An Exploratory Study of Physician Decision-Making When Treating Uncontrolled COPD.

Purpose: Current guidelines recommend triple therapy maintenance inhalers for patients with recurrent exacerbations of chronic obstructive pulmonary disease (COPD); however, these maintenance therapies are underutilized. This study aimed to understand how physicians make COPD treatment decisions, and how combination maintenance therapies are utilized in a real-world setting. Patients and Methods: This exploratory, hypothesis-generating, non-interventional study used a cross-sectional online survey that was administered to a sample of practicing physicians in the United States. The survey included five fictitious vignettes detailing common symptoms experienced by patients with COPD. Survey questions included factors physicians consider in their decisions, and perceived barriers to prescribing treatments. Repeated measures multivariable analyses were conducted to evaluate how likely physicians were to switch to triple therapy versus no change to patient's current maintenance therapy or change to another maintenance therapy. Results: In total, 200 physicians completed the survey. Cost of treatment and patient access to treatment were reported as the most common barriers physicians consider in their prescribing decisions. Physicians were more likely to switch a patient's maintenance inhaler to triple therapy versus no change to maintenance inhaler if they considered the patient's history of new symptoms, insurance status, and clinical guidelines in their decision. Physicians with more experience treating patients with COPD, and those who treat more patients with COPD per week, were more likely to switch to triple therapy versus no change to maintenance inhaler. Conclusion: This study demonstrates the complexity of factors that can influence physicians' decisions when prescribing treatments for patients with COPD, including considerations of treatment cost, patient access and adherence, patient comorbidities, efficacy of current treatment, clinical guidelines, and provider's level of experience treating COPD. Further research may help elucidate the relative importance of the factors influencing physicians' decisions and inform what types of decision-support tools would be most beneficial.

Chronic obstructive pulmonary disease (COPD) symptoms can be effectively managed with maintenance therapies, which are treatments that are taken routinely to help improve symptoms. A combination of three different therapies (triple therapy maintenance) has been shown to be more effective than a combination of two different therapies (dual therapy maintenance) in patients with moderate-to-severe COPD. However, maintenance therapies, including triple therapy, are underutilized. This study aimed to explore how physicians make their treatment decisions for patients with COPD, and how combination maintenance therapies are utilized. To do so, we administered a survey to a sample of practicing physicians in the United States. The survey included five clinically based, fictitious profiles, or vignettes, of patients with COPD, with common symptoms and patient characteristics being described. Physicians were then asked to answer questions about what treatment they would prescribe for each patient, and any factors they considered when deciding on a treatment for a patient. We found that cost of treatment and patient access to treatment were the most common barriers that physicians considered when choosing a treatment. Physicians were also more likely to switch a patient's maintenance inhaler to a triple therapy maintenance inhaler if they considered the patient's history of new symptoms, patient's insurance status, and clinical guidelines when making their decisions. Our study shows that there are many complex factors that influence physicians' decisions when deciding on a treatment for patients with COPD.

Impact of the 2002 American society for Colposcopy and Cervical Pathology guidelines on cervical cancer diagnosis in a geographically diverse population of commercially insured women, 1999-2004.

OBJECTIVE: To report the impact of the release of the 2002 American Society for Colposcopy and Cervical Pathology guidelines on the management of abnormal cytological findings on time to diagnosis of cervical cancer in an insured population. METHODS: This retrospective study identified women with cervical cancer (invasive and carcinoma in situ) through commercially insured administrative claims data. The cervical cancer case definition required a claim for cervical cancer and a claim with a diagnostic procedure (colposcopy, conization, biopsy, or hysterectomy). Time to diagnosis was defined as days between the initial Pap screening and the diagnostic procedure. RESULTS: Between 1999 and 2004, there were 3,325 women aged 18 to 64 years who met the case definition for cervical cancer. Median time to diagnosis decreased from 42 days (interquartile range = 23-93 d) to 36.5 days (interquartile range = 20.5-80 d) for women with invasive cancer after the guideline change. The number of follow-up Pap screenings before biopsy also decreased (p = .0067). Among women with carcinoma in situ whose initial Pap screening was completed by a family practice clinician, time to diagnosis was projected to be more than 9 days longer compared with those whose screening was performed by a gynecologist. CONCLUSIONS: The 2002 American Society for Colposcopy and Cervical Pathology guidelines for the management of abnormal cytological findings seem to have had a positive impact on the time to diagnosis and Pap screening use before biopsy for women diagnosed with cervical cancer.

Incidence and Burden of Pertussis Among Infants Less Than 1 Year of Age.

BACKGROUND: Infant-specific pertussis data, especially among neonates, are limited and variable. This study (NCT01890850) provides overall and age-specific pertussis incidence and associated health care utilization and costs among commercially insured infants in the US. METHODS: Nearly 1.2 million infants born from 2005 to 2010 with commercial health plan coverage were followed during their first 12 months of life. Pertussis cases were identified from medical claims (International Classification of Diseases, 9th revision, Clinical Modification code: 033.0, 033.9, 484.3), and incidence rates were calculated. Each pertussis case was then matched to 10 comparators, so pertussis-related health care utilization and costs before and after the index date could be assessed. RESULTS: The overall pertussis incidence rate among infants <12 months of age was 117.7/100,000 person-years; infants 3 months of age had the highest incidence rate (247.7/100,000 person-years). Infants diagnosed with pertussis were significantly more likely to have prior diagnoses of upper respiratory infection, cough and wheezing-related illnesses than comparators (P < 0.001). Pertussis cases were more likely to be hospitalized within 14 days after the index date (31.8% vs. 0.5%; P < 0.001) and their adjusted health care costs during follow-up were 2.82 times higher than comparators (P < 0.001; 95% confidence interval: 2.08-3.81). The incremental cost of pertussis during the 12-month follow-up period averaged $8271 (P < 0.001). The average incremental cost varied substantially by age, ranging from $18,781 (P < 0.001) to $3772 (P = 0.02) among infants 1 month and 7-12 months of age, respectively. CONCLUSIONS: The health burden of pertussis, particularly in the youngest infants, remains substantial, highlighting the need to intensify efforts to protect this most vulnerable population.

Timing of colposcopy after cervical cytologic abnormalities.

OBJECTIVE: To examine the length of time from Pap test (index Pap) screening to follow-up colposcopy for women with abnormal Pap test results of low-grade squamous intraepithelial lesions (LSIL); atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesions (ASC-H); or high-grade squamous intraepithelial lesions (HSIL). METHODS: We identified 4,824 women aged 18 to 64 years with the index Pap test results of LSIL, HSIL, or ASC-H from health insurance claims in a large U.S. health care organization and who had a routine Pap test in 2004. We used a survival regression model to estimate factors related to the length of time (days) from the index Pap test to a follow-up colposcopy. RESULTS: The expected length of time from an abnormal Pap test to a colposcopy differed by age and Pap test result. For women with an ASC-H result, those who were older were more likely to delay colposcopy compared with the younger women. For women with LSIL and HSIL results, the timing of colposcopy did not differ by age; however, the time was shorter compared with ASC-H. We found that physician specialties, health care settings, and area-level racial and ethnic density were related to timing of receiving follow-up procedures after an abnormal index Pap test result. CONCLUSION: Women with LSIL and HSIL received a colposcopy in 3-4 months, but women with ASC-H were more likely to receive the procedure at a later time.

Documented tuberculin skin testing among infliximab users following a multi-modal risk communication interventions.

PURPOSE: Following its licensure, tuberculosis (TB) was reported as a potential adverse effect of infliximab. Subsequently, the product circular was changed to recommend tuberculin skin testing before patients received infliximab, which was reinforced by several risk communication efforts. The aim of this study was to evaluate patterns and predictors of documented tuberculin skin testing in patients before and after manufacturer, federal, and academic risk communications. METHODS: Patients administered infliximab were identified from 11 health plans located throughout the United States, and claims data were examined to determine whether the patients had received a tuberculin skin test. Patients were divided into three cohorts depending on the timing of their first infliximab treatment in relation to the risk communication efforts. RESULTS: The overall tuberculin skin testing rate doubled from 15.4% in the first cohort to 30.9% in the last cohort, while the rate of pre-infliximab treatment testing increased from 0 to 27.7% (Chi-squared test for trend, p < 0.0001 for both). Tuberculin skin testing rates were significantly higher in women, those with a diagnosis of rheumatoid or psoriatic arthritis, and those with a rheumatologist as prescriber. After multivariable analysis, only rheumatologist remained significantly associated with tuberculin skin testing. CONCLUSIONS: Although the tuberculin skin testing rate was relatively low overall, tuberculin skin testing doubled over 30 months of ongoing risk communication efforts and under ascertainment likely occurred. We also found variation in the tuberculin skin testing rate associated with physician specialty. This study demonstrates a significant change in patient care following risk communication efforts.