Racial and social inequities in medication use: A review of articles responding to the Journal of Managed Care + Specialty Pharmacy's Call to Action.

This article provides a summary of Viewpoint and Research articles responding to the 2020 Journal of Managed Care + Specialty Pharmacy Call to Action to address racial and social inequities in medication use. We find great heterogeneity in terms of topic, clinical condition examined, and health disparity addressed. Common recommendations across Viewpoint articles include the need to increase racial and ethnic diversity in clinical trial participants, the need to address drug affordability and health insurance literacy, and the need to incentivize providers and plans to participate in diversity initiatives, such as the better capture of information on social determinants of health (SDOH) in claims data to be able to address SDOH needs. Across research articles, we also find a large range of approaches and study designs, spanning from randomized controlled trials to surveys to observational studies. These articles identify disparities in which minoritized beneficiaries are shown to be less likely to receive medications and vaccines, as well as less likely to be adherent to medications, across a variety of conditions. Finally, we discuss Healthy People 2030 as a potential framework for future health disparity researchers.

Association between a national behavioral weight management program and real-world weight change.

OBJECTIVE: In a national cohort of Veterans, weight change was compared between participants in a US Department of Veterans Affairs (VA) behavioral weight management program (MOVE!) and matched non-participants, and between high-intensity and low-intensity participants. METHODS: Retrospective cohort study of Veterans with 1 + MOVE! visits in 2008-2017 were matched to MOVE! non-participants via sequential stratification. Percent weight change up to two years after MOVE! initiation of participants and non-participants was modeled using generalized additive mixed models, and 1-year weight change of high-intensity or low-intensity participants was also compared. RESULTS: MOVE! participants (n = 499,696) and non-participant controls (n = 1,336,172) were well-matched, with an average age of 56 years and average BMI of 35. MOVE! participants lost 1.4 % at 12 months and 1.2 % at 24 months, which was 0.89 % points (95 % CI: 0.83-0.96) more at 12 months than non-participants and 0.55 % points (95 % CI: 0.41-0.68) more at 24 months. 9.1 % of MOVE! participants had high-intensity use in one year, and they had 2.38 % point (95 % CI: 2.25-2.52) greater weight loss than low-intensity participation at 12 months (2.8 % vs 0.4 %). CONCLUSIONS: Participation in VA's system-wide behavioral weight management program (MOVE!) was associated with modest weight loss, suggesting that program modifications are needed to increase Veteran engagement and program effectiveness. Future research should further explore how variations in program delivery and the use of newer anti-obesity medications may impact the program's effectiveness.

Racial and ethnic disparities related to the Medicare Part D Medication Therapy Management Program.

Medicare's Part D Medication Therapy Management (MTM) programs serve approximately 4.5 million eligible beneficiaries. Prior research suggested that the thresholds to enter Part D MTM programs would disproportionately favor White beneficiaries compared with Black or Hispanic beneficiaries. This article summarizes those initial studies and compares the results with more recent analyses of racial and ethnic differences in MTM program enrollment, which, in general, show higher odds of MTM enrollment for minority beneficiaries compared with White beneficiaries. Disparities in the utilization of comprehensive medication review (CMR), a core MTM service, are also discussed. Although trends vary, disparities exist for various minority groups. For example, Black beneficiaries and Hispanic beneficiaries are less likely to be offered a CMR compared with White beneficiaries. Additionally, minority (Asian, Hispanic, and North American Native) beneficiaries are less likely to receive a CMR after being offered the service compared with White beneficiaries. Black, Hispanic, and Asian beneficiaries are more likely than White beneficiaries to have a longer duration between MTM enrollment and CMR offer. There is also a distinct difference in the type of pharmacist (ie, plan pharmacist, MTM vendor pharmacist, or community pharmacist) completing the CMR for certain racial and ethnic groups. For example, compared with White beneficiaries, Black beneficiaries were less likely to receive a CMR from a community pharmacist, whereas Asian beneficiaries were more likely.

Impact of comprehensive medication reviews on potentially inappropriate medication discontinuation in Medicare beneficiaries.

BACKGROUND: The use of potentially inappropriate medications (PIMs) is associated with increased risk of hospitalizations and emergency room visits and varies by racial and ethnic subgroups. Medicare's nationwide medication therapy management (MTM) program requires that Part D plans offer an annual comprehensive medication review (CMR) to all beneficiaries who qualify, and provides a platform to reduce PIM use. The objective of this study was to assess the impact of CMR on PIM discontinuation in Medicare beneficiaries and whether this differed by race or ethnicity. METHODS: Retrospective cohort study of community-dwelling Medicare Part D beneficiaries ≥66 years of age who were eligible for MTM from 2013 to 2019 based on 5% Medicare fee-for-service claims data linked to the 100% MTM data file. Among those using a PIM, MTM-eligible CMR recipients were matched to non-recipients via sequential stratification. The probability of PIM discontinuation was estimated using regression models that pooled yearly subcohorts accounting for within-beneficiary correlations. The most common PIMs that were discontinued after CMR were reported. RESULTS: We matched 24,368 CMR recipients to 24,368 CMR non-recipients during the observation period. Median age was 74-75, 35% were males, most were White beneficiaries (86%-87%), and the median number of PIMs was 1. In adjusted analyses, CMR receipt was positively associated with PIM discontinuation (adjusted relative risk [aRR]: 1.26, 95% CI: 1.20-1.32). There was no evidence of differential impact of CMR by race or ethnicity. The PIMs most commonly discontinued after CMR were glimepiride, zolpidem, digoxin, amitriptyline, and nitrofurantoin. CONCLUSIONS: Among Medicare beneficiaries who are using a PIM, CMR receipt was associated with PIM discontinuation, suggesting that greater CMR use could facilitate PIM reduction for all racial and ethnic groups.

Comprehensive Medication Review Completion Rates and Disparities After Medicare Star Rating Measure.

Importance: Comprehensive medication reviews (CMRs) are offered to qualifying US Medicare beneficiaries annually to optimize medication regimens and therapeutic outcomes. In 2016, Medicare adopted CMR completion as a Star Rating quality measure to encourage the use of CMRs. Objective: To examine trends in CMR completion rates before and after 2016 and whether racial, ethnic, and socioeconomic disparities in CMR completion changed. Design, Setting, and Participants: This observational study using interrupted time-series analysis examined 2013 to 2020 annual cohorts of community-dwelling Medicare beneficiaries aged 66 years and older eligible for a CMR as determined by Part D plans and by objective minimum eligibility criteria. Data analysis was conducted from September 2022 to February 2024. Exposure: Adoption of CMR completion as a Star Rating quality measure in 2016. Main Outcome and Measures: CMR completion modeled via generalized estimating equations. Results: The study included a total of 561 950 eligible beneficiaries, with 253 561 in the 2013 to 2015 cohort (median [IQR] age, 75.8 [70.7-82.1] years; 90 778 male [35.8%]; 6795 Asian [2.7%]; 24 425 Black [9.6%]; 7674 Hispanic [3.0%]; 208 621 White [82.3%]) and 308 389 in the 2016 to 2020 cohort (median [IQR] age, 75.1 [70.4-80.9] years; 126 730 male [41.1%]; 8922 Asian [2.9%]; 27 915 Black [9.1%]; 7635 Hispanic [2.5%]; 252 781 White [82.0%]). The unadjusted CMR completion rate increased from 10.2% (7379 of 72 225 individuals) in 2013 to 15.6% (14 185 of 90 847 individuals) in 2015 and increased further to 35.8% (18 376 of 51 386 individuals) in 2020, in part because the population deemed by Part D plans to be MTM-eligible decreased by nearly half after 2015 (90 487 individuals in 2015 to 51 386 individuals in 2020). Among a simulated cohort based on Medicare minimum eligibility thresholds, the unadjusted CMR completion rate increased but to a lesser extent, from 4.4% in 2013 to 12.6% in 2020. Compared with White beneficiaries, Asian and Hispanic beneficiaries experienced greater increases in likelihood of CMR completion after 2016 but remained less likely to complete a CMR. Dual-Medicaid enrollees also experienced greater increases in likelihood of CMR completion as compared with those without either designation, but still remained less likely to complete CMR. Conclusion and Relevance: This study found that adoption of CMR completion as a Star Rating quality measure was associated with higher CMR completion rates. The increase in CMR completion rates was achieved partly because Part D plans used stricter eligibility criteria to define eligible patients. Reductions in disparities for eligible Asian, Hispanic, and dual-Medicaid enrollees were seen, but not eliminated. These findings suggest that quality measures can inform plan behavior and could be used to help address disparities.

Deprescribing in older adults with polypharmacy.

Polypharmacy is common in older adults and is associated with adverse drug events, cognitive and functional impairment, increased healthcare costs, and increased risk of frailty, falls, hospitalizations, and mortality. Many barriers exist to deprescribing, but increased efforts have been made to develop and implement deprescribing interventions that overcome them. This narrative review describes intervention components and summarizes findings from published randomized controlled trials that have tested deprescribing interventions in older adults with polypharmacy, as well as reports on ongoing trials, guidelines, and resources that can be used to facilitate deprescribing. Most interventions were medication reviews in primary care settings, and many contained components such as shared decision making and/or a focus on patient care priorities, training for healthcare professionals, patient facing education materials, and involvement of family members, representing great heterogeneity in interventions addressing polypharmacy in older adults. Just over half of study interventions were found to perform better than usual care in at least one of their primary outcomes, and most study interventions were assessed over 12 months or less.

Differences in healthcare costs over 10 years following discharge from military service by weight trajectory.

The prevalence of overweight and obesity among military personnel has increased substantially in the past two decades. Following military discharge many personnel can receive integrated health care from the Veterans Health Administration. Prior research related to the economic impacts of obesity has not examined health care costs following the transition into civilian life following military discharge. To address this evidence gap, this study sought to compare longitudinal costs over 10 years across weight categories among VA enrollees recently discharged from the military.

Association Between a National Behavioral Weight Management Program and Veterans Affairs Health Expenditures.

OBJECTIVE: The association between participation in a behavioral weight intervention and health expenditures has not been well characterized. We compared Veterans Affairs (VA) expenditures of individuals participating in MOVE!, a VA behavioral weight loss program, and matched comparators 2 years before and 2 years after MOVE! initiation. METHODS: Retrospective cohort study of Veterans who had one or more MOVE! visits in 2008-2017 who were matched contemporaneously to up to 3 comparators with overweight or obesity through sequential stratification on an array of patient characteristics, including sex. Baseline patient characteristics were compared between the two cohorts through standardized mean differences. VA expenditures in the 2 years before MOVE! initiation and 2 years after initiation were modeled using generalized estimating equations with a log link and distribution with variance proportional to the standard deviation (gamma). RESULTS: MOVE! participants (n=499,696) and comparators (n=1,336,172) were well-matched, with an average age of 56, average body mass index of 35, and similar total VA expenditures in the fiscal year before MOVE! initiation ($9662 for MOVE! participants and $10,072 for comparators, standardized mean difference=-0.019). MOVE! participants had total expenditures that were statistically lower than matched comparators in the 6 months after initiation but modestly higher in the 6 months to 2 years after initiation, though differences were small in magnitude (1.0%-1.6% differences). CONCLUSIONS: The VA's system-wide behavioral weight intervention did not realize meaningful short-term health care cost savings for participants.

Patient Risk-Benefit Preferences for Transcatheter Versus Surgical Mitral Valve Repair.

BACKGROUND: Transcatheter edge-to-edge repair (TEER) of mitral regurgitation is less invasive than surgery but has greater 5-year mortality and reintervention risks, and leads to smaller improvements in physical functioning. The study objective was to quantify patient preferences for risk-benefit trade-offs associated with TEER and surgery. METHODS AND RESULTS: A discrete choice experiment survey was administered to patients with mitral regurgitation. Attributes included procedure type; 30-day mortality risk; 5-year mortality risk and physical functioning for 5 years; number of hospitalizations in the next 5 years; and risk of additional surgery in the next 5 years. A mixed-logit regression model was fit to estimate preference weights. Two hundred one individuals completed the survey: 63% were female and mean age was 74 years. On average, respondents preferred TEER over surgery. To undergo a less invasive procedure (ie, TEER), respondents would accept up to a 13.3% (95% CI, 8.7%-18.5%) increase in reintervention risk above a baseline of 10%, 4.6 (95% CI, 3.1-6.2) more hospitalizations above a baseline of 1, a 10.7% (95% CI, 6.5%-14.5%) increase in 5-year mortality risk above a baseline of 20%, or more limited physical functioning representing nearly 1 New York Heart Association class (0.7 [95% CI, 0.4-1.1]) over 5 years. CONCLUSIONS: Patients in general preferred TEER over surgery. When holding constant all other factors, a functional improvement from New York Heart Association class III to class I maintained over 5 years would be needed, on average, for patients to prefer surgery over TEER.

Real World Use of Anti-Obesity Medications and Weight Change in Veterans.

BACKGROUND: Anti-obesity medications (AOMs) can be initiated in conjunction with participation in the VA national behavioral weight management program, MOVE!, to help achieve clinically meaningful weight loss. OBJECTIVE: To compare weight change between Veterans who used AOM + MOVE! versus MOVE! alone and examine AOM use, duration, and characteristics associated with longer duration of use. DESIGN: Retrospective cohort study using VA electronic health records. PARTICIPANTS: Veterans with overweight or obesity who participated in MOVE! from 2008-2017. MAIN MEASURES: Weight change from baseline was estimated using marginal structural models up to 24 months after MOVE! initiation. The probability of longer duration of AOM use (≥ 180 days) was estimated via a generalized linear mixed model. RESULTS: Among MOVE! participants, 8,517 (1.6%) used an AOM within 24 months after MOVE! initiation with a median of 90 days of cumulative supply. AOM + MOVE! users achieved greater weight loss than MOVE! alone users at 6 (3.2% vs. 1.6%, p < 0.001), 12 (3.4% vs. 1.4%, p < 0.001), and 24 months (2.7% vs. 1.5%, p < 0.001), and had a greater probability of achieving ≥ 5% weight loss at 6 (38.8% vs. 26.0%, p < 0.001), 12 (43.1% vs. 28.4%, p < 0.001), and 24 months (40.4% vs. 33.3%, p < 0.001). Veterans were more likely to have ≥ 180 days of supply if they were older, exempt from medication copays, used other medications with significant weight-gain, significant weight-loss, or modest weight-loss side effects, or resided in the West North Central or Pacific regions. Veterans were less likely to have ≥ 180 days of AOM supply if they had diabetes or initiated MOVE! later in the study period. CONCLUSIONS: AOM use following MOVE! initiation was uncommon, and exposure was time-limited. AOM + MOVE! was associated with a higher probability of achieving clinically significant weight loss than MOVE! alone.

A primer on brand-name prescription drug reimbursement in the United States.

Branded prescription drug reimbursement in the United States is complex and comprises multiple transactions among the parties involved in the drug supply chain, including manufacturers, wholesalers, pharmacies, health care providers, health plans or insurers, pharmacy benefit managers, and patients. This primer provides an overview of the parties involved in the reimbursement of brand-name drugs under both the pharmacy and medical benefits of an insurance policy and the flow of products and payments among them. Prescription drug spending in the United States grew from $30 billion in 1980 to $335 billion in 2018, and 80% of spending is on brand-name drugs.1,2 Pharmaceutical spending and drug prices have been the focus of intense debate in recent years, which has brought attention to the complexity of the drug supply chain. This primer provides a high-level overview of the distribution and reimbursement of brand-name drugs (italicized words are defined in the Glossary) used in the outpatient setting and covered by health plans or insurers in the United States. The focus is on the parties involved and the flow of products and payments among them. The purchase of drug products outside of insurance and differences in drug reimbursement between private and public insurers are outside of the scope of this primer.

Mapping potentially inappropriate medications in older adults using the Anatomical Therapeutic Chemical (ATC) classification system.

BACKGROUND: Potentially inappropriate medications (PIMs) in older adults are medications in which risks often outweigh benefits and are suggested to be avoided. Worldwide, many distinct guidelines and tools classify PIMs in older adults. Collating these guidelines and tools, mapping them to a medication classification system, and creating a crosswalk will enhance the utility of PIM guidance for research and clinical practice. METHODS: We used the Anatomical Therapeutic Chemical (ATC) Classification System, a hierarchical classification system, to map PIMs from eight distinct guidelines and tools (2019 Beers Criteria, Screening Tool for Older Person's Appropriate Prescriptions [STOPP], STOPP-Japan, German PRISCUS, European Union-7 Potentially Inappropriate Medication [PIM] list, Centers for Medicare & Medicaid Services [CMS] High-Risk Medication, Anticholinergic Burden Scale, and Drug Burden Index). Each PIM was mapped to ATC Level 5 (drug) and to ATC Level 4 (drug class). We then used the crosswalk (1) to compare PIMs and PIM drug classes across guidelines and tools to determine the number of PIMs that were index (drug-induced adverse event) or marker (treatment of drug-induced adverse event) drug of prescribing cascades, and (2) estimate the prevalence of PIM use in older adults continuously enrolled with fee-for-service Medicare in 2018 as use cases. Data visualization and descriptive statistics were used to assess guidelines and tools for both use cases. RESULTS: Out of 480 unique PIMs identified, only three medications-amitriptyline, clomipramine, and imipramine and two drug classes-N06AA (tricyclic antidepressants) and N06AB (selective serotonin reuptake inhibitors), were noted in all eight guidelines and tools. Using the crosswalk, 50% of classes of index drugs and 47% of classes of marker drugs of known prescribing cascades were PIMs. Additionally, 88% of Medicare beneficiaries were dispensed ≥1 PIM across the eight guidelines and tools. CONCLUSION: We created a crosswalk of eight PIM guidelines and tools to the ATC classification system and created two use cases. Our findings could be used to expand the ease of PIM identification and harmonization for research and clinical practice purposes.

Impact of medication therapy management programs on potentially inappropriate medication use in older adults: A systematic review.

BACKGROUND: The use of potentially inappropriate medications (PIMs) is prevalent, costly, and harmful for older adults. These medications are to be avoided among older adults because they generally have (1) a high risk of adverse events in this population and/or (2) limited evidence of benefits in the presence of safer or more effective alternatives. Medication therapy management (MTM) programs can help address PIM use; however, there has not been a synthesis of studies examining the impact of MTM programs on PIM use. OBJECTIVE: To review published literature evaluating the impact of MTM on PIM use in older adults. METHODS: A systematic literature review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines using MEDLINE (PubMed) studies were included if they (1) had a Medicare population, (2) were based in the United States, (3) examined an MTM program (ie, used the term "medication therapy management"), (4) focused on the impact of MTM programs on PIM use as the primary outcome, (5) had a randomized controlled trial or an observational study design, and (6) were available in English. RESULTS: Of 221 articles identified, 31 full-text articles were assessed, and 7 met all inclusion and exclusion criteria. The studies took place in various settings, ranging from single-site tertiary medical centers to multisite outpatient clinics, community pharmacies, and nationwide telehealth MTM providers. Patient populations were majority female sex (ranging from 61% to 71%) and majority White (ranging from 81% to 94%), with a mean age of 73 to 78 years. In 5 of the 7 studies, MTM reduced the use of PIMs; however, 3 did not adjust for confounding or apply a comparator group. Measurement of MTM impacts on PIM use varied across studies. Patient-level and plan-level studies mostly assessed shorter-term PIM usage reduction (4 months or less), whereas studies performed at the provider and institutional level assessed PIM usage reduction trends across consecutive measurement years. CONCLUSIONS: Based on the current limited evidence, MTM programs in older adults appear to have a positive impact on reducing PIM use. However, evidence was limited by study design, the lack of consistency in outcome measures, and a short follow-up period. Future work should adjust for confounding, apply comparator groups, include longer-term outcomes, and develop a core set of measures that can be consistently applied across studies.

Development and Validation of a Tool to Identify Patients Diagnosed With Castration-Resistant Prostate Cancer.

PURPOSE: Several novel therapies for castration-resistant prostate cancer (CRPC) have been approved with randomized phase III studies with continuing observational research either planned or ongoing. Accurately identifying patients with CRPC in electronic health care data is critical for quality observational research, resource allocation, and quality improvement. Previous work in this area has relied on either structured laboratory results and medication data or natural language processing (NLP) methods. However, a computable phenotype using both structured data and NLP identifies these patients with more accuracy. METHODS: The Corporate Data Warehouse (CDW) of the Veterans Health Administration (VHA) was used to collect PCa diagnoses, prostate-specific antigen test results, and information regarding patient characteristics and medication use. The final system used for validation and subsequent analysis combined the NLP system and an algorithm of structured laboratory and medication data to identify patients as being diagnosed with CRPC. Patients with both a documented diagnosis of CRPC and a documented diagnosis of metastatic PCa were classified as having mCRPC by this system. RESULTS: Among 1.2 million veterans with PCa, the International Classification of Diseases (ICD)-10 diagnosis code for CRPC (Z19.2) identifies 3,791 patients from 2016 when the code was created until 2022, compared with the combined algorithm which identifies 14,103, 10,312 more than ICD-10 codes alone, from 2016 to 2022. The combined algorithm showed a sensitivity of 97.9% and a specificity of 99.2%. CONCLUSION: ICD-10 codes proved to be insufficient for capturing CRPC in the VHA CDW data. Using both structured and unstructured data identified more than double the number of patients compared with ICD-10 codes alone. Application of this combined approach drastically improved identification of real-world patients and enables high-quality observational research in mCRPC.

Patient Preferences for Postmastectomy Breast Reconstruction.

Importance: Up to 40% of women experience dissatisfaction after breast reconstruction due to unexpected outcomes that are poorly aligned with personal preferences. Identifying what attributes patients value when considering surgery could improve shared decision-making. Adaptive choice-based conjoint (ACBC) analysis can elicit individual-level treatment preferences. Objectives: To identify which attributes of breast reconstruction are most important to women considering surgery and to describe how these attributes differ by those who prefer flap vs implant reconstruction. Design, Setting, and Participants: This web-based, cross-sectional study was conducted from March 1, 2022, to January 31, 2023, at Duke University and between June 1 and December 31, 2022, through the Love Research Army with ACBC analysis. Participants were 105 women at Duke University with a new diagnosis of or genetic predisposition to breast cancer who were considering mastectomy with reconstruction and 301 women with a history of breast cancer or a genetic predisposition as identified through the Love Research Army registry. Main Outcomes and Measures: Relative importance scores, part-worth utility values, and maximum acceptable risks were estimated. Results: Overall, 406 women (105 from Duke University [mean (SD) age, 46.3 (10.5) years] and 301 from the Love Research Army registry [mean (SD) age, 59.2 (11.9) years]) participated. The attribute considered most important was the risk of abdominal morbidity (mean [SD] relative importance [RI], 28% [11%]), followed by chance of major complications (RI, 25% [10%]), number of additional operations (RI, 23% [12%]), appearance of the breasts (RI, 13% [12%]), and recovery time (RI, 11% [7%]). Most participants (344 [85%]) preferred implant-based reconstruction; these participants cared most about abdominal morbidity (mean [SD] RI, 30% [11%]), followed by the risk of complications (mean [SD], RI, 26% [11%]) and additional operations (mean [SD] RI, 21% [12%]). In contrast, participants who preferred flap reconstruction cared most about additional operations (mean [SD] RI, 31% [15%]), appearance of the breasts (mean [SD] RI, 27% [16%]), and risk of complications (mean [SD] RI, 18% [6%]). Factors independently associated with choosing flap reconstruction included being married (odds ratio [OR], 2.30 [95% CI, 1.04-5.08]; P = .04) and higher educational level (college education; OR, 2.43 [95% CI, 1.01-5.86]; P = .048), while having an income level of greater than $75 000 was associated with a decreased likelihood of choosing the flap profile (OR, 0.45 [95% CI, 0.21-0.97]; P = .01). Respondents who preferred flap appearance were willing to accept a mean (SD) increase of 14.9% (2.2%) chance of abdominal morbidity (n = 113) or 6.4% (4.8%) chance of complications (n = 115). Conclusions and Relevance: This study provides information on how women value different aspects of their care when making decisions for breast reconstruction. Future studies should assess how decision aids that elicit individual-level preferences can help tailor patient-physician discussions to focus preoperative counseling on factors that matter most to each patient and ultimately improve patient-centered care.

Tumor testing and treatment patterns in veterans with metastatic castration-resistant prostate cancer.

INTRODUCTION: In 2016, the Department of Veterans Affairs (VA) and Prostate Cancer Foundation (PCF) began a partnership to improve access to testing. The primary objective of this analysis was to describe the use of tumor testing and treatment patterns in Veterans who progressed to metastatic castration-resistant prostate cancer (mCRPC) from 2016 to 2021. Secondary objectives including identifying factors associated with receipt of tumor testing, and reporting HRR mutation results among a subset who were tested. METHODS AND MATERIALS: Natural language processing algorithms were applied to VA electronic health record data to identify a nationwide cohort of veterans with mCRPC. Tumor testing over time and by region were reported, alongside first-, second-, and third-line treatment patterns. Factors associated with receipt of tumor testing were identified using generalized linear mixed models with binomial distributions and logit links to account for clustering by VA facility. RESULTS: Of the 9,852 veterans analyzed, 1,972 (20%) received tumor testing, with 73% of testing occurring in 2020-2021. Factors associated with tumor testing included younger age, later diagnosis year, being treated in the Midwest, or Puerto Rico or other compared to the South, and being treated at a PCF-VA Center of Excellence. Fifteen percent of tests were positive for a pathogenic HRR mutation. Seventy-six percent of the study cohort received first-line treatment, and among those, a subsequent 52% received second-line treatment. A subsequent 46% received third-line treatment. CONCLUSION: After the VA-PCF partnership, one-fifth of veterans with mCRPC received tumor testing, with most tests occurring in 2020-2021.

Bariatric Surgery and Suicide Risk in Patients With Obesity.

OBJECTIVE: In a large multisite cohort of Veterans who underwent Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy, we compared the 5-year suicidal ideation and attempt rates with matched nonsurgical controls. BACKGROUND: Bariatric surgery has significant health benefits but has also been associated with adverse mental health outcomes. METHODS: Five-year rates of suicidal ideation and suicide attempts of Veterans who underwent Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy from the fiscal year 2000-2016 to matched nonsurgical controls using sequential stratification using cumulative incidence functions (ideation cohort: n=38,199; attempt cohort: n=38,661 after excluding patients with past-year outcome events). Adjusted differences in suicidal ideation and suicide attempts were estimated using a Cox regression with a robust sandwich variance estimator. RESULTS: In the matched cohorts for suicidal ideation analyses, the mean age was 53.47 years and the majority were males (78.7%) and White (77.7%). Over 40% were treated for depression (41.8%), had a nonrecent depression diagnosis (40.9%), and 4.1% had past suicidal ideation or suicide attempts >1 year before index. Characteristics of the suicide attempt cohort were similar. Regression results found that risk of suicidal ideation was significantly higher for surgical patients (adjusted hazard ratio=1.21, 95% CI: 1.03-1.41), as was risk of suicide attempt (adjusted hazard ratio=1.62, 95% CI: 1.22-2.15). CONCLUSIONS: Bariatric surgery appears to be associated with a greater risk of suicidal ideation and attempts than nonsurgical treatment of patients with severe obesity, suggesting that patients need careful monitoring for suicidal ideation and additional psychological support after bariatric surgery.

Cost-Utility Analysis of a Medication Adherence-Enhancing Educational Intervention for Glaucoma.

OBJECTIVE: To evaluate the cost utility of a glaucoma medication-enhancing intervention compared to standard of care over a lifetime from the United States Department of Veterans Affairs (VA) payer perspective. DESIGN: Model-based cost-utility analysis of a glaucoma medication-enhancing intervention from a randomized clinical trial. SUBJECTS: Veterans with glaucoma, or suspected glaucoma who were prescribed topical glaucoma medications, had their visual field assessed within the last 9 months, and endorsed poor glaucoma medication adherence. METHODS: Veterans were randomized either to a behavioral intervention to promote adherence or to a standard of care (control) session about general eye health. A decision analytic model was developed to simulate lifelong costs and quality-adjusted life years (QALYs) for an intervention tested in a randomized clinical trial at a single VA eye clinic. Costs included direct medical costs that the VA payer would incur, as informed initially by the clinical trial and then by published estimates. Health-state quality of life was based on published utility values. Scenario analyses included addition of booster interventions, a 3% decline in chance of staying medication adherent annually, and the combination of the two. Analyses were also conducted in the following subgroups: those with companion versus not, and those with once-daily versus more than once-daily dosing frequency. MAIN OUTCOME MEASURES: Incremental cost-effectiveness ratio (ICER). RESULTS: Compared to standard of care, the intervention dominated resulting in lower costs ($23 339.28 versus $23 504.02) and higher QALYs (11.62 versus 11.58). Among the 4 subgroups, the intervention dominated for 3 of them. In the fourth subgroup, those with more than once-daily dosing, the ICER was $2625/QALY. Compared to standard of care, an intervention with booster interventions led to an ICER of $3278/QALY. Assuming both a 3% annual loss in chance of continuing to be adherent and addition of booster interventions, the ICER increased to $71 371/QALY. CONCLUSIONS: From a VA payer perspective over a lifetime, the glaucoma medication-enhancing behavioral intervention dominated standard of care in terms of generating cost savings and greater QALYs. FINANCIAL DISCLOSURES: Proprietary or commercial disclosure may be found after the references.