Pregnancy-related risk factors and receipt of postpartum care among Texas Medicaid pregnant enrollees: Opportunities for pharmacist services.

BACKGROUND: The United States (US) experiences the highest rate of maternal mortality of similar countries. Postpartum care (PPC) focused on chronic disease management is potentially lifesaving, especially among pregnancies complicated by risk factors such as diabetes, hypertension, and mental health conditions (MHCs), which are conditions in which pharmacists can have an impact. OBJECTIVE: To evaluate the prevalence of maternal mortality risk factors and their relationships with receipt of PPC among Texas Medicaid enrollees. METHODS: A retrospective study included women with a delivery between 3/25/2014-11/1/2019 who were continuously enrolled in Texas Medicaid during the study period from 84 days pre-delivery to 60 days post-delivery. PPC was defined as ≥1 visit associated with postpartum follow-up services. Maternal mortality risk factors (diabetes, hypertension, and MHCs) during and after pregnancy were identified using diagnoses and medication utilization. Age, race/ethnicity, cesarean delivery, and preterm birth served as covariates. Multivariable logistic regression was used to address the study objective. RESULTS: The sample (N = 617,010) was 26.5±5.7 years, primarily (52.8%) Hispanic, and 33.0% had cesarean deliveries and 9.3% had preterm births. Risk factor prevalence included: diabetes (14.0%), hypertension (14.3%), and MHCs during (6.3%) and after (9.1%) pregnancy. A majority (77.9%) had a PPC visit within 60 days of delivery. The odds of receiving PPC were 1.2 times higher for patients with diabetes (OR = 1.183; 95% CI = 1.161-1.206; P < 0.0001), 1.1 times higher for patients with hypertension (OR = 1.109; 95% CI= 1.089-1.130; P < 0.0001), and 1.1 times higher for patients with MHCs (OR=1.138; 95% CI = 1.108-1.170; P < 0.0001) than patients without, respectively. CONCLUSION: Over three-quarters of Texas Medicaid pregnant enrollees received PPC within 60 days of delivery and risk factors were prevalent and predictive of receipt of PPC. Pharmacists can have a positive impact on maternal health by addressing hypertension, diabetes, and MHC risk factors.

Comparing survival outcomes between neoadjuvant and adjuvant chemotherapy within breast cancer subtypes and stages among older women: a SEER-Medicare analysis.

BACKGROUND: This study aimed to compare survival outcomes of neoadjuvant (NAC) and adjuvant chemotherapy (AdC) within each breast cancer subtype and stage among older women. METHODS: Older (≥ 66 years) women newly diagnosed with stage I-III invasive ductal breast cancer during 2010-2017 and treated with both chemotherapy and surgery within one year were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Analyses were performed within each of six groups, jointly defined based on subtype (hormone receptor [HR]-positive/human epidermal growth factor receptor 2 [HER2]-negative, HER2 + , and triple-negative) and stage (I-II and III). Kaplan-Meier curves and multivariable Cox models were used to compare overall and recurrence-free survival between NAC and AdC, with optimal full matching performed for confounding adjustment. RESULTS: Among 8,495 included patients, 8,329 (20.6% received NAC) remained after matching. Before multiple testing adjustment, Cox models showed that NAC was associated with a lower hazard for death among stage III HER2 + patients (hazard ratio = 0.347, 95% confidence interval CI 0.161-0.745) but a higher hazard for death among triple-negative patients (stage I-II: hazard ratio = 1.558, 95% CI 1.024-2.370; stage III: hazard ratio = 2.453; 95% CI 1.254-4.797). A higher hazard for death/recurrence was associated with NAC among stage I-II HR + /HER2- patients (hazard ratio = 1.305, 95% CI 1.007-1.693). No significant difference remained after multiple testing adjustment. CONCLUSIONS: The opposite trends (before multiple testing adjustment) of survival comparisons for advanced HER2 + and triple-negative disease warrant further research. Caution is needed due to study limitations such as cancer stage validity.

Gender equity perceptions among social and administrative science faculty: A qualitative evaluation.

BACKGROUND: Anecdotal evidence suggests that gender inequity persists in academic pharmacy. To date, there are limited published data about the perception of gender inequity in academic pharmacy. OBJECTIVE: The objective of this project was to determine themes associated with gender inequity perceptions in social and administrative science faculty from 2 national pharmacy organizations. METHODS: A gender equity task force comprising 13 members from Social and Administrative Sciences (SAS) sections of the American Pharmacists Association and the American Association of Colleges of Pharmacy was formed. The task force designed a semistructured interview guide comprising questions about demographics and core areas where inequities likely exist. When the survey invitation was sent to faculty members of the SAS sections via Qualtrics, faculty indicated whether they were willing to be interviewed. Interviews were conducted by 2 members of the task force via video conferencing application. The interviews were transcribed. Topic coding involving general categorization by theme followed by refinement to delineate subcategories was used. Coding was conducted independently by 3 coders followed by consensus when discrepancies were identified. RESULTS: A total of 21 faculty participated in the interviews. Respondents were primarily female (71%), were white (90%), had Doctor of Philosophy as their terminal degree (71%), and were in nontenure track positions (57%). Most respondents (90%) experienced gender inequity. A total of 52% reported experiencing gender inequity at all ranks from graduate student to full professor. Four major themes were identified: microaggression (57%), workload (86%), respect (76%), and opportunities (38%). Workload, respect, and opportunities included multiple subthemes. CONCLUSION: Faculty respondents perceive gender inequities in multiple areas of their work. Greater inequity perceptions were present in areas of workload and respect. The task force offers multiple recommendations to address these inequities.

Reliability and Validity Evidence for an Academic Gender Equity Questionnaire.

Objective. The majority of practicing pharmacists and student pharmacists are women. However, instruments to assess perceptions of gender equity within pharmacy academia are not available. The objective of this research was to describe the psychometric analysis of a questionnaire developed to assess gender equity by a Gender Equity Task Force and to report reliability and validity evidence.Methods. A questionnaire with 21 items addressing the teaching, research, service, advancement, mentoring, recruitment, and gender of college leaders was created. The survey was distributed via email in December 2020 to all social and administrative science section members of two professional associations. Rasch analysis was performed to evaluate the reliability and validity evidence for the questionnaire.Results. After reverse coding, all items met parameters for unidimensionality necessary for Rasch analysis. Once adjacent categories were merged to create a 3-point scale, the scale and items met parameters for appropriate functionality. Items were ordered hierarchically in order of difficulty. The modified instrument and scale can be treated as interval level data for future use.Conclusion. This analysis provides reliability and validity evidence supporting use of the gender equity questionnaire in the social and administrative academic pharmacy population if recommended edits such as the 3-point scale are used. Future research on gender equity can benefit from use of a psychometrically sound questionnaire for data collection.

Gender inequity: Enough talk, time for action.

While gender inequity has been shown to be an ongoing issue in the pharmacy profession, it has moved to the forefront due to increasing numbers of women in pharmacy. Two national organizations, American Pharmacists Association (APhA) and American Association of Colleges of Pharmacy (AACP) convened a joint Gender Equity Task Force to examine this matter among social and administrative sciences pharmacy faculty. The Task Force launched a survey and conducted interviews, as well as held several forums to solicit recommendations. This commentary provides recommendations for pharmacy constituents and stakeholders regarding: training and programming, leadership and mentoring, policy, and expansion. The goal is for organizations and leadership to incorporate recommendations with the goal of closing the gap in gender inequity.

Real-world opioid use among patients with migraine enrolled in US commercial insurance and risk factors associated with migraine progression.

BACKGROUND: Migraineurs may be categorized as having episodic migraine (EM: < 15 headache days/month) or chronic migraine (CM: ≥ 15 days/month for > 3 months with ≥ 8 days/month having features of migraine). Opioid use has been linked to progression from EM to CM. OBJECTIVE: To describe the utilization of opioid prescriptions among patients with migraine, to determine the association between opioid use and migraine progression, and to explore demographic and clinical risk factors for migraine progression. METHODS: This retrospective cohort study used Optum's deidentified Clinformatics Data Mart Database from January 2015 to December 2018. Adult patients with a migraine diagnosis and continuous health plan enrollment were included. Opioid use was measured by average daily morphine equivalent dose, also known as morphine milligram equivalent (MME). Descriptive statistics were used to summarize the opioid use by patient demographic and clinical characteristics. A Cox proportional hazards model with stepwise selection was used to determine the risk factors of new-onset CM. RESULTS: Overall, 35% of patients with migraine (27,331 of 78,134) received prescription opioids (> 0 MME/day) during the 12-month follow-up period. Higher opioid dosage was found in patients who had CM and comorbidities of interest. Compared with patients with EM, patients with CM were twice as likely to receive at least 20 MME/day (CM 3.8% vs EM 1.9%) and had a higher median opioid day supply (CM 20 vs EM 10) during follow-up. About 7% of patients with CM with at least 1 opioid prescription had at least 50 MME/day in any 90-day period during follow-up. A significant association was found between MME level and the likelihood of new-onset CM. Additional significant risk factors of migraine progression included younger age, female sex, South and West regions, and having a diagnosis of medication overuse headache, depression, back pain, or fibromyalgia (all P < 0.05). CONCLUSIONS: Despite guidelines and the availability of more migraine-specific treatments, opioids are still commonly prescribed to patients with migraines in real-world practice, especially for those with CM. In this study population, a higher risk of new-onset CM was associated with receiving higher opioid doses.

Neoadjuvant chemotherapy use trends among older women with breast cancer: 2010-2017.

PURPOSE: This study assessed chemotherapy use trends before (neoadjuvant chemotherapy [NAC]) or after surgery (adjuvant chemotherapy [AdC]) among older women with breast cancer and examined factors related to NAC receipt. METHODS: Women (> 65 years) diagnosed with stage I-III breast cancer during 2010-2017 who received NAC or AdC were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. All patients were stratified into six strata based on subtype (hormone receptor-positive/human epidermal growth factor receptor 2-negative [HR + /HER2-], HER2 + , and triple-negative breast cancer [TNBC]) and stage (I-II and III). Cochran-Armitage tests were performed to test temporal trends of NAC use in each stratum. Multivariable logistic regression analyses were performed to identify factors (sociodemographic and clinical) related to NAC use. RESULTS: Among included older (mean ± standard deviation: 72.3 ± 5.2 years) women (N = 8,495) with stage I-III breast cancer, NAC use increased from 11.7% (2010) to 32.6% (2017). Significant increases in NAC were found in all strata (p < .0001) with more substantial increases in HER2 + disease and TNBC compared to HR + /HER2- disease. Multivariable logistic regressions identified the youngest age category (66-69 years) and later stage as significant (p < 0.05) predictors of NAC receipt in most strata, in addition to diagnosis year. CONCLUSION: Similar to the overall breast cancer population, NAC use increased among a population of older women. NAC was received by most patients with stage III HER2 + disease or TNBC in more recent years and was more common among younger elderly women and those in stage III.

Healthcare Fraud Data Mining Methods: A Look Back and Look Ahead.

Healthcare fraud is an expensive, white-collar crime in the United States, and it is not a victimless crime. Costs associated with fraud are passed on to the population in the form of increased premiums or serious harm to beneficiaries. There is an intense need for digital healthcare fraud detection systems to evolve in combating this societal threat. Due to the complex, heterogenic data systems and varied health models across the US, implementing digital advancements in healthcare is difficult. The end goal of healthcare fraud detection is to provide leads to the investigators that can then be inspected more closely with the possibility of recoupments, recoveries, or referrals to the appropriate authorities or agencies. In this article, healthcare fraud detection systems and methods found in the literature are described and summarized. A tabulated list of peer-reviewed articles in this research domain listing the main objectives, conclusions, and data characteristics is provided. The potential gaps identified in the implementation of such systems to real-world healthcare data will be discussed. The authors propose several research topics to fill these gaps for future researchers in this domain.

Economic Burden of Chronic Comorbidities Among Community-Dwelling Older Adults With Dementia: A Propensity Score Matched National-Level Study.

OBJECTIVE: This study examined the extent to which chronic comorbidities contribute to excess health care expenditures between older adults with dementia and propensity score (PS)-matched nondementia controls. METHODS: This was a retrospective, cross-sectional, PS-matched case (dementia): control (nondementia) study of older adults (65 y or above) using alternative years data from pooled 2005 to 2015 Medical Expenditure Panel Surveys (MEPS). Chronic comorbidities were identified based on Clinical Classifications System or ICD-9-CM codes. Ordinary least squares regression was utilized to quantify the impact of chronic comorbidities on the excess expenditures with logarithmic transformation. Expenditures were expressed as 2019 US dollars. All analyses accounted for the complex survey design of MEPS. RESULTS: The mean yearly home health care expenditures were particularly higher among older adults with dementia and co-occurring anemia, eye disorders, hyperlipidemia, and hypertension compared with PS-matched controls. Ordinary least squares regression models revealed that home health care expenditures were 131% higher (ß=0.837, P <0.001) among older adults with dementia compared with matched nondementia controls before adjusting for chronic comorbidities. When additionally adjusting for chronic comorbidities, the percentage increase, while still significant ( P <0.001) decreased from 131% to 102%. CONCLUSIONS: The excess home health care expenditures were partially explained by chronic comorbidities among community-dwelling older adults with dementia.

Healthcare utilization and costs among patients with chronic migraine, episodic migraine, and tension-type headache enrolled in commercial insurance plans.

OBJECTIVE: To quantify and compare healthcare utilization and costs for patients with chronic migraine (CM), episodic migraine (EM), and tension-type headache (TTH) enrolled in US commercial health plans. METHODS: This retrospective cohort study used the Optum Clinformatics® Data Mart database from January 2015 to December 2018. Adult patients with a diagnosis of EM, CM or TTH and at least 12 months of continuous enrollment before and after diagnosis were included. Inverse probability of treatment weighting was used to adjust for baseline differences among the three groups. Patient demographic and clinical characteristics at baseline, and healthcare utilization and costs during follow-up, were described and compared between the three groups. RESULTS: A total of 45,849 patients were included: 8955 with CM, 31,961 with EM, and 4933 with TTH. The total all-cause annual direct medical costs of patients with CM ($17,878) were 1.38 times higher (95% CI: 1.31-1.44) than those with EM ($12,986), and 2.26 times higher (95% CI: 2.08-2.47) than those with TTH ($7902). The annual migraine/TTH-related costs of patients with CM ($1869) were 4.19 times higher (95% CI: 3.92-4.48) than those with EM ($446), and 11.90 times (95% CI: 10.59-13.52) higher than those with TTH ($157). In the adjusted analyses, for all service categories (emergency department, inpatient, outpatient, and prescriptions), the expected costs in the migraine groups were higher than in the TTH group (all p < 0.001), while controlling for covariates. Main findings were consistent in both weighted and unweighted samples, and with both unadjusted and adjusted analyses. CONCLUSION: This study provides an updated assessment of healthcare utilization and expenditures for adult patients with primary headache disorders. Compared to TTH, migraine is associated with higher resource use and direct medical costs, especially for those with a chronic condition. Future studies are needed to understand the indirect medical costs (productivity loss) and humanistic burden (quality of life) between migraine and TTH.

Medication Therapy Management for Texas MediCAID Patients With Asthma and Chronic Obstructive Pulmonary Disease-A Pilot Study.

BACKGROUND: Pharmacists can play an important role in providing medication therapy management (MTM) services, which focus on appropriate medication use. This pilot study aimed to describe pharmacists' MTM service provision, results/outcomes of pharmacists' recommendations and resolution/acceptance rate among patients with high-risk asthma and/or chronic obstructive pulmonary disease (COPD). METHODS: This was a prospective descriptive study of MTM services provided by community pharmacists to Texas Medicaid patients (5-63 years) with "high risk" asthma or COPD. Patients received in-person and telephone consultations that included medication review, asthma control test assessment, and education on adherence and proper medication/device use. Data extracted from MTM software was used to describe: reasons for MTM services, type of pharmacists' interventions, outcomes of pharmacists' recommendations and acceptance rate. RESULTS: Twenty-eight pharmacists provided 139 MTM interventions with 63 patients (2.2 interventions per patient). The most frequent intervention reason was complex drug therapy (53.2%), underuse of medication (8.6%), need for drug therapy (8.6%), new or changed prescription therapy (6.5%), and administration technique (5.0%). The resolution rate was 77.7%. Patient and prescriber, respectively, refused recommendation in 12% and 6% of the interventions. Outcomes included comprehensive medication review (46.7%), improved adherence (6.5%), therapeutic success (6.5%), improved administration technique (5.0%), and initiation of new therapy (5.0%). CONCLUSION: Through the provision of MTM, pharmacists were able to identify and intervene with medication-related problems. These interventions are instrumental in helping patients better manage their asthma/COPD. The high resolution rate was encouraging. Larger scale studies are needed to assess clinical and economic outcomes.

Age-related prescription medication utilization for the -management of sickle cell disease among Texas Medicaid patients.

INTRODUCTION: Sickle cell disease (SCD) is associated with recurrent complications and healthcare burden. Although SCD management guidelines differ based on age groups, little is known regarding actual utilization of preventative (hydroxyurea) and palliative therapies (opioid and nonopioid analgesics) to manage complications. This study assessed whether there were agerelated differences in SCD index therapy type and SCD-related medication utilization. DESIGN AND PATIENTS: Texas Medicaid prescription claims from September 1, 2011 to August 31, 2016 were retrospectively analyzed for SCD patients aged 2-63 years who received one or more SCD-related medications (hydroxyurea, opioid, or nonopioid analgesics). OUTCOME MEASURES: The primary outcomes were SCD index drug type and medication utilization: hydroxyurea adherence, and days' supply of opioid, and nonopioid analgesics. Chi-square, analysis of variance, and Kruskal-Wallis tests were used. RESULTS: Index therapy percentages for included patients (N = 2,339) were the following: opioids (45.7 percent), nonopioids (36.6 percent), dual therapy-opioids and nonopioids (11.2 percent), and hydroxyurea (6.5 percent), and they differed by age-groups (χ2 = 243.0, p < 0.0001). Hydroxyurea as index therapy was higher among children (2-12:9.1 percent) compared to adults (26-40:3.7 percent; 41-63:2.9 percent). Opioids as index therapy were higher among adults (18-25:48.0 percent; 26-40:54.9 percent; 41-63:65.2 percent) compared to children (2-12:36.6 percent). Mean hydroxyurea adherence was higher (p < 0.0001) for younger ages, and opioid days' supply was higher for older ages. CONCLUSIONS: Texas Medicaid SCD patients had low hydroxyurea utilization and adherence across all age groups. Interventions to increase the use of hydroxyurea and newer preventative therapies could result in better management of SCD-related complications and reduce the frequency of pain crises, which may reduce the need for opioid use.

Off-label antipsychotic use patterns among Texas Medicaid adults 2013-2016.

Aim: To describe trends in off-label antipsychotic use among Texas Medicaid adults and examine whether demographic and clinical characteristics were associated with off-label use. Methods: Three diagnostic groups (i.e. no diagnosis, on label and off-label) were created based on mental health disorder diagnoses and related antipsychotic prescriptions. Results: During 2013-2016, the prevalence of off-label antipsychotic use decreased from 22.5% to 17.4% and the proportions of no mental health diagnosis remained stable (7.3-9.4%). Patients aged ≥25 years and second-generation antipsychotic users had significantly lower odds of receiving antipsychotics off-label or with no diagnosis. Conclusion: Compared with previous Medicaid database studies, the proportions of off-label antipsychotic use and antipsychotic use with no concurrent psychiatric diagnosis were notably lower.

Trends in off-label use of antipsychotic medications among Texas Medicaid children and adolescents from 2013 to 2016.

BACKGROUND: Antipsychotics are frequently prescribed for off-label indications in the pediatric population. However, little is known regarding this issue in Texas Medicaid. OBJECTIVES: To (1) describe off-label antipsychotic use among Texas Medicaid children and adolescents and (2) examine factors associated with off-label use. METHODS: Texas Medicaid prescription and medical claims from January 2013 to August 2016 were analyzed retrospectively among subjects aged 2-17 years with an antipsychotic prescription. Three diagnostic status groups (on-label, off-label, no diagnosis) were categorized based on FDA-approved indications. Descriptive and chi-square tests were conducted to determine if diagnostic status differed by age group (2-4, 5-9, 10-14, and 15-17 years), sex, and antipsychotic type. A logistic regression analysis was used to identify factors associated with off-label use. RESULTS: In this study, 43,792, 44,335, 37,221, and 24,879 (January-August) children with at least 1 antipsychotic prescription were identified from 2013 to 2016, respectively. The proportions with off-label use declined from 66.9% (2013) to 59.8% (2016). Among off-label users, more than one-half (51.3%-55.8%) had a diagnosis of attention-deficit/hyperactivity disorder. Less than 8% (6.0%-7.7%) of subjects had no mental health disorder diagnosis. Chisquare analyses (2015 data) revealed that the proportion of off-label and no diagnosis users combined were significantly (P < 0.01) higher among users aged 5-9 years (82.5%) than adolescents 10-14 years (61.9%) and 15-17 years (56.5%); males (67.7%) than females (65.3%); and first-generation antipsychotics (FGAs; 79.3%) than second-generation antipsychotics (66.7%) users. Logistic regression analyses revealed younger age and FGA users had higher odds of off-label/no diagnosis use. CONCLUSIONS: The proportion of off-label/no diagnosis antipsychotic use declined from 2013 to 2016. Younger children and those receiving FGAs were more likely to be off-label antipsychotic users, with attention-deficit/hyperactivity disorder being the most prevalent off-label diagnosis. DISCLOSURES: No outside funding supported this study. The authors have nothing to disclose. This study was presented as an abstract at the American Academy of Child and Adolescent Psychiatry's 67th Annual Meeting (Virtual), October 2020.

Prevalence of and Factors Associated with Gabapentinoid Use and Misuse Among Texas Medicaid Recipients.

BACKGROUND AND OBJECTIVES: Gabapentin and pregabalin have been considered relatively safe opioid-sparing adjuncts for pain management. However, rising prescribing trends, presence of gabapentinoids in opioid-related overdoses, and the growing body of evidence regarding gabapentinoid misuse and abuse, have caused gabapentinoids to emerge as a drug class of public health concern. This study aimed to assess the prevalence of, and factors associated with gabapentinoid use and misuse. METHODS: This retrospective study of Texas Medicaid data from 1/1/2012 to 30/8/2016 included patients aged 18-63 years at index date, with ≥ 1 gabapentinoid prescription, and continuously enrolled 6 months pre-index and 12 months post-index. Gabapentinoid misuse was defined as ≥ 3 claims exceeding daily doses of 3600 mg for gabapentin and 600 mg for pregabalin. Age, gender, concurrent opioid use, neuropathic pain diagnoses and gabapentinoid type were independent variables. Descriptive and inferential statistics were used. RESULTS: Of included subjects (N = 39,000), 0.2% (N = 81) met study criteria for gabapentinoid misuse. Overall, the majority (76.4%) of gabapentinoid users were aged 41-63 years with a mean ± SD age of 48.2 ± 10.7 years. Those patients meeting the study criteria for gabapentinoid misuse were significantly younger (45.1 ± 11.0 vs 48.2 ± 10.7, p = 0.0084). Majority of the study sample was female (68.1%). However, a significantly higher proportion of males met the study criteria for gabapentinoid misuse compared to females (0.3% vs 0.2%, p = 0.0079). Approximately one-half (51.9%) of the study sample had neuropathic pain, and gabapentinoid misuse was significantly higher in neuropathic pain patients compared to those without neuropathic pain (0.3% vs 0.1%, p = 0.0078). Over three-quarters (77.4%) of patients were using gabapentin; however, gabapentinoid misuse was significantly higher among pregabalin users (0.4% vs 0.2%, p = 0.0003). Approximately 20% (17.3%) of gabapentinoid users had ≥ 90 days of concurrent opioid use. However, there was no significant difference in gabapentinoid misuse among patients with concurrent opioid use compared to patients without (0.3% vs 0.2%, p = 0.1440). Factors significantly associated with misuse included: male sex (odds ratio [OR] 0.486; 95% confidence interval [CI] 0.313-0.756; p = 0.0013); neuropathic pain (OR 2.065; 95% CI 1.289-3.308; p = 0.0026); and pregabalin versus gabapentin use (OR 2.337, 95% CI 1.492-3.661; p = 0.0002). Concurrent opioid use was not significantly associated with gabapentinoid misuse (OR 1.542, 95% CI 0.920-2.586; p = 0.1006). CONCLUSION: Prevalence of gabapentinoid misuse was low (0.2%) among Texas Medicaid recipients. Younger age, male gender, neuropathic pain diagnosis and pregabalin use were significantly associated with higher levels of gabapentinoid misuse.

Use of a claims-based algorithm to estimate disease severity in the multiple sclerosis Medicare population.

BACKGROUND/OBJECTIVE: To compare algorithm determined disease severity, risk of multiple sclerosis (MS) relapse, and MS-related hospitalization between the age-eligible and disability-eligible MS Medicare populations. METHODS: Using the Humana claims dataset (2013 - 2015), patients were divided into Medicare age-eligible and disability-eligible groups. A previously developed algorithm, which used MS symptoms and healthcare utilization to categorize MS disease severity into three groups (low, moderate, high) at baseline was employed. Flexible parametric and Cox proportional hazard models were used to estimate the risk for MS relapses and MS-related hospitalizations among the MS disease severity groups and the two eligibility cohorts in the follow-up period. RESULTS: Of the overall sample (N = 6,559), the majority (N = 4,813, 73.4%) were disability-eligible and in the low disease severity group (N = 4,468, 68.1%). In 10 of 16 disease severity algorithm predictors, the prevalence of these predictors was significantly (p<0.001) higher in the disability-eligible group compared to the age-eligible group. Survival analyses revealed that the disability-eligible group had a significantly higher risk for follow-up MS relapses and follow-up MS-related hospitalizations (HR = 1.79 [CI 1.54 - 2.08] and HR = 1.38 [CI 1.11-1.72], respectively) compared to those in the age-eligible group. When both eligibility and disease severity were considered in the model increases in hazard ratios corresponded generally to increases in disease severity. However, the type of Medicare eligibility does not appear to have a clear pattern across MS disease severity groups for either MS relapse or hospitalizations, CONCLUSION: The disability-eligible Medicare population had a significantly higher prevalence of MS comorbidities and higher MS severity scores at baseline. In addition, they had a higher risk for MS-related relapses and MS-related hospitalizations in the follow-up period. It is important to account for disability status when assessing disease severity and healthcare utilization.

The association between hydroxyurea adherence and opioid utilization among Texas Medicaid enrollees with sickle cell disease.

BACKGROUND: Individuals with sickle cell disease (SCD) suffer from recurrent catastrophic pain crises that are often managed by opioid analgesics. Being adherent to hydroxyurea has been associated with decreased health care resource use for pain; however, evidence of its association with opioid use is limited. OBJECTIVE: To determine if adherence to hydroxyurea is associated with opioid use among patients with SCD. METHODS: This retrospective study used Texas Medicaid data from September 1, 2011, to August 31, 2016 (study period). The index date was the date of hydroxyurea initiation. Patients who were aged 2-63 years at the index date, had ≥ 1 inpatient or ≥ 2 outpatient SCD diagnoses during the study period, had ≥ 1 hydroxyurea prescription during the identification period (September 1, 2011-August 31, 2015), had no diagnosis of other indications for hydroxyurea during the study period, and were continuously enrolled for at least 12 months after the index date were included. Hydroxyurea adherence was measured using medication possession ratio (MPR). The study outcomes (measured 1-year post-index) were (a) opioid use; (b) number of opioid prescriptions; (c) strong opioid use (morphine, hydromorphone, fentanyl, and methadone); (d) number of strong opioid prescriptions; (e) high-dose opioid use (≥ 50 mg morphine milligram equivalent [MME]); and (f) days supply for opioid prescriptions. Covariates included demographic (age and gender) and clinical (vaso-occlusive crisis [VOC], avascular necrosis, iron overload, acute chest syndrome, and blood transfusion) characteristics. Descriptive, bivariate (chi-square and Wilcoxon-Mann-Whitney tests), multiple logistic regression, and negative binomial regression analyses were performed. RESULTS: 1,146 patients (18.3 [12.3] years) met the inclusion criteria. Of these, 19.6% were adherent to hydroxyurea (defined as MPR ≥ 80%) and mean (SD) MPR was 48.3% (29.7%). In the 1 year following hydroxyurea initiation, 923 (80.5%) patients had ≥ 1 opioid prescription with 7.6 (9.4) opioid prescriptions per patient, while 259 (22.6%) patients had ≥ 1 strong opioid prescription with 1.5 (4.4) strong opioid prescriptions per patient. Average (SD) opioid dose was 41.7 (74.3) mg MME, and 27.1% had high daily MME doses (≥ 50 mg MME). Average (SD) opioid days supply was 83.1 (112.2) days. After adjusting for covariates, compared with being nonadherent, being adherent to hydroxyurea was associated with a 50.5% decreased risk of having strong opioids (OR = 0.495, 95% CI = 0.278-0.879, P = 0.0165). Additionally, SCD-related complications (VOC, avascular necrosis, and iron overload) and older age were significant factors associated with opioid use and higher MME. Post hoc analyses showed that being adherent to hydroxyurea was significantly associated with lower probabilities of experiencing SCD-related complications. CONCLUSIONS: Results showed that patients with SCD are moderately adherent to hydroxyurea. Being adherent to hydroxyurea was found to be associated with a lower risk of receiving a prescription for strong opioids. Findings suggest that close monitoring and interventions to improve adherence may help mitigate strong opioid use among these patients. DISCLOSURES: This research did not receive any specific funding. Barner and Kang report grants from Novartis Pharmaceuticals, unrelated to this work. A part of this study was presented as a poster at the American Pharmacists Association (APhA) 2019 Annual Meeting and Exposition (March 22-25, 2019, Seattle, WA) and received the 2019 APhA-APRS Presentation Award in the APhA-APRS Contributed Research Paper, Graduate Student/Fellow/Postdoctoral Scholar category.

Assessment of basal insulin adherence using 2 methodologies among Texas Medicaid enrollees with type 2 diabetes.

BACKGROUND: Basal insulin is often recommended as the initial therapy for patients with type 2 diabetes who require insulin treatment. Adequate adherence is critical to diabetes management, yet suboptimal insulin adherence has been reported. Second-generation long-acting (SGLA) insulin has higher dosing flexibility and lower hypoglycemia risk and may improve adherence. However, little is known regarding adherence to SGLA insulin and how adherence to SGLA insulin compares with intermediate-acting neutral protamine Hagedorn (NPH) and first-generation long-acting (FGLA) insulin. Measurement of insulin adherence is challenging because of the inaccuracies of recorded days supply of insulin, and traditional medication possession ratio (MPR) may be negatively affected. Adjusted MPR (aMPR) has been developed in an effort to address this issue. OBJECTIVE: To examine the unadjusted and adjusted associations between basal insulin type and adherence to basal insulin using MPR and aMPR. METHODS: This retrospective database study used Texas Medicaid prescription claims from January 1, 2014, through June 30, 2017. The index date was the date of the first basal insulin prescription without the same prescription 6 months before (pre-index), and all patients were followed for 12 months (post-index). Patients aged 18-63 years with ≥ 1 pre-index prescription of an oral hypoglycemia agent (OHA) or a glucagon-like peptide-1 receptor agonist (GLP-1 RA), without any post-index prescription of premixed insulin or a basal insulin different from index insulin, and with continuous enrollment throughout the pre- and post-index periods, were included. The dependent variable was basal insulin adherence over 12 months, measured using MPR and aMPR. Unadjusted and adjusted adherence comparisons were conducted by basal (background) insulin type (NPH, FGLA, and SGLA). Covariates included age, gender, baseline use of basal insulins and comorbid medications, total number of medications, OHA adherence, post-index number of OHAs, and use of bolus insulins and GLP-1 RAs. Analysis of variance, chi-square tests, and multiple logistic regression analyses were performed. RESULTS: Of the 5,034 patients included, NPH, FGLA, and SGLA insulin users accounted for 3.7%, 89.8%, and 6.5%, respectively. The overall mean (SD) age was 50.9 (9.9) years, and 65.9% were female. In the unadjusted bivariate analyses, SGLA insulin users had significantly higher adherence, using either MPR (SGLA 0.68 [0.25] vs. FGLA 0.59 [0.27] vs. NPH 0.55 [0.27]; P < 0.0001) or aMPR (0.83 [0.23] vs. 0.78 [0.26] vs. 0.73 [0.28]; P = 0.0001). After controlling for covariates, insulin type was not significantly associated with the likelihood of being adherent (MPR or aMPR ≥ 0.8) using either measure. CONCLUSIONS: Adherence to SGLA insulin was not different from adherence to other basal insulins after controlling for patient characteristics. Yet, MPR and aMPR have limitations and warrant further confirmation of the study findings. Before new adherence measures for insulin therapy are developed, MPR and aMPR should be used with caution. DISCLOSURES: No specific funding was received for this manuscript. The authors report no potential conflicts of interest. Part of the data from this study was presented as posters at the American Pharmacists Association 2020 Annual Meeting & Exposition, March 20-23, 2020, in National Harbor, MD, and at the International Society for Pharmacoeconomics and Outcomes Research 2020 Conference, May 16-20, 2020, in Orlando, FL.

Willingness to Seek Help for Depression in Young African American Adults: Study Protocol.

BACKGROUND: In the United States, among those living with mental illness, 81% of African American (AA) young adults do not seek treatment compared with 66% of their white counterparts. Although the literature has identified unique culturally related factors that impact help seeking among AAs, limited information exists regarding the development and evaluation of interventions that incorporate these unique factors. OBJECTIVE: This study aims to describe a study protocol designed to develop a culturally relevant, theory-based, psychoeducational intervention for AA young adults; to determine if exposure to the intervention impacts AA young adults' willingness to seek help; and to determine whether cultural factors and stigma add to the prediction of willingness to seek help. METHODS: The Theory of Planned Behavior (TPB) and Barrera and Castro's framework for cultural adaptation of interventions were used as guiding frameworks. In stage 1 (information gathering), a literature review and three focus groups were conducted to identify salient cultural beliefs. Using stage 1 results, the intervention was designed in stage 2 (preliminary adaptation design), and in stage 3 (preliminary adaptation tests), the intervention was tested using pretest, posttest, and 3-month follow-up surveys. An experimental, mixed methods, prospective one-group intervention design was employed, and the primary outcomes were participants' willingness and intention to seek help for depression and actual help-seeking behavior. RESULTS: This study was funded in May 2016 and approved by the University of Texas at Austin institutional review board. Data were collected from November 2016 to March 2016. Of the 103 students who signed up to participate in the study, 70 (67.9%) completed the pre- and posttest surveys. The findings are expected to be submitted for publication in 2020. CONCLUSIONS: The findings from this research are expected to improve clinical practice by providing empirical evidence as to whether a culturally relevant psychoeducational intervention is useful for improving help seeking among young AAs. It will also inform future research and intervention development involving the TPB and willingness to seek help by identifying the important factors related to willingness to seek help. Advancing this field of research may facilitate improvements in help-seeking behavior among AA young people and reduce the associated mental health disparities that apparently manifest early on. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/16267.

Association between quality-of-care indicators for HIV infection and healthcare resource utilization and costs.

OBJECTIVES: Multiple care quality indicators for HIV infection exist but few studies examine their impact on health outcomes. This study assessed which HIV care quality indicators were associated with healthcare resource utilization and costs. DESIGN: Retrospective analysis of Texas Medicaid claims data (01 January 2012 to 31 September 2016). METHODS: Included patients had at least two HIV-related medical claims during the identification period (01 July 2012 to 31 August 2014) (index = date of first HIV claim), were 18-62 years at index, and were continuously enrolled in the 6-month pre-index and 1-year post-index periods. Dependent variables included emergency department (ED) visits, inpatient hospitalizations, prescription count, and all-cause healthcare costs. Independent variables included CD4 cell count monitoring, syphilis, chlamydia, gonorrhea, hepatitis B, hepatitis C, and tuberculosis screenings, influenza and pneumococcal vaccinations, retention in care, and HAART initiation. Covariates included age, chronic hepatitis C virus infection, AIDS diagnosis, sex, and baseline healthcare cost. The study objective was addressed using generalized linear modeling. RESULTS: CD4 cell count monitoring and HAART initiation were significantly associated with reduced emergency department visits (P < 0.0001 for each). Influenza vaccination was significantly associated with reduced inpatient hospitalization (P < 0.0001). CD4 cell count monitoring (P < 0.0001), TB screening (P = 0.0006), influenza vaccination (P < 0.0001), and HAART initiation (P < 0.0001) were significantly associated with increase prescription claims. CD4 cell count monitoring, TB screening, and HAART initiation (P < 0.0001 for each) were significantly associated with all-cause healthcare costs. CONCLUSION: HAART may reduce use of emergency care services as early as 1 year following initiation.