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Luebke MC, Davidson ERW, Crotty BH, Fergestrom N, O'Connor RC, Schmitt E, Winn AN, Flynn KE, Neuner JM. Referral and Prescription Patterns for Female Patients With Urinary Incontinence. Urogynecology (Phila) 2024; 30:489-497. [PMID: 37881958 PMCID: PMC11002977 DOI: 10.1097/spv.0000000000001423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
IMPORTANCE Although behavioral modifications, medications, and other interventions can improve urinary incontinence (UI), many women never receive them. OBJECTIVES To better characterize UI treatment patterns in primary care, we examined prescriptions and referrals to pelvic floor physical therapy (PFPT) and specialist physicians within a large Midwestern academic health system. STUDY DESIGN Electronic health records were queried to identify a cohort of adult female patients receiving a new UI diagnosis during outpatient primary care visits from 2016 to 2020. Urinary incontinence referrals and referral completion were examined for the overall cohort, and medication prescriptions were examined for women with urgency or mixed UI. Logistic regression was used to assess the association of prescriptions and/or referrals with patient demographics, comorbidities, and UI diagnosis dates. RESULTS In the year after primary care UI diagnosis, 37.2% of patients in the overall cohort (n = 4,382) received guideline-concordant care. This included 20.6% of women who were referred for further management: 17.7% to urology/urogynecology and 3.2% to PFPT. Most women who were referred attended an initial appointment. Among those with urgency (n = 2,398) or mixed UI (n = 552), 17.1% were prescribed medication. Women with stress (odds ratio [OR], 3.10; 95% CI, 2.53-3.79) and mixed UI (OR, 6.17; 95% CI, 4.03-9.66) were more likely to be referred for further management, and women diagnosed during the COVID-19 pandemic were less likely to be referred for further care (OR, 0.39; 95% CI, 0.29, 0.48). CONCLUSION Only slightly above 1 in 3 women with a new diagnosis of UI in primary care received guideline-based medications or referrals within 1 year, suggesting missed opportunities for timely care.
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Mitchell AP, Kinlaw AC, Peacock-Hinton S, Dusetzina SB, Winn AN, Sanoff HK, Lund JL. Commercial Versus Medicaid Insurance and Use of High-Priced Anticancer Treatments. Oncologist 2024:oyae035. [PMID: 38484395 DOI: 10.1093/oncolo/oyae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/16/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Because the markups on cancer drugs vary by payor, providers' financial incentive to use high-price drugs is differential according to each patient's insurance type. We evaluated the association between patient insurer (commercial vs Medicaid) and the use of high-priced cancer treatments. MATERIALS AND METHODS We linked cancer registry, administrative claims, and demographic data for individuals diagnosed with cancer in North Carolina from 2004 to 2011, with either commercial or Medicaid insurance. We selected cancers with multiple FDA-approved, guideline-recommended chemotherapy options and large price differences between treatment options: advanced colorectal, lung, and head and neck cancer. The outcome was a receipt of a higher-priced option, and the exposure was insurer: commercial versus Medicaid. We estimated risk ratios (RRs) for the association between insurer and higher-priced treatment using log-binomial models with inverse probability of exposure weights. RESULTS Of 812 patients, 209 (26%) had Medicaid. The unadjusted risk of receiving higher-priced treatment was 36% (215/603) for commercially insured and 27% (57/209) for Medicaid insured (RR: 1.31, 95% CI: 1.02-1.67). After adjustment for confounders the association was attenuated (RR: 1.15, 95% CI: 0.81-1.65). Exploratory subgroup analysis suggested that commercial insurance was associated with increased receipt of higher-priced treatment among patients treated by non-NCI-designated providers (RR: 1.53, 95% CI: 1.14-2.04). CONCLUSIONS Individuals with Medicaid and commercial insurance received high-priced treatments in similar proportion, after accounting for differences in case mix. However, modification by provider characteristics suggests that insurance type may influence treatment selection for some patient groups. Further work is needed to determine the relationship between insurance status and newer, high-price drugs such as immune-oncology agents.
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Affiliation(s)
- Aaron P Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Alan C Kinlaw
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Sharon Peacock-Hinton
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, United States
- Vanderbilt-Ingram Cancer Center, Nashville, TN, United States
| | - Aaron N Winn
- University of Illinois at Chicago, Chicago, IL, United States
| | - Hanna K Sanoff
- Department of Hematology/ Oncology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Jennifer L Lund
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Basu A, Winn AN, Johnson KM, Jiao B, Devine B, Hankins JS, Arnold SD, Bender MA, Ramsey SD. Gene Therapy Versus Common Care for Eligible Individuals With Sickle Cell Disease in the United States : A Cost-Effectiveness Analysis. Ann Intern Med 2024; 177:155-164. [PMID: 38252942 DOI: 10.7326/m23-1520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Sickle cell disease (SCD) and its complications contribute to high rates of morbidity and early mortality and high cost in the United States and African heritage community. OBJECTIVE To evaluate the cost-effectiveness of gene therapy for SCD and its value-based prices (VBPs). DESIGN Comparative modeling analysis across 2 independently developed simulation models (University of Washington Model for Economic Analysis of Sickle Cell Cure [UW-MEASURE] and Fred Hutchinson Institute Sickle Cell Disease Outcomes Research and Economics Model [FH-HISCORE]) using the same databases. DATA SOURCES Centers for Medicare & Medicaid Services claims data, 2008 to 2016; published literature. TARGET POPULATION Persons eligible for gene therapy. TIME HORIZON Lifetime. PERSPECTIVE U.S. health care sector and societal. INTERVENTION Gene therapy versus common care. OUTCOME MEASURES Incremental cost-effectiveness ratios (ICERs), equity-informed VBPs, and price acceptability curves. RESULTS OF BASE-CASE ANALYSIS At an assumed $2 million price for gene therapy, UW-MEASURE and FH-HISCORE estimated ICERs of $193 000 per QALY and $427 000 per QALY, respectively, under the health care sector perspective. Corresponding estimates from the societal perspective were $126 000 per QALY and $281 000 per QALY. The difference in results between models stemmed primarily from considering a slightly different target population and incorporating the quality-of-life (QOL) effects of splenic sequestration, priapism, and acute chest syndrome in the UW model. From a societal perspective, acceptable (>90% confidence) VBPs ranged from $1 million to $2.5 million depending on the use of alternative effective metrics or equity-informed threshold values. RESULTS OF SENSITIVITY ANALYSIS Results were sensitive to the costs of myeloablative conditioning before gene therapy, effect on caregiver QOL, and effect of gene therapy on long-term survival. LIMITATION The short-term effects of gene therapy on vaso-occlusive events were extrapolated from 1 study. CONCLUSION Gene therapy for SCD below a $2 million price tag is likely to be cost-effective when applying a societal perspective at an equity-informed threshold for cost-effectiveness analysis. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute.
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Affiliation(s)
- Anirban Basu
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, Department of Pharmacy; Department of Health Systems and Population Health; and Department of Economics, University of Washington, Seattle, Washington (A.B.)
| | - Aaron N Winn
- Pharmacy Administration, Department of Clinical Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin (A.N.W.)
| | - Kate M Johnson
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, Washington, and Faculty of Pharmaceutical Sciences and Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (K.M.J.)
| | - Boshen Jiao
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, Washington, and Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (B.J.)
| | - Beth Devine
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, Department of Pharmacy, and Department of Health Systems and Population Health, University of Washington, Seattle, Washington (B.D.)
| | - Jane S Hankins
- Department of Global Pediatric Medicine and Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee (J.S.H.)
| | - Staci D Arnold
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia (S.D.A.)
| | - M A Bender
- Department of Pediatrics, University of Washington, and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (M.A.B.)
| | - Scott D Ramsey
- Division of Public Health Sciences and Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, and the Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, Washington, and Pharmacy Administration, Department of Clinical Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin (S.D.R.)
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Affiliation(s)
| | - Aaron N Winn
- University of Illinois Chicago, Chicago, IL, USA
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Lin M, Estrada-Merly N, Eapen M, Zamora AE, Pezzin LE, Winn AN, Philip J, Schinke C, Drobyski WR, Anderson LD, D'Souza A. Widening demographic gaps in CAR-T therapy utilization for multiple myeloma in the United States. Bone Marrow Transplant 2023; 58:1400-1402. [PMID: 37673983 DOI: 10.1038/s41409-023-02102-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 08/17/2023] [Accepted: 08/30/2023] [Indexed: 09/08/2023]
Affiliation(s)
- Mingqian Lin
- Medical College of Wisconsin (MCW) Medical School, Milwaukee, WI, USA
| | - Noel Estrada-Merly
- Division of Hematology/Oncology, Department of Medicine, MCW, Milwaukee, WI, USA
| | - Mary Eapen
- Division of Hematology/Oncology, Department of Medicine, MCW, Milwaukee, WI, USA
| | - Anthony E Zamora
- Division of Hematology/Oncology, Department of Medicine, MCW, Milwaukee, WI, USA
| | | | | | - Joyce Philip
- ThedaCare Regional Cancer Center, Appleton, WI, USA
| | - Carolina Schinke
- Division of Hematology/Oncology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - William R Drobyski
- Division of Hematology/Oncology, Department of Medicine, MCW, Milwaukee, WI, USA
| | - Larry D Anderson
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - Anita D'Souza
- Division of Hematology/Oncology, Department of Medicine, MCW, Milwaukee, WI, USA.
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Winn AN, Atallah E, Cortes J, Deininger MWN, Kota V, Larson RA, Moore JO, Mauro MJ, Oehler VG, Pinilla-Ibarz J, Radich JP, Shah NP, Thompson JE, Flynn KE. Estimated Savings After Stopping Tyrosine Kinase Inhibitor Treatment Among Patients With Chronic Myeloid Leukemia. JAMA Netw Open 2023; 6:e2347950. [PMID: 38109114 PMCID: PMC10728762 DOI: 10.1001/jamanetworkopen.2023.47950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/02/2023] [Indexed: 12/19/2023] Open
Abstract
Importance Patients with chronic myeloid leukemia (CML) who have a sustained deep molecular response using tyrosine kinase inhibitors (TKIs) can safely attempt to stop their use. As these medications are very costly, this change in treatment protocols may result in large savings. Objective To estimate future savings from attempting to stop TKI use among patients with CML who have deep molecular response. Design, Setting, and Participants A microsimulation model was developed for this decision analytical modeling study to estimate costs for US adults moving from using a TKI, to attempting discontinuation and then reinitiating TKI therapy, if clinically appropriate. Estimates were calculated for US patients who currently have CML and simulated newly diagnosed cohorts of patients over the next 30 years. Exposure Attempting to stop using a TKI. Main Outcomes and Measures Estimated savings after attempted discontinuation of TKI use. Results A simulated population of individuals with CML in 2018 and future populations were created using estimates from the SEER*Explorer website. The median age at diagnosis was 66 years for men and 65 years for women. Between 2022 and 2052, the savings associated with eligible patients attempting discontinuation of TKI therapy was estimated at more than $30 billion among those currently diagnosed and over $15 billion among those who will develop CML in the future, for a total savings of over $54 billion by 2052 for drug treatment and polymerase chain reaction testing. The estimate is conservative as it does not account for complications and other health care-associated costs for patients continuing TKI therapy. Conclusions and Relevance The findings of this decision analytical modeling study of patients with CML suggest that attempting discontinuation of TKI therapy could save over $54 billion during the next 30 years. Further education for patients and physicians is needed to safely increase the number of patients who can successfully attain treatment-free remission.
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Affiliation(s)
- Aaron N. Winn
- Department of Health Systems, Outcomes and Policy, School of Pharmacy, University of Illinois at Chicago
| | - Ehab Atallah
- Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Jorge Cortes
- Georgia Cancer Center, Augusta University Medical Center, Augusta
| | | | - Vamsi Kota
- Georgia Cancer Center, Augusta University Medical Center, Augusta
| | - Richard A. Larson
- Department of Medicine and Comprehensive Cancer Center, University of Chicago, Chicago, Illinois
| | | | | | | | | | | | - Neil P. Shah
- Department of Medicine, University of California at San Francisco
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Mitchell AP, Dusetzina SB, Mishra Meza A, Trivedi NU, Bach PB, Winn AN. Pharmaceutical industry payments and delivery of non-recommended and low value cancer drugs: population based cohort study. BMJ 2023; 383:e075512. [PMID: 37879723 PMCID: PMC10599253 DOI: 10.1136/bmj-2023-075512] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE To estimate the association between oncologists' receipt of payments from the pharmaceutical industry and delivery of non-recommended or low value interventions among their patients. DESIGN Cohort study. SETTING Fee-for-service Medicare claims. PARTICIPANTS Medicare beneficiaries with a diagnosis of incident cancer (new occurrence of a cancer diagnosis code in proximity to claims for cancer treatment, and no such diagnosis codes during a ≥1 year washout period) during 2014-19, who met additional requirements identifying them as at risk for one of four non-recommended or low value interventions: denosumab for castration sensitive prostate cancer, granulocyte colony stimulating factors (GCSF) for patients at low risk for neutropenic fever, nab-paclitaxel for cancers with no evidence of superiority over paclitaxel, and a branded drug in settings where a generic or biosimilar version was available. MAIN OUTCOME MEASURES Receipt of the non-recommended or low value drug for which the patient was at risk. The primary association of interest was the assigned oncologist's receipt of any general payments from the manufacturer of the corresponding non-recommended or low value drug (measured in Open Payments) within 365 days before the patient's index cancer date. The two modeling approaches used were general linear model controlling for patients' characteristics and calendar year, and general linear model with physician level indicator variables. RESULTS Oncologists were in receipt of industry payments for 2962 of 9799 patients (30.2%) at risk for non-recommended denosumab (median $63), 76 747 of 271 485 patients (28.3%) at risk for GCSF (median $60); 18 491 of 86 394 patients (21.4%) at risk for nab-paclitaxel (median $89), and 4170 of 13 386 patients (31.2%) at risk for branded drugs (median $156). The unadjusted proportion of patients who received non-recommended denosumab was 31.4% for those whose oncologist had not received payment and 49.5% for those whose oncologist had (prevalence difference 18.0%); the corresponding values for GCSF were 26.6% v 32.1% (5.5%), for nab-paclitaxel were 7.3% v 15.1% (7.8%), and for branded drugs were 88.3% v 83.5% (-4.8%). Controlling for patients' characteristics and calendar year, payments from industry were associated with increased use of denosumab (17.5% (95% confidence interval 15.3% to 19.7%)), GCSF (5.8% (5.4% to 6.1%)), and nab-paclitaxel (7.6% (7.1% to 8.1%)), but lower use of branded drugs (-4.6% (-5.8% to -3.3%)). In physician level indicator models, payments from industry were associated with increased use of denosumab (7.4% (2.5% to 12.2%)) and nab-paclitaxel (1.7% (0.9% to 2.5%)), but not with GCSF (0.4% (-0.3% to 1.1%)) or branded drugs (1.2% (-6.0 to 8.5%)). CONCLUSIONS Within some clinical scenarios, industry payments to physicians are associated with non-recommended and low value drugs. These findings raise quality of care concerns about the financial relationships between physicians and industry.
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Affiliation(s)
- Aaron P Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10017, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stacie B Dusetzina
- Department of Health Policy and Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Akriti Mishra Meza
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10017, USA
| | | | | | - Aaron N Winn
- University of Illinois Chicago, Chicago, IL, USA
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Laiteerapong N, Alexander J, Philipson L, Winn AN, Huang ES. First-Line Therapy for Type 2 Diabetes With Sodium-Glucose Cotransporter-2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists. Ann Intern Med 2023; 176:eL230007. [PMID: 37068291 DOI: 10.7326/l23-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Affiliation(s)
- Neda Laiteerapong
- Section of General Internal Medicine and Center for Chronic Disease Research and Policy, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Jason Alexander
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Louis Philipson
- Sections of Adult and Pediatric Endocrinology, Diabetes & Metabolism, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Aaron N Winn
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Elbert S Huang
- Section of General Internal Medicine and Center for Chronic Disease Research and Policy, Department of Medicine, University of Chicago, Chicago, Illinois
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Gopalan A, Winn AN, Karter AJ, Laiteerapong N. Racial and Ethnic Differences in Medication Initiation Among Adults Newly Diagnosed with Type 2 Diabetes. J Gen Intern Med 2023; 38:994-1000. [PMID: 35927604 PMCID: PMC10039131 DOI: 10.1007/s11606-022-07746-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/13/2022] [Indexed: 10/16/2022]
Abstract
OBJECTIVE Given persistent racial/ethnic differences in type 2 diabetes outcomes and the lasting benefits conferred by early glycemic control, we examined racial/ethnic differences in diabetes medication initiation during the year following diagnosis. METHODS Among adults newly diagnosed with type 2 diabetes (2005-2016), we examined how glucose-lowering medication initiation differed by race/ethnicity during the year following diagnosis. We specified modified Poisson regression models to estimate the association between race/ethnicity and medication initiation in the entire cohort and within subpopulations defined by HbA1c, BMI, age at diagnosis, comorbidity, and neighborhood deprivation index (a census tract-level socioeconomic indicator). RESULTS Among the 77,199 newly diagnosed individuals, 47% started a diabetes medication within 12 months of diagnosis. The prevalence of medication initiation ranged from 32% among Chinese individuals to 58% among individuals of Other/Unknown races/ethnicities. Compared to White individuals, medication initiation was less likely among Chinese (relative risk: 0.78 (95% confidence interval 0.72, 0.84)) and Japanese (0.82 (0.75, 0.90)) individuals, but was more likely among Hispanic/Latinx (1.27 (1.24, 1.30)), African American (1.14 (1.11, 1.17)), other Asian (1.13 (1.08, 1.18)), South Asian (1.10 (1.04, 1.17)), Other/Unknown (1.31 (1.24, 1.39)), American Indian or Alaska Native (1.11 (1.04, 1.18)), and Native Hawaiian/Pacific Islander (1.28 (1.19, 1.37)) individuals. Racial/ethnic differences dissipated among individuals with higher HbA1c values. CONCLUSIONS Initiation of glucose-lowering treatment during the year following type 2 diabetes diagnosis differed markedly by race/ethnicity, particularly for those with lower HbA1c values. Future research should examine how patient preferences, provider implicit bias, and shared decision-making contribute to these early treatment differences.
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Affiliation(s)
- Anjali Gopalan
- Kaiser Permanente Northern California Division of Research, 2000 Broadway, Oakland, CA, 94612, USA.
| | - Aaron N Winn
- Department of Clinical Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Andrew J Karter
- Kaiser Permanente Northern California Division of Research, 2000 Broadway, Oakland, CA, 94612, USA
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Centor RM, Laiteerapong N, Winn AN. Web Exclusive. Annals On Call - First-Line Drug Therapy for Type 2 Diabetes. Ann Intern Med 2023; 176:eA220004. [PMID: 36802895 DOI: 10.7326/a22-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Affiliation(s)
- Robert M Centor
- Huntsville Regional Medical Campus, University of Alabama Birmingham School of Medicine, Birmingham, Alabama (R.M.C.)
| | - Neda Laiteerapong
- Section of General Internal Medicine and Center for Chronic Disease Research and Policy, Department of Medicine, University of Chicago, Chicago, Illinois (N.L.)
| | - Aaron N Winn
- Medical College of Wisconsin, Milwaukee, Wisconsin (A.N.W.)
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Neuner JM, Fergestrom N, Pezzin LE, Laud PW, Ruddy KJ, Winn AN. Medication delivery factors and adjuvant endocrine therapy adherence in breast cancer. Breast Cancer Res Treat 2023; 197:223-233. [PMID: 36357711 DOI: 10.1007/s10549-022-06704-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/31/2022] [Indexed: 11/12/2022]
Abstract
PURPOSE Over 50% of breast cancer patients prescribed a 5-year course of daily oral adjuvant endocrine therapy (ET) are nonadherent. We investigated the role of costs and cancer medication delivery mode and other medication delivery factors on adherence. METHODS We conducted a retrospective cohort study of commercially insured and Medicare advantage patients with newly diagnosed breast cancer in 2007-2015 who initiated ET. We examined the association between 12-month ET adherence (proportion of days covered by fills ≥ 0.80) and ET copayments, 90-day prescription refill use, mail order pharmacy use, number of pharmacies, and synchronization of medications. We used regression models to estimate nonadherence risk ratios adjusted for demographics (age, income, race, urbanicity), comorbidities, total medications, primary cancer treatments, and generic AI availability. Sensitivity analyses were conducted using alternative specifications for independent variables. RESULTS Mail order users had higher adherence in both commercial and Medicare-insured cohorts. Commercially insured patients who used mail order were more likely to be adherent if they had low copayments (< $5) and 90-day prescription refills. For commercially insured patients who used local pharmacies, use of one pharmacy and better synchronized refills were also associated with adherence. Among Medicare patients who used mail order pharmacies, only low copayments were associated with adherence, while among Medicare patients using local pharmacies both low copayments and 90-day prescriptions were associated with ET adherence. CONCLUSION Out-of-pocket costs, medication delivery mode, and other pharmacy-related medication delivery factors are associated with adherence to breast cancer ET. Future work should investigate whether interventions aimed at streamlining medication delivery could improve adherence for breast cancer patients.
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Affiliation(s)
- Joan M Neuner
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA. .,Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Nicole Fergestrom
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Liliana E Pezzin
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Purushottam W Laud
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA.,Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kathryn J Ruddy
- The Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Aaron N Winn
- School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI, USA
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Holt JM, Cusatis R, Mortensen N, Wolfrath N, Hyun N, Winn AN, Brown SA, Somai MM, Crotty BH. Twenty-first century house calls: a survey of ambulatory care providers to inform organisational telehealth strategy. BMJ Health Care Inform 2022; 29:bmjhci-2022-100626. [PMID: 36564094 PMCID: PMC9791455 DOI: 10.1136/bmjhci-2022-100626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 11/13/2022] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES While patient interest in telehealth increases, clinicians' perspectives may influence longer-term adoption. We sought to identify facilitators and barriers to continued clinician incorporation of telehealth into practice. METHODS A cross-sectional 24-item web-based survey was emailed to 491 providers with ≥50 video visits (VVs) within an academic health system between 1 March 2020 and 31 December 2020. We quantitatively summarised the characteristics and perceptions of respondents by using descriptive and test statistics. We used systematic content analysis to qualitatively code open-ended responses, double coding at least 25%. RESULTS 247 providers (50.3%) responded to the survey. Seventy-nine per cent were confident in their ability to deliver excellent clinical care through VV. In comparison, 48% were confident in their ability to troubleshoot technical issues. Most clinicians (87%) expressed various concerns about VV. Providers across specialties generally agreed that VV reduced infection risk (71%) and transportation barriers (71%). Three overarching themes in the qualitative data included infrastructure and training, usefulness and expectation setting for patients and providers. DISCUSSION As healthcare systems plan for future delivery directions, they must address the tension between patients' and providers' expectations of care within the digital space. Telehealth creates new friction, one where the healthcare system must fit into the patient's life rather than the usual dynamic of the patient fitting into the healthcare system. CONCLUSION Telehealth infrastructure and patient and clinician technological acumen continue to evolve. Clinicians in this survey offered valuable insights into the directions healthcare organisations can take to right-size this healthcare delivery modality.
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Affiliation(s)
- Jeana M Holt
- College of Nursing, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA,Family and Community Medicine, Medical College of Wisconsin Department of Family and Community Medicine, Milwaukee, Wisconsin, USA
| | - Rachel Cusatis
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Natalie Mortensen
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nathan Wolfrath
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Noorie Hyun
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente, Seattle, Washington, USA
| | - Aaron N Winn
- School of Pharmacy, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sherry-Ann Brown
- Cardio-Oncology, Medical College of Wisconsin Cardiovascular Center, Milwaukee, Wisconsin, USA
| | - Melek M Somai
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Bradley H Crotty
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Choi JG, Winn AN, Skandari MR, Franco MI, Staab EM, Alexander J, Wan W, Zhu M, Huang ES, Philipson L, Laiteerapong N. First-Line Therapy for Type 2 Diabetes With Sodium-Glucose Cotransporter-2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists : A Cost-Effectiveness Study. Ann Intern Med 2022; 175:1392-1400. [PMID: 36191315 PMCID: PMC10155215 DOI: 10.7326/m21-2941] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Guidelines recommend sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP1) receptor agonists as second-line therapy for patients with type 2 diabetes. Expanding their use as first-line therapy has been proposed but the clinical benefits may not outweigh their costs. OBJECTIVE To evaluate the lifetime cost-effectiveness of a strategy of first-line SGLT2 inhibitors or GLP1 receptor agonists. DESIGN Individual-level Monte Carlo-based Markov model. DATA SOURCES Randomized trials, Centers for Disease Control and Prevention databases, RED BOOK, and the National Health and Nutrition Examination Survey. TARGET POPULATION Drug-naive U.S. patients with type 2 diabetes. TIME HORIZON Lifetime. PERSPECTIVE Health care sector. INTERVENTION First-line SGLT2 inhibitors or GLP1 receptor agonists. OUTCOME MEASURES Life expectancy, lifetime costs, incremental cost-effectiveness ratios (ICERs). RESULTS OF BASE-CASE ANALYSIS First-line SGLT2 inhibitors and GLP1 receptor agonists had lower lifetime rates of congestive heart failure, ischemic heart disease, myocardial infarction, and stroke compared with metformin. First-line SGLT2 inhibitors cost $43 000 more and added 1.8 quality-adjusted months versus first-line metformin ($478 000 per quality-adjusted life-year [QALY]). First-line injectable GLP1 receptor agonists cost more and reduced QALYs compared with metformin. RESULTS OF SENSITIVITY ANALYSIS By removing injection disutility, first-line GLP1 receptor agonists were no longer dominated (ICER, $327 000 per QALY). Oral GLP1 receptor agonists were not cost-effective (ICER, $823 000 per QALY). To be cost-effective at under $150 000 per QALY, costs for SGLT2 inhibitors would need to be under $5 per day and under $6 per day for oral GLP1 receptor agonists. LIMITATION U.S. population and costs not generalizable internationally. CONCLUSION As first-line agents, SGLT2 inhibitors and GLP1 receptor agonists would improve type 2 diabetes outcomes, but their costs would need to fall by at least 70% to be cost-effective. PRIMARY FUNDING SOURCE American Diabetes Association.
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Affiliation(s)
- Jin G Choi
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (J.G.C., M.I.F., E.M.S., J.A., M.Z.)
| | - Aaron N Winn
- Medical College of Wisconsin, Milwaukee, Wisconsin (A.N.W.)
| | - M Reza Skandari
- Centre for Health Economics & Policy Innovation, Imperial College Business School, Imperial College London, London, United Kingdom (M.R.S.)
| | - Melissa I Franco
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (J.G.C., M.I.F., E.M.S., J.A., M.Z.)
| | - Erin M Staab
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (J.G.C., M.I.F., E.M.S., J.A., M.Z.)
| | - Jason Alexander
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (J.G.C., M.I.F., E.M.S., J.A., M.Z.)
| | - Wen Wan
- Section of General Internal Medicine and Center for Chronic Disease Research and Policy, Department of Medicine, University of Chicago, Chicago, Illinois (W.W., E.S.H., N.L.)
| | - Mengqi Zhu
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (J.G.C., M.I.F., E.M.S., J.A., M.Z.)
| | - Elbert S Huang
- Section of General Internal Medicine and Center for Chronic Disease Research and Policy, Department of Medicine, University of Chicago, Chicago, Illinois (W.W., E.S.H., N.L.)
| | - Louis Philipson
- Sections of Adult and Pediatric Endocrinology, Diabetes & Metabolism, Department of Medicine, University of Chicago, Chicago, Illinois (L.P.)
| | - Neda Laiteerapong
- Section of General Internal Medicine and Center for Chronic Disease Research and Policy, Department of Medicine, University of Chicago, Chicago, Illinois (W.W., E.S.H., N.L.)
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Holt JM, Spanbauer C, Cusatis R, Winn AN, Talsma A, Asan O, Somai M, Hanson R, Moore J, Makoul G, Crotty BH. Real-world implementation evaluation of an electronic health record-integrated consumer informatics tool that collects patient-generated contextual data. Int J Med Inform 2022; 165:104810. [PMID: 35714549 DOI: 10.1016/j.ijmedinf.2022.104810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 05/09/2022] [Accepted: 06/05/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Use the RE-AIM framework to examine the implementation of a patient contextual data (PCD) Tool designed to share patients' needs, values, and preferences with care teams ahead of clinical encounters. MATERIALS & METHODS Observational study that follows initial PCD Tool scaling across primary care at a Midwestern academic health network. Program invitations, enrollment, patient submissions, and clinician views were tracked over a 1-year study period. Logistic regression modeled the likelihood of using the PCD Tool, accounting for patient covariates. RESULTS Of 58,874 patients who could be contacted by email, 9,183 (15.6%) became PCD Tool users. Overall, 76% of primary care providers had patients who used the PCD Tool. Older age, female gender, non-minority race, patient portal activation, and Medicare coverage were significantly associated with increased likelihood of use. Number of office visits, medical issues, and behavioral health conditions also associated with use. Primary care staff viewed 18.7% of available PCD Tool summaries, 1.1% to 57.6% per clinic. DISCUSSION The intervention mainly reached non-minority patients and patients who used more health services. Given the requirement for an email address on file, some patients may have been underrepresented. Overall, patient reach and adoption and clinician adoption, implementation, and maintenance of this Tool were modest but stable, consistent with a non-directive approach to fostering adoption by introducing the Tool in the absence of clear expectations for use. CONCLUSION Healthcare organizations must implement effective methods to increase the reach, adoption, implementation, and maintenance of PCD tools across all patient populations. Assisting people, particularly racial minorities, with PCD Tool registration and actively supporting clinician use are critical steps in implementing technology that facilitates care.
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Affiliation(s)
- Jeana M Holt
- University of Wisconsin-Milwaukee, College of Nursing, 2901 E. Hartford Ave, Milwaukee, WI 53201, USA.
| | - Charles Spanbauer
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Rachel Cusatis
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aaron N Winn
- School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI, USA
| | - AkkeNeel Talsma
- University of Wisconsin-Milwaukee, College of Nursing, 2901 E. Hartford Ave, Milwaukee, WI 53201, USA
| | - Onur Asan
- School of Systems and Enterprises, Stevens Institute of Technology, Hoboken, NJ, USA
| | - Melek Somai
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ryan Hanson
- Collaborative for Healthcare Delivery Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jennifer Moore
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Gregory Makoul
- NRC Health, Lincoln, Nebraska, USA, Department of Medicine, Yale, School of Medicine, New Haven, CT, USA
| | - Bradley H Crotty
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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15
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Alexander JT, Staab EM, Wan W, Franco M, Knitter A, Skandari MR, Bolen S, Maruthur NM, Huang ES, Philipson LH, Winn AN, Thomas CC, Zeytinoglu M, Press VG, Tung EL, Gunter K, Bindon B, Jumani S, Laiteerapong N. Longer-term Benefits and Risks of Sodium-Glucose Cotransporter-2 Inhibitors in Type 2 Diabetes: a Systematic Review and Meta-analysis. J Gen Intern Med 2022; 37:439-448. [PMID: 34850334 PMCID: PMC8811049 DOI: 10.1007/s11606-021-07227-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 10/19/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter-2 inhibitors (SGLT2Is) are a recent class of medication approved for the treatment of type 2 diabetes (T2D). Previous meta-analyses have quantified the benefits and harms of SGLT2Is; however, these analyses have been limited to specific outcomes and comparisons and included trials of short duration. We comprehensively reviewed the longer-term benefits and harms of SGLT2Is compared to placebo or other anti-hyperglycemic medications. METHODS We searched PubMed, Scopus, and clinicaltrials.gov from inception to July 2019 for randomized controlled trials of minimum 52 weeks' duration that enrolled adults with T2D, compared an SGLT2I to either placebo or other anti-hyperglycemic medications, and reported at least one outcome of interest including cardiovascular risk factors, microvascular and macrovascular complications, mortality, and adverse events. We conducted random effects meta-analyses to provide summary estimates using weighted mean differences (MD) and pooled relative risks (RR). The study was registered a priori with PROSPERO (CRD42018090506). RESULTS Fifty articles describing 39 trials (vs. placebo, n = 28; vs. other anti-hyperglycemic medication, n = 12; vs. both, n = 1) and 112,128 patients were included in our analyses. Compared to placebo, SGLT2Is reduced cardiovascular risk factors (e.g., hemoglobin A1c, MD - 0.55%, 95% CI - 0.62, - 0.49), macrovascular outcomes (e.g., hospitalization for heart failure, RR 0.70, 95% CI 0.62, 0.78), and mortality (RR 0.87, 95% CI 0.80, 0.94). Compared to other anti-hyperglycemic medications, SGLT2Is reduced cardiovascular risk factors, but insufficient data existed for other outcomes. About a fourfold increased risk of genital yeast infections for both genders was observed for comparisons vs. placebo and other anti-hyperglycemic medications. DISCUSSION We found that SGLT2Is led to durable reductions in cardiovascular risk factors compared to both placebo and other anti-hyperglycemic medications. Reductions in macrovascular complications and mortality were only observed in comparisons with placebo, although trials comparing SGLT2Is vs. other anti-hyperglycemic medications were not designed to assess longer-term outcomes.
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Affiliation(s)
- Jason T Alexander
- Department of Medicine, University of Chicago, Chicago, IL, USA.
- , Chicago, USA.
| | - Erin M Staab
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Wen Wan
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Melissa Franco
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - M Reza Skandari
- Centre for Health Economics and Policy Innovation, Imperial College Business School, London, UK
| | - Shari Bolen
- Department of Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Nisa M Maruthur
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elbert S Huang
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Aaron N Winn
- Department of Clinical Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | - Valerie G Press
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Kathryn Gunter
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Brittany Bindon
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Sanjay Jumani
- Department of Medicine, University of Chicago, Chicago, IL, USA
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Alexander JT, Staab EM, Wan W, Franco M, Knitter A, Skandari MR, Bolen S, Maruthur NM, Huang ES, Philipson LH, Winn AN, Thomas CC, Zeytinoglu M, Press VG, Tung EL, Gunter K, Bindon B, Jumani S, Laiteerapong N. The Longer-Term Benefits and Harms of Glucagon-Like Peptide-1 Receptor Agonists: a Systematic Review and Meta-Analysis. J Gen Intern Med 2022; 37:415-438. [PMID: 34508290 PMCID: PMC8810987 DOI: 10.1007/s11606-021-07105-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/19/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Previous meta-analyses of the benefits and harms of glucagon-like peptide-1 receptor agonists (GLP1RAs) have been limited to specific outcomes and comparisons and often included short-term results. We aimed to estimate the longer-term effects of GLP1RAs on cardiovascular risk factors, microvascular and macrovascular complications, mortality, and adverse events in patients with type 2 diabetes, compared to placebo and other anti-hyperglycemic medications. METHODS We searched PubMed, Scopus, and clinicaltrials.gov (inception-July 2019) for randomized controlled trials ≥ 52 weeks' duration that compared a GLP1RA to placebo or other anti-hyperglycemic medication and included at least one outcome of interest. Outcomes included cardiovascular risk factors, microvascular and macrovascular complications, all-cause mortality, and treatment-related adverse events. We performed random effects meta-analyses to give summary estimates using weighted mean differences (MD) and pooled relative risks (RR). Risk of bias was assessed using the Cochrane Collaboration risk of bias in randomized trials tool. Quality of evidence was summarized using the Grading of Recommendations, Assessment, Development, and Evaluation approach. The study was registered a priori with PROSPERO (CRD42018090506). RESULTS Forty-five trials with a mean duration of 1.7 years comprising 71,517 patients were included. Compared to placebo, GLP1RAs reduced cardiovascular risk factors, microvascular complications (including renal events, RR 0.85, 0.80-0.90), macrovascular complications (including stroke, RR 0.86, 0.78-0.95), and mortality (RR 0.89, 0.84-0.94). Compared to other anti-hyperglycemic medications, GLP1RAs only reduced cardiovascular risk factors. Increased gastrointestinal events causing treatment discontinuation were observed in both comparisons. DISCUSSION GLP1RAs reduced cardiovascular risk factors and increased gastrointestinal events compared to placebo and other anti-hyperglycemic medications. GLP1RAs also reduced MACE, stroke, renal events, and mortality in comparisons with placebo; however, analyses were inconclusive for comparisons with other anti-hyperglycemic medications. Given the high costs of GLP1RAs, the lack of long-term evidence comparing GLP1RAs to other anti-hyperglycemic medications has significant policy and clinical practice implications.
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Affiliation(s)
| | - Erin M Staab
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Wen Wan
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Melissa Franco
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - M Reza Skandari
- Centre for Health Economics and Policy Innovation, Imperial College Business School, London, UK
| | - Shari Bolen
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Nisa M Maruthur
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elbert S Huang
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Aaron N Winn
- Department of Clinical Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | - Valerie G Press
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Kathryn Gunter
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Brittany Bindon
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Sanjay Jumani
- Department of Medicine, University of Chicago, Chicago, IL, USA
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Crotty BH, Hyun N, Polovneff A, Dong Y, Decker MC, Mortensen N, Holt JM, Winn AN, Laud PW, Somai MM. Analysis of Clinician and Patient Factors and Completion of Telemedicine Appointments Using Video. JAMA Netw Open 2021; 4:e2132917. [PMID: 34735013 PMCID: PMC8569484 DOI: 10.1001/jamanetworkopen.2021.32917] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
IMPORTANCE Telemedicine provides patients access to episodic and longitudinal care. Policy discussions surrounding future support for telemedicine require an understanding of factors associated with successful video visits. OBJECTIVE To assess patient and clinician factors associated with successful and with failed video visits. DESIGN, SETTING, AND PARTICIPANTS This was a quality improvement study of 137 846 scheduled video visits at a single academic health system in southeastern Wisconsin between March 1 and December 31, 2020, supplemented with patient experience survey data. Patient information was gathered using demographic information abstracted from the electronic health record and linked with block-level socioeconomic data from the US Census Bureau. Data on perceived clinician experience with technology was obtained using the survey. MAIN OUTCOMES AND MEASURES The primary outcome of interest was the successful completion of a scheduled video visit or the conversion of the video visit to a telephone-based service. Visit types and administrative data were used to categorize visits. Mixed-effects modeling with pseudo R2 values was performed to compare the relative associations of patient and clinician factors with video visit failures. RESULTS In total, 75 947 patients and 1155 clinicians participated in 137 846 scheduled video encounters, 17 190 patients (23%) were 65 years or older, and 61 223 (81%) patients were of White race and ethnicity. Of the scheduled video encounters, 123 473 (90%) were successful, and 14 373 (10%) were converted to telephone services. A total of 16 776 patients (22%) completed a patient experience survey. Lower clinician comfort with technology (odds ratio [OR], 0.15; 95% CI, 0.08-0.28), advanced patient age (66-80 years: OR, 0.28; 95% CI, 0.26-0.30), lower patient socioeconomic status (including low high-speed internet availability) (OR, 0.85; 95% CI, 0.77-0.92), and patient racial and ethnic minority group status (Black or African American: OR, 0.75; 95% CI, 0.69-0.81) were associated with conversion to telephone visits. Patient characteristics accounted for systematic components for success; marginal pseudo R2 values decreased from 23% (95% CI, 21.1%-26.1%) to 7.8% (95% CI, 6.3%-9.4%) with exclusion of patient factors. CONCLUSIONS AND RELEVANCE As policy makers consider expanding telehealth coverage and hospital systems focus on investments, consideration of patient support, equity, and friction should guide decisions. In particular, this quality improvement study suggests that underserved patients may become disproportionately vulnerable by cuts in coverage for telephone-based services.
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Affiliation(s)
- Bradley H. Crotty
- Collaborative for Healthcare Delivery Science, Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee
- Inception Labs at Froedtert & Medical College of Wisconsin Health Network, Milwaukee
| | - Noorie Hyun
- Collaborative for Healthcare Delivery Science, Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee
| | - Alexandra Polovneff
- Collaborative for Healthcare Delivery Science, Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee
| | - Yilu Dong
- Collaborative for Healthcare Delivery Science, Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee
| | - Michael C. Decker
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee
| | - Natalie Mortensen
- Inception Labs at Froedtert & Medical College of Wisconsin Health Network, Milwaukee
| | - Jeana M. Holt
- Collaborative for Healthcare Delivery Science, Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee
- Inception Labs at Froedtert & Medical College of Wisconsin Health Network, Milwaukee
- School of Nursing, University of Wisconsin, Milwaukee
| | - Aaron N. Winn
- Collaborative for Healthcare Delivery Science, Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee
| | - Purushottam W. Laud
- Collaborative for Healthcare Delivery Science, Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee
| | - Melek M. Somai
- Collaborative for Healthcare Delivery Science, Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee
- Inception Labs at Froedtert & Medical College of Wisconsin Health Network, Milwaukee
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Mitchell AP, Mishra A, Dey P, Curry MA, Trivedi NU, Haddadin M, Rahman MW, Winn AN, Dusetzina SB, Bach PB. Personal Payments from Pharmaceutical Companies to Authors of Oncology Clinical Practice Guidelines. Oncologist 2021; 26:e1897. [PMID: 34546620 DOI: 10.1002/onco.13983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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19
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Mitchell AP, Mishra A, Dey P, Curry MA, Trivedi NU, Haddadin M, Rahman MW, Winn AN, Dusetzina SB, Bach PB. Personal Payments from Pharmaceutical Companies to Authors of Oncology Clinical Practice Guidelines. Oncologist 2021; 26:771-778. [PMID: 33982829 PMCID: PMC8417859 DOI: 10.1002/onco.13823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/30/2021] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Oncologists who author clinical practice guidelines frequently have financial relationships with the pharmaceutical industry. It is unknown whether participation on clinical practice guideline committees is associated with differences in the amounts of industry money received. MATERIALS AND METHODS We conducted a nested case-control study from August 2013 to December 2018. We manually abstracted membership records of National Comprehensive Cancer Network (NCCN) Guidelines committees for the 20 most common cancers and linked to Open Payments. The study sample included medical oncologists selected to join an NCCN Guidelines committee ("joiners") during the study period. Joiners were matched 1:2 to medical oncologists who had no participation on NCCN committees (controls) by gender, NCCN institution, and medical school graduation year. We performed difference-in-differences (DiD) estimation to assess whether selection to an NCCN committee was associated with the dollar value of payments received from industry, using generalized estimating equations to address correlation between matched pairs and between repeated observations of the same pair. RESULTS During the study period, 54 physicians joined an NCCN Guidelines committee. These physicians received more payments than matched controls in the year prior to joining ($11,259 vs. $3,427; p = .02); this difference did not increase in the year after joining (DiD = $731; p = .45). CONCLUSION Medical oncologists selected to NCCN Guidelines committees had greater financial ties to industry than their peers. The potential influence of industry in oncology clinical practice guidelines may be reduced through the selection of committee members with fewer ties to industry. IMPLICATIONS FOR PRACTICE Oncologists who author clinical practice guidelines frequently have financial conflicts of interest with the pharmaceutical industry. This creates concern about the potential for industry influence on guidelines. However, it is unknown whether oncologists who author guidelines have greater industry relationships than their peers. This study compared medical oncologists who were newly selected to join a National Comprehensive Cancer Network (NCCN) Guidelines panel with medical oncologists at the same institutions and at similar career stages. At the time they joined, oncologists joining NCCN Guidelines panels had received more than three times the dollar value of industry payments than their peers. The potential for industry influence may be reduced by the selection of less-conflicted panel members.
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Affiliation(s)
- Aaron P. Mitchell
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Akriti Mishra
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Pranam Dey
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
- Yale University School of MedicineNew HavenConnecticutUSA
| | - Michael A. Curry
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Niti U. Trivedi
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Michael Haddadin
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
- University of Massachusetts Memorial Medical CenterWorcesterMassachusettsUSA
| | - Mohammed W. Rahman
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
- Hunter College, State University of New YorkNew YorkNew YorkUSA
| | - Aaron N. Winn
- Department of Clinical Sciences, School of Pharmacy, Medical College of WisconsinMilwaukeeWisconsinUSA
| | - Stacie B. Dusetzina
- Department of Health Policy, School of Medicine, Vanderbilt UniversityNashvilleTennesseeUSA
| | - Peter B. Bach
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
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Winn AN, Mitchell AP, Fergestrom N, Neuner JM, Trogdon JG. The Role of Physician Professional Networks in Physicians' Receipt of Pharmaceutical and Medical Device Industries' Payments. J Gen Intern Med 2021; 36:1858-1866. [PMID: 33904046 PMCID: PMC8298740 DOI: 10.1007/s11606-021-06802-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/03/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Financial relationships between physicians and the pharmaceutical and medical device industries are common, but the factors associated with physicians receiving payments are unknown. OBJECTIVE The objective of this study is to evaluate the influence of physicians' professional networks' characteristics on the receipt of payments among physicians. DESIGN Network analysis of cross-sectional data PARTICIPANTS: US physicians who shared Medicare patients with other physicians in 2015 (N=357,813). EXPOSURE (INTERVENTION) Proportion of a physician's professional network that received industry payments and other network characteristics including number of physician connections, how central the physician is within the network, and the tightness of the referral network in which a physician is located. MAIN OUTCOME MEASURES Relative risk of receiving industry payments. We used modified Poisson regression to control for confounding by gender, time since graduation, practice size, and practice setting (teaching hospital vs. not). We included dummy variables for specialty and hospital referral region level. KEY RESULTS The proportion of a physician's peers in their professional network that received payments was strongly associated with receipt of pharmaceutical or device industry payments by the physician (top vs bottom quartile aRR=1.28, 95%CI=1.25-1.31). Physician's centrality within a network had a small positive effect on receiving payment (top vs bottom quartile aRR=1.02, 95%CI=1.01-1.04). Network density also had a small negative association with receipt of payment (top vs bottom quartile aRR=0.97, 95%CI=0.96-0.98). CONCLUSIONS Network characteristics, particularly the receipt of payments among physicians one shares patients with, are associated with whether a physician receives payments. This finding has implications for institutional regulation of industry payments to physicians and demonstrates how institutional policy may impact not only the physicians within the institution but also physicians outside of the institution.
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Affiliation(s)
- Aaron N Winn
- Department of Clinical Sciences, Medical College of Wisconsin, School of Pharmacy, Milwaukee, WI, USA.
- Cancer Center, Medical College of Wisconsin, Milwaukee, WI, USA.
- Center for the Advancing Population Sciences, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Aaron P Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nicole Fergestrom
- Center for the Advancing Population Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
- Section of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Joan M Neuner
- Cancer Center, Medical College of Wisconsin, Milwaukee, WI, USA
- Center for the Advancing Population Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
- Section of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Justin G Trogdon
- Gillings School of Global Public Health, Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
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21
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Winn AN, Kelly M, Ciprut S, Walter D, Gold HT, Zeliadt SB, Sherman SE, Makarov DV. The cost, survival, and quality-of-life implications of guideline-discordant imaging for prostate cancer. Cancer Rep (Hoboken) 2021; 5:e1468. [PMID: 34137520 PMCID: PMC8842701 DOI: 10.1002/cnr2.1468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 11/16/2022] Open
Abstract
Background National Comprehensive Cancer Network (NCCN) guidelines for incident prostate cancer staging imaging have been widely circulated and accepted as best practice since 1996. Despite these clear guidelines, wasteful and potentially harmful inappropriate imaging of men with prostate cancer remains prevalent. Aim To understand changing population‐level patterns of imaging among men with incident prostate cancer, we created a state‐transition microsimulation model based on existing literature and incident prostate cancer cases. Methods To create a cohort of patients, we identified incident prostate cancer cases from 2004 to 2009 that were diagnosed in men ages 65 and older from SEER. A microsimulation model allowed us to explore how this cohort's survival, quality of life, and Medicare costs would be impacted by making imaging consistent with guidelines. We conducted a probabilistic analysis as well as one‐way sensitivity analysis. Results When only imaging high‐risk men compared to the status quo, we found that the population rate of imaging dropped from 53 to 38% and average per‐person spending on imaging dropped from $236 to $157. The discounted and undiscounted incremental cost‐effectiveness ratios indicated that ideal upfront imaging reduced costs and slightly improved health outcomes compared with current practice patterns, that is, guideline‐concordant imaging was less costly and slightly more effective. Conclusion This study demonstrates the potential reduction in cost through the correction of inappropriate imaging practices. These findings highlight an opportunity within the healthcare system to reduce unnecessary costs and overtreatment through guideline adherence.
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Affiliation(s)
- Aaron N Winn
- School of Pharmacy, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Cancer Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Matthew Kelly
- Department of Urology, New York University School of Medicine, New York, USA.,Department of Population Health, New York University School of Medicine, New York, USA.,VA New York Harbor Healthcare System, New York, USA
| | - Shannon Ciprut
- Department of Urology, New York University School of Medicine, New York, USA.,Department of Population Health, New York University School of Medicine, New York, USA.,VA New York Harbor Healthcare System, New York, USA
| | - Dawn Walter
- Department of Urology, New York University School of Medicine, New York, USA.,Department of Population Health, New York University School of Medicine, New York, USA.,VA New York Harbor Healthcare System, New York, USA
| | - Heather T Gold
- Department of Population Health, New York University School of Medicine, New York, USA.,VA New York Harbor Healthcare System, New York, USA.,Robert F. Wagner Graduate School of Public Service, New York University, New York, USA
| | - Steven B Zeliadt
- Health Services Research and Development, Department of Veterans Affairs Medical Center, Seattle, Washington, USA.,Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Scott E Sherman
- Department of Population Health, New York University School of Medicine, New York, USA.,VA New York Harbor Healthcare System, New York, USA.,Perlmutter Cancer Center, New York University School of Medicine, New York, USA
| | - Danil V Makarov
- Department of Urology, New York University School of Medicine, New York, USA.,Department of Population Health, New York University School of Medicine, New York, USA.,VA New York Harbor Healthcare System, New York, USA.,Robert F. Wagner Graduate School of Public Service, New York University, New York, USA.,Perlmutter Cancer Center, New York University School of Medicine, New York, USA
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22
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Dusetzina SB, Huskamp HA, Jazowski SA, Winn AN, Basch E, Keating NL. Comparison of Anticancer Medication Use and Spending Under US Oncology Parity Laws With and Without Out-of-Pocket Spending Caps. JAMA Health Forum 2021; 2:e210673. [PMID: 35977314 PMCID: PMC8796987 DOI: 10.1001/jamahealthforum.2021.0673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/29/2021] [Indexed: 11/14/2022] Open
Abstract
Question How does orally administered anticancer medication (OAM) use and spending differ among states that adopted parity with vs without out-of-pocket spending caps? Findings In this cohort study of 23 states and 207 579 OAM prescription fills, out-of-pocket spending caps were associated with higher OAM use and lower out-of-pocket spending by $831 per OAM prescription fill among the highest spenders. Savings were larger for enrollees in states with caps that applied predeductible and postdeductible vs those that applied postdeductible only. Meaning Caps may offer improved financial protection for the highest spenders without increasing mean health plan spending on OAMs. Importance By 2020, nearly all states had adopted oncology parity laws in the US, ensuring that patients in fully insured private health plans pay no more for orally administered anticancer medications (OAMs) than infused therapies. Between 2013 and mid-2017, 11 states implemented parity with out-of-pocket spending caps, which may further reduce patient out-of-pocket spending. Objective To compare OAM uptake and out-of-pocket and health plan spending on OAMs in states with parity with and without spending caps, as well as to assess out-of-pocket spending for caps that apply predeductible vs postdeductible. Design, Setting, and Participants This cohort study analyzed OAM users enrolled in commercial health plans offered by Aetna, Humana, and United Healthcare in the US from 2011 to 2017, aggregated by the Health Care Cost Institute, using difference-in-difference-in-differences (DDD) analysis. Data analysis was conducted between June and August 2020. Exposures Time (before vs after parity), whether the state parity law included an out-of-pocket spending cap, and whether the plan was fully insured (subject to parity) or self-funded (not subject to parity). Among states with caps, out-of-pocket spending was also compared by whether the cap was applied predeductible and postdeductible vs only postdeductible. Main Outcomes and Measures Monthly OAM prescription fills per 100 000 enrollees, per-OAM prescription-fill out-of-pocket spending, and annual per-user health plan spending on OAMs. Results In this study of 23 states (11 with caps and 12 without) and 207 579 OAM prescription fills, caps were associated with a modest increase in OAM use (DDD, 7.40 [95% CI, 3.41-11.39] per 100 000 enrollees). There was no difference in mean out-of-pocket spending comparing fully insured and self-funded enrollees in states with vs without caps (DDD, −$17 [95% CI, −$57 to $24), but caps were associated with lower spending among OAM users in the 95th percentile of out-of-pocket spending by $831 (95% CI, −$871 to −$791) per OAM prescription fill. Caps applied predeductible were associated with greater out-of-pocket savings relative to caps applied only postdeductible. This included per-OAM prescription-fill savings at the 75th, 90th, and 95th percentiles. Postparity, mean annual spending on OAMs among users was $113 589 in states without caps and $102 252 in states with caps, with no differences between groups (DDD, $9799 [95% CI, −$4230 to $23 829). Conclusions and Relevance In this cohort study, among states adopting oncology parity laws between 2013 and 2017, mean out-of-pocket spending per OAM prescription fill and mean health plan spending among OAM users was similar in states with and without caps. However, enrollees in states with parity plus out-of-pocket caps had greater reductions in out-of-pocket spending among the highest spenders. Caps may offer improved financial protection for the highest spenders without increasing mean health plan spending on OAMs.
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Affiliation(s)
- Stacie B. Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Haiden A. Huskamp
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Shelley A. Jazowski
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Aaron N. Winn
- School of Pharmacy, Medical College of Wisconsin, Milwaukee
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee
- Cancer Center, Medical College of Wisconsin, Milwaukee
| | - Ethan Basch
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
- Division of Oncology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill
- Associate Editor, JAMA
| | - Nancy L. Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
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23
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Kim NH, Look KA, Dague L, Winn AN. Financial burden and medication adherence among near-poor older adults in a pharmaceutical assistance program. Res Social Adm Pharm 2021; 18:2517-2523. [PMID: 34030976 DOI: 10.1016/j.sapharm.2021.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 04/20/2021] [Accepted: 04/20/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND With increasing drug prices in the past decade, affordability and medication adherence are a growing concern for near-poor older adults, especially for those who are not receiving Low-Income Subsidy in Medicare Part D. SeniorCare is a pharmaceutical assistance program in Wisconsin for near-poor older adults, providing comprehensive prescription coverage with flat copayments. OBJECTIVES To evaluate five-year trends in financial hardship and medication adherence and to examine factors associated with these outcomes in SeniorCare members. METHODS SeniorCare program enrollment and pharmacy claims data from 2014 to 2018 were used. The study population was near-poor older adults in SeniorCare with annual family income ≤200% of the federal poverty level. Financial burden was assessed using the proportion of total annual out-of-pocket costs to total annual income. Medication adherence was assessed by adapting the measures endorsed by the Pharmacy Quality Alliance and National Quality Forum. Descriptive statistics and independent t-tests were used to evaluate the trends, and multivariate logistic regressions were conducted to examine factors associated with financial burden and medication adherence. RESULTS From 2014 to 2018, mean annual out-of-pocket costs per member declined by 3.7% (p < 0.001) for all drugs, while those for specialty drugs increased by 31.2% (p < 0.05). Around 3.3% spent more than 5% of their income for prescription drugs in 2014, which decreased to 2.4% in 2018 (p < 0.001). The proportions of adherent patients increased from 78.1% to 81.2% (p < 0.001) for diabetes medications (excluding insulins), from 77.3% to 79.5% (p < 0.001) for statins, and from 79.8% to 80.8% (p < 0.05) for RASA. Members subject to a $500 annual deductible were more likely to experience high financial burden (adjusted odds ratio (AOR) = 1.677, p < 0.001) and less likely to be adherent to diabetes medications (AOR = 0.484, p < 0.001). CONCLUSIONS The near-poor older adults enrolled in Wisconsin SeniorCare program had low financial burden and good medication adherence within the program.
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Affiliation(s)
- Nam Hyo Kim
- University of Wisconsin-Madison, School of Pharmacy, 777 Highland Avenue, Madison, WI, 53705, USA.
| | - Kevin A Look
- University of Wisconsin-Madison, School of Pharmacy, 777 Highland Avenue, Madison, WI, 53705, USA.
| | - Laura Dague
- Texas A&M University, Bush School of Government and Public Service, 4220 TAMU, College Station, TX, 77843, USA.
| | - Aaron N Winn
- Medical College of Wisconsin, Pharmacy School, 8701 Watertown Plank Rd., HRC H2600, Milwaukee, WI, 53226, USA.
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24
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Bakken BK, Winn AN. Clinician burnout during the COVID-19 pandemic before vaccine administration. J Am Pharm Assoc (2003) 2021; 61:e71-e77. [PMID: 33962895 PMCID: PMC8056845 DOI: 10.1016/j.japh.2021.04.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/31/2021] [Accepted: 04/08/2021] [Indexed: 11/24/2022]
Abstract
Background Coronavirus disease 2019 (COVID-19) has disrupted pharmacy practice. Little research has been done to assess how COVID-19 has affected pharmacists’ employment, workload, and feelings of burnout. Objectives The objectives of this study were to characterize the impact of COVID-19 on pharmacists’ employment status, workload, and feelings of burnout, as well as to examine emotional health concerns related to COVID-19. Methods Wisconsin pharmacists were surveyed using an online instrument between August 25, 2020, and September 22, 2020. The data analysis, performed in December 2020, examined employment status, 3 common burnout risk factors (workload, rewards, and social depersonalization), and emotional health concerns related to COVID-19. Results Of the 1300 pharmacists, 439 completed the survey (33.8%). The study analysis included pharmacists in community (n = 127) and hospital or health system (n = 107) settings. With regard to employment changes and workload, hospital pharmacists (36%) were more likely to have their hours reduced than community pharmacists (13%) (P < 0.01), and, conversely, community pharmacists (19%) were more likely to have their hours increased than hospital pharmacists (8%) (P = 0.01). For the burnout domain of workload, 45% of the pharmacists reported increased feelings of physical exhaustion at work, and 53% reported increased feelings of emotional exhaustion at work, with no difference between settings. Regarding the burnout domain of rewards, 6% of the hospital pharmacists and 1% of the community pharmacists experienced a reduction in hourly wages or salaries as a result of COVID-19. For the burnout domain of depersonalization, 25% of the pharmacists reported that their ability to connect with colleagues and patients decreased during the COVID-19 pandemic. Additional emotional health concerns reported by the pharmacists included 40% experiencing more anxiety and 25% experiencing more sadness or depression during the COVID-19 pandemic, with no difference between settings. Conclusion This study found that the burnout domains related to workload, rewards, and depersonalization were negatively affected by COVID-19. Pharmacy managers need to proactively combat burnout as well as be reactive when employees show signs of burnout to maintain their workforce and meet the COVID-19–associated challenges.
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25
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Dusetzina SB, Huskamp HA, Jazowski SA, Winn AN, Wood WA, Olszewski A, Basch E, Keating NL. Oral Oncology Parity Laws, Medication Use, and Out-of-Pocket Spending for Patients With Blood Cancers. J Natl Cancer Inst 2021; 112:1055-1062. [PMID: 31883008 DOI: 10.1093/jnci/djz243] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/16/2019] [Accepted: 12/24/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In this study, we sought to estimate the association between oral oncology parity law adoption and anticancer medication use for patients with chronic myeloid leukemia or multiple myeloma. METHODS This was an observational study of administrative claims from 2008 to 2017. Among individuals initiating tyrosine kinase inhibitors (TKIs) for chronic myeloid leukemia or immunomodulatory drugs for multiple myeloma, we compared out-of-pocket spending, adherence, and discontinuation before and after parity among individuals in fully insured plans (subject to parity) vs self-funded plans (exempt from parity) using propensity-score weighted difference-in-differences regression models. RESULTS Among patients initiating TKIs (N = 2082) or immunomodulatory drugs (N = 3326) there were no statistically significant differences in adherence or discontinuation associated with parity. The proportion of patients with initial out-of-pocket payments of $0 increased in fully insured plans after parity from 5.7% to 46.1% for TKIs and from 10.9% to 48.8% for immunomodulatory drugs. Relative to changes in self-funded plans, those in fully insured plans were 4.27 (95% CI = 2.20 to 8.27) times as likely to pay nothing for TKIs and 1.96 (95% CI = 1.40 to 2.73) times as likely to pay nothing for immunomodulatory drugs after parity. Similarly, the proportion paying more than $100 decreased from 30.3% to 24.7% for TKIs and 30.6% to 27.5% for immunomodulatory drugs in fully insured plans after parity. Relative to changes in self-funded plans, those in fully insured plans were 0.74 (95% CI = 0.54 to 1.01) times as likely to pay more than $100 for TKIs and 0.85 (95% CI = 0.68 to 1.06) times as likely to pay more than $100 for immunomodulatory drugs after parity. CONCLUSIONS Among patients initiating TKIs or immunomodulatory drugs, parity was not associated with better adherence or less discontinuation of therapy but yielded decreased patient out-of-pocket payments for some patients.
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Affiliation(s)
- Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, USA.,Vanderbilt-Ingram Comprehensive Cancer Center, Nashville, TN, USA
| | - Haiden A Huskamp
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Shelley A Jazowski
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Aaron N Winn
- Medical College of Wisconsin, School of Pharmacy, Milwaukee, WI, USA.,Center for Advancement of Population Science, Medical College of Wisconsin, Milwaukee, WI, USA.,Cancer Center, Medical College of Wisconsin, Milwaukee, WI, USA
| | - William A Wood
- School of Medicine, Division of Hematology and Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | | | - Ethan Basch
- School of Medicine, Division of Hematology and Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
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26
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Zhou Y, Beyer KMM, Laud PW, Winn AN, Pezzin LE, Nattinger AB, Neuner J. An adapted two-step floating catchment area method accounting for urban-rural differences in spatial access to pharmacies. J Pharm Health Serv Res 2021; 12:69-77. [PMID: 33717229 DOI: 10.1093/jphsr/rmaa022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 11/03/2020] [Indexed: 11/12/2022]
Abstract
Objective To adapt the two-step floating catchment area approach to account for urban-rural differences in pharmacy access in the United States. Methods The urban-rural two-step floating catchment area method was described mathematically. To calculate urban-rural-two-step floating catchment area measure, census tracts and pharmacies within the study area (Southeastern Wisconsin) were classified as urban, suburban or rural, and then different catchment area sizes (2, 5 and 15 miles) were applied, based on the Centers for Medicare & Medicaid Services (CMS)' criteria for Medicare Part D service access within urban, suburban and rural areas. The urban-rural-two-step floating catchment area measures were compared to traditional two-step floating catchment area measures computed using three fixed catchment area sizes (2, 5, and 15 miles) by visually examining their spatial distributions. Associations between the four pharmacy accessibility measures and selected socio-demographics are calculated using Spearman's rank-order correlation and further compared. Key findings The urban-rural two-step floating catchment area measure outperforms all the fixed catchment size measures and has the strongest Spearman correlations with the selected census variables. It also reduces the number of census tracts characterized as 'no access' when compared to the original measures. The spatial distribution of urban-rural two-step floating catchment area pharmacy access exhibits a more granular variation across the study area. Conclusions The results support our hypothesis that spatial access to pharmacies should account for urbanicity/rurality patterns within a region.
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Affiliation(s)
- Yuhong Zhou
- Institute for Health & Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kirsten M M Beyer
- Institute for Health & Equity, Medical College of Wisconsin, Milwaukee, WI, USA.,Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Purushottam W Laud
- Institute for Health & Equity, Medical College of Wisconsin, Milwaukee, WI, USA.,Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aaron N Winn
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA.,Department of Clinical Sciences, School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Liliana E Pezzin
- Institute for Health & Equity, Medical College of Wisconsin, Milwaukee, WI, USA.,Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA.,Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ann B Nattinger
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA.,Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Joan Neuner
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA.,Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Check DK, Winn AN, Fergestrom N, Reeder-Hayes KE, Neuner JM, Roberts AW. Response to Strassels and Durham. J Natl Cancer Inst 2020; 112:1280. [DOI: 10.1093/jnci/djaa146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 09/04/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, Duke Cancer Institute, Durham, NC, USA
| | - Aaron N Winn
- Department of Clinical Sciences, School of Pharmacy, Center for Advancing Population Science, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Nicole Fergestrom
- Center for Advancing Population Science, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Katherine E Reeder-Hayes
- Department of Medicine, Division of Hematology and Oncology, University of North Carolina at Chapel Hill (UNC-CH) School of Medicine, UNC-CH Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Joan M Neuner
- Department of Medicine, Division of General Internal Medicine, Center for Advancing Population Science, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Andrew W Roberts
- Department of Population Health and Department of Anesthesiology, University of Kansas Medical Center (KUMC), Kansas City, KS, USA
- KU Cancer Center, KUMC, Kansas City, KS, USA
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Seymour EK, Ruterbusch JJ, Winn AN, George JA, Beebe-Dimmer JL, Schiffer CA. The costs of treating and not treating patients with chronic myeloid leukemia with tyrosine kinase inhibitors among Medicare patients in the United States. Cancer 2020; 127:93-102. [PMID: 33119175 DOI: 10.1002/cncr.33267] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/21/2020] [Accepted: 09/04/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with high cost-sharing of tyrosine kinase inhibitors (TKIs) experience delays in treatment for chronic myeloid leukemia (CML). To the authors' knowledge, the clinical outcomes among and costs for patients not receiving TKIs are not well defined. METHODS Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, the authors evaluated differences in TKI initiation, health care use, cost, and survival among patients with CML with continuous Medicare Parts A and B and Part D coverage who were diagnosed between 2007 and 2015. RESULTS A total of 941 patients were included. Approximately 29% of all patients did not initiate treatment with TKIs within 6 months (non-TKI users), and had lower rates of BCR-ABL testing and more hospitalizations compared with TKI users. Approximately 21% were not found to have any TKI claims at any time. TKI initiation rates within 6 months of diagnosis increased for all patients over time (61% to 85%), with greater improvements observed in patients receiving subsidies (55% to 90%). Total Medicare costs were greater in patients treated with TKIs, with approximately 50% because of TKI costs. Non-TKI users had more inpatient costs compared with TKI users. Trends in cost remained significant when adjusting for age and comorbidities. The median overall survival was 40 months (95% confidence interval [95% CI], 34-48 months) compared with 86 months (95% CI, 73 months to not reached), respectively, for non-TKI users versus TKI users, a finding that remained consistent when adjusting for age, comorbidities, and subsidy status (hazard ratio, 2.23; 95% CI, 1.77-2.81). CONCLUSIONS Approximately 21% of all patients with CML did not receive TKIs at any time. Cost-sharing subsidies consistently are found to be associated with higher initiation rates. Non-TKI users had higher inpatient costs and poorer survival outcomes. Interventions to lower TKI costs for all patients are desirable.
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Affiliation(s)
- Erlene K Seymour
- Department of Oncology, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
| | - Julie J Ruterbusch
- Department of Oncology, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
| | - Aaron N Winn
- Department of Clinical Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Julie A George
- Department of Oncology, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
| | - Jennifer L Beebe-Dimmer
- Department of Oncology, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
| | - Charles A Schiffer
- Department of Oncology, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
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Abstract
IMPORTANCE National efforts to improve safe opioid prescribing focus on preventing misuse, overdose, and opioid use disorder. This approach overlooks opportunities to better prevent other serious opioid-related harms in complex populations, such as older adult survivors of cancer. Little is known about the rates and risk factors for comprehensive opioid-related harms in this population. OBJECTIVE To determine rates of multiple opioid-related adverse drug events among older adults who survived breast cancer and estimate the risk of these events associated with opioid use in the year after completing cancer treatment. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used 2007 to 2016 Surveillance, Epidemiology and End Results-Medicare data from fee-for-service Medicare beneficiaries with first cancer diagnosis of stage 0 to III breast cancer at age 66 to 90 years from January 1, 2008, through December 31, 2015, who completed active breast cancer treatment. Data were analyzed from October 31, 2019, to June 10, 2020. EXPOSURES Repeated daily measure indicating possession of any prescription opioid supply in Medicare Part D prescription claims. MAIN OUTCOMES AND MEASURES Adjusted risk ratios (aRRs), estimated using modified Poisson generalized estimating equation models, for adverse drug events related to substance misuse (ie, diagnosed opioid abuse, dependence, or poisoning), other adverse drug events associated with opioid use (ie, gastrointestinal events, infections, falls and fractures, or cardiovascular events), and all-cause hospitalization associated with opioid supply the prior day, controlling for patient characteristics. RESULTS Among 38 310 women included in the study (mean [SD] age, 74.3 [6.3] years), there were 0.010 (95% CI, 0.008-0.011) adverse drug events related to substance misuse per 1000 person-days, 0.237 (95% CI, 0.229-0.245) other adverse drug events associated with opioid use per 1000 person-days, and 0.675 (95% CI, 0.662-0.689) all-cause hospitalizations per 1000 person-days. Opioid use was associated with increased risk of adverse drug events related to substance misuse (aRR, 14.62; 95% CI, 9.69-22.05; P < .001), other adverse drug events related to opioid use (aRR, 2.50; 95% CI, 2.11-2.96; P < .001), and all-cause hospitalization (aRR, 2.77; 95% CI, 2.55-3.02; P < .001). In a dose-response effect, individuals with high daily opioid doses had consistently higher risks of all study outcomes compared with individuals who had low opioid doses. Compared with days with no opioid exposure, the risk of any adverse drug event related to substance misuse was 3.4-fold higher for individuals with a current opioid supply ≥50 mg morphine equivalent dose per day (aRR, 3.40; 95% CI, 2.47-4.68; P < .001), while the risk was 2.3-fold higher for individuals with 1 to 49 mg morphine equivalent dose per day (aRR, 2.29; 95% CI, 1.89-2.77; P < .001). CONCLUSIONS AND RELEVANCE These findings suggest that among older adults who survived breast cancer, continued prescription opioid use in the year after completing active cancer treatment was associated with an immediate increased risk of a broad range of serious adverse drug events related to substance misuse and other adverse drug events associated with opioid use. Clinicians should consider the comprehensive risks of managing cancer pain with long-term opioid therapy.
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Affiliation(s)
- Aaron N. Winn
- School of Pharmacy, Department of Clinical Sciences, Medical College of Wisconsin, Milwaukee
| | - Devon K. Check
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Amy Farkas
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Nicole M. Fergestrom
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee
| | - Joan M. Neuner
- Division of General Internal Medicine, Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee
| | - Andrew W. Roberts
- Department of Population Health, University of Kansas Medical Center, Kansas City
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City
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Check DK, Winn AN, Fergestrom N, Reeder-Hayes KE, Neuner JM, Roberts AW. Concurrent Opioid and Benzodiazepine Prescriptions Among Older Women Diagnosed With Breast Cancer. J Natl Cancer Inst 2020; 112:765-768. [PMID: 31605134 PMCID: PMC7357325 DOI: 10.1093/jnci/djz201] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/18/2019] [Accepted: 10/02/2019] [Indexed: 11/13/2022] Open
Abstract
Guidelines recommend using caution in co-prescribing opioids with benzodiazepines, yet, in practice, the extent of concurrent prescribing is poorly understood. Notably, no population-based studies, to our knowledge, have investigated concurrent prescribing among patients with cancer. We conducted a retrospective cohort study using data from the Surveillance, Epidemiology, and End Results (SEER) database linked with Medicare claims (2012-2016) for women diagnosed with breast cancer. We used modified Poisson regression to examine predictors of any concurrent prescriptions in the year post-diagnosis and Poisson regression to examine predictors of the number of overlapping days. We found that 13.0% of the 19 267 women in our sample had concurrent prescriptions. Women who underwent more extensive treatment and those with previous use of opioids or benzodiazepines were at increased risk for concurrent prescriptions (adjusted risk ratio of previous benzodiazepine use vs no previous use = 15.05, 95% confidence interval = 13.19 to 17.19). Among women with concurrent prescriptions, overlap was most pronounced among low-income, rural, and Hispanic women (adjusted incidence rate ratio of Hispanic vs non-Hispanic white = 1.25, 95% confidence interval = 1.20 to 1.30). Our results highlight opportunities to reduce patients' unnecessary exposure to this combination.
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Affiliation(s)
- Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, Duke Cancer Institute, Durham, NC
| | - Aaron N Winn
- Department of Clinical Sciences, School of Pharmacy, Center for Advancing Population Science, Medical College of Wisconsin, Wauwatosa, WI
| | - Nicole Fergestrom
- Center for Advancing Population Science, Medical College of Wisconsin, Wauwatosa, WI
| | - Katherine E Reeder-Hayes
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina at Chapel Hill (UNC-CH) School of Medicine, UNC-CH Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Joan M Neuner
- Department of Medicine, Division of General Internal Medicine, Center for Advancing Population Science, Medical College of Wisconsin, Wauwatosa, WI
| | - Andrew W Roberts
- Department of Population Health and Department of Anesthesiology, University of Kansas Medical Center (KUMC), KU Cancer Center, KUMC, Kansas City, KS
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Winn AN, Check D, Fergestrom N, Neuner JM, Roberts A. The impact of the use of opioids among older breast cancer survivors and adverse events. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.12098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12098 Background: Older adults and cancer survivors are underrepresented in the literature underpinning recent opioid prescribing guidelines. As prevention of unnecessary persistent opioid use and inadvertent opioid-related harms gains importance in clinical practice, it is necessary to fully capture the risks of opioid related adverse events among patients with cancer pain. The objective of this study was to determine the association between opioid use after cancer diagnosis and comprehensive opioid-related adverse events among older adult breast cancer survivors. Methods: We conducted a retrospective cohort study using Surveillance, Epidemiology, and End Results tumor registry data linked with Medicare administrative claims data from 2007-2016 of women with newly diagnosed non-metastatic breast cancer. The study observation period was the year following a patient’s end of active cancer treatment. The primary exposure was a daily measure of opioid exposure based on Part D prescription claims. The primary outcomes were daily indicators of all-cause hospitalization, substance use event and a composite of other opioid-related adverse events (infections, gastrointestinal events, falls/fractures, cardiovascular events) and each component of the composite adverse event. We estimated the association of current opioid use and the immediate risk of an outcome event the following day using modified Poisson generalized estimating equation models. We adjusted for patient demographics, cancer characteristics and cancer treatments received. Results: We found that opioid exposure more than doubled the immediate risk of all-cause hospitalization (aRR = 2.77; 95%CI = 2.57, 2.99; p < 0.001) and having a composite adverse event (aRR = 2.50; 95%CI = 2.18, 2.87; p < 0.001) and dramatically increases the immediate risk of a substance use event (aRR = 14.26; 95%CI = 7.11, 28.59; p < 0.001). We find consistent results when looking at individual components of the composite adverse event measure. Conclusions: Older adult breast cancer survivors with continued prescription opioid use in the year after completing active cancer treatment experienced an immediate increased risk of all-cause hospitalization, substance use events, and myriad opioid-related adverse effects.
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Mitchell AP, Mishra AA, Dey P, Curry MA, Trivedi NA, Haddadin M, Rahman M, Winn AN, Dusetzina S, Bach P. The association between drug industry payments and NCCN guideline panel membership. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.2068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
2068 Background: The high frequency of financial relationships between the pharmaceutical industry and influential oncologists who author clinical practice guidelines may influence guideline recommendations. Therefore, we assessed the financial relationships held by NCCN Guidelines panelists before and after joining the panel, compared to those held by a matched set of oncologists. Methods: Membership of NCCN Guidelines panels for the 20 most common cancers was obtained from archival guidelines and linked manually to Open Payments records of industry payments. We identified physicians who newly joined an NCCN panel during the August 2013-December 2018 study period, and we included medical oncologists who had at least 1 year of Open Payments data before and after joining. These medical oncologists who joined an NCCN panel (panelists) were matched 1:2 to medical oncologists with the same gender, institutional affiliation, and medical school graduation year, who did not join an NCCN panel (non-panelists). The dollar value of industry payments was then calculated over the 1 year before (pre-join) and after (post-join) the date that each panelist joined. We used generalized linear models to assess differences in industry payments between the panelists and matched non-panelists in the pre-join period. We used difference-in-difference estimation (DiD) to assess whether joining an NCCN panel was associated with increased payments in the post-join period. Results: There were 54 panelists and 108 non-panelists (matched from 1447 eligible oncologists at NCCN institutions). Mean per-oncologist payments among panelists were greater than non-panelists in the pre-join period ($11,259 vs $3,427, p = 0.02). From the pre-join to post-join period there was a similar increase in mean per-oncologist payments among panelists and non-panelists ($2,236 vs. $1,569, DiD estimate +$667, p = 0.77). Conclusions: Medical oncologists who were selected to an NCCN Guidelines panel had greater financial ties to industry compared to peer oncologists who were not selected. This difference was present prior to joining; oncologists did not experience a greater increase in financial payments from industry in the 1-year period after joining an NCCN panel. These results suggest an opportunity to reduce the potential influence of industry in oncology clinical practice guidelines through the selection of guideline panelists with fewer ties to industry.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Peter Bach
- Memorial Sloan Kettering Cancer Center, New York, NY
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Neuner JM, Winn AN, Pezzin LE, Laud PW, Nattinger AB, Fergestrom N. Factors associated with adjuvant endocrine therapy adherence in non-metastatic breast cancer. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
533 Background: Over 50% of breast cancer patients prescribed adjuvant endocrine therapy (ET) are nonadherent during the recommended 5-year course of therapy. We investigated the role of cancer medication delivery on adherence, including mail order pharmacy use, number of pharmacies and copays. Methods: We conducted a retrospective cohort study of 15,769 commercially insured breast cancer patients age 18-64 with newly diagnosed breast cancer in 2007-2015 that initiated ET. Incident breast cancer was identified by a validated algorithm which identifies mainly non-metastatic breast cancer. We examined the association between 12-month AET adherence (proportion of days covered by fills ≥0.80) and mail order pharmacy use, number of pharmacies, and AET copays. We used Poisson regression to estimate nonadherence risk ratios and adjusted for demographics (age, income, race, urbanicity), comorbidities, total medications, primary cancer treatments (surgery, radiation, chemo, and ET initiated), and generic AI availability. Sensitivity analyses were conducted using alternate specifications for independent variables. To test whether any observed differences were due to self-selection, we also conducted a negative control analysis. Results: Most patients were white (74.4%) and age 55-64 (43.3%). Only 16% of patients used a mail order pharmacy for ET fills, most patients only used one pharmacy (58.8%) and 25.2% had a co-pay of $20 or more. In the primary analysis, mail order patients were more likely to be adherent to their ET (aRR 1.21; 95% CI 1.18-1.24), patients using one pharmacy were more likely to be adherent (1 vs 3+: aRR 1.09; 95% CI 1.06-1.13), and patients with lower copays were more likely to be adherent (quartile 1 vs 4: aRR 1.04; 95% CI 1.01-1.08). Results were consistent across sensitivity analyses, and there was no association between mail order and copays and the negative control outcome of any pneumonia diagnoses. Conclusions: Medication delivery factors are associated with adherence to breast cancer AET. Future work should investigate whether interventions to streamline medication delivery could improve adherence for this population.
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Winn AN, Fergestrom NM, Pezzin LE, Laud PW, Neuner JM. The impact of generic aromatase inhibitors on initiation, adherence, and persistence among women with breast cancer: Applying multi-state models to understand the dynamics of adherence. Pharmacoepidemiol Drug Saf 2020; 29:550-557. [PMID: 32196839 DOI: 10.1002/pds.4995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 02/13/2020] [Accepted: 02/26/2020] [Indexed: 01/30/2023]
Abstract
PURPOSE Clinical trials have clearly documented the survival benefit of aromatase inhibitors (AIs); however, many women fail to initiate (primary nonadherence) or remain adherent to AIs (secondary nonadherence). Prior studies have found that costs impact secondary nonadherence to medications but have failed to examine primary nonadherence. The purpose of this study is to examine primary and secondary adherence following the reduction in copays due to the introduction of generic AIs. METHODS Using Surveillance, Epidemiology, and End Results-Medicare data, we identified 50 054 women diagnosed with incident breast cancer between 2008 and 2013. We compare women whose copays would change and those whose would not, due to the receipt of cost-sharing subsidies before and after generics were introduced using a difference-in-difference (DinD) analysis. To examine primary and secondary nonadherence, we rely on a multistate model with four states (Not yet initiated, User, Not Using, and Death). We adjusted for baseline factors using inverse probability treatment weights and then simulated adherence for 36 months following diagnosis. RESULTS The generic introduction of AIs resulted in patients initiating AIs faster (DinD = -4.7%, 95%CI = -7.0, -2.3; patients not yet initiating treatment at 6-months), being more adherent (DinD ranging in absolute increase of 8.1%-10.4%) and being less likely to not be using the therapy (DinD range in absolute decrease of 1.2% at 6 months to 8.8% at 24 months) for women that do not receive a subsidy after generics were available. CONCLUSIONS Introduction of generic alternatives to AIs significantly reduced primary and secondary nonadherence.
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Affiliation(s)
- Aaron N Winn
- Department of Clinical Sciences, School of Pharmacy, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Cancer Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Center for the Advancing Population Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nicole M Fergestrom
- Center for the Advancing Population Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Section of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Liliana E Pezzin
- Cancer Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Center for the Advancing Population Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Purushottam W Laud
- Cancer Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Center for the Advancing Population Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Section of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Joan M Neuner
- Cancer Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Center for the Advancing Population Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Section of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Roberts AW, Fergestrom N, Neuner JM, Winn AN. New-onset persistent opioid use following breast cancer treatment in older adult women. Cancer 2019; 126:814-822. [PMID: 31846054 DOI: 10.1002/cncr.32593] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/08/2019] [Accepted: 05/13/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Patients with cancer-related pain are underrepresented in the opioid literature despite high opioid exposure and numerous risk factors for adverse opioid outcomes, including unnecessary persistent opioid use. The objective of this study was to determine the extent, historical trends, and predictors of new-onset persistent opioid use among older adult women after active breast cancer treatment. METHODS Using Surveillance, Epidemiology, and End Results-Medicare data for opioid-naive women diagnosed with stage 0 to III breast cancer at the age of 66 to 90 years between 2008 and 2013, this study estimated overall and quarterly adjusted probabilities of new-onset persistent opioid use, which was defined as receiving ≥90 days' supply of opioids in the year after active breast cancer treatment. Sensitivity analyses were conducted with an alternative definition of persistent opioid use: any opioid fill 90 to 180 days after active cancer treatment. RESULTS Nearly two-thirds of the subjects received prescription opioid therapy during cancer treatment. Quarterly probabilities of new-onset persistent opioid use after active treatment ranged from 2% to 4%; in sensitivity analyses, the alternative outcome definition resulted in predicted probabilities ranging from 11.4% to 14.7%. Subjects with more advanced disease, a higher comorbidity burden, a low-income status, and greater opioid exposure during active cancer treatment were more likely to develop persistent opioid use. CONCLUSIONS Persistent opioid use was an infrequent occurrence among older adult patients with breast cancer completing cancer treatment between 2008 and 2013. This finding was encouraging because of the concerning opioid trends seen in noncancer populations. However, opportunities to further mitigate unsafe opioid use as a complication of cancer care, including standardization of persistent opioid use definitions, should be explored.
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Affiliation(s)
- Andrew W Roberts
- Department of Population Health, University of Kansas Medical Center, Kansas City, Kansas.,Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas.,The University of Kansas Cancer Center, University of Kansas Medical Center, Kansas City, Kansas
| | - Nicole Fergestrom
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Joan M Neuner
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, Wisconsin.,Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Aaron N Winn
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Clinical Sciences, School of Pharmacy, Medical College of Wisconsin, Milwaukee, Wisconsin.,Cancer Center, Medical College of Wisconsin, Milwaukee, Wisconsin
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Abstract
This cross-sectional study examines the association of patient use of a free online symptom checker tool with patient plans for seeking medical care.
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37
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Affiliation(s)
- Bradley H Crotty
- Collaborative for Healthcare Delivery Science, Medical College of Wisconsin, Milwaukee, WI, USA. .,Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA. .,Division of General Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Aaron N Winn
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA.,School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Onur Asan
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA.,Division of General Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.,School of Systems and Enterprises, Stevens Institute of Technology, Hoboken, NJ, USA
| | - Sneha Nagavally
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rebekah J Walker
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA.,Division of General Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Leonard E Egede
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA.,Division of General Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Check D, Winn AN, Fergestrom N, Neuner JM, Roberts A. Concurrent opioid and benzodiazepine use after breast cancer diagnosis. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.27_suppl.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
28 Background: Benzodiazepines contribute to one-third of opioid overdose deaths in the U.S. Guidelines caution against co-prescribing these two drug classes. Although patients with cancer commonly experience pain and anxiety, no studies have assessed trends in concurrent opioid/benzodiazepine use after cancer diagnosis. Our study examined trends in, and predictors of concurrent opioid/benzodiazepine use in older women diagnosed with breast cancer. Methods: We conducted a retrospective cohort analysis using 2012-2016 SEER-Medicare data for women diagnosed with stage 0-III breast cancer who had no concurrent opioid/benzodiazepine use in the 3 months prior to diagnosis. Using modified Poisson regression, we estimated the adjusted probability of concurrent use (≥1 day of overlapping opioid/benzodiazepine supply) in the 12 months post-diagnosis for patients diagnosed in each calendar quarter from Q2:2013 to Q4:2015. We also estimated the overall relative risk (RR) of concurrent use associated with patient demographic and clinical characteristics. Results: Among the 19, 267 women in our cohort, the quarterly adjusted probabilities of concurrent use were stable over time, ranging from 12% to 15%. Risk of concurrent use decreased with age but increased with cancer stage. Prior opioid use and prior benzodiazepine use increased the risk of concurrent use in the 12 months post-diagnosis (RR prior vs. no prior opioids = 2.57, 95% CI = 2.27-2.92; RR prior vs. no prior benzodiazepines = 15.05, 95% CI = 13.19-17.19). Women who underwent mastectomy (vs. no or minimal surgery) were 71% more likely to have concurrent use (RR = 1.71, 95% CI = 1.40-2.10). Similarly, women who received chemotherapy (vs. no chemotherapy) were 28% more likely to have concurrent use (RR = 1.28, 95% CI = 1.07-1.54). Finally, Black women (vs. White women) were 38% less likely to have concurrent use (RR = 0.62, 95% CI = 0.50-0.76). Conclusions: Up to 1 in 8 older women diagnosed with breast cancer exhibited concurrent opioid/benzodiazepine use in the 12 months after diagnosis. Clinicians must be mindful of exposing patients to this high-risk combination during cancer and survivorship care, particularly among patients with more intensive cancer treatment or prior use of either drug.
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Affiliation(s)
- Devon Check
- Duke University School of Medicine, Durham, NC
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Winn AN, Keating NL, Trogdon JG, Basch EM, Dusetzina SB. Spending by Commercial Insurers on Chemotherapy Based on Site of Care, 2004-2014. JAMA Oncol 2019; 4:580-581. [PMID: 29470578 DOI: 10.1001/jamaoncol.2017.5544] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Aaron N Winn
- Department of Clinical Sciences, Pharmacy School, Medical College of Wisconsin, Milwaukee
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Justin G Trogdon
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill
| | - Ethan M Basch
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill.,Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
| | - Stacie B Dusetzina
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill.,Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill.,Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
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Wan W, Skandari MR, Minc A, Nathan AG, Zarei P, Winn AN, O'Grady M, Huang ES. Cost-effectiveness of Initiating an Insulin Pump in T1D Adults Using Continuous Glucose Monitoring Compared with Multiple Daily Insulin Injections: The DIAMOND Randomized Trial. Med Decis Making 2019; 38:942-953. [PMID: 30403576 DOI: 10.1177/0272989x18803109] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The economic impact of both continuous glucose monitoring (CGM) and insulin pumps (continuous subcutaneous insulin infusion [CSII]) in type 1 diabetes (T1D) have been evaluated separately. However, the cost-effectiveness of adding CSII to existing CGM users has not yet been assessed. OBJECTIVE The aim of this study was to evaluate the societal cost-effectiveness of CSII versus continuing multiple daily injections (MDI) in adults with T1D already using CGM. METHODS In the second phase of the DIAMOND trial, 75 adults using CGM were randomized to either CGM+CSII or CGM+MDI (control) and surveyed at baseline and 28 weeks. We performed within-trial and lifetime cost-effectiveness analyses (CEAs) and estimated lifetime costs and quality-adjusted life-years (QALYs) via a modified Sheffield T1D model. RESULTS Within the trial, the CGM+CSII group had a significant reduction in quality of life from baseline (-0.02 ± 0.05 difference in difference [DiD]) compared with controls. Total per-person 28-week costs were $8,272 (CGM+CSII) versus $5,623 (CGM+MDI); the difference in costs was primarily attributable to pump use ($2,644). Pump users reduced insulin intake (-12.8 units DiD) but increased the use of daily number of test strips (+1.2 DiD). Pump users also increased time with glucose in range of 70 to 180 mg/dL but had a higher HbA1c (+0.13 DiD) and more nonsevere hypoglycemic events. In the lifetime CEA, CGM+CSII would increase total costs by $112,045 DiD, decrease QALYs by 0.71, and decrease life expectancy by 0.48 years. CONCLUSIONS Based on this single trial, initiating an insulin pump in adults with T1D already using CGM was associated with higher costs and reduced quality of life. Additional evidence regarding the clinical effects of adopting combinations of new technologies from trials and real-world populations is needed to confirm these findings.
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Affiliation(s)
- Wen Wan
- Section of General Internal Medicine, University of Chicago, Chicago, IL (WW, MRS, AM, AGN, PZ, ESH).,School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI (ANW).,National Opinion Research Center, University of Chicago, Chicago, IL (MO)
| | - M Reza Skandari
- Section of General Internal Medicine, University of Chicago, Chicago, IL (WW, MRS, AM, AGN, PZ, ESH).,School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI (ANW).,National Opinion Research Center, University of Chicago, Chicago, IL (MO)
| | - Alexa Minc
- Section of General Internal Medicine, University of Chicago, Chicago, IL (WW, MRS, AM, AGN, PZ, ESH).,School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI (ANW).,National Opinion Research Center, University of Chicago, Chicago, IL (MO)
| | - Aviva G Nathan
- Section of General Internal Medicine, University of Chicago, Chicago, IL (WW, MRS, AM, AGN, PZ, ESH).,School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI (ANW).,National Opinion Research Center, University of Chicago, Chicago, IL (MO)
| | - Parmida Zarei
- Section of General Internal Medicine, University of Chicago, Chicago, IL (WW, MRS, AM, AGN, PZ, ESH).,School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI (ANW).,National Opinion Research Center, University of Chicago, Chicago, IL (MO)
| | - Aaron N Winn
- Section of General Internal Medicine, University of Chicago, Chicago, IL (WW, MRS, AM, AGN, PZ, ESH).,School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI (ANW).,National Opinion Research Center, University of Chicago, Chicago, IL (MO)
| | - Michael O'Grady
- Section of General Internal Medicine, University of Chicago, Chicago, IL (WW, MRS, AM, AGN, PZ, ESH).,School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI (ANW).,National Opinion Research Center, University of Chicago, Chicago, IL (MO)
| | - Elbert S Huang
- Section of General Internal Medicine, University of Chicago, Chicago, IL (WW, MRS, AM, AGN, PZ, ESH).,School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI (ANW).,National Opinion Research Center, University of Chicago, Chicago, IL (MO)
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Winn AN, Maciejewski ML, Dusetzina SB. Identifying Heterogeneous Treatment Effects of Drug Policy in Quasi-experimental Settings. CURR EPIDEMIOL REP 2019. [DOI: 10.1007/s40471-019-00213-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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42
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Winn AN, Neuner JM. Making Sure We Don't Forget the Basics When Using Machine Learning. J Natl Cancer Inst 2019; 111:529-530. [PMID: 30346555 DOI: 10.1093/jnci/djy179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 09/06/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Aaron N Winn
- Department of Clinical Sciences, School of Pharmacy
| | - Joan M Neuner
- Department of Medicine and Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI
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43
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Winn AN, Knueppel P, Neuner JM. The impact of ACA on medical financial hardship among cancer survivors. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.e18160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18160 Background: Prior research has documented that privately insured cancer patients are exposed to significant financial burdens which can result in bankruptcy. A key provision of the Affordable Care Act (ACA) was to set limits on patients out-of-pocket (OOP) spending, which was implemented in 2014. This study aims to assess if OOP limits reduces financial hardship. Methods: Using the 2000-2017 National Health Interview Survey we identified cancer survivors under age 65. We performed a difference in difference analysis which compared financial hardship for low- or moderate-income individuals (LMII), family income under $50,000, to those with higher incomes before and after OOP limits were implemented for privately insured patients. Financial hardship was measured in the following ways: delayed medical care due to cost and the number of family members delayed medical care due to costs, could not afford a prescription, medical care or seeing a specialist, and problems paying medical bills. We used multivariate regression models adjusting for age, race, marital status, gender and size of family. All analyses accounted for the complex survey design and weights. Results: We identified 20,879 privately insured, cancer survivors age 65 or younger. The impact of the ACA resulted in lower financial hardships for LMII compared to higher income persons for most outcomes. The impact of the OOP limits on financial hardship for LMII was seen in any family member delaying care due to costs (difference-in-difference (DiD) = -3.6%; 95% CI = -5.9%, -1.5%; p-value = 0.002), number of family members delaying care due to costs (DiD = -0.048; 95% CI = -0.082, -0.135; p-value = 0.002), had problems paying medical bills (DiD = -3.3%; 95% CI = -6.3%, -0.4%; p-value = 0.028), could not afford prescription medication (DiD = -2.3%; 95% CI = -4.2%, -0.3%; p-value = 0.023), could not afford medical care (DiD = -1.9%; 95% CI = -3.5%, -0.3%; p-value = 0.021), but there was no statistically significant difference in the ability to afford seeing a specialist (DiD = -1.1%; 95% CI = -2.6%, -0.5%; p-value = 0.002). Conclusions: Little research has examined the impact of the ACA’s OOP spending limits. In this study we find that after the introduction of OOP spending limits, financial hardship measured in a variety of ways significantly decreased for LMII.
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Affiliation(s)
- Aaron N Winn
- Medical College of Wisconsin Pharmacy School, Milwaukee, WI
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Mitchell AP, Winn AN, Lund JL, Dusetzina SB. Evaluating the Strength of the Association Between Industry Payments and Prescribing Practices in Oncology. Oncologist 2019; 24:632-639. [PMID: 30728276 DOI: 10.1634/theoncologist.2018-0423] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/30/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Financial relationships between physicians and the pharmaceutical industry are common, but factors that may determine whether such relationships result in physician practice changes are unknown. MATERIALS AND METHODS We evaluated physician use of orally administered cancer drugs for four cancers: prostate (abiraterone, enzalutamide), renal cell (axitinib, everolimus, pazopanib, sorafenib, sunitinib), lung (afatinib, erlotinib), and chronic myeloid leukemia (CML; dasatinib, imatinib, nilotinib). Separate physician cohorts were defined for each cancer type by prescribing history. The primary exposure was the number of calendar years during 2013-2015 in which a physician received payments from the manufacturer of one of the studied drugs; the outcome was relative prescribing of that drug in 2015, compared with the other drugs for that cancer. We evaluated whether practice setting at a National Cancer Institute (NCI)-designated Comprehensive Cancer Center, receipt of payments for purposes other than education or research (compensation payments), maximum annual dollar value received, and institutional conflict-of-interest policies were associated with the strength of the payment-prescribing association. We used modified Poisson regression to control confounding by other physician characteristics. RESULTS Physicians who received payments for a drug in all 3 years had increased prescribing of that drug (compared with 0 years), for renal cell (relative risk [RR] 1.81, 95% confidence interval [CI] 1.58-2.07), CML (RR 1.22, 95% CI 1.08-1.39), and lung (RR 1.69, 95% CI 1.58-1.82), but not prostate (RR 0.97, 95% CI 0.93-1.02). Physicians who received compensation payments or >$100 annually had increased prescribing compared with those who did not, but NCI setting and institutional conflict-of-interest policies were not consistently associated with the direction of prescribing change. CONCLUSION The association between industry payments and cancer drug prescribing was greatest among physicians who received payments consistently (within each calendar year). Receipt of payments for compensation purposes, such as for consulting or travel, and higher dollar value of payments were also associated with increased prescribing. IMPLICATIONS FOR PRACTICE Financial payments from pharmaceutical companies are common among oncologists. It is known from prior work that oncologists tend to prescribe more of the drugs made by companies that have given them money. By combining records of industry gifts with prescribing records, this study identifies the consistency of payments over time, the dollar value of payments, and payments for compensation as factors that may strengthen the association between receiving payments and increased prescribing of that company's drug.
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Affiliation(s)
- Aaron P Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York New York, USA
| | - Aaron N Winn
- School of Pharmacy, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Medical College of Wisconsin Cancer Center, Milwaukee, Wisconsin, USA
| | - Jennifer L Lund
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
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Winn AN, Dusetzina SB. More evidence on the limited impact of state oral oncology parity laws. Cancer 2018; 125:335-336. [DOI: 10.1002/cncr.31904] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 11/09/2018] [Indexed: 01/09/2023]
Affiliation(s)
- Aaron N. Winn
- Department of Clinical Sciences, School of Pharmacy Medical College of Wisconsin Milwaukee Wisconsin
- Medical College of Wisconsin Cancer Center Milwaukee Wisconsin
- Center for Advancing Population Sciences Medical College of Wisconsin Milwaukee Wisconsin
| | - Stacie B. Dusetzina
- Department of Health Policy Vanderbilt University School of Medicine Nashville Tennessee
- Vanderbilt‐Ingram Cancer Center Vanderbilt University Medical Center Nashville Tennessee
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Drangsholt S, Walter D, Ciprut S, Lepor A, Sedlander E, Curnyn C, Loeb S, Malloy P, Winn AN, Makarov DV. Quantifying downstream impact of inappropriate staging imaging in a cohort of veterans with low- and intermediate-risk incident prostate cancer. Urol Oncol 2018; 37:145-149. [PMID: 30578160 DOI: 10.1016/j.urolonc.2018.11.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 11/12/2018] [Accepted: 11/21/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION According to current National Comprehensive Cancer Network guidelines, routine imagining for staging low-risk prostate cancer is not recommended. However, extensive overuse of guideline-discordant imaging continues to persist. Incidental findings are common on imaging and little is known about the optimal management. Rates of incidental findings vs. false positive diagnosis from inappropriate imaging are poorly understood and have yet to be quantified for low- and intermediate-risk prostate cancer patients. OBJECTIVE To determine the frequency of positive radiologic findings in patients with low- and intermediate-risk prostate cancer during initial staging at VA New York Harbor Healthcare System. METHODS We retrospectively reviewed all low- and intermediate-risk prostate cancer patients' medical records from the VA New York Harbor Healthcare System for diagnosis from 2005 to 2015. We reviewed each individual's prebiopsy prostate specific antigen (PSA), Gleason score, and clinical stage. We also determined if imaging obtained yielded a false positive, incidental finding, or if metastatic disease occurred within the 6 months following initial diagnosis. RESULTS There were 414 men, who were classified as low- to intermediate-risk prostate cancer and underwent inappropriate staging imaging of 4,306 men diagnosed with prostate cancer. Of these 414 men, 178 (43%) had additional follow-up imaging for positive findings. We calculated an incidental finding rate of 10% and a false positive rate of 38% for patients. Five (1%) patients had metastatic disease. CONCLUSION Despite guideline recommendations, imaging overuse remains an issue for low-intermediate-risk prostate cancer patients. The false positive rate found in this analysis is alarmingly high at 38%. This use of scans is burdensome to the healthcare system and patient. This study highlights the frequency of inappropriate imaging and its negative consequences.
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Affiliation(s)
| | - Dawn Walter
- Department of Urology, New York University, NY; Department of Population Heath, New York University, NY
| | - Shannon Ciprut
- Department of Urology, New York University, NY; Department of Population Heath, New York University, NY
| | - Abbey Lepor
- Department of Urology, New York University, NY
| | - Erica Sedlander
- Department of Urology, New York University, NY; Department of Population Heath, New York University, NY
| | - Caitlin Curnyn
- Department of Urology, New York University, NY; Department of Population Heath, New York University, NY
| | - Stacy Loeb
- Department of Urology, New York University, NY; Department of Population Heath, New York University, NY; The Manhattan Veterans Affairs Medical Center, NY
| | | | - Aaron N Winn
- School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI; Cancer Center, Medical College of Wisconsin, Milwaukee, WI
| | - Danil V Makarov
- Department of Urology, New York University, NY; Department of Population Heath, New York University, NY; The Manhattan Veterans Affairs Medical Center, NY.
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Dusetzina SB, Huskamp HA, Winn AN, Basch E, Keating NL. Out-of-Pocket and Health Care Spending Changes for Patients Using Orally Administered Anticancer Therapy After Adoption of State Parity Laws. JAMA Oncol 2018; 4:e173598. [PMID: 29121177 DOI: 10.1001/jamaoncol.2017.3598] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Oral anticancer medications are increasingly important but costly treatment options for patients with cancer. By early 2017, 43 states and Washington, DC, had passed laws to ensure patients with private insurance enrolled in fully insured health plans pay no more for anticancer medications administered by mouth than anticancer medications administered by infusion. Federal legislation regarding this issue is currently pending. Despite their rapid acceptance, the changes associated with state adoption of oral chemotherapy parity laws have not been described. Objective To estimate changes in oral anticancer medication use, out-of-pocket spending, and health plan spending associated with oral chemotherapy parity law adoption. Design, Setting, and Participants Analysis of administrative health plan claims data from 2008-2012 for 3 large nationwide insurers aggregated by the Health Care Cost Institute. Data analysis was first completed in 2015 and updated in 2017. The study population included 63 780 adults living in 1 of 16 states that passed parity laws during the study period and who received anticancer drug treatment for which orally administered treatment options were available. Study analysis used a difference-in-differences approach. Exposures Time period before and after adoption of state parity laws, controlling for whether the patient was enrolled in a plan subject to parity (fully insured) or not (self-funded, exempt via the Employee Retirement Income Security Act). Main Outcomes and Measures Oral anticancer medication use, out-of-pocket spending, and total health care spending. Results Of the 63 780 adults aged 18 through 64 years, 51.4% participated in fully insured plans and 48.6% in self-funded plans (57.2% were women; 76.8% were aged 45 to 64 years). The use of oral anticancer medication treatment as a proportion of all anticancer treatment increased from 18% to 22% (adjusted difference-in-differences risk ratio [aDDRR], 1.04; 95% CI, 0.96-1.13; P = .34) comparing months before vs after parity. In plans subject to parity laws, the proportion of prescription fills for orally administered therapy without copayment increased from 15.0% to 53.0%, more than double the increase (12.3%-18.0%) in plans not subject to parity (P < .001). The proportion of patients with out-of-pocket spending of more than $100 per month increased from 8.4% to 11.1% compared with a slight decline from 12.0% to 11.7% in plans not subject to parity (P = .004). In plans subject to parity laws, estimated monthly out-of-pocket spending decreased by $19.44 at the 25th percentile, by $32.13 at the 50th percentile, and by $10.83 at the 75th percentile but increased at the 90th ($37.19) and 95th ($143.25) percentiles after parity (all P < .001, controlling for changes in plans not subject to parity). Parity laws did not increase 6-month total spending for users of any anticancer therapy or for users of oral anticancer therapy alone. Conclusions and Relevance While oral chemotherapy parity laws modestly improved financial protection for many patients without increasing total health care spending, these laws alone may be insufficient to ensure that patients are protected from high out-of-pocket medication costs.
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Affiliation(s)
- Stacie B Dusetzina
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill.,Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill.,University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill.,Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill
| | - Haiden A Huskamp
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Aaron N Winn
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
| | - Ethan Basch
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill.,University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill.,Division of Hematology and Oncology, University of North Carolina at Chapel Hill School of Medicine
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Abstract
This study examines the association between oncologists’ receipt of payments from pharmaceutical manufacturers and drug selection in 2 situations where there are multiple treatment options.
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Affiliation(s)
- Aaron P Mitchell
- Division of Hematology/Oncology, Department of Medicine, UNC School of Medicine, The University of North Carolina at Chapel Hill.,Lineberger Comprehensive Cancer Center, UNC School of Medicine, The University of North Carolina at Chapel Hill.,The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill
| | - Aaron N Winn
- School of Pharmacy, Medical College of Wisconsin, Milwaukee.,Cancer Center, Medical College of Wisconsin, Milwaukee
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee.,Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee
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Laiteerapong N, Cooper JM, Skandari MR, Clarke PM, Winn AN, Naylor RN, Huang ES. Individualized Glycemic Control for U.S. Adults With Type 2 Diabetes: A Cost-Effectiveness Analysis. Ann Intern Med 2018; 168:170-178. [PMID: 29230472 PMCID: PMC5989575 DOI: 10.7326/m17-0537] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Intensive glycemic control in type 2 diabetes (glycated hemoglobin [HbA1c] level <7%) is an established, cost-effective standard of care. However, guidelines recommend individualizing goals on the basis of age, comorbidity, diabetes duration, and complications. OBJECTIVE To estimate the cost-effectiveness of individualized control versus uniform intensive control (HbA1c level <7%) for the U.S. population with type 2 diabetes. DESIGN Patient-level Monte Carlo-based Markov model. DATA SOURCES National Health and Nutrition Examination Survey 2011-2012. TARGET POPULATION The approximately 17.3 million persons in the United States with diabetes diagnosed at age 30 years or older. TIME HORIZON Lifetime. PERSPECTIVE Health care sector. INTERVENTION Individualized versus uniform intensive glycemic control. OUTCOME MEASURES Average lifetime costs, life-years, and quality-adjusted life-years (QALYs). RESULTS OF BASE-CASE ANALYSIS Individualized control saved $13 547 per patient compared with uniform intensive control ($105 307 vs. $118 854), primarily due to lower medication costs ($34 521 vs. $48 763). Individualized control decreased life expectancy (20.63 vs. 20.73 years) due to an increase in complications but produced more QALYs (16.68 vs. 16.58) due to fewer hypoglycemic events and fewer medications. RESULTS OF SENSITIVITY ANALYSIS Individualized control was cost-saving and generated more QALYs compared with uniform intensive control, except in analyses where the disutility associated with receiving diabetes medications was decreased by at least 60%. LIMITATION The model did not account for effects of early versus later intensive glycemic control. CONCLUSION Health policies and clinical programs that encourage an individualized approach to glycemic control for U.S. adults with type 2 diabetes reduce costs and increase quality of life compared with uniform intensive control. Additional research is needed to confirm the risks and benefits of this strategy. PRIMARY FUNDING SOURCE National Institute of Diabetes and Digestive and Kidney Diseases.
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Affiliation(s)
- Neda Laiteerapong
- University of Chicago, Chicago, Illinois (N.L., J.M.C., M.R.S., R.N.N., E.S.H.)
| | - Jennifer M Cooper
- University of Chicago, Chicago, Illinois (N.L., J.M.C., M.R.S., R.N.N., E.S.H.)
| | - M Reza Skandari
- University of Chicago, Chicago, Illinois (N.L., J.M.C., M.R.S., R.N.N., E.S.H.)
| | | | - Aaron N Winn
- University of North Carolina, Chapel Hill, North Carolina (A.N.W.)
| | - Rochelle N Naylor
- University of Chicago, Chicago, Illinois (N.L., J.M.C., M.R.S., R.N.N., E.S.H.)
| | - Elbert S Huang
- University of Chicago, Chicago, Illinois (N.L., J.M.C., M.R.S., R.N.N., E.S.H.)
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Anderson C, Winn AN, Dusetzina SB, Nichols HB. Endocrine Therapy Initiation among Older Women with Ductal Carcinoma In Situ. J Cancer Epidemiol 2017; 2017:6091709. [PMID: 29056966 PMCID: PMC5615957 DOI: 10.1155/2017/6091709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 08/14/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Although treatment of ductal carcinoma in situ (DCIS) is controversial, national guidelines recommend considering endocrine therapy for women with estrogen receptor- (ER-) positive DCIS or those undergoing breast conserving surgery (BCS) without radiation. We evaluated uptake and predictors of endocrine therapy use among older women with DCIS. METHODS In the SEER-Medicare database, we identified women aged 65+ years diagnosed with DCIS during 2007-2011. We evaluated demographic, tumor, and treatment characteristics associated with endocrine therapy initiation. RESULTS Among 2,945 women with DCIS, 41% initiated endocrine therapy (66% tamoxifen, 34% aromatase inhibitors). Initiation was more common among women with ER-positive than ER-negative DCIS (48% versus 16%; HR = 3.75, 95% CI: 2.91-4.83); 28% of women with unknown ER status initiated endocrine therapy. Initiation was less common after BCS alone compared to BCS with radiation (32% versus 50%; HR = 0.69, 95% CI: 0.59-0.80). CONCLUSIONS Less than half of older women with DCIS initiate endocrine therapy to prevent second breast cancers. Our findings suggest use was more common, but not exclusive, among women with ER-positive DCIS, but not among women who underwent BCS alone. Endocrine therapy should be targeted toward patients most likely to benefit from its use.
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Affiliation(s)
- Chelsea Anderson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Aaron N. Winn
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stacie B. Dusetzina
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Hazel B. Nichols
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
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