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Hou Y, Trogdon JG, Freburger JK, Bushnell CD, Halladay JR, Duncan PW, Kucharska-Newton AM. Association of Continuity of Care With Health Care Utilization and Expenditures Among Patients Discharged Home After Stroke or Transient Ischemic Attack. Med Care 2024; 62:270-276. [PMID: 38447009 DOI: 10.1097/mlr.0000000000001983] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
OBJECTIVES To examine the association of prestroke continuity of care (COC) with postdischarge health care utilization and expenditures. STUDY POPULATION The study population included 2233 patients with a diagnosis of stroke or a transient ischemic attack hospitalized in one of 41 hospitals in North Carolina between March 2016 and July 2019 and discharged directly home from acute care. METHODS COC was assessed from linked Centers for Medicare and Medicaid Services Medicare claims using the Modified, Modified Continuity Index. Logistic regressions and 2-part models were used to examine the association of prestroke primary care COC with postdischarge health care utilization and expenditures. RESULTS Relative to patients in the first (lowest) COC quartile, patients in the second and third COC quartiles were more likely [21% (95% CI: 8.5%, 33.5%) and 33% (95% CI: 20.5%, 46.1%), respectively] to have an ambulatory care visit within 14 days. Patients in the highest COC quartile were more likely to visit a primary care provider but less likely to see a stroke specialist. Highest as compared with lowest primary care COC quartile was associated with $45 lower (95% CI: $14, $76) average expenditure for ambulatory care visits within 30 days postdischarge. Patients in the highest, as compared with the lowest, primary care COC quartile were 36% less likely (95% CI: 8%, 64%) to be readmitted within 30 days postdischarge and spent $340 less (95% CI: $2, $678) on unplanned readmissions. CONCLUSIONS These findings underscore the importance of primary care COC received before stroke hospitalization to postdischarge care and expenditures.
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Affiliation(s)
- Yucheng Hou
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Management, Policy and Community Health, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Janet K Freburger
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA
| | - Cheryl D Bushnell
- Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC
| | - Jacqueline R Halladay
- Department of Family Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Pamela W Duncan
- Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC
| | - Anna M Kucharska-Newton
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY
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2
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Biddell CB, Spees LP, Trogdon JG, Kent EE, Rosenstein DL, Angove RS, Rogers CD, Wheeler SB. Economic Evaluation of a Nonmedical Financial Assistance Program on Missed Treatment Appointments Among Adults With Cancer. J Clin Oncol 2024; 42:300-311. [PMID: 37897261 PMCID: PMC10824376 DOI: 10.1200/jco.23.00993] [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] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/29/2023] [Accepted: 09/18/2023] [Indexed: 10/30/2023] Open
Abstract
PURPOSE We retrospectively evaluated the clinical and economic impact of a program providing nonmedical financial assistance on missed treatment appointments among patients receiving cancer treatment at a large, Southeastern public hospital system. MATERIALS AND METHODS We used patient electronic health records, program records, and cancer registry data to examine the impact of the program on rates of missed (or no-show) radiation therapy and infusion chemotherapy/immunotherapy appointments in the 180 days after treatment initiation. We used propensity weighting to estimate the effect of the program, stratified by treatment appointment type (radiation therapy, infusion chemotherapy/immunotherapy). We developed a decision tree-based economic model to conduct a cost-consequence analysis from the health system perspective in a hypothetical cohort over a 6-month time horizon. RESULTS Of 1,347 patients receiving radiation therapy between 2015 and 2019, 53% (n = 715) had ≥1 no-shows and 28% (n = 378) received program assistance. Receipt of any assistance was associated with a 2.1 percentage point (95% CI, 0.6 to 3.5) decrease in the proportion of no-shows, corresponding to a 51% decrease in the overall mean no-show proportion. Under the current funding model, the program is estimated to save the health system $153 in US dollars per missed appointment averted, relative to not providing nonmedical financial assistance. Of the 1,641 patients receiving infusion chemotherapy/immunotherapy, 33% (n = 541) received program assistance, and only 14% (n = 223) had ≥1 no-shows. The financial assistance program did not have a significant effect on no-show proportions among infusion visits. CONCLUSION This study used a novel approach to retrospectively evaluate a nonmedical financial assistance program for patients undergoing active cancer treatment. Findings support investment in programs that address patients' nonmedical financial needs, particularly for those undergoing intensive radiation therapy.
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Affiliation(s)
- Caitlin B. Biddell
- Department of Health Policy and Management, University of North Carolina at Chapel Hill (UNC), Chapel Hill, NC
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Lisa P. Spees
- Department of Health Policy and Management, University of North Carolina at Chapel Hill (UNC), Chapel Hill, NC
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Justin G. Trogdon
- Department of Health Policy and Management, University of North Carolina at Chapel Hill (UNC), Chapel Hill, NC
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Erin E. Kent
- Department of Health Policy and Management, University of North Carolina at Chapel Hill (UNC), Chapel Hill, NC
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Donald L. Rosenstein
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
- Department of Psychiatry, UNC School of Medicine, Chapel Hill, NC
| | | | | | - Stephanie B. Wheeler
- Department of Health Policy and Management, University of North Carolina at Chapel Hill (UNC), Chapel Hill, NC
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
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Smith NR, Hassmiller Lich K, Ng SW, Hall MG, Trogdon JG, Frerichs L. Implementation costs of sugary drink policies in the United States. J Public Health Policy 2023; 44:566-587. [PMID: 37714964 PMCID: PMC10841536 DOI: 10.1057/s41271-023-00435-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2023] [Indexed: 09/17/2023]
Abstract
To support implementation of important public health policies, policymakers need information about implementation costs over time and across stakeholder groups. We assessed implementation costs of two federal sugar-sweetened beverage (SSB) policies of current policy interest and with evidence to support their effects: excise taxes and health warning labels. Our analysis encompassed the entire policy life cycle using the Exploration, Preparation, Implementation, and Sustainment framework. We identified implementation actions using key informant interviews and developed quantitative estimates of implementation costs using published literature and government documents. Results show that implementation costs vary over time and among stakeholders. Explicitly integrating implementation science theory and using mixed methods improved the comprehensiveness of our results. Although this work is specific to federal SSB policies, the process can inform how we understand the costs of many public health policies, providing crucial information for public health policy making.
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Affiliation(s)
- Natalie Riva Smith
- Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA.
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Shu Wen Ng
- Department of Nutrition, Gillings School of Global Public Health, Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA
| | - Marissa G Hall
- Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Leah Frerichs
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
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Salgado Hernandez JC, Ng SW, Stearns SC, Trogdon JG. Cost-benefit analysis of alternative tax policies on sugar-sweetened beverages in Mexico. PLoS One 2023; 18:e0292276. [PMID: 37788248 PMCID: PMC10547152 DOI: 10.1371/journal.pone.0292276] [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] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 09/15/2023] [Indexed: 10/05/2023] Open
Abstract
In 2014, Mexico implemented a tax on sugar-sweetened beverages (SSB) equivalent to one Mexican peso (MP) per liter to address the high obesity prevalence. This tax has effectively reduced SSB purchases and yielded healthcare savings; however, it remains unknown whether SSB taxes lead to net benefits at the societal level in Mexico. Moreover, public health experts recommend increasing the tax. The objective of this study is to estimate the net benefits of SSB taxes compared to a scenario of no tax in urban Mexico. Taxes include the one-MP tax and alternative higher taxes (two and three MP per SSB liter). Thus, we conducted a cost-benefit analysis from the perspective of the government, producers, and consumers for a simulated closed cohort of adults in a life-table model. We defined net benefits as the difference between economic benefits (the value of statistical life, healthcare savings, and tax revenue) and costs (consumer surplus and profit losses). We found that, at the societal level, all simulated taxes will eventually generate benefits that surpass costs within ten years. Overall net benefits can reach USD 7.1 billion and 15.3 billion for the one-MP and the three-MP tax, respectively. Hence, these benefits increased at a declining rate compared to taxes. The government and consumers will experience overall positive net benefits among society's members. Policymakers should consider time horizons and tradeoffs between health gains and economic outcomes across different society members.
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Affiliation(s)
- Juan Carlos Salgado Hernandez
- National Institute of Public Health, National Council of Humanities, Science and Technology, Mexico and Center for Research in Nutrition and Health, Cuernavaca, Mexico
| | - Shu Wen Ng
- Carolina Population Center and Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Sally C. Stearns
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Justin G. Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Hou Y, D'Souza K, Kucharska-Newton AM, Freburger JK, Bushnell CD, Halladay JR, Duncan PW, Trogdon JG. Postacute Expenditures Among Patients Discharged Home After Stroke or Transient Ischemic Attack: The COMprehensive Post-Acute Stroke Services (COMPASS) Trial. Value Health 2023; 26:1453-1460. [PMID: 37422076 DOI: 10.1016/j.jval.2023.06.018] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 05/23/2023] [Accepted: 06/14/2023] [Indexed: 07/10/2023]
Abstract
OBJECTIVES The COMPASS (COMprehensive Post-Acute Stroke Services) pragmatic trial cluster-randomized 40 hospitals in North Carolina to the COMPASS transitional care (TC) postacute care intervention or usual care. We estimated the difference in healthcare expenditures postdischarge for patients enrolled in the COMPASS-TC model of care compared with usual care. METHODS We linked data for patients with stroke or transient ischemic attack enrolled in the COMPASS trial with administrative claims from Medicare fee-for-service (n = 2262), Medicaid (n = 341), and a large private insurer (n = 234). The primary outcome was 90-day total expenditures, analyzed separately by payer. Secondary outcomes were total expenditures 30- and 365-days postdischarge and, among Medicare beneficiaries, expenditures by point of service. In addition to intent-to-treat analysis, we conducted a per-protocol analysis to compare Medicare patients who received the intervention with those who did not, using randomization status as an instrumental variable. RESULTS We found no statistically significant difference in total 90-day postacute expenditures between intervention and usual care; the results were consistent across payers. Medicare beneficiaries enrolled in the COMPASS intervention arm had higher 90-day hospital readmission expenditures ($682, 95% CI $60-$1305), 30-day emergency department expenditures ($132, 95% CI $13-$252), and 30-day ambulatory care expenditures ($67, 95% CI $38-$96) compared with usual care. The per-protocol analysis did not yield a significant difference in 90-day postacute care expenditures for Medicare COMPASS patients. CONCLUSIONS The COMPASS-TC model did not significantly change patients' total healthcare expenditures for up to 1 year postdischarge.
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Affiliation(s)
- Yucheng Hou
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Karishma D'Souza
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anna M Kucharska-Newton
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Janet K Freburger
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Cheryl D Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Jacqueline R Halladay
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Pamela W Duncan
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Lee S, Bennett AV, Zhou X, Betof Warner A, Trogdon JG, Kent EE, Lund JL. Real-world treatment patterns and outcomes for patients with advanced melanoma treated with immunotherapy or targeted therapy. Pharmacoepidemiol Drug Saf 2023; 32:988-1000. [PMID: 37095605 DOI: 10.1002/pds.5630] [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: 11/18/2022] [Revised: 03/17/2023] [Accepted: 04/12/2023] [Indexed: 04/26/2023]
Abstract
OBJECTIVE To identify real-world patterns of first line treatment, treatment sequence and outcomes for older adults diagnosed with advanced melanoma who received immunotherapy or targeted therapy. METHODS The study population included older adults (ages 65+) diagnosed with unresectable or metastatic melanoma between 2012 and 2017 and who received first line immunotherapy or targeted therapy. Using the linked surveillance, epidemiology, and end results-medicare data, we described patterns of first line treatment and treatment sequence through 2018. We used descriptive statistics to report patient and provider characteristics by first line treatment receipt and changes in first line therapy use over calendar time. We also described overall survival (OS) and time to treatment failure (TTF) by first line treatment using the Kaplan-Meier method. For patterns of treatment sequence, we reported commonly observed treatment switch patterns by treatment sub-category and calendar year. RESULTS The analyses included 584 patients (mean age = 76.3 years). A majority (n = 502) received first line immunotherapy. There was a sustained increase in immunotherapy uptake, most notably from 2015 to 2016. The estimated median OS and TTF were longer with first line immunotherapy than with targeted therapy. Individuals treated with CTLA-4 + PD-1 inhibitors had the longest median OS (28.4 months). The most common treatment switch pattern was from a first line CTLA-4 inhibitor to a second line PD-1 inhibitor. CONCLUSIONS Our findings inform understanding of treatment patterns of currently used immunotherapies and targeted therapies in older adults with advanced melanoma. Immunotherapy use has increased steadily with PD-1 inhibitors becoming a dominant treatment option since 2015.
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Affiliation(s)
- Sejin Lee
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Antonia V Bennett
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Xi Zhou
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Justin G Trogdon
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Erin E Kent
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, 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 at Chapel Hill, Chapel Hill, North Carolina, USA
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7
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Biddell CB, Spees LP, Trogdon JG, Kent EE, Rosenstein DL, Angove RSM, Wheeler SB. Association of patient-reported financial barriers with healthcare utilization among Medicare beneficiaries with a history of cancer. J Cancer Surviv 2023:10.1007/s11764-023-01409-x. [PMID: 37266819 PMCID: PMC10692305 DOI: 10.1007/s11764-023-01409-x] [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: 03/06/2023] [Accepted: 05/22/2023] [Indexed: 06/03/2023]
Abstract
PURPOSE We examined characteristics associated with financial barriers to healthcare and the association of financial barriers with adverse healthcare events among US adult cancer survivors enrolled in Medicare. METHODS We used nationally representative Medicare Current Beneficiary Survey data (2011-2013, 2015-2017) to identify adults with a history of non-skin cancer. We defined financial barriers as cost-related trouble accessing and/or delayed care in the prior year. Using propensity-weighted multivariable logistic regression, we examined associations between financial barriers and adverse healthcare events (any ED visits, any inpatient hospitalizations). RESULTS Overall, 11.0% of adult Medicare beneficiaries with a history of cancer reported financial barriers in the prior year, with higher burden among beneficiaries < 65 years of age vs. ≥ 65 (32.5% vs. 8.2%, p < 0.0001) and with annual income < $25,000 vs. ≥ $25,000 (18.1% vs. 6.9%, p < 0.0001). In bivariate models, financial barriers were associated with a 7.8 percentage point (95% CI: 1.5-14.0) increase in the probability of ED visits. In propensity-weighted models, this association was not statistically significant. The association between financial barriers and hospitalizations was not significant in the overall population; however, financial barriers were associated with a decreased probability of hospitalization among Black/African American beneficiaries. CONCLUSIONS Despite Medicare coverage, beneficiaries with a history of cancer are at risk for experiencing financial barriers to healthcare. In the overall population, financial barriers were not associated with ED visits or hospitalizations. IMPLICATIONS FOR CANCER SURVIVORS Policies limiting Medicare patient out-of-pocket spending and care models addressing health-related social needs are needed to reduce financial barriers experienced.
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Affiliation(s)
- Caitlin B Biddell
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA.
| | - Lisa P Spees
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Justin G Trogdon
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Erin E Kent
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Donald L Rosenstein
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
- Department of Psychiatry, UNC School of Medicine, Chapel Hill, NC, USA
| | | | - Stephanie B Wheeler
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
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8
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Jazowski SA, Samuel-Ryals CA, Wood WA, Zullig LL, Trogdon JG, Dusetzina SB. Association between low-income subsidies and inequities in orally administered antimyeloma therapy use. Am J Manag Care 2023; 29:246-254. [PMID: 37229783 PMCID: PMC10268034 DOI: 10.37765/ajmc.2023.89357] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES The Medicare Part D low-income subsidy program drastically reduces patient cost sharing and may improve access to and equitable use of high-cost antimyeloma therapy. We compared initiation of and adherence to orally administered antimyeloma therapy between full-subsidy and nonsubsidy enrollees and assessed the association between full subsidies and racial/ethnic inequities in orally administered antimyeloma treatment use. STUDY DESIGN Retrospective cohort study. METHODS We used Surveillance, Epidemiology, and End Results-Medicare data to identify beneficiaries diagnosed with multiple myeloma between 2007 and 2015. Separate Cox proportional hazards models assessed time from diagnosis to treatment initiation and time from therapy initiation to discontinuation. Modified Poisson regression examined therapy initiation in the 30, 60, and 90 days following diagnosis and adherence to and discontinuation of treatment in the 180 days following initiation. RESULTS Receipt of full subsidies was not associated with earlier initiation of or improved adherence to orally administered antimyeloma therapy. Full-subsidy enrollees were 22% (adjusted HR [aHR], 1.22; 95% CI, 1.08-1.38) more likely to experience earlier treatment discontinuation than nonsubsidy enrollees. Receipt of full subsidies did not appear to reduce racial/ethnic inequities in orally administered antimyeloma therapy use. Black full-subsidy and nonsubsidy enrollees were 14% less likely than their White counterparts to ever initiate treatment (full subsidy: aHR, 0.86; 95% CI, 0.73-1.02; nonsubsidy: aHR, 0.86; 95% CI, 0.74-0.99). CONCLUSIONS Full subsidies alone are insufficient to increase uptake or equitable use of orally administered antimyeloma therapy. Addressing known barriers to care (eg, social determinants of health, implicit bias) could improve access to and use of high-cost antimyeloma therapy.
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Affiliation(s)
- Shelley A Jazowski
- Department of Health Policy, Vanderbilt University School of Medicine, 2525 West End Ave, Ste 1200, Nashville, TN 37203.
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9
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Wheeler SB, Rotter J, Gogate A, Reeder-Hayes KE, Drier SW, Ekwueme DU, Fairley TL, Rocque GB, Trogdon JG. Cost-Effectiveness of Pharmacologic Treatment Options for Women With Endocrine-Refractory or Triple-Negative Metastatic Breast Cancer. J Clin Oncol 2023; 41:32-42. [PMID: 36054865 PMCID: PMC9788984 DOI: 10.1200/jco.21.02473] [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] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 05/31/2022] [Accepted: 07/12/2022] [Indexed: 12/30/2022] Open
Abstract
PURPOSE Treatments for endocrine-refractory or triple-negative metastatic breast cancer (mBC) are modestly effective at prolonging life and improving quality of life but can be extremely expensive. Given these tradeoffs in quality of life and cost, the optimal choice of treatment sequencing is unclear. Cost-effectiveness analysis can explicitly quantify such tradeoffs, enabling more informed decision making. Our objective was to estimate the societal cost-effectiveness of different therapeutic alternatives in the first- to third-line sequences of single-agent chemotherapy regimens among patients with endocrine-refractory or triple-negative mBC. METHODS Using three dynamic microsimulation models of 10,000 patients each, three cohorts were simulated, based upon prior chemotherapy exposure: (1) unexposed to either taxane or anthracycline, (2) taxane- and anthracycline-exposed, and (3) taxane-exposed/anthracycline-naive. We focused on the following single-agent chemotherapy regimens as reasonable and commonly used options in the first three lines of therapy for each cohort, based upon feedback from oncologists treating endocrine-refractory or triple-negative mBC: (1) for taxane- and anthracycline-unexposed patients, paclitaxel, capecitabine (CAPE), or pegylated liposomal doxorubicin; (2) for taxane- and anthracycline-exposed patients, Eribulin, CAPE, or carboplatin; and (3) for taxane-exposed/anthracycline-naive patients, pegylated liposomal doxorubicin, CAPE, or Eribulin. RESULTS In each cohort, accumulated quality-adjusted life-years were similar between regimens, but total societal costs varied considerably. Sequences beginning first-line treatment with paclitaxel, carboplatin, and CAPE, respectively, for cohorts 1, 2, and 3, had lower costs and similar or slightly better outcomes compared with alternative options. CONCLUSION In this setting where multiple single-agent chemotherapy options are recommended by clinical guidelines and share similar survival and adverse event trajectories, treatment sequencing approaches that minimize costs early may improve the value of care.
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Affiliation(s)
- Stephanie B. Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jason Rotter
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Anagha Gogate
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Katherine E. Reeder-Hayes
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of Medical Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sarah W. Drier
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Donatus U. Ekwueme
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention (CDC), Atlanta, GA
| | - Temeika L. Fairley
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention (CDC), Atlanta, GA
| | - Gabrielle B. Rocque
- Division of Hematology/Oncology, Departments of Medicine and Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, AL
| | - Justin G. Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC
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10
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Izguttinov A, Trogdon JG. Can Medicaid be a Solution to the Problem? Underinsurance in Medicaid Expansion Versus Non-Expansion States. Inquiry 2023; 60:469580231202640. [PMID: 37776294 PMCID: PMC10542319 DOI: 10.1177/00469580231202640] [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] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 07/18/2023] [Accepted: 09/01/2023] [Indexed: 10/02/2023]
Abstract
The positive effects of Medicaid expansions have been extensively documented in the literature. However, it is not clear whether the reform has had an equally meaningful effect with respect to underinsurance, which is the state of having health insurance yet lacking adequate coverage or facing substantial financial risks upon usage of services. Based on a quasi-experimental difference-in-differences approach, we analyzed the data from a nationally representative sample to estimate the effect of Medicaid expansion on the probability of underinsurance among the non-elderly low-income adult population of the U.S. We found no evidence of significant changes in the likelihood of underinsurance due to Medicaid expansion during the first 4 years after the ACA implementation. However, a supplementary analysis of the longer-term impact (2018-2019) suggests that there might be a time lag between Medicaid expansion and its effect on underinsurance. It is important to realize that expansion of coverage alone may not be sufficient to protect millions of Americans, particularly those with low incomes, from underinsurance. It is, therefore, crucial for policymakers to build legislative frameworks that protect individuals from excessive healthcare expenses and prevent treatment avoidance or delay.
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Affiliation(s)
- Aniyar Izguttinov
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Policy and Management, Chapel Hill, NC, USA
| | - Justin G. Trogdon
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Policy and Management, Chapel Hill, NC, USA
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11
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Shafer PR, Dusetzina SB, Sabik LM, Platts-Mills TF, Stearns SC, Trogdon JG. High Deductible Health Plans and Use of Free Preventive Services Under the Affordable Care Act. Inquiry 2023; 60:469580231182512. [PMID: 37329296 DOI: 10.1177/00469580231182512] [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] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
The Affordable Care Act aimed to increase use of preventive services by eliminating cost-sharing to consumers. However, patients may be unaware of this benefit or they may not seek preventive services if they anticipate that the cost of potential diagnostic or treatment services will be too high, both more likely among those in high deductible health plans. We used nationally representative private health insurance claims (100% sample of IBM® MarketScan®) for the United States from 2006 to 2018, restricting the data to enrollment and claims for non-elderly adults who were enrolled for the full plan year. The cross-sectional sample (185 million person-years) is used to describe trends in preventive service use and costs from 2008 through 2016. The cohort sample (9 million people) focuses on the elimination of cost-sharing for certain high-value preventive services in late 2010, requiring continuous enrollment across 2010 and 2011. We examine whether HDHP enrollment is associated with use of eligible preventive services using semi-parametric difference-in-differences to account for endogenous plan selection. Our preferred model implies that HDHP enrollment was associated with a reduction of the post-ACA change in any use of eligible preventive services by 0.2 percentage points or 12.5%. Cancer screenings were unaffected but HDHP enrollment was associated with smaller increases in wellness visits, immunizations, and screening for chronic conditions and sexually transmitted infections. We also find that the policy was ineffective at reducing out-of-pocket costs for the eligible preventive services, likely due to implementation issues.
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Affiliation(s)
- Paul R Shafer
- Department of Health Law, Policy, and Management, School of Public Health, Boston University, Boston, MA, USA
| | | | - Lindsay M Sabik
- School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Sally C Stearns
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Justin G Trogdon
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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12
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Izguttinov A, Yanguela J, Trogdon JG. Cost-based Underinsurance After the Affordable Care Act. J Health Care Poor Underserved 2023; 34:949-971. [PMID: 38015131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
The Affordable Care Act has significantly reduced the number of uninsured individuals in the U.S., yet millions of insured Americans lack adequate coverage or face substantial health-related financial risks. In this study, we conduct an analysis of a nationally representative sample to generate up-to-date evidence on the association between insurance types and demographic factors and the probability of cost-related underinsurance among continuously insured, lower-income adults in the U.S. We extend the previously established definition of underinsurance by including a measure of subjective financial burden. Our estimates suggest that 33.2% of lower-income individuals in our sample were underinsured, with a fourth of them meeting two or three criteria. We also find that Medicaid beneficiaries were significantly less likely than others to experience underinsurance. Our findings provide evidence that underinsurance is a major concern, and expansion of coverage alone may not suffice to protect individuals from financial risks and cost barriers to health care use.
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13
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Biddell C, Spees L, Trogdon JG, Kent EE, Rosenstein DL, Angove RSM, Wheeler SB. Association of patient-reported financial barriers with healthcare utilization among Medicare beneficiaries with a history of cancer. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.220] [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
220 Background: Cancer survivors are at heightened risk of experiencing financial barriers to healthcare (FBs), which may increase the likelihood of adverse clinical outcomes. We aimed to (1) identify characteristics associated with experiencing FBs, and (2) examine the association of FBs with emergency department (ED) visits and inpatient hospitalizations among US adult cancer survivors enrolled in Medicare. Methods: We used 2011 – 2013 and 2015 – 2017 Medicare Current Beneficiary Survey (MCBS) data, a nationally representative survey, to identify adults with a history of non-skin cancer (N = 4511). We defined FBs as trouble accessing care and/or delayed care due to cost in the prior year. Healthcare utilization is captured in MCBS by reconciling self-reported events and fee-for-service claims. After examining bivariate associations between beneficiary characteristics and FBs, we used propensity-weighted logistic regression to examine associations between FBs and adverse healthcare events (any ED visits, any inpatient hospitalizations) in the year following report of FBs. Results: Overall, 11.8% (95% CI: 10.7% - 13.0%) of adult Medicare beneficiaries with a history of cancer reported FBs in the prior year, with higher burden among beneficiaries less than 65 years of age (35.6% vs. 8.6%, p< 0.0001), with annual income < $25,000 (19.4% vs. 7.4%, p< 0.0001), and identifying as persons of color (15.7% vs. 11.2%, p= 0.01). Beneficiaries eligible for a Part D low-income subsidy were more likely to report FBs compared to those who were not eligible, with those with eligibility for only part of the year (vs. the full year) reporting the highest prevalence of FBs (36.5% vs. 20.8%, p< 0.0001). The overall prevalence of ED visits and inpatient hospitalization was 18.2% and 18.8%, respectively. In bivariate models, reporting FBs was associated with an 8.1 percentage point (95% CI: 1.7 – 14.5) increase in the probability of ED visits. In propensity-weighted multivariate models, this association was insignificant (0.8; 95% CI: -3.7 – 5.3). The association between FBs and inpatient hospitalization was not significant. Number of chronic conditions was the strongest predictor of utilization, with having 5+ conditions (vs. cancer only) associated with a 21.1 (95% CI: 16.5 – 25.7) and 15.4 (95% CI: 9.2 – 21.7) percentage point increase in the probability of ED visits and inpatient hospitalizations, respectively. Conclusions: Over one in ten Medicare beneficiaries with a history of cancer report trouble accessing care or delayed care for cost-related reasons, with a heightened prevalence among beneficiaries less than 65 and those eligible for a low-income subsidy. Reporting FBs is not associated with increased ED and inpatient utilization. Nevertheless, identifying characteristics associated with FBs among cancer survivors can inform targeted clinic- and policy-level intervention.
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Affiliation(s)
- Caitlin Biddell
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lisa Spees
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Erin E. Kent
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
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14
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Trogdon JG, Amin K, Gupta P, Urick BY, Reeder-Hayes KE, Farley JF, Wheeler SB, Spees L, Lund JL. Providers' mediating role for medication adherence among cancer survivors. PLoS One 2021; 16:e0260358. [PMID: 34843550 PMCID: PMC8629272 DOI: 10.1371/journal.pone.0260358] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 11/08/2021] [Indexed: 11/23/2022] Open
Abstract
Background We conducted a mediation analysis of the provider team’s role in changes to chronic condition medication adherence among cancer survivors. Methods We used a retrospective, longitudinal cohort design following Medicare beneficiaries from 18-months before through 24-months following cancer diagnosis. We included beneficiaries aged ≥66 years newly diagnosed with breast, colorectal, lung or prostate cancer and using medication for non-insulin anti-diabetics, statins, and/or anti-hypertensives and similar individuals without cancer from Surveillance, Epidemiology, and End Results-Medicare data, 2008–2014. Chronic condition medication adherence was defined as a proportion of days covered ≥ 80%. Provider team structure was measured using two factors capturing the number of providers seen and the historical amount of patient sharing among providers. Linear regressions relying on within-survivor variation were run separately for each cancer site, chronic condition, and follow-up period. Results The number of providers and patient sharing among providers increased after cancer diagnosis relative to the non-cancer control group. Changes in provider team complexity explained only small changes in medication adherence. Provider team effects were statistically insignificant in 13 of 17 analytic samples with significant changes in adherence. Statistically significant provider team effects were small in magnitude (<0.5 percentage points). Conclusions Increased complexity in the provider team associated with cancer diagnosis did not lead to meaningful reductions in medication adherence. Interventions aimed at improving chronic condition medication adherence should be targeted based on the type of cancer and chronic condition and focus on other provider, systemic, or patient factors.
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Affiliation(s)
- Justin G. Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | - Krutika Amin
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Parul Gupta
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Benjamin Y. Urick
- Division of Practice Advancement and Clinical Education, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Katherine E. Reeder-Hayes
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Division of Hematology/Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Joel F. Farley
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Stephanie B. Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Lisa Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Jennifer L. Lund
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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15
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Sloan CE, Hoffman A, Maciejewski ML, Coffman CJ, Trogdon JG, Wang V. Trends in Dialysis Industry Consolidation After Medicare Payment Reform, 2006-2016. JAMA Health Forum 2021; 2:e213626. [PMID: 35977264 PMCID: PMC8796909 DOI: 10.1001/jamahealthforum.2021.3626] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 09/20/2021] [Indexed: 11/14/2022] Open
Abstract
Question Findings Meaning Importance Objective Design, Setting, and Participants Exposures Main Outcomes and Measures Results Conclusions and Relevance
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Affiliation(s)
- Caroline E. Sloan
- Department of Medicine, Duke University Health System, Durham, North Carolina
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, North Carolina
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Abby Hoffman
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Matthew L. Maciejewski
- Department of Medicine, Duke University Health System, Durham, North Carolina
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Cynthia J. Coffman
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Justin G. Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Virginia Wang
- Department of Medicine, Duke University Health System, Durham, North Carolina
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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16
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Urick B, Burbage S, Baggett C, Lafata JE, Sanoff HK, Trogdon JG. Influence of social determinants of health on oncology care quality rankings. J Clin Oncol 2021. [DOI: 10.1200/jco.2020.39.28_suppl.139] [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
139 Background: Adjustment for social determinants of health (SDOH) when assessing provider care quality remains limited. The Oncology Care Model (OCM), for example, includes low-income status/dual eligibility (LIS/DE) as a part of the risk adjustment model for some quality measures, but does not account for any social risk variables in the hospice measure. No measures within the OCM account for additional social risk factors beyond LIS/DE such as patients’ race, rurality, and social deprivation. Additional SDOH adjustment could increase the accuracy of provider quality rankings and better align performance-based payments with true provider quality. Methods: North Carolina Medicare claims from 2015-2017 comprised the data for this study. The year 2015 was used to establish baseline covariates. Episodes were attributed to physician practices’ Tax Identification Number (TIN), lasted 6 months, and were divided into performance years beginning 1/1/2016 and 7/1/2016. Three measures were used: 1) all-cause hospital admissions; 2) all-cause emergency department visits or observation stays; and 3) admission to hospice for 3 days or more among patients who died. SDOH included patient-level race as well as county-level rurality and social deprivation, measured using the social deprivation index (SDI). TIN-level scores with and without expanded SDOH variables were divided into quintiles and compared descriptively as well as using weighted kappa statistics. Results: No SDOH were significantly associated with the hospitalization outcome (P = 0.118-0.944). For the ED measure, Black patients and rural patients were significantly more likely to have an ED visit or observation stay during an episode than white patients and urban patients (P < 0.0001). For the hospice measure, greater SDI values were associated with less hospice use (P < 0.05). Accordingly, including SDOH variables for ED visit/observation stay and hospice measures had a greater impact on TIN rankings than for the hospitalization measure (Table). Conclusions: Because quintile rankings in determine potential shared savings under models like the OCM, differences in rankings due to additional SDOH variables could have a meaningful impact on TIN-level revenue. Additional work is needed to expand the scope of patient-level SDOH variables used for risk adjustment and to explore differences across TINs which contribute to SDOH-sensitive changes in rankings.[Table: see text]
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Affiliation(s)
| | | | | | | | - Hanna Kelly Sanoff
- UNC Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
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17
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Urick B, Burbage S, Baggett C, Lafata JE, Sanoff HK, Trogdon JG. Reliability of claims-based measures used to assess cancer care quality. J Clin Oncol 2021. [DOI: 10.1200/jco.2020.39.28_suppl.42] [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
42 Background: As value-based payment models for cancer care expand, the need for measures which reliably assess the quality of care provided increases. This is especially true for models like the Oncology Care Model (OCM) that rely on quality rankings to determine potential shared savings. Under models like these, unreliable measures may result in arbitrary application of value-based payments. The goal of this project is to evaluate the extent to which measures used within the OCM are reliable indicators of provider performance. Methods: Data for this project came from North Carolina Medicare claims from 2015-2017. Episodes were attributed to physician practices at the tax identification number (TIN) level, lasted 6 months, and were divided into two performance years beginning 1/1/2016 and 7/1/2016. TINs with fewer than 20 attributed patients were excluded. Three claims-based OCM measures were used in this evaluation: 1) proportion of episodes with all-cause hospital admissions; 2) proportion of episodes with all-cause emergency department (ED) visits or observation stays; and 3) proportion of patients that died who were admitted to hospice for 3 days or more. Risk adjustment followed the method described by measure specifications from the OCM. Reliability was calculated as the ratio of between practice variation (e.g. signal) to the sum of between practice variation and within practice variation (e.g. noise). Variance estimates were derived from hierarchical logistic regression models used for risk adjustment. Results: For the hospitalization and ED visit measures, episode counts for years 1 and 2 were 30,746 and 28,430 and TIN counts were 86 and 84, respectively. Hospice use measures had fewer episodes (2,677 and 2,428) and TINs (36 and 33). Across all measures, median reliability scores failed to achieve the recommended 0.7 threshold and only hospice had a median reliability score above 0.5 (Table). Conclusions: These findings suggest claims-based measures included in the OCM may produce imprecise estimates of provider performance and are vulnerable to random variation. Consideration should be given to developing alternative measures which may be more reliable estimates of provider performance and to increasing minimum denominator requirements for existing measures.[Table: see text]
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Affiliation(s)
| | | | | | - Jennifer Elston Lafata
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Hanna Kelly Sanoff
- UNC Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
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18
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Spencer JC, Brewer NT, Coyne-Beasley T, Trogdon JG, Weinberger M, Wheeler SB. Reducing Poverty-Related Disparities in Cervical Cancer: The Role of HPV Vaccination. Cancer Epidemiol Biomarkers Prev 2021; 30:1895-1903. [PMID: 34503948 DOI: 10.1158/1055-9965.epi-21-0307] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 05/21/2021] [Accepted: 07/29/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Near elimination of cervical cancer in the United States is possible in coming decades, yet inequities will delay this achievement for some populations. We sought to explore the effects of human papillomavirus (HPV) vaccination on disparities in cervical cancer incidence between high- and low-poverty U.S. counties. METHODS We calibrated a dynamic simulation model of HPV infection to reflect average counties in the highest and lowest quartile of poverty (percent of population below federal poverty level), incorporating data on HPV prevalence, cervical cancer screening, and HPV vaccination. We projected cervical cancer incidence through 2070, estimated absolute and relative disparities in incident cervical cancer for high- versus low-poverty counties, and compared incidence with the near-elimination target (4 cases/100,000 women annually). RESULTS We estimated that, on average, low-poverty counties will achieve near-elimination targets 14 years earlier than high-poverty counties (2029 vs. 2043). Absolute disparities by county poverty will decrease, but relative differences are estimated to increase. We estimate 21,604 cumulative excess cervical cancer cases in high-poverty counties over the next 50 years. Increasing HPV vaccine coverage nationally to the Healthy People 2020 goal (80%) would reduce excess cancer cases, but not alter estimated time to reach the near-elimination threshold. CONCLUSIONS High-poverty U.S. counties will likely be delayed in achieving near-elimination targets for cervical cancer and as a result will experience thousands of potentially preventable cancers. IMPACT Alongside vaccination efforts, it is important to address the role of social determinants and health care access in driving persistent inequities by area poverty.
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Affiliation(s)
- Jennifer C Spencer
- Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts. .,Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Tamera Coyne-Beasley
- Departments of Pediatrics and Internal Medicine, Division of Adolescent Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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19
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Gogate A, Wheeler SB, Reeder-Hayes KE, Ekwueme DU, Fairley TL, Drier S, Trogdon JG. Projecting the Prevalence and Costs of Metastatic Breast Cancer From 2015 through 2030. JNCI Cancer Spectr 2021; 5:pkab063. [PMID: 34409255 PMCID: PMC8364673 DOI: 10.1093/jncics/pkab063] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/09/2021] [Indexed: 12/31/2022] Open
Abstract
Background This study projected the number of metastatic breast cancer (mBC) cases and costs (medical and productivity) attributable to mBC through 2030 among 3 age groups: younger (aged 18-44 years), midlife (aged 45-64 years), and older women (aged 65 years and older). Methods We developed a stock/flow model in which women enter the mBC population at initial diagnosis (de novo stage IV) or through progression of an earlier-stage cancer. Women exit the mBC population through death. Input parameters by age and phase of treatment came from the US Census, Surveillance, Epidemiology, and End Results and peer-reviewed literature. Results In 2030, we estimated there would be 246 194 prevalent cases of mBC, an increase of 54.8% from the 2015 estimate of 158 997. We estimated total costs (medical and productivity) of mBC across all age groups and phases of care were $63.4 billion (95% sensitivity range = $59.4-$67.4 billion) in 2015 and would increase to $152.4 billion (95% sensitivity range = $111.6-$220.4 billion) in 2030, an increase of 140%. Trends in estimated costs were higher for younger and midlife women than for older women. Conclusions The cost of mBC could increase substantially in the coming decade, especially among younger and midlife women. Although accounting for trends in incidence, progression, and survival, our model did not attempt to forecast structural changes such as technological innovations in breast cancer treatment and health-care delivery reforms. These findings can motivate early detection activities, direct value-driven mBC treatment, and provide a useful baseline against which to measure the effect of prevention and treatment efforts.
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Affiliation(s)
- Anagha Gogate
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Katherine E Reeder-Hayes
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Division of Hematology/Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Donatus U Ekwueme
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Temeika L Fairley
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sarah Drier
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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20
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Drake C, Lian T, Trogdon JG, Edelman D, Eisenson H, Weinberger M, Reiter K, Shea CM. Evaluating the association of social needs assessment data with cardiometabolic health status in a federally qualified community health center patient population. BMC Cardiovasc Disord 2021; 21:342. [PMID: 34261446 PMCID: PMC8278633 DOI: 10.1186/s12872-021-02149-5] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 07/06/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Health systems are increasingly using standardized social needs screening and response protocols including the Protocol for Responding to and Assessing Patients' Risks, Assets, and Experiences (PRAPARE) to improve population health and equity; despite established relationships between the social determinants of health and health outcomes, little is known about the associations between standardized social needs assessment information and patients' clinical condition. METHODS In this cross-sectional study, we examined the relationship between social needs screening assessment data and measures of cardiometabolic clinical health from electronic health records data using two modelling approaches: a backward stepwise logistic regression and a least absolute selection and shrinkage operation (LASSO) logistic regression. Primary outcomes were dichotomized cardiometabolic measures related to obesity, hypertension, and atherosclerotic cardiovascular disease (ASCVD) 10-year risk. Nested models were built to evaluate the utility of social needs assessment data from PRAPARE for risk prediction, stratification, and population health management. RESULTS Social needs related to lack of housing, unemployment, stress, access to medicine or health care, and inability to afford phone service were consistently associated with cardiometabolic risk across models. Model fit, as measured by the c-statistic, was poor for predicting obesity (logistic = 0.586; LASSO = 0.587), moderate for stage 1 hypertension (logistic = 0.703; LASSO = 0.688), and high for borderline ASCVD risk (logistic = 0.954; LASSO = 0.950). CONCLUSIONS Associations between social needs assessment data and clinical outcomes vary by cardiometabolic condition. Social needs assessment data may be useful for prospectively identifying patients at heightened cardiometabolic risk; however, there are limits to the utility of social needs data for improving predictive performance.
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Affiliation(s)
- Connor Drake
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA.
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27519, USA.
| | - Tyler Lian
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27519, USA
| | - David Edelman
- Department of Medicine, Duke University School of Medicine, 2301 Erwin Rd, Durham, NC, 27705, USA
- Durham VA Healthcare System, 508 Fulton St, Durham, NC, 27705, USA
| | - Howard Eisenson
- Lincoln Community Health Center, 1301 Fayetteville St, Durham, NC, 27707, USA
- Department of Family Medicine and Community Health, Duke University School of Medicine, DUMC 2914, Durham, NC, 27710, USA
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27519, USA
| | - Kristin Reiter
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27519, USA
| | - Christopher M Shea
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27519, USA
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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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22
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Wheeler DC, Miller CA, Do EK, Ksinan AJ, Trogdon JG, Chukmaitov A, Fuemmeler BF. Identifying Area-Level Disparities in Human Papillomavirus Vaccination Coverage Using Geospatial Analysis. Cancer Epidemiol Biomarkers Prev 2021; 30:1689-1696. [PMID: 34172461 DOI: 10.1158/1055-9965.epi-21-0331] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/13/2021] [Accepted: 06/14/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Human papillomavirus (HPV) is the most common sexually transmitted infection within the United States (US). Despite clinical agreement on the effectiveness and widespread availability of the prophylactic HPV vaccine, vaccination coverage in the US is suboptimal and varies by geographic region and area-level variables. The goals of this article were to model the variation in vaccination rates among boys and girls within ZIP Codes in Virginia, determine whether neighborhood sociodemographic variables explain variation in HPV vaccination, and identify areas with significantly depressed vaccination coverage. METHODS We used Bayesian hierarchical spatial regression models with statewide immunization registry data to consider the correlation in vaccination among boys and girls, as well as the spatial correlation in vaccination for each sex. RESULTS The results showed low vaccination coverage in our birth cohort (28.9% in girls and 23.8% in boys) relative to the national level (56.8% and 51.8%, respectively). Several area-level variables were significantly and positively associated with vaccination coverage, including population density, percentage of Hispanic population, and average number of vehicles. In addition, there were several areas of significantly lowered vaccination coverage, including predominantly rural ones, and overall large geographic disparities in HPV vaccination. CONCLUSIONS Determining the geospatial patterning and area-level factors associated with HPV vaccination within a prescribed geographic area helps to inform future planning efforts. IMPACT The results of this study will help inform future planning efforts for geographically targeted interventions and policies, as well as drive new research to implement clinical and community strategies to increase HPV vaccination.
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Affiliation(s)
- David C Wheeler
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia. .,Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
| | - Carrie A Miller
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - Elizabeth K Do
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia.,Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC
| | - Albert J Ksinan
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Askar Chukmaitov
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - Bernard F Fuemmeler
- Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia.,Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
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23
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Hou Y, Bushnell CD, Duncan PW, Kucharska-Newton AM, Halladay JR, Freburger JK, Trogdon JG. Hospital to Home Transition for Patients With Stroke Under Bundled Payments. Arch Phys Med Rehabil 2021; 102:1658-1664. [PMID: 33811853 PMCID: PMC10152978 DOI: 10.1016/j.apmr.2021.03.010] [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: 07/29/2020] [Revised: 02/19/2021] [Accepted: 03/02/2021] [Indexed: 11/29/2022]
Abstract
Bundled payments are a promising alternative payment model for reducing costs and improving the coordination of postacute stroke care, yet there is limited evidence supporting the effectiveness of bundled payments for stroke. This may be due to the lack of effective strategies to address the complex needs of stroke survivors. In this article, we describe COMprehensive Post-Acute Stroke Services (COMPASS), a comprehensive transitional care intervention focused on discharge from the acute care setting to home. COMPASS may serve as a potential care redesign strategy under bundled payments for stroke, such as the Centers for Medicare & Medicaid Innovation Bundled Payment for Care Improvement Initiative. The COMPASS care model is aligned with the incentive structures and essential components of bundled payments in terms of care coordination, patient assessment, patient and family involvement, and continuity of care. Ongoing evaluation will inform the design of incorporating COMPASS-like transitional care interventions into a stroke bundle.
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Affiliation(s)
- Yucheng Hou
- Department of Health Policy and Management, Gillings School of Global Public Health, the University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Cheryl D Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC
| | - Pamela W Duncan
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC
| | - Anna M Kucharska-Newton
- Department of Epidemiology, Gillings School of Global Public Health, the University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY
| | - Jacqueline R Halladay
- Department of Family Medicine, UNC School of Medicine, the University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Janet K Freburger
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, the University of North Carolina at Chapel Hill, Chapel Hill, NC
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24
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Bayliss WS, Bushnell CD, Halladay JR, Duncan PW, Freburger JK, Kucharska-Newton AM, Trogdon JG. The Cost of Implementing and Sustaining the COMprehensive Post-Acute Stroke Services Model. Med Care 2021; 59:163-168. [PMID: 33273292 PMCID: PMC8594619 DOI: 10.1097/mlr.0000000000001462] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The COMprehensive Post-Acute Stroke Services (COMPASS) model, a transitional care intervention for stroke patients discharged home, was tested against status quo postacute stroke care in a cluster-randomized trial in 40 hospitals in North Carolina. This study examined the hospital-level costs associated with implementing and sustaining COMPASS. METHODS Using an activity-based costing survey, we estimated hospital-level resource costs spent on COMPASS-related activities during approximately 1 year. We identified hospitals that were actively engaged in COMPASS during the year before the survey and collected resource cost estimates from 22 hospitals. We used median wage data from the Bureau of Labor Statistics and COMPASS enrollment data to estimate the hospital-level costs per COMPASS enrollee. RESULTS Between November 2017 and March 2019, 1582 patients received the COMPASS intervention across the 22 hospitals included in this analysis. Average annual hospital-level COMPASS costs were $2861 per patient (25th percentile: $735; 75th percentile: $3,475). Having 10% higher stroke patient volume was associated with 5.1% lower COMPASS costs per patient (P=0.016). About half (N=10) of hospitals reported postacute clinic visits as their highest-cost activity, while a third (N=7) reported case ascertainment (ie, identifying eligible patients) as their highest-cost activity. CONCLUSIONS We found that the costs of implementing COMPASS varied across hospitals. On average, hospitals with higher stroke volume and higher enrollment reported lower costs per patient. Based on average costs of COMPASS and readmissions for stroke patients, COMPASS could lower net costs if the model is able to prevent about 6 readmissions per year.
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Affiliation(s)
- William S Bayliss
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill
| | - Cheryl D Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston Salem
| | - Jacqueline R Halladay
- Department of Family Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Pamela W Duncan
- Department of Family Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Janet K Freburger
- Department of Physical Therapy, University of Pittsburgh, Bridgeside Point 1, Pittsburgh, PA
| | - Anna M Kucharska-Newton
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill
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25
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Vielot NA, Butler AM, Trogdon JG, Ramadas R, Smith JS, Eyler A. Association of State Legislation of Human Papillomavirus Vaccination with Vaccine Uptake Among Adolescents in the United States. J Community Health 2021; 45:278-287. [PMID: 31520188 DOI: 10.1007/s10900-019-00734-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
We assessed the association of state legislation with adolescent human papillomavirus (HPV) vaccination rates in states that legislated information dissemination or administration of HPV vaccination. Using insurance claims, we calculated monthly HPV vaccination rates (November 2009-December 2017) among adolescents in states that passed HPV vaccination legislation during that period: Missouri (July 2010), Kentucky (February 2012), Indiana (March 2013), Oregon (June 2013). We used segmented regression to estimate levels and trends of HPV vaccination rates, comparing pre-legislation to post-legislation segments, adjusting for seasonal vaccination patterns and changes to the vaccination recommendation among males during the study period. Indiana's legislation allowed pharmacists to administer HPV vaccination; legislation in Kentucky, Missouri, and Oregon included provisions HPV and cervical cancer education. No statistically significant increases in HPV vaccination levels or trends were observed in the post-legislation segments among adolescents overall; however, a significant post-legislation increase in vaccination trends was observed among boys in Missouri (β = 0.16, p = 0.03). Evidence for a positive impact of legislation on HPV vaccination rates is limited. The scarcity of policies that directly facilitate or promote HPV vaccination, and the breadth of exemptions to school vaccination requirements, may limit the effectiveness of these policies. Continuing efforts to introduce and pass legislation that directly facilitates HPV vaccination, combined with promoting existing evidence-based interventions, can provide opportunities to identify the most effective strategies to increase adolescent HPV vaccination rates.
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Affiliation(s)
- Nadja A Vielot
- Department of Family Medicine, University of North Carolina at Chapel Hill, 590 Manning Drive, Chapel Hill, NC, 27599, USA.
| | - Anne M Butler
- Division of Infectious Diseases, Washington University at St. Louis, St. Louis, MO, USA.,Division of Public Health Sciences, Washington University at St. Louis, St. Louis, MO, USA
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ramya Ramadas
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Jennifer S Smith
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Amy Eyler
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
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26
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Kim C, Tappis H, Natiq L, Fried B, Lich KH, Delamater PL, Weinberger M, Trogdon JG. Travel time, availability of emergency obstetric care, and perceived quality of care associated with maternal healthcare utilisation in Afghanistan: A multilevel analysis. Glob Public Health 2021; 17:569-586. [PMID: 33460359 DOI: 10.1080/17441692.2021.1873400] [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] [Indexed: 10/22/2022]
Abstract
Limited understanding of factors such as travel time, availability of emergency obstetric care (EmOC), and satisfaction/perceived quality of care on the utilisation of maternal health services exists in fragile and conflict-affect settings. We examined these key factors on three utilisation outcomes: at least one skilled antenatal care (ANC) visit, in-facility delivery, and bypassing the nearest public facility for childbirth in Afghanistan from 2010 to 2015. We used three-level multilevel mixed effects logistic regression models to assess the relationships between women's and their nearest public facilities' characteristics and outcomes. The nearest facility score for satisfaction/perceived quality was associated with having at least one skilled ANC visit (AOR: 2.02, 95% CI: 1.21, 3.36). Women whose nearest facility provided EmOC had a higher odds of in-facility childbirth compared to women whose nearest facility did not (AOR: 1.24, 95% CI: 1.04, 1.48). Nearest hospital travel time (AOR: 0.95, 95% CI: 0.93, 0.98) and nearest facility satisfaction/perceived quality (AOR: 0.34, 95% CI: 0.14, 0.82) were associated with lower odds of women bypassing their nearest facility. Afghanistan has made progress in expanding access to maternal healthcare services during the ongoing conflict. Addressing key barriers is essential to ensure that women have access to life-saving services.
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Affiliation(s)
- Christine Kim
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hannah Tappis
- Technical Leadership and Innovations Department, Jhpiego, Baltimore, MD, USA
| | - Laila Natiq
- Silk Route Training and Research Organization, Kabul, Afghanistan
| | - Bruce Fried
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Paul L Delamater
- Department of Geography, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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27
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Lund JL, Gupta P, Amin KB, Meng K, Urick BY, Reeder-Hayes KE, Farley JF, Wheeler SB, Spees L, Trogdon JG. Changes in chronic medication adherence in older adults with cancer versus matched cancer-free cohorts. J Geriatr Oncol 2021; 12:72-79. [PMID: 32423699 PMCID: PMC7666657 DOI: 10.1016/j.jgo.2020.04.012] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/13/2020] [Accepted: 04/26/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVES A cancer diagnosis can influence medication adherence for chronic conditions by shifting care priorities or reinforcing disease prevention. This study describes changes in adherence to medications for treating three common chronic conditions - diabetes, hyperlipidemia, and hypertension - among older adults newly diagnosed with non-metastatic breast, colorectal, lung, or prostate cancer. METHODS We identified Medicare beneficiaries aged ≥66 years newly diagnosed with cancer and using medication for at least one chronic condition, and similar cohorts of matched individuals without cancer. To assess medication adherence, proportion of days covered (PDC) was measured in six-month windows starting six-months before through 24 months following cancer diagnosis or matched index date. Generalized estimating equations were used to estimate difference-in-differences (DID) comparing changes in PDCs across cohorts using the pre-diagnosis window as the referent. Analyses were run separately for each cancer type-chronic condition combination. RESULTS Across cancer types and non-cancer cohorts, adherence was highest for anti-hypertensives (90-92%) and lowest for statins (77-79%). In older adults with colorectal and lung cancer, adherence to anti-diabetics and statins declined post-diagnosis compared with the matched non-cancer cohorts, with estimates ranging from a DID of -2 to -4%. In older adults with breast and prostate cancer cohorts, changes in adherence for all medications were similar to non-cancer cohorts. CONCLUSION Our findings highlight variation in medication adherence by cancer type and chronic condition. As many older adults with early stage cancer eventually die from non-cancer causes, it is imperative that cancer survivorship interventions emphasize medication adherence for other chronic conditions.
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Affiliation(s)
- Jennifer L Lund
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America.
| | - Parul Gupta
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America
| | - Krutika B Amin
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America
| | - Ke Meng
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America
| | - Benjamin Y Urick
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America
| | - Katherine E Reeder-Hayes
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America; Division of Hematology/Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America
| | - Joel F Farley
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, MN 55455, United States of America
| | - Stephanie B Wheeler
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America
| | - Lisa Spees
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America
| | - Justin G Trogdon
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America
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28
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Drake C, Reiter K, Weinberger M, Eisenson H, Edelman D, Trogdon JG, Shea CM. The Direct Clinic-Level Cost of the Implementation and Use of a Protocol to Assess and Address Social Needs in Diverse Community Health Center Primary Care Clinical Settings. J Health Care Poor Underserved 2021; 32:1872-1888. [PMID: 34803048 PMCID: PMC9996544 DOI: 10.1353/hpu.2021.0171] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE Social determinants of health, including food insecurity, housing instability, social isolation, and unemployment are important drivers of health outcomes and utilization. To inform implementation of social needs screening and response protocols, there is a need to identify the associated costs in routine primary care encounters. METHODS We interviewed key stakeholders in four diverse community health centers that had adopted a widely used social needs screening and response protocol. We evaluated costs using an activity-based costing tool across both the initial implementation phase and ongoing maintenance phase. RESULTS Clinic costs were associated with workforce development, planning, and electronic health record integration. These initial implementation costs varied by site ($6,644-$49,087). On a per-patient basis, ongoing maintenance costs ranged from $9.76 to $47.98. CONCLUSION Our findings can aid in designing reimbursement mechanisms tied to social needs screening and response to accelerate translational efforts and promote health equity.
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29
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Savitz ST, Bailey SC, Dusetzina SB, Jones WS, Trogdon JG, Stearns SC. Treatment selection and medication adherence for stable angina: The role of area-based health literacy. J Eval Clin Pract 2020; 26:1711-1721. [PMID: 31994280 PMCID: PMC7552995 DOI: 10.1111/jep.13341] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/28/2019] [Accepted: 11/29/2019] [Indexed: 01/09/2023]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Clinical studies show equivalent health outcomes from interventional procedures and treatment with medication only for stable angina patients. However, patients may be subject to overuse or access barriers for interventional procedures and may exhibit suboptimal adherence to medications. Our objective is to evaluate whether community-level health literacy is associated with treatment selection and medication adherence patterns. METHOD The sample included Medicare fee-for-service beneficiaries (20% random sample) with stable angina in 2007-2013. We used an area-level health literacy variable because of the lack of an individual measure in claims. We measured the association between (a) area-based health literacy with treatment selection (medication only, percutaneous coronary intervention [PCI], or coronary artery bypass grafting (CABG) surgery) and (b) area-based health literacy with medication adherence. We controlled for other factors including demographics, co-morbidity burden, dual eligibility, and area deprivation index. RESULTS We identified 8300 patients of whom 8.7% lived in a low health literacy area. Overall, 56% of patients received medication only, 28% received PCI, and 15% received CABG. Patients in low health literacy areas were less likely to receive CABG (-3.5 percentage points; 95% CI, -6.8 to -0.3) than were patients in high health literacy areas, but the significance was sensitive to specification. Overall, 81.5% and 71.5% of patients were adherent to antianginals and statins, respectively. Living in low health literacy areas was associated with lower adherence to antianginals (-3.3 percentage points; 95% CI, -6.1 to -0.6) but not statins. CONCLUSIONS Low area-based health literacy was associated with being less likely to receive CABG and lower adherence, but the differences between low and high health literacy areas were small and sensitive to model specification. Individual factors such as dual eligibility status and race/ethnicity had stronger associations with outcomes than had area-based health literacy, suggesting that this area-based measure was inadequate to account for social determinants in this study.
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Affiliation(s)
- Samuel T Savitz
- Department of Health Policy & Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stacy Cooper Bailey
- Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - W Schuyler Jones
- Department of Medicine, Duke Heart Center, Duke University Medical Center, Durham, North Carolina
| | - Justin G Trogdon
- Department of Health Policy & Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Sally C Stearns
- Department of Health Policy & Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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30
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Spencer JC, Brewer NT, Trogdon JG, Weinberger M, Coyne-Beasley T, Wheeler SB. Cost-effectiveness of Interventions to Increase HPV Vaccine Uptake. Pediatrics 2020; 146:peds.2020-0395. [PMID: 33199466 PMCID: PMC7786823 DOI: 10.1542/peds.2020-0395] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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] [Accepted: 09/23/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We sought to prioritize interventions for increasing human papillomavirus (HPV) vaccination coverage based on cost-effectiveness from a US state perspective to inform decisions by policy makers. METHODS We developed a dynamic simulation model of HPV transmission and progression scaled to a medium-sized US state (5 million individuals). We modeled outcomes over 50 years comparing no intervention to a one-year implementation of centralized reminder and recall for HPV vaccination, school-located HPV vaccination, or quality improvement (QI) visits to primary care clinics. We used probabilistic sensitivity analysis to assess a range of plausible outcomes associated with each intervention. Cost-effectiveness was evaluated relative to a conservative willingness-to-pay threshold; $50 000 per quality-adjusted life-year (QALY) . RESULTS All interventions were cost-effective, relative to no intervention. QI visits had the lowest cost and cost per QALY gained ($1538 versus no intervention). Statewide implementation of centralized reminder and recall cost $28 289 per QALY gained versus QI visits. School-located vaccination had the highest cost but was cost-effective at $18 337 per QALY gained versus QI visits. Scaling to the US population, interventions could avert 3000 to 14 000 future HPV cancers. When varying intervention cost and impact over feasible ranges, interventions were typically preferred to no intervention, but cost-effectiveness varied between intervention strategies. CONCLUSIONS Three interventions for increasing HPV vaccine coverage were cost-effective and offered substantial health benefits. Policy makers seeking to increase HPV vaccination should, at minimum, dedicate additional funding for QI visits, which are consistently effective at low cost and may additionally consider more resource-intensive interventions (reminder and recall or school-located vaccination).
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Affiliation(s)
- Jennifer C. Spencer
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts;,Departments of Health Policy and Management and
| | - Noel T. Brewer
- Health Behavior, Gillings School of Global Public Health and,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina; and
| | - Justin G. Trogdon
- Departments of Health Policy and Management and,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina; and
| | | | - Tamera Coyne-Beasley
- Division of Adolescent Medicine, Departments of Pediatrics and Internal Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Stephanie B. Wheeler
- Departments of Health Policy and Management and,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina; and
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Biddell CB, Spees LP, Mayer DK, Wheeler SB, Trogdon JG, Rotter J, Birken SA. Developing personalized survivorship care pathways in the United States: Existing resources and remaining challenges. Cancer 2020; 127:997-1004. [PMID: 33259060 DOI: 10.1002/cncr.33355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/27/2020] [Accepted: 11/12/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Caitlin B Biddell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Deborah K Mayer
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina.,School of Nursing, University of North Carolina, Chapel Hill, North Carolina
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | | | - Sarah A Birken
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
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Cykert S, Keyserling TC, Pignone M, DeWalt D, Weiner BJ, Trogdon JG, Wroth T, Halladay J, Mackey M, Fine J, In Kim J, Cene C. A controlled trial of dissemination and implementation of a cardiovascular risk reduction strategy in small primary care practices. Health Serv Res 2020; 55:944-953. [PMID: 33047340 DOI: 10.1111/1475-6773.13571] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 12/23/2022] Open
Abstract
OBJECTIVE To assess the effect of dissemination and implementation of an intervention consisting of practice facilitation and a risk-stratified, population management dashboard on cardiovascular risk reduction for patients at high risk in small, primary care practices. STUDY SETTING A total of 219 small primary care practices (≤10 clinicians per site) across North Carolina with primary data collection from electronic health records (EHRs) from the fourth quarter of 2015 through the second quarter of 2018. STUDY DESIGN We performed a stepped-wedge, stratified, cluster randomized trial of a one-year intervention consisting of practice facilitation utilizing quality improvement techniques coupled with a cardiovascular dashboard that included lists of risk-stratified adults, aged 40-79 years and their unmet treatment opportunities. The primary outcome was change in 10-Year ASCVD Risk score among all patients with a baseline score ≥10 percent from baseline to 3 months postintervention. DATA COLLECTION/ EXTRACTION METHODS Data extracts were securely transferred from practices on a nightly basis from their EHR to the research team registry. PRINCIPLE FINDINGS ASCVD risk scores were assessed on 437 556 patients and 146 826 had a calculated 10-year risk ≥10 percent. The mean baseline risk was 23.4 percent (SD ± 12.6 percent). Postintervention, the absolute risk reduction was 6.3 percent (95% CI 6.3, 6.4). Models considering calendar time and stepped-wedge controls revealed most of the improvement (4.0 of 6.3 percent) was attributable to the intervention and not secular trends. In multivariate analysis, male gender, age >65 years, low-income (<$40 000), and Black race (P < .001 for all variables) were each associated with greater risk reductions. CONCLUSION A risk-stratified, population management dashboard combined with practice facilitation led to substantial reductions of 10-year ASCVD risk for patients at high risk. Similar approaches could lead to effective dissemination and implementation of other new evidence, especially in rural and other under-resourced practices. Registration: ClinicalTrials.Gov 15-0479.
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Affiliation(s)
- Samuel Cykert
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of General Internal Medicine and Clinical Epidemiology, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Thomas C Keyserling
- Division of General Internal Medicine and Clinical Epidemiology, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,Center for Health Promotion and Disease Prevention, The Gillings School of Global Public Health, The University of North Carolina, Chapel Hill, North Carolina, USA
| | - Michael Pignone
- Department of Internal Medicine, The Dell Medical School, University of Texas, Austin, Texas, USA
| | - Darren DeWalt
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of General Internal Medicine and Clinical Epidemiology, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Bryan J Weiner
- Department of Global Public Health, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Justin G Trogdon
- Department of Health Policy and Management, The Gillings School of Global Public Health, The University of North Carolina, Chapel Hill, North Carolina, USA
| | - Thomas Wroth
- Community Care of North Carolina, Raleigh, North Carolina, USA
| | - Jacqueline Halladay
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Family Medicine, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Monique Mackey
- The North Carolina Area Health Education Centers Program, Chapel Hill, North Carolina, USA
| | - Jason Fine
- Department of Biostatistics, The Gillings School of Global Public Health, The University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jung In Kim
- Department of Statistics, Eberly College of Science, The Pennsylvania State University, University Park, Pennsylvania, USA.,Department of Nutritional Sciences, College of Health and Human Development, The Pennsylvania State University, University Park, Pennsylvania, USA
| | - Crystal Cene
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of General Internal Medicine and Clinical Epidemiology, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Wheeler SB, Spees L, Biddell CB, Rotter J, Trogdon JG, Birken SA, Mayer D. Development of a personalized follow-up care algorithm for Medicare breast cancer survivors. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.29_suppl.204] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
204 Background: The rapidly growing number of cancer survivors in the US have substantial healthcare needs requiring surveillance and care for the late and long-term effects of cancer treatment and comorbidities. Lacking a clear system of care, experts recommend a personalized approach to survivorship care. The objective of this study was to test a clinical prediction algorithm to distinguish low-complexity breast cancer survivors who may be suited to self-manage their survivorship care and be followed by their primary care provider (PCP) from survivors who require specialty care. Methods: We used the Surveillance and Epidemiology End Results (SEER) registry – Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data to identify women diagnosed with stage 0-3 breast cancer between 2003 and 2011. Cross-validated random forest machine learning models separately estimated survivors’ independent risk of all-cause death, cancer-specific death, recurrence, or severe late effects within 3 years following treatment completion. The absence of these outcomes identified survivors as potentially eligible for self-management and PCP care. Predictors included measures of baseline health status and health care utilization, patient socio-demographic characteristics, cancer characteristics, and financial burden. Results: Among the 4,516 survivors in the primary cohort, 82% were white, and the mean (SD) age was 75.1 (7.8) years. Almost 50% were diagnosed with Stage I breast cancer, followed by 25.2% with Stage 2, 19.3% with Stage 0, and 5.6% with Stage III. Within the 3-year follow-up period, 372 (8.2%) survivors died (111 or 2.5% from cancer), 665 (14.7%) experienced recurrence, and 488 (10.8%) were hospitalized due to severe late effects. Predicting all-cause death resulted in 91.9% out-of-sample accuracy, a 37.6% improvement over an uninformed model. Important predictors across outcomes included age, geographic region, diagnosis year, financial burden, comorbidities, and cancer stage. Conclusions: Survivors requiring specialty care are characterized by higher comorbidity, lower educational attainment, and advanced age, suggesting that, in addition to cancer characteristics, personalized care pathways developed in response to our findings must account for social and contextual factors as well.
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Affiliation(s)
| | - Lisa Spees
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | - Sarah A. Birken
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Deborah Mayer
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
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Karmali RN, Skinner AC, Trogdon JG, Weinberger M, George SZ, Hassmiller Lich K. The association between the supply of select nonpharmacologic providers for pain and use of nonpharmacologic pain management services and initial opioid prescribing patterns for Medicare beneficiaries with persistent musculoskeletal pain. Health Serv Res 2020; 56:275-288. [PMID: 33006158 DOI: 10.1111/1475-6773.13561] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 12/29/2022] Open
Abstract
OBJECTIVE To test the relationship between the supply of select nonpharmacologic providers (physical therapy (PT) and mental health (MH)) and use of nonpharmacologic services among older adults with a persistent musculoskeletal pain (MSP) episode. DATA SOURCES/STUDY SETTING Claims data from a 5 percent random sample of Medicare beneficiaries enrolled fee-for-service (2007-2014) and the Area Health Resource File (AHRF). STUDY DESIGN This retrospective study used generalized estimating equations to estimate the association between the county nonpharmacologic provider supply and individual service use with opioid prescriptions filled during Phase 1 (first three months of an episode) and Phase 2 (three months following Phase 1). DATA COLLECTION/EXTRACTION METHODS We identified beneficiaries (>65 years) with ≥2 MSP diagnoses ≥90 days apart and no opioid prescription six months before the first pain diagnosis (N = 69 456). Beneficiaries' county characteristics were assigned using the AHRF. PRINCIPAL FINDINGS About 13.9 percent of beneficiaries used PT, 1.8 percent used MH services, and 10.7 percent had an opioid prescription during the first three months of a persistent MSP episode. An additional MH provider/10 000 people/county [aOR: 0.97, 95% CI: 0.96-0.98] and PT/10 000 people/county [aOR: 0.98, 95% CI: 0.97-1.00] was associated with lower odds of filling an opioid prescription in Phase 1. An additional MH provider/10 000 people/county [aOR: 0.97, 95% CI: 0.96-0.98] and PT use in Phase 1 [aOR: 0.62, 95% CI: 0.58-0.67] were associated with lower odds of filling an opioid prescription in Phase 2. The associations between the supply of providers and nonpharmacologic service use in Phase 1 and Phase 1 opioid prescriptions significantly differed by metropolitan and rural counties (P-value: .019). CONCLUSIONS Limited access to nonpharmacologic services is associated with opioid prescriptions at the onset of a persistent MSP episode. Initiating PT at the onset of an episode may reduce future opioid use. Strategies for engaging beneficiaries in nonpharmacologic services should be tailored for metropolitan and rural counties.
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Affiliation(s)
- Ruchir N Karmali
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Oakland, California, USA.,Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA.,Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Asheley C Skinner
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA.,Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Oakland, California, USA
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Oakland, California, USA
| | - Steven Z George
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA.,Department of Orthopedic Surgery, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Oakland, California, USA
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Kim C, Tappis H, McDaniel P, Soroush MS, Fried B, Weinberger M, Trogdon JG, Kristen Hassmiller Lich, Delamater PL. National and subnational estimates of coverage and travel time to emergency obstetric care in Afghanistan: Modeling of spatial accessibility. Health Place 2020; 66:102452. [PMID: 33011490 DOI: 10.1016/j.healthplace.2020.102452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 09/20/2020] [Accepted: 09/22/2020] [Indexed: 12/30/2022]
Abstract
In Afghanistan, the risk of maternal death is among the highest in the world, with wide variation across the country. One explanation may be wide geographic disparities in access and use of maternal health care services. This study describes the spatial distribution of public facilities providing maternal health care in Afghanistan, specifically emergency obstetric care (EmOC), and the differences in travel time estimates using different transportation modes from 2010 to 2015 at the national and subnational levels. We conducted mapping and spatial analyses to measure the proportion of pregnant women able to access any EmOC health facility within 2 h by foot, animal, motor vehicle and a combination of transport modes. In 2015, adequate coverage of active public health facilities within 2 h of travel time was 36.6% by foot and 71.2% by a combination of transport modes. We found an 8.3% and 63.2% increase in access to EmOC facilities within 2 h of travel time by a combination of transport modes and by foot only, respectively, by 2015. Access to a combination of transportation options such as motor vehicles and animals may benefit pregnant women in reaching health facilities efficiently. Afghanistan made impressive gains in maternal healthcare access; despite these improvements, large disparities remain in geographic access by province and overall access to facilities is still poor.
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Affiliation(s)
- Christine Kim
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Hannah Tappis
- Technical Leadership and Innovations Department, Jhpiego, Baltimore, MD, USA.
| | - Philip McDaniel
- Davis Library, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | | | - Bruce Fried
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Paul L Delamater
- Department of Geography, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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36
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Trogdon JG, Liu X, Reeder-Hayes KE, Rotter J, Ekwueme DU, Wheeler SB. Productivity costs associated with metastatic breast cancer in younger, midlife, and older women. Cancer 2020; 126:4118-4125. [PMID: 32648979 DOI: 10.1002/cncr.33077] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 02/14/2020] [Revised: 06/02/2020] [Accepted: 06/03/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND The objective of the current study was to estimate productivity costs due to metastatic breast cancer (mBC) via productive time lost among survivors and potential life-years lost from premature mortality among 3 age groups: younger (aged 18-44 years), midlife (aged 45-64 years), and older (aged ≥65 years) women. METHODS The authors estimated the number of work and home productivity days missed due to mBC by age group using data from the 2000 to 2016 National Health Interview Survey. Years of potential life lost (YPLL) due to mBC were calculated for each age group using 2015 National Vital Statistics System data. The authors valued both sources of lost productivity time using the Current Population Survey and prior studies. RESULTS The per-woman value of lost productive days (work and home) due to mBC ranged from $680 for older women to $5169 for younger women. In 2015, the value of lost work and home productivity days associated with mBC nationally was $67 million for younger women, $246 million for midlife women, and $66 million for older women. YPLL were highest among midlife women (403,786 life-years), followed by older women (248,522 life-years) and younger women (95,943 life-years). Midlife women were found to have the highest market value of YPLL ($4.1 billion), followed by younger women ($1.6 billion) and older women ($527 million). CONCLUSIONS The results of the current study demonstrated that mBC generates a high economic burden through lost productivity, especially among midlife women.
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Affiliation(s)
- Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Xuejun Liu
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Katherine E Reeder-Hayes
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Division of Hematology and Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jason Rotter
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Donatus U Ekwueme
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Shafer PR, Dusetzina SB, Sabik LM, Platts-Mills TF, Stearns SC, Trogdon JG. Insurance instability and use of emergency and office-based care after gaining coverage: An observational cohort study. PLoS One 2020; 15:e0238100. [PMID: 32886675 PMCID: PMC7473517 DOI: 10.1371/journal.pone.0238100] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 08/10/2020] [Indexed: 11/21/2022] Open
Abstract
Background The Affordable Care Act led to improvements in reporting a usual source of care, but it is unclear whether patients are changing their usual source of care in response to coverage gains. We assess whether prior insurance instability is associated with changes in use of emergency and office-based care after the Marketplace and Medicaid expansion were introduced. Methods Our study draws from the 2013–14 Medical Expenditure Panel Survey, identifying a cohort of non-elderly adults with full-year health insurance coverage in 2014. We use linear and multinomial logistic regression to assess the relationship between insurance instability prior to 2014 (uninsured for 1–11 months, ≥12 months) and person-level changes in use of health care after gaining coverage (change in ED and office visits from 2013 to 2014) with continuously insured individuals serving as a comparison group. Results Being uninsured for at least one year prior to gaining full-year coverage in 2014 was associated with a 33% increase in ED visits (0.06 visits, p<0.01) and a 47% increase in office visits (1.10 visits, p<0.01), driven by those gaining public coverage. We found no evidence of substitution across settings in the short term, often a stated goal of expansion. Conclusion The long-term uninsured may have substantial health needs and pent-up demand for health care, seeing more physicians across multiple settings in the year after gaining coverage as they seek to get unmanaged conditions under control. Closing the gap in primary care use between the previously uninsured and those with health insurance coverage may help improve long-term health outcomes.
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Affiliation(s)
- Paul R. Shafer
- Department of Health Law, Policy, and Management, School of Public Health, Boston University, Boston, Massachusetts, United States of America
- * E-mail:
| | - Stacie B. Dusetzina
- Department of Health Policy, School of Medicine, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Lindsay M. Sabik
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Timothy F. Platts-Mills
- Department of Emergency Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Sally C. Stearns
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Justin G. Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Freeman AT, Kuo M, Zhou L, Trogdon JG, Baggett CD, Tuchman SA, Shea TC, Wood WA. Influence of Treating Facility, Provider Volume, and Patient-Sharing on Survival of Patients With Multiple Myeloma. J Natl Compr Canc Netw 2020; 17:1100-1108. [PMID: 31487686 DOI: 10.6004/jnccn.2019.7298] [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: 08/24/2018] [Accepted: 03/25/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Population-based studies suggest that patients with multiple myeloma (MM) have better outcomes when treated at high-volume facilities, but the relative contribution of provider expertise and hospital resources to improved outcomes is unknown. This study explored how treating facility, individual provider volume, and patient-sharing between MM specialists and community providers influenced outcomes for patients with MM. PATIENTS AND METHODS A state cancer registry linked to public and private insurance claims was used to identify a cohort of patients diagnosed with MM in 2006 through 2012. Three multivariable Cox models were used to examine how the following factors impacted overall survival: (1) evaluation at an NCI-designated Comprehensive Cancer Center (NCICCC), (2) the primary oncologist's volume of patients with MM, and (3) patient-sharing between MM specialists and community oncologists. RESULTS A total of 1,029 patients diagnosed with MM in 2006 through 2012 were identified. Patients who were not evaluated at an NCICCC had an increased risk of mortality compared with those evaluated at an NCICCC (hazard ratio [HR], 1.50; 95% CI, 1.21-1.86; P<.001). Compared with patients treated by NCICCC MM specialists, those treated by both low-volume community providers (HR, 1.47; 95% CI, 1.14-1.90; P<.01) and high-volume community providers (HR, 1.29; 95% CI, 1.04-1.61; P<.05) had a higher risk of mortality. No difference in mortality was seen between patients treated by NCICCC MM specialists and those treated by the highest-volume community oncologists in the ninth and tenth deciles (HR, 1.08; 95% CI, 0.84-1.37; P=.5591). Patients treated by community oncologists had a higher risk of mortality regardless of patient-sharing compared with patients treated by MM specialists (eg, community oncologist with a history of sharing vs NCICCC MM specialist: HR, 1.49; 95% CI, 1.10-2.02; P<.05). CONCLUSIONS Findings of this study add to the accumulating evidence showing that patients with MM benefit from care at high-volume facilities, and suggest that similar outcomes can be achieved by the highest-volume providers in the community.
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Affiliation(s)
| | - May Kuo
- Lineberger Comprehensive Cancer Center, and
| | - Lei Zhou
- Lineberger Comprehensive Cancer Center, and
| | - Justin G Trogdon
- Lineberger Comprehensive Cancer Center, and.,Gillings School of Public Health, University of North Carolina, Chapel Hill, North Carolina
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Spees LP, Wheeler SB, Zhou X, Amin KB, Baggett CD, Lund JL, Urick BY, Farley JF, Reeder-Hayes KE, Trogdon JG. Changes in chronic medication adherence, costs, and health care use after a cancer diagnosis among low-income patients and the role of patient-centered medical homes. Cancer 2020; 126:4770-4779. [PMID: 32780539 DOI: 10.1002/cncr.33147] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/09/2020] [Accepted: 07/18/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Approximately 40% of patients with cancer also have another chronic medical condition. Patient-centered medical homes (PCMHs) have improved outcomes among patients with multiple chronic comorbidities. The authors first evaluated the impact of a cancer diagnosis on chronic medication adherence among patients with Medicaid coverage and, second, whether PCMHs influenced outcomes among patients with cancer. METHODS Using linked 2004 to 2010 North Carolina cancer registry and claims data, the authors included Medicaid enrollees who were diagnosed with breast, colorectal, or lung cancer who had hyperlipidemia, hypertension, and/or diabetes mellitus. Using difference-in-difference methods, the authors examined adherence to chronic disease medications as measured by the change in the percentage of days covered over time among patients with and without cancer. The authors then further evaluated whether PCMH enrollment modified the observed differences between those patients with and without cancer using a differences-in-differences-in-differences approach. The authors examined changes in health care expenditures and use as secondary outcomes. RESULTS Patients newly diagnosed with cancer who had hyperlipidemia experienced a 7-percentage point to 11-percentage point decrease in the percentage of days covered compared with patients without cancer. Patients with cancer also experienced significant increases in medical expenditures and hospitalizations compared with noncancer controls. Changes in medication adherence over time between patients with and without cancer were not determined to be statistically significantly different by PCMH status. Some PCMH patients with cancer experienced smaller increases in expenditures (diabetes) and emergency department use (hyperlipidemia) but larger increases in their inpatient hospitalization rates (hypertension) compared with non-PCMH patients with cancer relative to patients without cancer. CONCLUSIONS PCMHs were not found to be associated with improvements in chronic disease medication adherence, but were associated with lower costs and emergency department visits among some low-income patients with cancer.
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Affiliation(s)
- Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Xi Zhou
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Krutika B Amin
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Christopher D Baggett
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jennifer L Lund
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Benjamin Y Urick
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Joel F Farley
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
| | - Katherine E Reeder-Hayes
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Division of Hematology/Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Garcia Reeves AB, Trogdon JG, Stearns SC, Lewis JW, Weber DJ, Weinberger M. Are Rates of Methicillin-Resistant Staphylococcus aureus and Clostridioides difficile Associated With Quality and Clinical Outcomes in US Acute Care Hospitals? Am J Med Qual 2020; 36:90-98. [PMID: 32686484 DOI: 10.1177/1062860620942310] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this study was to examine the association between rates of methicillin-resistant Staphylococcus aureus (MRSA)/Clostridioides difficile and quality and clinical outcomes in US acute care hospitals. The population was all Medicare-certified US acute care hospitals with MRSA/C difficile standardized infection ratio (SIR) data available from 2013 to 2017. Hospital-level data from the Centers for Medicare & Medicaid Services were used to estimate hospital and time fixed effects models for 30-day hospital readmissions, length of stay, 30-day mortality, and days in the intensive care unit. The key explanatory variables were SIR for MRSA and C difficile. No association was found between MRSA or C difficile rates and any of the 4 outcomes. The null results add to the mixed evidence in the field, but there are likely residual confounding factors. Future research should use larger samples of patient-level data and appropriate methods to provide evidence to guide efforts to tackle antimicrobial resistance.
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Affiliation(s)
- Alessandra B Garcia Reeves
- University of North Carolina, Chapel Hill, NC North Carolina Department of Health and Human Services, Raleigh, NC
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Trogdon JG, Baggett CD, Gogate A, Reeder-Hayes KE, Rotter J, Zhou X, Ekwueme DU, Fairley TL, Wheeler SB. Medical costs associated with metastatic breast cancer in younger, midlife, and older women. Breast Cancer Res Treat 2020; 181:653-665. [PMID: 32346820 DOI: 10.1007/s10549-020-05654-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 04/17/2020] [Indexed: 01/02/2023]
Abstract
PURPOSE We estimated average medical costs due to metastatic breast cancer (mBC) among younger (aged 18-44), midlife (aged 45-64), and older women (aged 65 and older) by phase of care: initial, continuing, and terminal. METHODS We used 2003-2014 North Carolina cancer registry data linked with administrative claims from public and private payers. We developed a claims-based algorithm to identify breast cancer patients who progressed to metastatic disease. We matched breast cancer patients (mBC and earlier stage) to non-cancer patients on age group, county of residence, and insurance plan. Outcomes were average monthly medical expenditures and expected medical expenditures by phase. We used regression to estimate excess costs attributed to mBC as the difference in mean payments between patients with mBC (N = 4806) and patients with each earlier-stage breast cancer (stage 1, stage 2, stage 3, and unknown stage; N = 21,772) and non-cancer controls (N = 109,631) by treatment phase and age group. RESULTS Adjusted monthly costs for women with mBC were significantly higher than for women with earlier-stage breast cancer and non-cancer controls for all age groups and treatment phases except the initial treatment among women with stage 3 breast cancer at diagnosis. The largest expected total costs were for women aged 18-44 with mBC during the continuing phase ($209,961 95% Confidence Interval $165,736-254,186). CONCLUSIONS We found substantial excess costs for mBC among younger women and during the continuing and terminal phases of survivorship. It is important to assess whether this care is high value for these women.
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Affiliation(s)
- Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Christopher D Baggett
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anagha Gogate
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Katherine E Reeder-Hayes
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Hematology/Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jason Rotter
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Xi Zhou
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Donatus U Ekwueme
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Temeika L Fairley
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Mbah OM, Kinlaw AC, Trogdon JG, Wheeler SB, Samuel CA. The Affordable Care Act and Ethnic Disparities in Colorectal Cancer Screening. Am J Prev Med 2020; 58:175-181. [PMID: 31959320 PMCID: PMC8285085 DOI: 10.1016/j.amepre.2019.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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] [Received: 03/13/2019] [Revised: 09/02/2019] [Accepted: 09/03/2019] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Cost sharing can deter the use of health services and act as a potential contributor to racial/ethnic disparities in cancer. The Affordable Care Act required most health plans to cover, without cost sharing, preventive services, including colorectal cancer screening. Population-based data were used to estimate the impact of the Affordable Care Act's cost-sharing provision (together with other Affordable Care Act provisions targeting preventive care) on ethnic disparities in colorectal cancer screening, comparing Hispanics with non-Hispanics. METHODS An interrupted time series quasi-experimental analysis was used to examine ethnic differences in colorectal cancer screening pre- and post-implementation of the Affordable Care Act (analysis performed in 2018). The study cohort included insured individuals aged 50-64 years who participated in the Medical Expenditure Panel Survey from 2007 through 2015 (n=44,343). RESULTS During the pre-Affordable Care Act period, screening rates decreased annually for non-Hispanics by -0.38 per 100 adults per year (95% CI= -0.55, -0.22) but remained level for Hispanics (annual trend per 100 adults: 0.01, 95% CI= -0.34, 0.35). After cost sharing was eliminated in 2011, colorectal cancer screening rates increased for both Hispanics (by 1.29 per 100 adults, 95% CI=0.69, 1.89) and non-Hispanics (by 0.58 per 100 adults, 95% CI=0.18, 0.99). The difference in trend increases between Hispanics and non-Hispanics was not statistically significant (0.70%, 95% CI= -0.24, 1.64). CONCLUSIONS These findings suggest that Affordable Care Act implementation resulted in increased colorectal cancer screening; however, the effect of the law was not significantly different between Hispanics and non-Hispanics. These results provide indications that more needs to be done to reduce racial/ethnic disparities in colorectal cancer screening.
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Affiliation(s)
- Olive M Mbah
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Alan C Kinlaw
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Cleo A Samuel
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Anderson C, Kaddas HK, Ou JY, Ramsay JM, Trogdon JG, Kirchhoff AC, Nichols HB. Hospitalization after Adolescent and Young Adult (AYA) Cancer: A Population-Based Study in Utah. Cancer Epidemiol Biomarkers Prev 2020; 29:336-342. [PMID: 31959598 DOI: 10.1158/1055-9965.epi-19-1229] [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: 10/03/2019] [Revised: 10/24/2019] [Accepted: 11/15/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Adolescents and young adults (AYA, age 15-39 years) with cancer may be at elevated risk for late morbidity following their cancer treatment, but few studies have quantified the excess burden of severe disease in this population. Using population-based data from Utah, we examined the risk of inpatient hospitalizations among AYA cancer survivors compared with their siblings and the general population. METHODS Survivors of AYA cancer who were ≥2 years from diagnosis and diagnosed from 1994 to 2015 (N = 6,330), their siblings (N = 12,924), and an age- and sex-matched comparison cohort (N = 18,171) were identified using the Utah Population Database (UPDB). Hospitalizations from 1996 to 2017 were identified from statewide discharge records in the UPDB. We estimated multivariable-adjusted hazard ratios (HR) for first hospitalization and rate ratios (RR) for total hospitalizations for survivors relative to the matched comparison cohort and siblings. RESULTS Overall, the risk of a first hospitalization was higher among AYA cancer survivors than the matched population-based cohort [HR = 1.93; 95% confidence interval (CI), 1.81-2.06]. Risk was most elevated for survivors of leukemia (HR = 4.76), central nervous system tumors (HR = 3.45), colorectal cancers (HR = 2.83), non-Hodgkin lymphoma (HR = 2.76), and breast cancer (HR = 2.37). The rate of total hospitalizations was also increased among survivors relative to the comparison cohort (RR = 2.05; 95% CI, 1.95-2.14). Patterns were generally similar in analyses comparing survivors to their siblings. CONCLUSIONS AYA cancer survivors have a higher burden of inpatient hospitalization than their siblings and the general population. IMPACT Results indicate the importance of long-term, risk-based follow-up care to prevent and treat severe morbidities after cancer treatment.
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Affiliation(s)
- Chelsea Anderson
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina.
| | - Heydon K Kaddas
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Judy Y Ou
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Joemy M Ramsay
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Justin G Trogdon
- Department of Health Policy and Management, University of North Carolina, Chapel Hill, North Carolina
| | - Anne C Kirchhoff
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah.,Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Utah, Salt Lake City, Utah
| | - Hazel B Nichols
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
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Trogdon JG, Falchook AD, Basak R, Carpenter WR, Chen RC. Total Medicare Costs Associated With Diagnosis and Treatment of Prostate Cancer in Elderly Men. JAMA Oncol 2019; 5:60-66. [PMID: 30242397 DOI: 10.1001/jamaoncol.2018.3701] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Importance Localized prostate cancer diagnosis and treatment among elderly men who are not likely to benefit represents a potential source of low-value health care services. Objective To quantify the costs to the Medicare program associated with detection and treatment of prostate cancer among elderly men in the United States. Design, Setting, and Participants This nationwide, population-based, retrospective cohort study uses the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to identify men 70 years or older diagnosed with localized prostate cancer between 2004 and 2007 and to ascertain Medicare costs associated with diagnosis and workup, treatment, follow-up, and morbidity management of the disease. National Medicare costs were estimated using per-person costs, stage-adjusted prostate cancer incidence rates by age from SEER 2007 through 2011, and 2010 Census population estimates by age. Main Outcomes and Measures Estimated costs to the Medicare program overall, and in each (mutually exclusive) category related to diagnosis and workup, treatment, follow-up, and morbidity management. Results This nationwide, population-based, retrospective cohort study included 49 692 men with nonmetastatic prostate cancer from the SEER-Medicare database (all participants were 70 years or older; 25 981 [52.3%] were 76 years or older). The median per-patient cost within 3 years after prostate cancer diagnosis was $14 453 (interquartile range [IQR], $4887-$27 899). The majority of this cost was attributable to treatment costs (median, $10 558; IQR, $1990-$23 718). Patients with a Gleason score of 6 or lower who pursued initial conservative management (no treatment within 12 months of diagnosis) had a 3-year median total cost of $1914 per patient. The estimated total 3-year cost to the Medicare program associated with the annual detection of prostate cancer in men 70 years or older is approximately $1.2 billion. Increasing active surveillance use in those with Gleason score of 6 or lower could reduce this cost by $320 million. Conclusions and Relevance There is substantial cost to the Medicare program associated with the diagnosis and treatment of localized prostate cancer among elderly men in the United States, despite the fact that these men are unlikely to die of prostate cancer. The majority of costs are related to treatment. Reducing provision of low-value health care services among this patient population could result in significant health care savings.
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Affiliation(s)
- Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill.,Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Aaron D Falchook
- Department of Radiation Oncology, Memorial Cancer Institute, Memorial Healthcare System, Pembroke Pines, Florida
| | - Ramsankar Basak
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill
| | - William R Carpenter
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill
| | - Ronald C Chen
- Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina.,Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill.,Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill
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Vaughn AE, Studts CR, Powell BJ, Ammerman AS, Trogdon JG, Curran GM, Hales D, Willis E, Ward DS. The impact of basic vs. enhanced Go NAPSACC on child care centers' healthy eating and physical activity practices: protocol for a type 3 hybrid effectiveness-implementation cluster-randomized trial. Implement Sci 2019; 14:101. [PMID: 31805973 PMCID: PMC6896698 DOI: 10.1186/s13012-019-0949-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/16/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND To prevent childhood obesity and promote healthy development, health authorities recommend that child care programs use the evidence-based practices that foster healthy eating and physical habits in children. Go NAPSACC is an intervention shown to improve use of these recommended practices, but it is known to encounter barriers that limit its impact and widespread use. METHODS This study will use a type 3 hybrid effectiveness-implementation cluster-randomized trial to compare effectiveness and implementation outcomes achieved from Go NAPSACC delivered with a basic or enhanced implementation approach. Participants will include approximately 25 coaches from Child Care Aware of Kentucky (serving four geographic regions), 97 child care centers with a director and teacher from each and two cross-sectional samples of 485 3-4-year-old children (one recruitment at baseline, another at follow-up). Coaches will be randomly assigned to deliver Go NAPSACC using either the basic or enhanced implementation approach. "Basic Go NAPSACC" represents the traditional way of delivering Go NAPSACC. "Enhanced Go NAPSACC" incorporates preparatory and support activities before and during their Go NAPSACC work, which are guided by the Quality Implementation Framework and the Consolidated Framework for Implementation Research. Data will be collected primarily at baseline and post-intervention, with select measures continuing through 6, 12, and 24 months post-intervention. Guided largely by RE-AIM, outcomes will assess change in centers' use of evidence-based nutrition and physical activity practices (primary, measured via observation); centers' adoption, implementation, and maintenance of the Go NAPSACC program (assessed via website use); center directors', teachers', and coaches' perceptions of contextual factors (assessed via self-report surveys); children's eating and physical activity behaviors at child care (measured via observation and accelerometers); and cost-effectiveness (assessed via logs and expense tracking). The hypotheses anticipate that "Enhanced Go NAPSACC" will have greater effects than "Basic Go NAPSACC." DISCUSSION This study incorporates many lessons gleaned from the growing implementation science field, but also offers opportunities to address the field's research priorities, including applying a systematic method to tailor implementation strategies, examining the processes and mechanisms through which implementation strategies produce their effects, and conducting an economic evaluation of implementation strategies. TRIAL REGISTRATION ClinicalTrials.gov, NCT03938103, Registered April 8, 2019.
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Affiliation(s)
- Amber E Vaughn
- Center for Health Promotion and Disease Prevention, The University of North Carolina at Chapel Hill, 1700 Martin L. King Jr. Blvd., CB 7426, Chapel Hill, NC, 27599-7426, USA.
| | - Christina R Studts
- Department of Health, Behavior & Society, College of Public Health, University of Kentucky, 151 Washington Ave, Lexington, KY, 40506-0059, USA
| | - Byron J Powell
- Brown School, Washington University, One Brookings Dr., CB 1196, St. Louis, MI, 63130, USA
- Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, 135 Dauer Drive, CB 7400, Chapel Hill, NC, 27599-7400, USA
| | - Alice S Ammerman
- Center for Health Promotion and Disease Prevention, The University of North Carolina at Chapel Hill, 1700 Martin L. King Jr. Blvd., CB 7426, Chapel Hill, NC, 27599-7426, USA
- Department of Nutrition, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, 135 Dauer Drive, CB 7461, Chapel Hill, NC, 27599-7461, USA
| | - Justin G Trogdon
- Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, 135 Dauer Drive, CB 7400, Chapel Hill, NC, 27599-7400, USA
| | - Geoffrey M Curran
- Center for Implementation Research, Division of Health Services Research, Psychiatric Research Institute, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Slot # 577, Little Rock, AR, 72205, USA
| | - Derek Hales
- Center for Health Promotion and Disease Prevention, The University of North Carolina at Chapel Hill, 1700 Martin L. King Jr. Blvd., CB 7426, Chapel Hill, NC, 27599-7426, USA
- Department of Nutrition, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, 135 Dauer Drive, CB 7461, Chapel Hill, NC, 27599-7461, USA
| | - Erik Willis
- Center for Health Promotion and Disease Prevention, The University of North Carolina at Chapel Hill, 1700 Martin L. King Jr. Blvd., CB 7426, Chapel Hill, NC, 27599-7426, USA
| | - Dianne S Ward
- Center for Health Promotion and Disease Prevention, The University of North Carolina at Chapel Hill, 1700 Martin L. King Jr. Blvd., CB 7426, Chapel Hill, NC, 27599-7426, USA
- Department of Nutrition, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, 135 Dauer Drive, CB 7461, Chapel Hill, NC, 27599-7461, USA
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Trogdon JG, Weir WH, Shai S, Mucha PJ, Kuo TM, Meyer AM, Stitzenberg KB. Comparing Shared Patient Networks Across Payers. J Gen Intern Med 2019; 34:2014-2020. [PMID: 30945065 PMCID: PMC6816773 DOI: 10.1007/s11606-019-04978-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 11/21/2018] [Accepted: 02/19/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Measuring care coordination in administrative data facilitates important research to improve care quality. OBJECTIVE To compare shared patient networks constructed from administrative claims data across multiple payers. DESIGN Social network analysis of pooled cross sections of physicians treating prevalent colorectal cancer patients between 2003 and 2013. PARTICIPANTS Surgeons, medical oncologists, and radiation oncologists identified from North Carolina Central Cancer Registry data linked to Medicare claims (N = 1735) and private insurance claims (N = 1321). MAIN MEASURES Provider-level measures included the number of patients treated, the number of providers with whom they share patients (by specialty), the extent of patient sharing with each specialty, and network centrality. Network-level measures included the number of providers and shared patients, the density of shared-patient relationships among providers, and the size and composition of clusters of providers with a high level of patient sharing. RESULTS For 24.5% of providers, total patient volume rank differed by at least one quintile group between payers. Medicare claims missed 14.6% of all shared patient relationships between providers, but captured a greater number of patient-sharing relationships per provider compared with the private insurance database, even after controlling for the total number of patients (27.242 vs 26.044, p < 0.001). Providers in the private network shared a higher fraction of patients with other providers (0.226 vs 0.127, p < 0.001) compared to the Medicare network. Clustering coefficients for providers, weighted betweenness, and eigenvector centrality varied greatly across payers. Network differences led to some clusters of providers that existed in the combined network not being detected in Medicare alone. CONCLUSION Many features of shared patient networks constructed from a single-payer database differed from similar networks constructed from other payers' data. Depending on a study's goals, shortcomings of single-payer networks should be considered when using claims data to draw conclusions about provider behavior.
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Affiliation(s)
- Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. .,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - W H Weir
- Carolina Center for Interdisciplinary Applied Mathematics, Department of Mathematics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Curriculum in Bioinformatics and Computational Biology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - S Shai
- Department of Mathematics and Computer Science, Wesleyan University, Marion, IN, USA
| | - P J Mucha
- Carolina Center for Interdisciplinary Applied Mathematics, Department of Mathematics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - T M Kuo
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - K B Stitzenberg
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Division of Surgical Oncology and Endocrinology Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Spees L, Wheeler SB, Zhou X, Amin KB, Baggett C, Lund JL, Urick B, Farley J, Reeder-Hayes KE, Trogdon JG. The effect of medical home enrollment on cardiometabolic medication adherence among Medicaid-insured cancer patients. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.27_suppl.279] [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
279 Background: Medical homes, developed to increase care coordination among vulnerable patient populations, have been successful in improving outcomes of patients with multiple chronic comorbidities, but have not been evaluated among cancer survivors. We determined the impact of medical home enrollment on adherence to anti-diabetics, anti-lipidemics, and anti-hypertensives among Medicaid patients diagnosed with non-metastatic breast, colorectal, or lung cancer. Methods: Using linked cancer registry and claims data from North Carolina, we included Medicaid-insured adults diagnosed from 2004-2012 with breast, colorectal, or lung cancer who had at least one cardiometabolic condition (i.e., hyperlipidemia, hypertension, and diabetes mellitus). For each cardiometabolic condition, we measured medication adherence using ambulatory proportion of days covered (PDC). We examined the impact of medical home enrollment on PDC across the phases of cancer care (i.e., pre-cancer diagnosis, treatment, and survivorship phases) using a differences-in-differences model. All models adjusted for age, sex, race/ethnicity, dual enrollment, cancer type, comorbidity index, and number of cardiometabolic conditions. Results: We included, respectively, 765, 1079, and 1634 cancer patients with diabetes, hyperlipidemia, and hypertension. Overall, adherence to anti-lipidemics was lower than adherence to anti-diabetics and anti-hypertensives. In the pre-diagnosis phase, mean PDC across all cardiometabolic conditions was slightly lower for cancer patients enrolled in a medical home than those not enrolled in a medical home. However, medication adherence improved 3-5% in the treatment phase and 7% in the survivorship phase for cancer patients in a medical home compared to cancer patients not in a medical home during the pre-diagnosis phase. Conclusions: These results provide evidence that enrollment in a medical home can improve medication adherence, even among vulnerable cancer patients with complex health needs. The medical home model is an effective healthcare system intervention through which to provide better care coordination and improve patient outcomes.
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Affiliation(s)
- Lisa Spees
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Xi Zhou
- Universiy of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Krutika B Amin
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Chris Baggett
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jennifer Leigh Lund
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Ben Urick
- Eshelman School of Pharmacy at University of North Carolina-Chapel Hill, Chapel Hill, NC
| | - Joel Farley
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN
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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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Trogdon JG, Ekwueme DU, Subramanian S, Miller JW, Wong FL. The effect of delivery structure on costs, screening and health promotional services in state level National Breast and Cervical Cancer Early Detection Programs. Cancer Causes Control 2019; 30:813-818. [DOI: 10.1007/s10552-019-01190-2] [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] [Received: 11/12/2018] [Accepted: 05/25/2019] [Indexed: 10/26/2022]
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Subramanian S, Ekwueme DU, Miller JW, Khushalani JS, Trogdon JG, Wong FL. Awardee-specific economic costs of providing cancer screening and health promotional services to medically underserved women eligible in the National Breast and Cervical Cancer Early Detection Program. Cancer Causes Control 2019; 30:827-834. [DOI: 10.1007/s10552-019-01174-2] [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] [Received: 11/08/2018] [Accepted: 04/23/2019] [Indexed: 10/26/2022]
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