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Rodriguez LA, Finertie H, Neugebauer RS, Gosiker B, Thomas TW, Karter AJ, Gilliam LK, Oshiro C, An J, Simonson G, Cassidy-Bushrow AE, Dombrowski S, Nolan M, O'Connor PJ, Schmittdiel JA. Race and ethnicity and pharmacy dispensing of SGLT2 inhibitors and GLP-1 receptor agonists in type 2 diabetes. LANCET REGIONAL HEALTH. AMERICAS 2024; 34:100759. [PMID: 38745886 PMCID: PMC11091531 DOI: 10.1016/j.lana.2024.100759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 04/16/2024] [Accepted: 04/22/2024] [Indexed: 05/16/2024]
Abstract
Background Sodium-Glucose Cotransporter 2 Inhibitors (SGLT2i) and Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RA) improve cardiorenal outcomes in patients with type 2 diabetes. Equitable use of SGLT2i and GLP-1 RA has the potential to reduce racial and ethnic health disparities. We evaluated trends in pharmacy dispensing of SGLT2i and GLP-1 RA by race and ethnicity. Methods Retrospective cohort study of patients (≥18 years) with type 2 diabetes using 2014-2022 electronic health record data from six US care delivery systems. Entry was at earliest pharmacy dispensing of any type 2 diabetes medication. We used multivariable logistic regression to evaluate the association between pharmacy dispensing of SGLT2i and GLP1-RA and race and ethnicity. Findings Our cohort included 687,165 patients (median 6 years of dispensing data; median 60 years; 0.3% American Indian/Alaska Native (AI/AN), 16.6% Asian, 10.5% Black, 1.4% Hawaiian or Pacific Islander (HPI), 31.1% Hispanic, 3.8% Other, and 36.3% White). SGLT2i was lower for AI/AN (OR 0.80, 95% confidence interval 0.68-0.94), Black (0.89, 0.86-0.92) and Hispanic (0.87, 0.85-0.89) compared to White patients. GLP-1 RA was lower for AI/AN (0.78, 0.63-0.97), Asian (0.50, 0.48-0.53), Black (0.86, 0.83-0.90), HPI (0.52, 0.46-0.57), Hispanic (0.69, 0.66-0.71), and Other (0.78, 0.73-0.83) compared to White patients. Interpretation Dispensing of SGLT2is, and GLP-1 RAs was lower in minority group patients. There is a need to evaluate approaches to increase use of these cardiorenal protective drugs in patients from racial and ethnic minority groups with type 2 diabetes to reduce adverse cardiorenal outcomes and improve health equity. Funding Patient-Centered Outcomes Research Institute and National Institutes of Health.
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Affiliation(s)
- Luis A. Rodriguez
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, USA
- Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science, Pasadena, CA, USA
- University of California, Department of Epidemiology & Biostatistics, San Francisco, CA, USA
| | - Holly Finertie
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, USA
| | - Romain S. Neugebauer
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, USA
- Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science, Pasadena, CA, USA
| | - Bennett Gosiker
- Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science, Pasadena, CA, USA
| | - Tainayah W. Thomas
- Stanford University School of Medicine, Department of Epidemiology and Population Health, Palo Alto, CA, USA
| | - Andrew J. Karter
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, USA
| | | | - Caryn Oshiro
- Kaiser Permanente Center for Integrated Health Care Research, Honolulu, HI, USA
| | - Jaejin An
- Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science, Pasadena, CA, USA
- Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Gregg Simonson
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN, USA
| | | | | | - Margaret Nolan
- HealthPartners Institute for Medical Education and Research, Bloomington, MN, USA
| | - Patrick J. O'Connor
- HealthPartners Institute for Medical Education and Research, Bloomington, MN, USA
| | - Julie A. Schmittdiel
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, USA
- Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science, Pasadena, CA, USA
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Maddox TM, Januzzi JL, Allen LA, Breathett K, Brouse S, Butler J, Davis LL, Fonarow GC, Ibrahim NE, Lindenfeld J, Masoudi FA, Motiwala SR, Oliveros E, Walsh MN, Wasserman A, Yancy CW, Youmans QR. 2024 ACC Expert Consensus Decision Pathway for Treatment of Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2024; 83:1444-1488. [PMID: 38466244 DOI: 10.1016/j.jacc.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
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Taliaferro LM, Dodson S, Norton MC, Ofei-Dodoo S. Evaluation of 340B prescription assistance program on healthcare use in chronic obstructive pulmonary disease. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 11:100295. [PMID: 37404594 PMCID: PMC10315920 DOI: 10.1016/j.rcsop.2023.100295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/13/2023] [Accepted: 06/13/2023] [Indexed: 07/06/2023] Open
Abstract
Background The federal 340B drug program was designed to stretch scarce federal resources to provide more comprehensive services for more eligible patients. To help satisfy community needs, 340B Prescription Assistance Programs (PAPs) allow eligible patients to access medications at significantly reduced costs. Objectives To measure the impact of reduced-cost medications for chronic obstructive pulmonary disease (COPD) through a 340B PAP on all-cause hospitalizations and emergency department visits. Methods This multi-site, retrospective, single-sample, pre-post cohort study involved patients with COPD who used a 340B PAP to fill prescriptions for an inhaler or nebulizer between April 1, 2018, and June 30, 2019. Data from included subjects were evaluated and compared in the year before and after each individual patient's respective prescription fill in the 340B PAP. The primary outcome evaluated the impact of 340B PAP on all-cause hospitalizations and emergency department visits. Secondary outcomes evaluated the financial impact associated with program use. Wilcoxon signed-rank test was utilized to assess changes in the outcome measures. Results Data for 115 patients were included in the study. Use of the 340B PAP resulted in a significant reduction in the composite mean number of all-cause hospitalizations and emergency department visits (2.42 vs 1.66, Z = -3.12, p = 0.002). There was an estimated $1012.82 mean cost avoidance per patient due to reduction in healthcare utilization. Annual program-wide prescription cost savings for patients totaled $178,050.21. Conclusions This study suggested that access to reduced-cost medications through the federal 340B Drug Pricing Program was associated with a significant reduction in hospitalizations and emergency department visits for patients with COPD, decreasing patients' utilization of healthcare resources.
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Affiliation(s)
- Leah M. Taliaferro
- Ascension Via Christi Hospitals Wichita, Inc., 929 N Saint Francis, Wichita, KS 67214, United States
| | - Sarah Dodson
- Ascension Via Christi Hospitals, 1 Mt Carmel Pl, Pittsburg, KS 66762, United States
| | - Melissa C. Norton
- Ascension Via Christi Hospitals Wichita, Inc., 929 N Saint Francis, Wichita, KS 67214, United States
| | - Samuel Ofei-Dodoo
- University of Kansas School of Medicine - Wichita, 1010 N Kansas, Wichita, KS 67214, United States
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Zeitouny S, Cheng L, Wong ST, Tadrous M, McGrail K, Law MR. Prevalence and predictors of primary nonadherence to medications prescribed in primary care. CMAJ 2023; 195:E1000-E1009. [PMID: 37553145 PMCID: PMC10446155 DOI: 10.1503/cmaj.221018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Most research on medication adherence has focused on secondary nonadherence and persistence to therapy. Medication prescriptions that are never filled by patients (primary nonadherence) remain understudied in the general population. METHODS We linked prescribing data from primary care electronic medical records to comprehensive pharmacy dispensing claims between January 2013 and April 2019 in British Columbia (BC) to estimate primary nonadherence, defined as failure to dispense a new medication or its equivalent within 6 months of the prescription date. We used hierarchical multivariable logistic regression to determine prescriber, patient and medication factors associated with primary nonadherence among community-dwelling patients in primary care. RESULTS Among 150 565 new prescriptions to 34 243 patients, 17% of prescriptions were never filled. Primary nonadherence was highest for drugs prescribed mostly on an as-needed basis, including topical corticosteroids (35.1%) and antihistamines (23.4%). In multivariable analysis, primary nonadherence was lower for prescriptions issued by male prescribers (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.50-0.88). Primary nonadherence decreased with patient age (OR 0.91, 95% CI 0.90-0.92 for each additional 10 years) but increased with polypharmacy among patients aged 65 years or older. Patients filled more than 82% of their medication prescriptions within 2 weeks after their primary care provider visit. INTERPRETATION The prevalence of primary nonadherence to new prescriptions was 17%. Interventions to address primary nonadherence could target older patients with multiple medication use and within the first 2 weeks of the prescription issue date.
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Affiliation(s)
- Seraphine Zeitouny
- Centre for Health Services and Policy Research, School of Population and Public Health (Zeitouny, Cheng, Wong, McGrail, Law), University of British Columbia, Vancouver, BC; Leslie Dan Faculty of Pharmacy (Tadrous), University of Toronto; Women's College Research Institute (Tadrous), Women's College Hospital, Toronto, Ont.
| | - Lucy Cheng
- Centre for Health Services and Policy Research, School of Population and Public Health (Zeitouny, Cheng, Wong, McGrail, Law), University of British Columbia, Vancouver, BC; Leslie Dan Faculty of Pharmacy (Tadrous), University of Toronto; Women's College Research Institute (Tadrous), Women's College Hospital, Toronto, Ont
| | - Sabrina T Wong
- Centre for Health Services and Policy Research, School of Population and Public Health (Zeitouny, Cheng, Wong, McGrail, Law), University of British Columbia, Vancouver, BC; Leslie Dan Faculty of Pharmacy (Tadrous), University of Toronto; Women's College Research Institute (Tadrous), Women's College Hospital, Toronto, Ont
| | - Mina Tadrous
- Centre for Health Services and Policy Research, School of Population and Public Health (Zeitouny, Cheng, Wong, McGrail, Law), University of British Columbia, Vancouver, BC; Leslie Dan Faculty of Pharmacy (Tadrous), University of Toronto; Women's College Research Institute (Tadrous), Women's College Hospital, Toronto, Ont
| | - Kimberlyn McGrail
- Centre for Health Services and Policy Research, School of Population and Public Health (Zeitouny, Cheng, Wong, McGrail, Law), University of British Columbia, Vancouver, BC; Leslie Dan Faculty of Pharmacy (Tadrous), University of Toronto; Women's College Research Institute (Tadrous), Women's College Hospital, Toronto, Ont
| | - Michael R Law
- Centre for Health Services and Policy Research, School of Population and Public Health (Zeitouny, Cheng, Wong, McGrail, Law), University of British Columbia, Vancouver, BC; Leslie Dan Faculty of Pharmacy (Tadrous), University of Toronto; Women's College Research Institute (Tadrous), Women's College Hospital, Toronto, Ont
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Franck L, Donovan A, Kellison M, McAdam-Marx C. Assessment of medication adherence after enrollment in a health system funded medication assistance program for patients with diabetes. J Am Pharm Assoc (2003) 2023; 63:1222-1229.e3. [PMID: 37075902 DOI: 10.1016/j.japh.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND High costs for patients' medications decrease medication access and adherence which contributes to poor clinical outcomes. Numerous medication assistance programs exist, but many patients needing assistance, particularly insured patients, do not receive assistance due to eligibility criteria. OBJECTIVE To determine if there is an association between medication adherence to antihyperglycemic therapy and patient access to Nebraska Medicine Charity Care (NMCC). PRACTICE DESCRIPTION NMCC covers up to 100% of medication out-of-pocket costs for patients in financial need who do not qualify for other programs. PRACTICE INNOVATION There is no published information about a long-term health system-led financial medication assistance program being utilized to improve patient medication adherence and clinical outcomes. EVALUATION METHODS A retrospective cohort analysis was conducted to assess adherence in patients who initiated NMCC between July 1, 2018 and June 30, 2020, with a focus on diabetes for feasibility. Adherence was assessed using a modified medication possession ratio (mMPR) for 6 months after initiating NMCC based on health system dispensing data. Overall population adherence analyses were conducted in all available data, while pre-post analyses were conducted in those with antihyperglycemic medication fills during the prior 6 months. RESULTS Of 2758 unique patients receiving NMCC support, 656 patients with diabetes medication use were included. Of these, 71% had prescription insurance and 28% had prescription fills in the baseline period. Mean (SD) adherence to noninsulin antihyperglycemic medications in the follow-up period was 0.80 (0.25) with 63% adherent per mMPR ≥0.80. In the prepost analysis, mMPR was significantly higher during the follow-up period at 0.83 (0.23) than during the preindex period at 0.34 (0.17), as was the proportion who were adherent (66% vs. 2%) (P < 0.001). CONCLUSION This practice innovation observed an improvement in adherence and A1C outcomes in patients with diabetes who received medication financial assistance through a health system.
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Schulz M, Laufs U. Not obtaining a medication the first time it is prescribed: primary non-adherence to cardiovascular pharmacotherapy. Clin Res Cardiol 2023:10.1007/s00392-023-02230-3. [PMID: 37209148 DOI: 10.1007/s00392-023-02230-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/08/2023] [Indexed: 05/22/2023]
Abstract
Primary medication non-adherence describes the situation when a first prescription for a new medication is never filled. Primary non-adherence is an important, yet understudied aspect of reduced effectiveness of pharmacotherapy. This review summarizes the frequency, impact, reasons, predictors, and interventions regarding primary non-adherence to cardiovascular/cardiometabolic drugs. The current literature reveals a high prevalence of primary non-adherence. The individual risk of primary non-adherence is determined on multiple factors, e.g., primary non-adherence of lipid-lowering drugs is higher compared to antihypertensive medications. However, the overall rate of primary non-adherence is > 10%. Additionally, this review identifies specific areas for research to better understand why patients forgo evidence-based beneficial pharmacotherapy and to explore targeted interventions. At the same time, measures to reduce primary non-adherence-once proven to be effective-may represent an important new opportunity to reduce cardiovascular diseases.
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Affiliation(s)
- Martin Schulz
- Institute of Pharmacy, Freie Universität Berlin, Kelchstraße 31, 12169, Berlin, Germany.
- Drug Commission of German Pharmacists (AMK), Heidestraße 7, 10557, Berlin, Germany.
- German Institute for Drug Use Evaluation (DAPI), Heidestraße 7, 10557, Berlin, Germany.
| | - Ulrich Laufs
- Department of Cardiology, University of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
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Roblin DW, Goodrich GK, Davis TL, Gander JC, McCracken CE, Weinfield NS, Ritzwoller DP. Did Access to Ambulatory Care Moderate the Associations Between Visit Mode and Ancillary Services Utilization Across the COVID-19 Pandemic Period? Med Care 2023; 61:S39-S46. [PMID: 36893417 PMCID: PMC9994577 DOI: 10.1097/mlr.0000000000001832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND/OBJECTIVE In recent years, 2 circumstances changed provider-patient interactions in primary care: the substitution of virtual (eg, video) for in-person visits and the COVID-19 pandemic. We studied whether access to care might affect patient fulfillment of ancillary services orders for ambulatory diagnosis and management of incident neck or back pain (NBP) and incident urinary tract infection (UTI) for virtual versus in-person visits. METHODS Data were extracted from the electronic health records of 3 Kaiser Permanente Regions to identify incident NBP and UTI visits from January 2016 through June 2021. Visit modes were classified as virtual (Internet-mediated synchronous chats, telephone visits, or video visits) or in-person. Periods were classified as prepandemic [before the beginning of the national emergency (April 2020)] or recovery (after June 2020). Percentages of patient fulfillment of ancillary services orders were measured for 5 service classes each for NBP and UTI. Differences in percentages of fulfillments were compared between modes within periods and between periods within the mode to assess the possible impact of 3 moderators: distance from residence to primary care clinic, high deductible health plan (HDHP) enrollment, and prior use of a mail-order pharmacy program. RESULTS For diagnostic radiology, laboratory, and pharmacy services, percentages of fulfilled orders were generally >70-80%. Given an incident NBP or UTI visit, longer distance to the clinic and higher cost-sharing due to HDHP enrollment did not significantly suppress patients' fulfillment of ancillary services orders. Prior use of mail-order prescriptions significantly promoted medication order fulfillments on virtual NBP visits compared with in-person NBP visits in the prepandemic period (5.9% vs. 2.0%, P=0.01) and in the recovery period (5.2% vs. 1.6%, P=0.02). CONCLUSIONS Distance to the clinic or HDHP enrollment had minimal impact on the fulfillment of diagnostic or prescribed medication services associated with incident NBP or UTI visits delivered virtually or in-person; however, prior use of mail-order pharmacy option promoted fulfillment of prescribed medication orders associated with NBP visits.
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Affiliation(s)
- Douglas W. Roblin
- Kaiser Permanente, Mid-Atlantic Permanente Research Institute, Rockville, MD
| | | | | | | | | | - Nancy S. Weinfield
- Kaiser Permanente, Mid-Atlantic Permanente Research Institute, Rockville, MD
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Keilman L, Jolaei S, Olsen DP. Moral distress and patients who forego care due to cost. Nurs Ethics 2023; 30:370-381. [PMID: 36708361 DOI: 10.1177/09697330221134983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND In the US, many patients forgo recommended care due to cost. The ANA Code of Ethics requires nurses to give care based on need. Therefore, US nurses are compelled to practice in a context which breaches their professional ethical code. RESEARCH OBJECTIVES This study sought to determine if nurses do care for patients who forgo treatment due to cost (PFTDC) and if so, does this result in an experience of moral distress (MD). RESEARCH DESIGN Semi-structured interviews were transcribed and analyzed using a qualitative content analysis. PARTICIPANTS AND RESEARCH CONTEXT A convenience sample of 20 nurses in practice for at least one year from a variety of health care setting participated. ETHICAL CONSIDERATIONS This project was approved by the Michigan State University Biomedical Institutional Review Board. RESULTS There were 19 female and one male nurse-participants, averaging 47 years old with an average of 10 years in practice. 18 reported caring for PFTDC. These 17 nurse-participants experienced a moderate degree of MD as a result, averaging 5.4 of 10 on the Moral Distress Thermometer. In the interviews, the following themes were identified, strategies to help PFTDC, and the broken US health care system which had the subthemes of preference for business over patient-oriented benefit, PFTDC using the emergency department, and limited support for treatment/management of PFTDC. CONCLUSIONS The existence of this phenomenon places the profession of nursing in the US in a position of moral compromise and threatens to corrupt the institution of nursing in the US.
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Affiliation(s)
- Linda Keilman
- College of Nursing, 3078Michigan State University, East Lansing, MI, USA
| | - Soudabeh Jolaei
- 27355Fraser Health Authority, UBC Center for Health Evaluation & Outcome Sciences, Vancouver, Canada
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Fusco N, Sils B, Graff JS, Kistler K, Ruiz K. Cost-sharing and adherence, clinical outcomes, health care utilization, and costs: A systematic literature review. J Manag Care Spec Pharm 2023; 29:4-16. [PMID: 35389285 PMCID: PMC10394195 DOI: 10.18553/jmcp.2022.21270] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND: US health plans are adopting benefit designs that shift greater financial burden to patients through higher deductibles, additional copay tiers, and coinsurance. Prior systematic reviews found that higher cost was associated with reductions in both appropriate and inappropriate medications. However, these reviews were conducted prior to contemporary benefit design and medication utilization. OBJECTIVE: To assess the relationship and factors associated with cost-sharing and (1) medication adherence, (2) clinical outcomes, (3) health care resource utilization (HRU), and (4) costs. METHODS: A systematic review of literature published between January 2010 and August 2020 was conducted to identify the relationship between cost-sharing and medication adherence, clinical outcomes, HRU, and health care costs. Data were extracted using a standardized template and were synthesized by key questions of interest. RESULTS: From 1,995 records screened, 79 articles were included. Most studies, 71 of 79 (90%), reported the relationship between cost-sharing and treatment adherence, persistence and/or discontinuation; 16 (20%) reported data on cost-sharing and HRU or medication initiation, 11 (14%) on costsharing and health care costs, and 6 (8%) on cost-sharing and clinical outcomes. The majority of publications found that, regardless of disease area, increased cost-sharing was associated with worse adherence, persistence, or discontinuation. The aggregate data suggested the greater the magnitude of cost-sharing, the worse the adherence. Among studies examining clinical outcomes, cost-sharing was associated with worse outcomes in 1 study and the remaining 3 found no significant differences. Regarding HRU, higher-cost-sharing trended toward decreased outpatient and increased inpatient utilization. The available evidence suggested higher cost-sharing has an overall neutral to negative impact on total costs. Studies evaluating elimination of copays found either decreased or no impact in total costs. CONCLUSIONS: The published literature shows consistent impacts of higher cost sharing on initiation and continuation of medications, and the greater the cost-sharing, the worse the medication adherence. The evidence is limited regarding the impact of cost-sharing on clinical outcomes, HRU, and costs. Limited evidence suggests increased cost-sharing is associated with more inpatient care and less outpatient care; however, a neutral to no difference was suggested for other outcomes. Although increased costsharing is intended to decrease total costs, studies evaluating reducing or eliminating cost-sharing found that total costs did not rise. Today's growing cost-containment environment should carefully consider the broader impact cost-sharing has on treatment adherence, clinical outcomes, resource use, and total costs. It may be that cost-sharing is a blunt, rather than precise, tool to curb health care costs, affecting both necessary and unnecessary health care use. DISCLOSURES: This study and the development of this article were funded by the National Pharmaceutical Council. Mr Sils is an employee of the National Pharmaceutical Council. Dr Graff is a former employee of the National Pharmaceutical Council. Drs Fusco and Kistler and Ms Ruiz are employees of Xcenda. Xcenda received funding to conduct the literature review.
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Affiliation(s)
| | - Brian Sils
- National Pharmaceutical Council, Washington, DC
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Silva-Tinoco R, Cuatecontzi-Xochitiotzi T, Bernal-Ceballos F, Torre-Saldaña VDL, Galindez-Fuentes A, Castillo-Martínez L. Adherence to antidiabetic treatment in primary health care in individuals with type 2 diabetes. A survey including socio-demographic, patient related and clinical factors. Prim Care Diabetes 2022; 16:780-785. [PMID: 36127243 DOI: 10.1016/j.pcd.2022.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 08/16/2022] [Accepted: 09/04/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Adherence to medications is a critical element in diabetes management. OBJECTIVE To investigate patient-related factors associated with adherence to antidiabetic treatment in patients with type 2 diabetes in primary health-care units. METHODS A cross-sectional study among patients receiving diabetes care in 18 primary care units in Mexico City was conducted. Data were collected from medical records and medical interviews. Adherence to antidiabetic therapy and patient-related factors associated with adherence were evaluated through a self-administered questionnaire. Socio-demographic, clinical, behavioral (self-care activities including a healthy diet, exercise or physical activity, self-monitoring of blood glucose testing, and foot care), and patients-adherence-related factors (health-care provider-patient communication; daily and social activities, and support network; alternative treatment beliefs; comorbidity, diabetes symptoms, and treatment; side effects and treatment access) were compared between the adherent and non-adherent group. RESULTS Of 319 outpatients, 48.3% were adherent to their antidiabetic therapy. In the adjusted analysis, patient-related factors associated to adherence were exercise and physical activity self-care behavior (OR=1.26; 95%CI 1.09-1.46), treatment interference with daily activities (OR=0.27; 95%CI 0.14-0.52), not satisfied with resolution of questions by the physician (OR=0.42; 95%CI 0.19-0.94), independently to increased cardiovascular risk and insulin treatment. CONCLUSION A low proportion of outpatients with T2D with regular primary care were adherent to diabetes treatment and this was associated with patient-related factors like answering patients' treatment-related questions by the physician. This information may be useful to identify patients at risk for low adherence, and to guide the design of quality-of-care strategies, like diabetes education programs to address suboptimal adherence in patients, and health-care professional communication skills training, particularly in primary care health systems.
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Affiliation(s)
- Ruben Silva-Tinoco
- Clinic Specialized in the Diabetes Management of the Mexico City Government, Servicios de Salud Pública de la Ciudad de México, Mexico.
| | - Teresa Cuatecontzi-Xochitiotzi
- Clinic Specialized in the Diabetes Management of the Mexico City Government, Servicios de Salud Pública de la Ciudad de México, Mexico.
| | | | - Viridiana de la Torre-Saldaña
- Clinic Specialized in the Diabetes Management of the Mexico City Government, Servicios de Salud Pública de la Ciudad de México, Mexico.
| | - Ana Galindez-Fuentes
- Clinic Specialized in the Diabetes Management of the Mexico City Government, Servicios de Salud Pública de la Ciudad de México, Mexico.
| | - Lilia Castillo-Martínez
- Department of Clinical Nutrition, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, México; Facultad de Medicina, Universidad Nacional Autónoma de México, México.
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Luo J, Feldman R, Rothenberger S, Korytkowski M, Fischer MA, Gellad WF. Incidence and Predictors of Primary Nonadherence to Sodium Glucose Co-transporter 2 Inhibitors and Glucagon-Like Peptide 1 Agonists in a Large Integrated Healthcare System. J Gen Intern Med 2022; 37:3562-3569. [PMID: 35048301 PMCID: PMC9585108 DOI: 10.1007/s11606-021-07331-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 12/14/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Newer glucose-lowering drugs, including sodium glucose co-transporter 2 inhibitors (SGLT2i) and GLP-1 agonists, have a key role in the pharmacologic management of type 2 diabetes. No studies have measured primary nonadherence for these two drug classes, defined as when a medication is prescribed for a patient but ultimately not dispensed to them. OBJECTIVE To describe the incidence and predictors of primary nonadherence to SGLT2i (canagliflozin, empagliflozin) or GLP-1 agonists (dulaglutide, liraglutide, semaglutide) using a dataset that links electronic prescribing with health insurance claims. DESIGN AND PARTICIPANTS A retrospective cohort design using data of adult patients from a large health system who had at least one prescription order for a SGLT2i or GLP-1 agonist between 2012 and 2019. We used mixed-effects multivariable logistic regression to determine associations between sociodemographic, clinical, and provider variables and primary nonadherence. MAIN MEASURES Primary medication nonadherence, defined as no dispensed claim within 30 days of an electronic prescription order for any drug within each medication class. KEY RESULTS The cohort included 5146 patients newly prescribed a SGLT2i or GLP-1 agonist. The overall incidence of 30-day primary medication nonadherence was 31.8% (1637/5146). This incidence rate was 29.8% (n = 726) and 33.6% (n = 911) among those initiating a GLP-1 agonist and SGLT2i, respectively. Age ≥ 65 (aOR 1.37 (95% CI 1.09 to 1.72)), Black race vs White (aOR 1.29 (95% CI 1.02 to 1.62)), diabetic nephropathy (aOR 1.31 (95% CI 1.02 to 1.68)), and hyperlipidemia (aOR 1.18 (95% CI 1.01 to 1.39)) were associated with a higher odds of primary nonadherence. Female sex (aOR 0.86 (95% CI 0.75 to 0.99)), peripheral artery disease (aOR 0.73 (95% CI 0.56 to 0.94)), and having the index prescription ordered by an endocrinologist vs a primary care provider (aOR 0.76 (95% CI 0.61 to 0.95)) were associated with lower odds of primary nonadherence. CONCLUSIONS One third of patients prescribed SGLT2i or GLP-1 agonists in this sample did not fill their prescription within 30 days. Black race, male sex, older age, having greater baseline comorbidities, and having a primary care provider vs endocrinologist prescribe the index drug were associated with higher odds of primary nonadherence. Interventions targeting medication adherence for these newer drugs must consider primary nonadherence as a barrier to optimal clinical care.
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Affiliation(s)
- Jing Luo
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburg, PA, USA.
| | - Robert Feldman
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburg, PA, USA
| | - Scott Rothenberger
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburg, PA, USA
| | - Mary Korytkowski
- Division of Endocrinology and Metabolism, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael A Fischer
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, MA, USA
| | - Walid F Gellad
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburg, PA, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
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Sendekie AK, Netere AK, Kasahun AE, Belachew EA. Medication adherence and its impact on glycemic control in type 2 diabetes mellitus patients with comorbidity: A multicenter cross-sectional study in Northwest Ethiopia. PLoS One 2022; 17:e0274971. [PMID: 36130160 PMCID: PMC9491880 DOI: 10.1371/journal.pone.0274971] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/07/2022] [Indexed: 11/17/2022] Open
Abstract
Background
Medication nonadherence in patients with chronic diseases, particularly in type 2 diabetes mellitus (T2DM) with comorbidity, has continued to be the cause of treatment failure. The current study assessed medication adherence and its impact on glycemic control in T2DM patients with comorbidity.
Methods
An institutional-based multicenter cross-sectional study was conducted among T2DM patients with comorbidity at the selected hospitals in Northwest Ethiopia. Medication adherence was measured using a structured questionnaire of the General Medication Adherence Scale (GMAS). A logistic regression model was used to identify predictors of the level of medication adherence and glycemic control. P < 0.05 at 95% confidence interval (CI) was statistically significant.
Results
A total of 403 samples were included in the final study. This study showed that more than three-fourths (76.9%) of the participants were under a low level of medication adherence. Source of medication cost coverage [AOR = 10.593, 95% CI (2.628–41.835; P = 0.003], monthly income (P < 0.00), self-monitoring of blood glucose (SMBG) practice [AOR = 0.266, 95% CI (0.117–0.604); P = 0.002], number of medications [AOR = 0.068, 95% CI (0.004–0.813); P = 0.014] and medical conditions [AOR = 0.307, 95% CI (0.026–0.437); P = 0.018] were found to be significant predictors of medication adherence. Significantly, majority (74.7%) of participants had poor levels of glycemic control. Patients who had a high level of medication adherence [AOR = 0.003, 95% CI (0.000–0.113); P = 0.002] were found less likely to have poor glycemic control compared with patients who were low adherent to their medications.
Conclusion
The current study concluded that medication adherence was low and significantly associated with poor glycemic control. Number of medical conditions and medications were found to be associated with medication adherence. Management interventions of T2DM patients with comorbidity should focus on the improvement of medication adherence.
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Affiliation(s)
- Ashenafi Kibret Sendekie
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
- * E-mail: ,
| | - Adeladlew Kassie Netere
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Asmamaw Emagn Kasahun
- Department of Pharmaceutics, School of Pharmacy, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Eyayaw Ashete Belachew
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
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Zargar AH, Kalra S, K M PK, Murthy S, Negalur V, Rajput R, Rastogi A, Saboo B, Sharma SK, Sahay R, Aravind SR, Shaikh S, Tiwaskar M, Ingole S, Kamble S. Rising cost of insulin: A deterrent to compliance in patients with diabetes mellitus. Diabetes Metab Syndr 2022; 16:102528. [PMID: 35863268 DOI: 10.1016/j.dsx.2022.102528] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND AIMS The rapid increase in burden of type 2 diabetes mellitus (T2DM), poses a huge medico-economic challenge, especially when the cost of care is funded by out-of-pocket expenses. The aim of this review is to highlight various issues associated with rising cost of insulin, prevalence of cost-related insulin underuse, insulin related cost-saving behaviors, and viable solutions for the benefit of patients with T2DM receiving insulin. METHODS Electronic databases (PubMed and Google Scholar) from 2000 to 2020 were searched using the key terms uncontrolled diabetes mellitus, insulin therapy, glycemic control, direct cost, indirect cost, out-of-pocket expenses, cost-related insulin underuse, cost-saving behaviors, and biosimilar insulin in developed countries and India. RESULTS In majority of the patients with T2DM on monotherapy, addition of another oral antidiabetic agent is required. Despite these measures, the target glycemic goals are not achieved in majority of the patients resulting in various complications. These complications can be prevented and target glycemic goals can be achieved with early initiation of insulin therapy. However, rising cost is a major deterrent to the lifelong use of insulin. This results in non-compliance and further deterioration of glycemic control. Recently, biosimilar insulins have revolutionized the management of T2DM and look promising from the economic point of view. CONCLUSIONS Biosimilar insulins are likely to further enhance the compliance of patients and should be used whenever feasible in patients with DM. However, the patient, along with prescriber should be allowed to make shared, informed decisions regarding the insulin they wish to use.
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Affiliation(s)
- Abdul Hamid Zargar
- Centre for Diabetes and Endocrine Care, Gulshan Nagar, Chanpora, Srinagar, 190015, Jammu and Kashmir, India.
| | - Sanjay Kalra
- Bharati Hospital, Karnal, 132001, Haryana, India.
| | - Prasanna Kumar K M
- Centre for Diabetes & Endocrine Care & Diabetacare, Kalyan Nagar Post, Bangalore, 560043, Karnataka, India.
| | - Sreenivasa Murthy
- Lifecare Hospital and Research Centre, Sahakaranagara, Bangalore, 560092, Karnataka, India.
| | - Vijay Negalur
- Dr Negalur's Diabetes & Thyroid Specialty Centre, Gloria Chambers, Thane, 400603, Maharashtra, India.
| | - Rajesh Rajput
- Department of Endocrinology, PGIMS Rohtak, Rohtak, 124001, Haryana, India.
| | - Ashu Rastogi
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
| | - Banshi Saboo
- Dia Care (Diabetes Care & Hormone Clinic), Department of Diabetology, Near Nehru Nagar Circle, Ahmedabad, Gujrat, India.
| | | | - Rakesh Sahay
- Department of Endocrinology, Osmania Medical College, Hyderabad, 500095, Telangana, India.
| | - S R Aravind
- Diacon Hospital, Rajajinagar, Bangalore, 560019, Karnataka, India.
| | - Shehla Shaikh
- K.G.N. Clinic, Patel Arcade, Nagpada Junction, Mumbai, 400008, Maharashtra, India.
| | - Mangesh Tiwaskar
- Department of Medicine, Shilpa Medical Research Centre, Dahisar East, Mumbai, 400068, Maharashtra, India.
| | - Shahu Ingole
- Department of Medical Affairs, Wockhardt Towers Bandra Kurla Complex, Bandra (East), Mumbai, 400051, Maharashtra, India.
| | - Sanjay Kamble
- Department of Medical Affairs, Wockhardt Towers Bandra Kurla Complex, Bandra (East), Mumbai, 400051, Maharashtra, India.
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Association Between High Deductible Health Plans and Cost-Related Non-adherence to Medications Among Americans with Diabetes: an Observational Study. J Gen Intern Med 2022; 37:1910-1916. [PMID: 34324130 PMCID: PMC9198142 DOI: 10.1007/s11606-021-06937-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/17/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND For people with diabetes, adherence to prescribed medications is essential. However, the rising prevalence of high-deductible health plans (HDHPs), and prices of diabetes medications such as insulin, could deter adherence. OBJECTIVE To assess the impact of HDHP on cost-related medication non-adherence (CRN) among non-elderly adults with diabetes in the US. DESIGN Repeated cross-sectional survey. SETTING National Health Interview Survey, 2011-2018. PARTICIPANTS A total of 7469 privately insured adults ages 18-64 with diabetes who were prescribed medications and enrolled in a HDHP or a traditional commercial health plan (TCP). MAIN MEASURES Self-reported measures of CRN were compared between enrollees in HDHPs and TCPs overall and among the subset using insulin. Analyses were adjusted for demographic and clinical characteristics using multivariable linear regression models. KEY RESULTS HDHP enrollees were more likely than TCP enrollees to not fill a prescription (13.4% vs 9.9%; adjusted percentage point difference (AD) 3.4 [95% CI 1.5 to 5.4]); skip medication doses (11.4% vs 8.5%; AD 2.8 [CI 1.0 to 4.7]); take less medication (11.1% vs 8.8%; AD 2.3 [CI 0.5 to 4.0]); delay filling a prescription to save money (14.4% vs 10.8%; AD 3.0 [CI 1.1 to 4.9]); and to have any form of CRN (20.4% vs 15.5%; AD 4.4 [CI 2.2 to 6.7]). Among those taking insulin, HDHP enrollees were more likely to have any CRN (25.1% vs 18.9%; AD 5.9 [CI 1.1 to 10.8]). CONCLUSION HDHPs are associated with greater CRN among people with diabetes, particularly those prescribed insulin. For people with diabetes, enrollment in non-HDHPs might reduce CRN to prescribed medications.
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15
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Wu YM, Huang J, Reed ME. Association Between High-Deductible Health Plans and Engagement in Routine Medical Care for Type 2 Diabetes in a Privately Insured Population: A Propensity Score-Matched Study. Diabetes Care 2022; 45:1193-1200. [PMID: 35290445 PMCID: PMC9375446 DOI: 10.2337/dc21-1885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 02/14/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE High-deductible health plans (HDHPs) are increasingly more common but can be challenging for patients to navigate and may negatively affect care engagement for chronic conditions such as type 2 diabetes. We sought to understand how higher out-of-pocket costs affect participation in provider visits, medication adherence, and routine monitoring by patients with type 2 diabetes with an HDHP. RESEARCH DESIGN AND METHODS In a retrospective cohort of 19,379 Kaiser Permanente Northern California patients with type 2 diabetes (age 18-64 years), 6,801 patients with an HDHP were compared with those with a no-deductible plan using propensity score matching. We evaluated the number of telephone and office visits with primary care, oral diabetic medication adherence, and rates of HbA1c testing, blood pressure monitoring, and retinopathy screening. RESULTS Patients with an HDHP had fewer primary care office visits compared with patients with no deductible (4.25 vs. 4.85 visits per person; P < 0.001), less retinopathy screening (49.9% vs. 53.3%; P < 0.001), and fewer A1c and blood pressure measurements (46.7% vs. 51.4%; P < 0.001 and 93.2% vs. 94.4%; P = 0.004, respectively) compared with the control group. Medication adherence was not significantly different between patients with an HDHP and those with no deductible (57.4% vs. 58.6%; P = 0.234). CONCLUSIONS HDHPs seem to be a barrier for patients with type 2 diabetes and reduce care participation in both visits with out-of-pocket costs and preventive care without out-of-pocket costs, possibly because of the increased complexity of cost sharing under an HDHP, potentially leading to decreased monitoring of important clinical measurements.
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Affiliation(s)
- You M Wu
- Department of Adult and Family Medicine, Kaiser Permanente, Santa Clara, CA
| | - Jie Huang
- Kaiser Permanente Division of Research, Oakland, CA
| | - Mary E Reed
- Kaiser Permanente Division of Research, Oakland, CA
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16
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Walsh BS, Kesselheim AS, Sarpatwari A, Rome BN. Indication-Specific Generic Uptake of Imatinib Demonstrates the Impact of Skinny Labeling. J Clin Oncol 2022; 40:1102-1110. [PMID: 35015587 DOI: 10.1200/jco.21.02139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Generic competition can be delayed if brand-name manufacturers obtain additional patents on supplemental uses. The US Food and Drug Administration allows generic drug manufacturers to market versions with skinny labels that exclude patent-protected indications. This study assessed whether use of generic versions of imatinib varied between indications included and excluded from the skinny labels. METHODS In this cross-sectional study, we identified adult patients covered by commercial insurance or Medicare Advantage plans who initiated imatinib from February 2016 (first generic availability) to September 2020. Generic versions were introduced with skinny labels that included indications covering treatment of chronic myelogenous leukemia (CML) but excluded treatment of gastrointestinal stromal tumors (GISTs) because of remaining patent protections. Logistic regression was used to determine whether use of generic versus brand-name imatinib differed between patients with a diagnosis of CML or GIST, adjusting for demographics, insurance type, prior use of brand-name drugs, and calendar month. RESULTS Among 2,000 initiators, 934 (47%) had CML and 686 (34%) had GIST. Within 3 years after generics entered the market, more than 90% of initiators in both groups used generic imatinib. Initiation of generic imatinib was slightly lower among patients with GIST than among patients with CML (85% v 88%; adjusted odds ratio 0.56; 95% CI, 0.39 to 0.80; P ≤ .001). CONCLUSION Generic versions of imatinib were dispensed frequently for indications both included (CML) and excluded (GIST) from the skinny labeling, although patients with GIST were slightly less likely to receive a generic version. The skinny labeling pathway allowed generics to enter the market before patent protection for treating patients with GIST expired, facilitating lower drug prices.
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Affiliation(s)
- Bryan S Walsh
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Aaron S Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ameet Sarpatwari
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Benjamin N Rome
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Ferraro RA, Leucker T, Martin SS, Banach M, Jones SR, Toth PP. Contemporary Management of Dyslipidemia. Drugs 2022; 82:559-576. [PMID: 35303294 PMCID: PMC8931779 DOI: 10.1007/s40265-022-01691-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 12/30/2022]
Abstract
The treatment of dyslipidemia continues to be a dynamic and controversial topic. Even the most appropriate therapeutic range for lipid levels-including that of triglycerides and low-density lipoprotein cholesterol-remain actively debated. Furthermore, with ever-increasing options and available treatment modalities, the management of dyslipidemia has progressed in both depth and complexity. An understanding of appropriate lipid-lowering therapy remains an essential topic of review for practitioners across medical specialties. The goal of this review is to provide an overview of recent research developments and recommendations for patients with dyslipidemia as a means of better informing the clinical practice of lipid management. By utilizing a guideline-directed approach, we provide a reference point on optimal lipid-lowering therapies across the spectrum of dyslipidemia. Special attention is paid to long-term adherence to lipid-lowering therapies, and the benefits derived from instituting appropriate medications in a structured manner alongside monitoring. Novel therapies and their impact on lipid lowering are discussed in detail, as well as potential avenues for research going forward. The prevention of cardiovascular disease remains paramount, and this review provides a roadmap for instituting appropriate therapies in cardiovascular disease prevention.
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Affiliation(s)
- Richard A Ferraro
- From the Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thorsten Leucker
- From the Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Seth S Martin
- From the Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz, Lodz, Poland
| | - Steven R Jones
- From the Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter P Toth
- From the Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- CGH Medical Center, 101 East Miller Road, Sterling, IL, 61081, USA.
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Yaguchi Y, Fujihara K, Yamada MH, Matsubayashi Y, Yamada T, Iwanaga M, Kitazawa M, Yamamoto M, Seida H, Kodama S, Sone H. Impact of Medication Adherence and Glycemic Control on the Risk of Micro- and Macrovascular Diseases in Patients with Diabetes. Am J Med 2022; 135:461-470.e1. [PMID: 34798099 DOI: 10.1016/j.amjmed.2021.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/18/2021] [Accepted: 10/11/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Our purpose in the research was to clarify the impact of medication adherence to oral hypoglycemic agents during a 1-year period and subsequent glycemic control on the risk of micro- and macrovascular diseases. METHODS Examined was a nationwide claims database on 13,256 individuals with diabetic eye disease without requiring prior treatment, 7,862 without prior initiation of dialysis, 15,556 without prior coronary artery disease, 16,243 without prior cerebrovascular disease, and 19,386 without prior heart failure from 2008 to 2016 in Japan. Medication adherence was evaluated by the proportion of days covered. Patients were considered to have poor adherence if the proportion of days covered was <80%. Multivariate Cox regression model identified risks of micro- and macrovascular diseases. RESULTS In each group, mean age was 53 to 54 years, HbA1c was 7.1% to 7.2%, and median follow-up period was 4.6 to 5.1 years, and the percentage of poor adherence was approximately 30%. During the study period, 532 treatment-requiring diabetic eye disease, 75 dialysis, 389 coronary artery disease, 316 cerebrovascular disease, and 144 heart failure events occurred. Multivariate Cox regression model revealed that the hazard ratio (95% confidence interval) of dialysis in the poor adherence group was 2.04 (1.27-3.30) compared with the good adherence group. The hazard ratios in the poor adherence/poor glycemic control group were 3.34 (2.63-4.24) for treatment-requiring diabetic eye disease, 4.23 (2.17-8.26) for dialysis, 1.69 (1.23-2.31) for coronary artery disease, and 2.08 (1.25-3.48) for heart failure compared with the good adherence/good glycemic control group. CONCLUSIONS Poor medication adherence was an independent risk factor for the initiation of dialysis, suggesting that clinicians must pay close attention to these patients.
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Affiliation(s)
- Yuta Yaguchi
- Department of Internal Medicine, Niigata University Faculty of Medicine, Niigata, Japan
| | - Kazuya Fujihara
- Department of Internal Medicine, Niigata University Faculty of Medicine, Niigata, Japan.
| | - Mayuko Harada Yamada
- Department of Internal Medicine, Niigata University Faculty of Medicine, Niigata, Japan
| | - Yasuhiro Matsubayashi
- Department of Internal Medicine, Niigata University Faculty of Medicine, Niigata, Japan
| | - Takaho Yamada
- Department of Internal Medicine, Niigata University Faculty of Medicine, Niigata, Japan
| | - Midori Iwanaga
- Department of Internal Medicine, Niigata University Faculty of Medicine, Niigata, Japan
| | - Masaru Kitazawa
- Department of Internal Medicine, Niigata University Faculty of Medicine, Niigata, Japan
| | - Masahiko Yamamoto
- Department of Internal Medicine, Niigata University Faculty of Medicine, Niigata, Japan
| | | | - Satoru Kodama
- Department of Internal Medicine, Niigata University Faculty of Medicine, Niigata, Japan
| | - Hirohito Sone
- Department of Internal Medicine, Niigata University Faculty of Medicine, Niigata, Japan
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Yeung K, Ulloa E. Incentivizing Prescription Drug Switching to Reduce Patient and Health Plan Spending: A Microsimulation Model. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:427-434. [PMID: 35227455 DOI: 10.1016/j.jval.2021.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/16/2021] [Accepted: 08/18/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Most spending for prescription drugs is on branded drugs that do not have direct generic equivalents but many of these drugs do have therapeutic alternatives within class. We estimate the potential savings from providing patients a financial incentive to switch from a higher cost drug to a lower cost, therapeutic alternative drug. METHODS We used individual state-transition microsimulations to model medication use and spending with and without financial incentives over a 12-month time horizon with a healthcare sector perspective. Costs and utilization inputs were from individuals on branded insulins or multiple sclerosis drugs enrolled in a regional mixed-model health maintenance organization. Base-case model used a one-time financial incentive of $83 and $250 offered to patients on higher cost insulin and multiple sclerosis treatments, respectively, to switch to lower cost drugs within class. RESULTS Savings per individual offered an incentive in the insulin and multiple sclerosis classes were, respectively, $84 (95% CI $46-$122) and $2,127 (95% CI $267-$3,987). Varying the incentive size and switch probability resulted in maximum savings of $712 at elasticity of 0.2 and incentive size $250 for the insulin drug class. For the multiple sclerosis drug class, maximum savings of $5945 was at elasticity of 0.2 and incentive size of $1000. Short time horizon makes our savings estimates conservative. CONCLUSIONS If programs such as financial incentives could encourage even a small proportion of patients to switch among drugs within therapeutic class, then substantial savings could be generated.
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Affiliation(s)
- Kai Yeung
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA; The Comparative Health Outcomes, Policy, and Economics Institute, University of Washington, Seattle, WA, USA; Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA.
| | - Ernesto Ulloa
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA; Department of Biostatistics, University of Washington, Seattle, WA, USA
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Initiating second-line antidiabetic medication among older adults with type 2 diabetes on Metformin. BMC Geriatr 2022; 22:97. [PMID: 35114955 PMCID: PMC8815155 DOI: 10.1186/s12877-022-02792-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 01/24/2022] [Indexed: 11/12/2022] Open
Abstract
Background Antidiabetic medications (ADM), especially sulfonylureas (SFU) and basal insulin (BI), are associated with increased risk of hypoglycemia, which is especially concerning among older adults in poor health. The objective of this study was to investigate prescribing patterns of ADM in older adults according to their health status. Methods This case control study analyzed administrative claims between 2013 and 2017 from a large national payer. The study population was derived from a nationwide database of 84,720 U.S. adults aged ≥65, who were enrolled in Medicare Advantage health insurance plans. Participants had type 2 diabetes on metformin monotherapy, and started a second-line ADM during the study period. The exposure was a binary variable for health status, with poor health defined by end-stage medical conditions, dementia, or residence in a long-term nursing facility. The outcome was a variable identifying which second-line ADM class was started, categorized as SFU, BI, or other (i.e. all other ADM classes combined). Results Over half of participants (54%) received SFU as initial second-line ADM, 14% received BI, and 32% received another ADM. In multivariable models, the odds of filling SFU or BI was higher for participants in poor health than those in good or intermediate health [OR 1.13 (95% CI 1.05-1.21) and OR 2.34 (95% CI 2.14-2.55), respectively]. SFU and BI were also more commonly filled by older adults with poor glycemic control. Conclusions Despite clinical consensus to use caution prescribing SFU and BI among older adults in poor health, these medications remain frequently used in this particularly vulnerable population.
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Association Between Cost-Saving Prescription Policy Changes and Adherence to Chronic Disease Medications: an Observational Study. J Gen Intern Med 2022; 37:531-538. [PMID: 34331213 PMCID: PMC8858373 DOI: 10.1007/s11606-021-07031-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 07/09/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Pharmacy benefit design is one tool for improving access and adherence to medications for the management of chronic disease. OBJECTIVE We assessed the effects of pharmacy benefit design programs, including a change in pharmacy benefit manager (PBM), institution of a prescription out-of-pocket maximum, and a mandated switch to 90 days' medication supply, on adherence to chronic disease medications over time. DESIGN We used a difference-in-differences design to assess changes in adherence to chronic disease medications after the transition to new prescription policies. SUBJECTS We utilized claims data from adults aged 18-64, on ≥ 1 medication for chronic disease, whose insurer instituted the prescription policies (intervention group) and a propensity score-matched comparison group from the same region. MAIN MEASURES The outcome of interest was adherence to chronic disease medications measured by proportion of days covered (PDC) using pharmacy claims. KEY RESULTS There were 13,798 individuals in each group after propensity score matching. Compared to the matched control group, adherence in the intervention group decreased in the first quarter of 2015 and then increased back to pre-intervention trends. Specifically, the change in adherence compared to the last quarter of 2014 in the intervention group versus controls was - 3.6 percentage points (pp) in 2015 Q1 (p < 0.001), 0.65 pp in Q2 (p = 0.024), 1.1 pp in Q3 (p < 0.001), and 1.4 pp in Q4 (p < 0.001). CONCLUSIONS In this cohort of commercially insured adults on medications for chronic disease, a change in PBM accompanied by a prescription out-of-pocket maximum and change to 90 days' supply was associated with short-term disruptions in adherence followed by return to pre-intervention trends. A small improvement in adherence over the year of follow-up may not be clinically significant. These findings have important implications for employers, insurers, or health systems wishing to utilize pharmacy benefit design to improve management of chronic disease.
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Ihm SH, Kim KI, Lee KJ, Won JW, Na JO, Rha SW, Kim HL, Kim SH, Shin J. Interventions for Adherence Improvement in the Primary Prevention of Cardiovascular Diseases: Expert Consensus Statement. Korean Circ J 2022; 52:1-33. [PMID: 34989192 PMCID: PMC8738714 DOI: 10.4070/kcj.2021.0226] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/05/2021] [Accepted: 11/10/2021] [Indexed: 01/01/2023] Open
Abstract
Over the last 2 decades, the management of chronic disease in Korea has been improved, but it has gradually stagnated. In order to improve care and reduce cardiovascular morbidity and mortality, it is crucial to improve primary prevention of cardiovascular diseases. In recent international guidelines for hypertension, diabetes, hyperlipidemia, obesity, and other conditions, adherence issues have become more frequently addressed. However, in terms of implementation in practice, separate approaches by dozens of related academic specialties need to be integrated into a systematic approach including clinician’s perspectives such as the science behind adherence, clinical skills, and interaction within team approach. In primary prevention for cardiovascular diseases, there are significant barriers to adherence including freedom from symptoms, long latency for therapeutic benefits, life-long duration of treatment, and need for combined lifestyle changes. However, to implement more systematic approaches, the focus on adherence improvement needs to be shifted away from patient factors to the effects of the treatment team and healthcare system. In addition to conventional educational approaches, more patient-oriented approaches such as patient-centered clinical communication skills, counseling using motivational strategies, decision-making by patient empowerment, and a multi-disciplinary team approach should be developed and implemented. Patients should be involved in a program of self-monitoring, self-management, and active counseling. Because most effective interventions on adherence improvement demand greater resources, the health care system and educational or training system of physicians and healthcare staff need to be supported for systematic improvement.
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Affiliation(s)
- Sang Hyun Ihm
- Division of Cardiology, Department of Internal Medicine and Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kwang-Il Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | | | | | - Jin Oh Na
- Cardiovascular Center, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Seung-Woon Rha
- Cardiovascular Center, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Hack-Lyoung Kim
- Division of Cardiology, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-Hyun Kim
- Division of Cardiology, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Jinho Shin
- Division of Cardiology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea.
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Lester M, Eidson D, Blair S, Gray S, Sapp P, Zupancic FJ, Marshall BC, Berlinski A. Cystic Fibrosis Foundation Nebulizer and Compressor Accessibility Survey. Respir Care 2021; 66:1840-1847. [PMID: 34610985 PMCID: PMC9993784 DOI: 10.4187/respcare.09197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Although guidelines for inhaled therapies for individuals with cystic fibrosis (CF) are available, recommendations for compressors/nebulizers to optimize care are lacking. The CF Foundation (CFF) convened a multidisciplinary task force to assess the use, durability, accessibility, and cost burden of compressors/nebulizers. METHODS Online surveys were developed and distributed to 287 CFF programs and adults with CF and parents of children with CF (adults with CF/parents). RESULTS Health care providers from 38 states completed the survey (59% response rate). Respiratory therapists were mostly responsible to coordinate ordering nebulizers and compressors. Durable medical equipment companies were the most common source of acquisition of compressors (71.8%) and nebulizers (45.9%). A majority of health care providers did not feel the compressors were durable (51.1%) or that they could get enough nebulizers to their patients (69.2%). Barriers to procure compressors were reported. The survey was completed by 734 adults with CF/parents from 48 states. Most adults with CF/parents rated their compressor as durable (65.8%); however, 85.5% of respondents reported some user-experience problem(s). "Hoses popping off" and "increased nebulization time" were most commonly reported. Almost 20% of respondents did not have access to a compressor at some point in the previous year. Most adults with CF/parents did not change compressor filters per manufacturer's recommendation (40% never). Adults with CF/parents reported performing a median of 4 inhaled treatments per day. Median use of nebulizers was 6 months. Most adults with CF/parents thought they had enough nebulizers (53.7%). Individuals with CF doing more inhaled treatments reported more compressor malfunctions. The median out-of-pocket expense was $75-99 and $50-74 for compressors and nebulizers, respectively. CONCLUSIONS Although the perceptions of health care providers and adults with CF/parents differed to a certain extent, the surveys uncovered several significant issues that may compromise quality of care. Improvement in access to devices and education are needed.
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Affiliation(s)
- Mary Lester
- Keck Medicine of USC, Keck School of Medicine of USC, Los Angeles, California
| | - Dabney Eidson
- Children's Hospital of Georgia, Augusta University Medical Center, Augusta, Georgia
| | - Shaina Blair
- Children's Healthcare of Atlanta, Emory Healthcare, Atlanta, Georgia
| | - Sue Gray
- Medical University of South Carolina, Charleston, South Carolina
| | - Pamela Sapp
- Cystic Fibrosis Foundation, Bethesda, Maryland
| | | | | | - Ariel Berlinski
- University of Arkansas for Medical Sciences, Little Rock, Arkansas; Arkansas Children's Hospital, Little Rock, Arkansas; and Pediatric Aerosol Research Laboratory, Arkansas Children's Research Institute, Little Rock, Arkansas.
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Hougen I, Whitlock RH, Komenda P, Rigatto C, Clemens KK, Tangri N. Safety of add-on sulfonylurea therapy in patients with type 2 diabetes using metformin: a population-based real-world study. BMJ Open Diabetes Res Care 2021; 9:9/2/e002352. [PMID: 34969692 PMCID: PMC8718392 DOI: 10.1136/bmjdrc-2021-002352] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 11/26/2021] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Metformin is the initial oral antihyperglycemic agent (OHA) of choice for most patients with type 2 diabetes (T2D). However, more than one agent is often required for optimal glucose control. As the choice of preferred second OHAs is less well defined, we sought to compare the real-world safety of sulfonylureas to other OHAs as add-on therapy to metformin in patients with T2D. RESEARCH DESIGN AND METHODS This retrospective cohort study included adults in Manitoba, Canada with T2D from 2006 to 2017. Using a new-user design, we divided patients who started on metformin into two groups: add-on therapy with a sulfonylurea and add-on therapy with a different OHA. Outcomes included all-cause mortality, cardiovascular events, and major hypoglycemic episodes. We calculated propensity scores and applied inverse probability of treatment weights to each individual. We compared groups using Cox proportional hazards regression and explored differences in HRs between pre-2008 (acarbose, meglitinides, and thiazolidinediones) and post-2008 (dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists, and sodium-glucose linked transporter-2 inhibitors) OHAs. RESULTS Our cohort included 32 576 individuals (28 077 metformin plus sulfonylurea and 4499 metformin plus 'other'). Patients newly prescribed a sulfonylurea in the setting of metformin had a higher risk of all-cause mortality (HR 1.44, 95% CI 1.12 to 1.84, p=0.005) and major hypoglycemic episodes (HR 2.78, 95% CI 1.66 to 4.66, p<0.001) than those prescribed an 'other' OHA. No differences in cardiovascular events were observed (HR 0.99, 95% CI 0.81 to 1.22, p=0.92). In subgroup analyses, mortality and cardiovascular event risk was higher in patients prescribed sulfonylureas versus post-2008 OHAs. CONCLUSIONS Sulfonylureas as add-on therapy to metformin are associated with increased risk of all-cause mortality and major hypoglycemic episodes compared with 'other' OHAs. Post hoc analysis suggests newer OHAs may be preferred to sulfonylureas as second-line therapy for glycemic control.
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Affiliation(s)
- Ingrid Hougen
- Department of Internal Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Reid H Whitlock
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Paul Komenda
- Department of Internal Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Claudio Rigatto
- Department of Internal Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Kristin K Clemens
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
| | - Navdeep Tangri
- Department of Internal Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
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Wang Y, Park J, Li R, Luman E, Zhang P. National Trends in Out-of-Pocket Costs Among U.S. Adults With Diabetes Aged 18-64 Years: 2001-2017. Diabetes Care 2021; 44:2510-2517. [PMID: 34429323 PMCID: PMC9578147 DOI: 10.2337/dc20-2833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 08/01/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess national trends in out-of-pocket (OOP) costs among adults aged 18-64 years with diabetes in the U.S. RESEARCH DESIGN AND METHODS Using data from the 2001-2017 Medical Expenditure Panel Survey, we estimated total per person annual OOP costs (insurance premiums, prescription drug costs, inpatient and outpatient deductibles, copays, and other payments not covered by insurance) and high OOP cost rate, defined as the percentage of people with OOP spending >10% of their family's pretax income. We examined trends overall, by subgroup (insurance type, income level, insulin use, size of patient's employer, and whether the patient was enrolled in a high deductible health plan), and by type of service. Changes in trends were identified using joinpoint analysis; costs were adjusted to 2017 U.S. dollars. RESULTS From 2001 to 2017, OOP costs decreased 4.3%, from $4,328 to $4,139, and the high OOP cost rate fell 32%, from 28 to 19% (P < 0.001). Changes in the high OOP cost rate varied by subgroup, declining among those with public or no insurance and those with an income <200% of the federal poverty level (P < 0.001) but remaining stable among those with private insurance and higher income. Drug prescription OOP costs decreased among all subgroups (P < 0.001). Decreases in total (-$58 vs. -$37, P < 0.001) and prescription (-$79 vs. -$68, P < 0.001) OOP costs were higher among insulin users than noninsulin users. CONCLUSIONS OOP costs among U.S. nonelderly adults with diabetes declined, especially among those least able to afford them. Future studies may explore factors contributing to the decline in OOP costs and the impact on the quality of diabetes care and complication rates.
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Affiliation(s)
- Yu Wang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Joohyun Park
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Rui Li
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Elizabeth Luman
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ping Zhang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
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Alpern JD, Vazquez‐Benitez G, DeFor TA, Stauffer WM, Shahriar AA, Kodet AJ, Pawloski PA, Dehmer SP. Population characteristics, use, and spending on sole‐source, off‐patent drugs among commercial insurance members in the United States—An analysis of outpatient claims data at a single health plan. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Jonathan D. Alpern
- HealthPartners Institute Bloomington Minnesota USA
- Department of Medicine University of Minnesota Minneapolis Minnesota USA
| | | | | | | | | | - Amy J. Kodet
- HealthPartners Institute Bloomington Minnesota USA
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Weeda ER, Muraoka AK, Brock MD, Cannon JM. Medication adherence to injectable glucagon-like peptide-1 (GLP-1) receptor agonists dosed once weekly vs once daily in patients with type 2 diabetes: A meta-analysis. Int J Clin Pract 2021; 75:e14060. [PMID: 33527605 DOI: 10.1111/ijcp.14060] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/23/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Suboptimal medication adherence has been associated with increased resource utilisation and mortality among patients with type 2 diabetes (T2D). Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are becoming increasingly important in the treatment of T2D. However, medications in this class differ considerably in their dosing frequency, which may impact adherence. We sought to perform a meta-analysis to compare adherence to injectable GLP-1RAs dosed once weekly vs once daily in patients with T2D. METHODS Medline and Scopus were searched from 1/2005 to 7/2020 using keywords and MeSH terms pertaining to adherence and GLP-1RAs. Studies of adults with T2D were included if they compared adherence (as measured by proportion of days covered [PDC]) to injectable GLP-1RAs dosed once weekly vs once daily. A meta-analysis of non-overlapping studies was performed to evaluate the primary outcome of non-adherence, defined as the proportion of patients with a PDC < 80. RESULTS A total of 7 studies evaluating 75 159 patients (range: 2886-30 097) with T2D were included. The follow-up periods of included studies ranged from 6 to 12 months. Injectable GLP-1RAs dosed once weekly were either dulaglutide, albiglutide or exenatide extended release; while liraglutide was the injectable once daily agent evaluated in all included studies. Upon meta-analysis, once weekly GLP-1RA dosing was associated with an 11% lower risk of non-adherence compared to once daily dosing (risk ratio = 0.89; 95% confidence interval = 0.83-0.95; I2 = 89%). CONCLUSION Once weekly dosing of injectable GLP-1RAs was associated with better adherence vs once daily dosing among patients with T2D. These findings coupled with the known detrimental consequences of non-adherence suggest that dosing frequency is an important factor to consider when selecting a GLP-1RA.
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Affiliation(s)
- Erin R Weeda
- Medical University of South Carolina College of Pharmacy, Charleston, SC, USA
| | - Alyssa K Muraoka
- Medical University of South Carolina College of Pharmacy, Charleston, SC, USA
| | - Matthew D Brock
- Medical University of South Carolina College of Pharmacy, Charleston, SC, USA
| | - Jessica M Cannon
- Medical University of South Carolina College of Pharmacy, Charleston, SC, USA
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Nelson DR, Heaton P, Hincapie A, Ghodke S, Chen J. Differential Cost-Sharing Undermines Treatment Adherence to Combination Therapy: Evidence from Diabetes Treatment. Diabetes Ther 2021; 12:2149-2164. [PMID: 34212316 PMCID: PMC8342747 DOI: 10.1007/s13300-021-01098-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/10/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION The objective of this study was to measure the influence of differences in out-of-pocket (OOP) costs for type 2 diabetes (T2D) medications on within-patient adherence behavior towards combination drug therapy regimens. METHODS This was an observational, retrospective, paired sample study in patients with T2D using longitudinal pharmacy data from the 2009-2014 Medical Expenditure Panel Survey (MEPS) augmented with socio-demographic factors. We took a within-patient approach to minimize confounding effects by including patients who maintained the same number of diabetes drug classes over 2 years of MEPS. For each patient, we selected the most and least costly drug classes in the second year and examined their corresponding adherence behavior measured by medication possession ratio. The primary hypothesis tested the significance of the correlation between magnitude of the OOP cost difference and behavioral response in adherence. RESULTS Analysis included 1189 patients representing over 4.2 million US residents with T2D. A significant negative correlation (p < 0.001) was observed between the differences of OOP costs and adherence to the most and least costly medications compared within patients. Reduction in adherence to the most costly medication was generally observed when the difference in OOP costs was greater than $33/month. A greater variability in adherence was observed when the cost difference exceeded $2.39/month as compared to other cost difference ranges (p < 0.001), indicative of choices being made. CONCLUSIONS As OOP costs increased, adherence variability increased initially until a cost threshold, beyond which the adherence to the more costly medication decreased. In addition to OOP cost, adherence was also influenced by type of medication and self-perception of health. Given the complex correlation between OOP costs and adherence to medication, we suggest a careful approach to cost-sharing in the current insurance drug design and relevant insurance policies.
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Affiliation(s)
- David R Nelson
- Lilly Corporate Center, Eli Lilly and Company, Indianapolis, IN, 46285, USA.
| | - Pamela Heaton
- James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, USA
| | - Ana Hincapie
- James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, USA
| | - Shirin Ghodke
- Eli Lilly Services India Private Limited, Bengaluru, Karnataka, India
| | - Jieling Chen
- Lilly Corporate Center, Eli Lilly and Company, Indianapolis, IN, 46285, USA
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Everett EM, Copeland TP, Moin T, Wisk LE. National Trends in Pediatric Admissions for Diabetic Ketoacidosis, 2006-2016. J Clin Endocrinol Metab 2021; 106:2343-2354. [PMID: 33942077 PMCID: PMC8277205 DOI: 10.1210/clinem/dgab287] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVES Diabetic ketoacidosis (DKA) rates in the United States are rising. Prior studies suggest higher rates in younger populations, but no studies have evaluated national trends in pediatric populations and differences by subgroups. As such, we sought to examine national trends in pediatric DKA. METHODS We used the 2006, 2009, 2012, and 2016 Kids' Inpatient Database to identify pediatric DKA admissions among a nationally representative sample of admissions of youth ≤20 years old. We estimate DKA admission per 10 000 admissions and per 10 000 population, charges, length of stay (LOS), and trends over time among all hospitalizations and by demographic subgroups. Regression models were used to evaluate differences in DKA rates within subgroups overtime. RESULTS Between 2006 and 2016, there were 149 535 admissions for DKA. Unadjusted DKA rate per admission increased from 120.5 (95% CI, 115.9-125.2) in 2006 to 217.7 (95% CI, 208.3-227.5) in 2016. The mean charge per admission increased from $14 548 (95% CI, $13 971-$15 125) in 2006 to $20 997 (95% CI, $19 973-$22 022) in 2016, whereas mean LOS decreased from 2.51 (95% CI, 2.45-2.57) to 2.28 (95% CI, 2.23-2.33) days. Higher DKA rates occurred among 18- to 20-year-old females, Black youth, without private insurance, with lower incomes, and from nonurban areas. Young adults, men, those without private insurance, and from nonurban areas had greater increases in DKA rates across time. CONCLUSIONS Pediatric DKA admissions have risen by 40% in the United States and vulnerable subgroups remain at highest risk. Further studies should characterize the challenges experienced by these groups to inform interventions to mitigate their DKA risk and to address the rising DKA rates nationally.
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Affiliation(s)
- Estelle M Everett
- Division of Endocrinology, Diabetes, & Metabolism, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Correspondence: Estelle Everett, MD, MHS, David Geffen School of Medicine, University of California, Los Angeles, 1100 Glendon Ste 850, Los Angeles, CA 90024, United States.
| | - Timothy P Copeland
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, California, USA
| | - Tannaz Moin
- Division of Endocrinology, Diabetes, & Metabolism, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Lauren E Wisk
- Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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The impact of a co-payment increase on the consumption of type 2 antidiabetics - A nationwide interrupted time series analysis. Health Policy 2021; 125:1166-1172. [PMID: 34078544 DOI: 10.1016/j.healthpol.2021.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 11/21/2020] [Accepted: 05/15/2021] [Indexed: 11/21/2022]
Abstract
International literature suggests that co-payment increases are associated with decreased medicine use, although the effects depend on context. We examined the impact of a co-payment increase on the consumption of type 2 antidiabetics in Finland, a country with a comprehensive health and social security system including ceiling mechanisms aiming to protect patients from high co-payment expenditures. We used administrative register data on all reimbursed purchases of antidiabetics during 2014-2018. An interrupted time series design with segmented regression was used to examine the mean monthly purchase per person, measured as Defined Daily Doses (DDDs), before and after the co-payment increase. At baseline, the mean monthly purchase per person of type 2 antidiabetics was 105 DDDs (95% CI 103.8; 106.0;p<0.001) and there was a decreasing trend of 0.2 DDDs per month (95% CI -0.23;-0.13;p<0.001). A statistically significant decrease of 5.6 DDDs (95% CI -7.3;-3.8;p<0.001) was detected after the reform; however, no significant change in the trend was observed. No significant increase was detected in the mean monthly per person purchase of insulins. The results suggest that a co-payment increase decreases consumption of necessary medicines despite the presence of a medicine co-payment ceiling mechanism. Whether the decrease was associated with negative health effects remains to be further investigated.
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Rome BN, Feldman WB, Desai RJ, Kesselheim AS. Correlation Between Changes in Brand-Name Drug Prices and Patient Out-of-Pocket Costs. JAMA Netw Open 2021; 4:e218816. [PMID: 33944925 PMCID: PMC8097497 DOI: 10.1001/jamanetworkopen.2021.8816] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE List prices set by manufacturers for brand-name prescription drugs in the US have been increasing faster than inflation, although confidential manufacturer rebates offset some of these increases. Most commercially insured patients pay at least some out-of-pocket costs for prescription drugs, and higher patient spending is associated with lower adherence and worse health outcomes. OBJECTIVE To examine whether price changes for brand-name drugs are correlated with changes in patient out-of-pocket spending and whether this association varies by insurance benefit design. DESIGN, SETTING, AND PARTICIPANTS A cohort study of 79 brand-name drugs with available pricing data from January 2015 to December 2017 was conducted, with data obtained from a national commercial insurance claims database. EXPOSURES Change in the list prices set by manufacturers and estimated net prices after rebates among non-Medicaid payers. MAIN OUTCOMES AND MEASURES Change in median out-of-pocket spending among all patients and stratified by insurance pharmacy benefit design, including high-deductible insurance plans and plans with any amount of deductibles or coinsurance. RESULTS Among 79 drugs, median increases were 16.7% (interquartile range [IQR], 13.6%-21.1%) for list prices, 5.4% (IQR, -3.9% to 11.7%) for net prices, and 3.5% (IQR, 1.4%-9.1%) for out-of-pocket spending from 2015 to 2017. Changes in list prices were correlated with changes in net prices (r = 0.34; P = .002). Overall, changes in out-of-pocket spending were not correlated with changes in list prices (r = 0.14; P = .22) or net prices (r = 0.04; P = .71). Among 53.7% of patients who paid any drug deductible or coinsurance, median out-of-pocket spending increased by 15.0%, and changes were moderately correlated with changes in list prices (r = 0.38; P = .001) but not net prices (r = 0.06; P = .62). CONCLUSIONS AND RELEVANCE Some commercially insured patients who pay only prescription drug copayments appear to be insulated from increases in drug prices. However, more than half of patients pay deductibles or coinsurance and may experience substantial increases in out-of-pocket spending when drug prices increase. Among these patients, there was no evidence that manufacturer rebates to insurers are associated with patients' out-of-pocket spending. Policies to rein in unregulated annual increases in list prices for brand-name drugs may have important consequences for patient out-of-pocket spending.
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Affiliation(s)
- Benjamin N. Rome
- Program On Regulation, Therapeutics, And Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - William B. Feldman
- Program On Regulation, Therapeutics, And Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Rishi J. Desai
- Program On Regulation, Therapeutics, And Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Aaron S. Kesselheim
- Program On Regulation, Therapeutics, And Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Rome BN, Gagne JJ, Avorn J, Kesselheim AS. Non-warfarin oral anticoagulant copayments and adherence in atrial fibrillation: A population-based cohort study. Am Heart J 2021; 233:109-121. [PMID: 33358690 DOI: 10.1016/j.ahj.2020.12.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/17/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND In patients with atrial fibrillation, incomplete adherence to anticoagulants increases risk of stroke. Non-warfarin oral anticoagulants (NOACs) are expensive; we evaluated whether higher copayments are associated with lower NOAC adherence. METHODS Using a national claims database of commercially-insured patients, we performed a cohort study of patients with atrial fibrillation who newly initiated a NOAC from 2012 to 2018. Patients were stratified into low (<$35), medium ($35-$59), or high (≥$60) copayments and propensity-score weighted based on demographics, insurance characteristics, comorbidities, prior health care utilization, calendar year, and the NOAC received. Follow-up was 1 year, with censoring for switching to a different anticoagulant, undergoing an ablation procedure, disenrolling from the insurance plan, or death. The primary outcome was adherence, measured by proportion of days covered (PDC). Secondary outcomes included NOAC discontinuation (no refill for 30 days after the end of NOAC supply) and switching anticoagulants. We compared PDC using a Kruskal-Wallis test and rates of discontinuation and switching using Cox proportional hazards models. RESULTS After weighting patients across the 3 copayment groups, the effective sample size was 17,558 patients, with balance across 50 clinical and demographic covariates (standardized differences <0.1). Mean age was 62 years, 29% of patients were female, and apixaban (43%), and rivaroxaban (38%) were the most common NOACs. Higher copayments were associated with lower adherence (P < .001), with a PDC of 0.82 (Interquartile range [IQR] 0.36-0.98) among those with high copayments, 0.85 (IQR 0.41-0.98) among those with medium copayments, and 0.88 (IQR 0.41-0.99) among those with low copayments. Compared to patients with low copayments, patients with high copayments had higher rates of discontinuation (hazard ratio [HR] 1.13, 95% confidence interval [CI] 1.08-1.19; P < .001). CONCLUSIONS Among atrial fibrillation patients newly initiating NOACs, higher copayments in commercial insurance were associated with lower adherence and higher rates of discontinuation in the first year. Policies to lower or limit cost-sharing of important medications may lead to improved adherence and better outcomes among patients receiving NOACs.
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Affiliation(s)
- Benjamin N Rome
- Program On Regulation, Therapeutics, And Law; Division of Pharmacoepidemiology and Pharmacoeconomics; Department of Medicine; Brigham and Women's Hospital; Boston, MA; Harvard Medical School, Boston, MA.
| | - Joshua J Gagne
- Program On Regulation, Therapeutics, And Law; Division of Pharmacoepidemiology and Pharmacoeconomics; Department of Medicine; Brigham and Women's Hospital; Boston, MA; Harvard Medical School, Boston, MA
| | - Jerry Avorn
- Program On Regulation, Therapeutics, And Law; Division of Pharmacoepidemiology and Pharmacoeconomics; Department of Medicine; Brigham and Women's Hospital; Boston, MA; Harvard Medical School, Boston, MA
| | - Aaron S Kesselheim
- Program On Regulation, Therapeutics, And Law; Division of Pharmacoepidemiology and Pharmacoeconomics; Department of Medicine; Brigham and Women's Hospital; Boston, MA; Harvard Medical School, Boston, MA
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Sacks CA, Van de Wiele VL, Fulchino LA, Patel L, Kesselheim AS, Sarpatwari A. Assessment of Variation in State Regulation of Generic Drug and Interchangeable Biologic Substitutions. JAMA Intern Med 2021; 181:16-22. [PMID: 32865564 PMCID: PMC7489381 DOI: 10.1001/jamainternmed.2020.3588] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Brand-name drugs, including biologics, have been the primary source of increasing prescription drug spending in the US. Each state has drug product selection laws that regulate whether and how pharmacists can substitute prescriptions for brand-name drugs with more affordable equivalents, either small-molecule generic drugs or interchangeable biologics, but the details of these laws can vary. OBJECTIVE To examine the variation in state drug product selection laws with regard to factors that may affect which version of a drug is dispensed. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional analysis was performed, using a legal database, to obtain information on state laws of all states plus Washington, DC, as they existed on September 1, 2019. EXPOSURES Whether substitution was mandatory or permissive, patient consent was needed prior to substitution, patient notification of substitution was required independent of the drug's packaging, and/or pharmacists were protected from special risk of liability for substitution. MAIN OUTCOMES AND MEASURES For small-molecule and biologic drugs, descriptive statistics were generated for the 4 exposure variables. In addition, for small-molecule drugs, a generic substitution score with a maximum of 1 point was assigned for each exposure variable (range, 0-4 points), with higher scores indicating regulatory requirements limiting substitution. RESULTS This cross-sectional analysis of the generic drug substitution regulations in the 50 US states and Washington, DC, found that for small-molecule drugs, 19 states required pharmacists to perform generic substitution; 7 states and Washington, DC, required patient consent; 31 states and Washington, DC, mandated patient notification independent of the drug's packaging, and 24 states did not explicitly protect pharmacists from greater liability. Nine states and Washington, DC, had a generic substitution score for small-molecule drugs of 3 or higher, and 45 states had more stringent requirements for interchangeable biologic substitution, most commonly mandatory physician notification. CONCLUSIONS AND RELEVANCE The findings of this study suggest that there is a need for optimizing state drug product selection laws to promote generic and interchangeable biologic substitution, which may help improve medication adherence and reduce drug spending.
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Affiliation(s)
- Chana A Sacks
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Mongan Institute and Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Victor L Van de Wiele
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lisa A Fulchino
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lajja Patel
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ameet Sarpatwari
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Olsen DP, Keilman LJ. The Moral Distress of Nurses When Patients Forgo Treatment Because of Cost. Am J Nurs 2020; 120:61-66. [PMID: 32858703 DOI: 10.1097/01.naj.0000697668.09031.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Nursing must recognize an ethical obligation to respond on behalf of these patients.
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Affiliation(s)
- Douglas P Olsen
- Douglas P. Olsen and Linda J. Keilman, a gerontological NP, are associate professors at the Michigan State University College of Nursing in East Lansing. Olsen is a contributing editor of AJN. Contact author: Douglas P. Olsen, . The authors have disclosed no potential conflicts of interest, financial or otherwise. A podcast with the authors is available at www.ajnonline.com
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Isaranuwatchai W, Fazli GS, Bierman AS, Lipscombe LL, Mitsakakis N, Shah BR, Wu CF, Johns A, Booth GL. Universal Drug Coverage and Socioeconomic Disparities in Health Care Costs Among Persons With Diabetes. Diabetes Care 2020; 43:2098-2105. [PMID: 32641377 DOI: 10.2337/dc19-1536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 05/25/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine whether neighborhood socioeconomic status (SES) is a predictor of non-drug-related health care costs among Canadian adults with diabetes and, if so, whether SES disparities in costs are reduced after age 65 years, when universal drug coverage commences as an insurable benefit. RESEARCH DESIGN AND METHODS Administrative health databases were used to examine publicly funded health care expenditures among 698,113 younger (20-64 years) and older (≥65 years) adults with diabetes in Ontario from April 2004 to March 2014. Generalized linear models were constructed to examine relative and absolute differences in health care costs (total and non-drug-related costs) across neighborhood SES quintiles, by age, with adjustment for differences in age, sex, diabetes duration, and comorbidity. RESULTS Unadjusted costs per person-year in the lowest SES quintile (Q1) versus the highest (Q5) were 39% higher among younger adults ($5,954 vs. $4,270 [Canadian dollars]) but only 9% higher among older adults ($10,917 vs. $9,993). Adjusted non-drug costs (primarily for hospitalizations and physician visits) were $1,569 per person-year higher among younger adults in Q1 vs. Q5 (modeled relative cost difference: 35.7% higher) and $139.3 million per year among all individuals in Q1. Scenarios in which these excess costs per person-year were decreased by ≥10% or matched the relative difference among seniors suggested a potential for savings in the range of $26.0-$128.2 million per year among all lower-SES adults under age 65 years (Q1-Q4). CONCLUSIONS SES is a predictor of diabetes-related health care costs in our setting, more so among adults under age 65 years, a group that lacks universal drug coverage under Ontario's health care system. Non-drug-related health care costs were more than one-third higher in younger, lower-SES adults, translating to >$1 billion more in health care expenditures over 10 years.
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Affiliation(s)
- Wanrudee Isaranuwatchai
- Centre for Excellence in Economic Analysis Research, St. Michael's Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Health Intervention and Technology Assessment Program, Bangkok, Thailand
| | - Ghazal S Fazli
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Arlene S Bierman
- ICES, Toronto, Ontario, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Lorraine L Lipscombe
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Nicholas Mitsakakis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada.,Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Baiju R Shah
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Ashley Johns
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Gillian L Booth
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada .,MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Reduced Cost-sharing for Preventive Drugs Preferentially Benefits Low-income Patients With Diabetes in High Deductible Health Plans With Health Savings Accounts. Med Care 2020; 58 Suppl 6 Suppl 1:S4-S13. [PMID: 32412948 DOI: 10.1097/mlr.0000000000001295] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND High deductible health plans linked to Health Savings Accounts (HSA-HDHPs) must include all care under the deductible except for select preventive services. Some employers and insurers have adopted Preventive Drug Lists (PDLs) that exempt specific classes of medications from deductibles. OBJECTIVE The objective of this study was to examine the association between shifts to PDL coverage and medication utilization among patients with diabetes in HSA-HDHPs. RESEARCH DESIGN A natural experiment comparing pre-post changes in monthly and annual outcomes in matched study groups. SUBJECTS The intervention group included 1744 commercially-insured HSA-HDHP patients with diabetes age 12-64 years switched by employers to PDL coverage; the control group included 3349 propensity-matched HSA-HDHP patients whose employers offered no PDL. MEASURES Outcomes were out-of-pocket (OOP) costs for medications and the number of pharmacy fills converted to 30-day equivalents. RESULTS Transition to the PDL was associated with a relative pre-post decrease of $612 (-35%, P<0.001) per member OOP medication expenditures; OOP reductions were higher for key classes of antidiabetic and cardiovascular medicines listed on the PDL; the policy did not affect unlisted classes. The PDL group experienced relative increases in medication use of 6.0 30-day fills per person during the year (+11.2%, P<0.001); the increase was more than twice as large for lower-income (+6.6 fills, +12.6%, P<0.001) than higher-income (+3.0 fills, +5.1%, P=0.024) patients. CONCLUSION Transition to a PDL which covers important classes of medication to manage diabetes and cardiovascular conditions is associated with substantial annual OOP cost savings for patients with diabetes and increased utilization of important classes of medications, especially for lower-income patients.
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Lam JO, Levine-Hall T, Hood N, Alexeeff SE, Horberg MA, Young-Wolff KC, Sterling SA, Williams A, Weisner C, Satre DD, Silverberg MJ. Smoking and cessation treatment among persons with and without HIV in a U.S. integrated health system. Drug Alcohol Depend 2020; 213:108128. [PMID: 32603975 PMCID: PMC7392076 DOI: 10.1016/j.drugalcdep.2020.108128] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Persons with HIV (PWH) are more likely to smoke and are more susceptible to the harmful effects of smoking than persons without HIV. We examined smoking patterns and use of cessation treatment among PWH and persons without HIV in a U.S. integrated health system. METHODS We identified adults (≥18 years) with HIV and demographically-matched persons without HIV between July 2013 and December 2017. Smoking status and cessation treatment were ascertained from health records. We calculated age-standardized annual prevalence of smoking and evaluated trends using Cochran-Armitage tests and Poisson regression. Factors associated with cessation treatment during the study period, and smoking in the last year of the study, were evaluated by HIV status using multivariable Poisson models. RESULTS The study included 11,235 PWH and 227,320 persons without HIV. Smoking prevalence was higher among PWH across all years but declined for both groups (from 16.6% to 14.6% in PWH and 11.6% to 10.5% in persons without HIV). Among smokers, PWH were more likely to initiate cessation treatment compared to persons without HIV (17.9% vs. 13.3%, covariate-adjusted prevalence ratio of 1.31, 95% CI = 1.15-1.50), with few differences in cessation treatment across subgroups of PWH. In 2017, smoking prevalence remained higher in PWH, especially among those who were younger or who had diagnoses of depression or substance use disorder. CONCLUSION In a setting with access to cessation resources, smoking prevalence decreased both in PWH and persons without HIV. PWH had greater uptake of cessation treatment, which is encouraging for smoking reduction and improved health.
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Affiliation(s)
- Jennifer O. Lam
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland CA, 94612, USA
| | - Tory Levine-Hall
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland CA, 94612, USA
| | - Nicole Hood
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland CA, 94612, USA
| | - Stacey E. Alexeeff
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland CA, 94612, USA
| | - Michael A. Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, 2101 East Jefferson Street, 3 East, Rockville, MD, 20852, USA
| | - Kelly C. Young-Wolff
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland CA, 94612, USA,Department of Psychiatry, Weill Institute for Neurosciences, University of California, 401 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Stacy A. Sterling
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland CA, 94612, USA,Department of Psychiatry, Weill Institute for Neurosciences, University of California, 401 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Andrew Williams
- Tufts Medical Center, 800 Washington Street, Boston, MA, 02111, USA
| | - Constance Weisner
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland CA, 94612, USA,Department of Psychiatry, Weill Institute for Neurosciences, University of California, 401 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Derek D. Satre
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland CA, 94612, USA,Department of Psychiatry, Weill Institute for Neurosciences, University of California, 401 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Michael J. Silverberg
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland CA, 94612, USA
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Health Outcomes and Primary Adherence to Secondary Prevention Treatment after St-Elevation Myocardial Infarction: a Spanish Cohort Study. J Cardiovasc Transl Res 2020; 14:308-316. [PMID: 32557320 DOI: 10.1007/s12265-020-10045-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/03/2020] [Indexed: 01/13/2023]
Abstract
This retrospective observational study aimed to establish the first prescription and its dispensation (primary adherence) in the first 30 days of the four pharmacotherapeutic classes recommended after a type 1 STEMI episode, determine the potential risk factors for lack of primary adherence, and evaluate the potential impact of primary adherence on cardiovascular outcomes. Of the 613 patients analyzed, 576 were included (64.7 ± 13.8 years, 73.8% men) between January 2008 and December 2013. Primary adherence exceeded 90% in all groups. Complete primary adherence was higher in high-drug coverage patients and was lower in patients with cardiovascular or neuropsychiatric diseases. According to competing risk analysis, 1-year cardiovascular mortality was significantly lower in patients with complete primary adherence than in those without complete prescription or adherence, 1.8% versus 5.6% (HR = 0.286; p = 0.012). Complete primary adherence did not prevent a 1-year cardiovascular event, 5.6% versus 5.5% (p = 0.904).
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White-Williams C, Rossi LP, Bittner VA, Driscoll A, Durant RW, Granger BB, Graven LJ, Kitko L, Newlin K, Shirey M. Addressing Social Determinants of Health in the Care of Patients With Heart Failure: A Scientific Statement From the American Heart Association. Circulation 2020; 141:e841-e863. [DOI: 10.1161/cir.0000000000000767] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Heart failure is a clinical syndrome that affects >6.5 million Americans, with an estimated 550 000 new cases diagnosed each year. The complexity of heart failure management is compounded by the number of patients who experience adverse downstream effects of the social determinants of health (SDOH). These patients are less able to access care and more likely to experience poor heart failure outcomes over time. Many patients face additional challenges associated with the cost of complex, chronic illness management and must make difficult decisions about their own health, particularly when the costs of medications and healthcare appointments are at odds with basic food and housing needs. This scientific statement summarizes the SDOH and the current state of knowledge important to understanding their impact on patients with heart failure. Specifically, this document includes a definition of SDOH, provider competencies, and SDOH assessment tools and addresses the following questions: (1) What models or frameworks guide healthcare providers to address SDOH? (2) What are the SDOH affecting the delivery of care and the interventions addressing them that affect the care and outcomes of patients with heart failure? (3) What are the opportunities for healthcare providers to address the SDOH affecting the care of patients with heart failure? We also include a case study (
Data Supplement
) that highlights an interprofessional team effort to address and mitigate the effects of SDOH in an underserved patient with heart failure.
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Kim NH, Look KA. The Effect of Reduced Drug Copayments on Adherence to Oral Diabetes Medications Among Childless Adults in Wisconsin Medicaid. J Manag Care Spec Pharm 2020; 25:1432-1441. [PMID: 31778619 PMCID: PMC10398115 DOI: 10.18553/jmcp.2019.25.12.1432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Medication adherence is an indicator of the quality of drug use, which is associated with better health outcomes and reduced health care expenditures. Drug cost sharing can be a barrier to adherence, especially for low-income individuals with chronic conditions. Most of the existing studies in a Medicaid population have evaluated the effects of increasing drug copayments, but few studies have evaluated the effects of reducing drug copayments on medication adherence. Medicaid coverage for low-income childless adults in Wisconsin was expanded on April 1, 2014, which included reductions in drug copayments and monthly caps on out-of-pocket spending. OBJECTIVE To evaluate changes in adherence to oral diabetes medications using proportion of days covered (PDC) among Medicaid childless adults with type 2 diabetes after the 2014 Medicaid drug copayment reduction. METHODS A difference-in-differences design was used to compare the changes in medication adherence between childless adults (treatment group) and parents/caretakers (control group). Wisconsin Medicaid's administrative enrollment records, pharmacy claims, and medical claims data were analyzed. Medication adherence was evaluated for 4 commonly used oral diabetes drug classes (i.e., biguanides, sulfonylureas, dipeptidyl peptidase-IV inhibitors, and thiazolidinediones) by adapting the medication adherence quality measures endorsed by the Pharmacy Quality Alliance. The PDC for all diabetes drugs was calculated among patients who filled ≥ 2 prescriptions for any of the 4 drug classes. PDC for each drug class was also measured among patients who had ≥ 2 drug fills for each drug class. The proportion of adherent patients was evaluated using a threshold of PDC ≥ 0.80. RESULTS Average PDC for all diabetes drugs was 0.87 in the childless adults at baseline and significantly increased by 0.02 (P = 0.025) relative to the parents/caretakers after the copayment reduction. The baseline proportion of adherent patients (PDC ≥ 0.80) among the childless adults was 76% and significantly increased by 6.2 percentage points (P = 0.003) relative to the control group. The odds of adherence to oral antidiabetic drugs increased by 47%, resulting in the proportion of adherent patients in the childless adults group reaching almost 80% after the coverage expansion. In the per class analyses, a significant effect was found for biguanides; the proportion of adherent patients increased by 5.5 percentage points in childless adults compared with the control group (P = 0.022). CONCLUSIONS This program evaluation found that a reduction of drug copayments in Wisconsin Medicaid improved the quality of medication use by increasing adherence to oral antidiabetic drugs among childless adults. DISCLOSURES This study was conducted as part of a larger study funded by the Wisconsin Department of Health Services. The authors are solely responsible for the content of this study. The authors report an evaluation contract with the Wisconsin Department of Health Services, unrelated to this study. An earlier version of this paper was presented at the AcademyHealth Annual Research Meeting; June 23-24, 2018; Seattle, WA.
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Affiliation(s)
- Nam Hyo Kim
- Social and Administrative Sciences Division, School of Pharmacy, University of Wisconsin-Madison
| | - Kevin A Look
- Social and Administrative Sciences Division, School of Pharmacy, University of Wisconsin-Madison
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Evaluating When and Why Patients Discontinue Chronic Therapy for Irritable Bowel Syndrome With Constipation and Chronic Idiopathic Constipation. Am J Gastroenterol 2020; 115:596-602. [PMID: 32022721 PMCID: PMC7565170 DOI: 10.14309/ajg.0000000000000530] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION To inform the patient-centered discussion regarding comparative outcomes with irritable bowel syndrome/chronic idiopathic constipation pharmacotherapy, we evaluated reasons and timing of discontinuation of FDA-approved pharmacotherapy for irritable bowel syndrome and chronic idiopathic constipation in a large observational real-world cohort. METHODS We identified patients initiating lubiprostone or linaclotide within the University of Michigan Electronic Medical Record (2012-2016). Medication start and stop dates were determined in manual chart review including detailed review of all documentation including office notes and telephone encounters. A Cox model was constructed to predict the hazard of discontinuation. RESULTS On multivariate analysis of 1,612 patients, linaclotide users had a lower risk of discontinuing therapy than lubiprostone users for any reason (hazard ratio [HR] = 0.6, 95% confidence interval [CI] 0.5-0.8). At 3 and 12 months, the overall discontinuation rates were 23% and 43% for lubiprostone compared with 14% and 24% for linaclotide. Over the first year of therapy, more than half of discontinuations due to intolerance occurred in the first 3 months for both drugs. Linaclotide users were more likely to discontinue due to intolerance (HR = 1.6 [95% CI, 1.2-2.3]) but less likely to discontinue due to insufficient efficacy of therapy (HR = 0.5 [95% CI, 0.4-0.8]). IBS diagnosis increased the hazard of discontinuation of lubiprostone relative to linactolide (HR = 1.4, 95% CI, 1.1-1.6). Loss of prescription drug coverage remained a common reason for discontinuation over the first year of therapy. DISCUSSION Individuals appear more likely to discontinue lubiprostone than linaclotide overall, but more likely to discontinue linaclotide compared with lubiprostone due to intolerance (mostly diarrhea). Most discontinuations due to intolerance occur in the first 3 months. These results may be useful in individualized treatment selection and enhancing patient knowledge regarding long-term outcomes.
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Reynolds EL, Burke JF, Banerjee M, Kerber KA, Skolarus LE, Magliocco B, Esper GJ, Callaghan BC. Association of out-of-pocket costs on adherence to common neurologic medications. Neurology 2020; 94:e1415-e1426. [PMID: 32075894 PMCID: PMC7274913 DOI: 10.1212/wnl.0000000000009039] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/04/2019] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE To determine the association between out-of-pocket costs and medication adherence in 3 common neurologic diseases. METHODS Utilizing privately insured claims from 2001 to 2016, we identified patients with incident neuropathy, dementia, or Parkinson disease (PD). We selected patients who were prescribed medications with similar efficacy and tolerability, but differential out-of-pocket costs (neuropathy with gabapentinoids or mixed serotonin/norepinephrine reuptake inhibitors [SNRIs], dementia with cholinesterase inhibitors, PD with dopamine agonists). Medication adherence was defined as the number of days supplied in the first 6 months. Instrumental variable analysis was used to estimate the association of out-of-pocket costs and other patient factors on medication adherence. RESULTS We identified 52,249 patients with neuropathy on gabapentinoids, 5,246 patients with neuropathy on SNRIs, 19,820 patients with dementia on cholinesterase inhibitors, and 3,130 patients with PD on dopamine agonists. Increasing out-of-pocket costs by $50 was associated with significantly lower medication adherence for patients with neuropathy on gabapentinoids (adjusted incidence rate ratio [IRR] 0.91, 0.89-0.93) and dementia (adjusted IRR 0.88, 0.86-0.91). Increased out-of-pocket costs for patients with neuropathy on SNRIs (adjusted IRR 0.97, 0.88-1.08) and patients with PD (adjusted IRR 0.90, 0.81-1.00) were not significantly associated with medication adherence. Minority populations had lower adherence with gabapentinoids and cholinesterase inhibitors compared to white patients. CONCLUSIONS Higher out-of-pocket costs were associated with lower medication adherence in 3 common neurologic conditions. When prescribing medications, physicians should consider these costs in order to increase adherence, especially as out-of-pocket costs continue to rise. Racial/ethnic disparities were also observed; therefore, minority populations should receive additional focus in future intervention efforts to improve adherence.
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Affiliation(s)
- Evan L Reynolds
- From the Health Services Research Program, Department of Neurology (E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and the Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - James F Burke
- From the Health Services Research Program, Department of Neurology (E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and the Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Mousumi Banerjee
- From the Health Services Research Program, Department of Neurology (E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and the Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Kevin A Kerber
- From the Health Services Research Program, Department of Neurology (E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and the Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Lesli E Skolarus
- From the Health Services Research Program, Department of Neurology (E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and the Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Brandon Magliocco
- From the Health Services Research Program, Department of Neurology (E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and the Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Gregory J Esper
- From the Health Services Research Program, Department of Neurology (E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and the Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Brian C Callaghan
- From the Health Services Research Program, Department of Neurology (E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and the Department of Neurology (G.J.E.), Emory University, Atlanta, GA.
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Go AS, Ambrosy AP, Kheder K, Fan D, Sung SH, Inveiss AI, Romo-LeTourneau V, Thomas SM, Koren A, Lo JC. Statin Therapy and Risk of Incident Diabetes Mellitus in Adults With Cardiovascular Risk Factors. Am J Cardiol 2020; 125:534-541. [PMID: 31848029 DOI: 10.1016/j.amjcard.2019.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 11/11/2019] [Accepted: 11/13/2019] [Indexed: 10/25/2022]
Abstract
The association between statins and diabetes mellitus (DM) remains controversial. The Kaiser Permanente CHAMP Study identified adults without DM who had cardiovascular (CV) risk factors and no previous lipid lowering therapy (LLT) between 2008 and 2010. The CV risk factors included known atherosclerotic CV disease (ASCVD), elevated low-density lipoprotein cholesterol ≥190 mg/dl, or a low-density lipoprotein cholesterol between 70 and 189 mg/dl and an estimated 10-year ASCVD risk ≥7.5%. Incident DM was defined as ≥2 abnormal tests (i.e., A1C ≥6.5% or a fasting blood glucose ≥126 mg/dl) or ≥1 abnormal test result plus a new diagnostic code or medication for DM. Among 213,289 eligible adults, 28,149 patients initiating statins were carefully matched to an equal number of patients who remained off LLT during follow-up. Compared with matched patients not receiving statins, those initiating statin therapy had the same mean age (67.9 ± 9.4 years) and gender (42.8% women). The crude rate (per 100 person-years) of incident DM was low (0.55, 95% confidence interval [CI] 0.52 to 0.59) but was marginally higher in patients who were treated with a statin (0.69, 95% CI 0.64 to 0.74) versus no LLT (0.42, 95% CI 0.38 to 0.46). After additional adjustment, statin therapy was associated with a modestly increased risk of incident DM (adjusted hazard ratio 1.17, 95% CI 1.02 to 1.34). In conclusion, in adults without DM at increased ASCVD risk, initiation of statin therapy was independently associated with a modestly higher risk of incident DM.
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Caraballo C, Valero-Elizondo J, Khera R, Mahajan S, Grandhi GR, Virani SS, Mszar R, Krumholz HM, Nasir K. Burden and Consequences of Financial Hardship From Medical Bills Among Nonelderly Adults With Diabetes Mellitus in the United States. Circ Cardiovasc Qual Outcomes 2020; 13:e006139. [DOI: 10.1161/circoutcomes.119.006139] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background:
The trend of increasing total and out-of-pocket expenditure among patients with diabetes mellitus represents a risk of financial hardship for Americans and a threat to medical and nonmedical needs. We aimed to describe the national scope and associated tradeoffs of financial hardship from medical bills among nonelderly individuals with diabetes mellitus.
Methods and Results:
We used the National Health Interview Survey data from 2013 to 2017, including adults ≤64 years old with a self-reported diagnosis of diabetes mellitus. Among 164 696 surveyed individuals, 8967 adults ≤64 years old reported having diabetes mellitus, representing 13.1 million individuals annually across the United States. The mean age was 51.6 years (SD 10.3), and 49.1% were female. A total of 41.1% were part of families that reported having financial hardship from medical bills, with 15.6% reporting an inability to pay medical bills at all. In multivariate analyses, individuals who lacked insurance, were non-Hispanic black, had low income, or had high-comorbidity burden were at higher odds of being in families with financial hardship from medical bills. When comparing the graded categories of financial hardship, there was a stepwise increase in the prevalence of high financial distress, food insecurity, cost-related nonadherence, and foregone/delayed medical care, reaching 70.5%, 49.4%, 49.5%, and 74% among those unable to pay bills, respectively. Compared with those without diabetes mellitus, individuals with diabetes mellitus had higher odds of financial hardship from medical bills (adjusted odds ratio [aOR], 1.27 [95% CI, 1.18–1.36]) or any of its consequences, including high financial distress (aOR, 1.14 [95% CI, 1.05–1.24]), food insecurity (aOR, 1.27 [95% CI, 1.16–1.40]), cost-related medication nonadherence (aOR, 1.43 [95% CI, 1.30–1.57]), and foregone/delayed medical care (aOR, 1.30 [95% CI, 1.20–1.40]).
Conclusions:
Nonelderly patients with diabetes mellitus have a high prevalence of financial hardship from medical bills, with deleterious consequences.
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Affiliation(s)
- César Caraballo
- Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.C., S.M., R.M., H.M.K.)
| | - Javier Valero-Elizondo
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX (J.V.-E., K.N.)
- Center for Outcomes Research, Houston Methodist, TX (J.V.-E., K.N.)
| | - Rohan Khera
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (R.K.)
| | - Shiwani Mahajan
- Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.C., S.M., R.M., H.M.K.)
| | - Gowtham R. Grandhi
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD (G.R.G.)
| | - Salim S. Virani
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.S.V.)
- Baylor College of Medicine, Houston, TX (S.S.V.)
| | - Reed Mszar
- Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.C., S.M., R.M., H.M.K.)
- Department of Chronic Disease Epidemiology (R.M.), Yale School of Public Health, New Haven, CT
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (C.C., S.M., R.M., H.M.K.)
- Department of Health Policy and Management (H.M.K.), Yale School of Public Health, New Haven, CT
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT (H.M.K.)
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX (J.V.-E., K.N.)
- Center for Outcomes Research, Houston Methodist, TX (J.V.-E., K.N.)
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Lauffenburger JC, Lewey J, Jan S, Lee J, Ghazinouri R, Choudhry NK. Association of Potentially Modifiable Diabetes Care Factors With Glycemic Control in Patients With Insulin-Treated Type 2 Diabetes. JAMA Netw Open 2020; 3:e1919645. [PMID: 31968115 PMCID: PMC6991273 DOI: 10.1001/jamanetworkopen.2019.19645] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Numerous factors are associated with the ability of patients with type 2 diabetes to achieve optimal glycemic control. However, many of these factors are not modifiable by quality improvement interventions. In contrast, the structure of how diabetes care is delivered, such as whether patients visit an endocrinologist or how prescriptions are filled, is potentially modifiable, yet its associations with glycemic control have not been rigorously evaluated. OBJECTIVE To investigate the association of diabetes care delivery with glycemic control in patients with type 2 diabetes using insulin. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used baseline claims and laboratory insurer data within a large pragmatic trial to identify individuals with type 2 diabetes using insulin with data for at least 1 hemoglobin A1c (HbA1c) test result from before trial randomization (July 1, 2014, to October 5, 2016) and for key nonmodifiable patient factors as well as diabetes care delivery and behavioral factors measured before the HbA1c test. Analyses were conducted from February 4, 2017, to November 13, 2018. MAIN OUTCOMES AND MEASURES Multivariable modified Poisson regression was used to evaluate the independent associations of nonmodifiable patient factors and potentially modifiable diabetes care delivery and patient behavioral factors with achieving adequate diabetes control (ie, HbA1c level <8%). The extent of measured variation explained in glycemic control by these factors was also explored using pseudo R2 and C statistics. RESULTS Of 1423 patients included, 565 (39.7%) were women, and the mean (SD) age was 56.4 (9.0) years. In total, 690 (48.5%) had HbA1c levels less than 8%. Age (relative risk [RR] per 1-unit increase, 1.01; 95% CI, 1.00-1.02), persistent use of basal insulin (RR, 1.20; 95% CI, 1.00-1.43), more frequent filling of glucose self-testing supplies (RR, 1.01; 95% CI, 1.01-1.02), visiting an endocrinologist (RR, 1.41; 95% CI, 1.19-1.67), and receipt of insulin prescriptions by mail order (RR, 1.23; 95% CI, 1.03-1.48) were all independently associated with adequate control. Measured potentially modifiable diabetes care factors explained more variation in adequate glycemic control than measured nonmodifiable patient factors (C statistic, 0.661 vs 0.598; pseudo R2 = 0.11 vs 0.04). CONCLUSIONS AND RELEVANCE These findings suggest that for patients with type 2 diabetes using insulin, the way in which care is delivered may be more strongly associated with achieving adequate control of HbA1c levels than patient factors that cannot be altered are. Given the potential for intervention, these care delivery factors could be the focus of efforts to improve diabetes outcomes.
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Affiliation(s)
- Julie C. Lauffenburger
- Center for Healthcare Delivery Sciences, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jennifer Lewey
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Saira Jan
- Horizon Blue Cross Blue Shield, Newark, New Jersey
- Department of Pharmacy Practice and Administration, Rutgers State University of New Jersey, New Brunswick
| | - Jessica Lee
- Center for Healthcare Delivery Sciences, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Roya Ghazinouri
- Center for Healthcare Delivery Sciences, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Niteesh K. Choudhry
- Center for Healthcare Delivery Sciences, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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Mohan V, Khunti K, Chan SP, Filho FF, Tran NQ, Ramaiya K, Joshi S, Mithal A, Mbaye MN, Nicodemus NA, Latt TS, Ji L, Elebrashy IN, Mbanya JC. Management of Type 2 Diabetes in Developing Countries: Balancing Optimal Glycaemic Control and Outcomes with Affordability and Accessibility to Treatment. Diabetes Ther 2020; 11:15-35. [PMID: 31773420 PMCID: PMC6965543 DOI: 10.1007/s13300-019-00733-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Indexed: 12/18/2022] Open
Abstract
With the growing prevalence of type 2 diabetes, particularly in emerging countries, its management in the context of available resources should be considered. International guidelines, while comprehensive and scientifically valid, may not be appropriate for regions such as Asia, Latin America or Africa, where epidemiology, patient phenotypes, cultural conditions and socioeconomic status are different from America and Europe. Although glycaemic control and reduction of micro- and macrovascular outcomes remain essential aspects of treatment, access and cost are major limiting factors; therefore, a pragmatic approach is required in restricted-resource settings. Newer agents, such as sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists in particular, are relatively expensive, with limited availability despite potentially being valuable for patients with insulin resistance and cardiovascular complications. This review makes a case for the role of more accessible second-line treatments with long-established efficacy and affordability, such as sulfonylureas, in the management of type 2 diabetes, particularly in developing or restricted-resource countries.
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Affiliation(s)
- Viswanathan Mohan
- Dr. Mohan's Diabetes Specialities Centre and Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India.
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Siew P Chan
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Fadlo F Filho
- Faculty of Medicine, ABC Foundation, Santo André, Brazil
| | - Nam Q Tran
- Department of Endocrinology, University Medical Center, Ho Chi Minh City, Vietnam
| | - Kaushik Ramaiya
- Shree Hindu Mandal Hospital, Dar es Salaam, Tanzania
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Shashank Joshi
- Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
| | | | | | - Nemencio A Nicodemus
- Department of Medicine, University of the Philippines-Philippine General Hospital, Manila, Philippines
- Department of Biochemistry and Molecular Biology, University of the Philippines-College of Medicine, Manila, Philippines
| | - Tint S Latt
- Department of Diabetes and Endocrinology, University of Medicine 2, Yangon, Myanmar
| | - Linong Ji
- Department of Endocrinology, Peking University People's Hospital, Beijing, China
| | - Ibrahim N Elebrashy
- Department of Internal Medicine, Diabetes, and Endocrinology, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Jean C Mbanya
- University of Yaoundé I, Yaoundé, Cameroon
- National Obesity Center, Central Hospital of Yaoundé, Yaoundé, Cameroon
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Daneshmand SS, Stortz S, Morrisey R, Faksh A. Bridging Gaps and Understanding Disparities in Gestational Diabetes Mellitus to Improve Perinatal Outcomes. Diabetes Spectr 2019; 32:317-323. [PMID: 31798289 PMCID: PMC6858080 DOI: 10.2337/ds19-0013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IN BRIEF For a woman who is facing financial, cultural, psychological, or social challenges, discovering that she has gestational diabetes mellitus (GDM) represents a significant burden. By better understanding challenges underserved women with GDM face, multidisciplinary clinical teams can make essential changes in health care delivery to optimize outcomes not just during pregnancy, but also, equally importantly, beyond pregnancy to prevent long-term disease.
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Affiliation(s)
- Sean S. Daneshmand
- Division of Perinatology, Department of Obstetrics and Gynecology, Scripps Memorial Hospital La Jolla, San Diego, CA
| | - Sharon Stortz
- Department of Obstetrics and Gynecology, Naval Medical Center, San Diego, CA
| | | | - Arij Faksh
- Division of Perinatology, Department of Obstetrics and Gynecology, Scripps Memorial Hospital La Jolla, San Diego, CA
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Callaghan BC, Reynolds E, Banerjee M, Kerber KA, Skolarus LE, Magliocco B, Esper GJ, Burke JF. Out-of-pocket costs are on the rise for commonly prescribed neurologic medications. Neurology 2019; 92:e2604-e2613. [PMID: 31043472 PMCID: PMC6556089 DOI: 10.1212/wnl.0000000000007564] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 01/08/2019] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE To determine out-of-pocket costs for neurologic medications in 5 common neurologic diseases. METHODS Utilizing a large, privately insured, health care claims database from 2004 to 2016, we captured out-of-pocket medication costs for patients seen by outpatient neurologists with multiple sclerosis (MS), peripheral neuropathy, epilepsy, dementia, and Parkinson disease (PD). We compared out-of-pocket costs for those in high-deductible health plans compared to traditional plans and explored cumulative out-of-pocket costs over the first 2 years after diagnosis across conditions with high- (MS) and low/medium-cost (epilepsy) medications. RESULTS The population consisted of 105,355 patients with MS, 314,530 with peripheral neuropathy, 281,073 with epilepsy, 120,720 with dementia, and 90,801 with PD. MS medications had the fastest rise in monthly out-of-pocket expenses (mean [SD] $15 [$23] in 2004, $309 [$593] in 2016) with minimal differences between medications. Out-of-pocket costs for brand name medications in the other conditions also rose considerably. Patients in high-deductible health plans incurred approximately twice the monthly out-of-pocket expense as compared to those not in these plans ($661 [$964] vs $246 [$472] in MS, $40 [$94] vs $18 [$46] in epilepsy in 2016). Cumulative 2-year out-of-pocket costs rose almost linearly over time in MS ($2,238 [$3,342]) and epilepsy ($230 [$443]). CONCLUSIONS Out-of-pocket costs for neurologic medications have increased considerably over the last 12 years, particularly for those in high-deductible health plans. Out-of-pocket costs vary widely both across and within conditions. To minimize patient financial burden, neurologists require access to precise cost information when making treatment decisions.
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Affiliation(s)
- Brian C Callaghan
- From the Health Services Research Program, Department of Neurology (B.C.C., K.A.K., L.E.S., J.F.B.), and the School of Public Health (E.R., M.B.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA.
| | - Evan Reynolds
- From the Health Services Research Program, Department of Neurology (B.C.C., K.A.K., L.E.S., J.F.B.), and the School of Public Health (E.R., M.B.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Mousumi Banerjee
- From the Health Services Research Program, Department of Neurology (B.C.C., K.A.K., L.E.S., J.F.B.), and the School of Public Health (E.R., M.B.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Kevin A Kerber
- From the Health Services Research Program, Department of Neurology (B.C.C., K.A.K., L.E.S., J.F.B.), and the School of Public Health (E.R., M.B.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Lesli E Skolarus
- From the Health Services Research Program, Department of Neurology (B.C.C., K.A.K., L.E.S., J.F.B.), and the School of Public Health (E.R., M.B.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Brandon Magliocco
- From the Health Services Research Program, Department of Neurology (B.C.C., K.A.K., L.E.S., J.F.B.), and the School of Public Health (E.R., M.B.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Gregory J Esper
- From the Health Services Research Program, Department of Neurology (B.C.C., K.A.K., L.E.S., J.F.B.), and the School of Public Health (E.R., M.B.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - James F Burke
- From the Health Services Research Program, Department of Neurology (B.C.C., K.A.K., L.E.S., J.F.B.), and the School of Public Health (E.R., M.B.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
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Myerson R, Lu T, Tonnu-Mihara I, Huang ES. Medicaid Eligibility Expansions May Address Gaps In Access To Diabetes Medications. Health Aff (Millwood) 2019; 37:1200-1207. [PMID: 30080463 DOI: 10.1377/hlthaff.2018.0154] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Diabetes is a top contributor to the avoidable burden of disease. Costly diabetes medications, including insulin and drugs from newer medication classes, can be inaccessible to people who lack insurance coverage. In 2014 and 2015 twenty-nine states and the District of Columbia expanded eligibility for Medicaid among low-income adults. To examine the impacts of Medicaid expansion on access to diabetes medications, we analyzed data on over ninety-six million prescription fills using Medicaid insurance in the period January 2008-December 2015. Medicaid eligibility expansions were associated with thirty additional Medicaid diabetes prescriptions filled per 1,000 population in 2014-15, relative to states that did not expand Medicaid eligibility. Age groups with higher prevalence of diabetes exhibited larger increases. The increase in prescription fills grew significantly over time. Overall, fills for insulin and for newer medications increased by 40 percent and 39 percent, respectively. Our findings suggest that Medicaid eligibility expansions may address gaps in access to diabetes medications, with increasing effects over time.
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Affiliation(s)
- Rebecca Myerson
- Rebecca Myerson ( ) is an assistant professor of pharmaceutical and health economics at the School of Pharmacy and the Leonard D. Schaeffer Center for Health Policy and Economics, both at the University of Southern California, in Los Angeles
| | - Tianyi Lu
- Tianyi Lu is a PhD student in the School of Pharmacy and the Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California
| | - Ivy Tonnu-Mihara
- Ivy Tonnu-Mihara is a director of program analytics and research for the Pharmacy Service, Veterans Affairs (VA) Long Beach Healthcare System, in Long Beach, California; and a pharmacist consultant for the Veterans Health Administration, Office of Academic Affiliations, in Washington, D.C
| | - Elbert S Huang
- Elbert S. Huang is a professor of medicine and director of the Center for Chronic Disease Research and Policy at the University of Chicago
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Humphries B, Irwin A, Zoratti M, Xie F. How do financial (dis)incentives influence health behaviour and costs? Protocol for a systematic literature review of randomised controlled trials. BMJ Open 2019; 9:e024694. [PMID: 31023752 PMCID: PMC6501998 DOI: 10.1136/bmjopen-2018-024694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION In this era of rising healthcare costs, there is a growing interest in understanding how funding policies can be used to improve health and healthcare efficiency. Financial incentives (eg, vouchers or access to health insurance) or disincentives (eg, fines or out-of-pocket costs) affect behaviours. To date, reviews have explored the effects of financial (dis)incentives on patient health and behaviour by focusing on specific behaviours or geographical areas. The objective of this systematic review is to provide a comprehensive overview on the use of financial (dis)incentives as a means of influencing health-related behaviour and costs in randomised trials. METHODS AND ANALYSIS We will search electronic databases, clinical trial registries and websites of health economic organisations for randomised controlled trials. The initial searches, which were conducted on 13 January 2018, will be updated every 12 months until the completion of data analysis. The reference lists of included studies will be manually screened to identify additional eligible studies. Two researchers will independently review titles, abstracts and full texts to determine eligibility according to a set of predetermined inclusion criteria. Data will be extracted from included studies using a form developed and piloted by the research team. Discrepancies will be resolved through discussion with a third reviewer. Risk of bias will be assessed using the Cochrane Collaboration tool. ETHICS AND DISSEMINATION Ethics approval is not required since this is a review of published data. Results will be disseminated through publication in peer-reviewed journals and presentations at relevant conferences. PROSPERO REGISTRATION NUMBER CRD42018097140.
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Affiliation(s)
- Brittany Humphries
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Andrew Irwin
- Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York City, New York, USA
| | - Michael Zoratti
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Centre for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Canada
- Program for Health Economics and Outcome Measures (PHENOM), McMaster University, Hamilton, Ontario, Canada
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