parkinson Research of Harvard Medical School and Brigham and Women's Hospital, Boston, MA, 02115, USA.
- Precision Neurology Program of Brigham & Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.
- Aligning Science Across Parkinson's (ASAP) Collaborative Research Network, Chevy Chase, MD, 20815, USA.
| |
Collapse
|
22
|
McCoy RG, Swarna KS, Jiang DH, Van Houten HK, Chen J, Davis EM, Herrin J. Enrollment in High-Deductible Health Plans and Incident Diabetes Complications. JAMA Netw Open 2024; 7:e243394. [PMID: 38517436 PMCID: PMC10960199 DOI: 10.1001/jamanetworkopen.2024.3394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 01/25/2024] [Indexed: 03/23/2024] Open
Abstract
Importance Preventing diabetes complications requires monitoring and control of hyperglycemia and cardiovascular risk factors. Switching to high-deductible health plans (HDHPs) has been shown to hinder aspects of diabetes care; however, the association of HDHP enrollment with microvascular and macrovascular diabetes complications is unknown. Objective To examine the association between an employer-required switch to an HDHP and incident complications of diabetes. Design, Setting, and Participants This retrospective cohort study used deidentified administrative claims data for US adults with diabetes enrolled in employer-sponsored health plans between January 1, 2010, and December 31, 2019. Data analysis was performed from May 26, 2022, to January 2, 2024. Exposures Adults with a baseline year of non-HDHP enrollment who had to switch to an HDHP because their employer offered no non-HDHP alternative in that year were compared with adults who were continuously enrolled in a non-HDHP. Main Outcomes and Measures Mixed-effects logistic regression models examined the association between switching to an HDHP and, individually, the odds of myocardial infarction, stroke, hospitalization for heart failure, lower-extremity complication, end-stage kidney disease, proliferative retinopathy, treatment for retinopathy, and blindness. Models were adjusted for demographics, comorbidities, and medications, with inverse propensity score weighting used to account for potential selection bias. Results The study included 42 326 adults who switched to an HDHP (mean [SD] age, 52 [10] years; 19 752 [46.7%] female) and 202 729 adults who did not switch (mean [SD] age, 53 [10] years; 89 828 [44.3%] female). Those who switched to an HDHP had greater odds of experiencing all diabetes complications (odds ratio [OR], 1.11; 95% CI, 1.06-1.16 for myocardial infarction; OR, 1.15; 95% CI, 1.09-1.21 for stroke; OR, 1.35; 95% CI, 1.30-1.41 for hospitalization for heart failure; OR, 2.53; 95% CI, 2.38-2.70 for end-stage kidney disease; OR, 2.23; 95% CI, 2.17-2.29 for lower-extremity complication; OR, 1.17; 95% CI, 1.13-1.21 for proliferative retinopathy; OR, 2.35; 95% CI, 2.18-2.54 for blindness; and OR, 2.28; 95% CI, 2.15-2.41 for retinopathy treatment). Conclusions and Relevance This study found that an employer-driven switch to an HDHP was associated with increased odds of experiencing all diabetes complications. These findings reinforce the potential harm associated with HDHPs for people with diabetes and the importance of affordable and accessible chronic disease management, which is hindered by high out-of-pocket costs incurred by HDHPs.
Collapse
Affiliation(s)
- Rozalina G. McCoy
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore
- University of Maryland Institute for Health Computing, Bethesda
- Division of Gerontology, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park
- OptumLabs, Eden Prairie, Minnesota
| | - Kavya S. Swarna
- OptumLabs, Eden Prairie, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | | | - Holly K. Van Houten
- OptumLabs, Eden Prairie, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Jie Chen
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park
| | - Esa M. Davis
- University of Maryland Institute for Health Computing, Bethesda
- Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
23
|
Wymer KM, Thao V, Narang G, Sharma V, Borah BJ, Cheney S, Humphreys MR. Evaluation of Private Payer and Patient Out-of-Pocket Costs Associated With the Surgical Management of Benign Prostatic Hyperplasia. Urology 2024; 184:87-93. [PMID: 38065310 DOI: 10.1016/j.urology.2023.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 09/28/2023] [Accepted: 10/14/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVE To evaluate and compare the financial burden of various surgical interventions for the management of benign prostatic hyperplasia (BPH). METHODS We identified commercially insured men with a diagnosis of BPH who underwent a procedure of interest (simple prostatectomy (SP), transurethral resection of the prostate (TURP), holmium laser enucleation of the prostate (HoLEP), photovaporization of the prostate (PVP), prostatic urethral lift (PUL), or water vapor thermal therapy (WVTT)) between 2015 and 2021 with the OptumLabs Data Warehouse. Primary outcome was total health care costs (THC) which included both patient out-of-pocket (OOP) and health plan paid costs for the index procedure and combined follow-up years 1-5. A generalized linear model was used to estimate adjusted costs controlling for demographic and clinical characteristics. Patients undergoing WVTT were excluded from extended follow-up analyses due to limited data. RESULTS Among 25,407 patients with BPH, 10,117 (40%) underwent TURP, 6353 (25%) underwent PUL, 5411 (21%) underwent PVP, 1319 (5%) underwent SP, 1243 (5%) underwent WVTT, and 964 (4%) underwent HoLEP. Index procedure costs varied significantly with WVTT being the least costly [THC: $2637 (95% confidence interval (CI): $2513-$2761)], and SP being the costliest [THC: $14,423 (95% CI: $12,772-$16,075)]. For aggregate index and 5-year follow-up costs, HoLEP ($31,926 [95% CI: $29,704-$34,148]) was the least costly and PUL ($36,596 [95% CI: $35,369-37,823]) was the costliest. CONCLUSION BPH surgical treatment is associated with significant system-level health care costs. The level of impact varies between procedures. Minimally invasive options, such as WVTT, may offer initial cost reductions; however, HoLEP and SP are associated with lower follow-up costs.
Collapse
Affiliation(s)
- Kevin M Wymer
- Department of Urology, Mayo Clinic, Rochester, MN; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN.
| | - Viengneesee Thao
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN
| | - Gopal Narang
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Vidit Sharma
- Department of Urology, Mayo Clinic, Rochester, MN
| | - Bijan J Borah
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN; Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
| | | | | |
Collapse
|
24
|
Satterfield BA, Dikilitas O, Van Houten H, Yao X, Gersh BJ. Daylight Saving Time Practice and the Rate of Adverse Cardiovascular Events in the United States: A Probabilistic Assessment in a Large Nationwide Study. Mayo Clin Proc Innov Qual Outcomes 2024; 8:45-52. [PMID: 38274333 PMCID: PMC10809088 DOI: 10.1016/j.mayocpiqo.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024] Open
Abstract
We investigated the association of daylight saving time (DST) transitions with the rates of adverse cardiovascular events in a large, US-based nationwide study. The study cohort included 36,116,951 unique individuals from deidentified administrative claims data of the OptumLabs Data Warehouse. There were 74,722 total adverse cardiovascular events during DST transition and the control weeks (2 weeks before and after) in spring and autumn of 2015-2019. We used Bayesian hierarchical Poisson regression models to estimate event rate ratios representing the ratio of composite adverse cardiovascular event rates between DST transition and control weeks. There was an average increase of 3% (95% uncertainty interval, -3% to -10%) and 4% (95% uncertainty interval, -2% to -12%) in adverse cardiovascular event rates during Monday and Friday of the spring DST transition, respectively. The probability of this being associated with a moderate-to-large increase in the event rates (estimate event rate ratio, >1.10) was estimated to be less than 6% for Monday and Friday, and less than 1% for the remaining days. During autumn DST transition, the probability of any decrease in adverse cardiovascular event rates was estimated to be less than 46% and a moderate-to-large decrease in the event rates to be less than 4% across all days. Results were similar when adjusted by age. In conclusion, spring DST transition had a suggestive association with a minor increase in adverse cardiovascular event rates but with a very low estimated probability to be of clinical importance. Our findings suggest that DST transitions are unlikely to meaningfully impact the rate of cardiovascular events.
Collapse
Affiliation(s)
| | - Ozan Dikilitas
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Holly Van Houten
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- OptumLabs, Minnetonka, MN
| | - Xiaoxi Yao
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Bernard J. Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
25
|
Dempsey TM, Thao V, Helfinstine D, Sangaralingham L, Limper AH. Comparing the Utilization of Antifibrotic Medications Based on Income Level. Chest 2024; 165:146-149. [PMID: 37543252 DOI: 10.1016/j.chest.2023.07.4215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 07/11/2023] [Accepted: 07/28/2023] [Indexed: 08/07/2023] Open
Affiliation(s)
- Timothy M Dempsey
- David Grant Medical Center, US Air Force, Travis AFB, CA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
| | - Viengneesee Thao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - David Helfinstine
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Lindsey Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; OptumLabs®, Cambridge, MA
| | - Andrew H Limper
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
26
|
Goldsweig AM, Deng Y, Yao X, Desai NR, Cohen DJ, Aronow HD, Messé S, Ross JS, Lansky AJ, Savitz ST. Approval, Evidence, and "Off-Label" Device Utilization: The Patent Foramen Ovale Closure Story. Circ Cardiovasc Qual Outcomes 2024; 17:e010200. [PMID: 38189127 PMCID: PMC10844981 DOI: 10.1161/circoutcomes.123.010200] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/27/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Following regulatory approval, medical devices may be used "off-label." Patent foramen ovale (PFO) closure is indicated to reduce recurrent stroke but has been proposed for other indications, including migraine, transient ischemic attack, and diving decompression illness. We sought to evaluate PFO closure rates and indications relative to the timing of regulatory approval and publication of key randomized trials. METHODS We performed a retrospective cohort study using the OptumLabs Data Warehouse of US commercial insurance enrollees from 2006 to 2019. We quantified PFO closure among individuals with ≥2 years of preprocedure coverage to establish indications, classified hierarchically as stroke/systemic embolism, migraine, transient ischemia attack, or other. RESULTS We identified 5315 patients undergoing PFO closure (51.8% female, 29.2%≥60 years old), which increased from 4.75 per 100 000 person-years in 2006 to 6.60 per 100 000 person-years in 2019. Patients aged ≥60 years accounted for 29.2% of closures. Procedure volumes corresponded weakly with supportive clinical publications and device approval. Among patients with PFO closure, 58.6% underwent closure for stroke/systemic embolism, 10.2% for transient ischemia attack, 8.8% for migraine, and 22.4% for other indications; 17.6% of patients had atrial fibrillation at baseline; and 11.9% developed atrial fibrillation postprocedure. Those aged ≥60 years and male were less likely to undergo closure for migraine than stroke/systemic embolism. CONCLUSIONS From 2006 to 2019, PFO closure use was consistently low and corresponded weakly with clinical trial publications and regulatory status. Nearly half of patients underwent PFO closure for indications unapproved by the Food and Drug Administration. Regulators and payers should coordinate mechanisms to promote utilization for approved indications to ensure patient safety and should facilitate clinical trials for other possible indications.
Collapse
Affiliation(s)
- Andrew M. Goldsweig
- Department of Cardiovascular Medicine, Baystate Medical
Center, Springfield, MA, USA
| | - Yihong Deng
- Kern Center for the Science of Health Care Delivery and
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Xiaoxi Yao
- Kern Center for the Science of Health Care Delivery and
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nihar R. Desai
- Section of Cardiovascular Medicine, Yale University, New
Haven, CT, USA
| | - David J. Cohen
- Cardiovascular Research Foundation, New York, NY, USA, and
St. Francis Hospital and Heart Center, Roslyn, NY, USA
| | - Herbert D. Aronow
- Department of Cardiovascular Medicine, Henry Ford Health
System, Detroit, MI, USA
| | - Steven Messé
- Department of Neurology, Hospital of the University of
Pennsylvania, Philadelphia, PA, USA
| | - Joseph S. Ross
- Section of General Medicine, Department of Internal
Medicine, Yale School of Medicine, and Department of Health Policy and Management,
Yale School of Public Health, New Haven, CT, USA
| | | | - Samuel T. Savitz
- Kern Center for the Science of Health Care Delivery and
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
27
|
Agasthi P, Van Houten HK, Yao X, Jain CC, Egbe A, Warnes CA, Miranda WR, Dunlay SM, Stephens EH, Johnson JN, Connolly HM, Burchill LJ. Mortality and Morbidity of Heart Failure Hospitalization in Adult Patients With Congenital Heart Disease. J Am Heart Assoc 2023; 12:e030649. [PMID: 38018491 PMCID: PMC10727341 DOI: 10.1161/jaha.123.030649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 10/04/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Little is known about outcomes following heart failure (HF) hospitalization among adults with congenital heart disease (CHD) in the United States. We aim to compare the outcomes of HF versus non-HF hospitalizations in adults with CHD. METHODS AND RESULTS Using a national deidentified administrative claims data set, patients with adult congenital heart disease (ACHD) hospitalized with and without HF (ACHDHF+, ACHDHF-) were characterized to determine the predictors of 90-day and 1-year mortality and quantify the risk of mortality, major adverse cardiac and cerebrovascular events, and health resource use. Cox proportional hazard regression was used to compare ACHDHF+ versus ACHDHF- for risk of events and health resource use. Of 26 454 unique ACHD admissions between January 1, 2010 and December 31, 2020, 5826 (22%) were ACHDHF+ and 20 628 (78%) were ACHDHF-. The ACHD HF+ hospitalizations increased from 6.6% to 14.0% (P<0.0001). Over a mean follow-up period of 2.23 ± 2.19 years, patients with ACHDHF+ had a higher risk of mortality (hazard ratio [HR], 1.86 [95% CI, 1.67-2.07], P<0.001), major adverse cardiac and cerebrovascular events (HR, 1.73 [95% CI, 1.63-1.83], P<0.001) and health resource use including rehospitalization (HR, 1.09 [95% CI, 1.05-1.14], P<0.001) and increased postacute care service use (HR, 1.56 [95% CI, 1.32-1.85], P<0.001). Cardiology clinic visits within 30 days of hospital admission were associated with lower 90-day and 1-year all-cause mortality (odds ratio [OR], 0.62 [95% CI, 0.49-0.78], P<0.001; OR, 0.69 [95% CI, 0.58-0.83], P<0.001, respectively). CONCLUSIONS HF hospitalization is associated with increased risk of mortality and morbidity with high health resource use in patients with ACHD. Recent cardiology clinic attendance appears to mitigate these risks.
Collapse
Affiliation(s)
| | - Holly K. Van Houten
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo ClinicRochesterMNUSA
- OptumLabsMinnetonkaMNUSA
| | - Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo ClinicRochesterMNUSA
- OptumLabsMinnetonkaMNUSA
| | - C. Charles Jain
- Department of Cardiovascular Medicine, Mayo ClinicRochesterMNUSA
| | - Alexander Egbe
- Department of Cardiovascular Medicine, Mayo ClinicRochesterMNUSA
| | - Carole A. Warnes
- Department of Cardiovascular Medicine, Mayo ClinicRochesterMNUSA
| | | | - Shannon M. Dunlay
- Department of Cardiovascular Medicine, Mayo ClinicRochesterMNUSA
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo ClinicRochesterMNUSA
| | | | - Jonathan N. Johnson
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic Children’s CenterRochesterMNUSA
| | | | - Luke J. Burchill
- Department of Cardiovascular Medicine, Mayo ClinicRochesterMNUSA
| |
Collapse
|
28
|
Benning TJ, Heien HC, Herges JR, Creo AL, Al Nofal A, McCoy RG. Glucagon fill rates and cost among children and adolescents with type 1 diabetes in the United States, 2011-2021. Diabetes Res Clin Pract 2023; 206:111026. [PMID: 38000667 PMCID: PMC10872944 DOI: 10.1016/j.diabres.2023.111026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/06/2023] [Accepted: 11/21/2023] [Indexed: 11/26/2023]
Abstract
AIMS To characterize glucagon fill rates and costs among youth with type 1 diabetes mellitus (T1DM). METHODS Claims-based analysis of commercially-insured youth with T1DM included in OptumLabs® Data Warehouse between 2011 and 2021. Glucagon fill rates and costs were calculated overall and by formulation (injectable, intranasal, autoinjector, and pre-filled syringe). Sociodemographic and clinical factors associated with glucagon fills were examined using Cox regression. RESULTS We identified 13,267 children with T1DM (76.4% non-Hispanic White). Over mean follow-up of 2.81 years (SD 2.62), 70.0% filled glucagon, with stable fill rates from 2011 to 2021. Intranasal glucagon had rapid uptake following initial approval, and it accounted for almost half (46.6%) of all glucagon fills by 2021. Family income was positively associated with glucagon fills in a stepwise fashion (HR 1.39 [95% CI 1.27-1.52] for annual household income ≥$200,000 vs. <$40,000), while Black race was negatively associated with fills (HR 0.83 [95% CI 0.76-0.91]) compared to White race). Annual mean out-of-pocket costs ranged from $21-$68 (IQR $29-$44). CONCLUSION Roughly 30% of commercially-insured youth with T1DM may lack access to unexpired glucagon, with significant disparities among Black and low-income patients. Health systems, clinicians, schools, and caregivers should work together to ensure children have reliable access to this critical medication.
Collapse
Affiliation(s)
- Tyler J Benning
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 1(st) St. SW, Rochester, MN 55905, United States
| | - Herbert C Heien
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 1(st) St. SW, Rochester, MN 55905, United States
| | - Joseph R Herges
- Pharmacy Services, Mayo Clinic, 200 1(st) St. SW, Rochester, MN 55905, United States
| | - Ana L Creo
- Division of Pediatric Endocrinology, Mayo Clinic, 200 1(st) St. SW, Rochester, MN 55905, United States
| | - Alaa Al Nofal
- Division of Pediatric Endocrinology, Mayo Clinic, 200 1(st) St. SW, Rochester, MN 55905, United States
| | - Rozalina G McCoy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 1(st) St. SW, Rochester, MN 55905, United States; Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, 670 West Baltimore Street, Baltimore, MD 21201, United States; University of Maryland Institute for Health Computing, 6116 Executive Blvd, Bethesda, MD 20852, United States; OptumLabs, 11000 Optum Circle, Eden Prairie, MN 55344, United States.
| |
Collapse
|
29
|
Huang Y, Schaff HV, Swarna KS, Sangaralingham LR, Nishimura RA, Dearani JA, Crestanello JA, Greason KL. Benefit of Anticoagulation Early After Surgical Aortic Valve Replacement Using Bioprosthetic Valves. Mayo Clin Proc 2023; 98:1797-1808. [PMID: 38043997 DOI: 10.1016/j.mayocp.2023.08.012] [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] [Received: 01/17/2023] [Revised: 08/01/2023] [Accepted: 08/08/2023] [Indexed: 12/05/2023]
Abstract
OBJECTIVE To compare all-cause mortality and thromboembolic events in patients undergoing surgical aortic valve replacement (sAVR) receiving anticoagulation with warfarin versus patients with no systemic anticoagulation. PATIENTS AND METHODS Using data from the OptumLabs Data Warehouse, we investigated adult patients having bioprosthetic sAVR with or without coronary artery bypass from January 1, 2007, through December 31, 2019. Patients were classified into groups of nonwarfarin or warfarin (≥30 days of continuous prescription coverage after sAVR). One-to-one propensity score (PS) matching was used to adjust for group differences. RESULTS Of 10,589 patients having sAVR, 7659 (72.3%) were in the nonwarfarin group and 2930 (27.7%) were in the warfarin group. After PS matching, 2930 pairs of patients were analyzed. Median follow-up was 4.1 months (interquartile range [IQR], 2.6-7.4 months) for the warfarin group and 21.3 months (IQR, 7.8-24.0 months) for the nonwarfarin group. Overall mortality was lower for the warfarin group than for the nonwarfarin group (hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.47 to 1.00; P=.047), and there was a trend toward decreased cumulative incidence of thromboembolic events (subdistribution HR [SHR], 0.62; 95% CI, 0.35 to 1.07; P=.09). Cumulative incidence of major bleeding events was higher for the warfarin group vs the nonwarfarin group (SHR, 1.94; 95% CI, 1.28 to 2.94; P=.002). Results were similar in a subgroup analysis of patients undergoing isolated sAVR. CONCLUSION During the prescription coverage period, warfarin use after bioprosthetic sAVR was associated with lower all-cause mortality and decreased risk of thromboembolism compared with not receiving warfarin. However, warfarin use was associated with an increased risk of major bleeding events.
Collapse
Affiliation(s)
- Ying Huang
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Kavya S Swarna
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|
30
|
Mathur V, Reaven NL, Funk SE, Ferguson TW, Tangri N. Association of body mass index with the development of metabolic acidosis in patients with chronic kidney disease. Obes Sci Pract 2023; 9:609-617. [PMID: 38090684 PMCID: PMC10712406 DOI: 10.1002/osp4.672] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 03/02/2023] [Accepted: 04/04/2023] [Indexed: 05/29/2024] Open
Abstract
AIMS Higher body mass index (BMI) is associated with higher bone mass and bone serves as a buffer during the development of metabolic acidosis. The authors sought to examine the relationship between BMI and metabolic acidosis in patients with chronic kidney disease (CKD). MATERIALS AND METHODS The study utilized a large US longitudinal data repository including over 103 million patients from healthcare provider organizations to evaluate the relationship between the exposure variable (BMI) and the prevalence and incidence of metabolic acidosis among patients with estimated glomerular filtration rate <60 ml/min/1.73 m2. Incident metabolic acidosis was identified at the first of two consecutive post-index serum bicarbonate values, 10-365 days apart, between 12 and <22 mEq/L in patients with normal index serum bicarbonate. Cox proportional hazard models were adjusted for multiple variables including demographics, comorbidities, income, education, and kidney function. RESULTS 103,766 patients qualified for this study; 6472 (6.2%) had metabolic acidosis at index. An inverse association between BMI category and metabolic acidosis was observed for both baseline (prevalence) and new-onset (incidence) metabolic acidosis. Compared to BMI category of 18.5 to <25 kg/m2, each category of incrementally higher BMI was associated with a decreasing risk of incident metabolic acidosis; the adjusted hazard ratios (95% confidence interval) were 0.866 (0.824-0.911), 0.770 (0.729-0.813), 0.664 (0.622-0.709), and 0.612 (0.571-0.655) for BMI 25 to <30, 30 to <35, 35 to <40, and 40+ kg/m2, respectively. CONCLUSIONS Among patients with CKD, an incremental increase in BMI was inversely associated with both the prevalence and incidence of metabolic acidosis. These associations suggest that increased body weight may protect against the development of metabolic acidosis, a risk factor for progressive loss of kidney function.
Collapse
Affiliation(s)
| | | | | | - Thomas W. Ferguson
- Department of Internal MedicineMax Rady College of MedicineRady Faculty of Health SciencesUniversity of ManitobaWinnipegManitobaCanada
| | - Navdeep Tangri
- Department of Internal MedicineMax Rady College of MedicineRady Faculty of Health SciencesUniversity of ManitobaWinnipegManitobaCanada
| |
Collapse
|
31
|
Xu Y, Chang AR, Inker LA, McAdams-DeMarco M, Grams ME, Shin JI. Associations of Apixaban Dose With Safety and Effectiveness Outcomes in Patients With Atrial Fibrillation and Severe Chronic Kidney Disease. Circulation 2023; 148:1445-1454. [PMID: 37681341 PMCID: PMC10840683 DOI: 10.1161/circulationaha.123.065614] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 08/04/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Recommendations for apixaban dosing on the basis of kidney function are inconsistent between the US Food and Drug Administration and European Medicines Agency for patients with atrial fibrillation. Optimal apixaban dosing in chronic kidney disease remains unknown. METHODS With the use of deidentified electronic health record data from the Optum Labs Data Warehouse, patients with atrial fibrillation and chronic kidney disease stage 4/5 initiating apixaban between 2013 and 2021 were identified. Risks of bleeding and stroke/systemic embolism were compared by apixaban dose (5 versus 2.5 mg), adjusted for baseline characteristics by the inverse probability of treatment weighting. The Fine-Gray subdistribution hazard model was used to account for the competing risk of death. Cox regression was used to examine risk of death by apixaban dose. RESULTS Among 4313 apixaban new users, 1705 (40%) received 5 mg and 2608 (60%) received 2.5 mg. Patients treated with 5 mg apixaban were younger (mean age, 72 versus 80 years), with greater weight (95 versus 80 kg) and higher serum creatinine (2.7 versus 2.5 mg/dL). Mean estimated glomerular filtration rate was not different between the groups (24 versus 24 mL·min-1·1.73 m-2). In inverse probability of treatment weighting analysis, apixaban 5 mg was associated with a higher risk of bleeding (incidence rate 4.9 versus 2.9 events per 100 person-years; incidence rate difference, 2.0 [95% CI, 0.6-3.4] events per 100 person-years; subdistribution hazard ratio, 1.63 [95% CI, 1.04-2.54]). There was no difference between apixaban 5 mg and 2.5 mg groups in the risk of stroke/systemic embolism (3.3 versus 3.0 events per 100 person-years; incidence rate difference, 0.2 [95% CI, -1.0 to 1.4] events per 100 person-years; subdistribution hazard ratio, 1.01 [95% CI, 0.59-1.73]), or death (9.9 versus 9.4 events per 100 person-years; incidence rate difference, 0.5 [95% CI, -1.6 to 2.6] events per 100 person-years; hazard ratio, 1.03 [95% CI, 0.77-1.38]). CONCLUSIONS Compared with 2.5 mg, use of 5 mg apixaban was associated with a higher risk of bleeding in patients with atrial fibrillation and severe chronic kidney disease, with no difference in the risk of stroke/systemic embolism or death, supporting the apixaban dosing recommendations on the basis of kidney function by the European Medicines Agency, which differ from those issued by the US Food and Drug Administration.
Collapse
Affiliation(s)
- Yunwen Xu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Alex R. Chang
- Division of Nephrology, Geisinger Health System, Danville, PA
| | - Lesley A Inker
- Division of Nephrology, Department of Internal Medicine, Tufts Medical Center, Boston, MA
| | - Mara McAdams-DeMarco
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, NY
- Department of Population Health, New York University Grossman School of Medicine and Langone Health, New York, NY
| | - Morgan E. Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Population Health, New York University Grossman School of Medicine and Langone Health, New York, NY
- Department of Medicine, New York University Grossman School of Medicine and Langone Health, New York, NY
| | - Jung-Im Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| |
Collapse
|
32
|
Subramaniam A, van Houten H, Redfield MM, Sangaralingham LR, Savitz ST, Glasgow A, Schulte PJ, LeMond LM, Dunlay SM. Advanced Heart Failure Characteristics and Outcomes in Commercially Insured U.S. Adults. JACC. HEART FAILURE 2023; 11:1595-1606. [PMID: 37589611 PMCID: PMC10752371 DOI: 10.1016/j.jchf.2023.06.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 06/13/2023] [Accepted: 06/28/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND The characteristics and outcomes of patients with advanced heart failure (HF) have been poorly defined due to challenges in applying the complex advanced HF definition broadly to populations. OBJECTIVES In this study, the authors sought to apply a validated advanced HF algorithm to a large U.S. administrative claims database and describe the population and use of advanced HF therapies. METHODS This study included adults with advanced HF identified in the OptumLabs Data Warehouse from 2009 to 2019. The algorithm for advanced HF required 2 hospitalizations for HF plus 1 additional sign of advanced HF in a 12-month period. The association of baseline characteristics with mortality was examined with the use of Cox proportional hazards models. Associations of patient characteristics with advanced therapies were estimated with the use of cause-specific Cox proportional hazard models. RESULTS In 60,197 patients identified with advanced HF, the mean age was 73 years, 51.5% were men, and 64.3% were non-Hispanic White, 1.9% Asian, 21.2% Black, and 8.2% Hispanic. The median survival with advanced HF was 2.0 years (IQR: 0.4-5.5 years). Differences in mortality and use of advanced therapies by age, sex, and race/ethnicity were observed. Adjusted mortality was higher in patients who were older, male, non-Hispanic White, and from rural areas (P < 0.05 for all). Advanced therapies were used less in older patients and women (P < 0.05 for both). Black patients were more likely to be treated with a left ventricular assist device (P = 0.010) but less likely to receive a heart transplant compared with White patients (P = 0.034). CONCLUSIONS In U.S. adults with advanced HF, variation in outcomes and use of advanced therapies exist by age, sex, and race/ethnicity.
Collapse
Affiliation(s)
- Anna Subramaniam
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Holly van Houten
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA; Optum Labs, Eden Prairie, Minnesota
| | - Margaret M Redfield
- Department of Cardiovascular Medicine, 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
| | - Samuel T Savitz
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Amy Glasgow
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Phillip J Schulte
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Lisa M LeMond
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Shannon M Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.
| |
Collapse
|
33
|
McCoy RG, Faust L, Heien HC, Patel S, Caffo B, Ngufor C. Longitudinal trajectories of glycemic control among U.S. Adults with newly diagnosed diabetes. Diabetes Res Clin Pract 2023; 205:110989. [PMID: 37918637 PMCID: PMC10842883 DOI: 10.1016/j.diabres.2023.110989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/27/2023] [Accepted: 10/31/2023] [Indexed: 11/04/2023]
Abstract
AIMS To identify longitudinal trajectories of glycemic control among adults with newly diagnosed diabetes, overall and by diabetes type. METHODS We analyzed claims data from OptumLabs® Data Warehouse for 119,952 adults newly diagnosed diabetes between 2005 and 2018. We applied a novel Mixed Effects Machine Learning model to identify longitudinal trajectories of hemoglobin A1c (HbA1c) over 3 years of follow-up and used multinomial regression to characterize factors associated with each trajectory. RESULTS The study population was comprised of 119,952 adults with newly diagnosed diabetes, including 696 (0.58%) with type 1 diabetes. Among patients with type 1 diabetes, 52.6% were diagnosed at very high HbA1c, partially improved, but never achieved control; 32.5% were diagnosed at low HbA1c and deteriorated over time; and 14.9% had stable low HbA1c. Among patients with type 2 diabetes, 67.7% had stable low HbA1c, 14.4% were diagnosed at very high HbA1c, partially improved, but never achieved control; 10.0% were diagnosed at moderately high HbA1c and deteriorated over time; and 4.9% were diagnosed at moderately high HbA1c and improved over time. CONCLUSIONS Claims data identified distinct longitudinal trajectories of HbA1c after diabetes diagnosis, which can be used to anticipate challenges and individualize care plans to improve glycemic control.
Collapse
Affiliation(s)
- Rozalina G McCoy
- Division of Endocrinology, Diabetes, & Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States; University of Maryland Institute for Health Computing, Bethesda, MD, United States; OptumLabs, Eden Prairie, MN, United States; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, United States.
| | - Louis Faust
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, United States
| | - Herbert C Heien
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, United States
| | - Shrinath Patel
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, United States
| | - Brian Caffo
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Che Ngufor
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, United States; Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
34
|
Coates A, Chung AQH, Lessard L, Grudniewicz A, Espadero C, Gheidar Y, Bemgal S, Da Silva E, Sauré A, King J, Fung-Kee-Fung M. The use and role of digital technology in learning health systems: A scoping review. Int J Med Inform 2023; 178:105196. [PMID: 37619395 DOI: 10.1016/j.ijmedinf.2023.105196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/12/2023] [Accepted: 08/12/2023] [Indexed: 08/26/2023]
Abstract
OBJECTIVE The review aimed to identify which digital technologies are proposed or used within learning health systems (LHS) and to analyze the extent to which they support learning processes in LHS. MATERIALS AND METHODS Multiple databases and grey literature were searched with terms related to LHS. Manual searches and backward searches of reference lists were also undertaken. The review considered publications from 2007 to 2022. Records focusing on LHS, referring to one or more digital technologies, and describing how at least one digital technology could be used in LHS were included. RESULTS 2046 records were screened for inclusion and 154 records were included in the analysis. Twenty categories of digital technology were identified. The two most common ones across records were data recording and processing and electronic health records. Digital technology was primarily leveraged to support data access and aggregation and data analysis, two of the seven recognized learning processes within LHS learning cycles. DISCUSSION The results of the review show that a wide array of digital technologies is being leveraged to support learning cycles within LHS. Nevertheless, an over-reliance on a narrow set of technologies supporting knowledge discovery, a lack of direct evaluation of digital technologies and ambiguity in technology descriptions are hindering the realization of the LHS vision. CONCLUSION Future LHS research and initiatives should aim to integrate digital technology to support practice change and impact evaluation. The use of recognized evaluation methods for health information technology and more detailed descriptions of proposed technologies are also recommended.
Collapse
Affiliation(s)
- Alison Coates
- Telfer School of Management, University of Ottawa, Ottawa, Canada
| | | | - Lysanne Lessard
- Telfer School of Management, University of Ottawa, Ottawa, Canada, Institut du Savoir Montfort - Research, Ottawa, Canada, LIFE Research Institute, University of Ottawa, Ottawa, Canada.
| | - Agnes Grudniewicz
- Telfer School of Management, University of Ottawa, Ottawa, Canada, Institut du Savoir Monfort - Research, Ottawa, Canada
| | - Cathryn Espadero
- Telfer School of Management, University of Ottawa, Ottawa, Canada
| | - Yasaman Gheidar
- Telfer School of Management, University of Ottawa, Ottawa, Canada
| | - Sampath Bemgal
- Telfer School of Management, University of Ottawa, Ottawa, Canada
| | | | - Antoine Sauré
- Telfer School of Management, University of Ottawa, Ottawa, Canada
| | - James King
- Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Michael Fung-Kee-Fung
- Departments of Obstetrics-Gynaecology and Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Canada, The Ottawa Hospital - General Campus, University of Ottawa/Ottawa Regional Cancer Centre, Ottawa, Canada
| |
Collapse
|
35
|
Chang J, Karaca-Mandic P, Jeffery MM. Uptake of Biosimilar Among Privately Insured Patients Undergoing Infliximab Treatment. Med Care 2023; 61:636-643. [PMID: 37582298 DOI: 10.1097/mlr.0000000000001906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
BACKGROUND Recent literature has found rapid uptake of short-acting filgrastim biosimilars but slower uptake of other biosimilars, such as infliximab, in both Medicare and privately insured enrollees. OBJECTIVES To describe patient, provider, and health plan characteristics associated with a switch to biosimilar among existing infliximab patients. RESEARCH DESIGN We constructed a retrospective panel dataset of patients undergoing active infliximab treatments and the choice of infliximab drug for each infusion. We used mixed logit regression controlling for patient, provider, and health plan characteristics as well as time-fixed effects. SUBJECTS Medicare Advantage and privately insured enrollees with evidence of active infliximab treatments between 2016 and 2020 (n=357,430). MEASURES Our primary outcome of interest was to switch from infliximab originator to one of the infliximab biosimilars. Exposure variables of interest variables such as out-of-pocket, site of care, and in-network deductible. RESULTS Our study found nominally low switching among existing infliximab originator users (3.4%). We found that patients who previously received 1 infliximab originator infusion were 63.7% more likely to switch to biosimilar compared with patients who previously received administration of 20 infliximab originators. We found that biosimilar's placement as health's plan preferred drug was attributed to higher likelihood of biosimilar use (odds ratio: 1.666; P -value=0.001). We did not observe any statistically significant effect among out-of-pocket amount or deductible with respect to switch to infliximab biosimilar. CONCLUSIONS To encourage uptake and switch to biosimilar, policymakers should consider targeted policies that include leveraging health plan tools such as placement of biosimilar as preferred drug and aim to educate patients on the clinical equivalence between infliximab biosimilar and originator.
Collapse
Affiliation(s)
- Jessica Chang
- Division of Health Policy and Management, University of Minnesota, School of Public Health
| | - Pinar Karaca-Mandic
- Department of Finance, Carlson School of Management, University of Minnesota, Minneapolis
| | - Molly M Jeffery
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
| |
Collapse
|
36
|
Ferrè S, Storfer-Isser A, Kinderknecht K, Montgomery E, Godwin M, Andrews A, Dunning S, Barton M, Roman D, Cuddeback J, Stempniewicz N, Chu CD, Tuot DS, Vassalotti JA. Fulfillment and Validity of the Kidney Health Evaluation Measure for People with Diabetes. Mayo Clin Proc Innov Qual Outcomes 2023; 7:382-391. [PMID: 37680649 PMCID: PMC10480072 DOI: 10.1016/j.mayocpiqo.2023.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023] Open
Abstract
Objective To evaluate the fulfillment and validity of the kidney health evaluation for people with diabetes (KED) Healthcare Effectiveness Data Information Set (HEDIS) measure. Patients and Methods Optum Labs Data Warehouse (OLDW) was used to identify the nationally distributed US population aged 18 years and older, with diabetes, between January 1, 2017, and December 31, 2017. The OLDW includes deidentified medical, pharmacy, laboratory, and electronic health record (EHR) data. The KED fulfillment was defined in 2017 as both estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio testing within the measurement year. The KED validity was assessed using bivariate analyses of KED fulfillment with diabetes care measures in 2017 and chronic kidney disease (CKD) diagnosis and evidence-based kidney protective interventions in 2018. Results Among eligible 5,635,619 Medicare fee-for-service beneficiaries, 736,875 Medicare advantage (MA) beneficiaries, and 660,987 commercial patients, KED fulfillment was 32.2%, 38.7%, and 37.7%, respectively. Albuminuria testing limited KED fulfillment with urinary albumin-creatinine ratio testing (<40%) and eGFR testing (>90%). The KED fulfillment was positively associated with receipt of diabetes care in 2017, CKD diagnosis in 2018, and evidence-based kidney protective interventions in 2018. The KED fulfillment trended lower for Black race, Medicare-Medicaid dual eligibility status, low neighborhood income, and low education status. Conclusion Less than 40% of adults with diabetes received guideline-recommended testing for CKD in 2017. Routine KED was associated with diabetes care and evidence-based CKD interventions. Increasing guideline-recommended testing for CKD among people with diabetes should lead to timely and equitable CKD detection and treatment.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Mary Barton
- National Committee for Quality Assurance, Washington, DC
| | - Dan Roman
- National Committee for Quality Assurance, Washington, DC
| | | | | | - Chi D. Chu
- University of California at San Francisco, San Francisco, CA
| | | | - Joseph A. Vassalotti
- National Kidney Foundation, New York, NY
- Department of Medicine, Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY
| |
Collapse
|
37
|
Overhage L, Hailu R, Busch AB, Mehrotra A, Michelson KA, Huskamp HA. Trends in Acute Care Use for Mental Health Conditions Among Youth During the COVID-19 Pandemic. JAMA Psychiatry 2023; 80:924-932. [PMID: 37436733 PMCID: PMC10339224 DOI: 10.1001/jamapsychiatry.2023.2195] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/21/2023] [Indexed: 07/13/2023]
Abstract
Importance Understanding how children's utilization of acute mental health care changed during the COVID-19 pandemic is critical for directing resources. Objective To examine youth acute mental health care use (emergency department [ED], boarding, and subsequent inpatient care) during the second year of the COVID-19 pandemic. Design, Setting, and Participants This cross-sectional analysis of national, deidentified commercial health insurance claims of youth mental health ED and hospital care took place between March 2019 and February 2022. Among 4.1 million commercial insurance enrollees aged 5 to 17 years, 17 614 and 16 815 youth had at least 1 mental health ED visit in the baseline year (March 2019-February 2020) and pandemic year 2 (March 2021-February 2022), respectively. Exposure The COVID-19 pandemic. Main outcomes and measures The relative change from baseline to pandemic year 2 was determined in (1) fraction of youth with 1 or more mental health ED visits; (2) percentage of mental health ED visits resulting in inpatient psychiatry admission; (3) mean length of inpatient psychiatric stay following ED visit; and (4) frequency of prolonged boarding (≥2 midnights) in the ED or a medical unit before admission to an inpatient psychiatric unit. Results Of 4.1 million enrollees, 51% were males and 41% were aged 13 to 17 years (vs 5-12 years) with 88 665 mental health ED visits. Comparing baseline to pandemic year 2, there was a 6.7% increase in youth with any mental health ED visits (95% CI, 4.7%-8.8%). Among adolescent females, there was a larger increase (22.1%; 95% CI, 19.2%-24.9%). The fraction of ED visits that resulted in a psychiatric admission increased by 8.4% (95% CI, 5.5%-11.2%). Mean length of inpatient psychiatric stay increased 3.8% (95% CI, 1.8%-5.7%). The fraction of episodes with prolonged boarding increased 76.4% (95% CI, 71.0%-81.0%). Conclusions and relevance Into the second year of the pandemic, mental health ED visits increased notably among adolescent females, and there was an increase in prolonged boarding of youth awaiting inpatient psychiatric care. Interventions are needed to increase inpatient child psychiatry capacity and reduce strain on the acute mental health care system.
Collapse
Affiliation(s)
- Lindsay Overhage
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Ruth Hailu
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Alisa B. Busch
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- McLean Hospital, Belmont, Massachusetts
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kenneth A. Michelson
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Haiden A. Huskamp
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
38
|
Herberts MB, Teague TT, Thao V, Sangaralingham LR, Henk HJ, Hovde KT, Dempsey TM, Limper AH. Idiopathic pulmonary fibrosis in the United States: time to diagnosis and treatment. BMC Pulm Med 2023; 23:281. [PMID: 37532984 PMCID: PMC10398946 DOI: 10.1186/s12890-023-02565-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 07/16/2023] [Indexed: 08/04/2023] Open
Abstract
OBJECTIVE Create a timeline of diagnosis and treatment for IPF in the US. DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis was performed in collaboration with the OptumLabs Data Warehouse using an administrative claims database of Medicare Fee for Service beneficiaries. Adults 50 and over with IPF were included (2014 to 2019). EXPOSURE To focus on IPF, the following diagnoses were excluded: post-inflammatory fibrosis, hypersensitivity pneumonitis, rheumatoid arthritis, sarcoidosis, scleroderma, and connective tissue disease. MAIN OUTCOMES AND MEASURES Data were collected from periods prior, during, and following initial clinical diagnosis of IPF. This included prior respiratory diagnoses, number of respiratory-related hospitalizations, anti-fibrotic and oxygen use, and survival. RESULTS A total of 44,891 with IPF were identified. The most common diagnoses prior to diagnosis of IPF were upper respiratory infections (47%), acute bronchitis (13%), other respiratory disease (10%), chronic obstructive pulmonary disease and bronchiectasis (7%), and pneumonia (6%). The average time to a diagnosis of IPF was 2.7 years after initial respiratory diagnosis. Half of patients had two or more respiratory-related hospitalizations prior to IPF diagnosis. Also, 37% of patients were prescribed oxygen prior to diagnosis of IPF. These observations suggest delayed diagnosis. We also observed only 10.4% were treated with anti-fibrotics. Overall survival declined each year after diagnosis with median survival of 2.80 years. CONCLUSIONS AND RELEVANCE Our retrospective cohort demonstrates that IPF is often diagnosed late, usually preceded by other respiratory diagnoses and hospitalizations. Use of available therapies is low and outcomes remain poor.
Collapse
Affiliation(s)
- Michelle B Herberts
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Gonda 18-South, 200 1st St SW, Rochester, MN, 55905, USA
| | - Taylor T Teague
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Gonda 18-South, 200 1st St SW, Rochester, MN, 55905, USA
| | - Viengneesee Thao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Gonda 18-South, 200 1st St SW, Rochester, MN, 55905, USA
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Gonda 18-South, 200 1st St SW, Rochester, MN, 55905, USA
| | - Henry J Henk
- OptumLabs ®, 1 Main Street #10, Cambridge, MA, 02142, USA
| | - Kevin T Hovde
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Gonda 18-South, 200 1st St SW, Rochester, MN, 55905, USA
| | - Timothy M Dempsey
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Gonda 18-South, 200 1st St SW, Rochester, MN, 55905, USA
- David Grant Medical Center, US Air Force, Travis AFB, CA, 94535, USA
| | - Andrew H Limper
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Gonda 18-South, 200 1st St SW, Rochester, MN, 55905, USA.
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Gonda 18-South, 200 1st St SW, Rochester, MN, 55905, USA.
| |
Collapse
|
39
|
Stevens MA, Melnick ER, Savitz ST, Jeffery MM, Nath B, Janke AT. National trends in emergency conditions through the Omicron COVID-19 wave in commercial and Medicare Advantage enrollees. J Am Coll Emerg Physicians Open 2023; 4:e13023. [PMID: 37576118 PMCID: PMC10423035 DOI: 10.1002/emp2.13023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/11/2023] [Accepted: 07/20/2023] [Indexed: 08/15/2023] Open
Abstract
Objective To evaluate trends in emergency care sensitive conditions (ECSCs) from pre-COVID (March 2018-February 2020) through Omicron (December 2021-February 2022). Methods This cross-sectional analysis evaluated trends in ECSCs using claims (OptumLabs Data Warehouse) from commercial and Medicare Advantage enrollees. Emergency department (ED) visits for ECSCs (acute appendicitis, aortic aneurysm/dissection, cardiac arrest/severe arrhythmia, cerebral infarction, myocardial infarction, pulmonary embolism, opioid overdose, pre-eclampsia) were reported per 100,000 person months from March 2018 to February 2022 by pandemic wave. We calculated the percent change for each pandemic wave compared to the pre-pandemic period. Results There were 10,268,554 ED visits (March 2018-February 2022). The greatest increases in ECSCs were seen for pulmonary embolism, cardiac arrest/severe arrhythmia, myocardial infarction, and pre-eclampsia. For commercial enrollees, pulmonary embolism visit rates increased 22.7% (95% confidence interval [CI], 18.6%-26.9%) during Waves 2-3, 37.2% (95% CI, 29.1%-45.8%] during Delta, and 27.9% (95% CI, 20.3%-36.1%) during Omicron, relative to pre-pandemic rates. Cardiac arrest/severe arrhythmia visit rates increased 4.0% (95% CI, 0.2%-8.0%) during Waves 2-3; myocardial infarction rates increased 4.9% (95% CI, 2.1%-7.8%) during Waves 2-3. Similar patterns were seen in Medicare Advantage enrollees. Pre-eclampsia visit rates among reproductive-age female enrollees increased 31.1% (95% CI, 20.9%-42.2%), 23.7% (95% CI, 7.5%,-42.3%), and 34.7% (95% CI, 16.8%-55.2%) during Waves 2-3, Delta, and Omicron, respectively. ED visits for other ECSCs declined or exhibited smaller increases. Conclusions ED visit rates for acute cardiovascular conditions, pulmonary embolism and pre-eclampsia increased despite declines or stable rates for all-cause ED visits and ED visits for other conditions. Given the changing landscape of ECSCs, studies should identify drivers for these changes and interventions to mitigate them.
Collapse
Affiliation(s)
- Maria A Stevens
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester Minnesota USA
- Division of Health Care Delivery Research Mayo Clinic Rochester Minnesota USA
- Department of Health Policy and Management University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
- OptumLabs Eden Prairie Minnesota USA
| | - Edward R Melnick
- Department of Emergency Medicine Yale School of Medicine New Haven Connecticut USA
- Department of Biostatistics (Health Informatics) Yale School of Public Health New Haven USA
| | - Samuel T Savitz
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester Minnesota USA
- Division of Health Care Delivery Research Mayo Clinic Rochester Minnesota USA
| | - Molly Moore Jeffery
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester Minnesota USA
- Division of Health Care Delivery Research Mayo Clinic Rochester Minnesota USA
- Department of Emergency Medicine Mayo Clinic Rochester USA
| | - Bidisha Nath
- Department of Emergency Medicine Yale School of Medicine New Haven Connecticut USA
| | - Alexander T Janke
- Department of Emergency Medicine Yale School of Medicine New Haven Connecticut USA
- Institute for Healthcare Policy and Innovation University of Michigan/VA Ann Arbor Ann Arbor Michigan USA
| |
Collapse
|
40
|
Ramsey SD, Bansal A, Li L, O'Donnell PV, Fuchs EJ, Brunstein CG, Eapen M, Thao V, Roth JA, Steuten LMG. Cost-Effectiveness of Unrelated Umbilical Cord Blood Transplantation versus HLA-Haploidentical Related Bone Marrow Transplantation: Evidence from BMT CTN 1101. Transplant Cell Ther 2023; 29:464.e1-464.e8. [PMID: 37120135 PMCID: PMC10353308 DOI: 10.1016/j.jtct.2023.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/06/2023] [Accepted: 04/24/2023] [Indexed: 05/01/2023]
Abstract
BMT CTN 1101 was a Phase III randomized controlled trial comparing reduced-intensity conditioning followed by double unrelated umbilical cord blood transplantation (UCBT) versus HLA-haploidentical related donor bone marrow transplantation (haplo-BMT) for patients with high-risk hematologic malignancies. Here we report the results of a parallel cost-effectiveness analysis of these 2 hematopoietic stem cell transplantation (HCT) techniques. In this study, 368 patients were randomized to unrelated UCBT (n = 186) or haplo-BMT (n = 182). We estimated healthcare utilization and costs using propensity score-matched haplo-BMT recipients from the OptumLabs Data Warehouse for trial participants age <65 years and Medicare claims for participants age ≥65 years. Weibull models were used to estimate 20-year survival. EQ-5D surveys by trial participants were used to estimate quality-adjusted life-years (QALYs). At a 5-year follow-up, survival was 42% for haplo-BMT recipients versus 36% for UCBT recipients (P = .06). Over a 20-year time horizon, haplo-BMT is expected to be more effective (+.63 QALY) and more costly (+$118,953) for persons age <65 years. For those age ≥65 years, haplo-BMT is expected to be more effective and less costly. In one-way uncertainty analyses, for persons age <65, the cost per QALY result was most sensitive to life-years and health state utilities, whereas for those age ≥65, life- years were more influential than costs and health state utilities. Compared to UCBT, haplo-BMT was moderately more cost-effective for patients age <65 years and less costly and more effective for persons age ≥65 years. Haplo-BMT is a fair value choice for commercially insured patients with high-risk leukemia and lymphoma who require HCT. For Medicare enrollees, haplo-BMT is a preferred choice when considering costs and outcomes.
Collapse
Affiliation(s)
- Scott D Ramsey
- Fred Hutchinson Cancer Center, Seattle, Washington; CHOICE Institute, Department of Pharmacy, University of Washington, Seattle, Washington.
| | - Aasthaa Bansal
- Fred Hutchinson Cancer Center, Seattle, Washington; CHOICE Institute, Department of Pharmacy, University of Washington, Seattle, Washington
| | - Lily Li
- Fred Hutchinson Cancer Center, Seattle, Washington
| | - Paul V O'Donnell
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Ephraim J Fuchs
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Claudio G Brunstein
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Mary Eapen
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Viengneesee Thao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; OptumLabs, Edina, Minnesota
| | - Joshua A Roth
- CHOICE Institute, Department of Pharmacy, University of Washington, Seattle, Washington; Pfizer, New York, New York
| | | |
Collapse
|
41
|
Desai M, Zhou B, Nalawade V, Murphy J, Veeravalli N, Henk H, Gyamfi-Bannerman C, Whitcomb B, Su HI. Maternal comorbidity and adverse perinatal outcomes in survivors of adolescent and young adult cancer: A cohort study. BJOG 2023; 130:779-789. [PMID: 36655360 PMCID: PMC10401611 DOI: 10.1111/1471-0528.17380] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 10/04/2022] [Accepted: 10/19/2022] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To evaluate risks of preterm birth (PTB) and severe maternal morbidity (SMM) in female survivors of adolescent and young adult cancer and assess maternal comorbidity as a potential mechanism. To determine whether associations differ by use of assisted reproductive technology (ART). DESIGN Retrospective cohort. SETTING Commercially insured females in the USA. SAMPLE Females with live births from 2000-2019 within a de-identified US administrative health claims data set. METHODS Log-binomial regression models estimated relative risks of PTB and SMM by cancer status and tested for effect modification. Causal mediation analysis evaluated the proportions explained by maternal comorbidity. MAIN OUTCOME MEASURES PTB and SMM. RESULTS Among 46 064 cancer survivors, 2440 singleton births, 214 multiple births and 2590 linked newborns occurred after cancer diagnosis. In singleton births, the incidence of PTB was 14.8% in cancer survivors versus 12.4% in females without cancer (aRR 1.19, 95% CI 1.06-1.34); the incidence of SMM was 3.9% in cancer survivors versus 2.4% in females without cancer (aRR 1.44, 95% CI 1.13-1.83). Cancer survivors had more maternal comorbidities before and during pregnancy; 26% of the association between cancer and PTB and 30% of the association between cancer and SMM was mediated by maternal comorbidities. Tests for effect modification of cancer status on perinatal outcomes by ART were non-significant. CONCLUSIONS Preterm birth and SMM risks were modestly increased after cancer. Significant proportions of elevated risks may result from increased comorbidities. ART did not significantly modify the association between adolescent and young adult cancer and adverse perinatal outcomes. The prevention and treatment of comorbidities provides an opportunity to improve perinatal outcomes among cancer survivors.
Collapse
Affiliation(s)
- Milli Desai
- Department of Obstetrics, Gynecology, and Reproductive Sciences; University of California, San Diego, 3855 Health Sciences Drive, Dept 0901, La Jolla, CA 92093-0901, USA
| | - Beth Zhou
- Department of Obstetrics, Gynecology, and Reproductive Sciences; University of California, San Diego, 3855 Health Sciences Drive, Dept 0901, La Jolla, CA 92093-0901, USA
| | - Vinit Nalawade
- Department of Radiation Medicine and Applied Sciences; University of California, San Diego, La Jolla CA
| | - James Murphy
- Department of Radiation Medicine and Applied Sciences; University of California, San Diego, La Jolla CA
| | | | | | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics, Gynecology, and Reproductive Sciences; University of California, San Diego, 3855 Health Sciences Drive, Dept 0901, La Jolla, CA 92093-0901, USA
| | - Brian Whitcomb
- Department of Biostatistics and Epidemiology; University of Massachusetts, 433 Arnold House, 715 N Pleasant St, Amherst, MA 01003, USA
| | - H. Irene Su
- Department of Obstetrics, Gynecology, and Reproductive Sciences; University of California, San Diego, 3855 Health Sciences Drive, Dept 0901, La Jolla, CA 92093-0901, USA
| |
Collapse
|
42
|
Nargesi AA, Clark C, Aminorroaya A, Chen L, Liu M, Reddy A, Amodeo S, Oikonomou EK, Suchard MA, McGuire DK, Lin Z, Inzucchi S, Khera R. Persistence on Novel Cardioprotective Antihyperglycemic Therapies in the United States. Am J Cardiol 2023; 196:89-98. [PMID: 37012183 PMCID: PMC11007258 DOI: 10.1016/j.amjcard.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 02/09/2023] [Accepted: 03/01/2023] [Indexed: 04/05/2023]
Abstract
Selected glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT-2is) have cardioprotective effects in patients with type 2 diabetes mellitus (T2D) and elevated cardiovascular risk. Prescription and consistent use of these medications are essential to realizing their benefits. In a nationwide deidentified United States administrative claims database of adults with T2D, the prescription practices of GLP-1RAs and SGLT-2i were evaluated across guideline-directed co-morbidity indications from 2018 to 2020. The monthly fill rates were assessed for 12 months after the initiation of therapy by calculating the proportion of days with consistent medication use. Of 587,657 subjects with T2D, 80,196 (13.6%) were prescribed GLP-1RAs and 68,149 (11.5%) SGLT-2i from 2018 to 2020, representing 12.9% and 11.6% of patients with indications for each medication, respectively. In new initiators, 1-year fill rate was 52.5% for GLP-1RAs and 52.9% for SGLT-2i, which was higher for patients with commercial insurance than those with Medicare Advantage plans for both GLP-1RAs (59.3% vs 51.0%, p <0.001) and SGLT-2i (63.4% vs 50.3%, p <0.001). After adjusting for co-morbidities, there were higher rates of prescription fills for patients with commercial insurance (odds ratio 1.17, 95% confidence interval 1.06 to 1.29 for GLP-1RAs, and 1.59 [1.42 to 1.77] for SGLT-2i); and higher income (odds ratio 1.09 [1.06 to 1.12] for GLP-1RAs, and 1.06 [1.03 to 1.1] for SGLT-2i). From 2018 to 2020, the use of GLP-1RAs and SGLT-2i remained limited to fewer than 1 in 8 patients with T2D and indications, with 1-year fill rates around 50%. The low and inconsistent use of these medications compromises their longitudinal health outcome benefits in a period of expanding indications for their use.
Collapse
Affiliation(s)
- Arash A Nargesi
- Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Lian Chen
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Mengni Liu
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | | | | | | | - Marc A Suchard
- Department of Biostatistics, Fielding School of Public Health and; Department of Biomathematics, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Cardiology Department, Parkland Health and Hospital Systems, Dallas, Texas
| | - Zhenqiu Lin
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Silvio Inzucchi
- Endocrinology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Rohan Khera
- Cardiovascular Medicine, and; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.
| |
Collapse
|
43
|
Sehrawat O, Kashou AH, Van Houten HK, Cohen K, Joe Henk H, Gersh BJ, Abraham NS, Graff-Radford J, Friedman PA, Siontis KC, Noseworthy PA, Yao X. Contemporary trends and barriers to oral anticoagulation therapy in Non-valvular atrial fibrillation during DOAC predominant era. IJC HEART & VASCULATURE 2023; 46:101212. [PMID: 37168417 PMCID: PMC10164915 DOI: 10.1016/j.ijcha.2023.101212] [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: 01/30/2023] [Revised: 04/11/2023] [Accepted: 04/18/2023] [Indexed: 05/13/2023]
Abstract
There is a need to reassess contemporary oral anticoagulation (OAC) trends and barriers against guideline directed therapy in the United States. Most previous studies were performed before major guideline changes recommended direct oral anticoagulant (DOAC) use over warfarin or have otherwise lacked patient level data. Data on overuse of OAC in low-risk group is also limited. To address these knowledge gaps, we performed a nationwide analysis to analyze current trends. This is a retrospective cohort study assessing non-valvular AF identified using a large United States de-identified administrative claims database, including commercial and Medicare Advantage enrollees. Prescription fills were assessed within a 90-day follow-up from the patient's index AF encounter between January 1, 2016, and December 31, 2020. Among the 339,197 AF patients, 4.4%, 8.0%, and 87.6% were in the low-, moderate-, and high-risk groups (according to CHA2DS2-VASc score). An over (29.6%) and under (52.2%) utilization of OAC was reported in low- and high-risk AF patients. A considerably high frequency for warfarin use was also noted among high-risk group patients taking OAC (33.1%). The results suggest that anticoagulation use for stroke prevention in the United States is still comparable to the pre-DOAC era studies. About half of newly diagnosed high-risk non-valvular AF patients remain unprotected against stroke risk. Several predictors of OAC and DOAC use were also identified. Our findings may identify a population at risk of complications due to under- or over-treatment and highlight the need for future quality improvement efforts.
Collapse
Affiliation(s)
- Ojasav Sehrawat
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Anthony H. Kashou
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Holly K. Van Houten
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
| | - Ken Cohen
- Optum Center for Research and Innovation, Minnetonka, MN, United States
| | - Henry Joe Henk
- UnitedHealthcare, 9700 Health Care Lane, Minnetonka, MN 55343, USA
| | - Bernard J. Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Neena S. Abraham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Scottsdale, AZ, United States
| | | | - Paul A. Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | | | - Peter A. Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
- Corresponding author at: Department of Cardiovascular Medicine Mayo Clinic, 200 First Street SW |, Rochester, MN 55905, United States.
| | - Xiaoxi Yao
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
44
|
Ngufor C, Yao X, Inselman JW, Ross JS, Dhruva SS, Graham DJ, Lee JY, Siontis KC, Desai NR, Polley E, Shah ND, Noseworthy PA. Identifying treatment heterogeneity in atrial fibrillation using a novel causal machine learning method. Am Heart J 2023; 260:124-140. [PMID: 36893934 PMCID: PMC10615250 DOI: 10.1016/j.ahj.2023.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 02/02/2023] [Accepted: 02/25/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Lifelong oral anticoagulation is recommended in patients with atrial fibrillation (AF) to prevent stroke. Over the last decade, multiple new oral anticoagulants (OACs) have expanded the number of treatment options for these patients. While population-level effectiveness of OACs has been compared, it is unclear if there is variability in benefit and risk across patient subgroups. METHODS We analyzed claims and medical data for 34,569 patients who initiated a nonvitamin K antagonist oral anticoagulant (non-vitamin K antagonist oral anticoagulant (NOAC); apixaban, dabigatran, and rivaroxaban) or warfarin for nonvalvular AF between 08/01/2010 and 11/29/2017 from the OptumLabs Data Warehouse. A machine learning (ML) method was applied to match different OAC groups on several baseline variables including, age, sex, race, renal function, and CHA2DS2 -VASC score. A causal ML method was then used to discover patient subgroups characterizing the head-to-head treatment effects of the OACs on a primary composite outcome of ischemic stroke, intracranial hemorrhage, and all-cause mortality. RESULTS The mean age, number of females and white race in the entire cohort of 34,569 patients were 71.2 (SD, 10.7) years, 14,916 (43.1%), and 25,051 (72.5%) respectively. During a mean follow-up of 8.3 (SD, 9.0) months, 2,110 (6.1%) of patients experienced the composite outcome, of whom 1,675 (4.8%) died. The causal ML method identified 5 subgroups with variables favoring apixaban over dabigatran; 2 subgroups favoring apixaban over rivaroxaban; 1 subgroup favoring dabigatran over rivaroxaban; and 1 subgroup favoring rivaroxaban over dabigatran in terms of risk reduction of the primary endpoint. No subgroup favored warfarin and most dabigatran vs warfarin users favored neither drug. The variables that most influenced favoring one subgroup over another included Age, history of ischemic stroke, thromboembolism, estimated glomerular filtration rate, Race, and myocardial infarction. CONCLUSIONS Among patients with AF treated with a NOAC or warfarin, a causal ML method identified patient subgroups with differences in outcomes associated with OAC use. The findings suggest that the effects of OACs are heterogeneous across subgroups of AF patients, which could help personalize the choice of OAC. Future prospective studies are needed to better understand the clinical impact of the subgroups with respect to OAC selection.
Collapse
Affiliation(s)
- Che Ngufor
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN.
| | - Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
| | - Jonathan W Inselman
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
| | - Joseph S Ross
- Department of Internal Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
| | - Sanket S Dhruva
- Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA; Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - David J Graham
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Joo-Yeon Lee
- Office of Biostatistics, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | | | - Nihar R Desai
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
| | - Eric Polley
- Department of Public Health Sciences, University of Chicago, Chicago, IL
| | | | - Peter A Noseworthy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
45
|
Dickow J, Kany S, Cardoso VR, Ellinor PT, Gkoutos GV, Van Houten HK, Kirchhof P, Metzner A, Noseworthy PA, Yao X, Rillig A. Outcomes of Early Rhythm Control Therapy in Patients With Atrial Fibrillation and a High Comorbidity Burden in Large Real-World Cohorts. Circ Arrhythm Electrophysiol 2023; 16:e011585. [PMID: 36942567 PMCID: PMC10205477 DOI: 10.1161/circep.122.011585] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/24/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND A recent subanalysis of the EAST-AFNET 4 (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial) suggests a stronger benefit of early rhythm control (ERC) in patients with atrial fibrillation and a high comorbidity burden when compared to patients with a lower comorbidity burden. METHODS We identified 109 739 patients with newly diagnosed atrial fibrillation in a large United States deidentified administrative claims database (OptumLabs) and 11 625 patients in the population-based UKB (UK Biobank). ERC was defined as atrial fibrillation ablation or antiarrhythmic drug therapy within the first year after atrial fibrillation diagnosis. Patients were classified as (1) ERC and high comorbidity burden (CHA2DS2-VASc score ≥4); (2) ERC and lower comorbidity burden (CHA2DS2-VASc score 2-3); (3) no ERC and high comorbidity burden; and (4) no ERC and lower comorbidity burden. Patients without an elevated comorbidity burden (CHA2DS2-VASc score 0-1) were excluded. Propensity score overlap weighting and cox proportional hazards regression were used to balance patients and compare groups for the primary composite outcome of all-cause mortality, stroke, or hospitalization with the diagnoses heart failure or myocardial infarction as well as for a primary composite safety outcome of death, stroke, and serious adverse events related to ERC. RESULTS In both cohorts, ERC was associated with a reduced risk for the primary composite outcome in patients with a high comorbidity burden (OptumLabs: hazard ratio, 0.83 [95% CI 0.72-0.95]; P=0.006; UKB: hazard ratio, 0.77 [95% CI, 0.63-0.94]; P=0.009). In patients with a lower comorbidity burden, the difference in outcomes was not significant (OptumLabs: hazard ratio, 0.92 [95% CI, 0.54-1.57]; P=0.767; UKB: hazard ratio, 0.94 [95% CI, 0.83-1.06]; P=0.310). The comorbidity burden interacted with ERC in the UKB (interaction- P=0.027) but not in OptumLabs (interaction-P=0.720). ERC was not associated with an increased risk for the primary safety outcome. CONCLUSIONS ERC is safe and may be more favorable in a population-based sample of patients with high a comorbidity burden (CHA2DS2-VASc score ≥4).
Collapse
Affiliation(s)
- Jannis Dickow
- Dept of Cardiology, Univ Heart & Vascular Center Hamburg, Univ Hospital Hamburg Eppendorf, Hamburg
- DZHK (German Ctr for Cardiovascular Rsrch), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
| | - Shinwan Kany
- Dept of Cardiology, Univ Heart & Vascular Center Hamburg, Univ Hospital Hamburg Eppendorf, Hamburg
- DZHK (German Ctr for Cardiovascular Rsrch), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
- Cardiovascular Disease Initiative, The Broad Inst of MIT & Harvard, Cambridge, MA
| | - Victor Roth Cardoso
- Institute of Cardiovascular Sciences
- Institute of Cancer & Genomic Sciences, Univ of Birmingham
- Health Data Rsrch UK, Midlands Site, Birmingham, United Kingdom
| | - Patrick T. Ellinor
- Cardiovascular Disease Initiative, The Broad Inst of MIT & Harvard, Cambridge, MA
- Cardiovascular Rsrch Ctr, Massachusetts General Hospital, Boston, MA
| | - Georgios V. Gkoutos
- Institute of Cardiovascular Sciences
- Institute of Cancer & Genomic Sciences, Univ of Birmingham
- Health Data Rsrch UK, Midlands Site, Birmingham, United Kingdom
| | - Holly K. Van Houten
- OptumLabs, Eden Prairie
- Robert D. & Patricia E. Kern Ctr for the Science of Health Care Delivery
| | - Paulus Kirchhof
- Dept of Cardiology, Univ Heart & Vascular Center Hamburg, Univ Hospital Hamburg Eppendorf, Hamburg
- DZHK (German Ctr for Cardiovascular Rsrch), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
- Institute of Cardiovascular Sciences
| | - Andreas Metzner
- Dept of Cardiology, Univ Heart & Vascular Center Hamburg, Univ Hospital Hamburg Eppendorf, Hamburg
- DZHK (German Ctr for Cardiovascular Rsrch), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
| | - Peter A. Noseworthy
- Robert D. & Patricia E. Kern Ctr for the Science of Health Care Delivery
- Dept of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Xiaoxi Yao
- Robert D. & Patricia E. Kern Ctr for the Science of Health Care Delivery
- Dept of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Andreas Rillig
- Dept of Cardiology, Univ Heart & Vascular Center Hamburg, Univ Hospital Hamburg Eppendorf, Hamburg
- DZHK (German Ctr for Cardiovascular Rsrch), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
| |
Collapse
|
46
|
Hane CA, Wasserman M. Designing Equitable Health Care Outreach Programs From Machine Learning Patient Risk Scores. Med Care Res Rev 2023; 80:216-227. [PMID: 35685000 DOI: 10.1177/10775587221098831] [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: 11/16/2022]
Abstract
There is growing interest in ensuring equity and guarding against bias in the use of risk scores produced by machine learning and artificial intelligence models. Risk scores are used to select patients who will receive outreach and support. Inappropriate use of risk scores, however, can perpetuate disparities. Commonly advocated solutions to improve equity are nontrivial to implement and may not pass legal scrutiny. In this article, we introduce pragmatic tools that support better use of risk scores for more equitable outreach programs. Our model output charts allow modeling and care management teams to see the equity consequences of different threshold choices and to select the optimal risk thresholds to trigger outreach. For best results, as with any health equity tool, we recommend that these charts be used by a diverse team and shared with relevant stakeholders.
Collapse
|
47
|
McCoy RG, Herrin J, Galindo RJ, Sindhu Swarna K, Umpierrez GE, Hill Golden S, O'Connor PJ. All-cause mortality after hypoglycemic and hyperglycemic emergencies among U.S. adults with diabetes, 2011-2020. Diabetes Res Clin Pract 2023; 197:110263. [PMID: 36693542 PMCID: PMC10023431 DOI: 10.1016/j.diabres.2023.110263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/12/2023] [Accepted: 01/19/2023] [Indexed: 01/22/2023]
Abstract
Estimated all-cause mortality within 30-days of hypoglycemic emergencies is 0.8 % in adults with type 1 diabetes and 1.7 % with type 2 diabetes; and within 30-days of hyperglycemic emergencies, it is 1.2 % with type 1 diabetes and 2.8 % with type 2 diabetes. These rates changed little between 2011 and 2020.
Collapse
Affiliation(s)
- Rozalina G McCoy
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN, United States; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 First Street SW, Rochester, MN, United States.
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Rodolfo J Galindo
- Division of Endocrinology, Department of Medicine, Comprehensive Diabetes Center at Lennar Medical Foundation, University of Miami, Miami, FL, United States
| | - Kavya Sindhu Swarna
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 First Street SW, Rochester, MN, United States; OptumLabs, Eden Prairie, MN, United States
| | - Guillermo E Umpierrez
- Emory University School of Medicine, Department of Medicine, Division of Endocrinology, Grady Memorial Hospital, Atlanta, GA, United States
| | - Sherita Hill Golden
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine Johns Hopkins Medicine, Baltimore, MD, United States; Office of Diversity, Inclusion, and Health Equity, Johns Hopkins Medicine, Baltimore, MD, United States
| | - Patrick J O'Connor
- Center for Chronic Care Innovation, HealthPartners Institute, Minneapolis, MN, United States
| |
Collapse
|
48
|
Metabolic Acidosis and Adverse Outcomes and Costs in CKD: An Observational Cohort Study. Kidney Med 2023; 5:100622. [PMID: 37139081 PMCID: PMC10149501 DOI: 10.1016/j.xkme.2023.100622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
Rationale & Objective Metabolic acidosis is a risk factor for progression of chronic kidney disease (CKD), but little is known about its effect on health care costs and resource utilization. We describe the associations between metabolic acidosis, adverse kidney outcomes, and health care costs in patients with CKD stages G3-G5 and not receiving dialysis. Study Design Retrospective cohort study. Setting & Participants An integrated claims-clinical data set of US patients with CKD stages G3-G5, with serum bicarbonate values of 12 to <22 mEq/L (metabolic acidosis group) or 22 to 29 mEq/L (normal serum bicarbonate level group). Predictor The primary exposure variable was the baseline serum bicarbonate level. Outcomes The primary clinical outcome was the composite of all-cause mortality, maintenance dialysis, kidney transplant, or a decline in the estimated glomerular filtration rate of ≥40% (DD40). The primary cost outcome was all-cause predicted per-patient per-year cost, assessed over a 2-year outcome period. Analytical Approach Logistic and generalized linear regression models, adjusted for key covariates such as age, sex, race, kidney function, comorbidities, and pharmacy insurance coverage, were used to assess serum bicarbonate levels as a predictor of DD40 and health care costs, respectively. Results 51,558 patients qualified. The metabolic acidosis group experienced higher rates of DD40 (48.3% vs. 16.7%, P < 0.001) and higher all-cause yearly costs ($65,172 vs. $24,681, P < 0.001). Two-year adjusted odds ratio of DD40 per 1-mEq/L increase in serum bicarbonate levels was 0.873 (95% CI, 0.866-0.879); the parameter estimate (±SE) for costs was -0.070 ± 0.0075 (P < 0.001). Limitations Possible residual confounding. Conclusions Patients with CKD and metabolic acidosis had higher costs and rates of adverse kidney outcomes compared with patients with normal serum bicarbonate levels. Each 1-mEq/L increase in serum bicarbonate levels was associated with a 13% decrease in 2-year DD40 events and a 7% decrease in per-patient per-year cost.
Collapse
|
49
|
Huang Y, Schaff HV, Swarna KS, Sangaralingham LR, Nishimura RA, Dearani JA, Crestanello JA, Greason KL. Anticoagulation After Bioprosthetic Aortic Valve Replacement: Are We Following the Guidelines? Ann Thorac Surg 2023; 115:619-625. [PMID: 35779595 DOI: 10.1016/j.athoracsur.2022.05.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 04/22/2022] [Accepted: 05/09/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Guideline-directed medication adherence is considered an important quality measure after cardiac surgery. We evaluated compliance with the American College of Cardiology/American Heart Association guidelines for warfarin use after surgical aortic valve replacement (sAVR) using bioprostheses and examined potential variations in anticoagulation practice over time. METHODS Using the OptumLabs Data Warehouse, we investigated adult patients having bioprosthetic sAVR with or without coronary artery bypass (2007-2019). Early postoperative warfarin use was defined as ≥30 days of continuous prescription coverage after sAVR. RESULTS Among 10 730 adult patients having sAVR, 3071 (28.6%) received warfarin early postoperatively. Median length of warfarin prescription coverage was 4.5 months (interquartile range, 3.0-8.9 months). However, only 11.1% (736/6634) had warfarin prescription coverage of 3 to 6 months in compliance with the most recent guidelines. Yearly warfarin prescription rate did not change significantly during the 13-year period (P = .386). Compared with patients from the non-warfarin group, those receiving warfarin prescriptions were older and more likely to be male and to have atrial fibrillation, congestive heart failure, chronic pulmonary disease, and CHA2DS2-VASc score ≥2; warfarin use was also greater in patients receiving prescriptions for other cardiac medications (P < .05). CONCLUSIONS Anticoagulation after sAVR as reflected by warfarin prescriptions may be underused; the rates of warfarin use have not changed in the last decade. Although additional studies are needed to confirm the benefit of early anticoagulation after sAVR, these results indicate that guideline recommendations are not followed by most clinicians. The findings highlight a potentially important area for quality improvement.
Collapse
Affiliation(s)
- Ying Huang
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | - Kavya S Swarna
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Rick A Nishimura
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
50
|
Reaven NL, Funk SE, Mathur V, Ferguson TW, Lai J, Tangri N. Association of the Kidney Failure Risk Equation With High Health Care Costs. Kidney Int Rep 2023. [DOI: 10.1016/j.ekir.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
|