Industry Payments for Vibegron and Prescribing Patterns Among Urologic Clinicians.

This cross-sectional study compares the prescribing practices among urologists and advanced practice clinicians who received vs did not receive payment from drug manufacturers.

Developing an Integrated Longitudinal Dataset for Patient-Centered Outcome Measures in Cost-Related Medication Nonadherence.

BACKGROUND: Cost-related medication nonadherence (CRN) is an important patient-centered outcome measure. Longitudinal follow-up of CRN is rare. OBJECTIVE: We propose to develop a novel integrated dataset to study CRN longitudinally. RESEARCH DESIGN: A dataset of 2000 Medicare beneficiaries at high risk of hospitalization surveyed quarterly on CRN and followed up individually for 8 quarters between 2013 and 2018 was linked to Medicare files. A metric of CRN categorizing persistent, intermittent, and transient CRN during the 8 quarters was developed. An ordered logit model and a logit model were developed to assess the factors influencing CRN overall and persistent CRN, respectively. RESULTS: A total of 1761 patients were included in the analysis, among whom 869 (49.3%) reported CRN at least once in the 8-quarter study period, 178 (10%) reported persistent CRN, 395 (22.4%) reported intermittent CRN, and 296 (16.8%) reported transient CRN. The conditional effect in the logit model for persistent CRN revealed that baseline dual eligibility was negatively associated (adjusted odds ratio = 0.45, P < 0.01) and depression positively associated (adjusted odds ratio = 1.55, P = 0.01) with persistent CRN. The marginal analysis in the ordered logit model revealed a clear pattern of higher probabilities of persistent and intermittent CRN at younger ages while transient CRN was flat. Among the 252 subjects who were deceased, 31 (12.3%) reported persistent CRN, compared with 147 (9.74%) who were alive (P = 0.21 by χ2 test). CONCLUSIONS: A significant number of patients reported persistent CRN, including those who were at the end of life. Research is critically needed to understand behavioral patterns among the younger Medicare population.

Prevalence and persistence of cost-related medication non-adherence before and during the COVID-19 pandemic among medicare patients at high risk of hospitalization.

OBJECTIVE: To study cost-related medication non-adherence (CRN) for a 30-month period before and during the COVID-19 pandemic using a sample of Medicare patients at high risk of hospitalization. DESIGN: A novel data set of quarterly surveys of CRN was used to evaluate CRN before and during the COVID-19 pandemic. Generalized Estimating Equation (GEE) analyses were conducted to evaluate the adjusted coefficients of change in CRN behaviors controlling for socio-demographic and health characteristics. PARTICIPANTS: Six hundred seventy-seven Medicare beneficiaries at high risk of hospitalization who were alive on January 1, 2020 and followed up through quarterly surveys on CRN for 30 months before and during the COVID-19 pandemic. MAIN OUTCOMES AND MEASURES: Two metrics of prevalence and persistence of CRN and their adjusted coefficients in GEE with binomial family distribution and log link function controlling for socio-demographic and health characteristics. RESULTS: A total of 5,990 quarterly surveys were completed by the 677 patients during the 30-month study period. Among the 677 patients, 250 (37%) were men, 591 (87%) were African American, and 288 (42%) were Medicare-Medicaid dual eligible. The unadjusted prevalence of CRN before and during the COVID-19 pandemic was 31.1% and 25.7% respectively (p = 0.02 by Chi-squared test), and persistent CRN rates were 12.1% and 9.7% respectively (p = 0.17 by Chi-squared test). The adjusted odds ratio of CRN prevalence during the pandemic compared to the pre-pandemic level was 0.75 (p<0.01), and 0.74 (p = 0.03) for persistent CRN in GEE estimations. CONCLUSION AND RELEVANCE: There are coherent evidence of a reversal of CRN rates during the COVID-19 pandemic among this high-need, high-cost resource utilization Medicare population. Patients' CRN behaviors may be responsive to exogenous impacts, and the behaviors changed in the same direction with similar magnitude in terms of prevalence (the extensive margin) and persistence (the intensive margin). More research is needed to advance the understanding of the driving forces behind patients' behavioral changes and to identify factors that may be informative for reducing CRN in the long run.

Industry Payments to Urologists and Urologic Advanced Practice Providers in 2021.

OBJECTIVE: To compare industry payments from drug and medical device companies to urologists and urologic advanced practice providers (APPs) in 2021. METHODS: We used the 2020 Medicare Data on Provider Practice and Specialty file to identify single-specialty urology practices, defined as those where the majority of physicians were urologists. We then used the Open Payments Program Year 2021 data to summarize the value and number of industry payments to urologists and APPs, including nurse practitioners and physician assistants, in these practices. We calculated the total value and number of payments and median total value and number of payments per provider for urologists and urologic APPs. RESULTS: We identified 4418 urologists and 1099 APPs working in single-specialty urology practices in 2021 (Table 1). Of these, 3646 (87%) urologists received at least one industry payment, totaling $14,755,003 from 116,039 payments, and 954 urologic APPs (87%) received at least one industry payment, including 463 nurse practitioners (85%), totaling $401,283 from 13,035 payments, and 491 physician assistants (89%), totaling $543,429 from 14,626 payments. We observed significantly greater median total value and number of payments per provider for urologists ($620 and 24 payments) compared to urologic APPs ($473 and 21 payments; P < .001 and P = .017, respectively). CONCLUSION: A similar percentage of urologists and urologic APPs received industry payments in 2021. While urologists received a higher total number and total value of payments in 2021, urologic APPs were a common target of industry marketing payments.

Assessing Disparities in Video-Telehealth Use and eHealth Literacy Among Hospitalized Patients: Cross-sectional Observational Study.

BACKGROUND: Medicare coverage for audio-only telehealth is slated to end this year after the public health emergency concludes. When the time comes, many patients may be unable to make the transition from audio-only to video telehealth due to digital inexperience. This study explores the second digital divide within video telehealth use, which is primarily characterized by skills and capabilities rather than access, by measuring eHealth literacy (eHL) and video capabilities in hospitalized patients. OBJECTIVE: The aim of this study is to evaluate video capabilities, eHealth literacy, and engagement with video telehealth among hospitalized patients. METHODS: The study design is a cross-sectional observational study of adult inpatients at the University of Chicago Medical Center. We assessed self-reported rates of audio versus video telehealth usage as well as the participants' self-reported willingness to use video telehealth for future health care visits. We used a multivariable binary logistic regression to determine the odds ratio for being unwilling to use video telehealth, adjusted for age, sex, race or ethnicity, educational level, eHL literacy scale (eHEALS), health literacy (brief health literacy screen), technology access, internet access, and video capability. RESULTS: Of the 297 enrolled participants, median age was 58 years, most (n=185, 62%) identified as Black, half (n=149, 50%) were female, one-quarter (n=66, 22%) lacked home internet access, and one-third (n=102, 34%) had inadequate eHL. CONCLUSIONS: Patients with low eHL reported greater participation in audio-only telehealth over video telehealth, of which the former may lose its flexible pandemic reimbursement policy. This may widen the existing health disparities as older adults and patients with low eHL face challenges in accessing video telehealth services. Low eHL is associated with lack of web-based skills, lower rates of video telehealth usage, and lower willingness to use video technology. The study results raise the question of how to improve video capability among patients who, despite having access to smartphones and laptops, face challenges in using telehealth optimally.

eHealth Literacy and Patient Portal Use and Attitudes: Cross-sectional Observational Study.

BACKGROUND: Throughout the COVID-19 pandemic, patient portals have become more widely used tools of patient care delivery. However, not all individuals have equivalent access or ability to use patient portals. OBJECTIVE: The aim of this study is to evaluate the relationships between eHealth literacy (eHL) and patient portal awareness, use, and attitudes among hospitalized patients. METHODS: Inpatients completed patient portal surveys; eHL was assessed (eHealth Literacy Scale). Multivariable logistic regression analyses adjusted for age, self-reported race, gender, and educational attainment were completed with significance at P<.006 (Bonferroni correction). RESULTS: Among 274 participants, most identified as Black (n=166, 61%) and female (n=140, 51%), mean age was 56.5 (SD 16.7) years, and 178 (65%) reported some college or higher educational attainment. One-quarter (n=79, 28%) had low eHL (mean 27, SD 9.5), which was associated with lower odds of portal access awareness (odds ratio 0.11, 95% CI 0.05-0.23; P<.001), having ever used portals (odds ratio 0.19, 95% CI 0.10-0.36; P<.001), less perceived usefulness of portals (odds ratio 0.20, 95% CI 0.10-0.38; P=.001), and lower likelihood of planning to use portals in the coming years (odds ratio 0.12, 95% CI 0.06-0.25; P<.001). As time through the COVID-19 pandemic passed, there was a trend toward increased perceived usefulness of patient portals (53% vs 62%, P=.08), but average eHL did not increase through time (P=.81). CONCLUSIONS: Low eHL was associated with less awareness, use, and perceived usefulness of portals. Perceived usefulness of portals likely increased through the COVID-19 pandemic, but patients' eHL did not. Interventions tailored for patients with low eHL could ensure greater equity in health care delivery through the COVID-19 pandemic.

Characterizing Multisystem High Users of the Homeless Services, Jail, and Hospital Systems in Chicago, Illinois.

BACKGROUND: This study investigated the demographic characteristics, service use patterns, and needs of people who were high users of the homeless services, Cook County Jail, or hospital systems in Chicago, Illinois. METHODS: Definitions of "high users" in each system were based on number of stays and days. K-means cluster analysis was performed on the subset of individuals who interacted with all three systems and were high users of at least one system. RESULTS: Cluster analysis was conducted on 1,232 individuals and revealed three profiles. The largest cluster (N=1,059; 86%) consisted of older single individuals exhibiting high rates of disabling conditions and health issues. A second cluster (N=124; 10%) distinguished a particularly vulnerable subgroup with the highest rates of medical and mental health needs. The final, smallest cluster (N=49; 4%) consisted of predominantly younger Black women with children who exhibited the lowest rates of behavioral health issues, but high hospital use.

Effect Modification by Social Determinants of Pharmacogenetic Medication Interactions on 90-Day Hospital Readmissions within an Integrated U.S. Healthcare System.

The present study builds on our prior work that demonstrated an association between pharmacogenetic interactions and 90-day readmission. In a substantially larger, more diverse study population of 19,999 adults tracked from 2010 through 2020 who underwent testing with a 13-gene pharmacogenetic panel, we included additional covariates to evaluate aggregate contribution of social determinants and medical comorbidity with the presence of identified gene-x-drug interactions to moderate 90-day hospital readmission (primary outcome). Univariate logistic regression analyses demonstrated that strongest associations with 90 day hospital readmissions were the number of medications prescribed within 30 days of a first hospital admission that had Clinical Pharmacogenomics Implementation Consortium (CPIC) guidance (CPIC medications) (5+ CPIC medications, odds ratio (OR) = 7.66, 95% confidence interval 5.45−10.77) (p < 0.0001), major comorbidities (5+ comorbidities, OR 3.36, 2.61−4.32) (p < 0.0001), age (65 + years, OR = 2.35, 1.77−3.12) (p < 0.0001), unemployment (OR = 2.19, 1.88−2.64) (p < 0.0001), Black/African-American race (OR 2.12, 1.47−3.07) (p < 0.0001), median household income (OR = 1.63, 1.03−2.58) (p = 0.035), male gender (OR = 1.47, 1.21−1.80) (p = 0.0001), and one or more gene-x-drug interaction (defined as a prescribed CPIC medication for a patient with a corresponding actionable pharmacogenetic variant) (OR = 1.41, 1.18−1.70). Health insurance was not associated with risk of 90-day readmission. Race, income, employment status, and gene-x-drug interactions were robust in a multivariable logistic regression model. The odds of 90-day readmission for patients with one or more identified gene-x-drug interactions after adjustment for these covariates was attenuated by 10% (OR = 1.31, 1.08−1.59) (p = 0.006). Although the interaction between race and gene-x-drug interactions was not statistically significant, White patients were more likely to have a gene-x-drug interaction (35.2%) than Black/African-American patients (25.9%) who were not readmitted (p < 0.0001). These results highlight the major contribution of social determinants and medical complexity to risk for hospital readmission, and that these determinants may modify the effect of gene-x-drug interactions on rehospitalization risk.

Decreasing rates of cost-related medication non-adherence by age advancement among American generational cohorts 2004-2014: a longitudinal study.

OBJECTIVES: The access barrier to medication has been a persistent and elusive challenge in the US healthcare system and around the globe. Cost-related medication non-adherence (CRN) is an important measure of medication non-adherence behaviours that aim to avoid costs. Longitudinal study of CRN behaviours for the ageing population is rare. DESIGN: Longitudinal study using the Health and Retirement Study to evaluate self-reported CRN biennially. SETTING: General population of older Americans. PARTICIPANTS: Three cohorts of Americans aged between 50 and 54 (baby boomers), 65-69 (the silent generation) and 80 or above (the greatest generation) in 2004 who were followed to 2014. INTERVENTION: Observational with no intervention. PRIMARY AND SECONDARY OUTCOME MEASURES: Longitudinal CRN rates for three generational cohorts from 2004 to 2014. Population-averaged effects of a broad set of variables including sociodemographics, income, insurance status, limitations in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), and comorbid conditions on CRN were derived using generalised estimating equation by taking into account repeated measurements of CRN over time for the three cohorts, respectively. RESULTS: The three cohorts of baby boomer, the silent generation and the greatest generation with 1925, 2839 and 2666 respondents represented 12.3 million, 8.2 million and 7.7 million people in 2004, respectively. Increasing age was associated with decreasing likelihood of reporting CRN in all three generational cohorts (p<0.05), controlling for demographics, income, insurance status, functional status and comorbid conditions. All three generational cohorts had a higher prevalence of diabetes, cancer, heart conditions, stroke, a higher percentage of respondents with Medicare-Medicaid dual eligibility and lower percentage with private insurance in 2014 compared with 2004 (p<0.05). CONCLUSION: The paradox of decreasing CRN rates, independent of disease burden, income and insurance status, suggests populations' CRN behaviours change as Americans age, bearing implications to social policy.

Primary care physician involvement during hospitalisation: a qualitative analysis of perspectives from frequently hospitalised patients.

OBJECTIVE: To explore frequently hospitalised patients' experiences and preferences related to primary care physician (PCP) involvement during hospitalisation across two care models. DESIGN: Qualitative study embedded within a randomised controlled trial. Semistructured interviews were conducted with patients. Transcripts were analysed using qualitative template analysis. SETTING: In the Comprehensive Care Programme (CCP) Study, in Illinois, USA, Medicare patients at increased risk of hospitalisation are randomly assigned to: (1) care by a CCP physician who serves as a PCP across both inpatient and outpatient settings or (2) care by a PCP as outpatient and by hospitalists as inpatients (standard care). PARTICIPANTS: Twelve standard care and 12 CCP patients were interviewed. RESULTS: Themes included: (1) Positive attitude towards PCP; (2) Longitudinal continuity with PCP valued; (3) Patient preference for PCP involvement in hospital care; (4) Potential for in-depth involvement of PCP during hospitalisation often unrealised (involvement rare in standard care; in CCP, frequent interaction with PCP fostered patient involvement in decision making); and (5) PCP collaboration with hospital-based providers frequently absent (no interaction for standard care patients; CCP patients emphasising PCP's role in interdisciplinary coordination). CONCLUSION: Frequently hospitalised patients value PCP involvement in the hospital setting. CCP patients highlighted how an established relationship with their PCP improved interdisciplinary coordination and engagement with decision making. Inpatient-outpatient relational continuity may be an important component of programmes for frequently hospitalised patients. Opportunities for enhancing PCP involvement during hospitalisation should be considered.

Applicability of Pharmacogenomically Guided Medication Treatment during Hospitalization of At-Risk Minority Patients.

Known disparities exist in the availability of pharmacogenomic information for minority populations, amplifying uncertainty around clinical utility for these groups. We conducted a multi-site inpatient pharmacogenomic implementation program among self-identified African-Americans (AA; n = 135) with numerous rehospitalizations (n = 341) from 2017 to 2020 (NIH-funded ACCOuNT project/clinicaltrials.gov#NCT03225820). We evaluated the point-of-care availability of patient pharmacogenomic results to healthcare providers via an electronic clinical decision support tool. Among newly added medications during hospitalizations and at discharge, we examined the most frequently utilized medications with associated pharmacogenomic results. The population was predominantly female (61%) with a mean age of 53 years (range 19-86). On average, six medications were newly prescribed during each individual hospital admission. For 48% of all hospitalizations, clinical pharmacogenomic information was applicable to at least one newly prescribed medication. Most results indicated genomic favorability, although nearly 29% of newly prescribed medications indicated increased genomic caution (increase in toxicity risk/suboptimal response). More than one of every five medications prescribed to AA patients at hospital discharge were associated with cautionary pharmacogenomic results (most commonly pantoprazole/suboptimal antacid effect). Notably, high-risk pharmacogenomic results (genomic contraindication) were exceedingly rare. We conclude that the applicability of pharmacogenomic information during hospitalizations for vulnerable populations at-risk for experiencing health disparities is substantial and warrants continued prospective investigation.

Association Between the Modalities of Complementary and Alternative Medicine Use and Cost-Related Nonadherence to Medical Care Among Older Americans: A Cohort Study.

Introduction: Complementary and alternative medicine (CAM) use has been increasingly prevalent among Americans, whereas its relationship with medical nonadherence is unknown. Methods: Using the National Health Interview Survey, we evaluated the use of CAM modalities and their association with cost-related nonadherence to medical care (CRN) among older Americans by gender strata. Results: Men and women were, in general, in the same pattern of higher likelihood of reporting CRN if they utilized herbal supplements, meditation, and chiropractic or osteopathic manipulations (p < 0.05, respectively). Conclusion: Both men and women are more likely to report financial distress while using various CAM modalities.

Prevalence and Persistence of Cost-Related Medication Nonadherence Among Medicare Beneficiaries at High Risk of Hospitalization.

Importance: The unaffordability of drugs has been a persistent and elusive challenge in the US health care system. Little is known about the prevalence and persistence of cost-related medication nonadherence (CRN) in a population with high-cost, high-need resource utilization. Objective: To evaluate the prevalence and persistence of CRN among Medicare beneficiaries at high risk of hospitalization as well as the characteristics associated with CRN in this population. Design, Setting, and Participants: This cohort study used survey data from Medicare patients at high risk of hospitalization and with a life expectancy greater than 12 months at an urban academic medical center from November 6, 2012, to January 30, 2018. Patients were followed up for 12 months at 3-month intervals from baseline, for a total of 5 surveys. Data were analyzed from September 1, 2020, to January 5, 2021. Main Outcomes and Measures: Self-reported CRN, using a metric of persistence and transiency. Based on the results of the 5 surveys, CRN was categorized as persistent (3 or more surveys), intermittent (2), transient (1), and any (1 or more). Multiple logistic regression analyses were used to evaluate factors associated with persistent and transient CRN. Results: Of the 1655 Medicare beneficiaries followed up during the 15-month study period, 1036 (62.6%) were women and 1452 (87.7%) were Black or African American; 769 (46.5%) were younger than 65 years, and 886 (53.5%) were 65 years or older (mean [SD] age, 62.4 [15.9] years). A total of 374 patients (22.6%) reported CRN at baseline, 810 (48.9%) reported any CRN, and 230 (13.9%) reported persistent CRN (148 [19.2%] of those younger than 65 years and 82 [9.3%] of those 65 years or older). The 230 patients who had persistent CRN accounted for 28% of those who reported CRN at least once during the 15-month study period. Younger age (eg, <50 years vs 75 years: adjusted odds ratio [AOR], 3.07; 95% CI, 1.61-5.86; P = .001), worse self-reported health (AOR, 1.59; 95% CI, 1.10-2.31; P = .01), and depression (AOR, 1.58; 95% CI, 1.11-2.24; P = .01) were associated with greater likelihood of persistent CRN. The population-adjusted prevalence of CRN was 53.6% (887 patients). Conclusions and Relevance: The findings suggest that CRN is prevalent, moderately persistent, and variable in the Medicare population at high risk of hospitalization despite coverage by insurance. Longitudinal follow-up and refined predictive modeling of CRN appear to be needed to identify and target more precisely those with persistent CRN and to develop effective interventions.

Advancing oral health policy through persuasive messaging and effective research measures.

Oral health is often excluded from broad health policy discussions, addressed only in a policy silo. There is a paucity of research to guide policymaking as it relates to oral health. In response, AcademyHealth's Oral Health Interest Group organized a meeting during the 2019 AcademyHealth Annual Research Meeting to promote transdisciplinary dialog on the current state of oral health policy and the steps necessary to improve the oral health of Americans. This article summarizes the two main themes that emerged from the proceedings of the Oral Health Interest Group meeting: a) recommendations for advocating the inclusion of oral health in policy discussions and b) critical research topics and measures needed for effective oral health policies in the future.

Simulation-based optimization to improve hospital patient assignment to physicians and clinical units.

A fundamental activity in hospital operations is patient assignment, which we define as the process of assigning hospital patients to specific physician services and clinical units based on their diagnosis. When the preferred assignment is not possible, typically due to capacity limits, hospitals often allow for overflow, which is the assignment of patients to other services and/or units. Overflow accelerates assignment, but can also reduce care quality and increase length of stay. This paper develops a discrete-event simulation model to evaluate different assignment strategies. Using a simulation-based optimization approach, we evaluate and heuristically optimize these strategies accounting for expected hospital and physician profit, care quality and patient waiting time. We apply the model using data from the University of Chicago Medical Center. We find that the strategies that use heuristically optimized designation of overflow services and units increase expected profit relative to the capacity-based strategy in which overflow patients are assigned to a service and unit with the most available capacity. We also find further improvement in the strategy that uses heuristically optimized overflow services and units as well as a holding unit that holds patients until a bed in their primary or secondary unit becomes available. Additionally, we demonstrate the effects of these strategies on other performance measures such as patient concentration, waiting time, and outcomes.

Development and testing of a module to promote generic oral contraceptive prescribing among nurse practitioners.

Although generic oral contraceptives (OCPs) can improve adherence and reduce health care expenditures, use of generic OCPs remains low, and the factors that affect generic prescribing are not well understood. We aimed to understand the barriers and facilitators of generic OCP prescribing and potential solutions to increase generic OCP prescribing, as well as pilot an educational module to address clinician misconceptions about generic OCPs. We developed focus group scripts using the 4D model of appreciative inquiry. A total of four focus groups occurred, two at the American Association of Nurse Practitioners (AANP) national conference and two at the American College of Physicians (ACP) Internal Medicine meeting. Focus group transcripts were analyzed using a constant comparative method with no a priori hypothesis to generate emerging and reoccurring themes. Findings from these focus groups were used to develop an educational module promoting generic OCP prescribing. Participants were recruited from the AANP Network for Research and the ACP Research Panel. This study demonstrates that health system factors, workflow factors, clinician factors, and patient factors were the main barriers to and facilitators of generic OCP prescribing. Nurse practitioners were responsive to an educational module and reported increased willingness to discuss and prescribe generic OCPs after completing the module. Interventions to increase generic OCP prescribing must address clinician and patient factors within the context of workflow and larger health system factors.

The impact of marital status on health care utilization among Medicare beneficiaries.

To explain prior literature showing that married Medicare beneficiaries achieve better health outcomes at half the per person cost of single beneficiaries, we examined different patterns of healthcare utilization as a potential driver.Using the Medicare Current Beneficiary Survey (MCBS) data, we sought to understand utilization patterns in married versus currently-not-married Medicare beneficiaries. We analyzed the relationship between marital status and healthcare utilization (classified based on setting of care utilization into outpatient, inpatient, and skilled nursing facility (SNF) use) using logistic regression modeling. We specified models to control for possible confounders based on the Andersen model of healthcare utilization.Based on 13,942 respondents in the MCBS dataset, 12,929 had complete data, thus forming the analytic sample, of whom 6473 (50.3%) were married. Of these, 58% (vs. 36% of those currently-not-married) were male, 45% (vs. 47%) were age >75, 24% (vs. 70%) had a household income below $25,000, 18% (vs. 14%) had excellent self-reported general health, and 56% (vs. 36%) had private insurance. Compared to unmarried respondents, married respondents had a trend toward higher odds of having a recent outpatient visit (unadjusted odds ratio (OR) 1.11, 95% confidence interval (CI) 1.04-1.19, adjusted odds ratio (AOR) 1.10, (CI) 0.99-1.22), and lower odds in the year prior to have had an inpatient stay (AOR 0.84, CI 0.72-0.99) or a SNF stay (AOR 0.55, CI 0.40-0.75).Based on MCBS data, odds of self-reported inpatient and SNF use were lower among married respondents, while unadjusted odds of outpatient use were higher, compared to currently-not-married beneficiaries.