Randomized Experiments to Reduce Overuse of Health Care: A Scoping Review

OBJECTIVE

Health care overuse is pervasive in countries with advanced health care delivery systems. We hypothesize that effective interventions to reduce low-value care that targets patients or clinicians are mediated by psychological and cognitive processes that change behaviors and that interventions targeting these processes are varied. Thus, we performed a scoping review of experimental studies of interventions, including the interventions' objectives and characteristics, to reduce low-value care that targeted psychological and cognitive processes.

METHODS

We systematically searched databases for experimental studies of interventions to change cognitive orientations and affective states in the setting of health care overuse. Outcomes included observed overuse or a stated intention to use services. We used existing frameworks for behavior change and mechanisms of change to categorize the interventions and the mediating processes.

RESULTS

Twenty-seven articles met the inclusion criteria. Sixteen studied the provision of information to patients or clinicians, with most providing cost information. Six studies used educational interventions, including the provision of feedback about individual practice. Studies rarely used counseling, behavioral nudges, persuasion, and rewards. Mechanisms for behavior change included gain in knowledge or confidence and motivation by social norms.

CONCLUSIONS

In this scoping review, we found few experiments testing interventions that directly target the psychological and cognitive processes of patients or clinicians to reduce low-value care. Most studies provided information to patients or clinicians without measuring or considering mediating factors toward behavior change. These findings highlight the need for process-driven experimental designs, including trials of behavioral nudges and persuasive language involving a trusting patient-clinician relationship, to identify effective interventions to reduce low-value care.

Patient, provider, and system-level factors associated with preoperative cardiac testing: A systematic review

BACKGROUND

Overuse of preoperative cardiac testing contributes to high healthcare costs and delayed surgeries. A large body of research has evaluated factors associated with variation in preoperative cardiac testing. However, patient, provider, and system-level factors associated with variation in testing have not been systematically studied.

OBJECTIVE

To conduct a systematic review to better delineate the patient, provider, and system-level factors associated with variation in preoperative cardiac testing.

METHODS

We included studies of an adult US population evaluating a patient, provider, or system-level factor associated with variation in preoperative cardiac testing for noncardiac surgery since 2012. Our search strategy used terms related to preoperative testing, diagnostic cardiac tests, and care variation with Ovid MEDLINE and Embase from inception through January 2023. We extracted study characteristics and factors associated with variation and qualitatively analyzed them. We assessed risk of bias using the Newcastle-Ottawa Scale and Evidence Project Risk of Bias tool.

RESULTS

Twenty-eight articles met inclusion criteria. Older age and higher comorbidity were strongly associated with higher-intensity testing. The evidence for provider and system-level covariates was weaker. However, there was strong evidence that a focus on primary care and away from preoperative clinic and cardiac consultations was associated with less testing and that interventions to reduce low-value testing can be successful.

CONCLUSIONS

There is significant interprovider and interhospital variation in preoperative cardiac testing, the correlates of which are not well-defined. Further work should aim to better understand these factors.

Reducing Overuse by Healthcare Systems: A Positive Deviance Analysis

BACKGROUND

Healthcare in the USA is increasingly delivered by large healthcare systems that include one or more hospitals and associated outpatient practices. It is unclear what role healthcare systems play in driving or preventing overutilization of healthcare services in the USA.

OBJECTIVE

To learn how high-value healthcare systems avoid overuse of services DESIGN: We identified "positive deviant" health systems using a previously constructed Overuse Index. These systems have much lower-than-average overuse of healthcare services. We confirmed that these health systems also delivered high-quality care. We conducted semi-structured interviews with executive leaders of these systems to validate a published framework for understanding drivers of overuse.

PARTICIPANTS

Leaders at select healthcare systems in the USA.

INTERVENTIONS

None APPROACH: We developed an interview guide and conducted semi-structured interviews. We iteratively developed a code book. Paired reviewers coded and reconciled each interview. We analyzed the interviews by applying constant comparative techniques. We mapped the emergent themes to provide the first empirical data to support a previously developed theoretical framework.

KEY RESULTS

We interviewed 15 leaders from 10 diverse healthcare systems. Consistent with important domains from the overuse framework, themes from our study support the role of clinicians and patients in avoiding overuse. The leaders described how they create a culture of professional practice and how they modify clinicians' attitudes to facilitate high-value practices. They also described how their patients view healthcare consumption and the characteristics of their patient populations allowed them to practice high-value medicine. They described the role of quality metrics, insurance plan ownership, and alternative payment model participation as encouraging avoidance of overuse.

CONCLUSIONS

Our qualitative analysis of positive deviant health systems supports the framework that is in the published literature, although health system leaders also described their financial structures as another important factor for reducing overuse and encouraging high-value care delivery.

Comparative effectiveness of omalizumab, mepolizumab, and dupilumab in asthma: A target trial emulation

BACKGROUND

Multiple mAbs are currently approved for the treatment of asthma. However, there is limited evidence on their comparative effectiveness.

OBJECTIVE

Our aim was to compare the effectiveness of omalizumab, mepolizumab, and dupilumab in individuals with moderate-to-severe asthma.

METHODS

We emulated a hypothetical randomized trial using electronic health records from a large US-based academic health care system. Participants aged 18 years or older with baseline IgE levels between 30 and 700 IU/mL and peripheral eosinophil counts of at least 150 cells/μL were eligible for study inclusion. The study period extended from March 2016 to August 2021. Outcomes included the incidence of asthma-related exacerbations and change in baseline FEV1 value over 12 months of follow-up.

RESULTS

In all, 68 individuals receiving dupilumab, 68 receiving omalizumab, and 65 receiving mepolizumab met the inclusion criteria. Over 12 months of follow-up, 31 exacerbations occurred over 68 person years (0.46 exacerbations per person year) in the dupilumab group, 63 over 68 person years (0.93 per person year) in the omalizumab group, and 86 over 65 person years (1.32 per person year) in the mepolizumab group (adjusted incidence rate ratios: dupilumab vs mepolizumab, 0.28 [95% CI = 0.09-0.84]; dupilumab vs omalizumab, 0.36 [95% CI = 0.12-1.09]; and omalizumab vs mepolizumab, 0.78 [95% CI = 0.32-1.91]). The differences in the change in FEV1 comparing patients who received the different biologics were as follows: 0.11 L (95% CI = -0.003 to 0.222 L) for dupilumab versus mepolizumab, 0.082 L (95% CI -0.040 to 0.204 L) for dupilumab versus omalizumab, and 0.026 L (95% CI -0.083 to 0.140 L) for omalizumab versus mepolizumab.

CONCLUSIONS

Among patients with asthma and eosinophil counts of at least 150 cells/μL and IgE levels of 30 to 700 kU/L, dupilumab was associated with greater improvements in exacerbation and FEV1 value than omalizumab and mepolizumab.

Assessing Heterogeneity of Treatment Effect in Real-World Data

Increasing availability of real-world data (RWD) generated from patient care enables the generation of evidence to inform clinical decisions for subpopulations of patients and perhaps even individuals. There is growing opportunity to identify important heterogeneity of treatment effects (HTE) in these subgroups. Thus, HTE is relevant to all with interest in patients' responses to interventions, including regulators who must make decisions about products when signals of harms arise postapproval and payers who make coverage decisions based on expected net benefit to their beneficiaries. Prior work discussed HTE in randomized studies. Here, we address methodological considerations when investigating HTE in observational studies. We propose 4 primary goals of HTE analyses and the corresponding approaches in the context of RWD: to confirm subgroup effects, to describe the magnitude of HTE, to discover clinically important subgroups, and to predict individual effects. We discuss other possible goals including exploring prognostic score- and propensity score-based treatment effects, and testing the transportability of trial results to populations different from trial participants. Finally, we outline methodological needs for enhancing real-world HTE analysis.

Clinical Care Among Individuals with Prediabetes in Primary Care: a Retrospective Cohort Study

BACKGROUND

The incidence of diabetes in the general US population (6.7 per 1000 adults in 2018) has not changed significantly since 2000, suggesting that individuals with prediabetes are not connecting to evidence-based interventions.

OBJECTIVE

We sought to describe the clinical care of individuals with prediabetes, determine patient factors associated with this care, and evaluate risk for diabetes development.

DESIGN

Retrospective cohort study using linked claims and electronic health record data.

PARTICIPANTS

We created a cohort of adults with prediabetes based on laboratory measures. We excluded patients with a prior history of diabetes, pregnancy in prior 6 months, or recent steroid use.

MAIN MEASURES

We measured ordering and completion of clinical services targeting prediabetes management and diabetes incidence within 12 months following cohort entry. We tested the strength of the association between individuals' characteristics and outcomes of interest using bivariate and multiple logistic regression.

RESULTS

Our cohort included 3888 patients with a laboratory diagnosis of prediabetes (incident or prevalent prediabetes). Within 12 months, 63.4% had repeat glycemic testing, yet only 10.4% had coded diagnoses of prediabetes, 1.0% were referred for nutrition services, and 5.4% were prescribed metformin. Most patients completed labs and nutrition visits when referred and filled metformin when prescribed. Individuals with a higher glycemic level or BMI were more likely to receive prediabetes clinical care. Six percent of individuals developed diabetes within 12 months of cohort entry and had higher glycemic levels and BMI ≥ 30 kg/m². In the adjusted model, Black individuals had 1.4 times higher odds of developing diabetes than White individuals.

CONCLUSIONS

Rates of prediabetes clinical care activities are low and have not improved. Strategies are urgently needed to improve prediabetes care delivery thereby preventing or delaying incident diabetes.

Comparative Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin Among Adults With Cancer and Atrial Fibrillation

BACKGROUND

While clinical guidelines recommend direct-acting oral anticoagulants (DOAC) over warfarin to treat isolated nonvalvular atrial fibrillation, guidelines are silent regarding nonvalvular atrial fibrillation treatment among individuals with cancer, reflecting the paucity of evidence in this setting. We quantified relative risk of ischemic stroke or systemic embolism and major bleeding (primary outcomes), and all-cause and cardiovascular death (secondary outcomes) among older individuals with cancer and nonvalvular atrial fibrillation comparing DOACs and warfarin.

METHODS

This retrospective cohort study used Surveillance, Epidemiology, and End Results cancer registry and linked US Medicare data from 2010 through 2016, and included individuals diagnosed with cancer and nonvalvular atrial fibrillation who newly initiated DOAC or warfarin. We used inverse probability of treatment weighting to control confounding. We used competing risk regression for primary outcomes and cardiovascular death, and Cox proportional hazard regression for all-cause death.

RESULTS

Among 7675 individuals included in the cohort, 4244 (55.3%) received DOACs and 3431 (44.7%) warfarin. In the inverse probability of treatment weighting analysis, there was no statistically significant difference among DOAC and warfarin users in the risk of ischemic stroke or systemic embolism (1.24 versus 1.19 events per 100 person-years, adjusted hazard ratio 1.41 [95% CI, 0.92-2.14]), major bleeding (3.08 versus 4.49 events per 100 person-years, adjusted hazard ratio 0.90 [95% CI, 0.70-1.17]), and cardiovascular death (1.88 versus 3.14 per 100 person-years, adjusted hazard ratio 0.82 [95% CI, 0.59-0.1.13]). DOAC users had significantly lower risk of all-cause death (7.09 versus 13.3 per 100 person-years, adjusted hazard ratio 0.81 [95% CI, 0.69-0.94]) compared to warfarin users.

CONCLUSIONS

Older adults with cancer and atrial fibrillation exposed to DOACs had similar risks of stroke and systemic embolism and major bleeding as those exposed to warfarin. Relative to warfarin, DOAC use was associated with a similar risk of cardiovascular death and a lower risk of all-cause death.

No association between initiation of phosphodiesterase-5 inhibitors and risk of incident Alzheimer's disease and related dementia: results from the Drug Repurposing for Effective Alzheimer's Medicines study

We evaluated the hypothesis that phosphodiesterase-5 inhibitors, including sildenafil and tadalafil, may be associated with reduced incidence of Alzheimer's disease and related dementia using a patient-level cohort study of Medicare claims and cell culture-based phenotypic assays. We compared incidence of Alzheimer's disease and related dementia after phosphodiesterase-5 inhibitor initiation versus endothelin receptor antagonist initiation among patients with pulmonary hypertension after controlling for 76 confounding variables through propensity score matching. Across four separate analytic approaches designed to address specific types of biases including informative censoring, reverse causality, and outcome misclassification, we observed no evidence for a reduced risk of Alzheimer's disease and related dementia with phosphodiesterase-5 inhibitors;hazard ratio (95% confidence interval): 0.99 (0.69-1.43), 1.00 (0.71-1.42), 0.67 (0.43-1.06), and 1.15 (0.57-2.34). We also did not observe evidence that sildenafil ameliorated molecular abnormalities relevant to Alzheimer's disease in most cell culture-based phenotypic assays. These results do not provide support to the hypothesis that phosphodiesterase-5 inhibitors are promising repurposing candidates for Alzheimer's disease and related dementia.

Development and Validation of the Summary Elixhauser Comorbidity Score for Use With ICD-10-CM-Coded Data Among Older Adults

BACKGROUND

Older adults have many comorbidities contributing to mortality.

OBJECTIVE

To develop a summary Elixhauser (S-Elixhauser) comorbidity score to predict 30-day, in-hospital, and 1-year mortality in older adults using the 38 comorbidities operationalized by the Agency for Healthcare Research and Quality (AHRQ).

DESIGN

Retrospective cohort study.

SETTING

Medicare beneficiaries from 2017 to 2019.

PATIENTS

Persons hospitalized in 2018 (n = 899 844) and 3 disease-specific hospitalized cohorts.

MEASUREMENTS

Weights were derived for 38 comorbidities to predict 30-day, in-hospital, and 1-year mortality. The S-Elixhauser score was internally validated and calibrated. Individual Elixhauser comorbidity indicators (38 comorbidities), the modified application of the AHRQ-derived Elixhauser summary score, the Charlson comorbidity indicators (17 comorbidities), and the Charlson summary score were externally validated. The c-statistic was used to evaluate discrimination of a comorbidity score model.

RESULTS

The S-Elixhauser score was well calibrated and internally validated, with a c-statistic of 0.705 (95% CI, 0.703 to 0.707) in predicting 30-day mortality, 0.654 (CI, 0.651 to 0.657) for in-hospital mortality, and 0.743 (CI, 0.741 to 0.744) for 1-year mortality. In external validation of other comorbidity indices for 30-day mortality, the c-statistic was 0.711 (CI, 0.709 to 0.713) for the individual Elixhauser comorbidity indicators, 0.688 (CI, 0.686 to 0.690) for the AHRQ Elixhauser score, 0.696 (CI, 0.694 to 0.698) for the Charlson comorbidity indicators, and 0.690 (CI, 0.688 to 0.693) for the Charlson summary score. In 3 disease-specific populations, the discrimination of the S-Elixhauser score in predicting 30-day mortality ranged from 0.657 to 0.732.

LIMITATION

Validation of the S-Elixhauser comorbidity score and head-to-head comparison with other comorbidity scores in an external population are needed to evaluate comparative performance.

CONCLUSION

The S-Elixhauser comorbidity score is well calibrated and internally validated but its advantage over the AHRQ Elixhauser and Charlson summary scores is unclear.

PRIMARY FUNDING SOURCE

National Institute on Aging.

Safety and effectiveness of apixaban versus warfarin for acute venous thromboembolism in patients with end-stage kidney disease: A national cohort study

BACKGROUND

Patients with end-stage kidney disease (ESKD) are at significantly increased risk for both thrombosis and bleeding relative to those with normal renal function. The optimal therapy of venous thromboembolism (VTE) in patients with ESKD is unknown.

OBJECTIVE

To compare the safety and effectiveness of apixaban relative to warfarin in patients with ESKD and acute VTE.

DESIGN, SETTING AND PARTICIPANTS

New-user, active-comparator retrospective United States population-based cohort with inverse probability of treatment weighting, using the United States Renal Data System data from 2014 to 2018. We included adults with ESKD on hemodialysis or peritoneal dialysis who were newly initiated on apixaban or warfarin for an acute VTE.

MAIN OUTCOME AND MEASURES

The coprimary outcomes were major bleeding, recurrent VTE, and all-cause mortality within 6 months of anticoagulant initiation. Secondary outcomes were intracranial hemorrhage and gastrointestinal bleeding. The primary analyses were based on intent-to-treat defined by the first drug received and accounted for competing risks of death. Sensitivity analyses included varied follow-up time, as-treated analyses, and dose-specific apixaban subgroups.

RESULTS

The apixaban and warfarin cohorts included 2302 and 9263 patients, respectively. Apixaban was associated with a lower risk of major bleeding (hazard ratio [HR] 0.81, 95% confidence interval [CI]: 0.70-0.94), intracranial bleeding (HR 0.69, 95% CI 0.48-0.98), and gastrointestinal bleeding (HR 0.82, 95% CI 0.69-0.96). Recurrent VTE and all-cause mortality were not significantly different between the groups.

CONCLUSION

Apixaban was associated with a lower risk of bleeding relative to warfarin when used to treat acute VTE in patients with ESKD on dialysis.

Use of oral anticoagulants among individuals with cancer and atrial fibrillation in the United States, 2010-2016

Background

Anticoagulation among patients with cancer and atrial fibrillation is challenging due to elevated risk of bleeding and stroke. We characterized use of oral anticoagulants among patients with cancer and non‐valvular atrial fibrillation (NVAF).

Methods

We used Surveillance, Epidemiology, and End Results (SEER)‐Medicare data and included patients with cancer aged ≥66 years with an incident diagnosis of NVAF from 2010 to 2016. We used a Cox proportional hazard model and multivariable logistic regression to identify factors associated with anticoagulant use versus no use and direct oral anticoagulants (DOACs) versus warfarin use, respectively.

Results

Of 27,702 patients with cancer and NVAF, 4469 (16.1%) used DOACs and 3577 (12.9%) used warfarin. Among 8046 anticoagulant users, DOACs use increased from 21.8% in 2011 to 76.2% in 2016, with a corresponding decline in warfarin use from 78.2% to 23.8%. Nearly 7 out of 10 patients with cancer and NVAF did not initiate anticoagulation in 2016. Anticoagulant use was more likely among those with higher CHA₂DS₂‐VASc scores (hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.27–1.90 for score ≥6 vs. 1) or with lower HAS‐BLED scores (HR 1.96, 95% CI 1.67–2.30 for score 1 vs. ≥6). Among anticoagulant users, DOAC use was less likely than warfarin in those with higher CHA₂DS₂‐VASc scores (odds ratio [OR] 0.53, 95% CI 0.33–0.84 for score ≥6 vs. 1).

Conclusions

Nearly 7 out of 10 patients with cancer and NVAF did not receive anticoagulation. Use of DOACs increased from 2010 to 2016, with a corresponding decline in warfarin use. DOACs are used less than warfarin among those at higher risk of stroke.

Factors Associated With Overuse of Health Care Within US Health Systems

Question

What features of health care systems in the US are associated with overuse of health care?

Findings

In this cross-sectional study of 676 US health care systems, those that were overusing health care had more beds, had fewer primary care physicians, had more physician practice groups, were more likely to be investor owned, and were less likely to include a major teaching hospital.

Meaning

In-depth exploration of the drivers of health care overuse is needed at the level of health systems as their incentives may not be aligned with high-value care.

Importance

Overuse of health care is a pervasive threat to patients that requires measurement to inform the development of interventions.

Objective

To measure low-value health care use within health systems in the US and explore features of the health systems associated with low-value care delivery.

Design, Setting, and Participants

In this cross-sectional analysis, we identified occurrences of 17 low-value services in 3745 hospitals and affiliated outpatient sites. Hospitals were linked to 676 health systems in the US using the Agency for Healthcare Research and Quality (AHRQ) Compendium of Health Systems. The participants were 100% of Medicare beneficiaries with claims from 2016 to 2018.

Exposures

We identified occurrences of 17 low-value services in 3839 hospitals and affiliated outpatient sites.

Main Outcomes and Measures

Hospitals were linked to health systems using AHRQ’s Compendium of Health Systems. Between March and August 2021, we modeled overuse occurrences with a negative binomial regression model including the year-quarter, procedure indicator, and a health system indicator. The model included random effects for hospital and beneficiary age, sex, and comorbidity count specific to each indicator, hospital, and quarter. The beta coefficients associated with the health system term, normalized, reflect the tendency of that system to use low-value services relative to all other systems. With ordinary least squares regression, we explored health system characteristics associated with the Overuse Index (OI), expressed as a standard deviation where the mean across all health systems is 0.

Results

There were 676 unique health systems assessed in our study that included from 1 to 163 hospitals (median of 2). The mean age of eligible beneficiaries was 75.5 years and 76% were women. Relative to the lowest tertile, health systems in the upper tertile of medical groups count and bed count had an OI that was higher by 0.38 standard deviations (SD) and 0.44 SD, respectively. Health systems that were primarily investor owned had an OI that was 0.56 SD higher than those that were not investor owned. Relative to the lowest tertile, health systems in the upper tertile of primary care physicians, upper tertile of teaching intensity, and upper quartile of uncompensated care had an OI that was lower by 0.59 SD, 0.45 SD, and 0.47 SD, respectively.

Conclusions and Relevance

In this cross-sectional study of US health systems, higher amounts of overuse among health systems were associated with investor ownership and fewer primary care physicians. The OI is a valuable tool for identifying potentially modifiable drivers of overuse and is adaptable to other levels of investigation, such as the state or region, which might be affected by local policies affecting payment or system consolidation.

Long-term use of immunosuppressive medicines and in-hospital COVID-19 outcomes: a retrospective cohort study using data from the National COVID Cohort Collaborative

BACKGROUND

Many individuals take long-term immunosuppressive medications. We evaluated whether these individuals have worse outcomes when hospitalised with COVID-19 compared with non-immunosuppressed individuals.

METHODS

We conducted a retrospective cohort study using data from the National COVID Cohort Collaborative (N3C), the largest longitudinal electronic health record repository of patients in hospital with confirmed or suspected COVID-19 in the USA, between Jan 1, 2020, and June 11, 2021, within 42 health systems. We compared adults with immunosuppressive medications used before admission to adults without long-term immunosuppression. We considered immunosuppression overall, as well as by 15 classes of medication and three broad indications for immunosuppressive medicines. We used Fine and Gray's proportional subdistribution hazards models to estimate the hazard ratio (HR) for the risk of invasive mechanical ventilation, with the competing risk of death. We used Cox proportional hazards models to estimate HRs for in-hospital death. Models were adjusted using doubly robust propensity score methodology.

FINDINGS

Among 231 830 potentially eligible adults in the N3C repository who were admitted to hospital with confirmed or suspected COVID-19 during the study period, 222 575 met the inclusion criteria (mean age 59 years [SD 19]; 111 269 [50%] male). The most common comorbidities were diabetes (23%), pulmonary disease (17%), and renal disease (13%). 16 494 (7%) patients had long-term immunosuppression with medications for diverse conditions, including rheumatological disease (33%), solid organ transplant (26%), or cancer (22%). In the propensity score matched cohort (including 12 841 immunosuppressed patients and 29 386 non-immunosuppressed patients), immunosuppression was associated with a reduced risk of invasive ventilation (HR 0·89, 95% CI 0·83-0·96) and there was no overall association between long-term immunosuppression and the risk of in-hospital death. None of the 15 medication classes examined were associated with an increased risk of invasive mechanical ventilation. Although there was no statistically significant association between most drugs and in-hospital death, increases were found with rituximab for rheumatological disease (1·72, 1·10-2·69) and for cancer (2·57, 1·86-3·56). Results were generally consistent across subgroup analyses that considered race and ethnicity or sex, as well as across sensitivity analyses that varied exposure, covariate, and outcome definitions.

INTERPRETATION

Among this cohort, with the exception of rituximab, there was no increased risk of mechanical ventilation or in-hospital death for the rheumatological, antineoplastic, or antimetabolite therapies examined.

FUNDING

None.

Changing patterns of use of implantable cardiac monitors from 2011 to 2018 for a large commercially-insured U.S. population

Implantable cardiac monitors (ICMs) provide long-term electrocardiographic monitoring for a number of indications. However, frequencies of use by indication and temporal changes have not been characterized on a national scale. We sought to characterize overall use and changes between 2011 and 2018. We used generalized linear models to characterize the incidence rate per 1,000,000 patient-quarters at risk and an autoregressive integrated moving average model to account for autocorrelation in this time series data. We studied commercially-insured patients and their insured dependents in the IBM MarketScan Commercial Database who had an ICM placed. We described the characteristics of individuals who received ICMs and the frequency of placements into 3 guideline concordance groups. We estimated the mean change per quarter in ICM placements (mean quarterly change in incidence rate per 1,000,000 patient-quarters at risk) for quarter (Q)1 2011 through Q1 2014, Q1 2014 to Q2 2014, and Q2 2014 through Q4 2018 for each guideline concordance group. The most common indications for categorizable ICM placement were syncope (24%), atrial fibrillation (11%), and stroke (11%). For each of the 3 guideline concordance groups except guideline unaddressed inpatient ICM placements, there was a significant increase in use either during the Q1 2014 to Q2 2014 or the Q2 2014 through Q4 2018 periods. A significant portion of ICM placements were for indications that lack strong evidence, such as established atrial fibrillation. The incidence of ICM placement for most of the indications and settings increased after miniaturization and technical improvements.

A Pragmatic, Randomized Controlled Trial of Oral Antivirals for the Treatment of Chronic Hepatitis C: The PRIORITIZE Study

BACKGROUND AND AIMS

Multiple direct-acting antiviral (DAA) regimens are available to treat HCV genotype 1 infection. However, comparative effectiveness from randomized controlled trials of DAA regimens is unavailable.

APPROACH AND RESULTS

We conducted a pragmatic randomized controlled trial (NCT02786537) to compare the effectiveness of DAAs for HCV genotype 1a or 1b on viral response, safety, tolerability, and medication nonadherence. Adults with compensated liver disease, HCV genotype 1, not pregnant or breastfeeding, and with health insurance likely to cover ledipasvir/sofosbuvir (LDV/SOF) were recruited from 34 US viral hepatitis clinics. Participants were randomized (± ribavirin) to LDV/SOF, elbasvir/grazoprevir (EBR/GZR), and paritaprevir/ritonavir/ombitasvir+dasabuvir (PrOD; treatment arm stopped early). Primary outcomes included sustained viral response at 12 weeks (SVR12), clinician-recorded adverse events, patient-reported symptoms, and medication nonadherence. Between June 2016 and March 2018, 1,609 participants were randomized. Among 1,128 participants who received ≥1 dose of EBR/GZR or LDV/SOF (± ribavirin), SVR12 was 95.2% (95% CI, 92.8%-97.6%) and 97.4% (95% CI, 95.5%-99.2%), respectively, with a difference estimate of 2.2% (-0.5% to 4.7%), falling within the "equivalence" interval (-5% to 5%). While most (56%) participants experienced adverse events, few were serious (4.2%) or severe (1.8%). In the absence of ribavirin, discontinuations due to adverse events were rare. Patient-reported symptoms and medication nonadherence were similar. Study limitations were dropout due to insurance denial and loss to follow-up after treatment, limiting the ability to measure SVR12.

CONCLUSIONS

This pragmatic trial demonstrated high SVR12 for participants treated with EBR/GZR and LDV/SOF with few adverse effects. Overall, the two regimens were equivalent in effectiveness. The results support current HCV guidelines that do not distinguish between ribavirin-free EBR/GZR and LDV/SOF.

Treatment of Acute Pain in Adults With Sickle Cell Disease in an Infusion Center Versus the Emergency Department : A Multicenter Prospective Cohort Study

BACKGROUND

Patients with sickle cell disease (SCD) have vaso-occlusive crises (VOCs). Infusion centers (ICs) are alternatives to emergency department (ED) care and may improve patient outcomes.

OBJECTIVE

To assess whether care in ICs or EDs leads to better outcomes for the treatment of uncomplicated VOCs.

DESIGN

Prospective cohort. (ClinicalTrials.gov: NCT02411396).

SETTING

4 U.S. sites, with recruitment between April 2015 and December 2016.

PARTICIPANTS

Adults with SCD living within 60 miles of a study site.

MEASUREMENTS

Participants were followed for 18 months after enrollment. Outcomes of interest were time to first dose of parenteral pain medication, whether pain reassessment was completed within 30 minutes after the first dose, and patient disposition on discharge from the acute care visit. Treatment effects for ICs versus EDs were estimated using a time-varying propensity score adjustment.

RESULTS

Researchers enrolled 483 participants; the 269 who had acute care visits on weekdays are included in this report. With inverse probability of treatment-weighted adjustment, the mean time to first dose was 62 minutes in ICs and 132 minutes in EDs; the difference was 70 minutes (95% CI, 54 to 98 minutes; E-value, 2.8). The probability of pain reassessment within 30 minutes of the first dose of parenteral pain medication was 3.8 times greater (CI, 2.63 to 5.64 times greater; E-value, 4.7) in the IC than the ED. The probability that a participant's visit would end in admission to the hospital was smaller by a factor of 4 (0.25 [CI, 0.18 to 0.33]) with treatment in an IC versus an ED.

LIMITATION

The study was restricted to participants with uncomplicated VOCs.

CONCLUSION

In adults with SCD having a VOC, treatment in an IC is associated with substantially better outcomes than treatment in an ED.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute.

Dipeptidyl peptidase-4 inhibitor cardiovascular safety in patients with type 2 diabetes, with cardiovascular and renal disease: a retrospective cohort study

Clinical trials investigating cardiovascular safety of dipeptidyl peptidase-IV inhibitors (DPP-4i) among patients with cardiovascular and renal disease rarely recruit patients with renal impairment, despite associations with increased risk for major adverse cardiovascular events (MACE). We investigated the risk of MACE associated with the use of DPP-4i among these high-risk patients. Using a new-user, retrospective, cohort design, we analyzed 2010–2015 IBM MarketScan Commercial Claims and Encounters for patients with diabetes, comorbid with cardiovascular disease and/or renal impairment. We compared time to first MACE for DPP-4i versus sulfonylurea and versus metformin. Of 113,296 individuals, 9146 (8.07%) were new DPP-4i users, 17,481 (15.43%) were new sulfonylurea users, and 88,596 (78.20%) were new metformin users. Exposure groups were not mutually exclusive. DPP-4i was associated with lower risk for MACE than sulfonylurea (aHR 0.84; 95% CI 0.74, 0.93) and similar risk for MACE to metformin (aHR 1.07; 95% CI [1.04, 1.16]). DPP-4i use was associated with lower risk for MACE compared to sulfonylureas and similar risk for MACE compared to metformin. This association was most evident in the first year of therapy, suggesting that DPP-4i is a safer choice than sulfonylurea for diabetes treatment initiation in high-risk patients.

Ultra-Expensive Drugs And Medicare Part D: Spending And Beneficiary Use Up Sharply

The proliferation of "ultra-expensive" drugs has sparked debate on their sustainability and affordability. Medicare Part D's share of annual spending on these drugs increased by 1,170 percent between 2012 and 2018, largely because the number of beneficiaries receiving them increased during this period.

To Expand the Evidence Base About Harms from Tests and Treatments

Rigorous evidence about the broad range of harms that might be experienced by a patient in the course of testing and treatment is sparse. We aimed to generate recommendations for how researchers might more comprehensively evaluate potential harms of healthcare interventions, to allow clinicians and patients to better include this evidence in clinical decision-making. We propose seven domains of harms of tests and treatments that are relevant to patients: (1) physical impairment, (2) psychological distress, (3) social disruption, (4) disruption in connection to healthcare, (5) labeling, (6) financial impact, and (7) treatment burden. These domains will include a range of severity of harms and variation in timing after testing or treatment, attributable to the service itself or a resulting care cascade. Although some new measures may be needed, diverse data and tools are available to allow the assessment of harms comprehensively across these domains. We encourage researchers to evaluate harms in sub-populations, since the harms experienced may differ importantly by demographics, social determinants, presence of comorbid illness, psychological state, and other characteristics. Regulators, funders, and editors might require either assessment or reporting of harms in each domain or require justification for inclusion and exclusion of different domains.

Time to Revisit a Voluntary FDA Comparative Effectiveness Pathway

Given the renewed policy focus on drug pricing and pharmaceutical innovation, this article examines the historical backdrop of efforts to integrate comparative effectiveness research into the FDA drug review process. Noting previous policy efforts over a decade ago, we characterize industry challenges and suggest a path forward.

Differences in Opioid Prescribing Among Generalist Physicians, Nurse Practitioners, and Physician Assistants

OBJECTIVE

To determine if there are differences in opioid prescribing among generalist physicians, nurse practitioners (NPs), and physician assistants (PAs) to Medicare Part D beneficiaries.

DESIGN

Serial cross-sectional analysis of prescription claims from 2013 to 2016 using publicly available data from the Centers for Medicare and Medicaid Services.

SUBJECTS

All generalist physicians, NPs, and PAs who provided more than 10 total prescription claims between 2013 and 2016 were included. These prescribers were subsetted as practicing in a primary care, urgent care, or hospital-based setting.

METHODS

The main outcomes were total opioid claims and opioid claims as a proportion of all claims in patients treated by these prescribers in each of the three settings of interest. Binomial regression was used to generate marginal estimates to allow comparison of the volume of claims by these prescribers with adjustment for practice setting, gender, years of practice, median income of the ZIP code, state fixed effects, and relevant interaction terms.

RESULTS

There were 36,999 generalist clinicians (physicians, NPs, and PAs) with at least one year of Part D prescription drug claims data between 2013 and 2016. The number of adjusted total opioid claims across these four years for physicians was 660 (95% confidence interval [CI] = 660-661), for NPs was 755 (95% CI = 753-757), and for PAs was 812 (95% CI = 811-814).

CONCLUSIONS

We find relatively high rates of opioid prescribing among NPs and PAs, especially at the upper margins. This suggests that well-designed interventions to improve the safety of NP and PA opioid prescribing, along with that of their physician colleagues, could be especially beneficial.

Association Between Filgrastim Biosimilar Availability and Changes in Claim Payments and Patient Out-of-Pocket Costs for Biologic Filgrastim Products

OBJECTIVES

To estimate the effect of filgrastim-sndz market entry on patient out-of-pocket costs and claim payments for filgrastim products.

METHODS

This study used a single interrupted time series design with longitudinal, nationally representative, individual-level claims data from IBM MarketScan. Analyses included all outpatient and prescription claims for branded filgrastim (filgrastim and tbo-filgrastim) and biosimilar filgrastim (filgrastim-sndz) from January 1, 2014, to December 31, 2017. Outcomes of interest included changes in monthly claim payments and monthly patient out-of-pocket costs for filgrastim products.

RESULTS

In the baseline period (January 2014 to February 2016), insurers paid an average of $472.21 (95% confidence interval [CI]: 465.38-479.03) for 480 mcg of branded filgrastim, whereas patients paid an average of $49.26 (CI: 34.25-64.27). Filgrastim-sndz market entry was associated with a statistically significant and immediate 1-month decrease in insurer payment of $30.77 (95% CI: -40.59 to -20.94) and a significant decrease in monthly insurer payment trend of $3.10 per month (95% CI: -3.90 to -2.31) relative to baseline. Long-term changes in patient out-of-pocket costs were modest and restricted to beneficiaries enrolled in high cost sharing plans.

CONCLUSIONS

Biosimilar filgrastim availability led to significant immediate and long-term decreases in claims payments for filgrastim products, supporting efforts to facilitate biosimilar adoption in the United States. Nevertheless, there were only slight changes in patient out-of-pocket costs, restricted to beneficiaries enrolled in high cost sharing plans, suggesting the importance of further work assessing the relationship between biosimilar availability and patient out-of-pocket costs.

Dipeptidyl peptidase-4 inhibitors and cardiovascular events in patients with type 2 diabetes, without cardiovascular or renal disease

Background

Cardiovascular safety of dipeptidyl peptidase-IV inhibitors (DPP-4i) in patients without cardiovascular or renal disease, a majority of newly diagnosed patients with type 2 diabetes often excluded from clinical trials on this association, is poorly understood. Thus, we investigate the risk of major adverse cardiovascular events (MACE) associated with DPP-4i in low-risk patients with diabetes

Methods

Using a new-user retrospective cohort derived from IBM MarketScan Commercial Claims and Encounters (2010–2015), we identified patients aged 35–65 with type 2 diabetes, without cardiovascular or renal disease, initiating DPP-4i, sulfonylureas, or metformin. Primary composite outcome of time to first MACE was defined as the first of any of the following: myocardial infarction, cardiac arrest, coronary artery bypass graft, coronary angioplasty, heart failure, and stroke. Secondary outcomes were time to first heart failure, acute myocardial infarction, and stroke. We compared outcomes for DPP-4i versus sulfonylurea and DPP-4i versus metformin using propensity score weighted Cox proportional hazards, adjusting for demographics, baseline comorbidities, concomitant medications, and cumulative exposure.

Results

Of 445,701 individuals, 236,431 (53.0%) were male, median age was 51 (interquartile range: [44, 57]), 30,267 (6.79%) initiated DPP-4i, 52,138 (11.70%) initiated sulfonylureas, and 367,908 (82.55%) initiated metformin. After adjustment, DPP-4i was associated with lower risk of MACE than sulfonylurea (adjusted hazard ratio (aHR) = 0.87; 95% confidence interval (CI): 0.78–0.98), and similar risk to metformin (aHR = 1.07; 95% CI: 0.97–1.18). Risk for acute myocardial infarction (aHR = 0.70; 95% CI: 0.51–0.96), stroke (aHR = 0.57; 95% CI: 0.41–0.79), and heart failure (aHR = 0.57; 95% CI: 0.41–0.79) with DPP-4i was lower compared to sulfonylureas.

Conclusion

Our findings show that for this cohort of low-risk patients newly treated for type 2 diabetes, DPP-4i exhibited 13% lower risk for MACE compared to sulfonylureas and similar risk for MACE compared to metformin, suggesting DPP-4i is a low cardiovascular risk option for low-risk patients initiating antihyperglycemic treatment.

The impact of global budget payment reform on systemic overuse in Maryland

BACKGROUND

Medical overuse is a leading contributor to the high cost of the US health care system and is a definitive misuse of resources. Elimination of overuse could improve health care efficiency. In 2014, the State of Maryland placed the majority of its hospitals under an all-payer, annual, global budget for inpatient and outpatient hospital services. This program aims to control hospital use and spending.

OBJECTIVE

To assess whether the Maryland global budget program was associated with a reduction in the broad overuse of health care services.

METHODS

We conducted a retrospective analysis of deidentified claims for 18-64 year old adults from the IBM MarketScan® Commercial Claims and Encounters Database. We matched 2 Maryland Metropolitan Statistical Areas (MSAs) to 6 out-of-state comparison MSAs. In a difference-in-differences analysis, we compared changes in systemic overuse in Maryland vs the comparison MSAs before (2011-2013) and after implementation (2014-2015) of the global budget program. Systemic overuse was measured using a semiannual Johns Hopkins Overuse Index.

RESULTS

Global budgets were not associated with a reduction in systemic overuse. Over the first 1.5 years of the program, we estimated a nonsignificant differential change of -0.002 points (95%CI, -0.372 to 0.369; p = 0.993) relative to the comparison group. This result was robust to multiple model assumptions and sensitivity analyses.

CONCLUSIONS

We did not find evidence that Maryland hospitals met their revenue targets by reducing systemic overuse. Global budgets alone may be too blunt of an instrument to selectively reduce low-value care.

Effect of delays in initiation of adjuvant endocrine therapy on survival among women with breast cancer

PURPOSE

Delays in initiating adjuvant endocrine therapy (AET) are a cause for concern among women with breast cancer and clinicians, but the impact of delayed AET on overall survival (OS) is unclear. This study seeks to describe the relationship between delayed AET and OS.

METHODS

Retrospective cohort study of women with stage II and III hormone receptor positive, human epidermal receptor 2 negative, invasive breast cancer, identified from the National Cancer Database. The primary exposure delayed AET, was defined as initiation of AET more than 12 months after breast cancer diagnosis. Using logistic regression, we examined predictors of delayed AET. The survival analysis with Cox proportional hazards regression adjusted for patient, tumor, and treatment characteristics.

RESULTS

Among the 391,594 included women, 12,162 (3.1%) had delayed AET. Predictors of delayed AET included Black race (adjusted odds ratio [aOR] = 1.61, 95% confidence interval [CI] 1.52-1.70) or Hispanic ethnicity (aOR = 1.25, 95% CI 1.16-1.35) vs white race, Medicare (aOR = 1.13, 95% CI 1.06-1.20) or Medicaid (aOR = 1.41, 95% CI 1.32-1.50) versus private insurance, and cancer stage III (aOR = 1.24, 95% CI 1.19-1.30) vs stage II. With median follow-up of 67.4 months, 67,335 (17.2%) patients died. Delayed AET had no statistically significant effect on the hazard of death (adjusted hazards ratio = 1.01; 95% CI 0.96-1.06) compared to initiation within 12 months of diagnosis.

CONCLUSION

This study suggests that there may be no adverse impact on survival if initiation of AET occurs 12 to 24 months after initial diagnosis compared to within 12 months of diagnosis as currently recommended.

Predictors of orphan drug coverage restrictions in Medicare Part D

OBJECTIVES

It is unclear on what basis Medicare drug plans impose coverage restrictions on orphan drugs. This study aims to investigate the factors associated with utilization controls in Medicare fee-for-service Part D formularies.

STUDY DESIGN

Cross-sectional analysis.

METHODS

We used multivariate logistic regression to assess the association between orphan drug characteristics and use of formulary utilization controls in 2016. We controlled for number of beneficiaries per drug, exclusivity expiration, and the number of plans and beneficiaries per formulary. We conducted sensitivity analyses using fixed and random effects.

RESULTS

On average, 85% of orphan drugs on a formulary were placed on its highest cost-sharing tier and 76% were subject to prior authorization (PA). Orphan drugs with annual costs of $50,000 or more had twice the odds of having PA requirements compared with less expensive ones. Relative to orphan drugs with a single indication, drugs with multiple indications were more likely to have restrictions. Less effective drugs had 1.5 times the odds of highest tier placement relative to more effective drugs. The presence of black box warnings and patient assistance programs were associated with more restricted access. Orphan drugs with generics were less likely to undergo restrictions than those without generics (all P < .05).

CONCLUSIONS

Plans are making evidence-based decisions by rewarding more clinically effective and safer orphan drugs. They are penalizing drugs with multiple indications. Surprisingly, plans place fewer restrictions on orphan drugs that have a generic equivalent, which may further discourage generic entry into the orphan space, where competition is already sparse.

Characteristics of registered clinical trials assessing treatments for COVID-19: a cross-sectional analysis

OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic has prompted many initiatives to identify safe and efficacious treatments, yet little is known regarding where early efforts have focused. We aimed to characterise registered clinical trials assessing drugs or plasma treatments for COVID-19.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional analysis of clinical trials for the treatment of COVID-19 that were registered in the USA or in countries contributing to the WHO's International Clinical Trials Registry Platform. Relevant trial entries of drugs or plasma were downloaded on 26 March 2020, deduplicated, verified with reviews of major medical journals and WHO websites and independently analysed by two reviewers.

MAIN OUTCOMES

Trial intervention, sponsorship, critical design elements and specified outcomes RESULTS: Overall, 201 clinical trials were registered for testing the therapeutic benefits of 92 drugs or plasma, including 64 in monotherapy and 28 different combinations. Only eight (8.7%) products or combinations involved new molecular entities. The other test therapies had a wide range of prior medical uses, including as antivirals, antimalarials, immunosuppressants and oncology treatments. In 152 trials (75.7%), patients were randomised to treatment or comparator, including 55 trials with some form of blinding and 97 open-label studies. The 49 (24.4%) of trials without a randomised design included 29 single armed studies and 20 trials with some comparison group. Most trial designs featured multiple endpoints. Clinical endpoints were identified in 134 (66.7%) of trials and included COVID-19 symptoms, death, recovery, required intensive care and hospital discharge. Clinical scales were being used in 33 (16.4%) trials, most often measures of oxygenation and critical illness. Surrogate endpoints or biomarkers were studied in 88 (42.3%) of trials, primarily assays of viral load. Although the trials were initiated in more than 17 countries or regions, 100 (49.8%) were registered in China and 78 (37.8%) in the USA. Registered trials increased rapidly, with the number of registered trials doubling from 1 March to 26 March 2020.

CONCLUSIONS

While accelerating morbidity and mortality from the COVID-19 pandemic has been paralleled by early and rapid clinical investigation, many trials lack features to optimise their scientific value. Global coordination and increased funding of high-quality research may help to maximise scientific progress in rapidly discovering safe and effective treatments.

Evaluation of Bedside Delivery of Medications Before Discharge: Effect on 30-Day Readmission

BACKGROUND

This study is an evaluation of a discharge intervention that occurred in multiple hospitals across Maryland. In this program, patients received medications at their bedside before discharge with the goal of reducing the risk of primary nonadherence to prescribed medications.

OBJECTIVE

To test if the intervention reduced the risk of 30-day readmission for the patients who received bedside medication delivery relative to comparable patients who did not receive bedside medication delivery.

METHODS

This was a retrospective cohort study. Patients who received the intervention were linked to their claims data in the Maryland Health Information Exchange. These patients were matched on age, sex, diagnosis-related group, and hospital to a set of patients who did not receive the intervention. We used propensity score matching, as well as inverse-probability weighting, to account for residual differences between the treated and comparison patients. With robust Poisson regression, adjusting for hospital, we generated risk ratios for 30-day readmission and explored risk ratios in key subgroups.

RESULTS

The cohort included 6,167 inpatients who received medications at bedside and 28,546 who did not from 10 Maryland hospitals. They were 60% female, 61% white, and 31% African American; the average age was 56 years. The risk ratio for readmission, comparing the intervention group to the propensity score-matched comparison group, was 1.21 (95% CI = 0.96-1.5). Inverse-probability weighting yielded a similar result (1.19 [95% CI = 0.98-1.45]).

CONCLUSIONS

In this study, the isolated intervention of bedside medication delivery did not reduce 30-day readmission risk. We expect it may have favorable outcomes on other metrics such as primary nonadherence and patient satisfaction. It may also have a favorable effect when bundled with other care transition activities. As an isolated intervention, however, bedside medication delivery is unlikely to affect 30-day readmission rates.

DISCLOSURES

This study was funded by Walgreen Co. through unrestricted funds to Johns Hopkins University, which has received fees from Walgreens for providing consultation as an institution to Walgreens. This arrangement has been reviewed and approved by the Johns Hopkins University in accordance with its conflict of interest policies. Segal received a grant from the National Institute on Aging during the conduct of this study. The other authors have nothing to disclose.

Association Between Treatment by Fraud and Abuse Perpetrators and Health Outcomes Among Medicare Beneficiaries

IMPORTANCE

Fraud and abuse contribute to unnecessary spending in the Medicare program, and federal agencies have prioritized fund recovery and the exclusion of health care practitioners who violate policy. However, the human costs of fraud and abuse in terms of patient health are unknown.

OBJECTIVE

To assess whether Medicare beneficiaries' receipt of health care services from fraud and abuse perpetrators (FAPs) is associated with worse health outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cross-sectional study comparing mortality and emergency hospitalization rates of 8204 patients treated by an FAP with those among patients treated by a randomly selected non-FAP in 2013. Known FAPs were identified from the December 2018 List of Excluded Individuals/Entities (LEIE) published by the Office of the Inspector General in the Department of Health and Human Services. Patients were identified in a 5% sample of Medicare claims data and were enrolled in the Fee-for-Service program.

EXPOSURES

Treatment by a health care professional subsequently excluded from Medicare for fraud, patient harm, or a revoked license.

MAIN OUTCOMES AND MEASURES

All-cause mortality between 2013 and 2015 and 2013 emergency hospitalizations.

RESULTS

A total of 8204 Medicare beneficiaries in the study sample (mean [SD] age, 69.2 [14.2] years; 58.2% female, and 23.0% nonwhite) saw an FAP for the first time in 2013. Of these, 5054 (61.6%) were treated by fraud perpetrators, 1157 (14.1%) by patient harm perpetrators, and 1193 (24.3%) by revoked license perpetrators. Compared with 296 298 beneficiaries treated by non-FAPs (mean [SD] age, 71.1 [12.4] years; 58.6% female, and 16.5% nonwhite), beneficiaries exposed to an FAP were more likely to be eligible for both Medicare and Medicaid (34.7% [2845 of 8204] vs 21.9% [64 989 of 296 298]; P < .001) and more likely to be disabled at an age younger than 65 years (27.2% [2231 of 8204] vs 18.6% [55 168 of 296 298]; P < .001). All FAP exposures were associated with higher mortality and emergency hospitalization rates after risk adjustment and propensity score weighting: for mortality, exposures to fraud FAPs were associated with an increase of 4.58 percentage points (95% CI, 2.02-7.13; P < .001); to patient harm FAPs, with an increase of 3.34 percentage points (95% CI, 1.40-5.27; P = .001); and to revoked license FAPs, with an increase of 3.33 percentage points (95% CI, 1.58-5.09; P < .001). Increases were similar for emergency hospitalization rates: for fraud FAP exposures, 3.24 percentage points (95% CI, 0.01-6.46; P = .049); for patient harm FAP exposures, 9.34 percentage points (95% CI, 6.02-12.65; P < .001); and for revoked license FAP exposures, 9.28 percentage points (95% CI, 6.43-12.13; P < .001).

CONCLUSIONS AND RELEVANCE

This study's findings suggest that receiving medical care from FAPs may be associated with significantly higher rates of all-cause mortality and emergency hospitalization after risk adjustment. Identifying and permanently removing FAPs from the Medicare program may be associated with improved beneficiary health in addition to financial savings.

Factors associated with potentially inappropriate medication use in community-dwelling older adults in the United States: a systematic review

OBJECTIVES

Potentially inappropriate medication (PIM) use in older adults is a prevalent problem associated with poor health outcomes. Understanding drivers of PIM use is essential for targeting interventions. This study systematically reviews the literature about the patient, clinician and environmental/system factors associated with PIM use in community-dwelling older adults in the United States.

METHODS

PRISMA guidelines were followed when completing this review. PubMed and EMBASE were queried from January 2006 to September 2017. Our search was limited to English-language studies conducted in the United States that assessed factors associated with PIM use in adults ≥65 years who were community-dwelling. Two independent reviewers screened titles and abstracts. Reviewers abstracted data sequentially and assessed risk of bias independently.

KEY FINDINGS

Twenty-two studies were included. Nineteen examined patient factors associated with PIM use. The most common statistically significant factors associated with PIM use were taking more medications, female sex, and higher outpatient and emergency department utilization. Only three studies examined clinician factors, and few were statistically significant. Fifteen studies examined system-level factors such as geographic region and health insurance. The most common statistically significant association was the south and west geographic region relative to the northeast United States.

CONCLUSIONS

Amongst older adults, women and persons on more medications are at higher risk of PIM use. There is evidence that increased healthcare use is also associated with PIM use. Future studies are needed exploring clinician factors, such as specialty, and their association with PIM prescribing.

Motivational factors for choosing treatment destinations among the patients treated overseas from the United Arab Emirates: results from the knowledge, attitudes and perceptions survey 2012

Background

Travelling seeking healthcare is becoming common phenomenon. There is limited research to understand factors associated with destinations of choice. Each year the Dubai Health Authority (DHA) spends millions of dollars to cover Emiratis seeking healthcare overseas. The objective of this study is to examine the association of treatment destinations, patients’ characteristics and motivation factors among the patients treated overseas from the UAE during 2009–2012.

Method

The data from the Knowledge, Attitudes and Perceptions Survey 2012 in Dubai on medical travel. Examining destinations by patients’ characteristics and motivational factors under push and pull factor framework. Modified Poisson regression model was used to identify factors associated with treatment destinations.

Results

Three hundred thirty-six UAE national families with a member who sought overseas treatment during 2009–2012 were analyzed for this study regarding their most recent trip. The aim of the survey is to explore their knowledge, attitudes and perceptions. The majority of respondents were family members not the patients who had experienced the medical treatment overseas (63%). Germany was the top treatment destination (45%). The top 3 medical conditions for which people traveled overseas were cancer (17%), bone and joint diseases (16%), and heart diseases (15%). However, patients diagnosed with stroke (brain hemorrhage or clot) are more likely to travel to Germany for medical treatment while patients diagnosed with eye diseases are more likely to seek medical treatment at other destinations. Cost was a primary motivational factor for choosing a treatment destination.

Conclusion

This study addressed knowledge gap related medical travel in the UAE. The results provided evidence about perceptions when choosing treatment destinations. Medical condition and financial factors were main predictors for choosing treatment destination. The result will influence policies related financial coverage by the government. The results suggest understanding patients’ perceptions in-depth related their medical conditions and financial factors for better regulation of overseas treatment strategy in the UAE.

Frailty Among Older Adults With Acute Myocardial Infarction and Outcomes From Percutaneous Coronary Interventions

Background

Frailty is a predictor of adverse outcomes after acute myocardial infarction (AMI).

Methods and Results

We estimated the prevalence of frailty among adults age ≥75 years admitted with AMI and examined the relationship between frailty, interventions, and mortality. We used the Premier Healthcare Database to identify older adults with primary diagnoses of AMI. We classified individuals as frail or not using the validated Claims‐based Frailty Index. We described patients’ characteristics and receipt of percutaneous coronary intervention stratified by frailty status. The primary outcome was hospital mortality. From 2000 to 2016, we identified 469 390 encounters for older patients admitted with AMI. The median age was 82 years, 53% were women, and 75% were white. The prevalence of frailty was 19%. Frail patients were less likely to receive percutaneous coronary intervention than nonfrail (15% versus 33%, P<0.001) and much less likely to receive coronary artery bypass surgery (1% versus 9%, P<0.001). There were far fewer interventions in individuals over age 85 years. Frailty was associated with higher mortality during AMI admission (unadjusted odds ratio [OR] 1.43, CI 1.39–1.46). While there was a differential benefit of the interventions because of frailty, frail patients had reduced hospital mortality with percutaneous coronary intervention (frail: OR 0.59, CI 0.55–0.63; nonfrail: OR 0.49, CI 0.47–0.50, P for interaction <0.001) and with coronary artery bypass surgery (frail: OR 0.77, CI 0.65–0.93; nonfrail: OR 0.74, CI 0.71–0.77, P for interaction <0.001) relative to no intervention.

Conclusions

In the United States, frailty is common among older patients admitted with AMI. While these vulnerable patients are at an increased risk for mortality, judicial use of revascularization with percutaneous coronary intervention in frail older patients still confers immediate survival benefit.

Treatment destinations and visit frequencies for patients seeking medical treatment overseas from the United Arab Emirates: results from Dubai Health Authority reporting during 2009-2016

BACKGROUND

Each year, the Dubai Health Authority (DHA) spends millions of dollars to cover the costs of United Arab Emirates (UAE) nationals seeking healthcare overseas. Patients may travel overseas to seek an array of treatments. It is important to analyze the number of trips and treatment destinations for patients travelling overseas to provide baseline information for the DHA to improve polices and strategies related to overseas treatment for UAE nationals.

METHODS

Administrative data were obtained from the DHA for UAE nationals who sought medical treatment overseas during 2009-2016. We examined the number of trips and treatment destinations by medical specialty, age, gender, years of travel and travel seasons. Multinomial logistic and negative binomial regression models were used to assess the relationships of the treatment destinations and number of trips, respectively, with the key variables of interest.

RESULTS

The study included data from 6557 UAE nationals. The top three treatment destinations were Germany (46%), the UK (19%) and Thailand (14%). The most common medical specialties were orthopedic surgery (13%), oncology (13%) and neurosurgery (10%). Oncology had the highest expected number of trips adjusted for a number of covariates (IRR 1.34, 95% CI: 1.24-1.44). Regarding destination variation, patients had a lower relative risk ratio of seeking healthcare in Germany in the winter (RRR 0.68, 95% CI: 0.57-0.80). Endocrinology was the most common medical specialty sought in the UK (RRR 3.36, 95% CI: 2.01-5.60).

CONCLUSIONS

This is the first study to systematically examine the current practice of medical treatment overseas among UAE nationals. The results demonstrate that treatment destinations, medical specialties for which treatment was sought, age, gender and travel season are significant factors in understanding overseas travel for medical care. The study can guide the DHA in collecting more data for further research that may lead to policy-relevant information about sending patients to the best-quality treatment choices at an optimal cost.

Systemic overuse of health care in a commercially insured US population, 2010-2015

BACKGROUND

Overuse is a leading contributor to the high cost of health care in the United States. Overuse harms patients and is a definitive waste of resources. The Johns Hopkins Overuse Index (JHOI) is a normalized measure of systemic health care services overuse, generated from claims data, that has been used to describe overuse in Medicare beneficiaries and to understand drivers of overuse. We aimed to adapt the JHOI for application to a commercially insured US population, to examine geographic variation in systemic overuse in this population, and to analyze trends over time to inform whether systemic overuse is an enduring problem.

METHODS

We analyzed commercial insurance claims from 18 to 64 year old beneficiaries. We calculated a semiannual JHOI for each of the 375 Metropolitan Statistical Areas and 47 rural regions of the US. We generated maps to examine geographic variation and then analyzed each region's change in their JHOI quintile from January 2011 to June 2015.

RESULTS

The JHOI varied markedly across the US. Across the country, rural regions tended to have less systemic overuse than their MSA counterparts (p < 0.01). Regional systemic overuse is positively correlated from one time period to the next (p < 0.001). Between 2011 and 2015, 53.7% (N = 226) of regions remained in the same quintile of the JHOI. Eighty of these regions had a persistently high or persistently low JHOI throughout study duration.

CONCLUSIONS

The systemic overuse of health care resources is an enduring, regional problem. Areas identified as having a persistently high rate of systemic overuse merit further investigation to understand drivers and potential points of intervention.

Warfarin use and the risk of stroke, bleeding, and mortality in older adults on dialysis with incident atrial fibrillation

AIM

There is conflicting evidence regarding the safety and effectiveness of warfarin for atrial fibrillation (AF) treatment among older end-stage renal disease (ESRD) patients, and differences among subgroups are unclear.

METHODS

Older dialysis patients who were newly diagnosed with AF (7/2007-12/2011) were identified in the United States Renal Data System. The adjusted hazard ratios (HR) of the outcomes (any stroke, ischaemic stroke, major bleeding, severe gastrointestinal bleeding, and death) by time-varying warfarin use were estimated using Cox regression accounting for the inverse probability of treatment weight.

RESULTS

Among 5765 older dialysis patients with incident AF, warfarin was associated with significantly increased risk of major bleeding (HR = 1.50, 95% CI 1.33-1.68), but was not statistically associated with any stroke (HR = 0.92, 95% CI 0.75-1.12), ischaemic stroke (HR = 0.88, 95%CI 0.70-1.11) or gastrointestinal bleeding (HR = 1.03, 95% CI 0.80-1.32). Warfarin use was associated with a reduced risk of mortality (HR = 0.72, 95%CI 0.65-0.80). The association between warfarin and major bleeding differed by sex (male: HR = 1.29; 95%CI 1.08-1.55; female: HR = 1.67; 95%CI 1.44-1.93; P-value for interaction = 0.03).

CONCLUSION

Older ESRD patients with AF who were treated with warfarin had a no difference in stroke risk, lower mortality risk, but increased major bleeding risk. The bleeding risk associated with warfarin was greater among women than men. The risk/benefit ratio of warfarin may be less favourable among older women.

Differences in National Diabetes Treatment Patterns and Trends between Older and Younger Adults

BACKGROUND/OBJECTIVES

The treatment of type 2 diabetes in older adults requires special considerations including avoidance of hypoglycemia, yet variation in diabetes treatment with aging is not well understood. In this study, we compared nationally representative diabetes treatment patterns and trends between older adults (≥65 y) and younger adults (30-64 y).

DESIGN

Repeated cross-sectional physician surveys from 2006 to 2015.

SETTING

The National Ambulatory Medical Care Survey, an annual probability sample of visits to office-based US physicians.

PARTICIPANTS

Adults with type 2 diabetes using one or more diabetes medications.

MEASUREMENTS

Proportions of visits in which patients treated with each diabetes medication class were compared between older and younger adults in 2-year intervals.

RESULTS

From 2006 to 2015, the average number of yearly visits for older and younger adults was 25.4 million and 24.2 million, respectively. In 2014-2015, visits for older compared with younger adults involved less use of metformin (56.0% vs 70.0%; p < .001) and glucagon-like peptide 1 receptor agonists (2.9% vs 6.2%; p = .004), and more use of long-acting insulin (30.2% vs 22.4%; p = .017); other classes were used similarly. During the study period, long-acting insulin use increased markedly in older adults, particularly between 2010 and 2015 where it rose from 12.5% to 30.2% of visits (P-trend <.001). In younger adult visits, long-acting insulin use increased modestly (17.2% to 22.4%) and at a slower rate compared with older adult visits (p < .001).

CONCLUSION

The ambulatory treatment of type 2 diabetes differs between older and younger adults, with the treatment of older adults characterized by low use of newer diabetes medications and a greater and rapidly increasing use of long-acting insulin. These findings call for further research clarifying the comparative effectiveness and safety of newer diabetes medications and long-acting insulin to optimize diabetes care for older patients. J Am Geriatr Soc 67:1066-1073, 2019.

Regional Supply of Medical Resources and Systemic Overuse of Health Care Among Medicare Beneficiaries

BACKGROUND

Overuse of health care resources has been identified as the leading contributor to waste in the US health care system.

OBJECTIVE

To explore health care system factors associated with regional variation in systemic overuse of health care resources as measured by the Johns Hopkins Overuse Index (JHOI) which aggregates systemic overuse of 20 health care services.

DESIGN

Using Medicare fee-for-service claims data from beneficiaries age 65 or over in 2008, we calculated the JHOI for the 306 hospital referral regions in the United States. We used ordinary least squares regression and multilevel models to estimate the association of JHOI scores and characteristics of regional health care delivery systems listed in the Area Health Resource File and Dartmouth Atlas.

KEY RESULTS

Regions with a higher density of primary care physicians had lower JHOI scores, indicating less systemic overuse (P < 0.001). Regional characteristics associated with higher JHOI scores, indicating more systemic overuse, included number per 1000 residents of acute care hospital beds (P = 0.002) and of hospital-based anesthesiologists, pathologists, and radiologists (P = 0.02).

CONCLUSIONS

Regional variations in health care resources including the clinician workforce are associated with the intensity of systemic overuse of health care. The role of primary care doctors in reducing health care overuse deserves further attention.

Trends and Variation in Oral Anticoagulant Choice in Patients with Atrial Fibrillation, 2010-2017

OBJECTIVE

Since 2010, several non-vitamin K antagonist oral anticoagulants (NOACs) have been brought to the U.S. market, yet little is known regarding their evolving adoption for prophylaxis of atrial fibrillation (AF)-related stroke. We examined temporal trends in choice of oral anticoagulants (OACs) among incident OAC users with AF and its association with patient demographic and clinical characteristics.

METHODS

We conducted a serial cross-sectional analysis of medical and pharmacy claims for commercial and Medicare Advantage enrollees in a large, private, U.S. health plan. We identified 112,187 adults with nonvalvular AF starting OACs between October 2010 and March 2017. Multivariable logistic regression was used to examine the associations of patient characteristics with prescription of NOACs versus warfarin. Multinomial logistic regression was used to test the associations of patient characteristics with choice among NOACs.

RESULTS

The prescription of NOACs has increased dramatically since their introduction in October 2010. In the first quarter of 2017 (2017Q1), 7502 patients started OACs, of whom 78.9% used NOACs and 21.1% warfarin. For NOACs, 3.8% used dabigatran, 25.0% rivaroxaban, and 50.1% apixaban. In multivariable analyses, factors associated with choice of NOACs versus warfarin included younger age, lower stroke or bleeding risk, fewer comorbidities, higher education level or household net worth, and prescription by cardiologists (all p<0.001). There was no sex difference in likelihood of filling NOACs versus warfarin in 2010Q4-2012, but women had higher odds of starting NOACs (odds ratio = 1.19; 95% confidence interval = 1.14-1.25) in 2015-2017Q1. Among NOAC users, the odds of apixaban prescription increased with age, female sex, stroke or bleeding risk, and comorbidities (all p<0.05).

CONCLUSION

NOAC prescriptions have increased substantially among incident OAC users with nonvalvular AF, predominantly driven by increased prescription of apixaban. Warfarin and apixaban were generally preferred for elderly patients, patients with higher stroke or bleeding risk, and patients with more comorbidities.