Identifying Measures of Suboptimal Healthcare Interaction (SOHI) to Develop a Claims-Based Model for Predicting Patients with Inflammatory Bowel Disease at Risk for SOHI.

BACKGROUND: Understanding the demographic and clinical characteristics of patients with Inflammatory Bowel Disease (IBD) who are likely to experience poor disease outcomes may allow early interventions that can improve health outcomes. OBJECTIVES: To describe demographic and clinical characteristics of patients with ulcerative colitis (UC) and Crohn's disease (CD) with the presence of at least one Suboptimal Healthcare Interaction (SOHI) event, which can inform the development of a model to predict SOHI in members with IBD based on insurance claims, with the goal of offering these patients some additional intervention. METHODS: We identified commercially insured individuals with IBD between 01 January 2019 and 31 December 2019 using Optum Labs' administrative claims database. The primary cohort was stratified on the presence or absence of ≥ 1 SOHI event (a SOHI-defining data point or characteristic at a specific time point) during the baseline observation period. SOHI was deployed as the basis for the development of a model to predict which individuals with IBD were most likely to continue to have SOHI within a 1-year timeframe (follow-up SOHI) using insurance claims data. All baseline characteristics were analyzed descriptively. Multivariable logistic regression was used to examine the association of follow-up SOHI with baseline characteristics. RESULTS: Of 19,824 individuals, 6872 (34.7%) were found to have follow-up SOHI. Individuals with follow-up SOHI were more likely to have had similar SOHI events in the baseline period than those with non-SOHI. A significantly greater proportion of individuals with SOHI had ≥ 1 claims-based C-reactive protein (CRP) test order and ≥ 1 CRP lab results compared with non-SOHI. Individuals with follow-up SOHI were more likely to incur higher healthcare expenditures and resource utilization as compared with non-SOHI individuals. A few of the most important variables used to predict follow-up SOHI included baseline mesalamine use, count of baseline opioid fills, count of baseline oral corticosteroid fills, baseline extraintestinal manifestations of disease, proxy for baseline SOHI, and index IBD provider specialty. CONCLUSION: Individuals with SOHI are likely to have higher expenditures, higher healthcare resource utilization, uncontrolled disease, and higher CRP lab results as compared with non-SOHI members. Distinguishing SOHI and non-SOHI patients in a dataset could efficiently identify potential cases of poor future IBD outcomes.

We have developed a model for identifying suboptimal healthcare interactions (SOHI) at follow-up and used it to predict the individuals with inflammatory bowel disease (IBD) who are likely to suffer poor healthcare outcomes. Our study showed that the SOHI and non-SOHI cohorts had notable differences in clinical baseline characteristics. Compared with non-SOHI members, individuals with SOHI experienced poor IBD outcomes and incurred higher healthcare resource utilization and costs. Understanding baseline characteristics of patients with SOHI to predict follow-up SOHI can improve health outcomes by early identification of patients with IBD who are likely to experience it. This can help in targeting efforts toward additional care, resulting in greater chances of a well-managed disease.

Risk Factors Associated with COVID-19 Hospitalization and Mortality: A Large Claims-Based Analysis Among People with Type 2 Diabetes Mellitus in the United States.

INTRODUCTION: Diabetes has been identified as a high-risk comorbidity for COVID-19 hospitalization. We evaluated additional risk factors for COVID-19 hospitalization and in-hospital mortality in a nationwide US database. METHODS: This retrospective study utilized the UnitedHealth Group Clinical Discovery Database (January 1, 2019-July 15, 2020) containing de-identified nationwide administrative claims, SARS-CoV-2 laboratory test results, and COVID-19 inpatient admissions data. Logistic regression was used to understand risk factors for hospitalization and in-hospital mortality among people with type 2 diabetes (T2D) and in the overall population. Robustness of associations was further confirmed by subgroup and sensitivity analyses in the T2D population. RESULTS: A total of 36,364 people were identified who were either SARS-CoV-2+ or hospitalized for COVID-19. T2D was associated with increased COVID-19-related hospitalization and mortality. Factors associated with increased hospitalization risk were largely consistent in the overall population and the T2D subgroup, including age, male sex, and these top five comorbidities: dementia, metastatic tumor, congestive heart failure, paraplegia, and metabolic disease. Biguanides (mainly metformin) were consistently associated with lower odds of hospitalization, whereas sulfonylureas and insulins were associated with greater odds of hospitalization among people with T2D. CONCLUSION: In this nationwide US analysis, T2D was identified as an independent risk factor for COVID-19 complications. Many factors conferred similar risk of hospitalization across both populations; however, particular diabetes medications may be markers for differential risk. The insights on comorbidities and medications may inform population health initiatives, including prevention efforts for high-risk patient populations such as those with T2D.

Predictors of high-cost managed care patients with acute coronary syndrome.

OBJECTIVE: To develop predictive models of high-cost acute coronary syndrome (ACS) patients using demographic, disease, and treatment characteristics. STUDY DESIGN: This was a retrospective, administrative claims analysis utilizing pharmacy, medical, and eligibility data from a large US managed care organization. METHODS: ACS was defined by ICD-9 codes for unstable angina (UA) or acute myocardial infarction (AMI). New onset patients (without ACS claims) in the prior six months were identified for the time period 07/01/99-06/30/01, and followed up to 12 months, health plan disenrollment, or death. Cost was measured as that incurred during the initial episode plus subsequent follow-up or during the subsequent follow-up only. Patients were dichotomized as high-cost (top 20%) or low-cost (bottom 80%), based on total costs. Logistic regression was used to examine the association for being classified as high-cost. RESULTS: A total of 13 731 patients were included: 51.7% with UA, 39.6% with AMI and 8.7% with both UA and AMI. The mean age was 54.2 years and 68.2% were male. A number of co-morbidities (hypertension, diabetes, heart failure, etc.) predicted high-cost patients. Among medications, prior ACE inhibitor use predicted high-cost patients. While revascularization procedures, in general, were strong predictors of high-cost, revascularization during the index ACS episode (opposed to revascularization during the follow-up) decreased the odds of being high-cost (odds ratio [95% CI] 0.615 [0.506-0.748]). CONCLUSION: High-cost patients with new onset ACS can be predicted by some characteristics, but many of these characteristics are non-modifiable co-morbidities. Payers and providers may find opportunities for clinical and cost-saving interventions for these patients.

Cost of care for new-onset acute coronary syndrome patients who undergo coronary revascularization.

OBJECTIVES: This study examines demographic, health characteristics, and total health care utilization in acute coronary syndrome (ACS) patients who underwent coronary revascularization within the first year of follow-up. BACKGROUND: Revascularization during or after the index ACS event is becoming more common, and it is important to further characterize these patients. METHODS: A retrospective claims analysis was conducted (July 1, 1999-June 30, 2001) with new onset ACS patients, defined as an emergency room visit or hospitalization with an ICD-9 code for unstable angina (UA) or acute myocardial infarction (AMI), but without an ACS claim in the previous 6 months. Patients were followed up to 12 months to identify total resource utilization (medical, pharmacy, revascularization procedures). RESULTS: A total of 6,929 patients were included and 69% had revascularization performed during the index hospitalization. Mean age was 55 years; 72.9% were male. Revascularization was percutaneous coronary intervention (PCI) in 5,002 and bypass surgery in 1,927. The index ACS event was AMI in 48.9%; 13.5% had both AMI and UA. Total first-year cost was 210.7 million dollars (30,402 dollars per patient); hospitalization costs were 161.7 million dollars (23,331 dollars per patient). During follow-up, 75.5% received a statin, 75.8% a beta-blocker, and 63.5% of all patients received clopidogrel (84.8% of PCI patients). Mean days of clopidogrel therapy were 83.5. CONCLUSIONS: Early revascularization is a frequent therapeutic strategy in these relatively young managed care patients. The majority of costs were medical and a majority of procedures were PCI. Many patients experienced AMI as their initial cardiovascular event. Drug utilization of statins, beta-blockers, and clopidogrel, according to practice guidelines, was acceptable.

Dose adjustment over time of etanercept and infliximab in patients with rheumatoid arthritis.

Dose escalation of biologics in patients with rheumatoid arthritis may affect the cost of care. Longitudinal claims data from a large U.S. health plan were analyzed retrospectively. A total of 4,426 health plan members had a medication claim for either etanercept (N = 690; mean age, 48.4 yr; 72% female) or infliximab (N = 424; mean age, 54.3 yr; 73% female) during the selection period. The study revealed that the mean dosage in patients receiving infliximab for rheumatoid arthritis symptoms increased by 29% from first to last dose. The mean weekly dosage for etanercept remained stable. Etanercept was associated with a significantly lower hazard of dose increase relative to infliximab. The estimated annual costs of infliximab and its administration varied by 31%, whereas the estimated costs of etanercept remained stable over time. This increased dose of infliximab may translate into increased costs for a payer over time.

Total first-year costs of acute coronary syndrome in a managed care setting.

OBJECTIVE: There is a limited amount of literature examining the burden and cost of illness of acute coronary syndrome (ACS) in the managed care population. The goal of this study was to estimate the total cost of health care utilization (health plan plus patient) in the 12-month period following newly onset ACS. The demographic and health characteristics of these patients are compared with the similar data from 2 large clinical trials: CURE (Clopidogrel in Unstable Angina to Prevent Recurrent Events) and PROVE IT-TIMI 22 (Pravastatin or Atorvastatin Evaluation and Infection Therapy--Thrombolysis in Myocardial Infarction 22). METHODS: A retrospective claims analysis was conducted for the 2-year period from July 1, 1999, through June 30, 2001. ACS was defined as an emergency room visit or hospitalization with a primary International Classification of Diseases, 9th Edition/Revision (ICD-9) diagnosis of 410.xx (acute myocardial infarction) or 411.1x (intermediate coronary syndrome). Patients were required to be free of any ACS claim in the previous 6 months. Patients without 6 months of prior continuous enrollment or those patients younger than 18 years were excluded. Patients were followed up to 12 months to identify total medical and pharmacy costs, revascularization procedures, and medication use. RESULTS: A total of 13,731 patients met the inclusion criteria, yielding 133,814 months of follow-up (mean: 9.75 months per patient) and representing approximately 0.4% of the managed care members in the database during the study period. The mean age was 54 years and 68% were male. The total direct cost incurred by the health plan and patients was dollar 309 million (dollar 2,312 per patient-month of follow-up); 72% of total costs were attributable to hospitalizations. The majority of costs were medical (dollar 286 million, 93%), and dollar 23 million (7%) were pharmacy costs. Fifty-one percent of patients had a revascularization procedure, which was typically performed during the index hospitalization (median time to revascularization was 0 days). Coronary artery stent implantation was the most common revascularization procedure (68%). During follow-up, 490 patients (3.6%) had a detectable death, 58% of patients received a beta-blocker, 60% received one or more cholesterol-lowering medications, and 36% of patients received clopidogrel therapy. Aspirin therapy was not measured. CONCLUSIONS: These managed-care patients with newly onset ACS incurred substantial costs in the 12 months following initial presentation. Revascularization was a common therapeutic intervention for these patients. There appear to be opportunities to improve medication therapy after an acute ACS event. There were some demographic and health characteristics that were different in these commercially insured patients from those in 2 large clinical trials.

Costs and utilization of triptan users who receive drug prophylaxis for migraine versus triptan users who do not receive drug prophylaxis.

OBJECTIVES: The objectives were 2-fold: (1) to describe the utilization patterns of new users of triptan therapy and (2) to measure the direct (pharmacy and medical) costs of migraine-related health care services in moderate-to-severe migraine patients treated with drug prophylaxis compared with migraine patients who are not treated with drug prophylaxis. METHODS: A retrospective administrative database study was conducted from the perspective of a managed care health plan. Patients initiating triptan therapy were identified, and utilization in the 12 months following initiation of drug therapy was determined. In addition, moderate-to-severe migraine patients were identified based on the quantity of triptan medication dispensed. Patients were classified as utilizing or not utilizing migraine prophylaxis. Migraine-specific health services costs in the 12 months following identification were determined. A multivariate ordinary least squares regression model was constructed to determine the impact of the use of drug prophylaxis on total cost. Utilizing the model, the difference in health services costs was predicted for each subject and the average treatment effect was computed. RESULTS: Thirty-nine percent of new triptan users received only 1 triptan claim during the 12-month follow-up period, accounting for 11.5% of the total triptan cost incurred by the health plan for this cohort. For new triptan users, triptan use in the first or second quarter was correlated with triptan use in the entire 12-month follow-up period (r = 0.187 and 0.279, respectively). The mean migrainerelated pharmacy cost per patient during the follow-up was $871; however, continuous users had mean costs ($1,505) nearly 3 times the mean costs for new users ($506, P<0.05). The average treatment effect of drug prophylaxis in moderate-to-severe migraine patients was a decrease of $560 ($514-$607) per patient per year in 1998-2001 dollars. CONCLUSION: High utilizers of migraine therapy can be identified early in treatment. Drug prophylaxis for migraine is cost saving, and an intervention program that increases the use of migraine prophylaxis in potential candidates could be cost beneficial.

Cost-effectiveness analysis of pharmaceutical care in a medicare drug benefit program.

OBJECTIVES: Although there has recently been substantial interest in a Medicare drug benefit program, little attention has focused on ensuring improved access to medication monitoring for Medicare beneficiaries. Using a societal perspective, we evaluated the impact pharmacists could have on inappropriate prescribing, patient compliance, and medication-related morbidity and mortality within a Medicare drug benefits program. METHODS: A cost-effectiveness analysis from a societal perspective was performed. A comprehensive MEDLINE search for relevant literature identified data sources and model parameters. RESULTS: In the base case, a pharmaceutical care benefit in the elderly population would cost US dollars 2100 (year 2000 prices) per life-year saved, which is highly cost-effective. Reasonable changes in model parameters did not raise the cost-effectiveness ratio above US dollars 13000 per life-year saved. CONCLUSION: Despite limitations in both the quantity and the specificity of data available, pharmaceutical care appears to be a highly cost-effective augmentation to a Medicare drug benefit program. This result is robust to model parameter changes. This model is conservative in that it does not include ongoing benefits from medication monitoring or increased elderly drug utilization and polypharmacy as the Medicare drug program is phased in.