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Kapoor R, Standaert B, Pezalla EJ, Demarteau N, Sutton K, Tichy E, Bungey G, Arnetorp S, Bergenheim K, Darroch-Thompson D, Meeraus W, Okumura LM, Tiene de Carvalho Yokota R, Gani R, Nolan T. Identification of an Optimal COVID-19 Booster Allocation Strategy to Minimize Hospital Bed-Days with a Fixed Healthcare Budget. Vaccines (Basel) 2023; 11:vaccines11020377. [PMID: 36851254 PMCID: PMC9965991 DOI: 10.3390/vaccines11020377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/17/2023] [Accepted: 02/04/2023] [Indexed: 02/10/2023] Open
Abstract
Healthcare decision-makers face difficult decisions regarding COVID-19 booster selection given limited budgets and the need to maximize healthcare gain. A constrained optimization (CO) model was developed to identify booster allocation strategies that minimize bed-days by varying the proportion of the eligible population receiving different boosters, stratified by age, and given limited healthcare expenditure. Three booster options were included: B1, costing US $1 per dose, B2, costing US $2, and no booster (NB), costing US $0. B1 and B2 were assumed to be 55%/75% effective against mild/moderate COVID-19, respectively, and 90% effective against severe/critical COVID-19. Healthcare expenditure was limited to US$2.10 per person; the minimum expected expense using B1, B2, or NB for all. Brazil was the base-case country. The model demonstrated that B1 for those aged <70 years and B2 for those ≥70 years were optimal for minimizing bed-days. Compared with NB, bed-days were reduced by 75%, hospital admissions by 68%, and intensive care unit admissions by 90%. Total costs were reduced by 60% with medical resource use reduced by 81%. This illustrates that the CO model can be used by healthcare decision-makers to implement vaccine booster allocation strategies that provide the best healthcare outcomes in a broad range of contexts.
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Affiliation(s)
- Ritika Kapoor
- Evidera, PPD Singapore, 08–11, 1 Fusionopolis Walk, Singapore 138628, Singapore
| | - Baudouin Standaert
- Faculty of Medicine and Life Sciences, University of Hasselt, Agoralaan, 3590 Diepenbeek, Belgium
| | - Edmund J. Pezalla
- Enlightenment Bioconsult, LLC, 140 S Beach Street, Suite 310, Daytona Beach, FL 32114, USA
| | | | | | | | - George Bungey
- Evidera, PPD the Ark, 2nd Floor, 201 Talgarth Road, London W6 8BJ, UK
| | - Sofie Arnetorp
- Health Economics & Payer Evidence, BioPharmaceuticals R&D, AstraZeneca, 431 83 Gothenberg, Sweden
| | - Klas Bergenheim
- Health Economics & Payer Evidence, BioPharmaceuticals R&D, AstraZeneca, 431 83 Gothenberg, Sweden
| | - Duncan Darroch-Thompson
- International Market Access, Vaccines and Immune Therapies, AstraZeneca, Singapore 339510, Singapore
| | - Wilhelmine Meeraus
- Medical Evidence, Vaccines and Immune Therapies, AstraZeneca, Cambridge CB2 8PA, UK
| | - Lucas M. Okumura
- Health Economics & Payer Evidence, BioPharmaceuticals R&D, AstraZeneca, São Paulo 06709-000, Brazil
| | - Renata Tiene de Carvalho Yokota
- Medical Evidence, Vaccines and Immune Therapies, AstraZeneca, Cambridge CB2 8PA, UK
- P95 Epidemiology & Pharmacovigilance, 3001 Leuven, Belgium
| | - Ray Gani
- Evidera, PPD the Ark, 2nd Floor, 201 Talgarth Road, London W6 8BJ, UK
- Correspondence: ; Tel.: +44-(0)-7720088940
| | - Terry Nolan
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Parkville, VIC 3010, Australia
- Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia
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Kalafatis C, Pezalla EJ, Rentz DM, Scheltens P. F3-01-04: PANEL DISCUSSION. Alzheimers Dement 2019. [DOI: 10.1016/j.jalz.2019.06.4599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Chris Kalafatis
- Kings College London; London United Kingdom
- Cognetivity Ltd; London United Kingdom
| | | | - Dorene M. Rentz
- Massachusetts General Hospital; Boston MA USA
- Brigham and Women's Hospital; Boston MA USA
- Harvard Medical School; Boston MA USA
| | - Philip Scheltens
- VU University Medical Center; Amsterdam Neuroscience; Amsterdam Netherlands
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Kuester MK, Jackson EA, Runyan BM, Pezalla EJ, Nussbaum SR. The Effect of a Pediatric Rare Disease on Subscriber Retention Rates for Commercial Health Insurers in the United States. J Manag Care Spec Pharm 2018; 25:186-195. [PMID: 30256693 PMCID: PMC10397796 DOI: 10.18553/jmcp.2018.18205] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The advent of personalized medicine creates opportunities for regenerative therapies to deliver extended clinical benefit from a single administration. Policymakers and health insurers in the United States are evaluating coverage and payment arrangements for these therapies. One challenge involved in these evaluations is the perception that subscribers change insurers relatively often. However, the effect of pediatric rare diseases on retention rates for commercial health insurers has not been well studied. OBJECTIVE To develop estimates for subscriber retention by a commercial insurer for up to 10 years. METHODS Three population cohorts were examined: (1) all subscribers, (2) subscribers with any dependent aged 16 years or younger, and (3) subscribers with any dependent aged 16 years or younger diagnosed with a chronic rare disease that typically results in a debilitating state or high mortality, usually associated with high health care costs regardless of whether a treatment is available. The analysis was conducted for a sample of fully insured and self-insured group business within the commercial health insurance market for these study cohorts. The MarketScan Commercial Claims and Encounters research database covering the time period from January 1, 2007, through December 31, 2016, was used as the basis for the analysis. Subscribers were included in the family-based cohorts beginning with the first observed month with a dependent aged 16 years or younger and were retained in the analysis until the subscriber or insurer withdrew from the dataset (whichever came first). Subscribers were included in the family-based rare disease cohorts if their qualifying dependent was reported with at least 2 occurrences for any of the rare diseases studied. A Kaplan-Meier estimator was used to produce retention rates for all populations for up to 120 months. An adjustment for interval censoring was applied to the family-based cohorts. A log rank test with chi-square statistic was used to determine statistical significance. RESULTS The analysis found that the subscriber retention rate within the self-insured groups was higher than within the fully insured groups (P < 0.0001). In addition, the probability of retaining subscribers with a dependent aged 16 years or younger compared with all subscribers was significantly greater (P < 0.0001). The analysis also found the probability of retaining subscribers with a qualifying dependent with a rare disease compared with subscribers with any dependent aged 16 years or younger was significantly greater (P < 0.0001). CONCLUSIONS This study demonstrated that families with a child with a rare disease remained with their commercial health insurer longer than families who did not have a child with a rare disease. The analysis will be a useful resource when evaluating alternative payment arrangements and cost/benefit analyses of regenerative therapies that offer an extended duration of clinical benefit. DISCLOSURES This study was sponsored by AveXis, which provided input into the study design, decided to submit the study results for publication, and performed an editorial review of the manuscript. Kuester, Jackson, and Runyan received consulting fees from AveXis during the conduct of this study. Pezalla and Nussbaum received consulting fees from Milliman during the conduct of this study. Nussbaum reports consulting fees from Sarepta Therapeutics and Ultragenyx Pharmaceutical outside of this study and serves on the Commercial Advisory Board of Gilead Sciences. A variation on this topic was presented at the Academy of Managed Care Pharmacy Nexus 2018; October 22-25, 2018; Orlando, FL.
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Affiliation(s)
| | | | | | | | - Samuel R Nussbaum
- 3 USC Schaeffer Center for Health Policy and Economics, Los Angeles, California
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Solow B, Pezalla EJ. ISPOR's Initiative on US Value Assessment Frameworks: The Use of Cost-Effectiveness Research in Decision Making among US Insurers. Value Health 2018; 21:166-168. [PMID: 29477395 DOI: 10.1016/j.jval.2017.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 12/07/2017] [Indexed: 06/08/2023]
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Sparks JA, Krumme AA, Shrank WH, Matlin OS, Brill G, Pezalla EJ, Choudhry NK, Solomon DH. Brief Report: Intensification to Triple Therapy After Treatment With Nonbiologic Disease-Modifying Antirheumatic Drugs for Rheumatoid Arthritis in the United States From 2009 to 2014. Arthritis Rheumatol 2017; 68:1588-95. [PMID: 26866506 DOI: 10.1002/art.39617] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 01/28/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Several trials suggest that triple therapy (methotrexate, sulfasalazine, and hydroxychloroquine) and biologic disease-modifying antirheumatic drugs (DMARDs) have similar efficacy in patients with rheumatoid arthritis (RA). This study was undertaken to investigate intensification to triple therapy after initial nonbiologic prescription among patients with RA. METHODS The use of triple therapy among patients with RA in 2009-2014 was evaluated using US insurance claims data. Patients with a health care visit for RA and an initial nonbiologic DMARD prescription were included. Frequencies of intensification to triple therapy or a biologic DMARD and rates of intensification per 6-month time period were calculated. Using Cox regression, we evaluated whether sociodemographic, temporal, geographic, clinical, and health care utilization factors were associated with intensification to triple therapy. Among those patients whose therapy was intensified, we investigated factors associated with triple therapy use by logistic regression. Hazard ratios (HRs) with 95% confidence intervals (95% CIs) for intensification to triple therapy in relation to various clinical and demographic factors were calculated. RESULTS There were 24,576 patients with a mean ± SD age of 50.3 ± 12.3 years, and 78% were female. During the study period, treatment was intensified to biologic DMARDs in 2,739 patients (11.1%) compared to 181 patients (0.7%) whose treatment was intensified to triple therapy. There was no significant change in triple therapy use across calendar years. Patients whose treatment was intensified to triple therapy were more likely to receive glucocorticoids (HR 1.91 [95% CI 1.41-2.60]) compared to patients who did not use glucocorticoids and were more likely to use nonsteroidal antiinflammatory drugs (NSAIDs) (HR 1.48, 95% CI 1.10-1.99 versus no NSAID use). Among those patients whose treatment was intensified to triple therapy or biologic DMARDs, factors significantly associated with triple therapy use included older age, US region (with the highest odds for triple therapy use in the West and lowest odds for triple therapy use in the Northeast), glucocorticoid use, and lower number of outpatient visits within 180 days of initial nonbiologic DMARD prescription. CONCLUSION Despite reports published during the study period suggesting equivalent efficacy of triple therapy and biologic DMARDs for RA, the use of triple therapy was infrequent and did not increase over time in this large nationwide study.
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Affiliation(s)
- Jeffrey A Sparks
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Alexis A Krumme
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | - Gregory Brill
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Niteesh K Choudhry
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Daniel H Solomon
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Abstract
Opioid abuse and misuse in the USA is a public health crisis. The use of prescription opioid analgesics increased substantially from 2002 through 2010, then plateaued and began to decrease in 2011. This study examined prescriptions of branded and generic immediate- and extended-release opioid analgesics from 1992 to 2016. This was juxtaposed against state and federal policies designed to decrease overutilization and abuse, as well as the launch of new opioid products, including opioids with abuse-deterrent properties (OADPs). The data indicate that these health policies, including the utilization and reimbursement of OADPs, have coincided with decreased opioid utilization. The hypothesis that OADPs will paradoxically increase opioid prescribing is not supported.
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Affiliation(s)
| | | | | | - J David Haddox
- Purdue Pharma L.P., Stamford, CT
- Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
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Lauffenburger JC, Shrank WH, Bitton A, Franklin JM, Glynn RJ, Krumme AA, Matlin OS, Pezalla EJ, Spettell CM, Brill G, Choudhry NK. Association Between Patient-Centered Medical Homes and Adherence to Chronic Disease Medications: A Cohort Study. Ann Intern Med 2017; 166:81-88. [PMID: 27842386 DOI: 10.7326/m15-2659] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Despite the widespread adoption of patient-centered medical homes into primary care practice, the evidence supporting their effect on health care outcomes has come primarily from geographically localized and well-integrated health systems. OBJECTIVE To assess the association between medication adherence and medical homes in a national patient and provider population, given the strong ties between adherence to chronic disease medications and health care quality and spending. DESIGN Retrospective cohort study. SETTING Claims from a large national health insurer. PATIENTS Patients initiating therapy with common medications for chronic diseases (diabetes, hypertension, and hyperlipidemia) between 2011 and 2013. MEASUREMENTS Medication adherence in the 12 months after treatment initiation was compared among patients cared for by providers practicing in National Committee for Quality Assurance-recognized patient-centered medical homes and propensity score-matched control practices in the same Primary Care Service Areas. Linear mixed models were used to examine the association between medical homes and adherence. RESULTS Of 313 765 patients meeting study criteria, 18 611 (5.9%) received care in patient-centered medical homes. Mean rates of adherence were 64% among medical home patients and 59% among control patients. Among 4660 matched control and medical home practices, medication adherence was significantly higher in medical homes (2.2% [95% CI, 1.5% to 2.9%]). The association between medical homes and better adherence did not differ significantly by disease state (diabetes, 3.0% [CI, 1.5% to 4.6%]; hypertension, 3.2% [CI, 2.2% to 4.2%]; hyperlipidemia, 1.5% [CI, 0.6% to 2.5%]). LIMITATION Clinical outcomes related to medication adherence were not assessed. CONCLUSION Receipt of care in a patient-centered medical home is associated with better adherence, a vital measure of health care quality, among patients initiating treatment with medications for common high-cost chronic diseases. PRIMARY FUNDING SOURCE CVS Health.
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Affiliation(s)
- Julie C Lauffenburger
- From Brigham and Women's Hospital, Ariadne Labs, Harvard T.H. Chan School of Public Health, and Harvard Medical School, Boston, Massachusetts; CVS Health, Woonsocket, Rhode Island; and Aetna, Hartford, Connecticut
| | - William H Shrank
- From Brigham and Women's Hospital, Ariadne Labs, Harvard T.H. Chan School of Public Health, and Harvard Medical School, Boston, Massachusetts; CVS Health, Woonsocket, Rhode Island; and Aetna, Hartford, Connecticut
| | - Asaf Bitton
- From Brigham and Women's Hospital, Ariadne Labs, Harvard T.H. Chan School of Public Health, and Harvard Medical School, Boston, Massachusetts; CVS Health, Woonsocket, Rhode Island; and Aetna, Hartford, Connecticut
| | - Jessica M Franklin
- From Brigham and Women's Hospital, Ariadne Labs, Harvard T.H. Chan School of Public Health, and Harvard Medical School, Boston, Massachusetts; CVS Health, Woonsocket, Rhode Island; and Aetna, Hartford, Connecticut
| | - Robert J Glynn
- From Brigham and Women's Hospital, Ariadne Labs, Harvard T.H. Chan School of Public Health, and Harvard Medical School, Boston, Massachusetts; CVS Health, Woonsocket, Rhode Island; and Aetna, Hartford, Connecticut
| | - Alexis A Krumme
- From Brigham and Women's Hospital, Ariadne Labs, Harvard T.H. Chan School of Public Health, and Harvard Medical School, Boston, Massachusetts; CVS Health, Woonsocket, Rhode Island; and Aetna, Hartford, Connecticut
| | - Olga S Matlin
- From Brigham and Women's Hospital, Ariadne Labs, Harvard T.H. Chan School of Public Health, and Harvard Medical School, Boston, Massachusetts; CVS Health, Woonsocket, Rhode Island; and Aetna, Hartford, Connecticut
| | - Edmund J Pezalla
- From Brigham and Women's Hospital, Ariadne Labs, Harvard T.H. Chan School of Public Health, and Harvard Medical School, Boston, Massachusetts; CVS Health, Woonsocket, Rhode Island; and Aetna, Hartford, Connecticut
| | - Claire M Spettell
- From Brigham and Women's Hospital, Ariadne Labs, Harvard T.H. Chan School of Public Health, and Harvard Medical School, Boston, Massachusetts; CVS Health, Woonsocket, Rhode Island; and Aetna, Hartford, Connecticut
| | - Gregory Brill
- From Brigham and Women's Hospital, Ariadne Labs, Harvard T.H. Chan School of Public Health, and Harvard Medical School, Boston, Massachusetts; CVS Health, Woonsocket, Rhode Island; and Aetna, Hartford, Connecticut
| | - Niteesh K Choudhry
- From Brigham and Women's Hospital, Ariadne Labs, Harvard T.H. Chan School of Public Health, and Harvard Medical School, Boston, Massachusetts; CVS Health, Woonsocket, Rhode Island; and Aetna, Hartford, Connecticut
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9
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Collymore DC, Kobilis SL, Lundquist TG, McGivney WT, Pezalla EJ, Poage W. Genomic testing in oncology to improve clinical outcomes while optimizing utilization: the evolution of diagnostic testing. Am J Manag Care 2016; 22:s20-s25. [PMID: 26978033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Cancer care is costly, particularly when chemotherapy and its supportive costs are considered. Yet, chemotherapy is not the right course for every patient. Patients with cancer need appropriate treatment that will give them the best possible outcome. Personalized medicine has become an important area of oncology. In addition to genetic testing, genomic testing has become a useful tool in diagnostics. For genomic assays to be viable, they must have clinical validity, analytic validity, and clinical utility. Stakeholders are willing to provide coverage for such testing through medical policy when there is strong evidence the tests are effective. Genomic testing can be used in decision making to rule out chemotherapy or other treatment options that would not be effective for the care of an individual patient. The use of genomic testing to help eliminate ineffective or possible harmful treatment options and determine appropriate care will benefit the patient while reducing healthcare utiliztion and costs.
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Berkowitz SA, Krumme AA, Avorn J, Brennan T, Matlin OS, Spettell CM, Pezalla EJ, Brill G, Shrank WH, Choudhry NK. Initial choice of oral glucose-lowering medication for diabetes mellitus: a patient-centered comparative effectiveness study. JAMA Intern Med 2014; 174:1955-62. [PMID: 25347323 DOI: 10.1001/jamainternmed.2014.5294] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Although many classes of oral glucose-lowering medications have been approved for use, little comparative effectiveness evidence exists to guide initial selection of therapy for diabetes mellitus. OBJECTIVE To determine the effect of initial oral glucose-lowering agent class on subsequent need for treatment intensification and 4 short-term adverse clinical events. DESIGN, SETTING, AND PARTICIPANTS This study was a retrospective cohort study of patients who were fully insured members of Aetna (a large national health insurer) who had been prescribed an oral glucose-lowering medication from July 1, 2009, through June 30, 2013. Individuals newly prescribed an oral glucose-lowering agent who filled a second prescription for a medication in the same class and with a dosage at or above the World Health Organization's defined daily dose within 90 days of the end-of-day's supply of the first prescription were studied. Individuals with interim prescriptions for other oral glucose-lowering medications were excluded. EXPOSURES Initiation of treatment with metformin, a sulfonylurea, a thiazolidinedione, or a dipeptidyl peptidase 4 inhibitor. MAIN OUTCOMES AND MEASURES Time to addition of a second oral agent or insulin, each component separately, hypoglycemia, other diabetes-related emergency department visits, and cardiovascular events. RESULTS A total of 15 516 patients met the inclusion criteria, of whom 8964 (57.8%) started therapy with metformin. In unadjusted analyses, use of medications other than metformin was significantly associated with an increased risk of adding a second oral agent only, insulin only, and a second agent or insulin (P < .001 for all). In propensity score and multivariable-adjusted Cox proportional hazards models, initiation of therapy with sulfonylureas (hazard ratio [HR], 1.68; 95% CI, 1.57-1.79), thiazolidinediones (HR, 1.61; 95% CI, 1.43-1.80), and dipeptidyl peptidase 4 inhibitors (HR, 1.62; 95% CI, 1.47-1.79) was associated with an increased hazard of intensification. Alternatives to metformin were not associated with a reduced risk of hypoglycemia, emergency department visits, or cardiovascular events. CONCLUSIONS AND RELEVANCE Despite guidelines, only 57.8% of individuals began diabetes treatment with metformin. Beginning treatment with metformin was associated with reduced subsequent treatment intensification, without differences in rates of hypoglycemia or other adverse clinical events. These findings have significant implications for quality of life and medication costs.
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Affiliation(s)
- Seth A Berkowitz
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts2Division of General Internal Medicine, Massachusetts General Hospital, Boston
| | - Alexis A Krumme
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jerry Avorn
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | - Gregory Brill
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Niteesh K Choudhry
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Berger J, Balfour DC, Biskupiak JE, Dunn J, Liotta DB, Merli GJ, Pezalla EJ, Shaya FT, Villanueva T. Research to real-world application: experts weigh in on the underuse of anticoagulants. Am J Manag Care 2014; 20:s312-s318. [PMID: 25734340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Although numerous studies have shown that anticoagulants can reduce the risk of stroke and thromboembolic events in patients with nonvalvular atrial fibrillation, they are underprescribed in the clinical setting. While standardized risk scoring assessments are recommended in treatment guidelines to determine when anticoagulant use may be appropriate, they are not widely used in the real-world clinical setting. Many factors contribute to anticoagulant underuse, including patient characteristics and comorbidities. Reluctance to prescribe an anticoagulant may also stem from concerns about bleeding or other perceived risks. In addition, physicians may be discouraged from prescribing anticoagulant therapy, particularly warfarin, if follow-up care and monitoring is potentially unfeasible. Patient fears of treatment and lack of access to the healthcare system also contribute to underuse. Increased awareness and education, medical therapy management programs, better care coordination, and improvements in monitoring and follow-up programs may help to increase the use of anticoagulant therapies in appropriate patients.
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Desai NR, Krumme AA, Schneeweiss S, Shrank WH, Brill G, Pezalla EJ, Spettell CM, Brennan TA, Matlin OS, Avorn J, Choudhry NK. Patterns of initiation of oral anticoagulants in patients with atrial fibrillation- quality and cost implications. Am J Med 2014; 127:1075-1082.e1. [PMID: 24859719 DOI: 10.1016/j.amjmed.2014.05.013] [Citation(s) in RCA: 168] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 04/24/2014] [Accepted: 05/09/2014] [Indexed: 01/13/2023]
Abstract
BACKGROUND Dabigatran, rivaroxaban, and apixaban have been approved for use in patients with atrial fibrillation based upon randomized trials demonstrating their comparable or superior efficacy and safety relative to warfarin. Little is known about their adoption into clinical practice, whether utilization is consistent with the controlled trials on which their approval was based, and how their use has affected health spending for patients and insurers. METHODS We used medical and prescription claims data from a large insurer to identify patients with nonvalvular atrial fibrillation who were prescribed an oral anticoagulant in 2010-2013. We plotted trends in medication initiation over time, assessed corresponding insurer and patient out-of-pocket spending, and evaluated the cumulative number and cost of anticoagulants. We identified predictors of novel anticoagulant initiation using multivariable logistic models. Finally, we estimated the difference in total drug expenditures over 6 months for patients initiating warfarin versus a novel anticoagulant. RESULTS There were 6893 patients with atrial fibrillation that initiated an oral anticoagulant during the study period. By the end of the study period, novel anticoagulants accounted for 62% of new prescriptions and 98% of anticoagulant-related drug costs. Female sex, lower household income, and higher CHADS2, CHA2DS2-VASC, and HAS-BLED scores were significantly associated with lower odds of receiving a novel anticoagulant (P <.001 for each). Average combined patient and insurer anticoagulant spending in the first 6 months after initiation was more than $900 greater for patients initiating a novel anticoagulant. CONCLUSIONS This study demonstrates rapid adoption of novel anticoagulants into clinical practice, particularly among patients with lower CHADS2 and HAS-BLED scores, and high health care cost consequences. These findings provide important directions for future comparative and cost-effectiveness research.
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Affiliation(s)
- Nihar R Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass; Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Conn; Center for Outcomes Research and Evaluation, Yale-New Haven Health Services Corporation, New Haven, Conn
| | - Alexis A Krumme
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - William H Shrank
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass; CVS Caremark, Woonsocket, RI
| | - Gregory Brill
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | | | | | | | | | - Jerry Avorn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Niteesh K Choudhry
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass.
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Gregory RS, Handelsman Y, Pezalla EJ, Pikelny D. Practical perspectives on the management of overweight and obesity. Am J Manag Care 2014; 20:S64-S75. [PMID: 24773374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The prevalence of obesity, defined as a body mass index of 30 or more, has reached epidemic proportions in the United States. Obesity is associated with an increased risk of multiple conditions, including type 2 diabetes mellitus, cardiovascular disease, arthritis, and sleep apnea. To discuss issues related to obesity in the workplace, healthcare, and managed care settings, stakeholders from these areas participated in a roundtable discussion on several topics, including the management of obesity, managed care coverage policies for obesity treatments, and potential strategies for improving patient outcomes. Participants agreed that obesity is a challenging condition to treat. Lifestyle modification, one of the most commonly recommended treatment modalities, is often inadequate on its own, as patients are unable to maintain weight loss over time. Although lifestyle modification remains important, additional tools are needed. In patients who undergo bariatric surgery, lifestyle modification is also necessary for long-term weight maintenance; however, surgery is not appropriate for all patients. Pharmacologic treatment may also be considered, but cost and managed care coverage policies have the potential to limit patient access to this treatment modality. Increased awareness and additional efforts on the part of all stakeholders are needed to improve outcomes for patients affected by obesity.
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Navarro RP, Ballow M, Fenrick B, Pezalla EJ. Considerations for the optimal use of immunoglobulin. Am J Manag Care 2012; 18:S67-S78. [PMID: 22774920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Immunoglobulins are large Y-shaped proteins produced by B-cells and plasma cells that are used by the immune system to identify and neutralize foreign objects such as bacteria and viruses. Immunoglobulin G (IgG) preparations are approved by the US Food and Drug Administration for the treatment of primary immunodeficiency disease, idiopathic thrombocytopenic purpura, Kawasaki disease, chronic lymphocytic leukemia with frequent infections, bone marrow transplantation, to prevent infection in pediatric human immunodeficiency virus, and chronic inflammatory demyelinating polyneuropathy. However, IgG products are frequently used off label in many autoimmune conditions. The advent of numerous intravenous and subcutaneous formulations of IgG presents new opportunities impacting patient preferences, site of care, and costs. The appropriate and optimal use of IgG is reviewed based on discussions from an expert roundtable panel and review of the scientific literature. Clinicians and payers should consider patient preferences, evidence- based guidelines, and policies when selecting an IgG product.
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Affiliation(s)
- Robert P Navarro
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, FL 32610, USA.
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