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Lee S, Frediani G, Lund BC, Kennelty K, Jeffery MM, Carnahan RM. A Nationwide Emergency Department Data Analysis to Predict Beers List Medications Use Among Older Adults. J Emerg Med 2024:S0736-4679(24)00070-2. [PMID: 38734547 DOI: 10.1016/j.jemermed.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 02/24/2024] [Accepted: 03/06/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND The use of potentially inappropriate medications (PIMs) is considered an important quality indicator for older adults seen in the ambulatory care setting. STUDY OBJECTIVES To evaluate the pattern of potentially inappropriate medication (PIMs) use as specified in the Beers Criteria, for older adults during emergency department (ED) visits in the United States. METHODS Using data from the National Hospital Ambulatory Care Survey (NHAMCS) we identified older adults (age 65 or older) discharged home from an ED visit in 2019. We defined PIMs as those with an 'avoid' recommendation under the American Geriatrics Society (AGS) 2019 Beers Criteria in older adults. Logistic regression models were used to assess demographic, clinical, and hospital factors associated with the use of any PIMs upon ED discharge. RESULTS Overall, 5.9% of visits by older adults discharged from the ED included administration or prescriptions for PIMs. Among those who received any PIMs, 25.5% received benzodiazepines, 42.5 % received anticholinergics, 1.4% received nonbenzodiazepine hypnotics, and 0.5% received barbiturates. A multivariable model showed statistically significant associations for age 65 to 74 (OR 1.91, 95% CI 1.39-2.62 vs. age >=75), dementia (OR 0.45, 95% CI 0.21-0.95), lower immediacy (OR 2.45, 95% CI 1.56-3.84 vs. higher immediacy), and Northeastern rural region (OR 0.34, 95% CI 0.21-0.55 vs. Midwestern rural). CONCLUSION We found that younger age and lower immediacy were associated with increased prescriptions of PIMs for older adults seen, while dementia and Northeastern rural region was associated with reduced use of PIMs seen and discharged from EDs in United States.
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Affiliation(s)
- Sangil Lee
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa.
| | - Gabrielle Frediani
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Brian C Lund
- Center for Access & Delivery Research and Evaluation and Department of Pharmacy Practice, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Korey Kennelty
- Division of Health Service Research, College of Pharmacy, Department of Family Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Molly Moore Jeffery
- Associate Professor of Emergency Medicine, Division of Health Care Delivery Research and Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ryan M Carnahan
- Department of Epidemiology, The University of Iowa College of Public Health, Iowa City, Iowa
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Thanarajasingam G, Kluetz P, Bhatnagar V, Brown A, Cathcart-Rake E, Diamond M, Faust L, Fiero MH, Huntington S, Jeffery MM, Jones L, Noble B, Paludo J, Powers B, Ross JS, Ritchie JD, Ruddy K, Schellhorn S, Tarver M, Dueck AC, Gross C. Integrating 4 methods to evaluate physical function in patients with cancer (In4M): protocol for a prospective cohort study. BMJ Open 2024; 14:e074030. [PMID: 38199641 PMCID: PMC10806877 DOI: 10.1136/bmjopen-2023-074030] [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: 03/31/2023] [Accepted: 08/03/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Accurate, patient-centred evaluation of physical function in patients with cancer can provide important information on the functional impacts experienced by patients both from the disease and its treatment. Increasingly, digital health technology is facilitating and providing new ways to measure symptoms and function. There is a need to characterise the longitudinal measurement characteristics of physical function assessments, including clinician-reported outcome, patient-reported ported outcome (PRO), performance outcome tests and wearable data, to inform regulatory and clinical decision-making in cancer clinical trials and oncology practice. METHODS AND ANALYSIS In this prospective study, we are enrolling 200 English-speaking and/or Spanish-speaking patients with breast cancer or lymphoma seen at Mayo Clinic or Yale University who will receive intravenous cytotoxic chemotherapy. Physical function assessments will be obtained longitudinally using multiple assessment modalities. Participants will be followed for 9 months using a patient-centred health data aggregating platform that consolidates study questionnaires, electronic health record data, and activity and sleep data from a wearable sensor. Data analysis will focus on understanding variability, sensitivity and meaningful changes across the included physical function assessments and evaluating their relationship to key clinical outcomes. Additionally, the feasibility of multimodal physical function data collection in real-world patients with breast cancer or lymphoma will be assessed, as will patient impressions of the usability and acceptability of the wearable sensor, data aggregation platform and PROs. ETHICS AND DISSEMINATION This study has received approval from IRBs at Mayo Clinic, Yale University and the US Food and Drug Administration. Results will be made available to participants, funders, the research community and the public. TRIAL REGISTRATION NUMBER NCT05214144; Pre-results.
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Affiliation(s)
| | - Paul Kluetz
- US Food and Drug Administration, Silver Spring, Maryland, USA
| | | | - Abbie Brown
- Health Education and Content Services, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Matthew Diamond
- US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Louis Faust
- Division of Health Care Delivery Research, Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Scott Huntington
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale's Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Molly Moore Jeffery
- Division of Health Care Delivery Research and Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Lee Jones
- Patient Advocate, Arlington, Virginia, USA
| | - Brie Noble
- Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, Arizona, USA
| | - Jonas Paludo
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Brad Powers
- CancerHacker Lab, Boston, Massachusetts, USA
| | - Joseph S Ross
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale-New Haven Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, Connecticut, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
| | - Jessica D Ritchie
- Yale-New Haven Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, Connecticut, USA
| | - Kathryn Ruddy
- Department of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sarah Schellhorn
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale's Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michelle Tarver
- US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Amylou C Dueck
- Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, Arizona, USA
| | - Cary Gross
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale's Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
- Yale-New Haven Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, Connecticut, USA
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
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Wallach JD, Deng Y, Polley EC, Dhruva SS, Herrin J, Quinto K, Gandotra C, Crown W, Noseworthy P, Yao X, Jeffery MM, Lyon TD, Ross JS, McCoy RG. Assessing the use of observational methods and real-world data to emulate ongoing randomized controlled trials. Clin Trials 2023; 20:689-698. [PMID: 37589143 PMCID: PMC10843567 DOI: 10.1177/17407745231193137] [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] [Indexed: 08/18/2023]
Abstract
BACKGROUND/AIMS There has been growing interest in better understanding the potential of observational research methods in medical product evaluation and regulatory decision-making. Previously, we used linked claims and electronic health record data to emulate two ongoing randomized controlled trials, characterizing the populations and results of each randomized controlled trial prior to publication of its results. Here, our objective was to compare the populations and results from the emulated trials with those of the now-published randomized controlled trials. METHODS This study compared participants' demographic and clinical characteristics and study results between the emulated trials, which used structured data from OptumLabs Data Warehouse, and the published PRONOUNCE and GRADE trials. First, we examined the feasibility of implementing the baseline participant characteristics included in the published PRONOUNCE and GRADE trials' using real-world data and classified each variable as ascertainable, partially ascertainable, or not ascertainable. Second, we compared the emulated trials and published randomized controlled trials for baseline patient characteristics (concordance determined using standardized mean differences <0.20) and results of the primary and secondary endpoints (concordance determined by direction of effect estimates and statistical significance). RESULTS The PRONOUNCE trial enrolled 544 participants, and the emulated trial included 2226 propensity score-matched participants. In the PRONOUNCE trial publication, one of the 32 baseline participant characteristics was listed as an exclusion criterion on ClinicalTrials.gov but was ultimately not used. Among the remaining 31 characteristics, 9 (29.0%) were ascertainable, 11 (35.5%) were partially ascertainable, and 10 (32.2%) were not ascertainable using structured data from OptumLabs. For one additional variable, the PRONOUNCE trial did not provide sufficient detail to allow its ascertainment. Of the nine variables that were ascertainable, values in the emulated trial and published randomized controlled trial were discordant for 6 (66.7%). The primary endpoint of time from randomization to the first major adverse cardiovascular event and secondary endpoints of nonfatal myocardial infarction and stroke were concordant between the emulated trial and published randomized controlled trial. The GRADE trial enrolled 5047 participants, and the emulated trial included 7540 participants. In the GRADE trial publication, 8 of 34 (23.5%) baseline participant characteristics were ascertainable, 14 (41.2%) were partially ascertainable, and 11 (32.4%) were not ascertainable using structured data from OptumLabs. For one variable, the GRADE trial did not provide sufficient detail to allow for ascertainment. Of the eight variables that were ascertainable, values in the emulated trial and published randomized controlled trial were discordant for 4 (50.0%). The primary endpoint of time to hemoglobin A1c ≥7.0% was mostly concordant between the emulated trial and the published randomized controlled trial. CONCLUSION Despite challenges, observational methods and real-world data can be leveraged in certain important situations for a more timely evaluation of drug effectiveness and safety in more diverse and representative patient populations.
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Affiliation(s)
- Joshua D Wallach
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Yihong Deng
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Eric C Polley
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA
| | - Sanket S Dhruva
- Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
- San Francisco School of Medicine, University of California, San Francisco, CA, USA
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Kenneth Quinto
- Office of Medical Policy, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Springs, MD, USA
| | - Charu Gandotra
- Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Springs, MD, USA
| | - William Crown
- Florence Heller Graduate School, Brandeis University, Waltham, MA, USA
| | - Peter Noseworthy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Molly Moore Jeffery
- Division of Health Care Delivery Research and Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | - Timothy D Lyon
- Department of Urology, Mayo Clinic, Jacksonville, FL, USA
| | - Joseph S Ross
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Rozalina G McCoy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- OptumLabs, Eden Prairie, MN, USA
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Stevens MA, Melnick ER, Savitz ST, Jeffery MM, Nath B, Janke AT. National trends in emergency conditions through the Omicron COVID-19 wave in commercial and Medicare Advantage enrollees. J Am Coll Emerg Physicians Open 2023; 4:e13023. [PMID: 37576118 PMCID: PMC10423035 DOI: 10.1002/emp2.13023] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/11/2023] [Accepted: 07/20/2023] [Indexed: 08/15/2023] Open
Abstract
Objective To evaluate trends in emergency care sensitive conditions (ECSCs) from pre-COVID (March 2018-February 2020) through Omicron (December 2021-February 2022). Methods This cross-sectional analysis evaluated trends in ECSCs using claims (OptumLabs Data Warehouse) from commercial and Medicare Advantage enrollees. Emergency department (ED) visits for ECSCs (acute appendicitis, aortic aneurysm/dissection, cardiac arrest/severe arrhythmia, cerebral infarction, myocardial infarction, pulmonary embolism, opioid overdose, pre-eclampsia) were reported per 100,000 person months from March 2018 to February 2022 by pandemic wave. We calculated the percent change for each pandemic wave compared to the pre-pandemic period. Results There were 10,268,554 ED visits (March 2018-February 2022). The greatest increases in ECSCs were seen for pulmonary embolism, cardiac arrest/severe arrhythmia, myocardial infarction, and pre-eclampsia. For commercial enrollees, pulmonary embolism visit rates increased 22.7% (95% confidence interval [CI], 18.6%-26.9%) during Waves 2-3, 37.2% (95% CI, 29.1%-45.8%] during Delta, and 27.9% (95% CI, 20.3%-36.1%) during Omicron, relative to pre-pandemic rates. Cardiac arrest/severe arrhythmia visit rates increased 4.0% (95% CI, 0.2%-8.0%) during Waves 2-3; myocardial infarction rates increased 4.9% (95% CI, 2.1%-7.8%) during Waves 2-3. Similar patterns were seen in Medicare Advantage enrollees. Pre-eclampsia visit rates among reproductive-age female enrollees increased 31.1% (95% CI, 20.9%-42.2%), 23.7% (95% CI, 7.5%,-42.3%), and 34.7% (95% CI, 16.8%-55.2%) during Waves 2-3, Delta, and Omicron, respectively. ED visits for other ECSCs declined or exhibited smaller increases. Conclusions ED visit rates for acute cardiovascular conditions, pulmonary embolism and pre-eclampsia increased despite declines or stable rates for all-cause ED visits and ED visits for other conditions. Given the changing landscape of ECSCs, studies should identify drivers for these changes and interventions to mitigate them.
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Affiliation(s)
- Maria A Stevens
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester Minnesota USA
- Division of Health Care Delivery Research Mayo Clinic Rochester Minnesota USA
- Department of Health Policy and Management University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
- OptumLabs Eden Prairie Minnesota USA
| | - Edward R Melnick
- Department of Emergency Medicine Yale School of Medicine New Haven Connecticut USA
- Department of Biostatistics (Health Informatics) Yale School of Public Health New Haven USA
| | - Samuel T Savitz
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester Minnesota USA
- Division of Health Care Delivery Research Mayo Clinic Rochester Minnesota USA
| | - Molly Moore Jeffery
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester Minnesota USA
- Division of Health Care Delivery Research Mayo Clinic Rochester Minnesota USA
- Department of Emergency Medicine Mayo Clinic Rochester USA
| | - Bidisha Nath
- Department of Emergency Medicine Yale School of Medicine New Haven Connecticut USA
| | - Alexander T Janke
- Department of Emergency Medicine Yale School of Medicine New Haven Connecticut USA
- Institute for Healthcare Policy and Innovation University of Michigan/VA Ann Arbor Ann Arbor Michigan USA
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Chang J, Karaca-Mandic P, Nikpay S, Jeffery MM. Association Between New 340B Program Participation and Commercial Insurance Spending on Outpatient Biologic Oncology Drugs. JAMA Health Forum 2023; 4:e231485. [PMID: 37351874 DOI: 10.1001/jamahealthforum.2023.1485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023] Open
Abstract
Importance Previous studies have found that hospitals participating in the 340B Drug Pricing Program have higher Medicare Part B spending and expansion into affluent neighborhoods. Less is known about the association of 340B participation with spending by commercial insurance, where reimbursements are higher than Medicare. Objective To use the Affordable Care Act expansion of eligibility for the 340B Drug Pricing Program to study the association between participation and spending on outpatient-administered oncological drugs for commercially insured patients. Design, Setting, and Participants This cohort study included a balanced panel hospital cohort containing new and never 340B program participants between 2007 and 2019; more recent data were not included to avoid the effect of disruptions in care due to the COVID-19 pandemic. Descriptive analyses documented spending trends for patients receiving common outpatient-administered biologics used in cancer treatments (bevacizumab, filgrastim, pegfilgrastim, rituximab, and trastuzumab) at 340B (treated) and non-340B (control) hospitals. A difference-in-differences model assessed changes in episode drug spending. Analyses were conducted between December 2021 and June 2022. Exposure New 340B program participation between 2010 and 2016. Main Outcome and Measures Total drug episode spending, with control variables including total billed units, drug, calendar-year fixed effects, and hospital fixed effects. Results Of 95 127 included episodes (56 917 [59.8%] episodes in female patients) across 478 hospitals, patients seen in 340B and non-340B hospitals were similar in sex and drug used, and 340B hospital patients were older than non-340B patients (median [IQR] age for all patients, 61 [51-71] years). New 340B participating hospitals were more likely to be small (<50 beds) and more likely to be in rural settings. In the difference-in-differences analysis, total episode drug spending increased by $4074.69 (95% CI, $1592.84-$6556.70; P = .001) in the year following start of 340B program participation relative to nonparticipants. Heterogeneous group time effects were seen, with earlier participants less likely to have increased episode spending. Conclusions and Relevance In this cohort study, new 340B participation was associated with statistically significant higher oncological drug episode spending compared with nonparticipants after changes in 340B inclusion rules in 2010. These findings raise questions about unintended consequences of the 340B program on drug spending from the commercially insured population.
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Affiliation(s)
- Jessica Chang
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
| | - Pinar Karaca-Mandic
- Department of Finance, Carlson School of Management, University of Minnesota, Minneapolis
| | - Sayeh Nikpay
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
| | - Molly Moore Jeffery
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota
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Chang J, Karaca-Mandic P, Go RS, Schondelmeyer S, Weisdorf D, Jeffery MM. Provider barriers in uptake of biosimilars: case study on filgrastim. Am J Manag Care 2023; 29:e155-e158. [PMID: 37229790 DOI: 10.37765/ajmc.2023.89363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
In this article, we used administrative claims data from the OptumLabs Data Warehouse and American Hospital Association Annual Survey data to examine associations between hospital characteristics and uptake of biosimilar granulocyte colony-stimulating factor treatments. We found that 340B-participating hospitals and non-rural referral center (RRC) hospitals that reported owning rural health clinics were less likely to administer the lower-cost biosimilars, whereas the opposite was true for hospitals that are RRCs. To our knowledge, our study offers a first look at an underappreciated source of disparities in access to lower-cost medications such as biosimilars. Results from our study reveal opportunities for targeted policies to encourage adoption of lower-cost treatments, particularly among hospitals that serve rural communities where patients often have fewer choices in care site.
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Affiliation(s)
- Jessica Chang
- University of Minnesota School of Public Health, 420 Delaware St SE, Minneapolis, MN 55455.
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Thanarajasingam G, Kluetz PG, Bhatnagar V, Brown A, Cathcart-Rake E, Diamond M, Faust L, Fiero MH, Huntington SF, Jeffery MM, Jones L, Noble BN, Paludo J, Powers B, Ross JS, Ritchie JD, Ruddy KJ, Schellhorn SE, Tarver ME, Dueck AC, Gross CP. Integrating 4 Measures to Evaluate Physical Function in Patients with Cancer (In4M): Protocol for a prospective study. medRxiv 2023:2023.03.08.23286924. [PMID: 36945495 PMCID: PMC10029056 DOI: 10.1101/2023.03.08.23286924] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
Introduction Accurate, patient-centered evaluation of physical function in patients with cancer can provide important information on the functional impacts experienced by patients both from the disease and its treatment. Increasingly, digital health technology is facilitating and providing new ways to measure symptoms and function. There is a need to characterize the longitudinal measurement characteristics of physical function assessments, including clinician-reported physical function (ClinRo), patient-reported physical function (PRO), performance outcome tests (PerfO) and wearable data, to inform regulatory and clinical decision-making in cancer clinical trials and oncology practice. Methods and analysis In this prospective study, we are enrolling 200 English- and/or Spanish-speaking patients with breast cancer or lymphoma seen at Mayo Clinic or Yale University who will receive standard of care intravenous cytotoxic chemotherapy. Physical function assessments will be obtained longitudinally using multiple assessment modalities. Participants will be followed for 9 months using a patient-centered health data aggregating platform that consolidates study questionnaires, electronic health record data, and activity and sleep data from a wearable sensor. Data analysis will focus on understanding variability, sensitivity, and meaningful changes across the included physical function assessments and evaluating their relationship to key clinical outcomes. Additionally, the feasibility of multi-modal physical function data collection in real-world patients with cancer will be assessed, as will patient impressions of the usability and acceptability of the wearable sensor, data aggregation platform, and PROs. Ethics and dissemination This study has received approval from IRBs at Mayo Clinic, Yale University, and the U.S. Food & Drug Administration. Results will be made available to participants, funders, the research community, and the public. Registration Details The trial registration number for this study is NCT05214144. Strengths & Limitations This study addresses an important unmet need by characterizing the performance characteristics of multiple patient-centered physical function measures in patients with cancerPhysical function is an important and undermeasured clinical outcome. Scientifically rigorous capture and measurement of physical function constitutes a key component of cancer treatment tolerability assessment both from a regulatory and clinical perspective.This study will include patients with lymphoma or breast cancer receiving a broad range of cytotoxic chemotherapy regimens. While recruitment will occur at two academic sites, patients who ultimately receive treatment at local community sites will be included.A patient-centered health data aggregating platform facilitates the delivery of patient-reported outcome measures and collection of wearable data to researchers, while reducing patient burden compared to traditional patient-generated data collection and aggregation methodsHeterogeneity in patient willingness or comfort engaging with mobile products including smartphones and wearables, enrollment primarily at large academic centers, and the modest sample size are potential limitations to the external validity of the study.
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Affiliation(s)
| | - Paul G. Kluetz
- U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | | | - Abbie Brown
- Health Education and Content Services, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Matthew Diamond
- U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Louis Faust
- Division of Health Care Delivery Research, Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Scott F. Huntington
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale’s Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Molly Moore Jeffery
- Division of Health Care Delivery Research, Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Lee Jones
- Patient advocate, Arlington, Virginia, USA
| | - Brie N. Noble
- Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, Arizona, USA
| | - Jonas Paludo
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Brad Powers
- CancerHacker Lab, Boston, Massachusetts, USA
| | - Joseph S. Ross
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale-New Haven Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
| | - Jessica D. Ritchie
- Yale-New Haven Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut, USA
| | - Kathryn J. Ruddy
- Department of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sarah E. Schellhorn
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale’s Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Amylou C. Dueck
- Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, Arizona, USA
| | - Cary P. Gross
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale’s Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
- Yale-New Haven Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut, USA
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
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Togun AT, Karaca-Mandic P, Wurtz R, Jeffery MM, Beebe T. Changes in opioid marketing practices after release of the CDC guidelines. Am J Manag Care 2022; 28:507-513. [PMID: 36252169 DOI: 10.37765/ajmc.2022.89248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES After the release of the CDC guidelines in March 2016, the rate of opioid prescriptions decreased. How or whether pharmaceutical companies changed their opioid marketing practices post release of the CDC guidelines is unknown. Our objectives were to (1) evaluate whether the release of the guidelines was associated with changes in total monthly marketing spending received per physician, monthly marketing encounter frequency per physician, and spending per encounter during opioid marketing; and (2) evaluate whether such changes in marketing differed between specialist physicians and primary care physicians (PCPs) and between urban and rural primary care service areas (PCSAs). STUDY DESIGN Retrospective observational cross-sectional study using opioid marketing spending data from the CMS Open Payments database between August 2013 and December 2017. METHODS Single-group and multiple-group interrupted time series analyses were used to evaluate differences in the immediate changes in level and trend over time in opioid marketing practices post release of the CDC guidelines. RESULTS Post release of the CDC guidelines, the monthly number of marketing encounters per physician and total monthly amount received per physician decreased. However, the amount spent at each marketing encounter increased. The release of the CDC guidelines was associated with an immediate increase in level of opioid marketing spending per encounter by $0.59 (95% CI, $0.51-$0.68; P < .001) and an over-time increase in rate of spending per encounter of $0.04 per month (95% CI, $0.03-$0.05; P < .001). These changes differed between specialists and PCPs and between urban and rural PCSAs. CONCLUSIONS It is important to continue ongoing education for physicians on changes in pharmaceutical opioid marketing practices.
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Affiliation(s)
- Adeniyi T Togun
- Department of Health Services Research, School of Public Health, University of Minnesota Twin Cities, 420 Delaware St SE, MMC 729, Minneapolis, MN 55455.
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Dreyer RP, Berkowitz A, Yaggi HK, Schneeberg L, Shah ND, Emanuel L, Kolla B, Jeffery MM, Deeg M, Ervin K, Thorndike F, Ross JS. Pre Scription Digita L Th Erap Eutic for Patients with Insomnia ( SLEEP-I): a protocol for a pragmatic randomised controlled trial. BMJ Open 2022; 12:e062041. [PMID: 35940841 PMCID: PMC9364397 DOI: 10.1136/bmjopen-2022-062041] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 07/17/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Cognitive behavioural therapy for insomnia (CBT-I) is effective at treating chronic insomnia, yet in-person CBT-I can often be challenging to access. Prior studies have used technology to bridge barriers but have been unable to extensively assess the impact of the digital therapeutic on real-world patient experience and multidimensional outcomes. Among patients with insomnia, our aim is to determine the impact of a prescription digital therapeutic (PDT) (PEAR-003b, FDA-authorised as Somryst; herein called PDT) that provides mobile-delivered CBT-I on patient-reported outcomes (PROs) and healthcare utilisation. METHODS AND ANALYSIS We are conducting a pragmatically designed, prospective, multicentre randomised controlled trial that leverages Hugo, a unique patient-centred health data-aggregating platform for data collection and patient follow-up from Hugo Health. A total of 100 participants with insomnia from two health centres will be enrolled onto the Hugo Health platform, provided with a linked Fitbit (Inspire 2) to track activity and then randomised 1:1 to receive (or not) the PDT for mobile-delivered CBT-I (Somryst). The primary outcome is a change in the insomnia severity index score from baseline to 9-week postrandomisation. Secondary outcomes include healthcare utilisation, health utility scores and clinical outcomes; change in sleep outcomes as measured with sleep diaries and a change in individual PROs including depressive symptoms, daytime sleepiness, health status, stress and anxiety. For those allocated to the PDT, we will also assess engagement with the PDT. ETHICS AND DISSEMINATION The Institutional Review Boards at Yale University and the Mayo Clinic have approved the trial protocol. This trial will provide important data to patients, clinicians and policymakers about the impact of the PDT device delivering CBT-I on PROs, clinical outcomes and healthcare utilisation. Findings will be disseminated to participants, presented at professional meetings and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04909229.
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Affiliation(s)
- Rachel P Dreyer
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Alyssa Berkowitz
- Center for Outcomes Research and Evaluation, Yale-New Haven Health, New Haven, Connecticut, USA
| | - Henry Klar Yaggi
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lynelle Schneeberg
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Nilay D Shah
- Department of Health Sciences Research, Mayo Clinic, Rochester, New York, USA
| | - Lindsay Emanuel
- Department of Health Sciences Research, Mayo Clinic, Rochester, New York, USA
| | - Bhanuprakash Kolla
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, New York, USA
| | - Molly Moore Jeffery
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, New York, USA
| | - Mark Deeg
- Cullgen Inc, Boston, Massachusetts, USA
| | - Keondae Ervin
- National Evaluation System for Health Technology Coordinating Center (NESTcc), Arlington, Virginia, USA
| | | | - Joseph S Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Health, New Haven, Connecticut, USA
- Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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10
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Jeffery MM, Oliveira J E Silva L, Bellolio F, Garovic VD, Dempsey TM, Limper A, Cummins NW. Association of outpatient use of renin-angiotensin-aldosterone system blockers on outcomes of acute respiratory illness during the COVID-19 pandemic: a cohort study. BMJ Open 2022; 12:e060305. [PMID: 35793915 PMCID: PMC9260198 DOI: 10.1136/bmjopen-2021-060305] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Evaluate the associations between patients taking ACE inhibitors and angiotensin receptor blockers (ARBs) and their clinical outcomes after an acute viral respiratory illness (AVRI) due to COVID-19. DESIGN Retrospective cohort. SETTING The USA; 2017-2018 influenza season, 2018-2019 influenza season, and 2019-2020 influenza/COVID-19 season. PARTICIPANTS People with hypertension (HTN) taking an ACEi, ARB or other HTN medications, and experiencing AVRI. MAIN OUTCOME MEASURES Change in hospital admission, intensive care unit (ICU) or coronary care unit (CCU), acute respiratory distress (ARD), ARD syndrome (ARDS) and all-cause mortality, comparing COVID-19 to pre-COVID-19 influenza seasons. RESULTS The cohort included 1 059 474 episodes of AVRI (653 797 filled an ACEi or ARB, and 405 677 other HTN medications). 58.6% were women and 72.9% with age ≥65. The ACEi/ARB cohort saw a larger increase in risk in the COVID-19 influenza season than the other HTN medication cohort for four out of five outcomes, with an additional 1.5 percentage point (pp) increase in risk of an inpatient stay (95% CI 1.2 to 1.9 pp) and of ICU/CCU use (95% CI 0.3 to 2.7 pp) as well as a 0.7 pp (0.1 to 1.2 pp) additional increase in risk of ARD and 0.9 pp (0.4 to 1.3 pp) additional increase in risk of ARDS. There was no statistically significant difference in the absolute risk of death (-0.2 pp, 95% CI -0.4 to 0.1 pp). However, the relative risk of death in 2019/2020 versus 2017/2018 for the ACEi/ARB group was larger (1.40 (1.36 to 1.44)) than for the other HTN medication cohort (1.24 (1.21 to 1.28)). CONCLUSIONS People with AVRI using ACEi/ARBs for HTN had a greater increase in poor outcomes during the COVID-19 pandemic than those using other medications to treat HTN. The small absolute magnitude of the differences likely does not support changes in clinical practice.
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Affiliation(s)
- Molly Moore Jeffery
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Visiting Fellow, OptumLabs, Eden Prairie, Minnesota, USA
| | | | | | - Vesna D Garovic
- Department of Medicine, Division of Nephrology & Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Timothy M Dempsey
- David Grant Medical Center, US Air Force, Travis Air Force Base, California, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew Limper
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nathan W Cummins
- Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
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11
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Jeffery MM, Ahadpour M, Allen S, Araojo R, Bellolio F, Chang N, Ciaccio L, Emanuel L, Fillmore J, Gilbert GH, Koussis P, Lee C, Lipkind H, Mallama C, Meyer T, Moncur M, Nuckols T, Pacanowski MA, Page DB, Papadopoulos E, Ritchie JD, Ross JS, Shah ND, Soukup M, St Clair CO, Tamang S, Torbati S, Wallace DW, Zhao Y, Heckmann R. Acute pain pathways: protocol for a prospective cohort study. BMJ Open 2022; 12:e058782. [PMID: 35790333 PMCID: PMC9258513 DOI: 10.1136/bmjopen-2021-058782] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Opioid analgesics are often used to treat moderate-to-severe acute non-cancer pain; however, there is little high-quality evidence to guide clinician prescribing. An essential element to developing evidence-based guidelines is a better understanding of pain management and pain control among individuals experiencing acute pain for various common diagnoses. METHODS AND ANALYSIS This multicentre prospective observational study will recruit 1550 opioid-naïve participants with acute pain seen in diverse clinical settings including primary/urgent care, emergency departments and dental clinics. Participants will be followed for 6 months with the aid of a patient-centred health data aggregating platform that consolidates data from study questionnaires, electronic health record data on healthcare services received, prescription fill data from pharmacies, and activity and sleep data from a Fitbit activity tracker. Participants will be enrolled to represent diverse races and ethnicities and pain conditions, as well as geographical diversity. Data analysis will focus on assessing patients' patterns of pain and opioid analgesic use, along with other pain treatments; associations between patient and condition characteristics and patient-centred outcomes including resolution of pain, satisfaction with care and long-term use of opioid analgesics; and descriptive analyses of patient management of leftover opioids. ETHICS AND DISSEMINATION This study has received approval from IRBs at each site. Results will be made available to participants, funders, the research community and the public. TRIAL REGISTRATION NUMBER NCT04509115.
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Affiliation(s)
- Molly Moore Jeffery
- Emergency Medicine and Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Mitra Ahadpour
- Center for Drug Evaluation and Research, Office of Surveillance and Epidemiology, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Summer Allen
- Knowledge and Evaluation Research Unit; Department of Family Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Richardae Araojo
- Office of the Commissioner, Office of Minority Health and Health Equity, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Fernanda Bellolio
- Emergency Medicine and Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Nancy Chang
- Center for Drug Evaluation and Research, Office of Translational Sciences, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Laura Ciaccio
- Division of Population Health and Genomics, University of Dundee School of Medicine, Dundee, UK
| | - Lindsay Emanuel
- Division of Health Care Delivery Research, Kern Center for the Science of Health Care Delivery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Jonathan Fillmore
- Department of Surgery, Mayo Clinic Division of Oral and Maxillofacial Surgery, Rochester, Minnesota, USA
| | - Gregg H Gilbert
- Department of Clinical and Community Sciences, School of Dentistry, The University of Alabama at Birmingham School of Dentistry, Birmingham, Alabama, USA
| | - Patricia Koussis
- Center for Drug Evaluation and Research, Office of Translational Sciences, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Christine Lee
- Office of the Commissioner, Office of Minority Health and Health Equity, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Heather Lipkind
- Department of Obstetrics, Gynecology, & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Celeste Mallama
- Center for Drug Evaluation and Research, Office of Surveillance and Epidemiology, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Tamra Meyer
- Center for Drug Evaluation and Research, Office of Surveillance and Epidemiology, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Megan Moncur
- Center for Drug Evaluation and Research, Office of New Drugs, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Teryl Nuckols
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael A Pacanowski
- Center for Drug Evaluation and Research, Office of Translational Sciences, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - David B Page
- Department of Emergency Medicine, Department of Medicine, Division of Pulmonary, Allergy & Critical Care Medicine, The University of Alabama, Birmingham, Alabama, USA
| | - Elektra Papadopoulos
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jessica D Ritchie
- Center for Outcomes Research and Evaluation, Yale University Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA
| | - Joseph S Ross
- Internal Medicine, Yale University Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA
| | - Nilay D Shah
- Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Mat Soukup
- Center for Drug Evaluation and Research, Office of Translational Sciences, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Christopher O St Clair
- Center for Drug Evaluation and Research, Office of New Drugs, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Stephen Tamang
- Department of Family Medicine, Monument Health, Rapid City, South Dakota, USA
| | - Sam Torbati
- Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Douglas W Wallace
- Department of Emergency Medicine, Department of Medicine, Division of Pulmonary, Allergy & Critical Care Medicine, The University of Alabama, Birmingham, Alabama, USA
| | - Yueqin Zhao
- Center for Drug Evaluation and Research, Office of Translational Sciences, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rebekah Heckmann
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
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12
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Stevens MA, Tsai J, Savitz ST, Nath B, Melnick ER, D’Onofrio G, Jeffery MM. Trends and Disparities in Access to Buprenorphine Treatment Following an Opioid-Related Emergency Department Visit Among an Insured Cohort, 2014-2020. JAMA Netw Open 2022; 5:e2215287. [PMID: 35657629 PMCID: PMC9166266 DOI: 10.1001/jamanetworkopen.2022.15287] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
This cross-sectional study examines trends in access to buprenorphine treatment following an opioid-related emergency department (ED) visit among adults with commercial or Medicare Advantage health insurance between 2014 and 2020.
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Affiliation(s)
- Maria A. Stevens
- Department of Health Care Policy Research, Mayo Clinic, Rochester, Minnesota
- Department of Health Policy and Management, University of North Carolina at Chapel Hill
- OptumLabs, Eden Prairie, Minnesota
| | - Jennifer Tsai
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Samuel T. Savitz
- Department of Health Care Policy Research, Mayo Clinic, Rochester, Minnesota
| | - Bidisha Nath
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Edward R. Melnick
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Gail D’Onofrio
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Molly Moore Jeffery
- Department of Health Care Policy Research, Mayo Clinic, Rochester, Minnesota
- OptumLabs, Eden Prairie, Minnesota
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
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13
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Rotenstein LS, Fong AS, Jeffery MM, Sinsky CA, Goldstein R, Williams B, Melnick ER. Gender Differences in Time Spent on Documentation and the Electronic Health Record in a Large Ambulatory Network. JAMA Netw Open 2022; 5:e223935. [PMID: 35323954 PMCID: PMC8948526 DOI: 10.1001/jamanetworkopen.2022.3935] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This cross-sectional study assesses gender differences in time spent on documentation and electronic health records in a large ambulatory care network.
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Affiliation(s)
- Lisa S. Rotenstein
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Allan S. Fong
- MedStar Institute for Biomedical Informatics, Washington, District of Columbia
| | - Molly Moore Jeffery
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota
- Division of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Edward R. Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
- Department of Biostatistics (Health Informatics), Yale School of Public Health, New Haven, Connecticut
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14
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Levin Z, Chang J, Karaca-Mandic P, Duarte-García A, Jeffery MM. Characteristics of Hydroxychloroquine Dispensing in the United States, January to May 2020. J Gen Intern Med 2022; 37:176-178. [PMID: 34704209 PMCID: PMC8547570 DOI: 10.1007/s11606-021-07175-9] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/27/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Zachary Levin
- University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Jessica Chang
- University of Minnesota School of Public Health, Minneapolis, MN, USA
| | | | | | - Molly Moore Jeffery
- Division of Health Care Delivery Research and Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA.
- OptumLabs Visiting Fellow, Eden Prairie, MN, USA.
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15
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Togun AT, Mandic PK, Wurtz R, Jeffery MM, Beebe T. Association of opioid fills with centers for disease control and prevention opioid guidelines and payer coverage policies: physician, insurance and geographic factors. Int J Clin Pharm 2021; 44:428-438. [PMID: 34855069 PMCID: PMC8636786 DOI: 10.1007/s11096-021-01360-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/21/2021] [Indexed: 11/07/2022]
Abstract
Background The Centers for Disease Control and Prevention (CDC) issued guidelines and certain healthcare payers have made pharmacy coverage changes (PCC) focusing on regulating prescription opioids. Aim We evaluated differences in the rate of first-time opioid fills at doses ≥ 50 morphine milligram equivalents (MME)/day and first-time opioid fills with benzodiazepine fill overlap following the CDC guidelines and following a PCC between provider types, geographic locations, and insurance types. Method We used OptumLabs® Data Warehouse claims data between 2014 and 2018. Subjects were opioid naïve non-cancer care patients, 18 years and older who had an identified chronic pain condition ICD diagnosis within 2 weeks prior to their first-time opioid fill. We used multiple treatment period segmented regression analysis with interaction terms to test the differences between primary care providers (PCPs) and specialist providers (SPs), urban and rural primary care service areas (PCSAs), and Medicare Advantage (MA) and commercially insured patients (CIPs) in their first-time opioid fill patterns. Results Prescribing first-time opioid fills at doses ≥ 50MME/day declined following the CDC guidelines and PCC, the decline was greater among SPs than PCPs and in rural PCSAs than urban PCSAs. Also, following the CDC guidelines, the decline was greater among MA patients however following the PCC the decline was greater among CIPs. There were no differences in rate of first-time opioid fill with benzodiazepine overlap between groups. Conclusion Responses to the CDC opioid guidelines and a PCC differed between PCPs and SPs, urban and rural PCSAs, and when prescribing to MA and CIPs. Understanding these differences is important to help inform future guidelines.
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Affiliation(s)
- Adeniyi T Togun
- Division of Health Services Research, Policy & Administration, School of Public Health, University of Minnesota Twin Cities, Minneapolis, US.
| | | | - Rebecca Wurtz
- Division of Health Policy and Management, School of Public Health, University of Minnesota Twin Cities, Minneapolis, US
| | | | - Timothy Beebe
- Division of Health Policy and Management, School of Public Health, University of Minnesota Twin Cities, Minneapolis, US
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16
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Everhart A, Harper K, Jeffery MM, Levin Z, Morden NE, Sankar A, Karaca-Mandic P. Trends in Testosterone Prescriptions for Older Men Enrolled in Commercial Insurance and Medicare Advantage. JAMA Netw Open 2021; 4:e2127349. [PMID: 34586370 PMCID: PMC8482052 DOI: 10.1001/jamanetworkopen.2021.27349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
This cohort study of health claims data examines trends in testosterone prescriptions for older men in the US following 2014 changes to the US Food and Drug Administration’s stance on testosterone’s effects and safety risks.
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Affiliation(s)
- Alexander Everhart
- University of Minnesota School of Public Health, Minneapolis, Minnesota
- OptumLabs Visiting Fellow, Eden Prairie, Minnesota
| | | | | | - Zachary Levin
- University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Nancy E. Morden
- UnitedHealthcare, Minnetonka, Minnesota
- Dartmouth College, Hanover, New Hampshire
| | - Ashwini Sankar
- Carlson School of Management, University of Minnesota, Minneapolis
| | - Pinar Karaca-Mandic
- Carlson School of Management, University of Minnesota, Minneapolis
- National Bureau of Economic Research, Cambridge, Massachusetts
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Abstract
OBJECTIVE To describe the epidemiology of paediatric pain-related visits to emergency departments (EDs) across the USA. DESIGN Cross-sectional study. SETTING A representative sample of US ED visits using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). PARTICIPANTS Paediatric (age ≤18 years) ED visits in the 2017 NHAMCS data set. DATA ANALYSIS Each visit was coded as pain-related or non-pain-related using the 'reason for visit' variable. Weighted proportions were calculated with 95% CIs. Logistic regression was used to compare odds of pain-related visits. OUTCOME MEASURES Prevalence of pain-related visits among paediatric ED visits. RESULTS There were an estimated 35 million paediatric ED visits in the USA in 2017, 55.6% (CI 53.3% to 57.8%) were pain related, which equates to 19.7 million annual visits. The prevalence of pain-related visits reached more than 50% of visits at age 6-7 and plateaued at relatively high proportions. Children of races other than white or black had lower odds of having a pain-related visit (OR 0.48, CI 0.29 to 0.81) than white children, as did children who were black, though the difference was not statistically significant (OR 0.88, CI 0.73 to 1.06). Relative to children covered by private insurance, children with Medicaid or CHIP (Children's Health Insurance Program) coverage had lower odds of a pain-related visit (OR 0.75, CI 0.60 to 0.93). Injuries represented 46.5% (CI 42.0% to 51.0%) of pain-related visits. Pain scores were reported in less than 50% of pain-related visits. CONCLUSION Pain is the reason for visit in 55.6% of paediatric ED visits across the USA. The prevalence of pain-related visits peak before adolescence and it continues relatively high until the age 18. Injury, racial disparities in pain and poor pain score reporting should remain major topics of study in the paediatric population.
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Affiliation(s)
- Jana L Anderson
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Shealeigh A Funni
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Molly Moore Jeffery
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
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18
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Goyal A, Payne S, Sangaralingham LR, Jeffery MM, Naessens JM, Gazelka HM, Habermann EB, Krauss W, Spinner RJ, Bydon M. Incidence and risk factors for prolonged postoperative opioid use following lumbar spine surgery: a cohort study. J Neurosurg Spine 2021; 35:583-591. [PMID: 34359026 DOI: 10.3171/2021.2.spine202205] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 02/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Sustained postoperative opioid use after elective surgery is a matter of growing concern. Herein, the authors investigated incidence and predictors of long-term opioid use among patients undergoing elective lumbar spine surgery, especially as a function of opioid prescribing practices at postoperative discharge (dose in morphine milligram equivalents [MMEs] and type of opioid). METHODS The OptumLabs Data Warehouse (OLDW) was queried for postdischarge opioid prescriptions for patients undergoing elective lumbar decompression and discectomy (LDD) or posterior lumbar fusion (PLF) for degenerative spine disease. Only patients who received an opioid prescription at postoperative discharge and those who had a minimum of 180 days of insurance coverage prior to surgery and 180 days after surgery were included. Opioid-naive patients were defined as those who had no opioid fills in 180 days prior to surgery. The following patterns of long-term postoperative use were investigated: additional fills (at least one opioid fill 90-180 days after surgery), persistent fills (any span of opioid use starting in the 180 days after surgery and lasting at least 90 days), and Consortium to Study Opioid Risks and Trends (CONSORT) criteria for persistent use (episodes of opioid prescribing lasting longer than 90 days and 120 or more total days' supply or 10 or more prescriptions in 180 days after the index fill). Multivariable logistic regression was performed to identify predictors of long-term use. RESULTS A total of 25,587 patients were included, of whom 52.7% underwent PLF (n = 13,486) and 32.5% (n = 8312) were opioid-naive prior to surgery. The rates of additional fills, persistent fills, and CONSORT use were 47%, 30%, and 23%, respectively, after PLF and 35.4%, 19%, and 14.2%, respectively, after LDD. The rates among opioid-naive patients were 18.9%, 5.6%, and 2.5% respectively, after PLF and 13.3%, 2.0%, and 0.8%, respectively, after LDD. Using multivariable logistic regression, the following were identified to be significantly associated with higher risk of long-term opioid use following PLF: discharge opioid prescription ≥ 500 MMEs, prescription of a long-acting opioid, female sex, multilevel surgery, and comorbidities such as depression and drug abuse (all p < 0.05). Elderly (age ≥ 65 years) and opioid-naive patients were found to be at lower risk (all p < 0.05). Similar results were obtained on analysis for LDD with the following significant additional risk factors identified: discharge opioid prescription ≥ 400 MMEs, prescription of tramadol alone at discharge, and inpatient surgery (all p < 0.05). CONCLUSIONS In an analysis of pharmacy claims from a national insurance database, the authors identified incidence and predictors of long-term opioid use after elective lumbar spine surgery.
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Affiliation(s)
| | | | | | | | | | | | - Elizabeth B Habermann
- 3Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
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Chang J, Karaca-Mandic P, Go RS, Schondelmeyer S, Weisdorf D, Jeffery MM. Site of care potentially limits cost savings from biosimilars. Am J Manag Care 2021; 27:e287-e289. [PMID: 34460183 DOI: 10.37765/ajmc.2021.88730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The first FDA-approved biosimilar was launched in 2015: filgrastim-sndz (Zarxio), a biosimilar for the reference drug filgrastim (Neupogen). Filgrastim is a granulocyte colony-stimulating factor used to prevent and treat neutropenia. In this study, we examined the association between site of care and drug cost across reference filgrastim, tbo-filgrastim (Granix; a version of filgrastim approved as a biosimilar in Europe and as a new drug in the United States), and biosimilar filgrastim administrations among the commercially insured. STUDY DESIGN Retrospective study using administrative claims data. METHODS We used OptumLabs Data Warehouse to identify the site of care of each short-acting filgrastim administration among commercial enrollees between January 1, 2014, and December 31, 2019. RESULTS For each filgrastim product, model-adjusted median drug costs were higher in the outpatient hospital setting than for the same drug administered in the office setting. Comparing drug costs within the same setting, in the office setting, costs of biosimilar and tbo-filgrastim were $103.61 and $94.07 lower than reference filgrastim, respectively (P < .001 for each comparison). In the outpatient hospital setting, adjusted median costs for tbo-filgrastim were lower than those for reference filgrastim (-$132.90; P < .001), but adjusted median costs of the biosimilar were slightly higher ($20.50; P = .025). CONCLUSIONS Although previous work has found lower costs for biosimilar filgrastim compared with reference filgrastim, here we found that site of care can change this calculus, reducing savings. After adjusting for patient characteristics and geography, we found that drug cost savings for biosimilar filgrastim were limited to the office setting, with no savings in the outpatient hospital setting.
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Jeffery MM, Cummins NW, Dempsey TM, Limper AH, Shah ND, Bellolio F. Association of outpatient ACE inhibitors and angiotensin receptor blockers and outcomes of acute respiratory illness: a retrospective cohort study. BMJ Open 2021; 11:e044010. [PMID: 33737435 PMCID: PMC7978099 DOI: 10.1136/bmjopen-2020-044010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES Evaluate associations between ACE inhibitors (ACEis) and angiotensin receptor blockers (ARBs) and clinical outcomes in acute viral respiratory illness (AVRI). DESIGN Retrospective cohort analysis of claims data. SETTING The USA; 2018-2019 influenza season. PARTICIPANTS Main cohort: people with hypertension (HTN) taking an ACEi, ARB or other HTN medications, and experiencing AVRI. Falsification cohort: parallel cohort receiving elective knee or hip replacement. MAIN OUTCOME MEASURES Main cohort: hospital admission, intensive care unit, acute respiratory distress (ARD), ARD syndrome and all-cause mortality. Falsification cohort: complications after surgery and all-cause mortality. RESULTS The main cohort included 236 843 episodes of AVRI contributed by 202 629 unique individuals. Most episodes were in women (58.9%), 81.4% in people with Medicare Advantage and 40.3% in people aged 75+ years. Odds of mortality were lower in the ACEi (0.78 (0.74 to 0.83)) and ARB (0.64 (0.61 to 0.68)) cohorts compared with other HTN medications. On all other outcomes, people taking ARBs (but not ACEis) had a >10% reduction in odds of inpatient stays compared with other HTN medications.In the falsification analysis (N=103 353), both ACEis (0.89 (0.80 to 0.98)) and ARBs (0.82 (0.74 to 0.91)) were associated with decreased odds of complications compared with other HTN medications; ARBs (0.64 (0.47 to 0.87)) but not ACEis (0.79 (0.60 to 1.05)) were associated with lower odds of death compared with other HTN medications. CONCLUSIONS Outpatient use of ARBs was associated with better outcomes with AVRI compared with other medications for HTN. ACEis were associated with reduced risk of death, but with minimal or no reduction in risk of other complications. A falsification analysis conducted to provide context on the possible causal implications of these findings did not provide a clear answer. Further analysis using observational data will benefit from additional approaches to assess causal relationships between these drugs and outcomes in AVRI.
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Affiliation(s)
- Molly Moore Jeffery
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota, USA
- Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nathan W Cummins
- Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Timothy M Dempsey
- Pulmonary Critical Care Medicine, David Grant Medical Center, Travis AFB, California, USA
| | - Andrew H Limper
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Robert D and Patricia E Kern Center for the Sciences of the Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nilay D Shah
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota, USA
- Robert D and Patricia E Kern Center for the Sciences of the Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
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Everhart A, Desai NR, Dowd B, Herrin J, Higuera L, Jeffery MM, Jena AB, Ross JS, Shah ND, Smith LB, Karaca-Mandic P. Physician variation in the de-adoption of ineffective statin and fibrate therapy. Health Serv Res 2021; 56:919-931. [PMID: 33569804 DOI: 10.1111/1475-6773.13630] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To describe physicians' variation in de-adopting concurrent statin and fibrate therapy for type 2 diabetic patients following a reversal in clinical evidence. DATA SOURCES We analyzed 2007-2015 claims data from OptumLabs® Data Warehouse, a longitudinal, real-world data asset with de-identified administrative claims and electronic health record data. STUDY DESIGN We modeled fibrate use among Medicare Advantage and commercially insured type 2 diabetic statin users before and after the publication of the ACCORD lipid trial, which found statins and fibrates were no more effective than statins alone in reducing cardiovascular events among type 2 diabetic patients. We modeled fibrate use trends with physician random effects and physician characteristics such as age and specialty. DATA EXTRACTION We identified patient-year-quarters with one year of continuous insurance enrollment, type 2 diabetes diagnoses, and fibrate use. We designated the physician most responsible for patients' diabetes care based on evaluation and management visits and prescriptions of glucose-lowering drugs. PRINCIPAL FINDINGS Fibrate use increased by 0.12 percentage points per quarter among commercial patients (95% CI, 0.10 to 0.14) and 0.17 percentage points per quarter among Medicare Advantage patients (95% CI, 0.13 to 0.20) before the trial and then decreased by 0.16 percentage points per quarter among commercial patients (95% CI, -0.18 to -0.15) and 0.05 percentage points per quarter among Medicare Advantage patients (95% CI, -0.06 to -0.03) after the trial. However, 45% of physicians treating commercial patients and 48% of physicians treating Medicare Advantage patients had positive trends in prescribing following the trial. Physicians' characteristics did not explain their variation (pseudo R2 = 0.000). CONCLUSION On average, physicians decreased fibrate prescribing following the ACCORD lipid trial. However, many physicians increased prescribing following the trial. Observable physician characteristics did not explain variations in prescribing. Future research should examine whether physicians vary similarly in other de-adoption settings.
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Affiliation(s)
- Alexander Everhart
- University of Minnesota, Minneapolis, Minnesota, USA.,OptumLabs Visiting Fellow, Eden Prairie, Minnesota, USA
| | - Nihar R Desai
- Yale School of Medicine, Charlottesville, Virginia, USA
| | - Bryan Dowd
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Jeph Herrin
- Yale School of Medicine, Charlottesville, Virginia, USA
| | - Lucas Higuera
- University of Minnesota, Minneapolis, Minnesota, USA.,Medtronic Plc, Mounds View, Minnesota, USA
| | | | - Anupam B Jena
- Harvard Medical School, Boston, Massachusetts, USA.,Massachusetts General Hospital, Boston, Massachusetts, USA.,National Bureau of Economic Research, Cambridge, Massachusetts, USA
| | - Joseph S Ross
- Yale School of Medicine, Charlottesville, Virginia, USA
| | | | | | - Pinar Karaca-Mandic
- University of Minnesota, Minneapolis, Minnesota, USA.,National Bureau of Economic Research, Cambridge, Massachusetts, USA
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Abstract
This cohort study assesses trends in the rates of initiation of pain medication among patients with newly diagnosed diabetic peripheral neuropathy and the types of pain medication prescribed from 2014 to 2018.
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Affiliation(s)
- Jungwei Fan
- Division of Digital Health Sciences, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Molly Moore Jeffery
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - W. Michael Hooten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Nilay D. Shah
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Rozalina G. McCoy
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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Karaca-Mandic P, Chang J, Go R, Schondelmeyer S, Weisdorf D, Jeffery MM. Biosimilar Filgrastim Uptake And Costs Among Commercially Insured, Medicare Advantage. Health Aff (Millwood) 2020; 38:1887-1892. [PMID: 31682491 DOI: 10.1377/hlthaff.2019.00253] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In 2015 the Food and Drug Administration approved filgrastim-sndz (Zarxio), the first US biosimilar. Following rapid uptake, by March 2018 filgrastim-sndz accounted for 47 percent of filgrastim administrations among commercially insured and 42 percent among Medicare Advantage beneficiaries. The initial cost difference between the originator and biosimilar was 31 percent in the former population but negligible in the latter.
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Affiliation(s)
- Pinar Karaca-Mandic
- Pinar Karaca-Mandic ( pkmandic@umn. edu ) is an associate professor in the Finance Department and academic director of the Medical Industry Leadership Institute, Carlson School of Management, University of Minnesota, in Minneapolis
| | - Jessica Chang
- Jessica Chang is a doctoral candidate in the Division of Health Policy and Management, School of Public Health, University of Minnesota
| | - Ronald Go
- Ronald Go is an associate professor of medicine in the Division of Hematology, Mayo Clinic, in Rochester, Minnesota
| | - Stephen Schondelmeyer
- Stephen Schondelmeyer is a professor of pharmaceutical care and health systems in the College of Pharmacy and director of the PRIME Institute, both at the University of Minnesota
| | - Daniel Weisdorf
- Daniel Weisdorf is a professor in the Division of Hematology, Oncology, and Transplantation, Medical School, University of Minnesota
| | - Molly Moore Jeffery
- Molly Moore Jeffery is a research associate in the Department of Health Care Policy and Research and scientific director of research in emergency medicine, Mayo Clinic, in Rochester
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Smith LB, Desai NR, Dowd B, Everhart A, Herrin J, Higuera L, Jeffery MM, Jena AB, Ross JS, Shah ND, Karaca-Mandic P. Patient and provider-level factors associated with changes in utilization of treatments in response to evidence on ineffectiveness or harm. Int J Health Econ Manag 2020; 20:299-317. [PMID: 32350680 PMCID: PMC7725279 DOI: 10.1007/s10754-020-09282-2] [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] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/20/2020] [Indexed: 06/11/2023]
Abstract
High-quality health care not only includes timely access to effective new therapies but timely abandonment of therapies when they are found to be ineffective or unsafe. Little is known about changes in use of medications after they are shown to be ineffective or unsafe. In this study, we examine changes in use of two medications: fenofibrate, which was found to be ineffective when used with statins among patients with Type 2 diabetes (ACCORD lipid trial); and dronedarone, which was found to be unsafe in patients with permanent atrial fibrillation (PALLAS trial). We examine the patient and provider characteristics associated with a decline in use of these medications. Using Medicare fee-for-service claims from 2008 to 2013, we identified two cohorts: patients with Type 2 diabetes using statins (7 million patient-quarters), and patients with permanent atrial fibrillation (83 thousand patient-quarters). We used interrupted time-series regression models to identify the patient- and provider-level characteristics associated with changes in medication use after new evidence emerged for each case. After new evidence of ineffectiveness emerged, fenofibrate use declined by 0.01 percentage points per quarter (95% CI - 0.02 to - 0.01) from a baseline of 6.9 percent of all diabetes patients receiving fenofibrate; dronedarone use declined by 0.13 percentage points per quarter (95% CI - 0.15 to - 0.10) from a baseline of 3.8 percent of permanent atrial fibrillation patients receiving dronedarone. For dronedarone, use declined more quickly among patients dually-enrolled in Medicare and Medicaid compared to Medicare-only patients (P < 0.001), among patients seen by male providers compared to female providers (P = 0.01), and among patients seen by cardiologists compared to primary care providers (P < 0.001).
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Affiliation(s)
- Laura Barrie Smith
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, USA
| | - Nihar R Desai
- Cardiovascular Medicine, Yale School of Medicine, New Haven, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, USA
| | - Bryan Dowd
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, USA
| | - Alexander Everhart
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, USA
| | - Jeph Herrin
- Cardiovascular Medicine, Yale School of Medicine, New Haven, USA
| | - Lucas Higuera
- Health Economics and Outcomes Research - Cardiac Rhythm and Heart Failure, Medtronic, Minneapolis, USA
| | - Molly Moore Jeffery
- Department of Health Sciences Research, Mayo Clinic, Rochester, USA
- Emergency Medicine Research, Mayo Clinic, Rochester, USA
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, USA
- Department of Medicine, Massachusetts General Hospital, Boston, USA
- National Bureau of Economic Research, Cambridge, MA, USA
| | - Joseph S Ross
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, USA
- General Internal Medicine, Yale School of Medicine, New Haven, USA
- Health Policy and Management, Yale School of Public Health, New Haven, USA
| | - Nilay D Shah
- Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | - Pinar Karaca-Mandic
- National Bureau of Economic Research, Cambridge, MA, USA.
- Carlson School of Management, University of Minnesota, Minneapolis, MN, USA.
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Kurani S, McCoy RG, Inselman J, Jeffery MM, Chawla S, Finney Rutten LJ, Giblon R, Shah ND. Place, poverty and prescriptions: a cross-sectional study using Area Deprivation Index to assess opioid use and drug-poisoning mortality in the USA from 2012 to 2017. BMJ Open 2020; 10:e035376. [PMID: 32423933 PMCID: PMC7239546 DOI: 10.1136/bmjopen-2019-035376] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [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] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To identify the relationships between county-level area deprivation and patterns of both opioid prescriptions and drug-poisoning mortality. DESIGN, SETTING AND PARTICIPANTS For this retrospective cross-sectional study, we used the IQVIA Xponent data to capture opioid prescriptions and Centres for Disease Control and Prevention National Vital Statistics System to assess drug-poisoning mortality. The Area Deprivation Index (ADI) is a composite measure of social determinants of health comprised of 17 US census indicators, spanning four socioeconomic domains. For all US counties with available opioid prescription (2712 counties) and drug-poisoning mortality (3133 counties) data between 2012 and 2017, we used negative binomial regression to examine the association between quintiles of county-level ADI and the rates of opioid prescriptions and drug-poisoning mortality adjusted for year, age, race and sex. PRIMARY OUTCOME MEASURES County-level opioid prescription fills and drug-poisoning mortality. RESULTS Between 2012 and 2017, overall rates of opioid prescriptions decreased from 96.6 to 72.2 per 100 people, while the rates of drug-poisoning mortality increased from 14.3 to 22.8 per 100 000 people. Opioid prescription and drug-poisoning mortality rates were consistently higher with greater levels of deprivation. The risk of filling an opioid prescription was 72% higher, and the risk of drug-poisoning mortality was 36% higher, for most deprived compared with the least deprived counties (both p<0.001). DISCUSSION Counties with greater area-level deprivation have higher rates of filled opioid prescriptions and drug-poisoning mortality. Although opioid prescription rates declined across all ADI quintiles, the rates of drug-poisoning mortality continued to rise proportionately in each ADI quintile. This underscores the need for individualised and targeted interventions that consider the deprivation of communities where people live.
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Affiliation(s)
- Shaheen Kurani
- Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minnesota, USA
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Rozalina Grubina McCoy
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonathan Inselman
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Molly Moore Jeffery
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Sagar Chawla
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, USA
| | - Lila J Finney Rutten
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Rachel Giblon
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nilay D Shah
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
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Kurani S, Jeffery MM, Thorsteinsdottir B, Hickson LJ, Barreto EF, Haag J, Giblon R, Shah ND, McCoy RG. Use of Potentially Nephrotoxic Medications by U.S. Adults with Chronic Kidney Disease: NHANES, 2011-2016. J Gen Intern Med 2020; 35:1092-1101. [PMID: 31792867 PMCID: PMC7174522 DOI: 10.1007/s11606-019-05557-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 10/22/2019] [Revised: 10/22/2019] [Accepted: 11/11/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND People with chronic kidney disease (CKD) are at risk for adverse events and/or CKD progression with use of renally eliminated or nephrotoxic medications. OBJECTIVE To examine the prevalence of potentially inappropriate medication (PIM) use by U.S. adults by CKD stage and self-reported CKD awareness. DESIGN Cross-sectional analysis of National Health and Nutrition Examination Surveys, 2011-2016 PARTICIPANTS: Non-pregnant adults with stages 3a (eGFR 45-59 mL/min/1.73 m2), 3b (eGFR 30-44), or 4-5 (eGFR < 30) CKD, stratified as CKD-aware/unaware. MAIN MEASURES PIMs were identified on the basis of KDIGO guidelines, label information, and literature review. We calculated proportions using any and individual PIMs, assessing for differences over CKD awareness within each CKD stage. Analyses were adjusted for age, sex, race/ethnicity, education, comorbidities, and insurance type. KEY RESULTS Adjusted proportions of U.S. adults taking any PIM(s) exceeded 50% for all CKD stages and awareness categories, and were highest among CKD-unaware patients with stages 4-5 CKD: 66.6% (95% CI, 55.5-77.8). Proton pump inhibitors, opioids, metformin, sulfonylureas, and non-steroidal anti-inflammatory drugs (NSAIDs) were all used frequently across CKD stages. NSAIDs were used less frequently when CKD-aware by patients with stage 3a CKD (2.2% [95% CI, - 0.3 to 4.7] vs. 10.7% [95% CI, 7.6 to 13.8]) and stages 4-5 CKD (0.8% [95% CI, - 0.9 to 2.5] vs. 16.5% [95% CI, 4.0 to 29.0]). Metformin was used less frequently when CKD-aware by patients with stage 3b CKD (8.1% [95% CI, 0.3-15.9] vs. 26.5% [95% CI, 17.4-35.7]) and stages 4-5 CKD (none vs. 20.8% [95% CI, 1.8-39.8]). The impact of CKD awareness was statistically significant after correction for multiple comparisons only for NSAIDs in stage 3a CKD. CONCLUSIONS PIMs are frequently used by people with CKD, with some impact of CKD awareness on NSAID and metformin use. This may lead to adverse outcomes or hasten CKD progression, reinforcing the need for improved medication management among people with CKD.
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Affiliation(s)
- Shaheen Kurani
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN, USA
| | - Molly Moore Jeffery
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Bjorg Thorsteinsdottir
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, First Street SW, Rochester, MN, USA
| | - LaTonya J Hickson
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Erin F Barreto
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Jordan Haag
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Rachel Giblon
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Nilay D Shah
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Rozalina G McCoy
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, First Street SW, Rochester, MN, USA.
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Jeffery MM, Chaisson CE, Hane C, Rumanes L, Tucker J, Hang L, McCoy R, Chen CL, Bicket MC, Hooten WM, Larochelle M, Becker WC, Kornegay C, Racoosin JA, Sanghavi D. Assessment of Potentially Inappropriate Prescribing of Opioid Analgesics Requiring Prior Opioid Tolerance. JAMA Netw Open 2020; 3:e202875. [PMID: 32293684 PMCID: PMC7160686 DOI: 10.1001/jamanetworkopen.2020.2875] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Opioid-tolerant only (OTO) medications, such as transmucosal immediate-release fentanyl products and certain extended-release opioid analgesics, require prior opioid tolerance for safe use, as patients without tolerance may be at increased risk of overdose. Studies using insurance claims have found that many patients initiating these medications do not appear to be opioid tolerant. OBJECTIVES To measure prevalence of opioid tolerance in patients initiating OTO medications and to determine whether linked electronic health record (EHR) data contribute evidence of opioid tolerance not found in insurance claims data. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used a national database of deidentified longitudinal health information, including medical and pharmacy claims, insurance enrollment, and EHR data, from January 1, 2007, to December 31, 2016. Data included 131 756 US residents with at least 183 days of continuous enrollment in commercial or Medicare Advantage insurance (including medical and pharmacy benefits) who had received an OTO medication and who had no inpatient stays in the 30 days prior to starting an OTO medication; of these, 20 044 individuals had linked EHR data within the prior 183 days. Data were analyzed from July 1, 2017, to August 31, 2018. EXPOSURES Initiating an OTO medication. MAIN OUTCOMES AND MEASURES Prior opioid tolerance demonstrated through pharmacy fills or EHR data on prescriptions written. RESULTS Among 153 385 OTO use episodes identified, 89 029 (58.0%) occurred among women, 62 900 (41.0%) occurred among patients with Medicare Advantage insurance, 39 394 (25.7%) occurred in the Midwest, 17 366 (11.3%) occurred in the Northeast, 73 316 (47.8%) occurred in the South, and 23 309 (15.2%) occurred in the West. Less than half of use episodes (73 117 episodes [47.7%]) involved patients with evidence in claims data of opioid tolerance prior to initiating therapy with an OTO medication, including 31 392 of 101 676 episodes (30.9%) involving transdermal fentanyl, 1561 of 2440 episodes (64.0%) involving transmucosal fentanyl, 36 596 of 43 559 episodes (84.0%) involving extended-release oxycodone, and 3568 of 5710 episodes (62.5%) involving extended-release hydromorphone. Among 20 044 OTO use episodes with linked EHR and claims data, less than 1% of OTO episodes identified in claims had evidence of opioid tolerance in structured EHR data that was not present in claims data (108 episodes [0.5%]). After limiting the sample to OTO episodes identified in claims with a matching OTO prescription within 14 days in the structured EHR data, only 40 of 939 episodes (4.0%) occurred among patients with evidence of tolerance that was not present in claims data. CONCLUSIONS AND RELEVANCE This cohort study found that most patients initiating OTO medications did not have evidence of prior opioid tolerance, suggesting they were at increased risk of opioid-related harms, including fatal overdose. Data from EHRs did not contribute substantial additional evidence of opioid tolerance beyond the data found in prescription claims. Future research is needed to understand the clinical rationale behind these observed prescribing patterns and to quantify the risk of harm to patients associated with potentially inappropriate prescribing.
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Affiliation(s)
| | | | | | | | | | | | - Rozalina McCoy
- Division of Health Care Policy Research, Mayo Clinic, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
- Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Catherine L. Chen
- Department of Anesthesia and Perioperative Care, University of California, San Francisco
| | - Mark C. Bicket
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Marc Larochelle
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - William C. Becker
- VA Connecticut Healthcare System, West Haven
- Yale School of Medicine, New Haven, Connecticut
| | - Cynthia Kornegay
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Judith A. Racoosin
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Darshak Sanghavi
- Previously with OptumLabs, Cambridge, Massachusetts
- UnitedHealthcare, Boston, Massachusetts
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Melnick ER, Jeffery MM, Dziura JD, Mao JA, Hess EP, Platts-Mills TF, Solad Y, Paek H, Martel S, Patel MD, Bankowski L, Lu C, Brandt C, D’Onofrio G. User-centred clinical decision support to implement emergency department-initiated buprenorphine for opioid use disorder: protocol for the pragmatic group randomised EMBED trial. BMJ Open 2019; 9:e028488. [PMID: 31152039 PMCID: PMC6550013 DOI: 10.1136/bmjopen-2018-028488] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [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: 12/12/2018] [Revised: 03/12/2019] [Accepted: 04/24/2019] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION The goal of this trial is to determine whether implementation of a user-centred clinical decision support (CDS) system can increase adoption of initiation of buprenorphine (BUP) into the routine emergency care of individuals with opioid use disorder (OUD). METHODS A pragmatic cluster randomised trial is planned to be carried out in 20 emergency departments (EDs) across five healthcare systems over 18 months. The intervention consists of a user-centred CDS integrated into ED clinician electronic workflow and available for guidance to: (1) determine whether patients presenting to the ED meet criteria for OUD, (2) assess withdrawal symptoms and (3) ascertain and motivate patient willingness to initiate treatment. The CDS guides the ED clinician to initiate BUP and facilitate follow-up. The primary outcome is the rate of BUP initiated in the ED. Secondary outcomes are: (1) rates of receiving a referral, (2) fidelity with the CDS and (3) rates of clinicians providing any ED-initiated BUP, referral for ongoing treatment and receiving Drug Addiction Act of 2000 training. Primary and secondary outcomes will be analysed using generalised linear mixed models, with fixed effects for intervention status (CDS vs usual care), prespecified site and patient characteristics, and random effects for study site. ETHICS AND DISSEMINATION The protocol has been approved by the Western Institutional Review Board. No identifiable private information will be collected from patients. A waiver of informed consent was obtained for the collection of data for clinician prescribing and other activities. As a minimal risk implementation study of established best practices, an Independent Study Monitor will be utilised in place of a Data Safety Monitoring Board. Results will be reported in ClinicalTrials.gov and published in open-access, peer-reviewed journals, presented at national meetings and shared with the clinicians at participating sites via a broadcast email notification of publications. TRIAL REGISTRATION NUMBER NCT03658642; Pre-results.
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Affiliation(s)
- Edward R Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - James D Dziura
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jodi A Mao
- Emergency Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Erik P Hess
- Department of Emergency Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Timothy F Platts-Mills
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Yauheni Solad
- Information Technology Services, Yale New-Haven Health, New Haven, Connecticut, USA
| | - Hyung Paek
- Information Technology Services, Yale New-Haven Health, New Haven, Connecticut, USA
| | - Shara Martel
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mehul D Patel
- Department of Emergency Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Laura Bankowski
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Charles Lu
- Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Cynthia Brandt
- Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Gail D’Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Jeffery MM, Hooten WM, Henk HJ, Bellolio MF, Hess EP, Meara E, Ross JS, Shah ND. Trends in opioid use in commercially insured and Medicare Advantage populations in 2007-16: retrospective cohort study. BMJ 2018; 362:k2833. [PMID: 30068513 PMCID: PMC6066997 DOI: 10.1136/bmj.k2833] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To describe trends in the rate and daily dose of opioids used among commercial and Medicare Advantage beneficiaries from 2007 to 2016. DESIGN Retrospective cohort study of administrative claims data. SETTING National database of medical and pharmacy claims for commercially insured and Medicare Advantage beneficiaries in the United States. PARTICIPANTS 48 million individuals with any period of insurance coverage between 1 January 2007 and 31 December 2016, including commercial beneficiaries, Medicare Advantage beneficiaries aged 65 years and over, and Medicare Advantage beneficiaries under age 65 years (eligible owing to permanent disability). MAIN ENDPOINTS Proportion of beneficiaries with any opioid prescription per quarter, average daily dose in milligram morphine equivalents (MME), and proportion of opioid use episodes that represented long term use. RESULTS Across all years of the study, annual opioid use prevalence was 14% for commercial beneficiaries, 26% for aged Medicare beneficiaries, and 52% for disabled Medicare beneficiaries. In the commercial beneficiary group, quarterly prevalence of opioid use changed little, starting and ending the study period at 6%; the average daily dose of 17 MME remained unchanged since 2011. For aged Medicare beneficiaries, quarterly use prevalence was also relatively stable, ranging from 11% at the beginning of the study period to 14% at the end. Disabled Medicare beneficiaries had the highest rates of opioid use, the highest rate of long term use, and the largest average daily doses. In this group, both quarterly use rates (39%) and average daily dose (56 MME) were higher at the end of 2016 than the low points observed in 2007 for each endpoint (26% prevalence and 53 MME). CONCLUSIONS Opioid use rates were high during the study period of 2007-16, with the highest rates in disabled Medicare beneficiaries versus aged Medicare beneficiaries and commercial beneficiaries. Opioid use and average daily dose have not substantially declined from their peaks, despite increased attention to opioid abuse and awareness of their risks.
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Affiliation(s)
- Molly Moore Jeffery
- Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Division of Health Care Policy Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN 55905, USA
| | - W Michael Hooten
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | | | - Erik P Hess
- Department of Emergency Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Ellen Meara
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA
- National Bureau of Economic Research, Cambridge, MA, USA
| | - Joseph S Ross
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Nilay D Shah
- Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Division of Health Care Policy Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN 55905, USA
- OptumLabs, Eden Prairie, MN, USA
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Weidner TK, Kidwell JT, Etzioni DA, Sangaralingham LR, Van Houten HK, Asante D, Jeffery MM, Shah N, Wasif N. Factors Associated with Emergency Department Utilization and Admission in Patients with Colorectal Cancer. J Gastrointest Surg 2018; 22:913-920. [PMID: 29435901 DOI: 10.1007/s11605-018-3707-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 01/31/2018] [Indexed: 01/31/2023]
Abstract
PURPOSE We assessed emergency department (ED) utilization in patients with colorectal cancer to identify factors associated with ED visits and subsequent admission, as well as identify a high-risk subset of patients that could be targeted to reduce ED visits. METHODS Data from Optum Labs Data Warehouse, a national administrative claims database, was retrospectively analyzed to identify patients with colorectal cancer from 2008 to 2014. Multivariable logistic regression was used to identify factors associated with ED visits and ED "super-users" (3+ visits). Repeated measures analysis was used to model ED visits resulting in hospitalization as a logistic regression based on treatments 30 days prior to ED visit. RESULTS Of 13,466 patients with colorectal cancer, 7440 (55.2%) had at least one ED visit within 12 months of diagnosis. Factors associated with having an ED visit included non-white race, advancing age, increased comorbidities, and receipt of chemotherapy or radiation. 69.2% of patients who visited the ED were admitted to the hospital. A group of 1834 "super-users" comprised 13.6% of our population yet accounted for 52.1% of the total number of ED visits and 32.3% of admissions. CONCLUSIONS Over half of privately insured patients undergoing treatment for colorectal cancer will visit the ED within 12 months of diagnosis. Within this group, we identify common factors for a high-risk subset of patients with three or more ED visits who account for over half of all ED visits and a third of all admissions. These patients could potentially be targeted with alternative management strategies in the outpatient setting.
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Affiliation(s)
- Tiffany K Weidner
- Department of General Surgery, Mayo Clinic, 5777 E Mayo Blvd., Phoenix, AZ, 85054, USA
| | - John T Kidwell
- Department of General Surgery, Mayo Clinic, 5777 E Mayo Blvd., Phoenix, AZ, 85054, USA
| | - David A Etzioni
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Division of Colorectal Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Lindsey R Sangaralingham
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Holly K Van Houten
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Dennis Asante
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Molly Moore Jeffery
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Nilay Shah
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- OptumLabs, Cambridge, MA, USA
| | - Nabil Wasif
- Department of General Surgery, Mayo Clinic, 5777 E Mayo Blvd., Phoenix, AZ, 85054, USA.
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
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Abstract
Elderly seasonal migrators share time between homes in different states, presenting challenges for care coordination and patient attribution methods. Medicare has prioritized alternative payment models, putting health care providers at risk for quality and value of services delivered to their attributed patients, regardless of the location of care. Little research is available to guide providers and payers on the service use of seasonal migrators. The authors use claims data on fee-for-service (FFS) Medicare beneficiaries' locations throughout the year to (1) identify seasonal migrators and (2) describe the care they receive in each seasonal home, focusing on primary care and emergency department (ED) visits and the relationships between the two. In all, 5.5% of the Medicare aged FFS population were identified as seasonal migrators, with 4.1% following the traditional snowbird pattern of migration, spending warm months in the north and cold months in the south. Migrators had higher rates of ED visits and primary care treatable (PCT) ED visits than the nonmigratory groups, controlling for location, age, race, sex, Medicaid status, season, and comorbidities. They also had more visits with specialist physicians, more days with outpatient services, and more days seeing a physician in any setting. Having local primary care strongly reduced rates of both PCT ED visits and total ED visits for all migration categories, with the greatest reduction seen in PCT ED visits by migrators (local primary care was associated with a 58% reduction in PCT ED visits by snowbirds and a 65% reduction in PCT ED visits by other migrators).
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Affiliation(s)
- Molly Moore Jeffery
- 1 Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Division of Health Care Policy and Research, Mayo Clinic , Rochester, Minnesota
| | - Julian Wolfson
- 2 Division of Biostatistics, School of Public Health, University of Minnesota , Minneapolis, Minnesota
| | - Sarah K Meier
- 3 RTI International , Washington, District of Columbia
| | - Bryan E Dowd
- 4 Division of Health Policy and Management, School of Public Health, University of Minnesota , Minneapolis, Minnesota
| | - Jean M Abraham
- 4 Division of Health Policy and Management, School of Public Health, University of Minnesota , Minneapolis, Minnesota
| | - Robert L Kane
- 4 Division of Health Policy and Management, School of Public Health, University of Minnesota , Minneapolis, Minnesota
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Abstract
OBJECTIVES We propose a new claims-computable measure of the primary care treatability of emergency department (ED) visits and validate it using a nationally representative sample of Medicare data. STUDY DESIGN AND SETTING This is a validation study using 2011-2012 Medicare claims data for a nationally representative 5% sample of fee-for-service beneficiaries to compare the new measure's performance to the Ballard variant of the Billings algorithm in predicting hospitalisation and death following an ED visit. OUTCOMES Hospitalisation within 1 day or 1 week of an ED visit; death within 1 week or 1 month of an ED visit. RESULTS The Minnesota algorithm is a strong predictor of hospitalisations and deaths, with performance similar to or better than the most commonly used existing algorithm to assess the severity of ED visits. The Billings/Ballard algorithm is a better predictor of death within 1 week of an ED visit; this finding is entirely driven by a small number of ED visits where patients appear to have been dead on arrival. CONCLUSIONS The procedure-based approach of the Minnesota algorithm allows researchers to use the clinical judgement of the ED physician, who saw the patient to determine the likely severity of each visit. The Minnesota algorithm may thus provide a useful tool for investigating ED use in Medicare beneficiaries.
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Affiliation(s)
- Molly Moore Jeffery
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Julian Wolfson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jean M Abraham
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Bryan E Dowd
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Robert L Kane
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
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Dowd B, Karmarker M, Swenson T, Parashuram S, Kane R, Coulam R, Jeffery MM. Emergency Department Utilization as a Measure of Physician Performance. Am J Med Qual 2013; 29:135-43. [DOI: 10.1177/1062860613487196] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Bryan Dowd
- University of Minnesota, Minneapolis, MN
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Butler M, Kane RL, Larson S, Moore Jeffery M, Grove M. Closing the quality gap: revisiting the state of the science (vol. 7: quality improvement measurement of outcomes for people with disabilities). Evid Rep Technol Assess (Full Rep) 2012:1-112. [PMID: 24423011 PMCID: PMC4781164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To examine how health care outcomes for general medical care have been assessed for people with disabilities within the rubrics of care coordination and quality improvement. DATA SOURCES MEDLINE®, PsychINFO, ERIC, and CIRRIE through March 27, 2012; hand searches of references from relevant literature and journals. A search of high-quality gray literature sources was also conducted. REVIEW METHODS We included all forms of disability except severe and persistent mental illness for all age groups in outpatient and community settings. We focused on outcomes, patient experience, and care coordination process measures. We looked for generic outcome measures rather than disability-condition-specific measures. We also looked for examples of outcomes used in the context of disability as a complicating condition for a set of basic service needs relevant to the general population, and secondary conditions common to disability populations. Two independent reviewers screened all articles; disagreements were resolved through consensus. Included articles were abstracted to evidence tables and quality-checked by a second reviewer. Data synthesis was qualitative. RESULTS A total of 15,513 articles were screened; 15 articles were included for general outcome measures and 44 studies for care coordination. A large number of outcome measures have been critically assessed and mapped to the International Classification of Functioning, Disability and Health. We found no eligible studies of basic medical needs or secondary conditions that examined mixed populations of disabled and nondisabled participants for disability as a complicating condition. Care coordination literature for people with disabilities is relatively new and focuses on initial implementation of interventions rather than assessing the quality of the implementation. CONCLUSIONS We found very few direct examples of work conducted from the perspective of disability as a complicating condition. The sparse literature indicates the early stages of research development. Capturing the disability perspective will require collaboration and coordination of measurement efforts across medical interventions, rehabilitation, and social support provision.
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