Trends in Medical Expenditures Prior to Diabetes Diagnosis: The Early Burden of Diabetes.

Diabetes is a costly chronic condition in the United States. The incremental increase in costs of the disease can begin and accelerate prior to first diagnosis. This study conducts a retrospective analysis of claims data from Truven Health MarketScan® Commercial Claims Database to track per capita annual medical expenditures among a single panel of commercially insured patients for 5 years preceding a new diabetes diagnosis. Case subjects, defined as individuals newly diagnosed with diabetes in 2014, are compared to control subjects, defined as individuals who do not have a diabetes diagnosis. Arithmetic means, compound annual growth rates, and propensity score matching models are used to track the differential in expenditures across health care sectors. This analysis finds that the incremental rise in costs of diabetes are shown to begin at least 5 years before diagnosis of the disease and accelerate immediately after diagnosis. Results of the matching model suggest that the newly diagnosed case subjects spent $8941 more than control subjects not diagnosed with diabetes over the span of 5 years, with approximately $4828 in the year of diagnosis. The compounded annual growth rate in per capita annual medical expenditures between 2010-2014 was almost 9% higher among case subjects at 14.3% in the matched models. Results show that the rise in medical spending associated with diabetes begins well in advance of the first diabetes diagnosis and support the need to encourage physicians to implement timely identification and prevention efforts to reduce the economic burden of the disease.

Measure Accurately, Act Rapidly, and Partner With Patients (MAP) improves hypertension control in medically underserved patients: Care Coordination Institute and American Medical Association Hypertension Control Project Pilot Study results.

Measure Accurately, Act Rapidly, and Partner With Patients (MAP) is an evidence-based protocol implemented to improve hypertension control in a clinic for underserved patients (49.9% Medicaid and 50.2% black). Patients with hypertension seen during the year before intervention and with at least one visit during the 6-month intervention (N = 714) were included. If initial attended blood pressure (BP; standard aneroid manometer) was ≥140/≥90 mm Hg, unattended automated office BP was measured in triplicate and averaged (Measure Accurately) using an Omron HEM-907XL. When automated office BP was ≥140/≥90 mm Hg, Act Rapidly included intensification of antihypertensive medications, assessed by therapeutic inertia. Partner With Patients included BP self-monitoring, reducing pill burden, and minimizing medication costs, which was assessed by systolic BP change per therapeutic intensification. Between baseline and the last study visit, BP control to <140/<90 mm Hg increased from 61.2% to 89.9% (P < .0001). MAP rapidly and significantly improved hypertension control in medically underserved patients, largely as a result of measuring BP accurately and partnering with patients.

Evaluation of Eligibility Criteria Used to Identify Patients for Medication Therapy Management Services: A Retrospective Cohort Study in a Medicare Advantage Part D Population.

BACKGROUND: General eligibility criteria used by the Centers for Medicare & Medicaid Services (CMS) to identify patients for medication therapy management (MTM) services include having multiple chronic conditions, taking multiple Part D drugs, and being likely to incur annual drug costs that exceed a predetermined threshold. The performance of these criteria in identifying patients in greatest need of MTM services is unknown. Although there are numerous possible versions of MTM identification algorithms that satisfy these criteria, there are limited data that evaluate the performance of MTM services using eligibility thresholds representative of those used by the majority of Part D sponsors. OBJECTIVES: To (a) evaluate the performance of the 2013 CMS MTM eligibility criteria thresholds in identifying Medicare Advantage Prescription Drug (MAPD) plan patients with at least 2 drug therapy problems (DTPs) relative to alternative criteria threshold levels and (b) identify additional patient risk factors significantly associated with the number of DTPs for consideration as potential future MTM eligibility criteria. METHODS: All patients in the Medicare Advantage Part D population who had pharmacy eligibility as of December 31, 2013, were included in this retrospective cohort study. Study outcomes included 7 different types of DTPs: use of high-risk medications in the elderly, gaps in medication therapy, medication nonadherence, drug-drug interactions, duplicate therapy, drug-disease interactions, and brand-to-generic conversion opportunities. DTPs were identified for each member based on 6 months of most recent pharmacy claims data and 14 months of most recent medical claims data. Risk factors examined in this study included patient demographics and prior health care utilization in the most recent 6 months. Descriptive statistics were used to summarize patient characteristics and to evaluate unadjusted relationships between the average number of DTPs identified per patient and each risk factor. Quartile values identified in the study population for number of diseases, number of drugs, and annual spend were used as potential new criteria thresholds, resulting in 27 new MTM criteria combinations. The performance of each eligibility criterion was evaluated using sensitivity, specificity, positive predictive values (PPVs), and negative predictive values (NPVs). Patients identified with at least 2 DTPs were defined as those who would benefit from MTM services and were used as the gold standard. As part of a sensitivity analysis, patients identified with at least 1 DTP were used as the gold standard. Lastly, a multivariable negative binomial regression model was used to evaluate the relationship between each risk factor and the number of identified DTPs per patient while controlling for the patients' number of drugs, number of chronic diseases, and annual drug spend. RESULTS: A total of 2,578,336 patients were included in the study. The sensitivity, specificity, PPV, and NPV of CMS MTM criteria for the 2013 plan year were 15.3%, 95.6%, 51.3%, and 78.8%, respectively. Sensitivity and PPV improved when the drug count threshold increased from 8 to 10, and when the annual drug cost decreased from $3,144 to $2,239 or less. Results were consistent when at least 1 DTP was used as the gold standard. The adjusted rate of DTPs was significantly greater among patients identified with higher drug and disease counts, annual drug spend, and prior ER or outpatient or hospital visits. Patients with higher median household incomes who were male, younger, or white had significantly lower rates of DTPs. CONCLUSIONS: The performance of MTM eligibility criteria can be improved by increasing the threshold values for drug count while decreasing the threshold value for annual drug spend. Furthermore, additional risk factors, such as a recent ER or hospital visit, may be considered as potential MTM eligibility criteria.

Cost Differences After Initial CT Colonography Versus Optical Colonoscopy in the Elderly.

RATIONALE AND OBJECTIVES: To compare differences in Medicare costs 1 year after initial computed tomographic colonography (CTC) or initial optical colonoscopy (OC). MATERIALS AND METHODS: We performed a retrospective cohort study of asymptomatic Medicare outpatients aged ≥ 66 years who received initial CTC (n = 531) or OC (n = 17,593) between January 2007 and December 2008; initial OC patients were matched on county of residence and year of screening. Outcomes included differences in total inpatient and outpatient Medicare costs 1 year after initial CTC or OC and differences in outpatient testing of potential findings in the colon, abdomen, pelvis, and lungs. RESULTS: Higher adjusted costs per patient were revealed in the year after initial CTC compared to initial OC for outpatient testing related to potential colonic ($50; 95% confidence interval [CI], $12-$88; P = .010) and extracolonic findings ($64; 95% CI, $23-$106; P = .002). However, there were no differences in adjusted total costs per patient in the year after either modality ($2065; 95% CI, $1672-$5803; P = .28). Similarly, adjusted costs did not differ between cohorts for inpatient ($267; 95% CI, $1017-$1550; P = .68) or outpatient care ($2828; 95% CI, $311-$5966; P = .08). CONCLUSIONS: Despite higher adjusted costs of outpatient testing potentially related to colonic and extracolonic findings among asymptomatic elderly patients 1 year after initial CTC compared to OC, we found no differences in adjusted total, inpatient, or outpatient costs between cohorts. Although Medicare does not cover screening CTC, our results suggest that these modalities generate comparable downstream costs to payers.

Increasing disparities in breast cancer mortality from 1979 to 2010 for US black women aged 20 to 49 years.

Racial disparities in breast cancer mortality persist, and young Black women have higher disease incidence compared with White women. We compared trends in breast cancer mortality for young Black and White women with mortality trends for other common diseases from 1979 to 2010. In contrast to other cancers, ischemic heart disease, and stroke, the breast cancer mortality disparity has widened over the past 30 years, suggesting that unique aspects of disease biology, prevention, and treatment may explain persistent racial differences for young women.

Predictors of CT colonography utilization among asymptomatic medicare beneficiaries.

BACKGROUND: Although the Centers for Medicare and Medicaid Services (CMS) denied coverage for screening computed tomography colonography (CTC) in March 2009, little is understood about whether CTC was targeted to the appropriate patient population prior to this decision. OBJECTIVE: Evaluate patient characteristics and known relative clinical indications for screening CTC among patients who received CTC compared to optical colonoscopy (OC). DESIGN/PARTICIPANTS: Cross-sectional study of all 10,538 asymptomatic Medicare beneficiaries who underwent CTC between January 2007 and December 2008, compared to a cohort of 160,113 asymptomatic beneficiaries who underwent OC, matched on county of residence and year of examination. MAIN MEASURES: Patient characteristics and known relative appropriate and inappropriate clinical indications for screening CTC. KEY RESULTS: CTC utilization was higher among women, patients > 65 years of age, white patients, and those with household income > 75 % (p = 0.001). Patients with relatively appropriate clinical indications for screening CTC were more likely to undergo CTC than OC including presumed incomplete OC (OR 80.7, 95 % CI 76.01-85.63); sedation risk (OR 1.11, 95 % CI 1.05-1.17); and chronic anticoagulation risk (OR 1.46, 95 % CI 1.38-1.54), after adjusting for patient characteristics and known clinical indications. Conversely, patients undergoing high-risk screening, an inappropriate indication, were less likely to receive CTC (OR 0.4, 95 % CI 0.37-0.42). Overall, 83 % of asymptomatic patients referred to CTC had at least one clinical indication relatively appropriate for CTC (8,772/10,538). CONCLUSION: During the 2 years preceding CMS denial for screening, CTC was targeted to asymptomatic patients with relatively appropriate clinical indications for CTC/not receiving OC. However, CTC utilization was lower among certain demographic groups, including minority patients. These findings raise the possibility that future coverage of screening CTC might exacerbate disparities in colorectal cancer screening while increasing overall screening rates.

Adherence, persistence, and switching patterns of dabigatran etexilate.

OBJECTIVE: To investigate adherence, persistence, and switching in patients initiating dabigatran. STUDY DESIGN: Descriptive analysis using pharmacy claims databases. METHODS: Patients with a claim for dabigatran and who were continuously enrolled in pharmacy benefits for 180 days prior to and 180 days following the initiation of dabigatran were identified and stratified by whether there was a history of warfarin treatment prior to dabigatran initiation. Medication adherence was calculated as the proportion of days covered (PDC). Persistence to treatment at 180 days was measured. Among patients who discontinued dabigatran, time to initiating warfarin was determined. RESULTS: In the overall population, 39.9% of 17,691 patients were nonpersistent to dabigatran. The PDC for the warfarin-naïve cohort was 0.674 (standard deviation [SD] 0.364), and 0.712 (SD 0.354) for the warfarin-experienced cohort. For patients persistent to dabigatran, the PDCs for warfarin-naïve and warfarin-experienced cohorts were 0.935 (SD 0.075) and 0.937 (SD 0.074), respectively. In patients discontinuing dabigatran, 16.1% of warfarin-naïve and 41.1% of warfarinexperienced patients initiated warfarin. Among patients discontinuing dabigatran, the mean time to discontinuation in warfarin-naïve and warfarinexperienced cohorts, respectively, was 59.8 (SD 36.2) and 59.6 (SD 36.2) days. The mean time to initiating warfarin in warfarin-naïve and warfarin experienced cohorts, respectively, was 62.5 (SD 47.2) and 60.5 (SD 43.0) days. CONCLUSIONS: Two in 5 patients discontinued dabigatran therapy within 6 months, and the majority of these patients were not anticoagulated with warfarin upon discontinuation. These findings highlight potential gaps in the care of patients treated with dabigatran in routine practice.

Cost-effectiveness of extended buprenorphine-naloxone treatment for opioid-dependent youth: data from a randomized trial.

AIMS: The objective is to estimate cost, net social cost and cost-effectiveness in a clinical trial of extended buprenorphine-naloxone (BUP) treatment versus brief detoxification treatment in opioid-dependent youth. DESIGN: Economic evaluation of a clinical trial conducted at six community out-patient treatment programs from July 2003 to December 2006, who were randomized to 12 weeks of BUP or a 14-day taper (DETOX). BUP patients were prescribed up to 24 mg per day for 9 weeks and then tapered to zero at the end of week 12. DETOX patients were prescribed up to 14 mg per day and then tapered to zero on day 14. All were offered twice-weekly drug counseling. PARTICIPANTS: 152 patients aged 15-21 years. MEASUREMENTS: Data were collected prospectively during the 12-week treatment and at follow-up interviews at months 6, 9 and 12. FINDINGS: The 12-week out-patient study treatment cost was $1514 (P < 0.001) higher for BUP relative to DETOX. One-year total direct medical cost was only $83 higher for BUP (P = 0.97). The cost-effectiveness ratio of BUP relative to DETOX was $1376 in terms of 1-year direct medical cost per quality-adjusted life year (QALY) and $25,049 in terms of out-patient treatment program cost per QALY. The acceptability curve suggests that the cost-effectiveness ratio of BUP relative to DETOX has an 86% chance of being accepted as cost-effective for a threshold of $100,000 per QALY. CONCLUSIONS: Extended BUP treatment relative to brief detoxification is cost effective in the US health-care system for the outpatient treatment of opioid-dependent youth.