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O’Hara NN, Frey KP, Stein DM, Levy JF, Slobogean GP, Castillo R, Firoozabadi R, Karunakar MA, Gary JL, Obremskey WT, Seymour RB, Cuschieri J, Mullins CD, O’Toole RV. Effect of Aspirin Versus Low-Molecular-Weight Heparin Thromboprophylaxis on Medication Satisfaction and Out-of-Pocket Costs: A Secondary Analysis of a Randomized Clinical Trial. J Bone Joint Surg Am 2024; 106:590-599. [PMID: 38381842 PMCID: PMC10980176 DOI: 10.2106/jbjs.23.00824] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
BACKGROUND Current guidelines recommend low-molecular-weight heparin for thromboprophylaxis after orthopaedic trauma. However, recent evidence suggests that aspirin is similar in efficacy and safety. To understand patients' experiences with these medications, we compared patients' satisfaction and out-of-pocket costs after thromboprophylaxis with aspirin versus low-molecular-weight heparin. METHODS This study was a secondary analysis of the PREVENTion of CLots in Orthopaedic Trauma (PREVENT CLOT) trial, conducted at 21 trauma centers in the U.S. and Canada. We included adult patients with an operatively treated extremity fracture or a pelvic or acetabular fracture. Patients were randomly assigned to receive 30 mg of low-molecular-weight heparin (enoxaparin) twice daily or 81 mg of aspirin twice daily for thromboprophylaxis. The duration of the thromboprophylaxis, including post-discharge prescription, was based on hospital protocols. The study outcomes included patient satisfaction with and out-of-pocket costs for their thromboprophylactic medication measured on ordinal scales. RESULTS The trial enrolled 12,211 patients (mean age and standard deviation [SD], 45 ± 18 years; 62% male), 9725 of whom completed the question regarding their satisfaction with the medication and 6723 of whom reported their out-of-pocket costs. The odds of greater satisfaction were 2.6 times higher for patients assigned to aspirin than those assigned to low-molecular-weight heparin (odds ratio [OR]: 2.59; 95% confidence interval [CI]: 2.39 to 2.80; p < 0.001). Overall, the odds of incurring any out-of-pocket costs for thromboprophylaxis medication were 51% higher for patients assigned to aspirin compared with low-molecular-weight heparin (OR: 1.51; 95% CI: 1.37 to 1.66; p < 0.001). However, patients assigned to aspirin had substantially lower odds of out-of-pocket costs of at least $25 (OR: 0.15; 95% CI: 0.12 to 0.18; p < 0.001). CONCLUSIONS Use of aspirin substantially improved patients' satisfaction with their medication after orthopaedic trauma. While aspirin use increased the odds of incurring any out-of-pocket costs, it protected against costs of ≥$25, potentially improving health equity for thromboprophylaxis. LEVEL OF EVIDENCE Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nathan N. O’Hara
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Katherine P. Frey
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Deborah M. Stein
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Joseph F. Levy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Gerard P. Slobogean
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Renan Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Reza Firoozabadi
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Madhav A. Karunakar
- Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Joshua L. Gary
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - William T. Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rachel B. Seymour
- Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Joseph Cuschieri
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - C. Daniel Mullins
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Robert V. O’Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
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McLaughlin KH, Levy JF, Fritz JM, Skolasky RL. Trends in Telerehabilitation Utilization in the United States 2020-2021. Arch Phys Med Rehabil 2024:S0003-9993(24)00841-4. [PMID: 38452882 DOI: 10.1016/j.apmr.2024.02.728] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/04/2023] [Accepted: 02/21/2024] [Indexed: 03/09/2024]
Abstract
OBJECTIVE To examine telerehabilitation utilization in the United States (US) during the first 2 years of the pandemic. DESIGN We performed a retrospective analysis of outpatient insurance claims from the IBM MarketScan Commercial Claims and Encounters Database to identify the number and proportion of patients using telerehabilitation from 2020 to 2021. Telerehabilitation was identified based on the presence of specific code modifiers and place of service. SETTING Retrospective claims analysis. PARTICIPANTS Individuals living in the United States with employer-sponsored insurance plans using outpatient physical or occupational therapy (PT/OT) (N=2,007,524). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Number and proportion of outpatient PT/OT visits completed via telerehabilitation. RESULTS We identified 21,026,608 PT/OT visits among 2,007,524 patients. Overall, 49,974 (2.5%) patients received ≥1 telerehabilitation visit during the specified timeframe. We observed trends in utilization over time, with utilization peaking in April 2020 when 10.9% of all PT/OT visits were conducted by telerehabilitation. We also observed geographic trends with lower rates of utilization identified in rural areas. State-by-state utilization rates ranged from 10.4% (California) to 0.3% (Wyoming). CONCLUSION Telerehabilitation may be underutilized as a means of improving access to PT/OT, especially in rural areas of the country. Further research is needed to examine contributing factors to low observed utilization rates, such as provider and patient perceptions of telerehabilitation.
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Affiliation(s)
- Kevin H McLaughlin
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Joseph F Levy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Julie M Fritz
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, Utah
| | - Richard L Skolasky
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Reider L, Falvey JR, Okoye SM, Wolff JL, Levy JF. Cost of U.S emergency department and inpatient visits for fall injuries in older adults. Injury 2024; 55:111199. [PMID: 38006782 DOI: 10.1016/j.injury.2023.111199] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 11/01/2023] [Accepted: 11/12/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND Falls are a leading cause of injury and hospital readmissions in older adults. Understanding the distribution of acute treatment costs across inpatient and emergency department settings is critical for informed investment and evaluation of fall prevention efforts. METHODS This study used the 2016-2018 National Inpatient Sample and National Emergency Department Sample. Annual treatment cost of fall injury among adults 65 years and older was estimated from charges, applying cost-to-charge and professional fee ratios. Weighted multivariable generalized linear models were used to separately estimate cost for inpatient and emergency department (ED) setting by injury type and individual demographic and health characteristics after adjusting for payer and hospital level characteristics. RESULTS Older adults incurred an estimated 922,428 inpatient and 2.3 million ED visits annually due to falls with combined annual costs of $19.8 billion. Over half of inpatient visits for fall injury were for fracture. Notably, 23% of inpatient visits were for fractures other than hip fracture and 14% of inpatient visits were for multiple fractures with costs totaling $3.4 billion and $2.5 billion, respectively. Annual ED costs were driven by superficial injury totaling $1.5 billion. Cost of ED visits were higher for adults 85 years and older (adjusted cost ratio (aCR): 1.11, 95% Confidence Interval (CI)I: 1.11-1.12) and those with dementia (aCR: 1.14, 95% CI: 1.13-1.15). Higher inpatient and ED visit cost was also associated with high-energy falls and discharge to post-acute care. CONCLUSION The study found that more than 3 million older adults in the United States seek hospital care for fall injuries annually, a major concern given increasing capacity strain on hospitals and EDs. The $20 billion in annual acute treatment costs attributed to fall injury indicate an urgent need to implement evidence-based fall prevention interventions and underscores the importance of newly launched ED-based fall prevention efforts and investments in geriatric emergency departments.
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Affiliation(s)
- Lisa Reider
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy, and Management, 624N. Broadway, Baltimore MD 21205, United States.
| | - Jason R Falvey
- Department of Physical Therapy and Rehabilitation Science, Department of Epidemiology and Public Health, University of Maryland School of Medicine, United States
| | - Safiyyah M Okoye
- Department of Graduate Nursing, Drexel University College of Nursing and Health Professions, United States; Department of Health Management and Policy, Drexel University Dornsife School of Public Health Philadelphia, PA, United States
| | - Jennifer L Wolff
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy, and Management, 624N. Broadway, Baltimore MD 21205, United States
| | - Joseph F Levy
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy, and Management, 624N. Broadway, Baltimore MD 21205, United States
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Sastry RA, Levy JF, Chen JS, Weil RJ, Oyelese AA, Fridley JS, Gokaslan ZL. Lumbar Decompression with and without Fusion for Lumbar Stenosis with Spondylolisthesis: A Cost Utility Analysis. Spine (Phila Pa 1976) 2024:00007632-990000000-00561. [PMID: 38251455 DOI: 10.1097/brs.0000000000004928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 09/16/2023] [Accepted: 01/04/2024] [Indexed: 01/23/2024]
Abstract
STUDY DESIGN Markov model. OBJECTIVE To compare the cost-effectiveness of lumbar decompression alone (DA) with lumbar decompression with fusion (DF) for the management of adults undergoing surgery for lumbar stenosis with associated degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA Rates of lumbar fusion have increased for all indications in the United States over the last 20 years. Recent randomized controlled trial data, however, have suggested comparable functional outcomes and lower reoperation rates for lumbar decompression and fusion as compared to lumbar decompression alone in the treatment of lumbar stenosis with degenerative spondylolisthesis. MATERIALS AND METHODS A multi-state Markov model was constructed from the U.S. payer perspective of a hypothetical cohort of patients with LSS requiring surgery. Data regarding clinical improvement, costs, and reoperation were generated from contemporary randomized trial evidence, meta-analyses of recent prospective studies, and large retrospective cohorts. Base case, one-way sensitivity analysis, and probabilistic sensitivity analyses were conducted and results were compared to a willingness to pay threshold of $100,000 (in 2022 USD) over a 2-year time horizon. A discount rate of 3% was utilized. RESULTS The incremental cost and utility of decompression with fusion relative to decompression alone were $12,778 and 0.00529 QALYs. The corresponding ICER of $2,416,281 far exceeded a willingness to pay threshold of $100,000. In sensitivity analysis, the results varied the most with respect to rate of improvement after lumbar decompression alone, rate of improvement after lumbar decompression and fusion, and odds ratio of reoperation between the two groups. 0% of one-way and probabilistic sensitivity analyses achieved cost-effectiveness at the willingness to pay threshold. CONCLUSIONS Within the context of contemporary surgical data, DF is not cost effective compared with DA in the surgical management of LSS over a 2-year time horizon.
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Affiliation(s)
- Rahul A Sastry
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert School of Medicine, Brown University, Providence, RI, 02903
| | - Joseph F Levy
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205
| | - Jia-Shu Chen
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205
| | - Robert J Weil
- Department of Neurosurgery, Brain & Spine, Southcoast Health, Dartmouth, MA, USA
| | - Adetokunbo A Oyelese
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205
| | - Jared S Fridley
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205
| | - Ziya L Gokaslan
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205
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McKibben NS, O’Hara NN, Slobogean GP, Gaski GE, Nascone JW, Sciadini MF, Natoli RM, McKinley T, Virkus WW, Sorkin AT, Howe A, O’Toole RV, Levy JF. Work Productivity Loss After Minimally Displaced Complete Lateral Compression Pelvis Fractures. J Orthop Trauma 2024; 38:42-48. [PMID: 37653607 PMCID: PMC10841261 DOI: 10.1097/bot.0000000000002681] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVE To quantify work impairment and economic losses due to lost employment, lost work time (absenteeism), and lost productivity while working (presenteeism) after a lateral compression pelvic ring fracture. Secondarily, productivity loss of patients treated with surgical fixation versus nonoperative management was compared. METHODS DESIGN Secondary analysis of a prospective, multicenter trial. SETTING Two level I academic trauma centers. PATIENT SELECTION CRITERIA Adult patients with a lateral compression pelvic fracture (OTA/AO 61-B1/B2) with a complete posterior pelvic ring fracture and less than 10 mm of initial displacement. Excluded were patients who were not working or non-ambulatory before their pelvis fracture or who had a concomitant spinal cord injury. OUTCOME MEASURES AND COMPARISONS Work impairment, including hours lost to unemployment, absenteeism, and presenteeism, measured by Work Productivity and Activity Impairment assessments in the year after injury. Results after non-operative and operative treatment were compared. RESULTS Of the 64 included patients, forty-seven percent (30/64) were treated with surgical fixation, and 53% (30/64) with nonoperative management. 63% returned to work within 1 year of injury. Workers lost an average of 67% of a 2080-hour average work year, corresponding with $56,276 in lost economic productivity. Of the 1395 total hours lost, 87% was due to unemployment, 3% to absenteeism, and 10% to presenteeism. Surgical fixation was associated with 27% fewer lost hours (1155 vs. 1583, P = 0.005) and prevented $17,266 in average lost economic productivity per patient compared with nonoperative management. CONCLUSIONS Lateral compression pelvic fractures are associated with a substantial economic impact on patients and society. Surgical fixation reduces work impairment and the corresponding economic burden. LEVEL OF EVIDENCE Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Natasha S. McKibben
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Nathan N. O’Hara
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Gerard P. Slobogean
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Greg E. Gaski
- Department of Orthopaedic Surgery, Inova Fairfax Medical Campus, Falls Church, VA
| | - Jason W. Nascone
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Marcus F. Sciadini
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Roman M. Natoli
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Todd McKinley
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Walter W. Virkus
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Anthony T. Sorkin
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Andrea Howe
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Robert V. O’Toole
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Joseph F. Levy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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DiStefano MJ, Levy JF, Odouard IC, Anderson GF. Estimated Savings From Using Added Therapeutic Benefit and Therapeutic Reference Pricing in United States Medicare Drug Price Negotiations. Value Health 2023; 26:1618-1624. [PMID: 37689264 DOI: 10.1016/j.jval.2023.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/25/2023] [Accepted: 08/30/2023] [Indexed: 09/11/2023]
Abstract
OBJECTIVES US Medicare will begin negotiating prices for top-selling drugs in 2023. This study describes and estimates potential savings from a therapeutic reference pricing approach, linking comparative effectiveness with the costs of existing therapeutic alternatives, that Medicare could use to adjust the starting point for price negotiations. METHODS First, we identified target drugs likely to be selected for Medicare negotiation. Second, we identified comparative effectiveness ratings for target drugs based on French Haute Autorité de Santé reports. For target drugs with minor or no added benefit, we identified therapeutic alternatives based on the French reports and US clinical guidelines. For each target drug with minor or no added benefit, we computed the difference between spending based on the drug's estimated statutory ceiling price and spending based on the weighted average cost of therapeutic alternatives or the lowest cost therapeutic alternative. Finally, we calculated potential annual savings from using a starting point in negotiations based on costs of therapeutic alternatives. RESULTS Potential drug-level savings to Medicare from using a starting point in negotiations based on average spending across therapeutic alternatives, compared with using the statutory ceiling price alone, ranged from $186 541 340 to $2 173 441 197. Potential savings from using a starting point based on the lowest cost alternative ranged from $199 872 163 to $3 605 904 765. CONCLUSIONS Although we do not expect Medicare to rely on French comparative effectiveness assessments, this study demonstrates the potential for additional savings when using comparative effectiveness and costs of therapeutic alternatives to inform the starting price for negotiations.
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Affiliation(s)
- Michael J DiStefano
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Joseph F Levy
- Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Ilina C Odouard
- Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Gerard F Anderson
- Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Mattingly TJ, Anderson GF, Levy JF. Comparison of Price Index Methods and Drug Price Inflation Estimates for Hepatitis C Virus Medications. JAMA Health Forum 2023; 4:e231317. [PMID: 37294584 DOI: 10.1001/jamahealthforum.2023.1317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Abstract
Importance Measuring drug price inflation is challenging because new drugs continually enter the market, some drugs transition from branded to generic, and current inflation indexes do not account for these market basket changes. Instead, they measure the price increases after new drugs have been launched. Therefore, the public pays the higher costs of newer and usually more expensive drugs, but the inflation indexes do not reflect the increases over existing drugs previously used to treat the same conditions. Objective To assess how price index methods can affect estimates of drug price inflation using a case study of hepatitis C virus (HCV) medication and to explore other approaches for constructing a price index. Design, Setting, and Participants This cross-sectional study used data from outpatient pharmacies to compile a list of all HCV medications that were ever on the market (brand and generic) from 2013 to 2020. Using National Drug Codes of HCV drugs, a 20% nationally representative sample of Medicare Part D claims from 2013 to 2020 was queried. Alternative drug price indexes, including product-level vs class-level product and quantity definitions were developed in which gross vs net price definitions were used and an adjustment was created and applied to capture treatment duration because newer drugs often required a shorter duration. Main Outcomes and Measures Price index value and rate of inflation from 2013 to 2020 for each methodologic approach to constructing a drug pricing index. Results In all, 27 different HCV drug regimens were identified in Medicare Part D claims in 2013 to 2020. A product-level approach for measuring inflation estimated a 10% gross drug price increase from 2013 to 2020 for HCV drugs, whereas a class-level approach including the higher prices of the new drugs showed a 31% gross price increase. After adjusting for manufacturer rebates to estimate net prices, the findings showed that HCV drug prices fell by 31% from 2013 to 2020. Conclusions and Relevance The findings of this cross-sectional study indicate that the current product-level methods to estimate drug price inflation underestimated price increases for HCV drugs by failing to include the high launch prices of new market entrants. Using a class-level approach, the index captured higher spending on new products at launch. Prescription-level analyses, which did not consider shorter durations of treatment, overestimated price increases.
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Affiliation(s)
- T Joseph Mattingly
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City
| | - Gerard F Anderson
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Joseph F Levy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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McQueen RB, Anderson KE, Levy JF, Carlson JJ. Incorporating Dynamic Pricing in Cost-Effectiveness Analysis: Are Known Unknowns Valuable? Pharmacoeconomics 2023; 41:321-327. [PMID: 36656509 DOI: 10.1007/s40273-022-01230-x] [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] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/11/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Current practice in health technology assessment (HTA) of pharmaceuticals conducts cost-effectiveness analyses (CEAs) based on a static price or the estimated price at market launch. Recent publications suggest incorporating dynamic pricing. To test the feasibility and importance of including dynamic pricing, we compared the standard static approach to four dynamic scenarios by replicating US-based HTA evaluations with dynamic pricing inputs. METHODS The four case examples included omalizumab (Xolair®) for the treatment of allergic asthma, elagolix (Orilissa®) for the treatment of endometriosis, ocrelizumab (Ocrevus®) for the treatment of primary progressive multiple sclerosis (PPMS), and dupilumab (Dupixent®) for the treatment of atopic dermatitis (AD). The primary outcome was the relative percentage change in incremental cost-effectiveness ratios (ICERs) per quality-adjusted life-year (QALY) for two dynamic pricing scenarios versus static pricing. Secondary outcomes included the absolute difference in ICERs versus base-case and an assessment of decision uncertainty. RESULTS Base-case ICERs were $327,000, $102,000, $700,000, and $102,000 for allergic asthma, endometriosis, PPMS, and AD, respectively. Across scenarios and case examples, the range of ICERs versus base-case varied from decreases of 56% to increases of 232%. The absolute difference in ICERs versus base-case ranged from decreases of $120,000 to increases of $758,000. Conclusions on cost effectiveness were altered in 2/16 scenarios across the four case examples. CONCLUSIONS Given the decision context that US payers face, with prices varying over time, findings suggest further research to reduce uncertainty around price trajectories, as well as conducting or updating multiple assessments over the lifecycle of pharmaceutical products.
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Affiliation(s)
- R Brett McQueen
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Mail Stop C238, 12850 E. Montview Blvd., Aurora, CO, USA.
| | - Kelly E Anderson
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Mail Stop C238, 12850 E. Montview Blvd., Aurora, CO, USA
| | - Joseph F Levy
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Josh J Carlson
- CHOICE Institute, University of Washington School of Pharmacy, Seattle, WA, USA
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Ippolito BN, Levy JF. The influence of Medicare Part D on the list pricing of brand drugs. Health Serv Res 2023. [PMID: 36737865 DOI: 10.1111/1475-6773.14139] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To compare the Medicare Part D market share of brand drugs with their net-to-list price ratio. DATA SOURCES AND STUDY SETTING SSR Health Brand Net Price Tool and Medical Expenditure Panel Survey, 2007-2019. STUDY DESIGN For each drug, we calculated the ratio of net to list price and the percent of users that were Medicare-eligible. We compared these cross-sectionally in each year and estimated a difference-in-differences model comparing drugs with high or low Medicare market shares (MMS) after following changes to program incentives in 2010. DATA COLLECTION/EXTRACTION METHODS The sample included brand drugs without generic competitors appearing in both datasets. PRINCIPAL FINDINGS Net-to-list price ratios were negatively correlated with MMS in the later years of our sample. In 2019, a 10% increase in MMS was associated with a significant 4.6% [95% CI: 2.1%, 7.1%] decrease in net-to-list ratio. Difference-in-differences showed net-to-list price ratios of drugs with above median MMS fell relative to those with below median MMS. By 2019, we observe an absolute reduction of -0.2 [95% CI: -0.29, -0.11], representing 28% reduction relative to the average ratio in 2010. CONCLUSIONS Greater exposure to the Medicare Part D market was associated with larger differences between net and list prices of drugs.
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Affiliation(s)
- Benedic N Ippolito
- Economic Policy Studies, American Enterprise Institute, Washington, DC, USA
| | - Joseph F Levy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Mouslim MC, Rashidi ES, Levy JF, Socal MP, Trujillo AJ. The price paradox of biosimilar-like long-acting insulin. Am J Manag Care 2022; 28:e405-e410. [PMID: 36374658 DOI: 10.37765/ajmc.2022.89265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To describe the uptake and out-of-pocket (OOP) costs of Basaglar, the first long-acting insulin biosimilar, in a commercially insured population in the United States. STUDY DESIGN Retrospective analysis of commercial pharmacy claims and pharmacy co-payment offsets. METHODS We assessed Basaglar uptake by examining trends in the composition of the long-acting insulin market in the United States from 2014 to 2018. As patient demographics and plan type may be important determinants of biosimilar uptake, we also assessed characteristics of all long-acting insulin users by drug. We examined Basaglar OOP costs by assessing mean OOP costs per claim for users of Basaglar and other long-acting insulins, overall and by plan type, and the number and source of co-payment offsets for Basaglar and other insulin glargine products from Basaglar market entry through 2018. We used multivariate linear models to examine the relationship between Basaglar OOP expenditures and insurer-negotiated amounts, overall and by plan type. RESULTS Basaglar experienced a rapid uptake. However, there was no evidence that Basaglar users had lower OOP costs than reference product (Lantus) users. CONCLUSIONS Given our results and the approval of the first interchangeable biosimilar, we recommend the empirical evaluation of biosimilar cost savings to patients and insurers prior to promoting their automatic substitution.
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Affiliation(s)
- Morgane C Mouslim
- University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, MD 21250.
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Levy JF, Reider L, Scharfstein DO, Pollak AN, Morshed S, Firoozabadi R, Archer KR, Gary JL, O'Toole RV, Castillo RC, Quinnan SM, Kempton LB, Jones CB, Bosse MJ, MacKenzie EJ. The 1-Year Economic Impact of Work Productivity Loss Following Severe Lower Extremity Trauma. J Bone Joint Surg Am 2022; 104:586-593. [PMID: 35089905 DOI: 10.2106/jbjs.21.00632] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 02/01/2023]
Abstract
BACKGROUND Severe lower extremity trauma among working-age adults is highly consequential for returning to work; however, the economic impact attributed to injury has not been fully quantified. The purpose of this study was to examine work and productivity loss during the year following lower extremity trauma and to calculate the economic losses associated with lost employment, lost work time (absenteeism), and productivity loss while at work (presenteeism). METHODS This is an analysis of data collected prospectively across 3 multicenter studies of lower extremity trauma outcomes in the United States. Data were used to construct a Markov model that accumulated hours lost over time due to lost employment, absenteeism, and presenteeism among patients from 18 to 64 years old who were working prior to their injury. Average U.S. wages were used to calculate economic loss overall and by sociodemographic and injury subgroups. RESULTS Of 857 patients working prior to injury, 47.2% had returned to work at 1 year. The average number of productive hours of work lost was 1,758.8/person, representing 84.6% of expected annual productive hours. Of the hours lost, 1,542.3 (87.7%) were due to working no hours or lost employment, 71.1 (4.0%) were due to missed hours after having returned, and 145.4 (8.3%) were due to decreased productivity while working. The 1-year economic loss due to injury totaled $64,427/patient (95% confidence interval [CI], $63,183 to $65,680). Of the 1,758.8 lost hours, approximately 88% were due to not being employed (working zero hours), 4% were due to absenteeism, and 8% were due to presenteeism. Total productivity loss was higher among older adults (≥40 years), men, those with a physically demanding job, and the most severe injuries (i.e., those leading to amputation as well as Gustilo type-IIIB tibial fractures and type-III pilon/ankle fractures). CONCLUSIONS Patients with severe lower extremity trauma carry a substantial economic burden. The costs of lost productivity should be considered when evaluating outcomes.
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Affiliation(s)
- Joseph F Levy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Lisa Reider
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Daniel O Scharfstein
- Department of Population Health Science, University of Utah School of Medicine, Salt Lake City, Utah
| | - Andrew N Pollak
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Saam Morshed
- Departments of Orthopaedic Surgery, Epidemiology, and Biostatistics, University of California San Francisco, San Francisco, California
| | - Reza Firoozabadi
- Department of Orthopaedics and Sports Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Kristin R Archer
- Department of Orthopaedic Surgery, Center for Musculoskeletal Research and Department of Physical Medicine and Rehabilitation and Osher Center for Integrative Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joshua L Gary
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Renan C Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Stephen M Quinnan
- The Paley Orthopedic & Spine Institute at St. Mary's Medical Center, West Palm Beach, Florida
| | - Laurence B Kempton
- Department of Orthopaedic Surgery, Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Clifford B Jones
- Dignity Health Medical Group, St. Joseph's Hospital Medical Center & Creighton University School of Medicine, Phoenix, Arizona
| | - Michael J Bosse
- Department of Orthopaedic Surgery, Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Ellen J MacKenzie
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Carlini AR, Collins SC, Staguhn ED, Frey KP, O’Toole RV, Archer KR, Obremskey WT, Agel J, Kleweno CP, Morshed S, Weaver MJ, Higgins TF, Bosse MJ, Levy JF, Wu AW, Castillo RC. Streamlining Trauma Research Evaluation With Advanced Measurement (STREAM) Study: Implementation of the PROMIS Toolbox Within an Orthopaedic Trauma Clinical Trials Consortium. J Orthop Trauma 2022; 36:S33-S39. [PMID: 34924517 PMCID: PMC8694658 DOI: 10.1097/bot.0000000000002291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 02/02/2023]
Abstract
LEVEL OF EVIDENCE Prognostic Level II.
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Affiliation(s)
- Anthony R. Carlini
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Susan C. Collins
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Elena D. Staguhn
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Katherine P. Frey
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Robert V. O’Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD
| | - Kristin R. Archer
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Center for Musculoskeletal Research and Department of Physical Medicine and Rehabilitation, Osher Center for Integrative Medicine, Nashville, TN
| | - William T. Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Julie Agel
- Department of Orthopaedics and Sports Medicine, University of Washington Harborview Medical Center, Seattle, WA
| | - Conor P. Kleweno
- Department of Orthopaedics and Sports Medicine, University of Washington Harborview Medical Center, Seattle, WA
| | - Saam Morshed
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael J. Weaver
- Department of Orthopedic Surgery, Harvard Orthopaedic Trauma Service, Boston, MA
| | - Thomas F. Higgins
- Department of Orthopaedic Surgery, The University of Utah; Salt Lake City, UT
| | - Michael J. Bosse
- Department of Orthopaedic Surgery, Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Joseph F. Levy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Albert W. Wu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Renan C. Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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13
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Kang SY, Sen AP, Levy JF, Long J, Alexander GC, Anderson GF. Factors Associated With Manufacturer Drug Coupon Use at US Pharmacies. JAMA Health Forum 2021; 2:e212123. [PMID: 35977193 PMCID: PMC8796883 DOI: 10.1001/jamahealthforum.2021.2123] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/17/2021] [Indexed: 11/14/2022] Open
Abstract
Question Why do manufacturers choose to offer coupons for some prescription drugs and not for others? Findings In this cohort analysis of 2501 unique brand-name prescription drug products, drug companies offered a coupon for approximately half of the drugs; coupons were likely to be used for later-in-class-entrant products with high total costs in settings where direct competitors also offered coupons. Coupon use was not associated with a given product’s mean out-of-pocket cost. Meaning Manufacturer-sponsored coupons were more likely to be used for high-cost later-in-class-entrant products facing within-class competition where coupon use is prevalent. Importance Drug companies offer coupons to lower the out-of-pocket costs for prescription drugs, yet little is known about why they do so for some drugs but not for others. Objective To examine whether the following factors are associated with manufacturer drug coupon use: (1) patient-cost characteristics (mean per-patient cost per drug, mean patient copay); (2) drug characteristics (generics availability or “later-in-class-entrant” drugs); (3) drug-class characteristics (in-class coupon use among competitors; in-class generic competition; in-class mean cost and copay). Design, Setting, and Participants This was a retrospective cohort analysis of anonymized transactional pharmacy claims sourced from retail US pharmacies from October 2017 to September 2019, supplemented with information derived from Medi-Span, Red Book, and FDA.gov. Data were analyzed from September 2020 to February 2021. Main Outcomes and Measures The primary outcome was availability of a manufacturer’s coupon. The secondary outcome was the mean proportion of transactions in which a coupon was used for each product. Results The sample of 2501 unique brand-name prescription drugs accounted for a total of 8 995 141 claims. Manufacturers offered a coupon for 1267 (50.7%) of these drugs. When the manufacturer offered a coupon, it was used in a mean (SD) 16.3% (20.3%) of the transactions. Within a drug class, higher mean total cost per patient was positively associated with the likelihood of coupon use (odds ratio [OR], 1.03 per 10% increase; 95% CI, 1.01-1.04), but higher mean patient copay was inversely associated (OR, 0.98; 95% CI, 0.97-0.99). For drug characteristics, single-source later-in-class-entrant products were associated with a greater likelihood of coupon use compared with first entrants and multisource brands (OR, 1.44; 95% CI, 1.09-1.89). The intensity of coupon use was associated with later-in-class-entrant products and the class mean per-patient cost (4.16-percentage-point increase; 95% CI, 1.20-7.13; 0.27 per 10% increase; 95% CI, 0.09-0.44). Drugs with a new in-class brand-name competitor had greater mean coupon use compared with drugs without a new competitor (10.2% of claims with a coupon vs 5.9%). Conclusions and Relevance In this cohort study of transactional pharmacy claims, higher mean per-patient total cost within a class was significantly associated with the likelihood of coupon use, but not patient out-of-pocket cost. Manufacturers’ coupons were more likely to be used for expensive later-in-class-entrant products facing within-class competition where coupon use was prevalent.
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Affiliation(s)
- So-Yeon Kang
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Aditi P. Sen
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Joseph F. Levy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jingmiao Long
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - G. Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, Maryland
| | - Gerard F. Anderson
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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14
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Levy JF, Wang KY, Ippolito BN, Ficke JR, Jain A. The Impact of the COVID-19 Pandemic on Elective Inpatient Surgical Admissions: Evidence From Maryland. J Surg Res 2021; 268:389-393. [PMID: 34403856 PMCID: PMC8363779 DOI: 10.1016/j.jss.2021.07.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/29/2021] [Accepted: 07/12/2021] [Indexed: 10/27/2022]
Abstract
BACKGROUND The COVID-19 pandemic led to large-scale cancellation and deferral of elective surgeries. We quantified volume declines, and subsequent recoveries, across all hospitals in Maryland. MATERIALS AND METHODS Data on elective inpatient surgical volumes were assembled from the Maryland Health Service Cost Review Commission for years 2019-2020. The data covered all hospitals in the state. We compared the volume of elective inpatient surgeries in the second (Q2) and fourth quarters (Q4) of 2020 to those same quarters in 2019. Analysis was stratified by patient, hospital, and service characteristics. RESULTS Surgical volumes were 55.8% lower in 2020 Q2 than in 2019 Q2. Differences were largest for orthopedic surgeries (74.3% decline), those on Medicare (61.4%), and in urban hospitals (57.3%). By 2020 Q4, volumes for most service lines were within 15% of volumes in 2019 Q4. Orthopedic surgery remained most affected (44.5% below levels in 2019 Q4) and Plastic Surgery (21.9% lower). CONCLUSIONS COVID-19 led to large volume declines across hospitals in Maryland followed by a partial recovery. We observed large variability, particularly across service lines. These results can help contextualize case-specific experiences and inform research studying potential health effects of these delays and cancellations.
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Affiliation(s)
- Joseph F Levy
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Kevin Y Wang
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | | | - James R Ficke
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Amit Jain
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland.
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15
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Reider L, Pollak A, Wolff JL, Magaziner J, Levy JF. National trends in extremity fracture hospitalizations among older adults between 2003 and 2017. J Am Geriatr Soc 2021; 69:2556-2565. [PMID: 34062611 DOI: 10.1111/jgs.17281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/29/2021] [Accepted: 05/01/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Fractures in late life are highly consequential for health, services use, and spending. Little is known about trends in extremity fracture hospitalizations among older adults in the United States. DESIGN Retrospective longitudinal cohort study. SETTING The 2003-2017 National Inpatient Sample (NIS), a representative sample of U.S. community hospitals. PARTICIPANTS Hospitalized adults aged 65 and older with a diagnosis of upper or lower extremity fracture. MEASUREMENTS Incidence of extremity fracture hospitalization and mortality, using NIS discharge and trend weights, and population denominators derived from the U.S. Census Bureau. Incidence was reported separately for men and women by age, fracture diagnosis, and injury mechanism. Weighted linear regression was used to test for significant trends over time. RESULTS Incidence of extremity fracture hospitalizations declined in both women (15.7%, p trend < 0.001) and men (3.2%, p trend < 0.001) between 2003 and 2017. This trend was primarily attributed to a decline in low energy femur fractures which accounted for 65% of all fracture hospitalizations. Among older adults with an extremity fracture hospitalization, mortality declined from 5.1% in 2003 to 3.3% in 2017 in men, and from 2.6% to 1.9% in women (p trend < 0.001). High energy fractures were due to falls (53%), motor vehicle accidents (34%), and other high impact injuries (13%). Overall, 12% of extremity fracture hospitalizations were attributed to high-energy injuries: increases were observed among men ages 65-74 (20%; p trend < 0.001) and 75-84 (10%; p trend = 0.013), but not among women of any age. CONCLUSION Observed declines in the incidence of extremity fracture hospitalizations and related mortality are encouraging. However, increasing incidence of fracture hospitalization from high energy injuries among men suggests that older adults with complex injuries will be seen with more prevalence in the future.
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Affiliation(s)
- Lisa Reider
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Andrew Pollak
- School of Medicine, Department of Orthopaedics, University of Maryland, Baltimore, Maryland, USA
| | - Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jay Magaziner
- School of Medicine, Department of Epidemiology and Public Health, University of Maryland, Baltimore, Maryland, USA
| | - Joseph F Levy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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16
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Bongiorno DM, Badolato GM, Boyle M, Vernick JS, Levy JF, Goyal MK. United States trends in healthcare charges for pediatric firearm injuries. Am J Emerg Med 2021; 47:58-65. [PMID: 33773299 DOI: 10.1016/j.ajem.2021.03.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 03/08/2021] [Accepted: 03/08/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND From 2009 to 2016, >21,000 children died and an estimated 118,000 suffered non-fatal injuries from firearms in the United States. Limited data is available on resource utilization by injury intent. We use hospital charges as a proxy for resource use and sought to: 1) estimate mean charges for initial ED and inpatient care for acute firearm injuries among children in the U.S.; 2) compare differences in charges by firearm injury intent among children; and 3) evaluate trends in charges for pediatric firearm injuries over time, including within intent subgroups. METHODS In this repeated cross-sectional analysis of the 2009-2016 Nationwide Emergency Department Sample, we identified firearm injury cases among children aged ≤19 years using ICD-9-CM and ICD-10-CM external cause of injury codes (e-codes). Injury intent was categorized using e-codes as unintentional, assault-related, self-inflicted, or undetermined. Linear regressions utilizing survey weighting were used to examine associations between injury intent and healthcare charges, and to evaluate trends in mean charges over time. RESULTS Among 21,951 unweighted cases representing 102,072 pediatric firearm-related injuries, mean age was 16.6 years, and a majority were male (88.2%) and publicly insured (51.5%). Injuries were 53.9% assault-related, 37.7% unintentional, 1.8% self-inflicted, and 6.7% undetermined. Self-inflicted injuries had higher mean charges ($98,988) than assault-related ($52,496) and unintentional ($28,618) injuries (p < 0.001). Self-inflicted injuries remained associated with higher mean charges relative to unintentional injuries, after adjusting for patient demographics, hospital characteristics, and injury severity (p = 0.015). Mean charges for assault-related injuries also remained significantly higher than charges for unintentional injuries in multivariable models (p < 0.001). After adjusting for inflation, mean charges for pediatric firearm-related injuries increased over time (p-trend = 0.018) and were 23.1% higher in 2016 versus 2009. Mean charges increased over time among unintentional injuries (p-trend = 0.002), but not among cases with assault-related or self-inflicted injuries. CONCLUSIONS Self-inflicted and assault-related firearm injuries are associated with higher mean healthcare charges than unintentional firearm injuries among children. Mean charges for pediatric firearm injuries have also increased over time. These findings can help guide prevention interventions aimed at reducing the substantial burden of firearm injuries among children.
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Affiliation(s)
- Diana M Bongiorno
- Johns Hopkins School of Medicine and Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.
| | - Gia M Badolato
- Division of Emergency Medicine and Trauma Services, Children's National Health System, Washington, DC, United States of America.
| | - Meleah Boyle
- Division of Emergency Medicine and Trauma Services, Children's National Health System, Washington, DC, United States of America.
| | - Jon S Vernick
- Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States of America.
| | - Joseph F Levy
- Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States of America.
| | - Monika K Goyal
- Division of Emergency Medicine and Trauma Services, Children's National Health System and George Washington University, Washington, DC, United States of America.
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17
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McLaughlin KH, Reider LM, Castillo RC, Ficke JR, Levy JF. Outpatient Physical Therapy Use Following Tibial Fractures: A Retrospective Commercial Claims Analysis. Phys Ther 2021; 101:6124110. [PMID: 33522593 PMCID: PMC8152919 DOI: 10.1093/ptj/pzab034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 05/01/2020] [Revised: 11/19/2020] [Accepted: 12/31/2020] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The purpose of this study was to characterize outpatient physical therapy (OPT) use following tibial fractures and examine the variability of OPT attendance, time of initiation, number of visits, and length of care by patient, injury, and treatment factors. In the absence of clinical guidelines, results will guide future efforts to optimize OPT following tibial fractures. METHODS This study used 2016 to 2017 claims from the IBM MarketScan Commercial Claims Research Database. The cohort included 9079 patients with International Classification of Diseases: Tenth Revision (ICD-10) diagnosis codes for tibial fractures. Use in the year following initial fracture management was determined using Current Procedural Terminology codes. Differences in use were examined using χ2 tests, t tests, and Kruskal-Wallace tests. RESULTS Sixty-seven percent of patients received OPT the year following fracture. OPT attendance was higher in female patients, in patients with 1 or no major comorbidity, and in the western United States. Attendance was higher in patients with upper tibial fractures, moderate-severity injuries, and treatment with external fixation and in patients discharged to an inpatient rehabilitation facility. Patients started OPT on average [SD] 50 [52.6] days after fracture and attended 18 [16.1] visits over the course of 101 [86.4] days. The timing of OPT, the number of visits attended, and the length of OPT care varied by patient, injury, and treatment-level factors. CONCLUSIONS One-third of insured patients do not receive OPT following tibial fracture. The timing of OPT initiation, the length of OPT care, and the number of visits attended by patients with tibial fractures were highly variable. Further research is needed to standardize referral and prescription practices for OPT following tibial fractures. IMPACT OPT use varies based on patient, injury, and treatment-level factors following tibial fractures. Results from this study can be used to inform future efforts to optimize rehabilitation care for patients with tibial fractures.
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Affiliation(s)
- Kevin H McLaughlin
- Johns Hopkins University School of Medicine, Physical Medicine and Rehabilitation, Baltimore, Maryland, USA,Address all correspondence to Dr McLaughlin at:
| | - Lisa M Reider
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, Maryland, USA
| | - Renan C Castillo
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, Maryland, USA
| | - James R Ficke
- Johns Hopkins University School of Medicine, Orthopaedic Surgery, Baltimore, Maryland, USA
| | - Joseph F Levy
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, Maryland, USA
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18
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Abstract
This study compares revenue of Maryland hospitals in March-July 2020 vs historical trends and assesses whether rate increases for inpatient and outpatient services that were permitted to offset pandemic-related decines in revenues were associated with changes to state hospital revenue.
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Affiliation(s)
- Joseph F. Levy
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Amit Jain
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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19
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Abstract
State fee-for-service Medicaid programs have traditionally based payments to pharmacies for drugs on a percentage of the drugs' list price. Because list prices have increased more quickly than the prices actually paid by pharmacies, estimating appropriate reimbursements has become challenging. In recent years most states have switched to models where payments were based instead on results from a survey of pharmacy invoices. We examined how this changed fee-for-service Medicaid drug spending. We found that the policy change had minimal, if any, effects on overall Medicaid drug spending. This was at least partially explained by concomitant sharp increases in dispensing fees paid to pharmacies, designed to help cover operating expenses and profit margins. We discuss ways to improve invoice-based pricing approaches and lower costs if desired.
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Affiliation(s)
- Benedic Ippolito
- Benedic Ippolito is an economist at the American Enterprise Institute, in Washington, D.C
| | - Joseph F Levy
- Joseph F. Levy is an assistant scientist in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland
| | - Gerard F Anderson
- Gerard F. Anderson is a professor of health policy and management and a professor of international health at the Johns Hopkins Bloomberg School of Public Health, a professor of medicine at the Johns Hopkins School of Medicine, and director of the Johns Hopkins Center for Hospital Finance and Management
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20
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Marrache M, Harris AB, Puvanesarajah V, Raad M, Hassanzadeh H, Srikumaran U, Ficke JR, Levy JF, Jain A. Hospital Payments Increase as Payments to Surgeons Decrease for Common Inpatient Orthopaedic Procedures. J Am Acad Orthop Surg Glob Res Rev 2020; 4:e20.00026. [PMID: 32377615 PMCID: PMC7188271 DOI: 10.5435/jaaosglobal-d-20-00026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 02/24/2020] [Indexed: 11/18/2022]
Abstract
As healthcare costs continue to increase in the United States, it is important to understand the trends in the allocation of healthcare spending for common orthopaedic surgical procedures. We investigated the recent trends in (1) total net payments (for episode of care), (2) payments to hospitals, (3) payments to physicians, (4) payments to physicians as a percentage of total net payments, and (5) regional variation in hospital and physician payments for four common orthopaedic procedures. Methods Using a private insurance claims database, we analyzed the payments to US hospitals and physicians from 2010 to 2016 for primary total hip arthroplasty (THA) (n = 128,269), total knee arthroplasty (TKA) (n = 223,319), 1-level anterior cervical diskectomy and fusion (ACDF) (n = 51,477), and 1-level lumbar-instrumented posterior spinal fusion (PSF) (n = 45,680). Regional variations in payments were also assessed. Trends were analyzed using linear regression models adjusting for age, sex, comorbidities, duration of hospital stay, and inflation (alpha = 0.05). Results Inflation-adjusted total net payments for the episode of care increased by the following percentages per year: 5.2% for ACDF, 3.2% for PSF, 2.9% for TKA, and 2.6% for THA. Annual inflation-adjusted hospital payments increased significantly for all 4 procedures, whereas annual inflation-adjusted physician payments decreased by -2.2%/year for PSF, -1.5%/year for TKA, -1.1%/year for THA, and -0.4%/year for ACDF (all, P < 0.001). As a percentage of total net payments, physician payments decreased markedly for ACDF (-4.6%), PSF (-3.1%), TKA (-2.1%), and THA (-1.8%). Hospital and physician payments varied significantly by region and were both highest in the West (P < 0.001). Conclusions From 2010 to 2016, inflation-adjusted total net payments for 4 common orthopaedic surgical procedures increased markedly, as did payments to the US hospitals for these procedures. Payments to orthopaedic surgeons for these procedures decreased markedly during the same period.
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Affiliation(s)
- Majd Marrache
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - Andrew B Harris
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - James R Ficke
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - Joseph F Levy
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - Amit Jain
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
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Abstract
Introduction. Estimating costs of medical care attributable to treatments over time is difficult due to costs that cannot be explained solely by observed risk factors. Unobserved risk factors cannot be accounted for using standard econometric techniques, potentially leading to imprecise prediction. The goal of this work is to describe methodology to account for latent variables in the prediction of longitudinal costs. Methods. Latent class growth mixture models (LCGMMs) predict class membership using observed risk factors and class-specific distributions of costs over time. Our motivating example models cost of care for children with cystic fibrosis from birth to age 17. We compare a generalized linear mixed model (GLMM) with LCGMMs. Both models use the same covariates and distribution to predict average costs by combinations of observed risk factors. We adopt a Bayesian estimation approach to both models and compare results using the deviance information criterion (DIC). Results. The 3-class LCGMM model has a lower DIC than the GLMM. The LCGMM latent classes include a low-cost group where costs increase slowly over time, a medium-cost group with initial higher costs than the low-cost group and with more rapidly increasing costs at older ages, and a high-cost group with a U-shaped trajectory. The risk profile-specific mixtures of classes are used to predict costs over time. The LCGMM model shows more delineation of costs by age by risk profile and with less uncertainty than the GLMM model. Conclusions. The LCGMM approach creates flexible prediction models when using longitudinal cost data. The Bayesian estimation approach to LCGMM presented fits well into cost-effectiveness modeling where the estimated trajectories and class membership can be used for prediction.
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Affiliation(s)
- Joseph F Levy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, and Department of Risk and Insurance, Wisconsin School of Business, University of Wisconsin-Madison, Madison, WI, USA
| | - Marjorie A Rosenberg
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, and Department of Risk and Insurance, Wisconsin School of Business, University of Wisconsin-Madison, Madison, WI, USA
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Mattingly TJ, Levy JF, Slejko JF, Onwudiwe NC, Perfetto EM. Estimating Drug Costs: How do Manufacturer Net Prices Compare with Other Common US Price References? Pharmacoeconomics 2018; 36:1093-1099. [PMID: 29752675 PMCID: PMC6061401 DOI: 10.1007/s40273-018-0667-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
BACKGROUND Drug costs are frequently estimated in economic analyses using wholesale acquisition cost (WAC), but what is the best approach to develop these estimates? Pharmaceutical manufacturers recently released transparency reports disclosing net price increases after accounting for rebates and other discounts. OBJECTIVE Our objective was to determine whether manufacturer net prices (MNPs) could approximate the discounted prices observed by the U.S. Department of Veterans Affairs (VA). METHODS We compared the annual, average price discounts voluntarily reported by three pharmaceutical manufacturers with the VA price for specific products from each company. The top 10 drugs by total sales reported from company tax filings for 2016 were included. The discount observed by the VA was determined from each drug's list price, reported as WAC, in 2016. Descriptive statistics were calculated for the VA discount observed and a weighted price index was calculated using the lowest price to the VA (Weighted VA Index), which was compared with the manufacturer index. RESULTS The discounted price as a percentage of the WAC ranged from 9 to 74%. All three indexes estimated by the average discount to the VA were at or below the manufacturer indexes (42 vs. 50% for Eli Lilly, 56 vs. 65% for Johnson & Johnson, and 59 vs. 59% for Merck). CONCLUSIONS Manufacturer-reported average net prices may provide a close approximation of the average discounted price granted to the VA, suggesting they may be a useful proxy for the true pharmacy benefits manager (PBM) or payer cost. However, individual discounts for products have wide variation, making a standard discount adjustment across multiple products less acceptable.
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Affiliation(s)
- T Joseph Mattingly
- University of Maryland School of Pharmacy, 20 North Pine Street, N415, Baltimore, MD, 21201, USA.
| | - Joseph F Levy
- University of Maryland School of Pharmacy, 20 North Pine Street, N415, Baltimore, MD, 21201, USA
| | - Julia F Slejko
- University of Maryland School of Pharmacy, 20 North Pine Street, N415, Baltimore, MD, 21201, USA
| | | | - Eleanor M Perfetto
- University of Maryland School of Pharmacy, 20 North Pine Street, N415, Baltimore, MD, 21201, USA
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23
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Levy JF, Rosenberg MA, Farrell PM. Innovative assessment of inpatient and pulmonary drug costs for children with cystic fibrosis. Pediatr Pulmonol 2016; 51:1295-1303. [PMID: 27740724 PMCID: PMC9359810 DOI: 10.1002/ppul.23554] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [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: 04/21/2016] [Revised: 07/08/2016] [Accepted: 07/27/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND Previous estimates of the cost of care for pediatric Cystic fibrosis (CF) showed wide variation, without specific summary of pulmonary drug costs. METHODS Enrolled CF children from the Wisconsin newborn screening trial were evaluated quarterly per protocol. Assessments systematically included all treatments, hospitalizations, and nutritional and pulmonary outcomes. Direct medical costs from hospital billing and medical records from 1989 to 2010 were used to describe costs by age-ranges and subgroups throughout follow-up. Outpatient drugs were separated by category (pulmonary/otherwise). Inpatient and drug costs were examined by clinical risk factors (presence of meconium ileus, pancreatic insufficiency, and expected severity of genetic mutations). RESULTS Seventy-three children were followed for an average of 12.9 years with an average annual total cost of care of $24,768. Outpatient drug costs (53%) and hospitalizations (32%) represented the majority of costs. Drug costs were 48% for pulmonary indications and 52% for non-pulmonary. Pulmonary drug costs for children taking dornase were 54% of their drug costs while pulmonary drug costs were only 31% for children not taking dornase. Significant differences in frequency of inpatient stays existed for children with pancreatic insufficiency. Substantial differences in treatment costs exist as children age and by clinical risk factor. CONCLUSION This study provides more accurate longitudinal estimates of CF care costs throughout childhood and shows that increasing age, pancreatic insufficiency, use of dornase, and hospitalizations are key determinants of cost. These estimates can be included in evaluations of the cost-effectiveness of new, highly expensive treatments being introduced for any CF population. Pediatr Pulmonol. 2016;51:1295-1303. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Joseph F Levy
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Marjorie A Rosenberg
- Department of Risk and Insurance, University of Wisconsin School of Business, Madison, Wisconsin
| | - Philip M Farrell
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin.,Departments of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Repplinger MD, Levy JF, Peethumnongsin E, Gussick ME, Svenson JE, Golden SK, Ehlenbach WJ, Westergaard RP, Reeder SB, Vanness DJ. Systematic review and meta-analysis of the accuracy of MRI to diagnose appendicitis in the general population. J Magn Reson Imaging 2015; 43:1346-54. [PMID: 26691590 DOI: 10.1002/jmri.25115] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 11/24/2015] [Indexed: 12/22/2022] Open
Abstract
PURPOSE To perform a systematic review and meta-analysis of all published studies since 2005 that evaluate the accuracy of magnetic resonance imaging (MRI) for the diagnosis of acute appendicitis in the general population presenting to emergency departments. MATERIALS AND METHODS All retrospective and prospective studies evaluating the accuracy of MRI to diagnose appendicitis published in English and listed in PubMed, Web of Science, Cinahl Plus, and the Cochrane Library since 2005 were included. Excluded studies were those without an explicitly stated reference standard, with insufficient data to calculate the study outcomes, or if the population enrolled was limited to pregnant women or children. Data were abstracted by one investigator and confirmed by another. Data included the number of true positives, true negatives, false positives, false negatives, number of equivocal cases, type of MRI scanner, type of MRI sequence, and demographic data including study setting and gender distribution. Summary test characteristics were calculated. Forest plots and a summary receiver operator characteristic plot were generated. RESULTS Ten studies met eligibility criteria, representing patients from seven countries. Nine were prospective and two were multicenter studies. A total of 838 subjects were enrolled; 406 (48%) were women. All studies routinely used unenhanced MR images, although two used intravenous contrast-enhancement and three used diffusion-weighted imaging. Using a bivariate random-effects model the summary sensitivity was 96.6% (95% confidence interval [CI]: 92.3%-98.5%) and summary specificity was 95.9% (95% CI: 89.4%-98.4%). CONCLUSION MRI has a high sensitivity and specificity for the diagnosis of appendicitis, similar to that reported previously for computed tomography. J. Magn. Reson. Imaging 2016;43:1346-1354.
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Affiliation(s)
- Michael D Repplinger
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Joseph F Levy
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Erica Peethumnongsin
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Megan E Gussick
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - James E Svenson
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Sean K Golden
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - William J Ehlenbach
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Ryan P Westergaard
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Scott B Reeder
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - David J Vanness
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Decker MR, Levy JF, Wilke LG, Vanness DJ, Neuman HB. Abstract P6-09-06: Balancing the harms and benefits of radiation therapy for DCIS: A decision analysis examining the risk of radiation-associated sarcoma. Cancer Res 2015. [DOI: 10.1158/1538-7445.sabcs14-p6-09-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
INTRODUCTION:
More than 60,000 women are diagnosed with ductal carcinoma in situ (DCIS) annually and offered the option of breast conserving surgery (BCS), often including radiation (RT) to reduce local recurrence. Although the incidence of radiation-associated sarcoma (RAS) is low (0.05-0.25% at 10 years), the low mortality associated with DCIS and large number of DCIS diagnoses means that an increasingly large number of women are at risk of RAS. This study sought to weigh the risk of RAS with the benefits of BCS+RT for DCIS.
METHODS: A second-order Monte Carlo micro-simulation model of women ages 35 and older with DCIS was constructed. The decision analysis compared harm-benefit ratios of sarcoma-related deaths per breast cancer deaths averted within 20 years of treatment with BCS+RT versus BCS alone. Stratified analyses were performed by age group to account for differential life expectancy. To generate parameter estimates for model inputs, Bayesian network meta-analysis was used to synthesize rates of DCIS and invasive recurrence from clinical trials of BCS+RT and BCS alone using a Weibull specification. Sarcoma incidence was estimated non-parametrically using SEER. Constant hazard rates for breast cancer mortality after invasive recurrence and RAS mortality were estimated from clinical trials. To account for uncertainty, probabilistic sensitivity analysis was conducted using 10,000 Monte Carlo samples and 95% credible intervals (CrI) were constructed for event rates and harm-benefit ratios.
RESULTS: The micro-simulation model of an age-distributed cohort demonstrated that 1 in 840 women with DCIS (95%CrI 1:648 to 1:3522) would develop RAS within 20 years after treatment with BCS+RT. Overall, there would be 1 RAS-related death for every 12 breast cancer deaths averted (95%CrI 1:7 to 1:19) by the addition of RT to BCS. Stratified analysis demonstrated that the harm-benefit ratio was higher in women <75 years of age, with more RAS-related deaths caused per breast cancer deaths averted. The model was most impacted by parameter estimates for rates of invasive recurrence, breast cancer mortality after invasive recurrence, and RAS incidence rates.
CONCLUSIONS:
The risk of developing a RAS following BCS+RT for DCIS should not be overlooked. This may be especially true for women at low risk of recurrence and younger women (<75 years in our model). These findings contribute to the ongoing conversation about consequences of overtreatment of DCIS, and should be incorporated into shared-decision making discussions regarding the optimal management of DCIS for a given patient.
Age-Stratified Incremental Harm-Benefit Ratios for BCS+RT versus BCS AloneAge GroupRAS Deaths: Breast Cancer Deaths Averted* Posterior Median Ratio (95% CrI)Overall1:12 (1:7 to 1:19)35 to 541:10 (1:6 to 1:14 )55 to 741:11 (1:7 to 1:15)75+1:17 (1:9 to 1:24)*Probabilistic sensitivity analysis using 10,000 second-order parameter samples with a 20 year time horizon
Citation Format: Marquita R Decker, Joseph F Levy, Lee G Wilke, David J Vanness, Heather B Neuman. Balancing the harms and benefits of radiation therapy for DCIS: A decision analysis examining the risk of radiation-associated sarcoma [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P6-09-06.
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Levy JF, Meek PD, Rosenberg MA. US-Based Drug Cost Parameter Estimation for Economic Evaluations. Med Decis Making 2014; 35:622-32. [PMID: 25532826 DOI: 10.1177/0272989x14563987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 11/08/2014] [Indexed: 12/13/2022]
Abstract
INTRODUCTION In the United States, more than 10% of national health expenditures are for prescription drugs. Assessing drug costs in US economic evaluation studies is not consistent, as the true acquisition cost of a drug is not known by decision modelers. Current US practice focuses on identifying one reasonable drug cost and imposing some distributional assumption to assess uncertainty. METHODS We propose a set of Rules based on current pharmacy practice that account for the heterogeneity of drug product costs. The set of products derived from our Rules, and their associated costs, form an empirical distribution that can be used for more realistic sensitivity analyses and create transparency in drug cost parameter computation. The Rules specify an algorithmic process to select clinically equivalent drug products that reduce pill burden, use an appropriate package size, and assume uniform weighting of substitutable products. Three diverse examples show derived empirical distributions and are compared with previously reported cost estimates. RESULTS The shapes of the empirical distributions among the 3 drugs differ dramatically, including multiple modes and different variation. Previously published estimates differed from the means of the empirical distributions. Published ranges for sensitivity analyses did not cover the ranges of the empirical distributions. In one example using lisinopril, the empirical mean cost of substitutable products was $444 (range = $23-$953) as compared with a published estimate of $305 (range = $51-$523). CONCLUSIONS Our Rules create a simple and transparent approach to creating cost estimates of drug products and assessing their variability. The approach is easily modified to include a subset of, or different weighting for, substitutable products. The derived empirical distribution is easily incorporated into 1-way or probabilistic sensitivity analyses.
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Affiliation(s)
- Joseph F Levy
- University of Wisconsin-Madison Department of Population Health Sciences, Madison, WI, USA (JFL)
| | - Patrick D Meek
- Albany College of Pharmacy and Health Sciences Department of Pharmacy, Research Institute for Health Outcomes, Albany, NY, USA (PDM)
| | - Marjorie A Rosenberg
- University of Wisconsin-Madison Department of Actuarial Science, Risk Management and Insurance and Department of Biostatistics and Medical Informatics, Madison, WI, USA (MAR)
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Cox ED, Nackers KA, Young HN, Moreno MA, Levy JF, Mangione-Smith RM. Influence of race and socioeconomic status on engagement in pediatric primary care. Patient Educ Couns 2012; 87:319-26. [PMID: 22070902 PMCID: PMC3359403 DOI: 10.1016/j.pec.2011.09.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Revised: 09/20/2011] [Accepted: 09/24/2011] [Indexed: 05/25/2023]
Abstract
OBJECTIVE To understand the association of race/ethnicity with engagement in pediatric primary care and examine how any racial/ethnic disparities are influenced by socioeconomic status. METHODS Visit videos and parent surveys were obtained for 405 children who visited for respiratory infections. Family and physician engagement in key visit tasks (relationship building, information exchange, and decision making) were coded. Two parallel regression models adjusting for covariates and clustering by physician were constructed: (1) race/ethnicity only and (2) race/ethnicity with SES (education and income). RESULTS With and without adjustment for SES, physicians seeing Asian families spoke 24% fewer relationship building utterances, compared to physicians seeing White, non-Latino families (p<0.05). Latino families gathered 24% less information than White, non-Latino families (p<0.05), but accounting for SES mitigates this association. Similarly, African American families were significantly less likely to be actively engaged in decision making (OR=0.32; p<0.05), compared to White, non-Latino families, but adjusting for SES mitigated this association. CONCLUSION While engagement during pediatric visits differed by the family's race/ethnicity, many of these differences were eliminated by accounting for socioeconomic status. PRACTICE IMPLICATIONS Effective targeting and evaluation of interventions to reduce health disparities through improving engagement must extend beyond race/ethnicity to consider socioeconomic status more broadly.
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Affiliation(s)
- Elizabeth D Cox
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA.
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Abstract
AIMS The aims of this study were (i) to extend a psychosocial taxonomy of patients with diabetes to a primary care setting, and (ii) to validate the taxonomy using more sophisticated clustering methods across an array of psychological dimensions independent of demographic and medical variables. METHODS In a cross-sectional study, 111 adults with Type 2 diabetes seen in a primary care setting completed the Multidimensional Diabetes Questionnaire and the Brief Symptom Inventory (BSI). They also provided diabetes-specific self-report measures along with HbA(1c). RESULTS Four psychosocial patient profiles were identified using model-based cluster analysis in a US primary care setting. The four profiles represent a replication of two and refinement of a third profile found previously in French-speaking patients at diabetes education centres. Validation of the profiles using the BSI was replicated for depression and extended to other psychological dimensions. The validity and distinctiveness of the four psychosocial profiles were independent of demographic and diabetes-specific medical variables. CONCLUSION Replication and extended validation of the psychosocial taxonomy into primary care may allow healthcare workers to supplement medical treatments with psychosocial interventions that can improve outcomes for patients with diabetes that are practical, individually tailored, and cost-effective.
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Affiliation(s)
- T P Guck
- Department of Family Medicine, Creighton University School of Medicine, Omaha, NE 68102, USA.
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Levy JF, DeMartinis JE. Trauma-induced severe acute pancreatitis in adults: conceptual review of pathophysiological events. Gastroenterol Nurs 1996; 19:18-24. [PMID: 8704005 DOI: 10.1097/00001610-199601000-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Trauma-induced severe acute pancreatitis in adults is used to demonstrate the complexity of a comprehensive conceptual pathophysiological review. The exemplar depicts a progression of pathological events evolving from pancreatic cell damage, as influenced by the stress response. Discussion of sequelae of the cardiovascular, respiratory, and renal systems is included, highlighting core concepts of inflammation, immunosuppression, fever, and impaired wound healing. Aspects of Neuman's Systems Model are introduced to guide the discussion. It is proposed that facilitating an in-depth conceptual understanding of pathology will enable nurses to improve "pattern" recognition, thereby enabling them to make quicker and more accurate assessments and diagnoses leading to treatment.
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Perez CA, Graham ML, Taylor ME, Levy JF, Mortimer JE, Philpott GW, Kucik NA. Management of locally advanced carcinoma of the breast. I. Noninflammatory. Cancer 1994; 74:453-65. [PMID: 8004621 DOI: 10.1002/cncr.2820741335] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The treatment of patients with locally advanced noninflammatory breast cancer has evolved substantially over the past 30 years. From 1968 to 1989, 281 women were treated at Mallinckrodt Radiation Oncology Center with four different treatment methods. Median follow-up was 6.2 years (range 3-22 years); no patient was lost to follow-up. METHODS Retrospective review of records and analysis of data on a computer file were carried out. Thirty-five patients were treated with irradiation alone, 33 with irradiation and adjuvant chemotherapy, 81 with mastectomy and irradiation, and 132 with mastectomy, irradiation, and chemotherapy (triple-modality). RESULTS Actuarial 5- and 10-year disease free survival (DFS) rates were 45% and 36%, respectively, with triple-modality therapy, 31% and 10% with irradiation and chemotherapy, 32% and 19% with irradiation and mastectomy, and 19% and 11% with irradiation alone. Cause specific survival (CSS) paralleled DFS in the four groups. Locoregional tumor control at 5 years was 91% for irradiation, mastectomy, and chemotherapy, 80% for irradiation and mastectomy, 54% for irradiation and chemotherapy, and 31% for irradiation alone. Systemic therapy and/or irradiation given before mastectomy yielded better locoregional tumor control, DFS, and CSS (not statistically significant). No difference in results was noted with radical, modified radical, or total mastectomy. In the triple-modality group, no chest wall failures occurred with chest wall doses greater than 5040 cGy. Grade 2 or higher treatment sequelae were noted in 10-42% of patients, depending on treatment modality. CONCLUSIONS Triple-modality therapy yielded improved locoregional tumor control, DFS, and CSS compared with other modalities. Patients treated with surgery had better locoregional tumor control than those who received irradiation alone or in combination with chemotherapy, but the impact on DFS and CSS was less impressive. Additional clinical trials are needed to define further the role and optimal use of the various therapeutic modalities in the management of locally advanced breast cancer.
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Affiliation(s)
- C A Perez
- Radiation Oncology Center, Mallinckrodt Institute of Radiology, St. Louis, Missouri
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Levy JF, Mockelstrom N. Internship programs for high-tech, high-touch home care. Caring 1992; 11:16-9. [PMID: 10116687] [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: 02/11/2023]
Abstract
An innovative internship program developed by Creighton University's School of Nursing assists professional nurses with the knowledge and skills needed to care for high-tech clients in the hospital or home.
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Levy JF, Herman C. High-tech, high-touch community health care: an internship program. Caring 1988; 7:17-9. [PMID: 10290333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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Levy JF, Butcher HR. Arterial emboli: an analysis of 125 patients. Surgery 1970; 68:968-73. [PMID: 5483249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Kouchoukos NT, Levy JF, Balfour JF, Butcher HR. Operative therapy for aortoiliac arterial occlusive disease. A comparison of therapeutic methods. Arch Surg 1968; 96:628-35. [PMID: 5640601 DOI: 10.1001/archsurg.1968.01330220144023] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Abstract
One hundred ninety-four patients underwent 222 operations for femoral-popliteal arterial occlusive disease between 1957 and 1965. The results of operative therapy employing synthetic bypass grafts, thromboendarterectomy, and autogenous saphenous veins were assessed by determining the accumulative patency rates for the three operative methods, the incidences of subsequent major amputations, and the degree of symptomatic relief (fig. 1, tables 9 and 10).
The 2-year accumulative patency rates for synthetic bypass grafts, thromboendarterectomy, and saphenous vein bypass grafts were 28%, 50%, and 63%, respectively (table 8). Subsequent major amputations were performed in 37%, 27%, and 12% of the extremities in the three groups. Improvement in symptoms occurred in 33%, 48%, and 73% of the patients in the respective groups.
When grouped according to severity of presenting symptoms and signs and the status of the arterial outflow by arteriography, patency rates were highest in the vein graft group and lowest in the synthetic graft groups. The patency rates after endarterectomy in those extremities with severe symptoms and poor arterial outflow tracts were similar to those of the synthetic graft group.
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Lyevre JJ, Levy JF. [Apropos of syndermatotic cataracts]. Bull Soc Ophtalmol Fr 1966; 66:676-679. [PMID: 5981478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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