Association between oral targeted cancer drug net health benefit, uptake, and spending

BACKGROUND

Targeted cancer drugs (TCDs) have revolutionized oncology but vary in clinical benefit and patient out-out-pocket (OOP) costs. The ASCO Value Framework uses survival, toxicity, and symptom palliation data to quantify the net health benefit (NHB) of cancer drugs. We evaluated associations between NHB, uptake, and spending on oral TCDs.

METHODS

We conducted a retrospective cohort study of patients aged 18-64 years with an incident oral TCD pharmacy claim in 2012-2020 in a nationwide de-identified commercial claims dataset. TCDs were categorized as having high (>60), medium (40-60), and low (<40) NHB scores. We plotted the uptake of TCDs by NHB category and used standard descriptive statistics to evaluate patient OOP and total spending. Generalized linear models evaluated the relationship between spending and TCD NHB, adjusted for cancer indication.

RESULTS

We included 8,524 patients with incident claims for eight oral TCDs with nine first-line indications in advanced melanoma, breast, lung, and pancreatic cancer. Medium- and high-NHB TCDs accounted for most TCD prescriptions. Median OOP spending was $18.78 for the first 28-day TCD supply (IQR $0.00-$87.57); 45% of patients paid $0 OOP. Median total spending was $10,118.79 (IQR $6,365.95-$10,600.37) for an incident 28-day TCD supply. Total spending increased $1,083.56 for each 10-point increase in NHB score (95% CI $1,050.27-$1,116.84, p < .01 for H0=$0).

CONCLUSION

Low-NHB TCDs were prescribed less frequently than medium- and high-NHB TCDs. Total spending on oral TCDs was high and positively associated with NHB. Commercially insured patients were largely shielded from high OOP spending on oral TCDs.

Analysis of Devices Authorized by the FDA for Clinical Decision Support in Critical Care

This case series study examines the clinical evidence cited for US Food and Drug Administration–approved clinical decision support devices for use in the critical care setting.

The Revolving Door In Health Care Regulation

Of people appointed to the Department of Health and Human Services between 2004 and 2020, 15 percent had been employed in private industry immediately before their appointment. At the end of their tenure, 32 percent exited to industry. The greatest net exits to industry were from the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services.

Using remotely monitored patient activity patterns after hospital discharge to predict 30 day hospital readmission: a randomized trial

Hospital readmission prediction models often perform poorly, but most only use information collected until the time of hospital discharge. In this clinical trial, we randomly assigned 500 patients discharged from hospital to home to use either a smartphone or wearable device to collect and transmit remote patient monitoring (RPM) data on activity patterns after hospital discharge. Analyses were conducted at the patient-day level using discrete-time survival analysis. Each arm was split into training and testing folds. The training set used fivefold cross-validation and then final model results are from predictions on the test set. A standard model comprised data collected up to the time of discharge including demographics, comorbidities, hospital length of stay, and vitals prior to discharge. An enhanced model consisted of the standard model plus RPM data. Traditional parametric regression models (logit and lasso) were compared to nonparametric machine learning approaches (random forest, gradient boosting, and ensemble). The main outcome was hospital readmission or death within 30 days of discharge. Prediction of 30-day hospital readmission significantly improved when including remotely-monitored patient data on activity patterns after hospital discharge and using nonparametric machine learning approaches. Wearables slightly outperformed smartphones but both had good prediction of 30-day hospital-readmission.

Insurance and racial disparities in prior authorization in gynecologic oncology

While prior authorization aims to reduce unnecessary care, it may limit or delay medically necessary care. Delays in cancer care can impact survival and are more common in historically-marginalized populations. Our objective was to examine to what extent disparities occurred in prior authorizations for gynecologic oncology. Using electronic medical records, we performed a retrospective review of prior authorization occurrence during gynecologic oncology care and analyzed the association with patient race and insurance in a multivariate regression model. In this cohort of 1,406 patients treated at an academic gynecologic oncology practice, patients with Medicare Advantage and patients of Asian descent were more likely to experience prior authorization. Addressing insurance-mediate disparities, such as in the occurrence of prior authorization, may help reduce disparities in gynecologic cancer care.

Effect of Nudges to Clinicians, Patients, or Both to Increase Statin Prescribing: A Cluster Randomized Clinical Trial

Importance

Statins reduce the risk of major adverse cardiovascular events, but less than one-half of individuals in America who meet guideline criteria for a statin are actively prescribed this medication.

Objective

To evaluate whether nudges to clinicians, patients, or both increase initiation of statin prescribing during primary care visits.

Design, Setting, and Participants

This cluster randomized clinical trial evaluated statin prescribing of 158 clinicians from 28 primary care practices including 4131 patients. The design included a 12-month preintervention period and a 6-month intervention period between October 19, 2019, and April 18, 2021.

Interventions

The usual care group received no interventions. The clinician nudge combined an active choice prompt in the electronic health record during the patient visit and monthly feedback on prescribing patterns compared with peers. The patient nudge was an interactive text message delivered 4 days before the visit. The combined nudge included the clinician and patient nudges.

Main Outcomes and Measures

The primary outcome was initiation of a statin prescription during the visit.

Results

The sample comprised 4131 patients with a mean (SD) age of 65.5 (10.5) years; 2120 (51.3%) were male; 1210 (29.3%) were Black, 106 (2.6%) were Hispanic, 2732 (66.1%) were White, and 83 (2.0%) were of other race or ethnicity, and 933 (22.6%) had atherosclerotic cardiovascular disease. In unadjusted analyses during the preintervention period, statins were prescribed to 5.6% of patients (105 of 1876) in the usual care group, 4.8% (97 of 2022) in the patient nudge group, 6.0% (104 of 1723) in the clinician nudge group, and 4.7% (82 of 1752) in the combined group. During the intervention, statins were prescribed to 7.3% of patients (75 of 1032) in the usual care group, 8.5% (100 of 1181) in the patient nudge group, 13.0% (128 of 981) in the clinician nudge arm, and 15.5% (145 of 937) in the combined group. In the main adjusted analyses relative to usual care, the clinician nudge significantly increased statin prescribing alone (5.5 percentage points; 95% CI, 3.4 to 7.8 percentage points; P = .01) and when combined with the patient nudge (7.2 percentage points; 95% CI, 5.1 to 9.1 percentage points; P = .001). The patient nudge alone did not change statin prescribing relative to usual care (0.9 percentage points; 95% CI, -0.8 to 2.5 percentage points; P = .32).

Conclusions and Relevance

Nudges to clinicians with and without a patient nudge significantly increased initiation of a statin prescription during primary care visits. The patient nudge alone was not effective.

Trial Registration

ClinicalTrials.gov Identifier: NCT04307472.

Association Between Nephrologist Ownership of Dialysis Facilities and Clinical Outcomes

Importance

Ownership of US dialysis facilities presents a financial conflict of interest for nephrologists, who may change their clinical practice to improve facility profitability.

Objective

To investigate the association between nephrologist ownership of freestanding dialysis facilities and clinical outcomes.

Design, Setting, and Participants

This cross-sectional study was conducted using US Renal Data System data linked to a data set of freestanding nonpediatric dialysis facility owners. Participants were a sample of all adults with fee-for-service Medicare receiving dialysis for end-stage kidney disease from January 2017 to November 2017 at included facilities. Data were analyzed from April 2020 through August 2022.

Exposures

Outcomes associated with nephrologist ownership were assessed using a difference-in-differences analysis comparing the difference in outcomes between patients treated by nephrologist owners and patients treated by nonowners within facilities owned by nephrologists after accounting for differences in patient outcomes between nephrologist owners and nonowners in other facilities.

Main Outcomes and Measures

Outcomes plausibly associated with nephrologist ownership were evaluated: (1) treatment volumes (missed treatments and transplant waitlist status); (2) erythropoietin-stimulating agent (ESA) use and related outcomes (anemia, defined as hemoglobin level <10 g/dL, and blood transfusions), (3) quality metrics (mortality, hospitalizations, 30-day readmissions, hemodialysis adequacy, arteriovenous fistula use, and hemodialysis catheter use for ≥3 months), and (4) home dialysis use.

Results

A cohort of 251 651 patients (median [IQR] age, 66 [46-85] years; 112 054 [44.5%] women; 9765 Asian [3.9%], 86 837 Black [34.5%], and 148 617 White [59.1%]; 38 938 Hispanic [15.5%]) receiving dialysis for end-stage kidney disease were included. Patient treatment by nephrologist owners at their owned facilities was associated with a 2.4 percentage point (95% CI, 1.1-3.8 percentage points) higher probability of home dialysis, a 2.2 percentage point (95% CI, 3.6-0.7 percentage points) lower probability of receiving an ESA, and no significant difference in anemia or blood transfusions. Patient treatment by nephrologist owners at their owned facilities was not associated with differences in missed treatments, transplant waitlisting, mortality, hospitalizations, 30-day readmissions, hemodialysis adequacy, or fistula or long-term dialysis catheter use.

Conclusions and Relevance

This cross-sectional cohort study found that nephrologist ownership was associated with increased home dialysis use, decreased ESA use, and no change in anemia or blood transfusions.

Trends in Medically Integrated Dispensing Among Oncology Practices

PURPOSE

The integration of pharmacies with oncology practices-known as medically integrated dispensing or in-office dispensing-could improve care coordination but may incentivize overprescribing or inappropriate prescribing. Because little is known about this emerging phenomenon, we analyzed historical trends in medically integrated dispensing.

METHODS

Annual IQVIA data on oncologists were linked to 2010-2019 National Council for Prescription Drug Programs pharmacy data; data on commercially insured patients diagnosed with any of six common cancer types; and summary data on providers' Medicare billing. We calculated the national prevalence of medically integrated dispensing among community and hospital-based oncologists. We also analyzed the characteristics of the oncologists and patients affected by this care model.

RESULTS

Between 2010 and 2019, the percentage of oncologists in practices with medically integrated dispensing increased from 12.8% to 32.1%. The share of community oncologists in dispensing practices increased from 7.6% to 28.3%, whereas the share of hospital-based oncologists in dispensing practices increased from 18.3% to 33.4%. Rates of medically integrated dispensing varied considerably across states. Oncologists who dispensed had higher patient volumes (P < .001) and a smaller share of Medicare beneficiaries (P < .001) than physicians who did not dispense. Patients treated by dispensing oncologists had higher risk and comorbidity scores (P < .001) and lived in areas with a higher % Black population (P < .001) than patients treated by nondispensing oncologists.

CONCLUSION

Medically integrated dispensing has increased significantly among oncology practices over the past 10 years. The reach, clinical impact, and economic implications of medically integrated dispensing should be evaluated on an ongoing basis.

Intensity of end-of-life care for gynecologic cancer patients by primary oncologist specialty

Objective

The association of primary oncologist specialty, medical oncology versus gynecologic oncology, on intensity of care at the end of life in elderly patients with gynecologic cancer is unclear.

Methods

This retrospective cohort study used Surveillance, Epidemiology and End Results-Medicare (SEER-M) data. Subjects were fee-for-service Medicare enrollees aged 65 years and older who died of a gynecologic cancer between January 2006 and December 2015. The primary outcome was a composite score for high-intensity care received in the last month of life. Secondary outcomes included invasive procedures and Medicare spending in the last month of life. Simple and multivariable linear and logistic regression analyses evaluated differences in outcomes by primary oncologist specialty. Linear regressions were repeated after creating a more similar control group through nearest-neighbor propensity score matching.

Results

Of 12 189 patients, 7705 (63%) had a medical primary oncologist in the last year of life. In adjusted analyses, patients with a gynecologic versus medical primary oncologist received lower rates of high-intensity end-of-life care (53.9% vs 56.6%; p=0.018). Results were similar for the propensity score-matched cohorts. However, having a gynecologic versus medical primary oncologist was associated with higher rates of invasive procedures in the last month of life (43% vs 41%; p=0.014) and higher Medicare spending ($83 859 vs $74 849; p=0.004).

Conclusions

Both specialties engage in overall high levels of intense end-of-life care, with differences by specialty in aspects of aggressive care and spending at the end of life. Physician-level training could be a target for educational or quality improvement initiatives to improve end-of-life cancer care delivery.

Association of gynecologic oncology versus medical oncology specialty with survival, utilization, and spending for treatment of gynecologic cancers

BACKGROUND

We examined the association of gynecologic oncology (GYO) versus medical oncology (MEDONC) based care with survival, health care utilization and spending outcomes in women undergoing chemotherapy for advanced gynecologic cancers.

METHODS

Women with newly diagnosed stage III-IV uterine, ovarian, and cervical cancers from 2000 to 2015 were identified in SEER-Medicare. We assessed the association of provider specialty with overall survival, emergency department utilization, admissions, and spending. Outcomes were assessed using unadjusted and Inverse Treatment Probability Weighted propensity-score applied, multi-variable cox modeling, Poisson regression, and generalized models of log-transformed data.

RESULTS

We identified 7930 gynecologic cancer patients (4360 ovarian, 2934 uterine, 643 cervix). 37% were treated by GYO and 63% by MEDONC. For ovarian patients, GYO care was associated with improved OS (median OS 3.3 v. 2.9 years; HR 0.85, 95%CI 0.80, 0.91, p < .0001) and similar mean spending per month ($4015 v. $4316, mean ratio 0.97 (95% CI 0.93, 1.02), p = .19), compared to MEDONC in adjusted analyses. For uterine patients, GYO care was associated with similar OS, but decreased spending ($3573 v. $4081, mean ratio 0.87 (95% CI.81, 0.93), p < .0001), and decreased ED utilization (RR 0.76, 95% CI 0.69, 0.85, p < .0001). For cervical patients, GYO care was associated with similar OS, and similar spending. Admissions were more likely in ovarian (RR 1.23, 95%CI 1.11, 1.37, p = .0001) and cervical patients (RR 1.26, 95% CI 1.05, 1.51, p = .015) treated by GYO, in adjusted analyses.

CONCLUSIONS

GYO based care was associated with improved OS and equal spending for patients with advanced stage ovarian cancer. Uterine and cervix patients had similar OS, and less or equal spending respectively, when treated by GYO compared to MEDONC.

Interventional cardiologists' attitudes towards pharmacogenetic testing and impact on antiplatelet prescribing decisions

Aim: To determine if interventional cardiologists' knowledge and attitudes toward pharmacogenetic (PGx) testing influenced their antiplatelet prescribing decisions in response to CYP2C19 results. Materials & methods: Surveys were administered prior to participating in a randomized trial of CYP2C19 testing. Associations between baseline knowledge/attitudes and agreement with the genotype-guided antiplatelet recommendations were determined using multivariable logistic regression. Results: 50% believed that PGx testing would be valuable to predict medication toxicity or efficacy. 64% felt well informed about PGx testing and its therapeutic application. However, PGx experience, knowledge, nor attitudes were significantly associated with agreement to genotype-guided antiplatelet recommendations. Conclusion: Cardiologists' knowledge and attitudes were not associated with CYP2C19-guided antiplatelet prescribing, but larger studies should be done to confirm this finding.

Historical trends in health care-related financial holdings among members of Congress

Background

Revelations that some members of Congress, including members of key health care committees, hold substantial personal investments in the health care industry have raised concerns about lawmakers’ financial conflicts of interest (COI) and their potential impact on health care legislation and oversight.

Aims

1) To assess historical trends in both the number of legislators holding health care-related assets and the value and composition of those assets. 2) To compare the financial holdings of members of health care-focused committees and subcommittees to those of other members of the House and Senate.

Methods

We analyzed 11 years of personal financial disclosures by all members of the House and Senate. For each year, we calculated the percentage of members holding a health care-related asset (overall, by party, and by committee); the total value of all assets and health care-related assets held; the mean and median values of assets held per member; and the share of asset values attributable to 9 health asset categories.

Findings

During the study period, over a third of all members of Congress held health care-related assets. These assets were often substantial, with a median total value per member of over $43,000. Members of health care-focused committees and subcommittees in the House and Senate did not hold health care-related assets at a higher rate than other members of their respective chambers.

Conclusions

These findings suggest that lawmakers’ health care-related COI warrant the same level of attention that has been paid to the COI of other actors in the health care system.

Access to pharmacies and pharmacy services in New York City, Los Angeles, Chicago, and Houston, 2015-2020

BACKGROUND

Despite the importance of pharmacies in ensuring medications and health care needs are met, there is limited up-to-date information regarding access to pharmacies or their services in the United States.

OBJECTIVES

To evaluate trends and disparities in access to pharmacies in 4 largest cities in the United States, New York City, Los Angeles, Houston, and Chicago, by neighborhood racial and ethnic composition from 2015 to 2020.

METHODS

Data from the National Council for Prescription Drug Programs (2015-2020) and the American Community Survey (2015-2019) were used. We examined neighborhoods (i.e., census tracts) and evaluated disparities in "pharmacy deserts" (low-income neighborhoods (1) whose average distance to the nearest pharmacy was at least 1 mile or (2) whose average distance to the nearest pharmacy was at least 0.5 mile and at least 100 households had no vehicle access). We also evaluated the differences in pharmacy closures and the availability of pharmacy services.

RESULTS

From 2015 to 2020, the percent of neighborhoods with pharmacy deserts declined in New York City (from 1.6% to 0.9% of neighborhoods, P < 0.01), remained stable in Los Angeles (13.7% to 13.4%, P = 0.58) and Houston (27.0% to 28.5%, P = 0.18), and increased in Chicago (15.0% to 19.9%, P < 0.01). Pharmacy deserts were persistently more common in Black and Latino neighborhoods in all 4 cities. As of 2020, pharmacies in Black and Latino neighborhoods were also more likely to close and less likely to offer immunization, 24-hour, and drive-through services than pharmacies in other neighborhoods.

CONCLUSION

To reduce disparities in access to medications and health care services, including those in response to the coronavirus disease 2019 pandemic (e.g., testing and vaccinations), policies that improve pharmacy access and expand the provision of pharmacy services in minority neighborhoods are critical.

Intensity of end-of-life care for gynecologic cancer patients by primary oncologist specialty

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Background: The impact of primary oncologist specialty, medical oncology (MO) versus gynecologic oncology (GO), on intensity of care at the end of life (EOL) in elderly patients with gynecologic cancer is unclear. Methods: This retrospective cohort study used Surveillance, Epidemiology and End Results (SEER) Medicare data. Subjects were fee-for-service Medicare enrollees over 65 years old, who had seen a GO or MO in an outpatient setting in the last year of life and died of a gynecologic cancer between 2006 and 2015. The primary oncologist was defined as the provider with the majority of outpatient visits in the last year of life. The primary outcome was intensity of care at the EOL, a composite score defined by receipt of chemotherapy in the last 14 days of life, death in the hospital, enrollment in hospice for less than three days, more than one ED visit, more than one hospital admission, spending more than 14 days in the hospital, or any ICU admission in the last 30 days of life. Simple and multivariable linear regression analyses were conducted to evaluate for differences in EOL care outcomes by primary oncologist specialty. Linear regressions were repeated after creating a more similar control group through nearest-neighbor propensity score matching, with and without replacement. Results: Of 12,189 subjects, 63% were primarily treated by a MO and only 27% by a GO for EOL care. Most died of ovarian cancer (55.1%), followed by uterine (31.4%), cervical (6.9%), and other cancers (6.7%). Compared to GO patients, MO patients were younger, more likely to be white, married, not dual-eligible, higher stage, and to die of ovarian cancer. Overall, 55.4% (95% CI 54.73-56.49) received intense care at the EOL. Although both specialties engaged in high levels of intense EOL care, the adjusted rates for GO (54.03%; 95% CI 52.28-55.77) were significantly less compared to MO (56.53%; 95% CI 55.36-57.69; p=0.023) in unadjusted and adjusted analyses of the entire and propensity-matched cohorts (Table). Conclusions: Approximately 2/3 of women with gynecologic cancer will receive EOL care from a MO, compared to 1/3 from a GO. Both specialists engage in high levels of intense EOL care in over half of their patients, although GO less so. Future work should focus on identifying approaches to reduce high-intensity EOL care, which may include additional training or incorporation of palliative medicine into cancer care.[Table: see text]

Multi-site practice and physician travel burden by oncology specialty

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Background: Having physicians who practice at multiple sites may increase patients’ access to care, but also burden physicians Gynecologic oncologists (GO) are increasingly practicing at more sites across a larger geographic area, but the degree to which medical oncologists (MO), surgical oncologists (SO) or radiation oncologists (RO) are also doing so is unknown. Methods: We conducted a retrospective, observational study using data from the 2020 Physician Compare National Dataset. We included GO, MO, SO, RO, as determined by self-reported specialty. Practice sites with incomplete street addresses were excluded. For each specialty, we calculated the number of practice sites per physician, geographic practice dispersion (median driving distance required to go to each practice site), and temporal practice dispersion (median travel time required to go to each practice site). We used linear regression to compare the number of practice sites, geographic practice dispersion, and temporal practice dispersion by specialty. Results: The number of physicians, mean number of practice sites, along with geographic and temporal practice dispersion by specialty are shown in the table. MO practiced at a smaller number of practice sites compared to GO (p<0.001) and RO (p<0.001). Compared to MO, SO had a smaller geographic dispersion (median driving distance 22 miles vs. 38 miles, p=<0.001) and temporal practice dispersion (median driving time 27 minutes vs. 43 minutes, p<0.001), whereas RO had a larger geographic dispersion (median RO driving distance 58 minutes, p<0.001) and temporal practice dispersion (median RO driving time 63 minutes, p<0.001). Conclusions: Oncologic specialties vary in the number of practice sites and practice dispersion per oncologist. In particular, GO and RO practice at more sites than MO, with MO practices more geographically concentrated than RO practices. While SO practice at a similar number of practice sites compared to MO, their practices are the most geographically concentrated. While these practice patterns may represent increased patient access to specialty oncology care, the impact on quality of care and physician wellness is unknown.[Table: see text]

Growth Of Public Coverage Among Working Families In The Private Sector

Working families have increasingly enrolled their children in Medicaid or the Children's Health Insurance Program in recent years. Parents' place of employment affects the availability and cost of family health insurance, making it a determinant of pediatric public insurance enrollment. We examined that enrollment in the period 2008-16 in families working full time and earning more than 100 percent of the federal poverty level at three types of employers. Among low-income families (100-199 percent of poverty), children's public health insurance coverage was highest for those with parents employed at small private firms, increasing from 53 percent to 79 percent, while the public insurance coverage rate also increased among children with parents working for large private firms (from 45 percent to 69 percent). Among moderate-income families (200-299 percent of poverty) working at small private firms, public coverage increased from 21 percent to 64 percent. Increases in the number of working families with pediatric public insurance were driven by employees of large private firms. Maintaining high pediatric insurance coverage rates will require policies that recognize the changing role of public insurance for working families as the cost of employer-based coverage grows.

Income Disparities In Access To Critical Care Services

The coronavirus disease 2019 (COVID-19) pandemic has highlighted the importance of intensive care unit (ICU) beds in preventing death from the severe respiratory illness associated with COVID-19. However, the availability of ICU beds is highly variable across the US, and health care resources are generally more plentiful in wealthier communities. We examined disparities in community ICU beds by US communities' median household income. We found a large gap in access by income: 49 percent of the lowest-income communities had no ICU beds in their communities, whereas only 3 percent of the highest-income communities had no ICU beds. Income disparities in the availability of community ICU beds were more acute in rural areas than in urban areas. Policies that facilitate hospital coordination are urgently needed to address shortages in ICU hospital bed supply to mitigate the effects of the COVID-19 pandemic on mortality rates in low-income communities.

Association of State Medicaid Expansion With Hospital Community Benefit Spending

IMPORTANCE

Medicaid expansion was widely expected to alleviate the financial stresses faced by hospitals by providing additional revenue in the form of Medicaid reimbursements from patients previously receiving uncompensated care. Among nonprofit hospitals, which receive tax-exempt status in part because of their provision of uncompensated care, Medicaid expansion could have released hospital funds toward other community benefit activities.

OBJECTIVE

To examine changes in nonprofit hospital spending on community benefit activities after Medicaid expansion.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used difference-in-differences analysis of 1666 US nonprofit hospitals that filed Internal Revenue Service Form 990 Schedule H detailing their community benefit expenditures between 2011 and 2017. The analysis was conducted from February to September 2019.

EXPOSURES

State Medicaid expansion between 2011 and 2017.

MAIN OUTCOMES AND MEASURES

Percentage of hospital operating expenditures attributable to charity care and subsidized care, bad debt (ie, unreimbursed spending for care of patients who did not apply for charity care), unreimbursed Medicaid spending, noncare direct community spending, and total community benefit spending.

RESULTS

Of 1478 hospitals in the sample in 2011, nearly half (653 [44.2%]) were small hospitals with fewer than 100 beds, and nearly 70% of hospitals (1023 [69.2%]) were in urban areas. Among the 1666 nonprofit hospitals, Medicaid expansion was associated with a decrease in spending on charity care and subsidized care (-0.68 [95% CI, -0.99 to -0.37] percentage points from a baseline mean [SD] of 3.6% [4.0%] of total hospital expenditures; P < .001) and in bad debt (-0.17 [95% CI, -0.32 to -0.01] percentage points). There was an increase in unreimbursed spending attributable to caring for Medicaid patients (0.85 [95% CI, 0.60 to 1.10] percentage points; P = .04), which canceled out uncompensated care savings from the expansion. Noncare direct community expenditures decreased overall (-0.24 [95% CI, -0.48 to 0.00] percentage points; P = .049). Direct community expenditures remained more stable in small hospitals (-0.07 [95% CI, -0.20 to 0.05] percentage points; P =.26) compared with large hospitals (-0.37 [95% CI, -0.86 to 0.12] percentage points; P = .14) and in nonurban hospitals (0.02 [95% CI, -0.09 to 0.14] percentage points; P = .70) compared with urban hospitals (-0.36 [95% CI, -0.73 to 0.01] percentage points; P = .06).

CONCLUSIONS AND RELEVANCE

In this study, Medicaid expansion was associated with a decrease in nonprofit hospitals' burden of providing uncompensated care, but this financial relief was not redirected toward spending on other community benefits.

Association of a Targeted Population Health Management Intervention with Hospital Admissions and Bed-Days for Medicaid-Enrolled Children

IMPORTANCE

As the proportion of children with Medicaid coverage increases, many pediatric health systems are searching for effective strategies to improve management of this high-risk population and reduce the need for inpatient resources.

OBJECTIVE

To estimate the association of a targeted population health management intervention for children eligible for Medicaid with changes in monthly hospital admissions and bed-days.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study, using difference-in-differences analysis, deployed integrated team interventions in an academic pediatric health system with 31 in-network primary care practices among children enrolled in Medicaid who received care at the health system's hospital and primary care practices. Data were collected from January 2014 to June 2017. Data analysis took place from January 2018 to June 2019.

EXPOSURES

Targeted deployment of integrated team interventions, each including electronic medical record registry development and reporting alongside a common longitudinal quality improvement framework to distribute workflow among interdisciplinary clinicians and community health workers.

MAIN OUTCOMES AND MEASURES

Trends in monthly inpatient admissions and bed-days (per 1000 beneficiaries) during the preimplementation period (ie, January 1, 2014, to June 30, 2015) compared with the postimplementation period (ie, July 1, 2015, to June 30, 2017).

RESULTS

Of 25 460 children admitted to the hospital's health system during the study period, 8418 (33.1%) (3869 [46.0%] girls; 3308 [39.3%] aged ≤1 year; 5694 [67.6%] black) were from in-network practices, and 17 042 (67.9%) (7779 [45.7%] girls; 6031 [35.4%] aged ≤1 year; 7167 [41.2%] black) were from out-of-network practices. Compared with out-of-network patients, in-network patients experienced a decrease of 0.39 (95% CI, 0.10-0.68) monthly admissions per 1000 beneficiaries (P = .009) and 2.20 (95% CI, 0.90-3.49) monthly bed-days per 1000 beneficiaries (P = .001). Accounting for disproportionate growth in the number of children with medical complexity who were in-network to the health system, this group experienced a monthly decrease in admissions of 0.54 (95% CI, 0.13-0.95) per 1000 beneficiaries (P = .01) and in bed-days of 3.25 (95% CI, 1.46-5.04) per 1000 beneficiaries (P = .001) compared with out-of-network patients. Annualized, these differences could translate to a reduction of 3600 bed-days for a population of 93 000 children eligible for Medicaid.

CONCLUSIONS AND RELEVANCE

In this quality improvement study, a population health management approach providing targeted integrated care team interventions for children with medical and social complexity being cared for in a primary care network was associated with a reduction in service utilization compared with an out-of-network comparison group. Standardizing the work of care teams with quality improvement methods and integrated information technology tools may provide a scalable strategy for health systems to mitigate risk from a growing population of children who are eligible for Medicaid.

US Growth Hormone Use in the Idiopathic Short Stature Era: Trends in Insurer Payments and Patient Financial Burden

Objective

To investigate trends in prevalence and expenditures of growth hormone (GH) use by US youth in the last 15 years, a period during which the US Food and Drug Administration (FDA) approved GH treatment of idiopathic short stature (ISS), and insurers imposed greater barriers to GH treatment reimbursements.

Design

With the use of 2001 to 2016 OptumInsight commercial claims data, we analyzed trends in claims of GH drugs among beneficiaries aged 0 to 18 years (n = 38,857 beneficiaries receiving GH). Outcome measures included annual prevalence of GH claims and annual total insurer and total patient payments for GH claims. t Tests were used for linear time trends in outcomes. The percentage of beneficiaries switching GH brands also was calculated.

Results

The number of members with GH claims per 10,000 beneficiaries under age 18 rose steadily from 5.1 in 2001 to 14.6 in 2016, without a dramatic change around 2003, the ISS approval date. Mean total GH expenditures decreased (−26% in constant dollars), as did the estimated insurance paid amount (−28%). However, mean total patient spending increased by 163%. Beneficiaries switching GH brands in the year ranged from 1.4% to 3.6% in 2001 to 2007 and from 5.1% to 8.8% after, with 25.6% switching in 2009 and 13.9% switching in 2015.

Conclusions

The FDA ISS approval was not a watershed event in the steady increase in GH use by US youth. Progressive restrictions on coverage and formulary preference coverage strategies appear to have succeeded in lowering total expenditures and insurer burden of GH treatment per beneficiary. However, those savings were not passed on to patients who bore greater burdens financially and from brand switches.

Design and implementation of outpatient-based rapid MRI protocols to rule out metastatic spinal cord compression and brain metastases

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Background: Metastatic spinal cord compression (MSCC) and symptomatic brain metastases (mets) are potential emergencies that demand coordinated multidisciplinary management. Patients (pts) with concerning symptoms are often referred to the Emergency Department (ED) for expedited imaging, but most do not require subsequent ED or inpatient management. Unnecessary ED visits incur substantial cost to the health system and patients, and cause psychosocial stress for patients often near the end-of-life. To improve access to expedited outpatient imaging for high-risk pts and reduce unnecessary ED visits, we developed outpatient rapid MRI protocols and pathways to rule out MSCC and brain mets. Methods: Tailored abbreviated MRI protocols were developed to allow rapid acquisition of brain ( < 13 minutes) and full spine ( < 25 minutes) exams. Dedicated appointments were reserved on the daily MRI schedule. Exams were immediately interpreted and reported by Radiology to the ordering clinician. This pathway was piloted within the Thoracic Oncology group beginning in 10/2018. Results: Referring specialties included Radiation Oncology (50%), Medical Oncology (36%), Pulmonology (7%), and Surgery (7%). For 6 pts who had outpatient rapid brain imaging, median time from order to exam start was 4.3 h (1.8-31) and order to final report 6.8 h (3.2-34.1). Brain mets were found in 4/6 patients. Only 1/4 positive studies required subsequent ED management. For 8 pts referred for rapid spine imaging, median time from order to exam start was 14.4 h (2.2-72.5) and order to final report 16.7 h (4.0-74.4). Only 1 patient was found to have cord compression and required ED/inpatient management. Overall, 86% of patients did not require ED or inpatient admission. 3 pts (all with negative imaging) died a median 13.4 d (1.4-28.3) after order placement. Conclusions: Outpatient rapid MRI protocols facilitate same-day imaging, interpretation, and management, improving care for thoracic oncology pts with new concerning neurologic symptoms and reducing unnecessary ED visits. Future work will expand access beyond Thoracic Oncology and further quantify improvements in cost savings and patient quality of life.

US Nationwide Disclosure of Industry Payments and Public Trust in Physicians

IMPORTANCE

Transparency of industry payments to physicians could engender greater public trust in physicians but might also lead to greater mistrust of physicians and the medical profession, adversely affecting the patient-physician relationship.

OBJECTIVE

To examine the association between nationwide public disclosure of industry payments and Americans' trust in their physicians and trust in the medical profession.

DESIGN, SETTING, AND PARTICIPANTS

Survey study using difference-in-difference analyses of a national longitudinal survey comparing changes in states where industry payments were newly disclosed by Open Payments with changes in states where payments information was already available because of state sunshine laws. The US population-based surveys were conducted in September 2014-shortly before the initial public disclosure of industry payments-and again in September 2016. Final analyses were conducted September through December 2018. Participants were adults 18 years and older (n = 1388).

EXPOSURES

National public disclosure through Open Payments of payments made by pharmaceutical and medical device firms to physicians.

MAIN OUTCOMES AND MEASURES

Wake Forest measure of trust in one's own physician and Wake Forest measure of trust in the medical profession.

RESULTS

Of the 3542 original survey respondents, 2180 (61.5%) completed the second survey 2 years later, and 1388 named the same most frequently seen physician in both surveys. The mean age of respondents at the time of the first survey was 53 years, and 749 (54.0%) were women. Race/ethnicity was white in 76.6% (1063 of 1388) and non-Hispanic black in 8.0% (111 of 1388). Public disclosure of payments was associated with lower trust in one's own physician regardless of whether respondents knew their physicians had received payments (decrease in Wake Forest measure of trust in one's own physician of 0.56 point; 95% CI, -0.79 to -0.32 point; P < .001). Open Payments was also associated with lower trust in the medical profession (decrease in Wake Forest measure of trust in the medical profession of 0.35 point; 95% CI, -0.58 to -0.12 point; P = .004).

CONCLUSIONS AND RELEVANCE

Nationwide public disclosure of industry payments may be associated with decreased trust in physicians and in the medical profession. More judicious presentation of payments information may counteract unintended negative trust and spillover consequences of public disclosure.

Effect of the public disclosure of industry payments information on patients: results from a population-based natural experiment

OBJECTIVE

To determine the effect of the public disclosure of industry payments to physicians on patients' awareness of industry payments and knowledge about whether their physicians had accepted industry payments.

DESIGN

Interrupted time series with comparison group (difference-in-difference analyses of longitudinal survey).

SETTING

Nationally representative US population-based surveys. Surveys were conducted in September 2014, shortly prior to the public release of Open Payments information, and again in September 2016.

PARTICIPANTS

Adults aged 18 and older (n=2180).

MAIN OUTCOME MEASURES

Awareness of industry payments as an issue; awareness that industry payments information was publicly available; knowledge of whether own physician had received industry payments.

RESULTS

Public disclosure of industry payments information through Open Payments did not significantly increase the proportion of respondents who knew whether their physician had received industry payments (p=0.918). It also did not change the proportion of respondents who became aware of the issue of industry payments (p=0.470) but did increase the proportion who knew that payments information was publicly available (9.6% points, p=0.011).

CONCLUSIONS

Two years after the public disclosure of industry payments information, Open Payments does not appear to have achieved its goal of increasing patient knowledge of whether their physicians have received money from pharmaceutical and medical device firms. Additional efforts will be required to improve the use and effectiveness of Open Payments for consumers.

Association of Physician Group Participation in Accountable Care Organizations With Patient Social and Clinical Characteristics

IMPORTANCE

Accountable care organizations (ACOs) may increase health care disparities by excluding physician groups that care for socially and clinically vulnerable patients.

OBJECTIVE

To estimate the association between the patient characteristics of a physician group and the group's participation in a newly formed ACO.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study investigated a 20% random sample of US Medicare fee-for-service beneficiaries attributed to physician groups identified in Medicare claims before ACO participation from January 1, 2010, through December 31, 2011. Physician groups that participated and did not participate in the Medicare Shared Savings Program (MSSP) from January 1, 2012, through December 31, 2014, were identified in the Medicare MSSP 2014 provider file. Data analyses were conducted from September 1, 2017, to March 30, 2018.

EXPOSURES

Using multivariable regression, the association between physician group participation in the MSSP and the group's patients' characteristics before ACO formation was estimated focusing on measures of the vulnerability of the group's patients. All ACO-participating physician groups were compared with ACO-nonparticipating physician groups for reference, and estimates were made at the physician and patient level.

MAIN OUTCOMES AND MEASURES

Percentage of a physician group's patient panel that was socially vulnerable (based on race, dual Medicare and Medicaid enrollment, or living in high-poverty zip code) or clinically high risk.

RESULTS

Among 67 891 physician groups caring for 5 394 181 patients, 7215 physician groups (10.6%) participated in an MSSP ACO by 2014. Comparing mean percentages across practices, the patients of non-ACO-participating physician groups, more patients of ACO-participating physician groups were black (mean percentage across practices, 12.1% vs 10.6%), dually enrolled in Medicare and Medicaid (23.0% vs 19.3%), living in poverty (10.7% vs 11.1%), and high risk (34.2% vs 30.2%). After adjustment, physician groups that participated in an ACO had 5.1 percentage points (95% CI, 0.1-10.0 percentage points; P = .05) more dually enrolled patients and 4.0 percentage points (95% CI, 1.9-6.1 percentage points; P < .001) more high-risk patients. At the patient level, patients who were at high risk were more likely to be attributed to a group that became part of an ACO, with 4.5 percentage points (95% CI, 0.5-8.5 percentage points; P = .03) more high-risk patients being attributed to an ACO, but other associations were not statistically different from zero.

CONCLUSIONS AND RELEVANCE

Accountable care organizations may be an effective approach to target care among high-risk patients. In this study, physician groups that participated in the MSSP ACO program cared for more clinically vulnerable patients than did nonparticipating groups, and ACO-participating physician groups cared for an equally large number of socially vulnerable patients compared with nonparticipating physician groups.

Campaign Contributions From Political Action Committees to Members of Congressional Committees Responding to the Opioid Crisis

This study examines recent campaign contributions to members of US congressional committees responsible for legislating on the opioid crisis by political action committees (PACs) associated with firms under investigation for having contributed to the crisis.

The Short-Term Impacts of the Philadelphia Beverage Tax on Beverage Consumption

INTRODUCTION

On January 1, 2017, Philadelphia implemented a beverage tax of $0.015/ounce on sugar ("regular") and sugar-substitute ("diet") beverages. The purpose of this study was to evaluate the immediate impact of the tax on residents' consumption of soda, fruit drinks, energy drinks, and bottled water.

METHODS

A repeat cross-sectional study design used data from a random-digit-dialing phone survey during a no-tax period (December 6-31, 2016) and a tax period (January 15-February 31, 2017) among 899 respondents in Philadelphia, Pennsylvania, and 878 respondents in three nearby comparison cities. Survey questions included frequency and volume of bottled water and beverages. Outcomes were daily consumption, and 30-day consumption frequency and volume. Propensity score-weighted difference-in-differences regression was used to control for secular time trend and confounding. Covariates were sociodemographics, BMI, health status, smoking, and alcohol use. Analyses were conducted in 2017.

RESULTS

Within the first 2 months of tax implementation, relative to the comparison cities, in Philadelphia the odds of daily consumption of regular soda was 40% lower (OR=0.6, 95% CI=0.37, 0.97); energy drink was 64% lower (OR=0.36, 95% CI=0.17, 0.76); bottled water was 58% higher (OR=1.58, 95% CI=1.13, 2.20); and the 30-day regular soda consumption frequency was 38% lower (ratio of consumption frequency=0.62, 95% CI=0.40, 0.98).

CONCLUSIONS

Early results suggest that the tax influenced daily consumption of regular soda, energy drinks, and bottled water. Future studies are needed to evaluate longer-term impact of the tax on sugared beverage consumption and substitutions.

Conflicts of Interest of Public Speakers at Meetings of the Anesthetic and Analgesic Drug Products Advisory Committee

This data review investigates the characteristics and conflicts of interest of public speakers at Anesthetic and Analgesic Drug Products Advisory Committee meetings.

Neighborhood price of healthier food relative to unhealthy food and its association with type 2 diabetes and insulin resistance: The multi-ethnic study of atherosclerosis

This study examined the association between the price of healthier food relative to unhealthy food and type 2 diabetes prevalence, incidence and insulin resistance (IR). Data came from the Multi-Ethnic Study of Atherosclerosis exam 5 administered 2010-2012 (exam 4, five years prior, was used only for diabetes incidence) and supermarket food/beverage prices derived from Information Resources Inc. For each individual, average price of a selection of healthier foods, unhealthy foods and their ratio was computed for supermarkets within 3miles of the person's residential address. Diabetes status was confirmed at each exam and IR was assessed via the homeostasis model assessment index. Multivariable-adjusted logistic, modified Poisson and linear regression models were used to model diabetes prevalence, incidence and IR, respectively as a function of price and covariates; 2353 to 3408 participants were included in analyses (depending on the outcome). A higher ratio of healthy-to-unhealthy neighborhood food price was associated with greater IR (4.8% higher HOMA-IR score for each standard deviation higher price ratio [95% CI -0.2% to 10.1%]) after adjusting for region, age, gender, race/ethnicity, family history of diabetes, income/wealth index, education, smoking status, physical activity, and neighborhood socioeconomic status. No association with diabetes incidence (relative risk=1.11, 95% CI 0.85 to 1.44) or prevalence (odds ratio=0.95, 95% CI 0.81 to 1.11) was observed. Higher neighborhood prices of healthier food relative to unhealthy food were positively associated with IR, but not with either diabetes outcome. This study provides new insight into the relationship between food prices with IR and diabetes.