Gaps in Care Among Uncontrolled Severe Asthma Patients in the United States

BACKGROUND

Understanding the implementation of key guideline recommendations is critical for managing severe asthma (SA) in the treatment of uncontrolled disease.

OBJECTIVE

To assess specialist visits and medication escalation in US patients with SA after events indicating uncontrolled disease (EUD) and associations with health outcomes and social disparity indicators.

METHODS

Patients with SA appearing in administrative claims data spanning 2015 to 2020 were indexed hierarchically on asthma-related EUD, including hospitalizations, emergency department visits with systemic corticosteroid treatment, or outpatient visits with systemic corticosteroid treatment. Patients with SA without EUD served as controls. Eligibility included age 12 or greater, 12 months enrollment before and after index, no biologic use, and no other major respiratory disease during the pre-period. Escalation of care in the form of specialist visits and medication escalation, health care resource use, costs, and disease exacerbations were assessed during follow-up.

RESULTS

We identified 180,736 patients with SA (90,368 uncontrolled and 90,368 controls). Between 35% and 51% of patients with SA with an EUD had no specialist visit or medication escalation. Follow-up exacerbations ranged from 51% to 4% across EUD cohorts, compared with 13% in controls. Among uncontrolled patients with SA who were Black or Hispanic/Latino, 41% and 38%, respectively, had no specialist visit or medication escalation after EUD, compared with 33% of non-Hispanic White patients.

CONCLUSIONS

A substantial proportion of uncontrolled patients with SA had no evidence of specialist visits or medication escalation after uncontrolled disease, and there was a clear relationship between uncontrolled disease and subsequent health care resource use and exacerbations. Findings highlight the need for improved guideline-based care delivery to patients with SA, particularly for those facing social disparities.

Exacerbations and Real-World Outcomes After Single-Inhaler Triple Therapy of Budesonide/Glycopyrrolate/Formoterol Fumarate, Among Patients with COPD: Results from the EROS (US) Study

Purpose

Triple therapy to prevent exacerbations from chronic obstructive pulmonary disease (COPD) is associated with improved health compared to single and dual-agent therapy in some populations. This study assessed the benefits of prompt administration of budesonide/glycopyrrolate/formoterol fumarate (BGF) following a COPD exacerbation.

Patients and methods

EROS was a retrospective analysis of people with COPD using the MORE2 Registry®. Inclusion required ≥1 severe, ≥2 moderate, or ≥1 moderate exacerbation while on other maintenance treatment. Within 12 months following the index exacerbation, ≥1 pharmacy claim for BGF was required. Primary outcomes were the rate of COPD exacerbations and healthcare costs for those that received BGF promptly (within 30 days of index exacerbation) versus delayed (31-180 days) and very delayed (181-365 days). The effect of each 30-day delay in initiation of BGF was estimated using a multivariable negative binomial regression model.

Results

2409 patients were identified: 434 prompt, 1187 delayed, and 788 very delayed. The rate (95% CI) of total exacerbations post-index increased as time to BGF initiation increased: prompt 1.52 (1.39-1.66); delayed 2.00 (1.92-2.09); and very delayed 2.30 (2.20-2.40). Adjusting for patient characteristics, each 30-day delay in receiving BGF was associated with a 5% increase in the average number of subsequent exacerbations (rate ratio, 95% CI: 1.05, 1.01-1.08; p<0.05). Prompt initiation of BGF was also associated with lower post-index annualized COPD-related costs ($5002 for prompt vs $7639 and $8724 for the delayed and very delayed groups, respectively).

Conclusion

Following a COPD exacerbation, promptly initiating BGF was associated with a reduction in subsequent exacerbations and reduced healthcare utilization and costs.

Real-world experience of CAR T-cell therapy in older patients with relapsed/refractory diffuse large B-cell lymphoma

The emergence of chimeric antigen receptor (CAR) T-cell therapy has changed the treatment landscape for diffuse large B-cell lymphoma (DLBCL); however, real-world experience reporting outcomes among older patients treated with CAR T-cell therapy is limited. We leveraged the 100% Medicare fee-for-service claims database and analyzed outcomes and cost associated with CAR T-cell therapy in 551 older patients (aged ≥65 years) with DLBCL who received CAR T-cell therapy between 2018 and 2020. CAR T-cell therapy was used in third line and beyond in 19% of patients aged 65 to 69 years and 22% among those aged 70 to 74 years, compared with 13% of patients aged ≥75 years. Most patients received CAR T-cell therapy in an inpatient setting (83%), with an average length of stay of 21 days. The median event-free survival (EFS) following CAR T-cell therapy was 7.2 months. Patients aged ≥75 years had significantly shorter EFS compared with patients aged 65 to 69 and 70 to 74 years, with 12-month EFS estimates of 34%, 43%, and 52%, respectively (P = .002). The median overall survival was 17.1 months, and there was no significant difference by age groups. The median total health care cost during the 90-day follow-up was $352 572 and was similar across all age groups. CAR T-cell therapy was associated with favorable effectiveness, but the CAR T-cell therapy use in older patients was low, especially in patients aged ≥75 years, and this age group had a lower rate of EFS, which illustrates the unmet need for more accessible, effective, and tolerable therapy in older patients, especially those aged ≥75 years.

Disparities in Lung Cancer: A Targeted Literature Review Examining Lung Cancer Screening, Diagnosis, Treatment, and Survival Outcomes in the United States

BACKGROUND

Although incidence and mortality of lung cancer have been decreasing, health disparities persist among historically marginalized Black, Hispanic, and Asian populations. A targeted literature review was performed to collate the evidence of health disparities among these historically marginalized patients with lung cancer in the U.S.

METHODS

Articles eligible for review included 1) indexed in PubMed®, 2) English language, 3) U.S. patients only, 4) real-world evidence studies, and 5) publications between January 1, 2018, and November 8, 2021.

RESULTS

Of 94 articles meeting selection criteria, 49 publications were selected, encompassing patient data predominantly between 2004 and 2016. Black patients were shown to develop lung cancer at an earlier age and were more likely to present with advanced-stage disease compared to White patients. Black patients were less likely to be eligible for/receive lung cancer screening, genetic testing for mutations, high-cost and systemic treatments, and surgical intervention compared to White patients. Disparities were also detected in survival, where Hispanic and Asian patients had lower mortality risks compared to White patients. Literature on survival outcomes between Black and White patients was inconclusive. Disparities related to sex, rurality, social support, socioeconomic status, education level, and insurance type were observed.

CONCLUSIONS

Health disparities within the lung cancer population begin with initial screening and continue through survival outcomes, with reports persisting well into the latter portion of the past decade. These findings should serve as a call to action, raising awareness of persistent and ongoing inequities, particularly for marginalized populations.

Demographics of and Costs to Users of Chiropractic Services in the United States with Neck or Back Pain not Meeting Guideline-Based Minimum Treatment Frequency Thresholds

Context

Acceptance of chiropractic services as an effective therapy for neck or back pain has been well established with randomized controlled trials (RCTs); however, there have been limited observations made on the treatment frequency patterns seen in the real world.

Objective

The purpose of this study is to identify chiropractic users with neck or back pain who did not meet recommended treatment frequency guidelines and examine their demographics and chiropractic costs.

Design

In this cross-sectional retrospective study, the nationally representative 2017 Medical Expenditure Panel Survey database was used.

Setting

This study used nationally representative US survey data.

Participants

Inclusion criteria were adults aged 18 years and older with a diagnosis of neck or back pain with one or more chiropractic visits in 2017.

Outcomes Measures

Chiropractic utilization was categorized as concordant or discordant with treatment frequency guidelines; concordant was defined as 5 or more visits to a chiropractor within any 2-month time frame or at least 12 total visits during the year. Discordant was defined as circumstances not meeting concordant criteria. The groups were compared by demographics including age, sex, race, region, years of education, health insurance coverage, employment status, family income, presence of headache diagnosis, Charlson Comorbidity Index score and the presence of any limitation of physical function. Comparisons were made between the two groups using Chi-squared tests. Logistic regression was used to adjust for covariates.

Results

There were 159 and 310 adults classified as concordant and discordant, respectively (weighted total: 1 849 108 [31.44%] and 4 032 541 [68.56%], with significantly different mean chiropractic costs of $2555 and $434, respectively. Significant independent predictors of discordant chiropractic utilization were race, years of education, family income and the presence of any limitation of physical function.

Conclusions

Most chiropractic users with diagnosed neck or back pain were considered discordant with treatment frequency guidelines, which may indicate inefficiencies in treatment and inefficient use of healthcare resources.

Effect of inadequate care on diabetes complications and healthcare resource utilization during management of type 2 diabetes in the United States

OBJECTIVE

To estimate the effects of inadequate type 2 diabetes mellitus (T2D) care on health outcomes, utilizing a model that incorporates patient, physician, and health-system factors.

METHODS

The most recently available (years 2016 - 2018) Medical Expenditure panel survey longitudinal data was used to identify adults with type 2 diabetes who had received inadequate diabetes care. American Diabetes Association Standards of Diabetes guidelines were used to define inadequate care, resulting in five categories: lifestyle management, immunization, pharmacologic therapy, physical examination, and laboratory evaluation. For each of the five categories, propensity score 1:1 matching was used to match individuals who received inadequate care to similar individuals who did not. After matching, cohorts were followed for one year. The cohorts were compared by total healthcare expenditure change from baseline, total emergency healthcare visits change from baseline, total newly developed diabetes related complications, and total days absent from school or work change from baseline.

RESULTS

1,619 adults with T2D, representing 15,781,346 individuals met study inclusion criteria, of which 22.60%, 22.80%, 49.21%, 23,93%, and 23,45% received inadequate lifestyle management, immunizations, pharmacologic therapies, physical examinations, and laboratory tests, respectively. After propensity score matching, those who had received inadequate care had increased healthcare expenditure change from baseline and more new diabetes related complications in the following year. After adjusting for residual covariate imbalance, those that had received inadequate pharmacologic therapies had approximately 0.20 increased instances of emergency healthcare utilization and 0.10 increase in new diabetes related complications. Those that had received inadequate laboratory tests had 0.26 additional increased instances emergency healthcare utilization.

CONCLUSION

Inadequate T2D care is an extensive issue that may have substantial economic burden and may lead to increased diabetes related complications. Those who did not receive medications or laboratory tests that were consistent with ADA guidelines had significantly increased emergency healthcare utilization in the following year. These findings highlight the importance of careful monitoring of T2D.

Development and evaluation of additional college of pharmacy admittance variables: Life experiences and holistic composite scores

INTRODUCTION

This study aimed to develop and evaluate new variables for assessment of doctor of pharmacy (PharmD) program candidates.

METHODS

Two new admissions variables were created. The life experiences variable included number of awards, letter of reference scores, degree attainment, publications, prior academic suspension, leadership experience, work experience, and a diversity score. The holistic composite variable consisted of Pharmacy College Admission Test score, pre-pharmacy grade point average (GPA), interview score, and the new life experiences score. Variables were retroactively applied to prior admissions data, and scores of successful applicants were compared to scores of unsuccessful applicants.

RESULTS

A total of 968 applicants from the 2015 and 2016 applicant pools were included in the evaluation analysis. Applicants offered admission had higher average scores for life experiences and holistic composite variables compared to those that were not offered admission (63.6 vs. 59.95 and 77.3 vs. 64, respectively). The life experiences and holistic composite scores were positively correlated with an offer of admission (0.142 and 0.547, respectively) and post-admission GPA (0.211 and 0.433, respectively) and negatively correlated with applicants accepting the offer of admission (-0.158 and - 0.25, respectively).

CONCLUSIONS

The holistic composite score was strongly predictive of an offer for admission and post-admission academic success, indicating that it may be a useful tool in assessing applicants. As new data becomes available, revisions could be considered to the life experiences score to better predict offer of an interview, offer of admission, and post-admission academic success.

Prescribers' perceptions on the impact of hydrocodone rescheduling on geriatric pain management: A qualitative study

OBJECTIVE

To qualitatively assess prescribers) perceptions regarding the consequences associated with hydrocodone rescheduling among geriatric patients being discharged from inpatient settings.

DESIGN

This was a cross-sectional study.

SETTING

Two focus groups were conducted by a trained facilitator in a metropolitan academic medical center in January 2016.

PARTICIPANTS

Prescribers who manage noncancer pain for geriatric patients were recruited. Focus groups were recorded, transcribed, and then analyzed using ATLAS.ti Qualitative Data Analysis software. Codes were derived from six primary research questions and results were summarized into key themes regarding the impact of rescheduling.

MAIN OUTCOME MEASURES

Prescribers) perceptions regarding hydrocodone rescheduling.

RESULTS

Prescribers mentioned that they review the prescription monitoring program (PMP) more often before prescribing opioids after rescheduling. They expressed concern regarding the required special serialized prescription forms needed to issue schedule II prescriptions. This led to substituting hydrocodone with potentially less effective pain medications, the inability to issue refills on hydrocodone prescriptions, and an ethical concern over prescribing hydrocodone to patients not under their direct care. Additionally, rescheduling has affected the coordination of care upon discharge, as patients moving to long-term care or skilled nursing facilities may not have adequate pain management when transferred.

CONCLUSIONS

The majority of physicians felt rescheduling negatively impacted both practical and ethical aspects of patient care related to pain management after discharge. Rescheduling has changed physicians) hydrocodone prescribing patterns, leading to more caution when prescribing hydrocodone and greater use of the PMP. Future studies should assess geriatric patients) satisfaction and quality of life regarding pain management since hydrocodone was rescheduled.

Predictors of on-site interview selection and admission for a doctor of pharmacy program using the pharmacy college application service (PharmCAS) variables

INTRODUCTION

The study aimed to identify predictors of selection for on-site interview and admission into the doctor of pharmacy (PharmD) program using variables from the Pharmacy College Application Service (PharmCAS).

METHODS

Admission data (de-identified) was obtained from University of Houston's College of Pharmacy for the years 2015 and 2016. The data consisted of relevant variables from the PharmCAS application system for all applicants during 2015 and 2016 admission cycles. Primary dependent variables were the admission committee decisions of (i) selection for on-site interview and (ii) admission into PharmD program. Descriptive frequency distributions, bivariate and multivariable logistic regression analyses were conducted to identify the predictors of admission decisions.

RESULTS

A total of 968 completed application records were obtained out of which 651 were selected for on-site interview and 413 were offered admission into the PharmD program. The logistic regression analyses indicated that as compared to pre-pharmacy grade-point-average (GPA) score of <3.2, applicants with a score of 3.2-3.49 (C.I 2.52-9.66) and ≥3.5 (C.I. 2.49-12.42) were more likely to be selected for interview. Applicants with pharmacy college admissions test (PCAT) score of 70-79 (C.I. 3.37-13.96) and ≥80 (C.I. 7.73-33.83) were more likely to be selected for interview as compared to those with PCAT < 70. With respect to admissions, female gender (C.I. 1.01-2.12), pre-pharmacy GPA ≥ 3.5 (C.I. 1.62-4.82), PCAT ≥ 80 (C.I. 2.33-6.61), letters of reference score ≥ 3.7 (C.I. 1.04-2.29) and at least one known additional language (C.I. 0.47-0.99) influenced the likelihood of being admitted into the PharmD program.

CONCLUSION

The study findings can be used to optimize the applicant review process by assigning more weightage to the significant predictors in decision making towards admission into PharmD programs. Future studies evaluating the influence of the predictors on academic performance are warranted.