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Marmor S, Karaca-Mandic P, Adams ME. Physical Therapy And Risk of Falls Among Patients With Dizziness-Reply. JAMA Otolaryngol Head Neck Surg 2024; 150:356-357. [PMID: 38358769 DOI: 10.1001/jamaoto.2023.4693] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Affiliation(s)
- Schelomo Marmor
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis
- Department of Surgery, University of Minnesota, Minneapolis
- Center for Clinical Quality & Outcomes Discovery and Evaluation (C-QODE), University of Minnesota, Minneapolis
| | - Pinar Karaca-Mandic
- Department of Finance, Carlson School of Management, University of Minnesota, Minneapolis
| | - Meredith E Adams
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis
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Marmor S, Karaca-Mandic P, Adams ME. Use of Physical Therapy and Subsequent Falls Among Patients With Dizziness in the US. JAMA Otolaryngol Head Neck Surg 2023; 149:1083-1090. [PMID: 37707824 PMCID: PMC10502691 DOI: 10.1001/jamaoto.2023.2840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/24/2023] [Indexed: 09/15/2023]
Abstract
Importance Among adults who present for clinical evaluation of dizziness, there is a critical need to identify interventions, such as physical therapy (PT), to mitigate the risk of falls over time. Objective The primary objective was to examine the association between receipt of PT and falls requiring medical care within 12 months of presentation for dizziness. Secondary objectives included identification of factors associated with falls requiring medical care and factors associated with receipt of PT after presentation for dizziness. Design, Setting, and Participants This cross-sectional study examined US commercial insurance and Medicare Advantage claims from January 1, 2006, through December 31, 2015. In all, 805 454 patients 18 years or older with a new diagnosis of symptomatic dizziness or vestibular disorders were identified. Data were analyzed from October 1, 2021, to February 1, 2023. Main Outcomes and Measures Receipt of PT services and the incidence of falls requiring medical care were measured. The association between receipt of PT and falls that occurred 12 months after presentation for dizziness was estimated after accounting for presentation setting (outpatient clinic or emergency department), Charlson Comorbidity Index (CCI; with higher scores indicating greater morbidity), diagnosis code, and sociodemographic characteristics. Results A total of 805 454 patients presented for dizziness from 2006 through 2015 (median [range] age, 52 [18-87] years; 502 055 females [62%]). Of these patients, 45 771 (6%) received PT within 3 months of presentation for dizziness and 60 060 (7%) experienced a fall resulting in a medical encounter within 12 months after presentation for dizziness. In adjusted models, patients least likely to receive PT were female (adjusted odds ratio [AOR], 0.80; 95% CI, 0.78-0.81), those aged 50 to 59 years (AOR, 0.67 [95% CI, 0.65-0.70] compared with patients aged 18-39 years), and those with more comorbidities (AOR, 0.71 [95% CI, 0.70-0.73] for CCI ≥ 2 vs 0). Receipt of PT services within 3 months of presentation for dizziness was associated with a reduced risk of falls over the subsequent 12 months, with the greatest risk reduction found within 3 months after PT (AOR, 0.14 [95% CI, 0.14-0.15] at 3-12 months vs 0.18 [95% CI, 0.18-0.19] at 6-12 months and 0.23 [95% CI, 0.23-0.24] at 9-12 months). Conclusions and Relevance Results of this cohort study suggest that receipt of PT after presentation for dizziness was associated with a reduction in fall risk during the subsequent 12 months; thus, timely PT referral for dizziness may be beneficial for these patients. Future research, ideally with a clinical trial design, is needed to explore the independent impact of PT on subsequent falls for adults with dizziness.
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Affiliation(s)
- Schelomo Marmor
- Department of Otolaryngology–Head and Neck Surgery, University of Minnesota, Minneapolis
- Department of Surgery, University of Minnesota, Minneapolis
- Center for Clinical Quality & Outcomes Discovery and Evaluation, University of Minnesota, Minneapolis
| | - Pinar Karaca-Mandic
- Department of Finance, Carlson School of Management, University of Minnesota, Minneapolis
| | - Meredith E. Adams
- Department of Otolaryngology–Head and Neck Surgery, University of Minnesota, Minneapolis
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Chang J, Karaca-Mandic P, Jeffery MM. Uptake of Biosimilar Among Privately Insured Patients Undergoing Infliximab Treatment. Med Care 2023; 61:636-643. [PMID: 37582298 DOI: 10.1097/mlr.0000000000001906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
BACKGROUND Recent literature has found rapid uptake of short-acting filgrastim biosimilars but slower uptake of other biosimilars, such as infliximab, in both Medicare and privately insured enrollees. OBJECTIVES To describe patient, provider, and health plan characteristics associated with a switch to biosimilar among existing infliximab patients. RESEARCH DESIGN We constructed a retrospective panel dataset of patients undergoing active infliximab treatments and the choice of infliximab drug for each infusion. We used mixed logit regression controlling for patient, provider, and health plan characteristics as well as time-fixed effects. SUBJECTS Medicare Advantage and privately insured enrollees with evidence of active infliximab treatments between 2016 and 2020 (n=357,430). MEASURES Our primary outcome of interest was to switch from infliximab originator to one of the infliximab biosimilars. Exposure variables of interest variables such as out-of-pocket, site of care, and in-network deductible. RESULTS Our study found nominally low switching among existing infliximab originator users (3.4%). We found that patients who previously received 1 infliximab originator infusion were 63.7% more likely to switch to biosimilar compared with patients who previously received administration of 20 infliximab originators. We found that biosimilar's placement as health's plan preferred drug was attributed to higher likelihood of biosimilar use (odds ratio: 1.666; P -value=0.001). We did not observe any statistically significant effect among out-of-pocket amount or deductible with respect to switch to infliximab biosimilar. CONCLUSIONS To encourage uptake and switch to biosimilar, policymakers should consider targeted policies that include leveraging health plan tools such as placement of biosimilar as preferred drug and aim to educate patients on the clinical equivalence between infliximab biosimilar and originator.
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Affiliation(s)
- Jessica Chang
- Division of Health Policy and Management, University of Minnesota, School of Public Health
| | - Pinar Karaca-Mandic
- Department of Finance, Carlson School of Management, University of Minnesota, Minneapolis
| | - Molly M Jeffery
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
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Sankar A, Everhart AO, Jena AB, Jeffery MM, Ross JS, Shah ND, Karaca-Mandic P. Longitudinal Patterns in Testosterone Prescribing After US FDA Safety Communication in 2014. Jt Comm J Qual Patient Saf 2023; 49:458-466. [PMID: 37380503 DOI: 10.1016/j.jcjq.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND The objective of this study was to describe changes in testosterone prescribing following a 2014 US Food and Drug Administration (FDA) safety communication and how changes varied by physician characteristics. METHODS Data were extracted from a 20% random sample of Medicare fee-for-service administrative claims data from 2011 through 2019. The sample included 1,544,604 unique male beneficiaries who received evaluation and management (E&M) services from 58,819 unique physicians that prescribed testosterone between 2011 and 2013. Patients were categorized based on presence of coronary artery disease (CAD) and non-age-related hypogonadism. Physician characteristics were identified in the OneKey database and included specialty and affiliations with teaching hospitals, for-profit hospitals, hospitals in integrated delivery networks, and hospitals in the top decile of case mix index. Linear segmented models described how testosterone prescriptions changed following a 2014 FDA safety communication and how changes were associated with physician and organizational characteristics. RESULTS Among 65,089,560 physician-patient-quarter-year observations, mean (standard deviation) age ranged from 72.16 (5.84) years for observations without CAD or non-age-related hypogonadism to 75.73 (6.92) years with CAD and without non-age-related hypogonadism. Following the safety communication, immediate changes in off-label testosterone prescription levels fell by 0.22 percentage points (pp) (95% confidence interval [CI] -0.33 to -0.11) for patients with CAD and by -0.16 pp (95% CI -0.19 to -0.16) for patients without CAD. A similar change was noticed in on-label prescribing levels. Off-label testosterone prescription quarterly trend, however, increased for patients with CAD and without CAD; on-label testosterone prescription trends declined for both groups. Declines in off-label prescribing were larger when treated by primary care physicians vs. non-primary care physicians, and physicians affiliated with teaching compared to nonteaching hospitals. Physician and organizational characteristics were not associated with changes in on-label prescribing. CONCLUSION On-label and off-label testosterone therapy declined following the FDA safety communication. Certain physician characteristics were associated with changes in off-label, but not on-label, prescribing.
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Karaca-Mandic P, Solid CA, Armer JM, Skoracki R, Campione E, Rockson SG. Lymphedema self-care: economic cost savings and opportunities to improve adherence. Cost Eff Resour Alloc 2023; 21:47. [PMID: 37516870 PMCID: PMC10386258 DOI: 10.1186/s12962-023-00455-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 07/20/2023] [Indexed: 07/31/2023] Open
Abstract
BACKGROUND Breast cancer-related lymphedema (BCRL) imposes a significant economic burden on patients, providers, and society. There is no curative therapy for BCRL, but management through self-care can reduce symptoms and lower the risk of adverse events. MAIN BODY The economic burden of BCRL stems from related adverse events, reductions in productivity and employment, and the burden placed on non-medical caregivers. Self-care regimens often include manual lymphatic drainage, compression garments, and meticulous skin care, and may incorporate pneumatic compression devices. These regimens can be effective in managing BCRL, but patients cite inconvenience and interference with daily activities as potential barriers to self-care adherence. As a result, adherence is generally poor and often worsens with time. Because self-care is on-going, poor adherence reduces the effectiveness of regimens and leads to costly treatment of BCRL complications. CONCLUSION Novel self-care solutions that are more convenient and that interfere less with daily activities could increase self-care adherence and ultimately reduce complication-related costs of BCRL.
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Affiliation(s)
- Pinar Karaca-Mandic
- Carlson School of Management, University of Minnesota, Carlson School of Management, 321 19th Avenue South, Minneapolis, MN, 55455, USA.
| | | | - Jane M Armer
- University of Missouri Sinclair School of Nursing, Columbia, MO, USA
| | - Roman Skoracki
- James Cancer Treatment and Research Center, Ohio State University, Columbus, OH, USA
| | | | - Stanley G Rockson
- Stanford Center for Lymphatic and Venous Disorders, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, 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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Abstract
Since the summer of 2020, the rate of coronavirus cases in the United States has been higher in rural areas than in urban areas, raising concerns that patients with coronavirus disease 2019 (COVID-19) will overwhelm under-resourced rural hospitals. Using data from the University of Minnesota COVID-19 Hospitalization Tracking Project and the U.S. Department of Health and Human Services, we document disparities in COVID-19 hospitalization rates between rural and urban areas. We show that rural-urban differences in COVID-19 admission rates were minimal in the summer of 2020 but began to diverge in fall 2020. Rural areas had statistically higher hospitalization rates from September 2020 through early 2021, after which rural-urban admission rates re-converged. The insights in this article are relevant to policymakers as they consider the adequacy of hospital resources across rural and urban areas during the COVID-19 pandemic.
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Affiliation(s)
- Yi Zhu
- University of Minnesota, Minneapolis, USA
| | - Caitlin Carroll
- University of Minnesota, Minneapolis, USA
- Caitlin Carroll, Division of Health Policy and Management, School of Public Health, University of Minnesota, 420 Delaware St. SE, MMC 729 Mayo, Minneapolis, MN 55455, USA.
| | - Khoa Vu
- University of Minnesota, Minneapolis, USA
| | - Soumya Sen
- University of Minnesota, Minneapolis, USA
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Karaca-Mandic P, Nikpay S, Gibbons S, Haynes D, Koranne R, Thakor R. Proposing An Innovative Bond To Increase Investments In Social Drivers Of Health Interventions In Medicaid Managed Care. Health Aff (Millwood) 2023; 42:383-391. [PMID: 36877901 DOI: 10.1377/hlthaff.2022.00821] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
Interventions to address social drivers of health (SDH), such as food insecurity, transportation, and housing, can reduce future health care costs but require up-front investment. Although Medicaid managed care organizations have incentives to reduce costs, volatile enrollment patterns and coverage changes may prevent them from realizing the full benefits of their SDH investments. This phenomenon results in the "wrong-pocket problem," in which managed care organizations underinvest in SDH interventions because they cannot capture the full benefit. We propose a financial innovation, an SDH bond, to increase investments in SDH interventions. Issued by multiple managed care organizations in a Medicaid coverage region, the bond would raise immediate funds for SDH interventions that are coordinated across the organizations and delivered to all enrollees of the region. As the benefits of SDH interventions accrue and cost savings are realized, the amount managed care organizations must pay back to bond holders adjusts according to enrollment, addressing the wrong-pocket problem.
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Affiliation(s)
| | | | | | | | - Rahul Koranne
- Rahul Koranne, Minnesota Hospital Association, Minneapolis, Minnesota
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Everhart AO, Sen S, Stern AD, Zhu Y, Karaca-Mandic P. Association Between Regulatory Submission Characteristics and Recalls of Medical Devices Receiving 510(k) Clearance. JAMA 2023; 329:144-156. [PMID: 36625811 PMCID: PMC9857565 DOI: 10.1001/jama.2022.22974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
IMPORTANCE Most regulated medical devices enter the US market via the 510(k) regulatory submission pathway, wherein manufacturers demonstrate that applicant devices are "substantially equivalent" to 1 or more "predicate" devices (legally marketed medical devices with similar intended use). Most recalled medical devices are 510(k) devices. OBJECTIVE To examine the association between characteristics of predicate medical devices and recall probability for 510(k) devices. DESIGN, SETTING, AND PARTICIPANTS In this exploratory cross-sectional analysis of medical devices cleared by the US Food and Drug Administration (FDA) between 2003 and 2018 via the 510(k) regulatory submission pathway, linear probability models were used to examine associations between a 510(k) device's recall status and characteristics of its predicate medical devices. Public documents for the 510(k) medical devices were collected using FDA databases. A text extraction algorithm was applied to identify predicate medical devices cited in 510(k) regulatory submissions. Algorithm-derived metadata were combined with 2003-2020 FDA recall data. EXPOSURES Citation of predicate medical devices with certain characteristics in 510(k) regulatory submissions, including the total number of predicate medical devices cited by the applicant device, the age of the predicate medical devices, the lack of similarity of the predicate medical devices to the applicant device, and the recall status of the predicate medical devices. MAIN OUTCOMES AND MEASURES Class I or class II recall of a 510(k) medical device between its FDA regulatory clearance date and December 31, 2020. RESULTS The sample included 35 176 medical devices, of which 4007 (11.4%) were recalled. The applicant devices cited a mean of 2.6 predicate medical devices, with mean ages of 3.6 years and 7.4 years for the newest and oldest, respectively, predicate medical devices. Of the applicant devices, 93.9% cited predicate medical devices with no ongoing recalls, 4.3% cited predicate medical devices with 1 ongoing class I or class II recall, 1.0% cited predicate medical devices with 2 ongoing recalls, and 0.8% cited predicate medical devices with 3 or more ongoing recalls. Applicant devices citing predicate medical devices with 3 or more ongoing recalls were significantly associated with a 9.31-percentage-point increase (95% CI, 2.84-15.77 percentage points) in recall probability compared with devices without ongoing recalls of predicate medical devices, or an 81.2% increase in recall probability relative to the mean recall probability. A 1-SD increase in the total number of predicate medical devices cited by the applicant device was significantly associated with a 1.25-percentage-point increase (95% CI, 0.62-1.87 percentage points) in recall probability, or an 11.0% increase in recall probability relative to the mean recall probability. A 1-SD increase in the newest age of a predicate medical device was significantly associated with a 0.78-percentage-point decrease (95% CI, 1.29-0.30 percentage points) in recall probability, or a 6.8% decrease in recall probability relative to the mean recall probability. CONCLUSIONS AND RELEVANCE This exploratory cross-sectional study of 510(k) medical devices cleared by the FDA between 2003 and 2018 demonstrated significant associations between 510(k) submission characteristics and recalls of medical devices. Further research is needed to understand the implications of these associations.
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Affiliation(s)
- Alexander O. Everhart
- Harvard-MIT Center for Regulatory Science, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Soumya Sen
- Department of Information and Decision Sciences, Carlson School of Management, University of Minnesota, Minneapolis
| | - Ariel D. Stern
- Harvard-MIT Center for Regulatory Science, Harvard Medical School, Harvard University, Boston, Massachusetts
- Technology and Operations Management Unit, Harvard Business School, Harvard University, Boston, Massachusetts
- Digital Health Center, Hasso Plattner Institute, Potsdam, Germany
| | - Yi Zhu
- Department of Information and Decision Sciences, Carlson School of Management, University of Minnesota, Minneapolis
| | - Pinar Karaca-Mandic
- Department of Finance, Carlson School of Management, University of Minnesota, Minneapolis
- Business Advancement Center for Health, Carlson School of Management, University of Minnesota, Minneapolis
- National Bureau of Economic Research, Cambridge, Massachusetts
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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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Vock DM, Neprash HT, Hanson AV, Elert BA, Satin DJ, Rothman AJ, Short S, Karaca-Mandic P, Markowitz R, Melton GB, Golberstein E. PRescribing Interventions for Chronic pain using the Electronic health record (PRINCE): Study protocol. Contemp Clin Trials 2022; 121:106905. [PMID: 36057376 DOI: 10.1016/j.cct.2022.106905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/23/2022] [Accepted: 08/28/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Primary care is a frequent source of pain treatment and opioid prescribing. The objective of the Prescribing Interventions for Chronic Pain using the Electronic health record (PRINCE) study is to assess the effects of two behavioral economics-informed interventions embedded within the electronic health record (EHR) on guideline-concordant pain treatment and opioid prescribing decisions in primary care settings. METHODS Setting: The setting for this study is 43 primary care clinics in Minnesota. DESIGN The PRINCE study uses a cluster-randomized 2 × 2 factorial design to test the effects of two interventions. An adaptive design allows for the possibility of secondary randomization to test if interventions can be titrated while maintaining efficacy. INTERVENTIONS One intervention alters the "choice architecture" within the EHR to nudge clinicians toward non-opioid treatments for opioid-naïve patients and toward tapering for patients currently receiving a "high risk" opioid. The other intervention integrates the prescription drug monitoring program (PDMP) directly within the EHR. OUTCOME The primary outcome for opioid-naïve patients is whether an opioid is prescribed in a primary care visit without a non-opioid alternative pain treatment. The primary outcome for current opioid-using patients is whether opioid prescriptions were tapered with a documented rationale. DISCUSSION The PRINCE study will provide real-world evidence on two approaches to improving pain treatment in primary care using the EHR. The adaptive study design strikes a balance between establishing intervention efficacy and testing whether efficacy varies with intervention intensity.
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Affiliation(s)
- David M Vock
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Hannah T Neprash
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | | | | | - David J Satin
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Sonja Short
- Fairview Health Services, Minneapolis, MN, USA
| | | | - Rebecca Markowitz
- Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Genevieve B Melton
- Fairview Health Services, Minneapolis, MN, USA; Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Ezra Golberstein
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA.
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Rockson SG, Karaca-Mandic P, Nguyen M, Shadduck K, Gingerich P, Campione E, Hetrrick H. A non-randomized, open-label study of the safety and effectiveness of a novel non-pneumatic compression device (NPCD) for lower limb lymphedema. Sci Rep 2022; 12:14005. [PMID: 35977981 PMCID: PMC9385615 DOI: 10.1038/s41598-022-17225-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/21/2022] [Indexed: 01/19/2023] Open
Abstract
Lower extremity lymphedema (LEL) can result in detriments to quality of life (QOL) and impose a significant economic burden on patients and payers. A common component of treatment is pneumatic compression, which requires patients to remain immobile. We investigated a novel non-pneumatic compression device (NPCD) that allows patients to remain active during compression treatment, to see if it reduces swelling and improves QOL. We conducted a non-randomized, open-label, 12-week pilot study of adult patients with primary or secondary unilateral LEL, and measured changes in limb edema and QOL using the Lymphedema Quality of Life Questionnaire (LYMQOL). Twenty-four subjects were enrolled; the majority were female (17) with secondary lymphedema (21). Eighteen completed the study. Statistically significant improvements were observed in overall QOL, aggregated LYMQOL total score, and three of four LYMQOL subscales (Function, Appearance, Mood). The fourth (Symptoms) trended toward significant improvement (p = 0.06). The average reduction in affected limb edema was 39.4%. The novel NPCD produced statistically significant improvements in QOL, functioning, and edema volume of patients with LEL. Innovations in devices to manage LEL can be effective while allowing patients to maintain mobility and physical activity during treatment.
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Affiliation(s)
- Stanley G. Rockson
- grid.168010.e0000000419368956Cardiovascular Medicine, Falk Cardiovascular Research Center, Stanford University, Stanford, CA 94305 USA
| | - Pinar Karaca-Mandic
- grid.17635.360000000419368657Carlson School of Management, University of Minnesota, Minneapolis, MN USA
| | | | | | | | - Elizabeth Campione
- grid.260024.20000 0004 0627 4571Department of Physical Therapy, Midwestern University, Downers Grove, IL USA
| | - Heather Hetrrick
- grid.261241.20000 0001 2168 8324Department of Physical Therapy, Nova Southeastern University, Ft. Lauderdale, FL USA
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14
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Abstract
IMPORTANCE As states reopened their economies state and local officials made decisions on policies and restrictions that had an impact on the evolution of the pandemic and the health of the citizens. Some states made the decision to lift mask mandates starting spring 2021. Data-driven methods help evaluate the appropriateness and consequences of such decisions. OBJECTIVE To investigate the association of lifting the mask mandate with changes in the cumulative coronavirus case rate. DESIGN Synthetic control study design on lifting mask mandate in the state of Iowa implemented on February 7, 2021. SETTING Daily state-level data from the COVID-19 Community Profile Report published by the US Department of Health & Human Services, COVIDcast dataset of the Delphi Research Group, and Google Community Mobility Reports. EXPOSURES AND OUTCOME Mask mandate policy lift at the state level. State-day observations of the cumulative case rate measured as the cumulative number of new cases per 100,000 people in the previous 7 days. RESULTS The cumulative case rate in Iowa increased by 20%-30% within 3 weeks of lifting the mask mandate as compared with a synthetic control unit. This association appeared to be related to people, in fact, reducing their mask-wearing habits. CONCLUSIONS Lifting the mask mandate in Iowa was associated with an increase in new COVID-19 cases. Caution should be applied when making this type of policy decision before having achieved a more stable control of the pandemic.
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Affiliation(s)
| | | | - Pinar Karaca-Mandic
- Finance, Carlson School of Management, University of Minnesota, Minneapolis, MN
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15
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Neprash HT, Vock DM, Hanson A, Elert B, Short S, Karaca-Mandic P, Rothman AJ, Melton GB, Satin D, Markowitz R, Golberstein E. Effect of Integrating Access to a Prescription Drug Monitoring Program Within the Electronic Health Record on the Frequency of Queries by Primary Care Clinicians. JAMA Health Forum 2022; 3:e221852. [PMID: 35977248 PMCID: PMC9168784 DOI: 10.1001/jamahealthforum.2022.1852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/10/2022] [Indexed: 01/14/2023] Open
Abstract
Question Does direct access to the prescription drug monitoring program (PDMP) from within the electronic health record (EHR) increase the frequency of PDMP queries by primary care clinicians? Finding This cluster randomized clinical trial involving 309 clinicians in 43 primary care clinics found that providing direct access to a PDMP tool from the EHR increased PDMP queries by 60% compared with clinicians in control clinics who did not have EHR-integrated access. Meaning The findings of this trial demonstrate that direct access from the EHR to a PDMP can increase the provision of guideline-concordant care. Importance Tools that are directly integrated with the electronic health record (EHR) workflow can reduce the hassle cost of certain guideline-concordant practices, such as querying a prescription drug monitoring program (PDMP) before prescribing opioids. Objective To investigate the effect of integrating access to a PDMP within the EHR on the frequency of program queries by primary care clinicians. Design, Settings, and Participants The PRINCE (Prescribing Interventions for Chronic Pain Using the Electronic Health Record) randomized trial used a factorial cluster design at the clinic level in 43 primary care clinics in Minnesota. In all, 309 clinicians participated; 161 clinicians were given EHR-integrated access to PDMP at the intervention clinics, and 148 clinicians had the usual access at the control clinics. The intervention went live on August 27, 2020, and data were collected through March 3, 2021. Intervention Single sign-on access to the Minnesota PDMP was integrated into the EHR, allowing clinicians to query a patient’s controlled substance prescription and dispensing history as recorded in the Minnesota PDMP directly from the patient’s EHR record without logging into a separate web portal. Additionally, the integration tool alerted clinicians and reminded them to review the PDMP if a patient had 3 or more opioid prescriptions in the past year and 1 or more in the past 6 months. Clinics in the control group did not receive access to the EHR-integrated PDMP tool; instead, these participants logged into the PDMP web portal separately. Main Outcomes and Measures Monthly PDMP query counts for primary care clinicians, overall and by modality (EHR-based, web-based, via a clinical delegate), adjusted for clinician characteristics, including type (physician, nurse practitioner, physician assistant), sex, and years in practice. Data were analyzed from August 2021 to May 2022. Results Of the 43 participating clinics with 309 clinicians, 21 clinics with 161 clinicians (102 [63.4%] women; 114 [70.8%] physicians; tenure, 10.6 [4.4] years) received the PDMP integration intervention. Baseline unadjusted monthly PDMP query rates for the average clinician were 6.6 (95% CI, 4.4-9.9) vs 8.8 (95% CI, 6.0-13.1) queries in the control vs the PDMP integration group, respectively. During the intervention, PDMP query rates for the average clinician were 6.9 (95% CI, 4.7-10.3) vs 14.8 (95% CI, 10.0-22.0) queries among the control vs the PDMP integration group, respectively. Compared with the control group, the EHR-integrated PDMP tool produced a 60% greater increase in the relative change in monthly PDMP queries (95% CI, 51%-70%). An increase in PDMP queries via the EHR-integrated PDMP tool drove this increase, while web-based and delegate queries declined by 39% more among the intervention compared with the control group (95% CI, 34%-43%). Conclusions and Relevance This cluster randomized clinical trial found that integrating access to the PDMP in the EHR increased PDMP-querying rates, suggesting that direct access reduced hassle costs and can dramatically improve adherence to guideline-concordant care practices among primary care clinicians. Trial Registration ClinicalTrials.gov Identifier: NCT04601506
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Affiliation(s)
- Hannah T. Neprash
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
| | - David M. Vock
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis
| | | | - Brent Elert
- Fairview Health Services, Minneapolis, Minnesota
| | - Sonja Short
- Fairview Health Services, Minneapolis, Minnesota
- Institute for Health Informatics, University of Minnesota, Minneapolis
| | | | - Alexander J. Rothman
- Department of Psychology, College of Liberal Arts, University of Minnesota, Minneapolis
| | - Genevieve B. Melton
- Fairview Health Services, Minneapolis, Minnesota
- Institute for Health Informatics, University of Minnesota, Minneapolis
- Department of Surgery, Medical School, University of Minnesota, Minneapolis
- Center for Learning Health System Sciences, University of Minnesota, Minneapolis
| | - David Satin
- Department of Family Medicine and Community Health, Medical School, University of Minnesota, Minneapolis
| | - Rebecca Markowitz
- Fairview Health Services, Minneapolis, Minnesota
- Institute for Health Informatics, University of Minnesota, Minneapolis
- Department of Medicine, Medical School, University of Minnesota, Minneapolis
| | - Ezra Golberstein
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
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16
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Adams ME, Karaca-Mandic P, Marmor S. Use of Neuroimaging for Patients With Dizziness Who Present to Outpatient Clinics vs Emergency Departments in the US. JAMA Otolaryngol Head Neck Surg 2022; 148:465-473. [PMID: 35389454 PMCID: PMC8990360 DOI: 10.1001/jamaoto.2022.0329] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Overuse of costly neuroimaging technology is associated with low-value care for the prevalent symptom of dizziness. Although quality improvement initiatives have focused on the overuse of computed tomography (CT) scans in emergency departments (EDs), most patients with dizziness present to outpatient clinics. To inform practice and policy, a comprehensive understanding of the uses and costs of neuroimaging across settings and episodes of care is needed. Objective To characterize neuroimaging use, timing, and spending as well as factors associated with imaging acquisition within 6 months of presentation for dizziness in outpatient vs ED settings. Design, Setting, and Participants This cross-sectional study of commercial and Medicare Advantage claims for 805 454 adults (≥18 years of age) with new diagnoses of dizziness was conducted from January 1, 2006, through December 31, 2015. Data were analyzed from October 1, 2020, to September 30, 2021. Main Outcomes and Measures Use of neuroimaging (CT scan, magnetic resonance imaging [MRI], angiography, and ultrasonography) and total spending on neuroimaging were measured. Kaplan-Meier analysis was performed. The associations of neuroimaging with setting, sociodemographic characteristics, and clinicians were estimated with multivariable analyses. Results A total of 805 454 individuals with dizziness (502 055 women [62%]; median age, 52 years [range, 18-87 years]) were included in this study; 156 969 (20%) underwent neuroimaging within 6 months of presentation (65 738 of 185 338 [36%] presented to EDs and 91 231 of 620 116 [15%] presented to outpatient clinics). The median time to neuroimaging was 0 days (95% CI, 0-2 days) after ED presentation and 10 days (95% CI, 9-10 days) after outpatient presentation. Neuroimaging was independently associated with advanced age, comorbidity, race and ethnicity, ED presentation, and outpatient clinician specialty. Across sites, a head CT scan was the most used test on presentation date (92% of tests [46 852 of 51 022]). Within 6 months of presentation, a head CT scan was the most used test (47% of all tests [177 949 of 376 149]), followed by brain MRI (25% [93 130 of 376 149]), cerebrovascular ultrasonography (15% [56 175 of 376 149]), and magnetic resonance angiography (9% [34 026 of 376 149]). Of $88 646 047.03 in total neuroimaging spending, MRI accounted for 70% ($61 730 251.95), CT scans for 19% ($16 910 506.24), and ultrasonography for 11% ($10 005 288.84). Per-test median spending ranged from $68.97 (CT scan of the head) to $319.63 (MRI of the brain) among commercially insured individuals and $43.21 (CT scan of the head) to $362.02 (MRI of the orbit, face, and neck) among Medicare Advantage beneficiaries. Conclusions and Relevance The findings of this cross-sectional study suggest that use of neuroimaging for dizziness is prevalent across settings. Interventions to optimize the use of neuroimaging must occur early in the patient care journey to discourage guideline-discordant use of CT scans, advocate for judicious MRI use (particularly in ambulatory settings), and account for the effects of price transparency.
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Affiliation(s)
- Meredith E Adams
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis.,OptumLabs Visiting Fellow
| | - Pinar Karaca-Mandic
- OptumLabs Visiting Fellow.,Department of Finance, Carlson School of Management, University of Minnesota, Minneapolis
| | - Schelomo Marmor
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis.,OptumLabs Visiting Fellow.,Department of Surgery, University of Minnesota, Minneapolis.,Center for Clinical Quality & Outcomes Discovery and Evaluation (C-QODE), University of Minnesota, Minneapolis
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17
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Abstract
This cross-sectional study examines the association of a $1000 financial incentive and COVID-19 vaccine uptake among employees at a large US company.
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Affiliation(s)
| | - Jessica Chang
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Pinar Karaca-Mandic
- Department of Finance, Carlson School of Management, University of Minnesota, Minneapolis
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18
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Abstract
In response to study findings showing the risk of cardiovascular adverse events associated with testosterone therapy, the FDA issued safety warnings in 2014 and modified testosterone labeling in March 2015 to indicate the increased risk of stroke and heart attack. It is unknown whether there were changes in testosterone marketing practices by pharmaceutical companies following the FDA label warning. Both primary care physicians (PCPs) and non-PCPs prescribe testosterone and are targeted by pharmaceutical marketing representatives to encourage testosterone prescribing. Likewise, pharmaceutical marketing occurs in both urban and rural areas. Our study is the first to examine testosterone marketing practices around the period of the testosterone label warning by physician specialty and rural vs urban primary care service area. In this study, we found that testosterone marketing efforts such as marketing spending per encounter, quarterly marketing spending per physician, and quarterly number of encounters per physician increased among non-PCPs and urban physicians for 4 quarters following an FDA boxed warning in 2015 on testosterone prescriptions. After the black box warning, off-label testosterone advertisements stopped. This reduction in advertising could have made it more attractive for pharmaceutical companies to increase their marketing spending targeting non-PCPs and physicians in urban areas. Understanding responses of pharmaceutical companies to FDA guidelines is important and can help inform future guideline initiatives.
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Affiliation(s)
| | | | - Pinar Karaca-Mandic
- University of Minnesota Carlson School of Management, 321 19th Ave S, Minneapolis, MN 55455.
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19
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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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20
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Sankar A, Swanson KM, Zhou J, Jena AB, Ross JS, Shah ND, Karaca-Mandic P. Association of Fluoroquinolone Prescribing Rates With Black Box Warnings from the US Food and Drug Administration. JAMA Netw Open 2021; 4:e2136662. [PMID: 34851398 PMCID: PMC8637256 DOI: 10.1001/jamanetworkopen.2021.36662] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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: 01/21/2023] Open
Abstract
IMPORTANCE In 2013 and 2016, the US Food and Drug Administration (FDA) issued warnings and recommended limited use of fluoroquinolones for patients with certain acute conditions. It is not clear how prescribers have responded to these warnings. OBJECTIVE To analyze changes in prescribing of fluoroquinolones after the 2013 and 2016 FDA warnings and to examine the physician characteristics associated with these changes. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used Medicare administrative claims data on Medicare fee-for-service beneficiaries and OneKey data on physicians and their organizations from January 1, 2011, to December 31, 2017. The sample was restricted to outpatient visits for sinusitis, bronchitis, and uncomplicated urinary tract infections. An interrupted time series approach was used to analyze the changes in the prescription rate after each FDA warning. Data analysis was performed between January 1, 2011, and December 31, 2017. INTERVENTIONS Two FDA black box warnings released in August 2013 and July 2016. MAIN OUTCOMES AND MEASURES The main outcome was an indicator for fluoroquinolone prescriptions in 3 periods: before the 2013 warning (baseline period), after the 2013 warning but before the 2016 warning (postwarning period 1), and after the 2016 warning (postwarning period 2). RESULTS The sample comprised 1 238 397 unique patients with a total of 2 720 071 outpatient acute care visits. Of this sample, 848 360 were women (68.5%), and the mean (SD) age was 69.7 (12.6) years. The immediate prescribing levels of fluoroquinolones in postwarning period 1 increased by 3.42 percentage points (95% CI, 3.23-3.62; P < .001) and declined by -0.77 percentage points (95% CI, -1.00 to -0.54; P < .001) in postwarning period 2. The prescribing trend increased by 0.08 percentage points per month (95% CI, 0.08-0.10; P < .001) in postwarning period 1 and 0.06 percentage points per month (95% CI, 0.04-0.08; P < .001) in postwarning period 2. In postwarning period 1, the prescribing levels for physicians who were affiliated with hospitals with a top 10th percentile case mix index vs those without such affiliation decreased by -1.13 percentage points (95% CI, -1.92 to -0.34; P = .005), whereas the levels for primary care physicians declined by -1.34 percentage points (95% CI, -1.78 to -0.88; P < .001) compared with non-primary care physicians in postwarning period 2. Physicians at teaching hospitals were the only ones who showed a decline in prescribing trend in postwarning period 1. CONCLUSIONS AND RELEVANCE This cross-sectional study found an overall decline in prescribing of fluoroquinolones after the release of FDA warnings. Understanding the association of physician and organizational characteristics with fluoroquinolone prescribing behavior may ultimately help to identify mechanisms to improve de-adoption.
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Affiliation(s)
- Ashwini Sankar
- Carlson School of Management, Department of Finance, University of Minnesota, Minneapolis
- Department of Economics, Macalester College, St Paul, Minnesota
| | - Kristi M. Swanson
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Jiani Zhou
- School of Public Health, University of Minnesota, Minneapolis
| | - Anupam Bapu Jena
- Department of Health Care Policy, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Joseph S. Ross
- Yale University, Yale School of Medicine, New Haven, Connecticut
| | - Nilay D. Shah
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
| | - Pinar Karaca-Mandic
- Carlson School of Management, Department of Finance, University of Minnesota, Minneapolis
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21
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Togun AT, Karaca-Mandic P, Wurtz R, Jeffrey M, Beebe T. Association of 3 CDC opioid prescription guidelines for chronic pain and 2 payer pharmacy coverage changes on opioid initiation practices. J Manag Care Spec Pharm 2021; 27:1352-1364. [PMID: 34595944 PMCID: PMC10391278 DOI: 10.18553/jmcp.2021.27.10.1352] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Due to the US opioid epidemic, in March of 2016, the Centers for Disease Control and Prevention (CDC) published new guidelines for primary care providers on opioid prescribing for chronic pain. Payer coverage changes were also implemented to help modify opioid prescribing behavior. Whether these initiatives were associated with changes in opioid initiation patterns is unknown. OBJECTIVE: To assess the association between 3 of the 2016 CDC guidelines and 2 subsequent payer pharmacy coverage changes with changes in opioid initiation behavior across different provider specialties. METHODS: We conducted a real-world evidence study using claims data from OptumLabs Data Warehouse between January of 2014 and December of 2018. Subjects were continuously enrolled opioid naive patients, aged at least 18 years, who had at least 1 chronic pain diagnosis within 2 weeks before their first (first-time) opioid prescription. The study used multiple treatment period segmented regression analysis to evaluate the association, across different provider specialties, between the CDC guideline release and the payer pharmacy coverage changes with immediate change in level and overall change in the rate of first-time extended-release opioid prescriptions, firsttime opioid prescriptions at doses of at least 50 MME (morphine milligram equivalent) per day, and first-time opioid prescriptions with overlapping benzodiazepine prescription. RESULTS: The CDC guidelines were not associated with any change in the rate of first-time prescriptions of extended-release opioids. However, a January 2017 payer pharmacy coverage change was associated with a reduction over time in first-time extended-release opioid prescription rates by 22.15 in every 100,000 prescriptions (CI = -40.04 to -2.92, P = 0.013). The CDC guidelines were associated with an immediate decline in level of first-time opioid prescription at doses of at least 50 MME per day by 74.00 in every 10,000 prescriptions (CI = -124.86 to -23.13, P = 0.004) and an increased rate of decline over time by 13.64 in every 10,000 prescriptions (CI = -17.07 to -10.21, P < 0.001). These associations varied across provider types and specialties. The March 2018, payer coverage change was associated with an immediate reduction in level of first-time opioid prescriptions at doses of at least 50 MME per day across all specialties and an increased reduction over time among surgeons. The CDC guidelines were associated, respectively, with a reduction in the rate of overlapping first-time opioid prescriptions with benzodiazepines among family medicine, internal medicine, surgeons, emergency medicine providers, and providers with unknown specialty by 6.11, 5.10, 2.89, 11.43, and 9.11 in every 10,000 prescriptions monthly (CI = -9.48 to -2.73, -9.86 to -0.35, -5.40 to -0.38, -17.26 to -5.61 and -11.96 to -6.25, respectively, P < 0.001, P = 0.035, P = 0.024, P < 0.001 and P < 0.001). CONCLUSIONS: Some specialist providers also adopted the CDC guidelines, and the response to the guidelines differed across various provider specialties. Some CDC guidelines were associated with a reduction in high-risk first-time opioid prescriptions. Payer pharmacy coverage changes reinforced the guidelines both in situations where the CDC guidelines did and did not show any association. DISCLOSURE: This research was funded by Agency for Healthcare Research and Quality (R01 HS025164; PI: Karaca-Mandic). Karaca-Mandic reports grants from the American Cancer Society and Sempre Health, along with fees from Tactile Medical and Precision Health Economics, unrelated to this study. The other authors have nothing to disclose.
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Affiliation(s)
- Adeniyi T Togun
- Department of Health Services Research, School of Public Health, University of Minnesota Twin Cities, Minneapolis
| | - Pinar Karaca-Mandic
- OptumLabs Visiting Fellow, Carlson School of Management, Department of Finance, University of Minnesota, Minneapolis, and National Bureau of Economic Research, Cambridge, MA
| | - Rebecca Wurtz
- Division of Health Policy and Management, School of Public Health, University of Minnesota Twin Cities, Minneapolis
| | - Molly Jeffrey
- Department of Health Services Research, Mayo Clinic, Rochester, MN
| | - Timothy Beebe
- Division of Health Policy and Management, School of Public Health, University of Minnesota Twin Cities, Minneapolis
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22
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Stecher C, Everhart A, Smith LB, Jena A, Ross JS, Desai NR, Shah N, Karaca-Mandic P. Physician Network Connections Associated With Faster De-Adoption of Dronedarone for Permanent Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2021; 14:e008040. [PMID: 34555928 DOI: 10.1161/circoutcomes.121.008040] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Physicians' professional networks are an important source of new medical information and have been shown to influence the adoption of new treatments, but it is unknown how physician networks impact the de-adoption of harmful practices. METHODS We analyzed changes in physicians' use of dronedarone after the PALLAS trial (Palbociclib Collaborative Adjuvant Study; November 2011) showed that dronedarone increased the risk of death from cardiovascular events among patients with permanent atrial fibrillation. Deidentified administrative claims from the OptumLabs Data Warehouse were combined with physicians' demographic information from the Doximity database and publicly available data on physicians' patient-sharing relationships compiled by the Centers for Medicare and Medicaid Services. We used a linear probability model with an interrupted linear time trend specification to model the impact of the PALLAS trial on physicians' dronedarone usage between 2009 and 2014. RESULTS Before the PALLAS trial, the use of dronedarone was increasing by 0.22 percentage points per quarter (95% CI, 0.19-0.25) in our Medicare Advantage sample (N=343 429 patient-quarter observations) and 0.63 percentage points per quarter (95% CI, 0.52-0.75) in our commercially insured sample (N=44 402 patient-quarter observations). After the PALLAS trial and subsequent United States Food and Drug Administration black box warning, physicians in the Medicare Advantage sample with an above-median number of network connections to other physicians decreased their quarterly usage of dronedarone by 0.12 percentage points more per quarter (95% CI, -0.20 to -0.04; P=0.031) than physicians with equal to or below the median number of network connections. Similar patterns existed in the commercially insured sample (P=0.0318). CONCLUSIONS After controlling for a wide range of patient, physician, and geographic characteristics, physicians with a greater number of network connections were faster de-adopters of dronedarone for patients with permanent atrial fibrillation after the PALLAS trial and subsequent United States Food and Drug Administration black box warning detailed the harmfulness of dronedarone for these patients. Policies for improving physicians' responsiveness to new medical information should consider utilizing the influence of these important professional network relationships.
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Affiliation(s)
| | - Alexander Everhart
- University of Minnesota School of Public Health, Minneapolis (A.E.).,OptumLabs Visiting Fellow, Boston, MA (A.E.)
| | | | - Anupam Jena
- Harvard Medical School, Boston, MA (A.J.).,National Bureau of Economic Research, Cambridge, MA (A.J., P.K.-M.)
| | - Joseph S Ross
- Yale School of Public Health, New Haven, CT (J.S.R.).,Yale School of Medicine, New Haven, CT (J.S.R., N.R.D.)
| | - Nihar R Desai
- Yale School of Medicine, New Haven, CT (J.S.R., N.R.D.)
| | - Nilay Shah
- Mayo Clinic Department of Health Sciences Research, Rochester, MN (N.S.)
| | - Pinar Karaca-Mandic
- National Bureau of Economic Research, Cambridge, MA (A.J., P.K.-M.).,University of Minnesota Carlson School of Management, Minneapolis (P.K.-M.)
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23
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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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24
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Vu K, Zhou J, Everhart A, Desai N, Herrin J, Jena AB, Ross JS, Shah ND, Karaca-Mandic P. Uptake of evidence by physicians: De-adoption of erythropoiesis-stimulating agents after the TREAT trial. BMC Nephrol 2021; 22:284. [PMID: 34419007 PMCID: PMC8379779 DOI: 10.1186/s12882-021-02491-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 08/03/2021] [Indexed: 11/10/2022] Open
Abstract
Background Variation in de-adoption of ineffective or unsafe treatments is not well-understood. We examined de-adoption of erythropoiesis-stimulating agents (ESA) in anemia treatment among patients with chronic kidney disease (CKD) following new clinical evidence of harm and ineffectiveness (the TREAT trial) and the FDA’s revision of its safety warning. Method We used a segmented regression approach to estimate changes in use of epoetin alfa (EPO) and darbepoetin alfa (DPO) in the commercial, Medicare Advantage (MA) and Medicare fee-for-service (FFS) populations. We also examined how changes in both trends and levels of use were associated with physicians’ characteristics. Results Use of DPO and EPO declined over the study period. There were no consistent changes in DPO trend across insurance groups, but the level of DPO use decreased right after the FDA revision in all groups. The decline in EPO use trend was faster after the TREAT trial for all groups. Nephrologists were largely more responsive to evidence than primary care physicians. Differences by physician’s gender, and age were not consistent across insurance populations and types of ESA. Conclusions Physician specialty has a dominant role in prescribing decision, and that specializations with higher use of treatment (nephrologists) were more responsive to new evidence of unsafety and ineffectiveness. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02491-y.
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Affiliation(s)
- Khoa Vu
- Department of Applied Economics, University of Minnesota, 1994 Buford Avenue, St. Paul, MN, 55108, USA
| | - Jiani Zhou
- University of Minnesota School of Public Health, 420 Delaware St. SE, Minneapolis, MN, 55455, USA
| | - Alexander Everhart
- University of Minnesota School of Public Health, 420 Delaware St. SE, Minneapolis, MN, 55455, USA
| | - Nihar Desai
- Cardiovascular Medicine, Yale School of Medicine, 15 York Street, PO Box 208017, New Haven, CT, 06520-8017, USA
| | - Jeph Herrin
- Yale School of Medicine, PO Box 2254, Charlottesville, Virginia, 22902, USA
| | - Anupam B Jena
- Harvard Medical School and National Bureau of Economic Research, 180 Longwood Avenue, Boston, MA, 02115, USA
| | - Joseph S Ross
- Yale School of Medicine, General Internal Medicine, P.O. Box 208093, New Haven, CT, 06520-8093, USA
| | | | - Pinar Karaca-Mandic
- National Bureau of Economic Research and OptumLabs Visiting Fellow, University of Minnesota Carlson School of Management, 321 19th Avenue South, Minneapolis, MN, 55455, USA.
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McCoy RG, Van Houten HK, Karaca-Mandic P, Ross JS, Montori VM, Shah ND. Second-Line Therapy for Type 2 Diabetes Management: The Treatment/Benefit Paradox of Cardiovascular and Kidney Comorbidities. Diabetes Care 2021; 44:dc202977. [PMID: 34348996 PMCID: PMC8929191 DOI: 10.2337/dc20-2977] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 06/24/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine whether glucagon-like peptide 1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2i) are preferentially initiated among patients with cardiovascular disease, heart failure (HF), or nephropathy, where these drug classes have established benefit, compared with dipeptidyl peptidase 4 inhibitors (DPP-4i), for which corresponding benefits have not been demonstrated. RESEARCH DESIGN AND METHODS We retrospectively analyzed claims of adults with type 2 diabetes included in OptumLabs Data Warehouse, a deidentified database of commercially insured and Medicare Advantage beneficiaries, who first started GLP-1RA, SGLT2i, or DPP-4i therapy between 2016 and 2019. Using multinomial logistic regression, we examined the relative risk ratios (RRR) of starting GLP-1RA and SGLT2i compared with DPP-4i for those with a history of myocardial infarction (MI), cerebrovascular disease, HF, and nephropathy after adjusting for demographic and other clinical factors. RESULTS We identified 75,395 patients who started GLP-1RA, 58,234 who started SGLT2i, and 91,884 who started DPP-4i. Patients with prior MI, cerebrovascular disease, or nephropathy were less likely to start GLP-1RA rather than DPP-4i compared with patients without these conditions (RRR 0.83 [95% CI 0.78-0.88] for MI, RRR 0.77 [0.74-0.81] for cerebrovascular disease, and RRR 0.87 [0.84-0.91] for nephropathy). Patients with HF or nephropathy were less likely to start SGLT2i (RRR 0.83 [0.80-0.87] for HF and RRR 0.57 [0.55-0.60] for nephropathy). Both medication classes were less likely to be started by non-White and older patients. CONCLUSIONS Patients with cardiovascular disease, HF, and nephropathy, for whom evidence suggests a greater likelihood of benefiting from GLP-1RA and/or SGLT2i therapy, were less likely to start these drugs. Addressing this treatment/benefit paradox, which was most pronounced in non-White and older patients, may help reduce the morbidity associated with these conditions.
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Affiliation(s)
- Rozalina G McCoy
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN
| | - Holly K Van Houten
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN
- OptumLabs, Eden Prairie, MN
| | - Pinar Karaca-Mandic
- Department of Finance and Medical Industry Leadership Institute, Carlson School of Management, University of Minnesota, Minneapolis, MN
- National Bureau of Economic Research, Cambridge, MA
| | - Joseph S Ross
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
| | - Victor M Montori
- Division of Endocrinology, Diabetes, Metabolism, & Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Nilay D Shah
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN
- OptumLabs, Eden Prairie, MN
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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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Rockson SG, Karaca-Mandic P, Skoracki R, Hock K, Nguyen M, Shadduck K, Gingerich P, Campione E, Leifer A, Armer J. Clinical Evaluation of a Novel Wearable Compression Technology in the Treatment of Lymphedema, an Open-Label Controlled Study. Lymphat Res Biol 2021; 20:125-132. [PMID: 34227842 PMCID: PMC9081034 DOI: 10.1089/lrb.2020.0126] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
A diagnosis of lymphedema comes with a lifetime requirement for careful self-care and treatment to control skin deterioration and the consequences of excessive fluid and protein buildup leading to abnormal limb volume and an increased risk of infection. The burden of care and psychosocial aspects of physical disfiguration and loss of function are associated with compromised quality of life (QoL). The current standard therapeutic intervention is complex decongestive therapy with manual lymph drainage and frequent wearing of compression garments. With insurance limitations on therapy visits and the time and travel required, additional home treatment options are needed. Pneumatic compression pumps that mimic the manual massage pressure and pattern are sometimes prescribed, but these are bulky, difficult to apply, and require immobility during treatment. An open-label pilot study in 40 subjects was performed to evaluate the QoL and limb volume maintenance efficacy of a novel wearable compression system (Dayspring™) that is low profile, easy to use, and allows for mobility during treatment. After 28 days of use, subjects had a statistically significant 18% (p < 0.001) improvement in overall QoL as measured by the Lymphedema Quality-of-Life Questionnaire compared with baseline. Individual QoL domains, and limb volume improved with therapy. Adherence was 98% over the course of the study. Results of the clinical evaluation suggest the Dayspring wearable compression device is safe and effective and improves QoL and limb volume. The novel, low-profile device is easy to use and allows for mobility during treatment, addressing a potential barrier to adherence with pneumatic compression devices.
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Affiliation(s)
- Stanley G Rockson
- Cardiovascular Medicine, Stanford University, Stanford, California, USA
| | - Pinar Karaca-Mandic
- Carlson School of Management, University of Minnesota, Minneapolis, Minnesota, USA
| | - Roman Skoracki
- James Cancer Treatment and Research Center, Ohio State University, Columbus, Ohio, USA
| | - Karen Hock
- James Cancer Treatment and Research Center, Ohio State University, Columbus, Ohio, USA
| | | | | | | | - Elizabeth Campione
- Department of Physical Therapy, Midwestern University, Downers Grove, Illinois, USA
| | | | - Jane Armer
- Ellis Fischel Cancer Center, University of Missouri, Columbia, Missouri, USA
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Rojanasarot S, Carlson AM, St Peter WL, Karaca-Mandic P, Wolfson J, Schommer JC. Translational Effect of Provider-Focused, Multi-State, Multi-Clinic Asthma Care Quality Improvement Program on Patient-Level Health Care Costs. J Prim Care Community Health 2021; 12:21501327211000246. [PMID: 33749359 PMCID: PMC7983490 DOI: 10.1177/21501327211000246] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION/OBJECTIVES Enhancing Care for Patients with Asthma (ECPA), a year-long provider-focused, multi-state, multi-clinic quality improvement program, decreased avoidable utilizations among patients with asthma, but its effects on health care expenditures were not determined. This study examined the translational and sustainable effects of improved care through ECPA on individual-level total health care costs due to asthma. METHODS We conducted a retrospective pretest-posttest quasi-experimental study in which attributed 1683 patients in a 12-month pre-ECPA implementation period served as their own control. We constructed the total annual asthma-related health care costs per patient occurred during pre-ECPA implementation, ECPA implementation, and post-ECPA completion. We used 3-level generalized linear mixed models (GLMMs) to estimate the ECPA effect on the annual health care costs and account for correlation between the repeated outcome measures for each patient and nested clinic. All costs were adjusted for inflation to 2014 U.S. dollars, the last year of program observation. RESULTS Total asthma-related health care costs among the 1683 included patients decreased from an average of $7033 to $3237 per person-year (pre-ECPA implementation vs implementation). Using the cost data from the 12-month pre-ECPA implementation period as a reference, GLMMs found that the ECPA implementation was associated with a reduction in total annual asthma-related health care costs by 56.4% (95% CI -60.7%, -51.8%). During the 12-months after ECPA completion period, health care costs were also found to be significantly lower, experiencing a 57.3% reduction. CONCLUSIONS The economic benefits of ECPA provide a justification to adopt this quality improvement initiative to more primary care clinics at a national level.
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Affiliation(s)
- Sirikan Rojanasarot
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Angeline M Carlson
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA.,Data Intelligence Consultants LLC, Eden Prairie, MN, USA
| | - Wendy L St Peter
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Pinar Karaca-Mandic
- Department of Finance, Carlson School of Management, University of Minnesota, Minneapolis, MN, USA
| | - Julian Wolfson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Jon C Schommer
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
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Sacks DW, Vu K, Huang TY, Karaca-Mandic P. How do insurance firms respond to financial risk sharing regulations? Evidence from the Affordable Care Act. Health Econ 2021; 30:1443-1460. [PMID: 33797143 DOI: 10.1002/hec.4252] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 02/04/2021] [Accepted: 02/15/2021] [Indexed: 06/12/2023]
Abstract
Many insurance markets have reinstated premium stabilization programs to ensure financial protection from market volatility. In this paper, we focus on one such regulation-risk corridors (RCs)-in the context of the Health Insurance Marketplaces established under the Affordable Care Act. We develop a model to show how the program provided incentives for some insurers to lower their premiums. The RCs program was defunded unexpectedly for coverage year 2016, before its legislated end in 2016. Consistent with the model, we find that making a RCs claim before the program ended is associated with higher premium growth after the program's demise. The model and empirical evidence are consistent with the view that the end of the RCs program contributed to premium growth in the Marketplaces.
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Affiliation(s)
- Daniel W Sacks
- Department of Business Economics and Public Policy, Kelley School of Business, Indiana University, Indiana, USA
| | - Khoa Vu
- Department of Applied Economics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Tsan-Yao Huang
- Office of Health Affairs, West Virginia University, Morgantown, West Virginia, USA
| | - Pinar Karaca-Mandic
- Department of Finance, Carlson School of Management, University of Minnesota, Minneapolis, Minnesota, USA
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Gupta S, Georgiou A, Sen S, Simon K, Karaca-Mandic P. US Trends in COVID-19-Associated Hospitalization and Mortality Rates Before and After Reopening Economies. JAMA Health Forum 2021; 2:e211262. [PMID: 35977172 PMCID: PMC8796994 DOI: 10.1001/jamahealthforum.2021.1262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 04/28/2021] [Indexed: 01/08/2023] Open
Abstract
Importance After abrupt closures of businesses and public gatherings in the US in late spring 2020 due to the COVID-19 pandemic, by mid-May 2020, most states reopened their economies. Owing in part to a lack of earlier data, there was little evidence on whether state reopening policies influenced important pandemic outcomes-COVID-19-related hospitalizations and mortality-to guide future decision-making in the remainder of this and future pandemics. Objective To investigate changes in COVID-19-related hospitalizations and mortality trends after reopening of US state economies. Design Setting and Participants Using an interrupted time series approach, this cross-sectional study examined trends in per-capita COVID-19-related hospitalizations and deaths before and after state reopenings between April 16 and July 31, 2020. Daily state-level data from the University of Minnesota COVID-19 Hospitalization Tracking Project on COVID-19-related hospitalizations and deaths across 47 states were used in the analysis. Exposures Dates that states reopened their economies. Main Outcomes and Measures State-day observations of COVID-19-related hospitalizations and COVID-19-related new deaths per 100 000 people. Results The study included 3686 state-day observations of hospitalizations and 3945 state-day observations of deaths. On the day of reopening, the mean number of hospitalizations per 100 000 people was 17.69 (95% CI, 12.54-22.84) and the mean number of daily new deaths per 100 000 people was 0.395 (95% CI, 0.255-0.536). Both outcomes displayed flat trends before reopening, but they started trending upward thereafter. Relative to the hospitalizations trend in the period before state reopenings, the postperiod trend was higher by 1.607 per 100 000 people (95% CI, 0.203-3.011; P = .03). This estimate implied that nationwide reopenings were associated with 5319 additional people hospitalized for COVID-19 each day. The trend in new deaths after reopening was also positive (0.0376 per 100 000 people; 95% CI, 0.0038-0.0715; P = .03), but the change in mortality trend was not significant (0.0443; 95% CI, -0.0048 to 0.0933; P = .08). Conclusions and Relevance In this cross-sectional study conducted over a 3.5-month period across 47 US states, data on the association of hospitalizations and mortality with state reopening policies may provide input to state projections of the pandemic as policy makers continue to balance public health protections with sustaining economic activity.
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Affiliation(s)
- Sumedha Gupta
- Department of Economics, Indiana University Purdue University, Indianapolis
| | | | - Soumya Sen
- Information & Decision Sciences, Carlson School of Management, Minneapolis, Minnesota
| | - Kosali Simon
- O’Neill School of Public and Environmental Affairs, Indiana University, Bloomington
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Abstract
This study examines coronavirus disease 2019 hospitalization trends for pediatric patients in 22 states.
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Affiliation(s)
- Zachary Levin
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Kimberly Choyke
- Department of Finance, Medical Industry Leadership Institute, University of Minnesota Carlson School of Management, Minneapolis
| | | | - Soumya Sen
- Department of Information and Decision Sciences, University of Minnesota Carlson School of Management, Minneapolis
| | - Pinar Karaca-Mandic
- Department of Finance, Medical Industry Leadership Institute, University of Minnesota Carlson School of Management, Minneapolis
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Huckfeldt PJ, Gu J, Escarce JJ, Karaca-Mandic P, Sood N. The association of vertically integrated care with health care use and outcomes. Health Serv Res 2021; 56:817-827. [PMID: 33728678 DOI: 10.1111/1475-6773.13642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To determine whether vertically integrated hospital and skilled nursing facility (SNF) care is associated with more efficient use of postdischarge care and better outcomes. DATA SOURCES Medicare provider, beneficiary, and claims data from 2012 to 2014. STUDY DESIGN We compared facility characteristics, quality of care, and health care use for hospital-based SNFs and "virtually integrated" SNFs (defined as freestanding SNFs with close referral relationships with a single hospital) relative to nonintegrated freestanding SNFs. Among patients admitted to integrated SNFs, we estimated differences in health care use and outcomes for patients originating from the parent hospital (ie, receiving vertically integrated care) versus other hospitals using linear regressions that included SNF fixed effects. We estimated bounds for our main estimates that incorporated potential omitted variables bias. DATA EXTRACTION METHODS We identified hospital-based SNFs based on provider data. We defined virtually integrated SNFs based on patient flows between hospitals and SNFs. We identified SNF episodes, preceding hospital stays, patient characteristics, health care use, and patient outcomes using Medicare data. PRINCIPAL FINDINGS Consistent with prior research, integrated SNFs performed better on quality measures and health care use relative to nonintegrated SNFs (eg, hospital-based SNFs had 11-day shorter stays compared with nonintegrated SNFs adjusting for patient characteristics, P < .001). Stroke patients admitted to hospital-based SNFs from the parent hospital had shorter preceding hospital stays (adjusted difference: -1.2 days, P = .001) and shorter initial SNF stays (adjusted difference: -2.7 days, P = .049); estimates were attenuated but still robust accounting for potential omitted variables bias. For stroke patients, associations between vertically integrated care and other outcomes were either statistically insignificant or not robust to accounting for potential omitted variables bias. CONCLUSIONS Vertically integrated hospital and SNF care was associated with shorter hospital and SNF stays. However, there were few beneficial associations with other outcomes, suggesting limited coordination benefits from vertical integration.
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Affiliation(s)
- Peter J Huckfeldt
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jing Gu
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - José J Escarce
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Pinar Karaca-Mandic
- Carlson School of Management, University of Minnesota, Minneapolis, Minnesota, USA
| | - Neeraj Sood
- Schaeffer Center for Health Policy and Economics, Sol Price School of Public Policy, University of Southern California, Los Angeles, California, 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 uses data from a COVID-19 tracking project to assess the prevalence of COVID-19 infection by race/ethnicity in 12 US states.
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Affiliation(s)
- Pinar Karaca-Mandic
- Carlson School of Management, Department of Finance, University of Minnesota, Minneapolis
| | | | - Soumya Sen
- Carlson School of Management, Department of Information & Decision Sciences, University of Minnesota, Minneapolis
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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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Karaca-Mandic P, Sen S, Georgiou A, Zhu Y, Basu A. Association of COVID-19-Related Hospital Use and Overall COVID-19 Mortality in the USA. J Gen Intern Med 2020:10.1007/s11606-020-06084-7. [PMID: 32815058 PMCID: PMC7437636 DOI: 10.1007/s11606-020-06084-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 07/27/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Pinar Karaca-Mandic
- Department of Finance, University of Minnesota Carlson School of Management, Minneapolis, MN, USA.
| | - Soumya Sen
- Department of Information & Decision Sciences, University of Minnesota Carlson School of Management, Minneapolis, MN, USA
| | | | - Yi Zhu
- Department of Information & Decision Sciences, University of Minnesota Carlson School of Management, Minneapolis, MN, USA
| | - Anirban Basu
- Departments of Pharmacy, Health Services, and Economics University of Washington, Seattle, WA, USA
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Abstract
This study uses state public health department data to describe trends in COVID-19 hospitalizations before and after state executive stay-at-home orders issued in March and April 2020 in Colorado, Minnesota, Ohio, and Virginia, and compares projected vs observed admissions to estimate associations between the orders and hospital admissions.
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Affiliation(s)
- Soumya Sen
- Department of Information and Decision Sciences, University of Minnesota Carlson School of Management, Minneapolis
| | - Pinar Karaca-Mandic
- Department of Finance, University of Minnesota Carlson School of Management, Minneapolis
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Rojanasarot S, Carlson AM, St Peter WL, Karaca-Mandic P, Wolfson J, Schommer JC. Reducing potentially preventable health events among patients with asthma through multi-state, multi-center quality improvement program. J Asthma 2020; 58:874-882. [PMID: 32162561 DOI: 10.1080/02770903.2020.1741611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Enhancing Care for Patients with Asthma is a multi-state, multi-center quality improvement program developed to augment guideline-based practice among health care providers through Plan-Do-Study-Act cycle. This study examined the association between the implementation of the guideline-based quality improvement program and subsequent changes in asthma-related emergency room visits and hospitalizations. METHODS This retrospective, interrupted time-series study used administrative claims data from a private insurer that provided coverage to patients receiving care from participating health centers (15 centers in New Mexico, Oklahoma, Texas, and Illinois). The 12-month implementation period started in January 2013 for centers in Cohort 1 and October 2013 for centers in Cohort 2. The claims of 1,828 patients with asthma from January 2012 to May 2015 were analyzed. The data included 12-month pre-program implementation, 12-month program implementation, and 5-month post-program completion periods. RESULTS The average number of asthma-related emergency room visits and hospitalizations decreased from 2.22 to 1.38 and 1.97 to 1.04 per 100 patients per month, respectively, in the 12-month pre-implementation period as compared to 12-month implementation period. The results of three-level generalized linear mixed models found that during the 12-month implementation period, patients had 37.7% and 47.1% lower rates of emergency room visits and hospitalizations, respectively, compared to the 12-month pre-implementation period (p < 0.001 in both comparisons). CONCLUSIONS Enhancing Care for Patients with Asthma is an effective quality improvement program that was successfully executed in diverse geographical states and associated with reductions in potentially preventable health events. The findings support the widespread use of the program in other settings.
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Affiliation(s)
- Sirikan Rojanasarot
- Social and Administrative Pharmacy Graduate Program, Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Angeline M Carlson
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Wendy L St Peter
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Pinar Karaca-Mandic
- Department of Finance, Carlson School of Management, University of Minnesota, Minneapolis, MN, USA
| | - Julian Wolfson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Jon C Schommer
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
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McCoy RG, Dykhoff HJ, Sangaralingham L, Ross JS, Karaca-Mandic P, Montori VM, Shah ND. Adoption of New Glucose-Lowering Medications in the U.S.-The Case of SGLT2 Inhibitors: Nationwide Cohort Study. Diabetes Technol Ther 2019; 21:702-712. [PMID: 31418588 PMCID: PMC7207017 DOI: 10.1089/dia.2019.0213] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [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] [Indexed: 12/14/2022]
Abstract
Background: High-quality diabetes care is evidence-based, timely, and equitable. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are the most recently approved class of glucose-lowering medications with additional cardio- and renal-protective benefits and low risk of hypoglycemia. Cardiovascular and kidney disease are among the most common chronic diabetes complications, whereas hypoglycemia is the most prevalent adverse effect of glucose-lowering therapy. We examine the sociodemographic and clinical factors associated with early SGLT2i initiation and appropriateness of use based on contemporaneous scientific evidence. Materials and Methods: Retrospective analysis of medical and pharmacy claims data from OptumLabs® Data Warehouse for commercially insured and Medicare Advantage adult beneficiaries with diabetes types 1 and 2, who filled any glucose-lowering medication between January 1, 2013 and December 31, 2016. Demographic (age, sex, race, income), clinical (comorbidities), and insurance-related factors affecting first prescription for a SGLT2i were examined using multivariable logistic regression. Results: Among 1,054,727 adults with pharmacologically treated diabetes, 7.2% (n = 75,500) initiated a SGLT2i. Patients with prior myocardial infarction (MI) (odds ratio [OR]: 0.94, 95% confidence interval [CI]: 0.91-0.96), heart failure (HF) (OR: 0.93, 95% CI: 0.91-0.94), kidney disease (OR: 0.80, 95% CI: 0.78-0.81), and severe hypoglycemia (OR: 0.96, 95% CI: 0.94-0.98) were all less likely to start a SGLT2i; P < 0.001 for all. SGLT2i were also less likely to be started by patients ≥75 years (OR: 0.57, 95% CI: 0.55-0.59, vs. 18-44 years), Black patients (OR: 0.93, 95% CI: 0.91-0.95, vs. White), and those with Medicare Advantage insurance (OR: 0.63, 95% CI: 0.62-0.64, vs. commercial). Conclusions: Younger, healthier, non-Black patients with commercial health insurance were most likely to start taking SGLT2i. Patients with MI, HF, kidney disease, and prior hypoglycemia were less likely to use SGLT2i, despite evidence supporting their preferential use in these patients. Efforts to address this treatment-risk paradox may help improve health outcomes among patients with type 2 diabetes.
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Affiliation(s)
- Rozalina G. McCoy
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Policy and Research, 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, Rochester, Minnesota
| | - Hayley J. Dykhoff
- Division of Health Care Policy and Research, 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, Rochester, Minnesota
| | - Lindsey Sangaralingham
- Division of Health Care Policy and Research, 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, Rochester, Minnesota
| | - Joseph S. Ross
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
| | - Pinar Karaca-Mandic
- Carlson School of Management, University of Minnesota, Minneapolis, Minnesota
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Victor M. Montori
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Nilay D. Shah
- Division of Health Care Policy and Research, 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, Rochester, Minnesota
- OptumLabs, Cambridge, Massachusetts
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Solotke MT, Ross JS, Shah ND, Karaca-Mandic P, Dhruva SS. Medicare Prescription Drug Plan Formulary Restrictions After Postmarket FDA Black Box Warnings. J Manag Care Spec Pharm 2019; 25:1201-1217. [PMID: 31663461 PMCID: PMC10397710 DOI: 10.18553/jmcp.2019.25.11.1201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The boxed warning (also known as "black box warning") is one of the FDA's strongest safety actions for pharmaceuticals. After the FDA issues black box warnings for drugs, prescribing changes have been inconsistent. Formulary management may provide an opportunity to restrict access to drugs with serious safety concerns. OBJECTIVE To examine Medicare prescription drug plan formulary changes after new FDA postmarket black box warnings and major updates to preexisting black box warnings. METHODS In this cohort study, we identified each drug that received a new FDA postmarket black box warning or a major update to a preexisting black box warning from January 2008 through June 2015 and examined its formulary coverage. The main outcome measure was the proportion of Medicare prescription drug plan formularies providing unrestrictive coverage immediately before the black box warning, at least 1 year after the warning and at least 2 years after the warning. Unrestrictive formulary coverage was defined as coverage of a drug without prior authorization or step-therapy requirements. RESULTS Of 101 new black box warnings and major updates to preexisting warnings affecting 68 unique drug formulations, the mean percentage of formularies providing unrestrictive coverage changed from 65.4% (95% CI = 59.6%-71.2%) prewarning; 62.6% (95% CI = 56.3%-68.9%, P = 0.04) at least 1 year postwarning; and 61.9% (95% CI = 55.4%-68.5%, P = 0.10) at least 2 years postwarning. CONCLUSIONS The mean percentage of Medicare prescription drug plan formularies providing unrestrictive coverage decreased modestly by approximately 3 percentage points after drugs received postmarket FDA black box warnings. Formulary restrictions may present an underused mechanism to reduce use of potentially unsafe medications. DISCLOSURES This study was supported by a student research grant received by Solotke and provided by the Yale School of Medicine Office of Student Research under National Institutes of Health training grant award T35DK104689. Karaca-Mandic, Shah, and Ross acknowledge support from Agency for Healthcare Research and Quality (AHRQ) grant R01 HS025164, which studies factors associated with de-adoption of drug therapies shown to be ineffective or unsafe. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors assume full responsibility for the accuracy and completeness of the ideas presented. Ross has received support from the following: the U.S. Food and Drug Administration (FDA) as part of the Centers for Excellence in Regulatory Science and Innovation (CERSI) program; Johnson and Johnson through Yale University to develop methods of clinical trial data sharing; Medtronic and the FDA to develop methods for postmarket surveillance of medical devices; the Blue Cross Blue Shield Association to better understand medical technology evaluation; the Centers for Medicare & Medicaid Services (CMS) to develop and maintain performance measures that are used for public reporting; the AHRQ to examine community predictors of health care quality; and the Laura and John Arnold Foundation, which established the Collaboration for Research Integrity and Transparency at Yale University. Shah has received support from the FDA as part of the CERSI program. In addition, he has received support through the Mayo Clinic from CMS, AHRQ, National Science Foundation, and Patient-centered Outcomes Research Institute. Karaca-Mandic has provided consulting services to Precision Health Economics and Tactile Medical for work unrelated to this manuscript. Dhruva and Solotke have no conflicts of interest to report.
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Affiliation(s)
| | - Joseph S. Ross
- National Clinician Scholars Program, Department of Internal Medicine, Yale University, New Haven, Connecticut; Section of General Internal Medicine, Department of Internal Medicine, Yale University, New Haven, Connecticut; Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut; and Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Nilay D. Shah
- Division of Health Care Policy and Research and Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Pinar Karaca-Mandic
- Carlson School of Management, Department of Finance, University of Minnesota, Minneapolis
| | - Sanket S. Dhruva
- Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Medical Center, and University of California, San Francisco, School of Medicine, San Francisco, California
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Jeffery MM, Hooten WM, Jena AB, Ross JS, Shah ND, Karaca-Mandic P. Rates of Physician Coprescribing of Opioids and Benzodiazepines After the Release of the Centers for Disease Control and Prevention Guidelines in 2016. JAMA Netw Open 2019; 2:e198325. [PMID: 31373650 PMCID: PMC6681551 DOI: 10.1001/jamanetworkopen.2019.8325] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [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: 11/24/2022] Open
Abstract
IMPORTANCE The Centers for Disease Control and Prevention guidelines in 2016 recommended avoiding concurrent use of opioids and benzodiazepines. OBJECTIVE To determine whether the release of the guidelines was associated with changes in coprescription of opioids and benzodiazepines. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used claims data obtained from a US national database of medical and pharmacy claims for 3 598 322 adult commercially insured patients and 1 299 142 Medicare Advantage (MA) beneficiaries with no recent history of cancer, sickle cell disease, or hospice care who ever used prescribed opioids during the study period, January 1, 2014, through March 31, 2018. EXPOSURES Overlapping opioid and benzodiazepine prescriptions filled. MAIN OUTCOMES AND MEASURES The extent (proportion of person-months with any overlapping days of prescription of opioids and benzodiazepines) and intensity (proportion of days with opioids prescribed where benzodiazepines were also available) of coprescription. RESULTS Of 4 897 464 patients (with 13.4 million person-months of opioid use), the total number of unique commercially insured individuals was 3 598 322 (1 974 731 women [54.9%]), and the total number of unique MA beneficiaries was 1 299 142 (770 256 women [59.3%]). Among 128 576 participants experiencing chronic pain episodes, more than one-half of person-months of long-term opioid use occurred in women (52.7% of person-months among those with commercial insurance and 62.4% of person-months among MA beneficiaries). The median (interquartile range) age of the participants was 51 (41-58) years for patients in the commercial insurance group and 70 (61-77) years for those in the MA group. The mean (SE) extent of coprescription was 23.0% (0.18%) for the commercial insurance group and 25.7% (0.18%) for the MA group. The extent of coprescription decreased in the targeted guideline population-individuals with long-term opioid use-after the guideline release (postguideline slope, -0.95 percentages point per year [95% CI, -1.44 to -0.46 percentage points per year] for the commercial insurance group and -1.06 percentage points per year [95% CI, -1.49 to -0.63 percentage points per year] for the MA group). Nontargeted short-term episodes of opioid use were associated with no change or small declines in trend (for the MA group, postguideline slope of 0.47 percentage point per year [95% CI, 0.35-0.59 percentage point per year]; for the commercial insurance group, postguideline slope of -0.05 percentage point per year [95% CI, -0.12 to 0.02 percentage point per year]). High coprescribing intensity was seen, with 79.3% (95% CI, 78.9%-79.6%) of opioid prescription days in the commercial insurance group and 83.9% (95% CI, 83.7%-84.2%) in the MA group overlapping with benzodiazepines. There was no change in the intensity of coprescribing. Intensity of coprescription was higher when the same clinician prescribed opioids and benzodiazepines. CONCLUSION AND RELEVANCE This study observed a reduction in the extent but not intensity of coprescribing of benzodiazepines for patients with long-term opioid use.
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Affiliation(s)
- Molly M. Jeffery
- Division of Health Care Policy Research, Mayo Clinic, Rochester, Minnesota
| | - W. Michael Hooten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anupam B. Jena
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Joseph S. Ross
- Section of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Nilay D. Shah
- Division of Health Care Policy Research, Mayo Clinic, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- OptumLabs, Cambridge, Massachusetts
| | - Pinar Karaca-Mandic
- National Bureau of Economic Research, Cambridge, Massachusetts
- Department of Finance, Carlson School of Management, University of Minnesota, Minneapolis
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Thornton Snider J, Brauer M, Kee R, Batt K, Karaca-Mandic P, Zhang J, Goldman DP. The potential impact of CAR T-cell treatment delays on society. Am J Manag Care 2019; 25:379-386. [PMID: 31419095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To date, breakthrough chimeric antigen receptor (CAR) T-cell therapies, such as tisagenlecleucel, indicated for pediatric acute lymphoblastic leukemia (pALL) and diffuse large B-cell lymphoma (DLBCL), and axicabtagene ciloleucel, indicated for DLBCL, although clinically effective, have been limited by treatment delays. Our study measured the social value of CAR T-cell therapy (CAR T) for relapsed or refractory pALL and DLBCL in the United States and quantified social value lost due to treatment delays. STUDY DESIGN We used an economic framework for therapy valuation, measuring social value as the sum of consumer surplus and manufacturer profit. Consumer surplus is the difference between the value of health gains from a therapy and its incremental cost, while accounting for indirect costs and benefits to patients. METHODS For 20 incident cohorts of pALL (n = 20 × 400 = 8000) and DLBCL (n = 20 × 5902 = 118,040), we quantified patient value, calculated as the value of additional quality-adjusted life-years gained with CAR T, minus the incremental cost of CAR T compared with standard of care (SOC). We calculated manufacturer profits using a range of production costs given uncertainties in the production process. Patient value and manufacturer profits were summed to obtain total social value. We measured social value lost from treatment delays, assuming that patients received the SOC while awaiting CAR T-cell treatment. RESULTS Depending on production costs, as much as $6.5 billion and $34.8 billion in social value was generated for patients with pALL and DLBCL, respectively. However, with 1, 2, or 6 months of treatment delay (assuming $200,000 production costs), the pALL population lost 9.8%, 36.2%, and 67.3% of social value, respectively, whereas the DLBCL population lost 4.2%, 11.5%, and 46.0%, relative to no delay. CONCLUSIONS The social value of CAR T is significantly limited by treatment delays. Efficient payment mechanisms, adequate capital, and payment policy reform are urgently needed to increase patient access and maximize the value of CAR T.
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MESH Headings
- Antigens, CD19/economics
- Antigens, CD19/therapeutic use
- Biological Products
- Drug Industry/economics
- Health Expenditures
- Humans
- Immunotherapy, Adoptive
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Models, Economic
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/drug therapy
- Quality-Adjusted Life Years
- Receptors, Antigen, T-Cell/antagonists & inhibitors
- Receptors, Antigen, T-Cell/therapeutic use
- Time-to-Treatment/economics
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Affiliation(s)
| | | | - Rebecca Kee
- Precision Health Economics, 1999 Harrison St, Ste 1420, Oakland, CA 94612.
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Weissblum L, Huckfeldt P, Escarce J, Karaca-Mandic P, Sood N. Skilled Nursing Facility Participation in Medicare's Bundled Payments for Care Improvement Initiative: A Retrospective Study. Arch Phys Med Rehabil 2019; 100:307-314. [PMID: 30291827 PMCID: PMC6348124 DOI: 10.1016/j.apmr.2018.08.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/13/2018] [Accepted: 08/26/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate differences in facility characteristics, patient characteristics, and outcomes between skilled nursing facilities (SNFs) that participated in Medicare's voluntary Bundled Payments for Care Improvement (BPCI) initiative and nonparticipants, prior to BPCI. DESIGN Retrospective, cross-sectional comparison of BPCI participants and nonparticipants. SETTING SNFs. PARTICIPANTS All Medicare-certified SNFs (N=15,172) and their 2011-2012 episodes of care for chronic obstructive pulmonary disease, congestive heart failure, femur and hip/pelvis fracture, hip and femur procedures, lower extremity joint replacement, and pneumonia (N=873,739). INTERVENTIONS Participation in a bundled payment program that included taking financial responsibility for care within a 90-day episode. MAIN OUTCOME MEASURES This study investigates the characteristics of bundled payment participants and their patient characteristics and outcomes relative to nonparticipants prior to BPCI, to understand the implications of a broader implementation of bundled payments. RESULTS SNFs participating in BPCI were more likely to be in urban areas (80.8%-98.4% vs 69.5%) and belong to a chain or system (73.8%-85.5% vs 55%), and were less likely to be located in the south (13.1%-20.2% vs 35.4%). Quality performance was similar or higher in most cases for SNFs participating in BPCI relative to nonparticipants. In addition, BPCI participants admitted higher socioeconomic status patients with similar clinical characteristics. Initial SNF length of stay was shorter and hospital readmission rates were lower for BPCI patients compared to nonparticipant patients. CONCLUSIONS We found that SNFs participating in the second financial risk-bearing phase of BPCI represented a diversity of SNF types, regions, and levels of quality and the results may provide insight into a broader adoption of bundled payment for postacute providers.
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Affiliation(s)
- Lianna Weissblum
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Peter Huckfeldt
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN
| | - José Escarce
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Pinar Karaca-Mandic
- Department of Finance, Carlson School of Management, University of Minnesota, Minneapolis, MN
| | - Neeraj Sood
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA.
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Barry CL, Bandara S, Arnold KT, Pintor JK, Baum LM, Niederdeppe J, Karaca-Mandic P, Fowler EF, Gollust SE. Assessing the Content of Television Health Insurance Advertising during Three Open Enrollment Periods of the ACA. J Health Polit Policy Law 2018; 43:961-989. [PMID: 31091327 PMCID: PMC6521724 DOI: 10.1215/03616878-7104392] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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] [Indexed: 06/09/2023]
Abstract
Television advertising has been a primary method for marketing new health plans available under the Affordable Care Act (ACA) to consumers. Data from Kantar Media's Campaign Media Analysis Group were used to analyze advertising content during three ACA open enrollment periods (fall 2013 to spring 2016). Few advertisement airings featured people who were elderly, disabled, or receiving care in a medical setting, and over time airings increasingly featured children, young adults, and people exercising. The most common informational messages focused on plan choice and availability of low-cost plans, but messages shifted over open enrollment cycles to emphasize avoidance of tax penalties and availability of financial assistance. Over the three open enrollment periods, there was a sharp decline in explicit mentions of the ACA or Obamacare in advertisements. Overall, television advertisements have increasingly targeted young, healthy consumers, and informational appeals have shifted toward a focus on financial factors in persuading individuals to enroll in marketplace plans. These advertising approaches make sense in the context of pressures to market plans to appeal to a sufficiently large, diverse group. Importantly, dramatic declines over time in explicit mention of the law mean that citizens may fail to understand the connection between the actions of government and the benefits they are receiving.
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Gollust SE, Wilcock A, Fowler EF, Barry CL, Niederdeppe J, Baum L, Karaca-Mandic P. TV Advertising Volumes Were Associated With Insurance Marketplace Shopping And Enrollment In 2014. Health Aff (Millwood) 2018; 37:956-963. [DOI: 10.1377/hlthaff.2017.1507] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Sarah E. Gollust
- Sarah E. Gollust is an associate professor in the Division of Health Policy and Management, School of Public Health, University of Minnesota, in Minneapolis
| | - Andrew Wilcock
- Andrew Wilcock is a postdoctoral fellow in the Department of Health Care Policy, Harvard Medical School, in Boston, Massachusetts
| | - Erika Franklin Fowler
- Erika Franklin Fowler is an associate professor in the Department of Government, Wesleyan University, in Middletown, Connecticut, and codirector of the Wesleyan Media Project
| | - Colleen L. Barry
- Colleen L. Barry is the Fred and Julie Soper Professor and Chair of the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland
| | - Jeff Niederdeppe
- Jeff Niederdeppe is an associate professor in the Department of Communication, Cornell University, in Ithaca, New York
| | - Laura Baum
- Laura Baum is project manager of the Wesleyan Media Project in the Department of Government, Wesleyan University
| | - Pinar Karaca-Mandic
- Pinar Karaca-Mandic is an associate professor in the Finance Department and academic director of the Medical Industry Leadership Institute, Carlson School of Management, University of Minnesota
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Snider JT, Brauer M, Batt K, Karaca-Mandic P, Zhang J, Goldman DP. The social value of tisagenlecleucel, a CAR-T cell therapy, for the treatment of relapsed or refractory pediatric acute lymphoblastic leukemia in the United States: What are consequences of treatment delays? J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.10529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | - Jie Zhang
- Novartis Pharmaceuticals, East Hanover, NJ
| | - Dana P. Goldman
- School of Policy, Planning, and Development, University of Southern California, Los Angeles, CA
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Rojanasarot S, Heins Nesvold J, Karaca-Mandic P, St Peter WL, Wolfson J, Schommer JC, Carlson AM. Enhancing guideline-based asthma care processes through a multi-state, multi-center quality improvement program. J Asthma 2018; 56:440-450. [PMID: 29641271 DOI: 10.1080/02770903.2018.1463378] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE This study investigated the effectiveness of Enhancing Care for Patients with Asthma (ECPA)-a collaborative quality improvement program implemented in 65 community health centers that serve asthma patients in four states-on clinic-based asthma performance measures consistent with national guidelines. METHODS This study utilized a pretest-posttest quasi-experimental design. Six clinic-based performance measures of each center were collected from a retrospective chart review at time points: before the ECPA implementation; at the end of the 12-month long ECPA program; and 6 months after program completion. The effectiveness of the ECPA was assessed using generalized linear mixed models with a Poisson distribution and log link by evaluating the change in each measure from baseline to program completion, from baseline to 6-month post-program completion and from program completion to 6-month post-program completion. RESULTS The ECPA implementation was positively associated with improvement in all measures from baseline to program completion: documentation of asthma severity (rate ratio (RR) 1.314; 95% confidence interval (CI) 1.206, 1.432); Asthma Control Test (RR 3.625; 95% CI 3.185, 4.124); pulmonary function testing (RR 1.771; 95% CI 1.527, 2.054), asthma education (RR 2.246; 95% CI 2.018, 2.501), asthma action plan (RR 2.335; 95% CI 2.070, 2.634) and controller medication (RR 1.961; 95% CI 1.504,2.556). Improvement was sustained for all six measures at the 6-month post-program completion time point. CONCLUSION This study demonstrated the favorable effect of the ECPA program on evidence-based asthma quality measures. This program could be considered a model worth replication on a broader scale.
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Affiliation(s)
- Sirikan Rojanasarot
- a Department of Pharmaceutical Care & Health Systems, College of Pharmacy , University of Minnesota , Minneapolis , Minnesota , USA
| | | | - Pinar Karaca-Mandic
- c Department of Finance , Carlson School of Management University of Minnesota , Minneapolis , Minnesota , USA
| | - Wendy L St Peter
- a Department of Pharmaceutical Care & Health Systems, College of Pharmacy , University of Minnesota , Minneapolis , Minnesota , USA
| | - Julian Wolfson
- d Division of Biostatistics, School of Public Health , University of Minnesota , Minneapolis , Minnesota , USA
| | - Jon C Schommer
- a Department of Pharmaceutical Care & Health Systems, College of Pharmacy , University of Minnesota , Minneapolis , Minnesota , USA
| | - Angeline M Carlson
- a Department of Pharmaceutical Care & Health Systems, College of Pharmacy , University of Minnesota , Minneapolis , Minnesota , USA.,e Data Intelligence Consultants, LLC , Eden Prairie , Minnesota , USA
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Huckfeldt PJ, Escarce JJ, Rabideau B, Karaca-Mandic P, Sood N. Less Intense Postacute Care, Better Outcomes For Enrollees In Medicare Advantage Than Those In Fee-For-Service. Health Aff (Millwood) 2018; 36:91-100. [PMID: 28069851 DOI: 10.1377/hlthaff.2016.1027] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [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
Traditional fee-for-service (FFS) Medicare's prospective payment systems for postacute care provide little incentive to coordinate care or control costs. In contrast, Medicare Advantage plans pay for postacute care out of monthly capitated payments and thus have stronger incentives to use it efficiently. We compared the use of postacute care in skilled nursing and inpatient rehabilitation facilities by enrollees in Medicare Advantage and FFS Medicare after hospital discharge for three high-volume conditions: lower extremity joint replacement, stroke, and heart failure. After accounting for differences in patient characteristics at discharge, we found lower intensity of postacute care for Medicare Advantage patients compared to FFS Medicare patients discharged from the same hospital, across all three conditions. Medicare Advantage patients also exhibited better outcomes than their FFS Medicare counterparts, including lower rates of hospital readmission and higher rates of return to the community. These findings suggest that payment reforms such as bundling in FFS Medicare may reduce the intensity of postacute care without adversely affecting patient health.
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Affiliation(s)
- Peter J Huckfeldt
- Peter J. Huckfeldt is an assistant professor in the Division of Health Policy and Management, School of Public Health, University of Minnesota, in Minneapolis
| | - José J Escarce
- José J. Escarce is a professor of medicine in the David Geffen School of Medicine, University of California, Los Angeles
| | - Brendan Rabideau
- Brendan Rabideau is a research programmer at the Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, in Los Angeles
| | - Pinar Karaca-Mandic
- Pinar Karaca-Mandic is an associate professor in the Division of Health Policy and Management, School of Public Health, University of Minnesota
| | - Neeraj Sood
- Neeraj Sood is a professor and vice dean for research at the Sol Price School for Public Policy and director of research at the Leonard D. Schaeffer Center for Health Policy and Economics, both at the University of Southern California
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Rockson SG, Gaebler JA, Lerman M, Izhakoff J, Gullet L, Karaca-Mandic P, Niecko T, Hoy SJ, O’Donnell T. Use of Advanced Pneumatic Compression Devices Confers a Cost-Effective Reduction of Medical Resource Utilization in Phlebolymphedema. J Vasc Surg Venous Lymphat Disord 2018. [DOI: 10.1016/j.jvsv.2017.12.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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