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Arnold DR, King JS, Fulton BD, Montague AD, Gudiksen KL, Greaney TL, Scheffler RM. New evidence on the impacts of cross-market hospital mergers on commercial prices and measures of quality. Health Serv Res 2024. [PMID: 38652542 DOI: 10.1111/1475-6773.14291] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
Abstract
OBJECTIVE To examine the impact of "cross-market" hospital mergers on prices and quality and the extent to which serial acquisitions contribute to any measured effects. DATA SOURCES 2009-2017 commercial claims from the Health Care Cost Institute (HCCI) and quality measures from Hospital Compare. STUDY DESIGN Event study models in which the treated group consisted of hospitals that acquired hospitals further than 50 miles, and the control group was hospitals that were not part of any merger activity (as a target or acquirer) during the study period. DATA EXTRACTION METHODS We extracted data for 214 treated hospitals and 955 control hospitals. PRINCIPAL FINDINGS Six years after acquisition, cross-market hospital mergers had increased acquirer prices by 12.9% (CI: 0.6%-26.6%) relative to control hospitals, but had no discernible impact on mortality and readmission rates for heart failure, heart attacks and pneumonia. For serial acquirers, the price effect increased to 16.3% (CI: 4.8%-29.1%). For all acquisitions, the price effect was 21.8% (CI: 4.6%-41.7%) when the target's market share was greater than the acquirer's market share versus 9.7% (CI: -0.5% to 20.9%) when the opposite was true. The magnitude of the price effect was similar for out-of-state and in-state cross-market mergers. CONCLUSIONS Additional evidence on the price and quality effects of cross-market mergers is needed at a time when over half of recent hospital mergers have been cross-market. To date, no hospital mergers have been challenged by the Federal Trade Commission on cross-market grounds. Our study is the third to find a positive price effect associated with cross-market mergers and the first to show no quality effect and how serial acquisitions contribute to the price effect. More research is needed to identify the mechanism behind the price effects we observe and analyze price effect heterogeneity.
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Affiliation(s)
- Daniel R Arnold
- School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Jaime S King
- Faculty of Law, The University of Auckland, Auckland, New Zealand
| | - Brent D Fulton
- School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Alexandra D Montague
- University of California College of the Law, San Francisco, San Francisco, California, USA
| | - Katherine L Gudiksen
- University of California College of the Law, San Francisco, San Francisco, California, USA
| | - Thomas L Greaney
- University of California College of the Law, San Francisco, San Francisco, California, USA
| | - Richard M Scheffler
- School of Public Health and Goldman School of Public Policy, University of California, Berkeley, Berkeley, California, USA
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Hughes GK, Sajjadi NB, Gardner B, Ramoin JK, Tuia J, Haslam A, Prasad V, Vassar M. Assessing patient burden and benefit: A decade of cabozantinib clinical trials. Int J Cancer 2024; 154:1464-1473. [PMID: 38108216 DOI: 10.1002/ijc.34812] [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] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 10/10/2023] [Accepted: 11/02/2023] [Indexed: 12/19/2023]
Abstract
Drug development is complex and costly. Clinical trial participants take on risks, making it essential to maximize trial efficiency and maintain participant safety. Identifying periods of excessive burden during drug development can inform trial design, ensure patient benefit and prevent harm. This study aims to examine all published clinical trials for cabozantinib to assess patient benefit and burden over time. We conducted a retrospective cross-sectional review of interventional clinical trials of cabozantinib for solid cancer treatment. We searched PubMed/MEDLINE, Embase, Cochrane (CENTRAL) and ClinicalTrials.gov. We extracted adverse event rates, median progression-free survival (PFS), median overall survival and objective response rate (ORR) for each included trial. We calculated frequencies of trial characteristics, cumulative grade 3-5 adverse event rates and cumulative ORRs. Out of 1735 studies, 54 publications were included that involved 6372 participants and 21 cancers. Of the 54 studies in our sample, 31 (57.41%) were single-arm trials and 23 (42.60%) had negative results. Trials among and within various indications had conflicting results over time. Cumulative risk to participants increased over time, and clinical benefit decreased. The findings suggest that the risk profile of cabozantinib increased from 2011 to 2016 and has remained elevated but stable while benefit has decreased over time. The use of non-randomized and single-arm trials is concerning, and more methodologically rigorous trials are needed. The results of trials for different indications are inconsistent, and empirical administration may reduce the drug's efficacy.
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Affiliation(s)
- Griffin K Hughes
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Nicholas B Sajjadi
- Department of Orthopedic Surgery and Rehabilitation, University of Oklahoma, College of Medicine, Oklahoma City, Oklahoma, USA
| | - Brooke Gardner
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Joshua K Ramoin
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Jordan Tuia
- University of California San Francisco, San Francisco, California, USA
| | - Alyson Haslam
- University of California San Francisco, San Francisco, California, USA
| | - Vinay Prasad
- University of California San Francisco, San Francisco, California, USA
| | - Matt Vassar
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
- Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
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3
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Mooghali M, Mitchell AP, Skydel JJ, Ross JS, Wallach JD, Ramachandran R. Characterization of accelerated approval status, trial endpoints and results, and recommendations in guidelines for oncology drug treatments from the National Comprehensive Cancer Network: cross sectional study. BMJ Med 2024; 3:e000802. [PMID: 38596814 PMCID: PMC11002412 DOI: 10.1136/bmjmed-2023-000802] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/24/2024] [Indexed: 04/11/2024]
Abstract
Objectives To evaluate National Comprehensive Cancer Network (NCCN) guideline recommendations for oncology drug treatments that have been granted accelerated approval, and to determine whether recommendations are updated based on the results of confirmatory trials after approval and based on status updates from the US Food and Drug Administration (FDA). Design Cross sectional study. Setting US FDA and NCCN guidelines. Population Oncology therapeutic indications (ie, specific oncological conditions for which the drug is recommended) that have been granted accelerated approval in 2009-18. Main outcome measures NCCN guideline reporting of accelerated approval status and postapproval confirmatory trials, and guideline recommendation alignment with postapproval confirmatory trial results and FDA status updates. Results 39 oncology drug treatments were granted accelerated approval for 62 oncological indications. Although all indications were recommended in NCCN guidelines, accelerated approval status was reported for 10 (16%) indications. At least one postapproval confirmatory trial was identified for all 62 indications, 33 (53%) of which confirmed benefit; among these indications, NCCN guidelines maintained the previous recommendation or strengthened the category of evidence for 27 (82%). Postapproval confirmatory trials failed to confirm benefit for 12 (19%) indications; among these indications, NCCN guidelines removed the previous recommendation or weakened the category of evidence for five (42%). NCCN guidelines reflected the FDA's decision to convert 30 (83%) of 36 indications from accelerated to traditional approval, of which 20 (67%) had guideline updates before the FDA's conversion decision. NCCN guidelines reflected the FDA's decision to withdraw seven (58%) of 12 indications from the market, of which four (57%) had guidelines updates before the FDA's withdrawal decision. Conclusions NCCN guidelines always recommend drug treatments that have been granted accelerated approval for oncological indications, but do not provide information about their accelerated approval status, including surrogate endpoint use and status of postapproval confirmatory trials. NCCN guidelines consistently provide information on postapproval trial results confirming clinical benefit, but not on postapproval trials failing to confirm clinical benefit. NCCN guidelines more frequently update recommendation for indications converted to traditional approval than for those approvals that were withdrawn.
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Affiliation(s)
- Maryam Mooghali
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Yale Collaboration for Regulatory Rigor, Integrity, and Transparency, Yale School of Medicine, New Haven, CT, USA
| | - Aaron P Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Joseph S Ross
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Yale Collaboration for Regulatory Rigor, Integrity, and Transparency, Yale School of Medicine, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health; and Center for Outcomes Research and Evaluation, Yale New Haven Health System, New Haven, CT, USA
| | - Joshua D Wallach
- Department of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA
| | - Reshma Ramachandran
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Yale Collaboration for Regulatory Rigor, Integrity, and Transparency, Yale School of Medicine, New Haven, CT, USA
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4
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Bond GR, Al-Abdulmunem M, Ressler DR, Drake RE. Mental Health Impact of COVID Pandemic on Veterans Transitioning from Military. J Behav Health Serv Res 2024; 51:275-288. [PMID: 38133794 PMCID: PMC10940484 DOI: 10.1007/s11414-023-09869-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Gary R Bond
- Social Policy and Economics Research, Westat, Inc., New Hampshire Office, Wheeler Professional Park, 1 Oak Ridge Road, Building 3, Second Floor, Suite 2 West, West Lebanon, NH, 03784, USA.
| | - Monirah Al-Abdulmunem
- Social Policy and Economics Research, Westat, Inc., New Hampshire Office, Wheeler Professional Park, 1 Oak Ridge Road, Building 3, Second Floor, Suite 2 West, West Lebanon, NH, 03784, USA
| | - Daniel R Ressler
- Social Policy and Economics Research, Westat, Inc., New Hampshire Office, Wheeler Professional Park, 1 Oak Ridge Road, Building 3, Second Floor, Suite 2 West, West Lebanon, NH, 03784, USA
| | - Robert E Drake
- Social Policy and Economics Research, Westat, Inc., New Hampshire Office, Wheeler Professional Park, 1 Oak Ridge Road, Building 3, Second Floor, Suite 2 West, West Lebanon, NH, 03784, USA
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY, USA
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5
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Elbaz J, Haslam A, Prasad V. An empirical analysis of overall survival in drug approvals by the US FDA (2006-2023). Cancer Med 2024; 13:e7190. [PMID: 38659418 PMCID: PMC11043668 DOI: 10.1002/cam4.7190] [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] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/18/2024] [Accepted: 04/03/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND The US Food and Drug Administration (FDA) has expanded the use of surrogate markers in drugs approved for oncology/hematology indications. This has likely resulted in a greater number of approvals and possibly drugs coming to market faster, but it is unknown whether these drugs also improve overall survival (OS) for patients taking them. METHODS We sought to estimate the percentage of oncology drugs that have shown to improve OS in a cross-sectional analysis of US FDA oncology drug approvals (2006-2023). We searched for OS data in registration trials and the peer-reviewed literature. RESULTS We found 392 oncology drug approvals. Eighty-seven (22%) drug approvals were based on OS, 147 drug approvals were later tested for OS benefit (38% of all approvals and 48% of drugs approved on a surrogate), and 130 (33%) have yet to be tested for OS benefit. Of the 147 drug approvals later tested for OS, 109 (28% of all approvals and 74% of drugs later tested for OS) have yet to show OS benefit, whereas 38 (10% of all approvals and 26% of drugs later tested for OS benefit) were later shown to have OS benefit. In total, 125 out of 392 (32%) drugs approved for any indication have been shown to improve OS benefit at some point, and 267 (68%) have yet to show approval. CONCLUSION About 32% of all oncology drug approvals have evidence for an improvement in OS. Higher standards are needed in drug regulation to ensure that approved drugs are delivering better patient outcomes, specifically in regards to survival.
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Affiliation(s)
| | - Alyson Haslam
- University of California San FranciscoSan FranciscoCaliforniaUSA
| | - Vinay Prasad
- University of California San FranciscoSan FranciscoCaliforniaUSA
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6
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Bhargava R, Brown N, Kapczynski A, Kesselheim AS, Lim SY, Morten CJ. The Constitutionality of Medicare Drug-Price Negotiation under the Takings Clause. J Law Med Ethics 2024; 51:961-971. [PMID: 38477274 DOI: 10.1017/jme.2024.10] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
In recent months, pharmaceutical manufacturers have brought legal challenges to a provision of the 2022 Inflation Reduction Act (IRA) empowering the federal government to negotiate the prices Medicare pays for certain prescription medications. One key argument made in these filings is that price negotiation is a "taking" of property and violates the Takings Clause of the US Constitution. Through original case law and health policy analysis, we show that government price negotiation and even price regulation of goods and services, including patented goods, are constitutional under the Takings Clause. Finding that the IRA violates the Takings Clause would radically upend settled constitutional law and jeopardize the US's most important state and federal health care programs.
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Affiliation(s)
- Raj Bhargava
- YALE UNIVERSITY, NEW HAVEN, CT, USA
- UNIVERSITY OF CALIFORNIA, BERKELEY, Berkeley, CA, USA
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7
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Rathi VK, Soler ZM, Schlosser RJ, Workman AD, Chapurin N, Rowan NR, Dusetzina SB. The Inflation Reduction Act: Implications for Medicare spending and access to biologic therapies for chronic rhinosinusitis with nasal polyposis and asthma. Int Forum Allergy Rhinol 2024. [PMID: 38465800 DOI: 10.1002/alr.23344] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 02/25/2024] [Indexed: 03/12/2024]
Abstract
KEY POINTS In 2021, Medicare spending on biologics was $926 million in Part B (FFS) and $1.3 billion in Part D (FFS/MA). Between 2017 and 2021, annual Medicare spending on biologics increased by approximately 200%. Between 2023 and 2025, Medicare Part D OOP costs for biologics will decrease by an estimated 50%-60%.
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Affiliation(s)
- Vinay K Rathi
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Zachary M Soler
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Rodney J Schlosser
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Surgery, Ralph H. Johnson VA Medical Center, Charleston, South Carolina, USA
| | - Alan D Workman
- Division of Rhinology, Department of Otolaryngology-Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nikita Chapurin
- Department of Otolaryngology-Head & Neck Surgery, University of Florida, Gainesville, Florida, USA
| | - Nicholas R Rowan
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
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8
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Kesselheim AS. Government Support of Meaningful Drug and Device Innovation: Pathways and Challenges. J Law Med Ethics 2024; 51:7-15. [PMID: 38433671 DOI: 10.1017/jme.2024.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
The US government supports drug innovation. It is therefore crucial that it distinguish between high-value and low-value innovation in purchasing expensive prescription drugs and medical devices and ensure the continued discovery of transformative drugs and that patient and taxpayer funds are not wasted.
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9
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Kesselheim A, Sarpatwari A, Rome B. INTRODUCTION: Promoting Drug and Vaccine Innovation and Managing High Prices: Introducing a Special Symposium. J Law Med Ethics 2024; 51:5-6. [PMID: 38433669 DOI: 10.1017/jme.2024.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
This special JLME symposium addresses ways that federal policy can incentivize innovation in medical therapeutics and make pharmaceuticals more financially accessible.
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10
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Dusetzina SB. Aiming at the Right Targets on Drug Price Reform. J Law Med Ethics 2024; 51:55-57. [PMID: 38433680 DOI: 10.1017/jme.2023.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
A lack of transparency and concerns over patients costs at the pharmacy counter have increased Congressional focus on pharmacy benefits management practices. However, applying regulations without transparency into pharmacy benefits managers practices could do more harm than good.
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11
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Benjamin DJ, Haslam A, Prasad V. Cardiovascular/anti-inflammatory drugs repurposed for treating or preventing cancer: A systematic review and meta-analysis of randomized trials. Cancer Med 2024; 13:e7049. [PMID: 38491813 PMCID: PMC10943275 DOI: 10.1002/cam4.7049] [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] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 01/09/2024] [Accepted: 02/08/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Due to encouraging pre-clinical data and supportive observational studies, there has been growing interest in applying cardiovascular drugs (including aspirin, angiotensin-converting enzyme [ACE] inhibitors, statins, and metformin) approved to treat diseases such as hypertension, hyperlipidemia, and diabetes mellitus to the field of oncology. Moreover, given growing costs with cancer care, these medications have offered a potentially more affordable avenue to treat or prevent recurrence of cancer. We sought to investigate the anti-cancer effects of drugs repurposed from cardiology or anti-inflammatories to treat cancer. We specifically evaluated the following drug classes: HMG-CoA reductase inhibitors (statins), cyclo-oxygenase inhibitors, aspirin, metformin, and both angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors. We also included non-steroidal anti-inflammatory drugs (NSAIDs) because they exert a similar mechanism to aspirin by blocking prostaglandins and reducing inflammation that is thought to promote the development of cancer. METHODS We performed a systematic literature review using PubMed and Web of Science with search terms including "aspirin," "NSAID," "statin" (including specific statin drug names), "metformin," "ACE inhibitors," and "ARBs" (including specific anti-hypertensive drug names) in combination with "cancer." Searches were limited to human studies published between 2000 and 2023. MAIN OUTCOMES AND MEASURES The number and percentage of studies reported positive results and pooled estimates of overall survival, progression-free survival, response, and disease-free survival. RESULTS We reviewed 3094 titles and included 67 randomized clinical trials. The most common drugs that were tested were metformin (n = 21; 30.9%), celecoxib (n = 20; 29.4%), and simvastatin (n = 8; 11.8%). There was only one study that tested cardiac glycosides and none that studied ACE inhibitors. The most common tumor types were non-small-cell lung cancer (n = 19; 27.9%); breast (n = 8; 20.6%), colorectal (n = 7; 10.3%), and hepatocellular (n = 6; 8.8%). Most studies were conducted in a phase II trial (n = 38; 55.9%). Most studies were tested in metastatic cancers (n = 49; 72.1%) and in the first-line setting (n = 36; 521.9%). Four studies (5.9%) were stopped early because of difficulty with accrual. The majority of studies did not demonstrate an improvement in either progression-free survival (86.1% of studies testing progression-free survival) or in overall survival (94.3% of studies testing overall survival). Progression-free survival was improved in five studies (7.4%), and overall survival was improved in three studies (4.4%). Overall survival was significantly worse in two studies (3.8% of studies testing overall survival), and progression-free survival was worse in one study (2.8% of studies testing progression-free survival). CONCLUSIONS AND RELEVANCE Despite promising pre-clinical and population-based data, cardiovascular drugs and anti-inflammatory medications have overall not demonstrated benefit in the treatment or preventing recurrence of cancer. These findings may help guide future potential clinical trials involving these medications when applied in oncology.
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Affiliation(s)
| | - Alyson Haslam
- Department of Epidemiology and BiostatisticsUniversity of CaliforniaSan FranciscoCaliforniaUnited States
| | - Vinay Prasad
- Department of Epidemiology and BiostatisticsUniversity of CaliforniaSan FranciscoCaliforniaUnited States
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12
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Kannan S, Song Z. Surprise billing in intensive care unit (ICU) hospitalizations. Health Aff Sch 2024; 2:qxae025. [PMID: 38486789 PMCID: PMC10932732 DOI: 10.1093/haschl/qxae025] [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] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/06/2024] [Accepted: 02/26/2024] [Indexed: 03/17/2024]
Abstract
Intensive care unit (ICU) care is expensive for patients and providers, and utilization and spending on ICU resources have increased. The No Surprises Act, passed in 2022, specifically prohibits balance billing by ICU specialists (intensivists) for emergency and most non-emergency care. The potential economic impact of this remains unclear, given few data exist on the magnitude of balance billing in the ICU. Using the MarketScan Commercial (IBM) database, we studied hospitalizations in which ICU care was provided ("ICU hospitalizations") between 2010 and 2019. Hospitalizations were characterized as fully in-network, fully out-of-network, or "mixed" (contained both in- and out-of-network services). The share of "mixed" hospitalizations among all ICU hospitalizations rose from 26% to 33% over the study period. Over half of these mixed hospitalizations contained out-of-network services specifically delivered within the ICU. Total hospitalization spending averaged $81 047, with ICU spending averaging $15 799. On average, 11% of ICU spending within these hospitalizations was out-of-network. Patients were plausibly balance-billed in approximately one-third of ICU hospitalizations, for thousands of dollars per hospitalization. Given that the No Surprises Act prevents this type of balance billing, the portended revenue loss may lead to changes in provider negotiations with insurers concerning network status and prices, which could affect the care patients receive.
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Affiliation(s)
- Sneha Kannan
- Division of Pulmonary/Critical Care, Massachusetts General Hospital, Boston, MA 02114, United States
- Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, United States
| | - Zirui Song
- Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, United States
- Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, United States
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13
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Miller SL, Haslam A, Prasad V. Financial conflicts of interest among presenters, panellists and moderators at haematology and oncology FDA workshops. Eur J Clin Invest 2024:e14184. [PMID: 38407501 DOI: 10.1111/eci.14184] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 02/07/2024] [Accepted: 02/07/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVE To assess the characteristics and financial conflicts of interest of presenters, panellists and moderators at haematology and oncology workshops held jointly with or hosted by the US FDA. SETTING We included information on all publicly available haematology or oncology FDA workshop agendas held between 1 January 2018 and 31 December 2022. EXPOSURE General and research payments reported on Open Payments, industry funding to patient advocacy organizations reported on their webpages or 990 tax forms and employment in both pharmaceutical and regulatory settings. RESULTS Among physicians eligible for payments, 78% received at least one payment from the industry between 2017 and 2021. The mean general payment amount was $82,170 for all years ($16,434 per year) and the median was $14,906 for all years ($2981 per year). Sixty-nine per cent of patient advocacy speakers were representing organizations that received financial support from the pharmaceutical industry. Among those representing regulatory agencies or pharmaceutical companies, 16% had worked in both settings during their careers. CONCLUSIONS AND RELEVANCE Our findings in this cross-sectional study show a majority of US-based physician presenters at haematology and oncology workshops held jointly with members of the US FDA have some financial conflict of interest with the pharmaceutical industry. These findings support the need for clear disclosures and suggest that a more balanced selection of presenters with fewer conflicts may help to limit bias in discussions between multiple stakeholders.
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Affiliation(s)
- Sarah L Miller
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Alyson Haslam
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
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14
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Daval CJR, Kesselheim AS, Sharpless L, Sarpatwari A. Independent Advice on Drug Approvals: an Investigation of EMA Practices. J Gen Intern Med 2024; 39:345-347. [PMID: 37904069 PMCID: PMC10853152 DOI: 10.1007/s11606-023-08495-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/16/2023] [Indexed: 11/01/2023]
Affiliation(s)
- C Joseph Ross Daval
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Aaron S Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Leigh Sharpless
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ameet Sarpatwari
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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Watson DP, Ray B, Phalen P, Duhart Clarke SE, Taylor L, Swartz J, Gastala N. Fentanyl Exposure and Detection Strategies Utilized by Clinical Trial Participants Seeking Linkage to Opioid Use Disorder Treatment at a Syringe Service Program. J Med Toxicol 2024; 20:13-21. [PMID: 38048033 PMCID: PMC10774457 DOI: 10.1007/s13181-023-00979-7] [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] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/30/2023] [Accepted: 11/10/2023] [Indexed: 12/05/2023] Open
Abstract
INTRODUCTION The USA continues to face a fentanyl-driven overdose epidemic. Prior research has demonstrated users of illicit opioids are concerned about fentanyl exposure and overdose, but the strategies they report using to detect fentanyl's presence lack empirical support. This study compares self-report and biologically detected fentanyl use and investigates overdose risk and risk reduction behaviors among a sample of high-risk people who use opioids. METHODS Structured enrollment interviews conducted as part of a larger clinical trial assessed self-reported fentanyl exposure as well as strategies used to determine believed fentanyl exposure and prevent overdose among 240 participants enrolled at a Chicago, IL syringe service program. Urinalysis measured actual fentanyl exposure. RESULTS Most participants identified as African American (66.7%) and had considerable overdose experience (76.7% lifetime and 48% in the past year). Most also tested positive for fentanyl (93.75%) despite reporting no past year use of fentanyl or fentanyl-adulterated drugs (64.17%). The most utilized approaches reported for identifying fentanyl exposure were stronger effects of the drug (60.7%), sight or taste (46.9%), and being told by someone using the same drugs (34.2%). Few participants (14%) reported using fentanyl test strips. No significant associations were identified between self-report and urinalysis measures or urinalysis results and risk reduction strategies. CONCLUSION This study adds to prior fentanyl exposure risk research. The disconnect between participants' fentanyl detection methods and reported overdose experiences supports the need for more research to identify and understand factors driving access and use of overdose prevention resources and strategies.
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Affiliation(s)
- Dennis P Watson
- Chestnut Health Systems, Lighthouse Institute, 221 W Walton Street, Chicago, IL, 60610, USA.
| | - Bradley Ray
- RTI International, 3040 Cornwallis Road, Research Triangle Park, Chapel Hill, NC, 27709, USA
| | - Peter Phalen
- Department of Psychiatry, University of Maryland School of Medicine, 655 W Baltimore Street, Baltimore, MD, 21201, USA
| | - Sarah E Duhart Clarke
- RTI International, 3040 Cornwallis Road, Research Triangle Park, Chapel Hill, NC, 27709, USA
| | - Lisa Taylor
- Chestnut Health Systems, Lighthouse Institute, 221 W Walton Street, Chicago, IL, 60610, USA
| | - James Swartz
- Jane Addams College of Social Work, The University of Illinois at Chicago, 1040 W Harrison Street, Chicago, IL, 60607, USA
| | - Nicole Gastala
- Department of Family Medicine, Mile Square Health Centers, University of Illinois College of Medicine at Chicago, Chicago, IL, USA
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Pacia DM, Brown BL, Minssen T, Darrow JJ. CRISPR-phage antibacterials to address the antibiotic resistance crisis: scientific, economic, and regulatory considerations. J Law Biosci 2024; 11:lsad030. [PMID: 38283616 PMCID: PMC10817822 DOI: 10.1093/jlb/lsad030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 09/22/2023] [Indexed: 01/30/2024]
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Smart R, Barnes-Proby D, Holmes P, Schell TL, Morral AR. Racial and ethnic differences in the effects of state firearm laws: a systematic review subgroup analysis. Inj Epidemiol 2023; 10:67. [PMID: 38098076 PMCID: PMC10722776 DOI: 10.1186/s40621-023-00477-y] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/04/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Despite growing evidence about how state-level firearm regulations affect overall rates of injury and death, little is known about whether potential harms or benefits of firearm laws are evenly distributed across demographic subgroups. In this systematic review, we synthesized available evidence on the extent to which firearm policies produce differential effects by race and ethnicity on injury, recreational or defensive gun use, and gun ownership or purchasing behaviors. MAIN BODY We searched 13 databases for English-language studies published between 1995 and February 28, 2023 that estimated a relationship between firearm policy in the USA and one of eight outcomes, included a comparison group, evaluated time series data, and provided estimated policy effects differentiated by race or ethnicity. We used pre-specified criteria to evaluate the quality of inference and causal effect identification. By policy and outcome, we compared policy effects across studies and across racial/ethnic groups using two different ways to express effect sizes: incidence rate ratios (IRRs) and rate differences. Of 182 studies that used quasi-experimental methods to evaluate firearm policy effects, only 15 estimated policy effects differentiated by race or ethnicity. These 15 eligible studies provided 57 separate policy effect comparisons across race/ethnicity, 51 of which evaluated interpersonal violence. In IRR terms, there was little consistent evidence that policies produced significantly different effects for different racial/ethnic groups. However, because of different baseline homicide rates, similar relative effects for some policies (e.g., universal background checks) translated into significantly greater absolute differences in homicide rates among Black compared to white victims. CONCLUSIONS The current literature does not support strong conclusions about whether state firearm policies differentially benefit or harm particular racial/ethnic groups. This largely reflects limited attention to these questions in the literature and challenges with detecting such effects given existing data availability and statistical power. Findings also emphasize the need for additional rigorous research that adopts a more explicit focus on testing for racial differences in firearm policy effects and that assesses the quality of race/ethnicity information in firearm injury and crime datasets.
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Affiliation(s)
- Rosanna Smart
- RAND Corporation, 1776 Main Street, PO Box 2138, Santa Monica, CA, 90407-2138, USA.
| | - Dionne Barnes-Proby
- RAND Corporation, 1776 Main Street, PO Box 2138, Santa Monica, CA, 90407-2138, USA
| | | | - Terry L Schell
- RAND Corporation, 1776 Main Street, PO Box 2138, Santa Monica, CA, 90407-2138, USA
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NEUMANN PETERJ, CRUMMER ELLIOTT, CHAMBERS JAMESD, TUNIS SEANR. Improving Food and Drug Administration-Centers for Medicare and Medicaid Services Coordination for Drugs Granted Accelerated Approval. Milbank Q 2023; 101:1047-1075. [PMID: 37644739 PMCID: PMC10726896 DOI: 10.1111/1468-0009.12670] [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] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/12/2023] [Accepted: 07/27/2023] [Indexed: 08/31/2023] Open
Abstract
Policy Points The increasing number of drugs granted accelerated approval by the Food and Drug Administration (FDA) has challenged the Medicare program, which often pays for expensive therapies despite substantial uncertainty about benefits and risks to Medicare beneficiaries. We recommend several administrative and legislative approaches for improving FDA-Centers for Medicare and Medicaid Services (CMS) coordination around accelerated-approval drugs, including promoting earlier discussions among the FDA, the CMS, and drug companies; strengthening Medicare's coverage with evidence development program; linking Medicare payment to evidence generation milestones; and ensuring that the CMS has adequate staffing and resources to evaluate new therapies. These activities can help improve the integrity; transparency; and efficiency of approval, coverage, and payment processes for drugs granted accelerated approval. CONTEXT The Food and Drug Administration (FDA)'s accelerated-approval pathway expedites patient access to promising treatments. However, increasing use of this pathway has challenged the Medicare program, which often pays for expensive therapies despite substantial uncertainty about benefits and risks to Medicare beneficiaries. We examined approaches to improve coordination between the FDA and Centers for Medicare and Medicaid Services (CMS) for drugs granted accelerated approval. METHODS We argue that policymakers have focused on expedited pathways at the FDA without sufficient attention to complementary policies at the CMS. Although differences between the FDA and CMS decisions are to be expected given the agencies' different missions and statutory obligations, procedural improvements can ensure that Medicare beneficiaries have timely access to novel therapies that are likely to improve health outcomes. To inform policy options and recommendations, we conducted semistructured interviews with stakeholders to capture diverse perspectives on the topic. FINDINGS We recommend ten areas for consideration: clarifying the FDA's evidentiary standards; strengthening FDA authorities; promoting earlier discussions among the FDA, the CMS, and drug companies; improving Medicare's coverage with evidence development program; tying Medicare payment for accelerated-approval drugs to evidence generation milestones; issuing CMS guidance on real-world evidence; clarifying Medicare's "reasonable and necessary" criteria; adopting lessons from international regulatory-reimbursement harmonization efforts; ensuring that the CMS has adequate staffing and expertise; and emphasizing equity. CONCLUSIONS Better coordination between the FDA and CMS could improve the transparency and predictability of drug approval and coverage around accelerated-approval drugs, with important implications for patient outcomes, health spending, and evidence generation processes. Improved coordination will require reforms at both the FDA and CMS, with special attention to honoring the agencies' distinct authorities. It will require administrative and legislative actions, new resources, and strong leadership at both agencies.
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Affiliation(s)
- PETER J. NEUMANN
- Center for the Evaluation of Value and Risk in HealthTufts Medical Center
| | - ELLIOTT CRUMMER
- Center for the Evaluation of Value and Risk in HealthTufts Medical Center
| | - JAMES D. CHAMBERS
- Center for the Evaluation of Value and Risk in HealthTufts Medical Center
| | - SEAN R. TUNIS
- Center for the Evaluation of Value and Risk in HealthTufts Medical Center
- Rubix Health
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Olsen A, Beall RF, Knox RP, Tu SS, Kesselheim AS, Feldman WB. Patents and regulatory exclusivities on FDA-approved insulin products: A longitudinal database study, 1986-2019. PLoS Med 2023; 20:e1004309. [PMID: 37971985 PMCID: PMC10653475 DOI: 10.1371/journal.pmed.1004309] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 10/05/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Insulin is the primary treatment for type 1 and some type 2 diabetes but remains costly in the United States, even though it was discovered more than a century ago. High prices can lead to nonadherence and are often sustained by patents and regulatory exclusivities that limit competition on brand-name products. We sought to examine how manufacturers have used patents and regulatory exclusivities on insulin products approved from 1986 to 2019 to extend periods of market exclusivity. METHODS AND FINDINGS We used the publicly available Food and Drug Administration (FDA) Approved Drug Products with Therapeutic Equivalence Evaluations (Orange Book) to identify all approved biosynthetic insulin products. Individual products approved under the same New Drug Application (NDA)-e.g., a vial and pen-were considered as separate products for the purposes of analysis. We recorded all patents and regulatory exclusivities listed in the Orange Book on each product and used Google Patents to extract the timing of patent application and whether patents were obtained on delivery devices or others aspects of the product. The primary outcome was the duration of expected protection, which was determined by subtracting the FDA approval date for each product from its last-to-expire patent or regulatory exclusivity (whichever occurred later). We performed a secondary analysis that considered overall protection on insulin lines-defined as groups of products approved under the same NDA with the same active ingredients manufactured by the same company. We also examined competition from follow-on insulin products-defined as products approved with the same active ingredients as originators but manufactured by different companies (approved via a specific drug approval pathway under section 505(b)(2) of the Food, Drug, and Cosmetic Act). During the study period, the FDA approved 56 individual products across 25 different insulin lines and 5 follow-ons across 3 different insulin lines. Thirty-three (59%) of the 56 products were drug-device combinations. Manufacturers of 9 products approved during the study period obtained patents filed after FDA approval that extended their duration of expected protection (by a median of 6 years). Approximately 63% of all patents on drug-device combinations approved during the study period were related to delivery devices. The median duration of expected protection on insulin products was 16.0 years, and the median protection on insulin lines was 17.6 years. An important limitation of our analysis is that manufacturers may continue to add patents on existing insulin products while competitors may challenge patents; therefore, periods of protection may change over time. CONCLUSIONS Among several strategies that insulin manufacturers have employed to extend periods of market exclusivity on brand-name insulin products are filing patents after FDA approval and obtaining a large number of patents on delivery devices. Policy reforms are needed to promote timely competition in the pharmaceutical market and ensure that patients have access to low-cost drugs.
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Affiliation(s)
- Anders Olsen
- Program On Regulation, Therapeutics, And Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Reed F. Beall
- Program On Regulation, Therapeutics, And Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Ryan P. Knox
- Program On Regulation, Therapeutics, And Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
- Harvard-MIT Center for Regulatory Science, Boston, Massachusetts, United States of America
| | - Sean S. Tu
- West Virginia University College of Law, Morgantown, West Virginia, United States of America
| | - Aaron S. Kesselheim
- Program On Regulation, Therapeutics, And Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - William B. Feldman
- Program On Regulation, Therapeutics, And Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
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Ganguli I, Mackwood MB, Yang CWW, Crawford M, Mulligan KL, O'Malley AJ, Fisher ES, Morden NE. Racial differences in low value care among older adult Medicare patients in US health systems: retrospective cohort study. BMJ 2023; 383:e074908. [PMID: 37879735 PMCID: PMC10599254 DOI: 10.1136/bmj-2023-074908] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE To characterize racial differences in receipt of low value care (services that provide little to no benefit yet have potential for harm) among older Medicare beneficiaries overall and within health systems in the United States. DESIGN Retrospective cohort study SETTING: 100% Medicare fee-for-service administrative data (2016-18). PARTICIPANTS Black and White Medicare patients aged 65 or older as of 2016 and attributed to 595 health systems in the United States. MAIN OUTCOME MEASURES Receipt of 40 low value services among Black and White patients, with and without adjustment for patient age, sex, and previous healthcare use. Additional models included health system fixed effects to assess racial differences within health systems and separately, racial composition of the health system's population to assess the relative contributions of individual patient race and health system racial composition to low value care receipt. RESULTS The cohort included 9 833 304 patients (6.8% Black; 57.9% female). Of 40 low value services examined, Black patients had higher adjusted receipt of nine services and lower receipt of 20 services than White patients. Specifically, Black patients were more likely to receive low value acute diagnostic tests, including imaging for uncomplicated headache (6.9% v 3.2%) and head computed tomography scans for dizziness (3.1% v 1.9%). White patients had higher rates of low value screening tests and treatments, including preoperative laboratory tests (10.3% v 6.5%), prostate specific antigen tests (31.0% v 25.7%), and antibiotics for upper respiratory infections (36.6% v 32.7%; all P<0.001). Secondary analyses showed that these differences persisted within given health systems and were not explained by Black and White patients receiving care from different systems. CONCLUSIONS Black patients were more likely to receive low value acute diagnostic tests and White patients were more likely to receive low value screening tests and treatments. Differences were generally small and were largely due to differential care within health systems. These patterns suggest potential individual, interpersonal, and structural factors that researchers, policy makers, and health system leaders might investigate and address to improve care quality and equity.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School and Brigham and Women's Hospital, Boston, MA, USA
| | - Matthew B Mackwood
- Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Ching-Wen Wendy Yang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Maia Crawford
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | | | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Elliott S Fisher
- Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Nancy E Morden
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- UnitedHealthcare, Minnetonka, MN, USA
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Thibault RT, Kovacs M, Hardwicke TE, Sarafoglou A, Ioannidis JPA, Munafò MR. Reducing bias in secondary data analysis via an Explore and Confirm Analysis Workflow (ECAW): a proposal and survey of observational researchers. R Soc Open Sci 2023; 10:230568. [PMID: 37830032 PMCID: PMC10565389 DOI: 10.1098/rsos.230568] [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] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/01/2023] [Indexed: 10/14/2023]
Abstract
Background. Although preregistration can reduce researcher bias and increase transparency in primary research settings, it is less applicable to secondary data analysis. An alternative method that affords additional protection from researcher bias, which cannot be gained from conventional forms of preregistration alone, is an Explore and Confirm Analysis Workflow (ECAW). In this workflow, a data management organization initially provides access to only a subset of their dataset to researchers who request it. The researchers then prepare an analysis script based on the subset of data, upload the analysis script to a registry, and then receive access to the full dataset. ECAWs aim to achieve similar goals to preregistration, but make access to the full dataset contingent on compliance. The present survey aimed to garner information from the research community where ECAWs could be applied-employing the Avon Longitudinal Study of Parents and Children (ALSPAC) as a case example. Methods. We emailed a Web-based survey to researchers who had previously applied for access to ALSPAC's transgenerational observational dataset. Results. We received 103 responses, for a 9% response rate. The results suggest that-at least among our sample of respondents-ECAWs hold the potential to serve their intended purpose and appear relatively acceptable. For example, only 10% of respondents disagreed that ALSPAC should run a study on ECAWs (versus 55% who agreed). However, as many as 26% of respondents agreed that they would be less willing to use ALSPAC data if they were required to use an ECAW (versus 45% who disagreed). Conclusion. Our data and findings provide information for organizations and individuals interested in implementing ECAWs and related interventions. Preregistration. https://osf.io/g2fw5 Deviations from the preregistration are outlined in electronic supplementary material A.
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Affiliation(s)
- Robert T. Thibault
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA 94305-6104, USA
- School of Psychological Science, University of Bristol, Bristol, UK
| | - Marton Kovacs
- Doctoral School of Psychology, ELTE Eotvos Lorand University, Budapest, Hungary
- Institute of Psychology, ELTE Eotvos Lorand University, Budapest, Hungary
| | - Tom E. Hardwicke
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Australia
| | - Alexandra Sarafoglou
- Department of Psychology, University of Amsterdam, Amsterdam, Noord-Holland, The Netherlands
| | - John P. A. Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA 94305-6104, USA
- Meta-Research Innovation Center Berlin (METRIC-B), QUEST Center for Transforming Biomedical Research, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Marcus R. Munafò
- School of Psychological Science, University of Bristol, Bristol, UK
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
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Powell K, Prasad V. Interpreting the results from the first randomised controlled trial of colonoscopy: does it save lives? BMJ Evid Based Med 2023; 28:306-308. [PMID: 36754585 PMCID: PMC10579474 DOI: 10.1136/bmjebm-2022-112155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2023] [Indexed: 02/10/2023]
Affiliation(s)
- Kerrington Powell
- School of Medicine, Texas A&M Health Science Center, Bryan, Texas, USA
| | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
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Gaebler JD, Barghouty P, Vicol S, Phillips C, Goel S. Forgotten but not gone: A multi-state analysis of modern-day debt imprisonment. PLoS One 2023; 18:e0290397. [PMID: 37703226 PMCID: PMC10499213 DOI: 10.1371/journal.pone.0290397] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 08/07/2023] [Indexed: 09/15/2023] Open
Abstract
In almost every state, courts can jail those who fail to pay fines, fees, and other court debts-even those resulting from traffic or other non-criminal violations. While debtors' prisons for private debts have been widely illegal in the United States for more than 150 years, the effect of courts aggressively pursuing unpaid fines and fees is that many Americans are nevertheless jailed for unpaid debts. However, heterogeneous, incomplete, and siloed records have made it difficult to understand the scope of debt imprisonment practices. We culled data from millions of records collected through hundreds of public records requests to county jails to produce a first-of-its-kind dataset documenting imprisonment for court debts in three U.S. states. Using these data, we present novel order-of-magnitude estimates of the prevalence of debt imprisonment, finding that between 2005 and 2018, around 38,000 residents of Texas and around 8,000 residents of Wisconsin were jailed each year for failure to pay (FTP), with the median individual spending one day in jail in both Texas and Wisconsin. Drawing on additional data on FTP warrants from Oklahoma, we also find that unpaid fines and fees leading to debt imprisonment most commonly come from traffic offenses, for which a typical Oklahoma court debtor owes around $250, or $500 if a warrant was issued for their arrest.
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Affiliation(s)
- Johann D. Gaebler
- Department of Statistics, Harvard University, Cambridge, MA, United States of America
| | - Phoebe Barghouty
- Communication Department, Stanford University, Stanford, CA, United States of America
| | - Sarah Vicol
- Department of Economics, Stanford University, Stanford, CA, United States of America
| | - Cheryl Phillips
- Communication Department, Stanford University, Stanford, CA, United States of America
| | - Sharad Goel
- Harvard Kennedy School, Harvard University, Cambridge, MA, United States of America
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Olivier T, Haslam A, Prasad V. Additional considerations before using a ctDNA-guided approach for informing adjuvant chemotherapy in colorectal cancer. BMC Med 2023; 21:344. [PMID: 37679732 PMCID: PMC10485976 DOI: 10.1186/s12916-023-03037-9] [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: 02/10/2023] [Accepted: 08/16/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND The DYNAMIC trial investigated the use of circulating tumor DNA (ctDNA) to guide adjuvant treatment decisions in stage II colon cancer. Despite the DYNAMIC trial's assertion that a ctDNA-guided approach could minimize the use of adjuvant treatment without compromising recurrence-free survival (RFS), we raised concerns regarding the trial's methodology and the practical implications of its findings in a Debate article. Here, we expand upon these concerns in a response to a correspondence by the authors of the DYNAMIC trial. MAIN BODY We dispute the choice of a large non-inferiority margin in the DYNAMIC trial, simply because an 8.5 percentage points decrease in recurrence-free survival could result in significant harm to patients. We challenge the authors' comparisons of the DYNAMIC trial outcomes with observational studies. Such comparison is subject to selection bias and changes over time that limit their relevance. The prognostic role of ctDNA do not automatically imply that more treatment in patients with ctDNA positivity would improve outcomes, which we highlight. In real-world settings, we anticipate a potential rise in chemotherapy use due to clinicians utilizing ctDNA alongside existing clinicopathologic factors, rather than using ctDNA as an entire replacement. Lastly, a key concern in DYNAMIC was an 350% higher use of oxaliplatin in the ctDNA arm compared with standard management (9.5% versus 2.7%, respectively), which poses a risk for long-term neuropathy. CONCLUSION We look forward improvements in patient selection in the adjuvant setting, but we maintain our reservations about the DYNAMIC trial and the real-life implementation of its results. As an alternative to exploring de-escalation strategies with large margins non-inferiority trials, we propose that superiority trials in stage II patients could be a more effective strategy.
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Affiliation(s)
- Timothée Olivier
- Department of Oncology, Geneva University Hospital, 4 Gabrielle-Perret-Gentil Street, 1205, Geneva, Switzerland.
| | - Alyson Haslam
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th St, 2nd Fl, San Francisco, CA, 94158, USA
| | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th St, 2nd Fl, San Francisco, CA, 94158, USA
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Sinaiko AD, Curto VE, Bambury E, Soto MJ, Rosenthal MB. Variation in tiered network health plan penetration and local provider market characteristics. Health Serv Res 2023. [PMID: 37670453 DOI: 10.1111/1475-6773.14223] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023] Open
Abstract
OBJECTIVE To understand variation in enrollment in tiered network health plans (TNPs) and the local provider market characteristics associated with TNP penetration. DATA SOURCES AND STUDY SETTING We used 2013-2017 Massachusetts three-digit ZIP code level employer-sponsored health insurance enrollment data, data on physician horizontal and vertical affiliations from the Massachusetts Provider Database, state hospital reports in 2013, 2015, and 2017, and the 2013-2017 Massachusetts All-Payer Claims database. STUDY DESIGN Linear regressions were used to estimate associations between TNP and local provider market characteristics. DATA EXTRACTION We constructed measures of TNP penetration and local provider market characteristics and linked these data using three-digit ZIP code. PRINCIPAL FINDINGS TNP penetration was at least 10% in all employer market sectors and highest among jumbo sized employers. All state employee health plan enrollees were in a tiered network health plan. Among enrollees not in the state employee health plan, TNP penetration varied from 6.0% to 19.6% across three-digit ZIP codes in Massachusetts. TNP penetration was higher in areas with less horizontal and vertical physician market concentration. CONCLUSIONS Market competition, rather than the absolute quantity of physicians in an area, is associated with TNP penetration.
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Affiliation(s)
- Anna D Sinaiko
- Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Vilsa E Curto
- Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Elizabeth Bambury
- Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Mark J Soto
- Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Meredith B Rosenthal
- Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Kar S, Bessette LG, Wyss R, Kesselheim AS, Lin KJ. The impact of electronic health record discontinuity on prediction modeling. PLoS One 2023; 18:e0287985. [PMID: 37410777 PMCID: PMC10325091 DOI: 10.1371/journal.pone.0287985] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 06/15/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND To determine the impact of electronic health record (EHR)-discontinuity on the performance of prediction models. METHODS The study population consisted of patients with a history of cardiovascular (CV) comorbidities identified using US Medicare claims data from 2007 to 2017, linked to EHR from two networks (used as model training and validation set, respectively). We built models predicting one-year risk of mortality, major CV events, and major bleeding events, stratified by high vs. low algorithm-predicted EHR-continuity. The best-performing models for each outcome were chosen among 5 commonly used machine-learning models. We compared model performance by Area under the ROC curve (AUROC) and Area under the precision-recall curve (AUPRC). RESULTS Based on 180,950 in the training and 103,061 in the validation set, we found EHR captured only 21.0-28.1% of all the non-fatal outcomes in the low EHR-continuity cohort but 55.4-66.1% of that in the high EHR-continuity cohort. In the validation set, the best-performing model developed among high EHR-continuity patients had consistently higher AUROC than that based on low-continuity patients: AUROC was 0.849 vs. 0.743 when predicting mortality; AUROC was 0.802 vs. 0.659 predicting the CV events; AUROC was 0.635 vs. 0.567 predicting major bleeding. We observed a similar pattern when using AUPRC as the outcome metric. CONCLUSIONS Among patients with CV comorbidities, when predicting mortality, major CV events, and bleeding outcomes, the prediction models developed in datasets with low EHR-continuity consistently had worse performance compared to models developed with high EHR-continuity.
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Affiliation(s)
- Shreyas Kar
- Department of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s, Boston, MA, United States of America
| | - Lily G. Bessette
- Department of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s, Boston, MA, United States of America
| | - Richard Wyss
- Department of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s, Boston, MA, United States of America
| | - Aaron S. Kesselheim
- Department of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s, Boston, MA, United States of America
| | - Kueiyu Joshua Lin
- Department of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s, Boston, MA, United States of America
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
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Xia S, Hefyan M, McCormick MP, Goldberg M, Swinth E, Huang S. Home visiting impacts during the pandemic: Evidence from a randomized controlled trial of child first. J Fam Psychol 2023:2023-81526-001. [PMID: 37326559 DOI: 10.1037/fam0001121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Existing research has found that home visiting programs for families with young children can improve children's development and strengthen caregiver and family well-being. However, the pandemic created numerous challenges for home visiting programs, forcing them to deliver services online or in a hybrid format to respond to pandemic-related challenges. Questions remain about the impacts of these programs when delivered at-scale via a hybrid model, especially during this uniquely challenging time. The present study reports 12-month impacts from a randomized controlled trial of Child First-an evidence-based home visiting program that provides psychotherapeutic, parent-child intervention (children ages 0-5) embedded in a coordinated system of care-when implemented as a hybrid service. This study estimates impacts within four domains: families' receipt of services, caregiver psychological well-being and parenting, child behavior, and family economic well-being. After randomly assigning families (N = 226) to receive Child First or typical community services, the research team surveyed caregivers (N = 183) about a year after study enrollment. Results from regression models with site fixed effects revealed suggestive evidence that Child First reduced caregivers' job loss, residential mobility, and self-reported substance abuse, and increased receipt of virtual services during the pandemic. There were null impacts on caregivers' psychological well-being, families' involvement with the child welfare system, children's behaviors, and other indicators of economic well-being. Implications for future research and policy are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Kim MS, Prasad V. Front-line chronic lymphocytic leukemia: The role of chemoimmunotherapy. Am J Hematol 2023; 98:560-561. [PMID: 36701133 DOI: 10.1002/ajh.26864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 01/17/2023] [Indexed: 01/27/2023]
Affiliation(s)
- Myung Sun Kim
- Medical Oncology/Hematology, Compass Oncology, Portland, Oregon, USA
| | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
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Gangopadhyaya A, Zuckerman S, Rao N. Assessing the difference in racial and ethnic disparities in access to and use of care between Traditional Medicare and Medicare Advantage. Health Serv Res 2023. [PMID: 36894493 DOI: 10.1111/1475-6773.14150] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Abstract
OBJECTIVE Test whether racial-ethnic disparities in the access and use of care differ between Traditional Medicare (TM) and Medicare Advantage (MA). DATA SOURCE Secondary data from the 2015-2018 Medicare Current Beneficiary Survey (MCBS). STUDY DESIGN Measure Black-White and Hispanic-White disparities in access to care and use of preventive services within TM, within MA, and assess the difference-in-disparities between the two programs with and without controls for factors that could influence enrollment, access, and use. DATA COLLECTION/EXTRACTION Pool 2015-2018 MCBS data and restrict to non-Hispanic Black, non-Hispanic White, or Hispanic respondents. PRINCIPAL FINDINGS Black enrollees have worse access to care relative to White enrollees in TM and MA, particularly for cost-related measures such as not having problems paying medical bills (11-13 pp. lower for Black enrollees; p < 0.05) and satisfaction with out-of-pocket costs (5-6 pp. lower; p < 0.05). We find no difference in Black-White disparities between TM and MA. Hispanic enrollees have worse access to care relative to White enrollees in TM but similar access relative to White enrollees in MA. Hispanic-White disparities in not delaying care due to cost and not reporting problems paying medical bills are narrower in MA relative to TM by about 4 pp (significant at the p < 0.05 level) each. We find no consistent evidence that Black-White or Hispanic-White differences in the use of preventive services differ between TM and MA. CONCLUSIONS Across the measures of access and use studied here, racial and ethnic disparities in MA are not substantially narrower than in TM for Black and Hispanic enrollees relative to White enrollees. For Black enrollees, this study suggests that system-wide reforms are required to reduce existing disparities. For Hispanic enrollees, MA does narrow some disparities in access to care relative to White enrollees but, in part, because White enrollees do not do as well in MA as they do in TM.
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Affiliation(s)
- Anuj Gangopadhyaya
- Health Policy Center, Urban Institute Health Policy Center, 500 L'Enfant Plaza SW, Washington, DC, 20024, USA
| | - Stephen Zuckerman
- Health Policy Center, Urban Institute Health Policy Center, 500 L'Enfant Plaza SW, Washington, DC, 20024, USA
| | - Nikhil Rao
- Health Policy Center, Urban Institute Health Policy Center, 500 L'Enfant Plaza SW, Washington, DC, 20024, USA
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McCourt AD, Tormohlen KN, Schmid I, Stone EM, Stuart EA, Davis CS, Bicket MC, McGinty EE. Effects of Opioid Prescribing Cap Laws on Opioid and Other Pain Treatments Among Persons with Chronic Pain. J Gen Intern Med 2023; 38:929-937. [PMID: 36138276 PMCID: PMC10039157 DOI: 10.1007/s11606-022-07796-8] [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: 03/21/2022] [Accepted: 09/07/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Many states have adopted laws that limit the amount or duration of opioid prescriptions. These limits often focus on prescriptions for acute pain, but there may be unintended consequences for those diagnosed with chronic pain, including reduced opioid prescribing without substitution of appropriate non-opioid treatments. OBJECTIVE To evaluate the effects of state opioid prescribing cap laws on opioid and non-opioid treatment among those diagnosed with chronic pain. DESIGN We used a difference-in-differences approach that accounts for staggered policy adoption. Treated states included 32 states that implemented a prescribing cap law between 2017 and 2019. POPULATION A total of 480,856 adults in the USA who were continuously enrolled in medical and pharmacy coverage from 2013 to 2019 and diagnosed with a chronic pain condition between 2013 and 2016. MAIN MEASURES Among individuals with chronic pain in each state: proportion with at least one opioid prescription and with prescriptions of a specific duration or dose, average number of opioid prescriptions, average opioid prescription duration and dose, proportion with at least one non-opioid chronic pain prescription, average number of such prescriptions, proportion with at least one chronic pain procedure, and average number of such procedures. KEY RESULTS State laws limiting opioid prescriptions were not associated with changes in opioid prescribing, non-opioid medication prescribing, or non-opioid chronic pain procedures among patients with chronic pain diagnoses. CONCLUSIONS These findings do not support an association between state opioid prescribing cap laws and changes in the treatment of chronic non-cancer pain.
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Affiliation(s)
- Alexander D McCourt
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Kayla N Tormohlen
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ian Schmid
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elizabeth M Stone
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elizabeth A Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Mark C Bicket
- Department of Anesthesiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Emma E McGinty
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- OptumLabs, Cambridge, USA
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
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Abstract
OBJECTIVE To estimate US public investment in the development of mRNA covid-19 vaccines. DESIGN Retrospective cohort study. SETTING Publicly funded science from January 1985 to March 2022. DATA SOURCES National Institutes of Health (NIH) Report Portfolio Online Reporting Tool Expenditures and Results (RePORTER) and other public databases. Government funded grants were scored as directly, indirectly, or not likely related to four key innovations underlying mRNA covid-19 vaccines-lipid nanoparticle, mRNA synthesis or modification, prefusion spike protein structure, and mRNA vaccine biotechnology-on the basis of principal investigator, project title, and abstract. MAIN OUTCOME MEASURE Direct public investment in research and vaccine development, stratified by the rationale, government funding agency, and pre-pandemic (1985-2019) versus pandemic (1 January 2020 to 31 March 2022). RESULTS 34 NIH funded research grants that were directly related to mRNA covid-19 vaccines were identified. These grants combined with other identified US government grants and contracts totaled $31.9bn (£26.3bn; €29.7bn), of which $337m was invested pre-pandemic. Pre-pandemic, the NIH invested $116m (35%) in basic and translational science related to mRNA vaccine technology, and the Biomedical Advanced Research and Development Authority (BARDA) ($148m; 44%) and the Department of Defense ($72m; 21%) invested in vaccine development. After the pandemic started, $29.2bn (92%) of US public funds purchased vaccines, $2.2bn (7%) supported clinical trials, and $108m (<1%) supported manufacturing plus basic and translational science. CONCLUSIONS The US government invested at least $31.9bn to develop, produce, and purchase mRNA covid-19 vaccines, including sizeable investments in the three decades before the pandemic through March 2022. These public investments translated into millions of lives saved and were crucial in developing the mRNA vaccine technology that also has the potential to tackle future pandemics and to treat diseases beyond covid-19. To maximize overall health impact, policy makers should ensure equitable global access to publicly funded health technologies.
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Affiliation(s)
- Hussain S Lalani
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sarosh Nagar
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard University Cambridge, MA, USA
| | - Ameet Sarpatwari
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Rachel E Barenie
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jerry Avorn
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Benjamin N Rome
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Aaron S Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Brown BL, Kesselheim AS, Sarpatwari A. Analysis of risk evaluation and mitigation strategies for teratogenic drugs: Variation in primary and secondary prevention measures. PLoS Med 2023; 20:e1004190. [PMID: 36877723 PMCID: PMC9987786 DOI: 10.1371/journal.pmed.1004190] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023] Open
Abstract
In an analysis of risk evaluation and mitigation strategies for teratogenic drugs, Ameet Sarpatwari, Beatrice Brown and Aaron Kesselheim explore the variation in primary and secondary prevention measures.
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Affiliation(s)
- Beatrice L. Brown
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Aaron S. Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ameet Sarpatwari
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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Tran AA, Prasad V. Visualizing the randomized sham-controlled trial in orthopedic research: proposed steps to conducting a total knee arthroplasty randomized controlled trial. J Comp Eff Res 2023; 12:e210275. [PMID: 36847310 PMCID: PMC10288945 DOI: 10.57264/cer-2021-0275] [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] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/05/2022] [Indexed: 03/01/2023] Open
Abstract
Performed more than 600,000 times annually in the USA alone, total knee arthroplasty is the one of the most common and costly elective operations in the world. A primary total knee arthroplasty is generally an elective procedure, for which total index hospitalization costs are estimated around $30,000 USD. Roughly four in five patients declare they are satisfied postoperatively, justifying the procedure's frequency and high costs. It is sobering to realize, however, that the evidence base in favor of this procedure remains circumstantial. We as a profession lack randomized trials showing a subjective improvement over placebo intervention. We argue for the necessity of sham-controlled surgical trials in this setting and provide a surgical atlas showing how a sham operation may be performed.
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Affiliation(s)
- Audrey A Tran
- Department of Epidemiology & Biostatistics, University of California San Francisco, CA, USA
| | - Vinay Prasad
- Department of Medicine, University of California San Francisco, CA, USA
- Department of Epidemiology & Biostatistics, University of California San Francisco, CA, USA
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Naaman K, Grant S, Kianersi S, Supplee L, Henschel B, Mayo-Wilson E. Exploring enablers and barriers to implementing the Transparency and Openness Promotion Guidelines: a theory-based survey of journal editors. R Soc Open Sci 2023; 10:221093. [PMID: 36756061 PMCID: PMC9890101 DOI: 10.1098/rsos.221093] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 01/09/2023] [Indexed: 05/27/2023]
Abstract
The Transparency and Openness Promotion (TOP) Guidelines provide a framework to help journals develop open science policies. Theories of behaviour change can guide understanding of why journals do (not) implement open science policies and the development of interventions to improve these policies. In this study, we used the Theoretical Domains Framework to survey 88 journal editors on their capability, opportunity and motivation to implement TOP. Likert-scale questions assessed editor support for TOP, and enablers and barriers to implementing TOP. A qualitative question asked editors to provide reflections on their ratings. Most participating editors supported adopting TOP at their journal (71%) and perceived other editors in their discipline to support adopting TOP (57%). Most editors (93%) agreed their roles include maintaining policies that reflect current best practices. However, most editors (74%) did not see implementing TOP as a high priority compared with other editorial responsibilities. Qualitative responses expressed structural barriers to implementing TOP (e.g. lack of time, resources and authority to implement changes) and varying support for TOP depending on study type, open science standard, and level of implementation. We discuss how these findings could inform the development of theoretically guided interventions to increase open science policies, procedures and practices.
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Affiliation(s)
- Kevin Naaman
- School of Public Health, Indiana University-Bloomington, Bloomington, IN, USA
- School of Education, Indiana University-Bloomington, Bloomington, IN, USA
| | - Sean Grant
- HEDCO Institute for Evidence-Based Educational Practice, University of Oregon, Eugene, OR, USA
- Richard M. Fairbanks School of Public Health, Indiana University-Indianapolis, Indianapolis, IN, USA
| | - Sina Kianersi
- School of Public Health, Indiana University-Bloomington, Bloomington, IN, USA
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Beate Henschel
- School of Public Health, Indiana University-Bloomington, Bloomington, IN, USA
| | - Evan Mayo-Wilson
- School of Public Health, Indiana University-Bloomington, Bloomington, IN, USA
- Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
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Abstract
BACKGROUND In the adjuvant setting of cancer treatment, de-escalation strategies have the goal of omitting or minimizing treatment in patients, without compromising outcomes. Historically, eligibility for adjuvant treatment solely relied on the patient's clinical and tumor's pathological characteristics. At the turn of the century, based on new biological understanding, molecular-based strategies were tested and sometimes implemented. MAIN BODY However, we illustrate how molecularly based de-escalation strategies may paradoxically lead to overtreatment. This may happen when the novel approach is tested in lieu of standard management and may not yield the same results when being implemented in addition to usual practice. In the DYNAMIC trial, adjuvant chemotherapy decision in stage II colon cancer was compared between a circulating tumor DNA (ctDNA)-based approach and the standard care. We show this may result in more patients receiving oxaliplatin-based chemotherapy and may expose a similar proportion of patients to chemotherapy if the novel strategy is implemented in addition to usual practice. The other potential risk is undertreatment. We provide an illustration of early breast cancer, where the decision of adjuvant chemotherapy based on the gene expression signature MammaPrint may lead to inferior outcomes as compared with the clinico-pathologic strategy. This may also happen when non-inferiority designs have large margins. Among solutions, it should be acknowledged that clinico-pathological features, like T4 in colon cancer, may not be abandoned and replaced by novel strategies in real-life practice. Therefore, novel strategies should be tested in addition to standard of care, and not in lieu of. Second, de-escalation trials should focus on the settings where the standard of care has a widespread agreement. This would avoid the risk of testing non-inferiority against an ineffective therapy, which guarantees successes without providing informative data. CONCLUSION Simply because a molecular test is rational does not mean it can improve patient outcomes. Here, we highlight how molecular test-based strategies may result in either overtreatment or undertreatment. In the rapidly evolving field of medicine, where technological advances may be transformative, our piece highlights scientific pitfalls to be aware of when considering running such trials or before implementing novel strategies in daily practice.
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Affiliation(s)
- Timothée Olivier
- Department of Oncology, Geneva University Hospital, 4 Gabrielle-Perret-Gentil Street, 1205, Geneva, Switzerland.
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th St., 2nd Fl, San Francisco, CA, 94158, USA.
| | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th St., 2nd Fl, San Francisco, CA, 94158, USA
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Abstract
OBJECTIVE To examine factors associated with accrual rate in industry sponsored clinical trials supporting US Food and Drug Administration (FDA) cancer drug approvals from 2015 to 2020. DESIGN, SETTING AND PARTICIPANTS Retrospective cross-sectional study included 194 pivotal trials supporting cancer drug approvals by the US FDA from 2015 to 2020. INTERVENTIONS Clinical trials were analysed for the type of blinding, primary endpoint, whether crossover was specified in the publication, study phase, line of therapy, response rate, investigational sites, manufacturer and randomisation ratio. MAIN OUTCOME MEASURES The main outcome was the rate of accrual, which is the number of patients accrued in the study per open month of enrolment. RESULTS The study consisted of 133 randomised (68%) and 61 (32%) non-randomised clinical trials. In randomised studies, we found the accrual rate was higher in trials investigating first and second line drugs (adjusted rate ratios (aRR): 1.55, 95% CI 1.18 to 2.09), phase III trials (aRR: 2.13, 95% CI 1.48 to 2.99), and for studies sponsored by Merck (aRR: 1.47, 95% CI 1.18 to 2.37), adjusting for other covariates. In contrast, the primary endpoint of a study, presence of crossover, single agent response rate, the number of investigational sites, population disease burden and skewed randomisation ratios were not associated with the rate of accrual. In the non-randomised adjusted model, the accrual rate was 2.03 higher (95% CI 1.10 to 3.92) for clinical trials sponsored by manufacturer, specifically Merck. Primary endpoint, crossover, trial phase, response rate, the number of investigational sites, disease burden or line of therapy were not associated with the rate of accrual. CONCLUSION In this cross-sectional study, line of therapy, study phase and manufacturer were the only factors associated with accrual rate. These findings suggest many proffered factors for speedy trial accrual are not associated with greater enrolment rates.
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Affiliation(s)
- Kristina Jenei
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Alyson Haslam
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Timothée Olivier
- Department of Oncology, Geneva University Hospital, Geneva, Switzerland
| | | | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
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Bushway S, Cabreros I, Paige JW, Schwam D, Wenger JB. Barred from employment: More than half of unemployed men in their 30s had a criminal history of arrest. Sci Adv 2022; 8:eabj6992. [PMID: 35179954 PMCID: PMC8856609 DOI: 10.1126/sciadv.abj6992] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 12/29/2021] [Indexed: 06/14/2023]
Abstract
We investigate what portion of the pool of unemployed men in the United States have been arrested, convicted, or incarcerated by age 35. Using the National Longitudinal Survey of Youth, 1997, we estimate 64% of unemployed men have been arrested, and 46% have been convicted. Unexpectedly, these rates vary only slightly by race and ethnicity. Further investigation of other outcomes such as marriage, education, household net worth, and earnings shows large differences between unemployed men who have a criminal history record and those who do not. One major implication of these findings is that employment services should focus more on the special challenges facing unemployed men with criminal history records. A second implication is that statistical discrimination against unemployed members of racial minority groups, to avoid hiring those with criminal histories, is both illegal and ineffective.
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Affiliation(s)
- Shawn Bushway
- The RAND Corporation, Santa Monica, CA 90401-3208, USA
- The State University of New York, Albany, NY 12246, USA
| | | | | | - Daniel Schwam
- The RAND Corporation, Santa Monica, CA 90401-3208, USA
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Chinnappa K, Cárdenas A, Prieto-Colomina A, Villalba A, Márquez-Galera Á, Soler R, Nomura Y, Llorens E, Tomasello U, López-Atalaya JP, Borrell V. Secondary loss of miR-3607 reduced cortical progenitor amplification during rodent evolution. Sci Adv 2022; 8:eabj4010. [PMID: 35020425 PMCID: PMC8754304 DOI: 10.1126/sciadv.abj4010] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
The evolutionary expansion and folding of the mammalian cerebral cortex resulted from amplification of progenitor cells during embryonic development. This process was reversed in the rodent lineage after splitting from primates, leading to smaller and smooth brains. Genetic mechanisms underlying this secondary loss in rodent evolution remain unknown. We show that microRNA miR-3607 is expressed embryonically in the large cortex of primates and ferret, distant from the primate-rodent lineage, but not in mouse. Experimental expression of miR-3607 in embryonic mouse cortex led to increased Wnt/β-catenin signaling, amplification of radial glia cells (RGCs), and expansion of the ventricular zone (VZ), via blocking the β-catenin inhibitor APC (adenomatous polyposis coli). Accordingly, loss of endogenous miR-3607 in ferret reduced RGC proliferation, while overexpression in human cerebral organoids promoted VZ expansion. Our results identify a gene selected for secondary loss during mammalian evolution to limit RGC amplification and, potentially, cortex size in rodents.
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Van de Wiele VL, Hammer M, Parikh R, Feldman WB, Sarpatwari A, Kesselheim AS. Competition law and pricing among biologic drugs: the case of VEGF therapy for retinal diseases. J Law Biosci 2022; 9:lsac001. [PMID: 35211322 PMCID: PMC8863367 DOI: 10.1093/jlb/lsac001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 12/23/2021] [Accepted: 12/28/2021] [Indexed: 05/26/2023]
Abstract
Neovascular age-related macular degeneration (AMD) is a progressive eye disease and is a leading cause of vision loss in the Western world. Vascular endothelial growth factor inhibitors have become a mainstay of treatment for this disease. Currently, treatment options include three originator biologics with approvals for neovascular AMD (aflibercept, ranibizumab, and brolucizumab-dbll) and one biologic that is commonly used off-label for the condition (bevacizumab). In the USA, Medicare spending on these drugs consistently surpassed $4 billion per year between 2015 and 2019, driven by high prices and varying off-label use of bevacizumab, which is substantially cheaper than the other biologics used to treat neovascular AMD. In this article, we discuss how legal reform can improve market competition for biologic drugs, using AMD therapies as a case study. We chose this group of drugs for their significant contribution to Medicare spending, the price difference between approved therapies and intravitreal bevacizumab, and because there currently exists a large biosimilar pipeline with many drug candidates in the final stage of development. We propose mechanisms for anticipating and facilitating the market introduction of biosimilars, as well as changes to the pricing model in Medicare that can promote use of cost-effective therapies. Reforms such as empowering Medicare to negotiate drug prices may help ensure that introduction of new biologics and biosimilars for AMD will lower spending and increase patient access.
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Affiliation(s)
- Victor L Van de Wiele
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Maximilian Hammer
- Institute of Physiology and Pathophysiology, Heidelberg University, Heidelberg, Germany
| | - Ravi Parikh
- Department of Ophthalmology and Visual Sciences, New York University School of Medicine, New York, NY, USA
- Manhattan Retina and Eye Consultants, New York, NY, USA
| | - William B Feldman
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Ameet Sarpatwari
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
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Errington TM, Mathur M, Soderberg CK, Denis A, Perfito N, Iorns E, Nosek BA. Investigating the replicability of preclinical cancer biology. eLife 2021; 10:e71601. [PMID: 34874005 PMCID: PMC8651293 DOI: 10.7554/elife.71601] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/16/2021] [Indexed: 12/18/2022] Open
Abstract
Replicability is an important feature of scientific research, but aspects of contemporary research culture, such as an emphasis on novelty, can make replicability seem less important than it should be. The Reproducibility Project: Cancer Biology was set up to provide evidence about the replicability of preclinical research in cancer biology by repeating selected experiments from high-impact papers. A total of 50 experiments from 23 papers were repeated, generating data about the replicability of a total of 158 effects. Most of the original effects were positive effects (136), with the rest being null effects (22). A majority of the original effect sizes were reported as numerical values (117), with the rest being reported as representative images (41). We employed seven methods to assess replicability, and some of these methods were not suitable for all the effects in our sample. One method compared effect sizes: for positive effects, the median effect size in the replications was 85% smaller than the median effect size in the original experiments, and 92% of replication effect sizes were smaller than the original. The other methods were binary - the replication was either a success or a failure - and five of these methods could be used to assess both positive and null effects when effect sizes were reported as numerical values. For positive effects, 40% of replications (39/97) succeeded according to three or more of these five methods, and for null effects 80% of replications (12/15) were successful on this basis; combining positive and null effects, the success rate was 46% (51/112). A successful replication does not definitively confirm an original finding or its theoretical interpretation. Equally, a failure to replicate does not disconfirm a finding, but it does suggest that additional investigation is needed to establish its reliability.
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Affiliation(s)
| | - Maya Mathur
- Quantitative Sciences Unit, Stanford UniversityStanfordUnited States
| | | | | | | | | | - Brian A Nosek
- Center for Open ScienceCharlottesvilleUnited States
- University of VirginiaCharlottesvilleUnited States
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Abstract
OBJECTIVE To identify all known ties between the medical product industry and the healthcare ecosystem. DESIGN Scoping review. METHODS From initial literature searches and expert input, a map was created to show the network of medical product industry ties across parties and activities in the healthcare ecosystem. Through a scoping review, the ties were then verified, cataloged, and characterized, with data abstracted on types of industry ties (financial, non-financial), applicable policies for conflict of interests, and publicly available data sources. MAIN OUTCOME MEASURES Presence and types of medical product industry ties to activities and parties, presence of policies for conflict of interests, and publicly available data. RESULTS A map derived through synthesis of 538 articles from 37 countries shows an extensive network of medical product industry ties to activities and parties in the healthcare ecosystem. Key activities include research, healthcare education, guideline development, formulary selection, and clinical care. Parties include non-profit entities, the healthcare profession, the market supply chain, and government. The medical product industry has direct ties to all parties and some activities through multiple pathways; direct ties extend through interrelationships among parties and activities. The most frequently identified parties were within the healthcare profession, with individual professionals described in 422 (78%) of the included studies. More than half (303, 56%) of the publications documented medical product industry ties to research, with clinical care (156, 29%), health professional education (145, 27%), guideline development (33, 6%), and formulary selection (8, 1%) appearing less often. Policies for conflict of interests exist for some financial and a few non-financial ties; publicly available data sources seldom describe or quantify these ties. CONCLUSIONS An extensive network of medical product industry ties to activities and parties exists in the healthcare ecosystem. Policies for conflict of interests and publicly available data are lacking, suggesting that enhanced oversight and transparency are needed to protect patient care from commercial influence and to ensure public trust.
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Affiliation(s)
- Susan Chimonas
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, New York, NY 10017, USA
| | - Maha Mamoor
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, New York, NY 10017, USA
| | - Sophia A Zimbalist
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, New York, NY 10017, USA
| | - Brooke Barrow
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Peter B Bach
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, New York, NY 10017, USA
- Delfi Diagnostics, Baltimore, MD, USA
| | - Deborah Korenstein
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, New York, NY 10017, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Smith KP, Oman RF, Lu M, Dawkins AD, Harding RW, Hepworth K, Wagner KD. The mobile emergency recovery intervention trial (MERIT): Protocol for a 3-year mixed methods observational study of mobile recovery outreach teams in Nevada's emergency departments. PLoS One 2021; 16:e0258795. [PMID: 34710132 PMCID: PMC8553041 DOI: 10.1371/journal.pone.0258795] [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] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 10/05/2021] [Indexed: 12/04/2022] Open
Abstract
Background The Substance Abuse and Mental Health Administration awarded State Targeted Response grants to support states’ efforts to address the opioid epidemic. In Nevada, one component of this grant was mobile recovery outreach teams (MROTs) that utilized peer recovery support specialists to provide care for qualifying patients in emergency departments (EDs). The Mobile Emergency Recovery Intervention Trial (MERIT) is a mixed methods study to assess the feasibility/acceptability and effectiveness of the MROT intervention. This protocol mainly describes the R33 research activities and outcomes. The full protocol can be found protocols.io. Methods Data will be derived from state-level data sets containing de-identified emergency department visits, substance use disorder treatment records, and mortality files; in-person mixed methods interviews; participant observation; and self-report process evaluation forms. Primary outcomes include Medication Assisted Treatment (MAT) initiation and non-fatal overdose; secondary outcomes include MAT retention and fatal overdose. Quantitative hypotheses will be tested using generalized linear mixed effects models, Bayesian hierarchical models, and marginal Cox models. Qualitative interview data will be analyzed using an inductive thematic analysis procedure. Discussion
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Affiliation(s)
- Krysti P. Smith
- School of Community Health Sciences, University of Nevada, Reno, NV, United States of America
- * E-mail:
| | - Roy F. Oman
- School of Community Health Sciences, University of Nevada, Reno, NV, United States of America
| | - Minggen Lu
- School of Community Health Sciences, University of Nevada, Reno, NV, United States of America
| | - Ashley D. Dawkins
- School of Community Health Sciences, University of Nevada, Reno, NV, United States of America
| | - Robert W. Harding
- School of Community Health Sciences, University of Nevada, Reno, NV, United States of America
| | - Katherine Hepworth
- School of Community Health Sciences, University of Nevada, Reno, NV, United States of America
| | - Karla D. Wagner
- School of Community Health Sciences, University of Nevada, Reno, NV, United States of America
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Axson S, Mello MM, Lincow D, Yang C, Gross C, Ross JS, Miller J. Clinical trial transparency and data sharing among biopharmaceutical companies and the role of company size, location and product type: a cross-sectional descriptive analysis. BMJ Open 2021; 11:e053248. [PMID: 34281933 PMCID: PMC8291313 DOI: 10.1136/bmjopen-2021-053248] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To examine company characteristics associated with better transparency and to apply a tool used to measure and improve clinical trial transparency among large companies and drugs, to smaller companies and biologics. DESIGN Cross-sectional descriptive analysis. SETTING AND PARTICIPANTS Novel drugs and biologics Food and Drug Administration (FDA) approved in 2016 and 2017 and their company sponsors. MAIN OUTCOME MEASURES Using established Good Pharma Scorecard (GPS) measures, companies and products were evaluated on their clinical trial registration, results dissemination and FDA Amendments Act (FDAAA) implementation; companies were ranked using these measures and a multicomponent data sharing measure. Associations between company transparency scores with company size (large vs non-large), location (US vs non-US) and sponsored product type (drug vs biologic) were also examined. RESULTS 26% of products (16/62) had publicly available results for all clinical trials supporting their FDA approval and 67% (39/58) had public results for trials in patients by 6 months after their FDA approval; 58% (32/55) were FDAAA compliant. Large companies were significantly more transparent than non-large companies (overall median transparency score of 95% (IQR 91-100) vs 59% (IQR 41-70), p<0.001), attributable to higher FDAAA compliance (median of 100% (IQR 88-100) vs 57% (0-100), p=0.01) and better data sharing (median of 100% (IQR 80-100) vs 20% (IQR 20-40), p<0.01). No significant differences were observed by company location or product type. CONCLUSIONS It was feasible to apply the GPS transparency measures and ranking tool to non-large companies and biologics. Large companies are significantly more transparent than non-large companies, driven by better data sharing procedures and implementation of FDAAA trial reporting requirements. Greater research transparency is needed, particularly among non-large companies, to maximise the benefits of research for patient care and scientific innovation.
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Affiliation(s)
- Sydney Axson
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Michelle M Mello
- Center for Health Policy/Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine; Stanford University Law School, Stanford, CA, USA
| | - Deborah Lincow
- Department of Genetics, Yale University School of Medicine, New Haven, CT, USA
| | - Catherine Yang
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Cary Gross
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Joseph S Ross
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jennifer Miller
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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Ballreich J, Jin J, Kundu P, Chatterjee N. Provider and Patient Characteristics of Medicare Beneficiaries Who Are High-Risk for COVID-19 Mortality. J Gen Intern Med 2021; 36:2189-2190. [PMID: 33959885 PMCID: PMC8102052 DOI: 10.1007/s11606-021-06857-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/26/2021] [Indexed: 11/20/2022]
Affiliation(s)
- Jeromie Ballreich
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Jin Jin
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Prosenjit Kundu
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Nilanjan Chatterjee
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- Department of Oncology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Zare H, Eisenberg M, Anderson G. Charity Care and Community Benefit in Non-Profit Hospitals: Definition and Requirements. Inquiry 2021; 58:469580211028180. [PMID: 34167375 PMCID: PMC8246580 DOI: 10.1177/00469580211028180] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 05/17/2021] [Accepted: 06/07/2021] [Indexed: 11/16/2022]
Abstract
Policymakers are using different ways to measure the community benefit provided by non-profit hospitals because different policy makers have different policy objectives. We compare 3 commonly used measures of community benefit; examine the correlation across the 3 measures; examine how the distribution of community benefits varies across non-profit hospitals; and compare the factors associated with the level of community benefit for each definition. The main dataset for this study is the Schedule H of IRS Form 990 data for 2017. We merged this data with the 2017 American Hospital Association (AHA), the 2017 CMS Hospital Cost Report, and the 2018 American Community Survey data. The final sample consists of 1904 non-profit hospitals. We define 3 measures of community benefit: (1) Total community benefits: combining all 17 possible measures in the 990 data; (2) Total community benefits less unreimbursed Medicaid care because it reflects a policy choice made by the state; and (3) only charity care. We also subdivided the community benefits into individual and service-based benefit. Gini Coefficients and descriptive analysis show the distribution of 3 types of community benefit measures. On average, hospitals spent 8.1% of their expenses on all community benefits; 4.3% on community benefits less unreimbursed Medicaid; and 1.7% on charity care. The provision of charity care showed more variation (Gini coefficient) than the other 2 measures. Different hospital and geographic characteristics were associated with each definition, suggesting that different types of hospitals place emphasis on different community benefits. When policy makers choose among different definitions of community benefit, they should consider what incentives they want to instill.
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Affiliation(s)
- Hossein Zare
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- University of Maryland Global Campus, Largo, MD, USA
| | | | - Gerard Anderson
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Baayd J, Simmons RG. Protocol for a process evaluation of Family Planning Elevated: a statewide initiative to improve contraceptive access in Utah (USA). BMJ Open 2020; 10:e038049. [PMID: 33004395 PMCID: PMC7534679 DOI: 10.1136/bmjopen-2020-038049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 08/18/2020] [Accepted: 08/28/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Many individuals in the USA do not have access to the contraceptive methods they desire. Contraceptive initiatives have emerged at the state and national levels to remove barriers to access, and many initiatives have reported success. Other initiatives may want to build on or replicate that success, but data are scarce on the details of how and why certain interventions work. This paper describes the protocol for the planned process evaluation of Family Planning Elevated (FPE), a statewide contraceptive initiative in Utah. METHODS FPE will conduct a process evaluation during the planning and implementation phases of the programme. The process evaluation will document (1) the community, state and national contexts in which the programme is implemented, (2) how FPE is implemented and (3) the mechanism by which FPE creates impact. We will collect qualitative data via interviews with FPE staff, providers and staff participating in the programme, and key stakeholders and policy-makers throughout the state. The team process evaluator will record FPE decision making and implementation activities by taking field notes during weekly FPE meetings. Quantitatively, we will collect monthly data reports from FPE-participating clinics, analytics reports from the media campaign and survey results from patients in FPE-participating clinics. The findings of the process evaluation will allow other contraceptive initiatives to learn from FPE's efforts and replicate successful components of the programme. ETHICS AND DISSEMINATION The study received approval from the University of Utah's Institutional Review Board. Findings from the process evaluation and outcome evaluation will be published, shared with other contraceptive initiatives and presented at conferences. TRIAL REGISTRATION NUMBER NCT03877757.
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Affiliation(s)
- Jami Baayd
- Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, USA
| | - Rebecca G Simmons
- Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, USA
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Hey SP, Gyawali B, D’Andrea E, Kanagaraj M, Franklin JM, Kesselheim AS. A Systematic Review and Meta-Analysis of Bevacizumab in First-Line Metastatic Breast Cancer: Lessons for Research and Regulatory Enterprises. J Natl Cancer Inst 2020; 112:335-342. [PMID: 31651981 PMCID: PMC7156929 DOI: 10.1093/jnci/djz211] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 10/14/2019] [Accepted: 10/23/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The US Food and Drug Administration's accelerated approval and later withdrawal of bevacizumab in patients with metastatic breast cancer (mBC) is a seminal case for ongoing debates about the validity of using progression-free survival (PFS) as a surrogate measure for overall survival (OS) in cancer drug approvals. We systematically reviewed and meta-analyzed the evidence around bevacizumab's regulatory approval and withdrawal in mBC. METHODS We searched for all published phase II or III clinical trials testing bevacizumab as a first-line therapy for patients with mBC. Data were extracted on trial demographics, interventions, and outcomes. Descriptive analysis was stratified by whether the trial was initiated before, during, or after the accelerated approval. We used a cumulative random-effects meta-analysis to assess the evolution of evidence of the effect of bevacizumab on PFS and OS. We estimated the association between the trial-level PFS and OS effect using a nonlinear mixed-regression model. RESULTS Fifty-two studies were included. Trial activity dramatically dropped after the accelerated approval was withdrawn. Eight clinical trials reported hazard ratios (hazard ratios) and were meta-analyzed. The cumulative hazard ratio for PFS was 0.72 (95% CI = 0.65 to 0.79), and the cumulative hazard ratio for OS was 0.90 (95% CI = 0.80 to 1.01). The regression model showed a statistically nonsignificant association between PFS benefit and OS benefit (β = 0.43, SE = 0.81). CONCLUSION The US Food and Drug Administration's decision-making in this case was consistent with the evolving state of evidence. However, the fact that seven clinical trials are insufficient to conclude validity (or lack thereof) for a trial-level surrogate suggests that it would be more efficient to conduct trials using the more clinically meaningful endpoints.
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Affiliation(s)
- Spencer Phillips Hey
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Harvard Center for Bioethics, Harvard Medical School, Boston, MA
| | - Bishal Gyawali
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Department of Oncology, Department of Public Health Sciences, and Division of Cancer Care and Epidemiology, Queen’s University, Kingston, Ontario, Canada
| | - Elvira D’Andrea
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | | | - Jessica M Franklin
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Harvard Center for Bioethics, Harvard Medical School, Boston, MA
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Vokinger KN, Kesselheim AS. Application of orphan drug designation to cancer treatments (2008-2017): a comprehensive and comparative analysis of the USA and EU. BMJ Open 2019; 9:e028634. [PMID: 31601584 PMCID: PMC6797305 DOI: 10.1136/bmjopen-2018-028634] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 08/22/2019] [Accepted: 08/29/2019] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To determine differences in the characteristics of cancer drugs designated as orphan drugs by the Food and Drug Administration (FDA) and European Medicines Agency (EMA). DESIGN AND SETTING Identification of all cancer drugs (initial or supplementary indication) with orphan status approved by the FDA between 2008-2017 based on publicly accessible reports. The European public assessment reports (EPAR) was searched to determine whether these FDA-approved drugs were also approved by the EMA. MAIN OUTCOME MEASURES Extraction of active ingredient, trade name, approval date and approved indication from two FDA data sources (Orphan Drug Product Designation Database, Drugs@FDA) and comparison with the same data from EPAR. RESULTS The FDA approved 135 cancer drugs with orphan indications that met our inclusion criteria, of which 101 (75%) were also approved by the EMA. 80/101 (79%) were first approved in the USA. Only 41/101 (41%) also received orphan designation by the EMA. 33/101 (33%) were approved for biomarker-based indications in the USA, however, only nine approved cancer drug indications by the EMA were biomarker-derived drugs. 78% (47/60) of approved cancer drugs that were only approved in the USA with orphan status were indicated for solid tumours, 22% (13/60) had indications for non-solid tumours. By contrast, out of those approved cancer drugs that received orphan designation by both agencies, 20% (8/41) were indicated for solid, and 80% (33/41) for non-solid tumours. CONCLUSIONS Orphan designation was intended to encourage drug development for rare conditions. This study shows that the FDA approves more cancer drugs with such designations compared with the EMA, especially for subgroups of more prevalent cancers. One reason for the difference could be that the European Union requires demonstration of significant benefit for drugs that target the same indication as a drug already on the market to earn the orphan designation.
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Affiliation(s)
- Kerstin Noëlle Vokinger
- Academic Chair for Public Law, Health Law, and Digitalization, Institute of Law, University of Zurich, Zurich, Switzerland
- Institute for Primary Care and Health Services Research, University Hospital of Zurich/University of Zurich, Zurich, Switzerland
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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