Identifying treatment heterogeneity in atrial fibrillation using a novel causal machine learning method.

BACKGROUND: Lifelong oral anticoagulation is recommended in patients with atrial fibrillation (AF) to prevent stroke. Over the last decade, multiple new oral anticoagulants (OACs) have expanded the number of treatment options for these patients. While population-level effectiveness of OACs has been compared, it is unclear if there is variability in benefit and risk across patient subgroups. METHODS: We analyzed claims and medical data for 34,569 patients who initiated a nonvitamin K antagonist oral anticoagulant (non-vitamin K antagonist oral anticoagulant (NOAC); apixaban, dabigatran, and rivaroxaban) or warfarin for nonvalvular AF between 08/01/2010 and 11/29/2017 from the OptumLabs Data Warehouse. A machine learning (ML) method was applied to match different OAC groups on several baseline variables including, age, sex, race, renal function, and CHA2DS2 -VASC score. A causal ML method was then used to discover patient subgroups characterizing the head-to-head treatment effects of the OACs on a primary composite outcome of ischemic stroke, intracranial hemorrhage, and all-cause mortality. RESULTS: The mean age, number of females and white race in the entire cohort of 34,569 patients were 71.2 (SD, 10.7) years, 14,916 (43.1%), and 25,051 (72.5%) respectively. During a mean follow-up of 8.3 (SD, 9.0) months, 2,110 (6.1%) of patients experienced the composite outcome, of whom 1,675 (4.8%) died. The causal ML method identified 5 subgroups with variables favoring apixaban over dabigatran; 2 subgroups favoring apixaban over rivaroxaban; 1 subgroup favoring dabigatran over rivaroxaban; and 1 subgroup favoring rivaroxaban over dabigatran in terms of risk reduction of the primary endpoint. No subgroup favored warfarin and most dabigatran vs warfarin users favored neither drug. The variables that most influenced favoring one subgroup over another included Age, history of ischemic stroke, thromboembolism, estimated glomerular filtration rate, Race, and myocardial infarction. CONCLUSIONS: Among patients with AF treated with a NOAC or warfarin, a causal ML method identified patient subgroups with differences in outcomes associated with OAC use. The findings suggest that the effects of OACs are heterogeneous across subgroups of AF patients, which could help personalize the choice of OAC. Future prospective studies are needed to better understand the clinical impact of the subgroups with respect to OAC selection.

Effect of an Integrated Clinical Pharmacist on the Drivers of Provider Burnout in the Primary Care Setting.

PURPOSE: As the prevalence of provider burnout continues to increase, it is critical to identify interventions that may impact provider satisfaction, such as an integrated clinical pharmacist. This study aimed to assess the perceived effect of pharmacist integration on primary care provider satisfaction and drivers of provider burnout in the primary care setting. METHODS: A cross-sectional survey with 11 questions across 4 domains was distributed to primary care providers in a large integrated health system. RESULTS: Of 295 providers invited to take the survey, 119 responded (40% response rate). Most providers had worked with a pharmacist for at least 2 years and utilized them weekly or daily. At least 87% of provider respondents strongly agreed or somewhat agreed that the integrated clinical pharmacist reduced their workload by working directly with patients and non-provider staff, improved overall medication use, helped patients meet health goals and quality measures, and overall helped them to effectively manage their panel of patients. Providers found greater meaning in work through the presence of the clinical pharmacist, which allowed them more time to focus on professionally fulfilling aspects of their work and helped them feel less emotional exhaustion. Overall, 91% of providers were extremely satisfied with the clinical pharmacy service. CONCLUSIONS: These findings may be used to justify the expansion of clinical pharmacy services in primary care to practice areas experiencing problems with 4 specific drivers of provider burnout: workload and job demands, efficiency and resources, meaning in work, and social support and community at work.

Optimizing Huddle Engagement Through Leadership and Problem Solving Within Primary Care: Results from a Cluster-Randomized Trial.

BACKGROUND: Leaders play a crucial role in implementing and sustaining changes in clinical practice, yet there is limited evidence on the strategies to engage them in team problem solving and communication. OBJECTIVE: Examine the impact of an intervention focused on facilitating leadership during daily huddles on optimizing team-based care and improving outcomes. DESIGN: Cluster-randomized trial using intention-to-treat analysis to measure the effects of the intervention (n = 13 teams) compared with routine practice (n = 16 teams). PARTICIPANTS: Twenty-nine primary care clinics affiliated with a large integrated health system in the upper Midwest; representing differing practice types and geographic settings. INTERVENTION: Full-day leadership training retreat for team leaders to facilitate of care team huddles. Biweekly coaching calls and two site visits with an assigned coach. MAIN MEASURES: Primary outcomes of team development and function were collected, pre- and post-intervention using surveys. Patient satisfaction and quality outcomes were compared pre- and post-intervention as secondary outcomes. Leadership engagement and adherence to the intervention were also assessed. KEY RESULTS: A total of 279 pre-intervention and 272 post-intervention surveys were completed. We found no impact on team development (- 0.98, 95% CI (- 3.18, 1.22)), improved team credibility (0.18, 95% CI (0.00, 0.35)), but worse psychological safety (- 0.19, 95% CI (- 0.38, 0.00)). No differences were observed in patient satisfaction; however, results were mixed among quality outcomes. Post hoc analysis within the intervention group showed higher adherence to the intervention was associated with improvement in team coordination (0.47, 95% CI (0.18, 0.76)), credibility (0.28, 95% CI (0.02, 0.53)), team learning (0.42, 95% CI (0.10, 0.74)), and knowledge creation (0.74, 95% CI (0.35, 1.13)) compared to teams that were less engaged. CONCLUSIONS: Results of this evaluation showed that leadership training and facilitation were not associated with better team functioning. Additional components to the intervention tested may be necessary to enhance team functioning. TRIAL REGISTRATION: Clinicaltrials.gov Identifier NCT03062670. Registration Date: February 23, 2017. URL: https://clinicaltrials.gov/ct2/show/NCT03062670.

Association of Neighborhood Measures of Social Determinants of Health With Breast, Cervical, and Colorectal Cancer Screening Rates in the US Midwest.

Importance: Despite advances in cancer treatment and cancer-related outcomes, disparities in cancer mortality remain. Lower rates of cancer prevention screening and consequent delays in diagnosis may exacerbate these disparities. Better understanding of the association between area-level social determinants of health and cancer screening may be helpful to increase screening rates. Objective: To examine the association between area deprivation, rurality, and screening for breast, cervical, and colorectal cancer in patients from an integrated health care delivery system in 3 US Midwest states (Minnesota, Iowa, and Wisconsin). Design, Setting, and Participants: In this cross-sectional study of adults receiving primary care at 75 primary care practices in Minnesota, Iowa, and Wisconsin, rates of recommended breast, cervical, and colorectal cancer screening completion were ascertained using electronic health records between July 1, 2016, and June 30, 2017. The area deprivation index (ADI) is a composite measure of social determinants of health composed of 17 US Census indicators and was calculated for all census block groups in Minnesota, Iowa, and Wisconsin (11 230 census block groups). Rurality was defined at the zip code level. Using multivariable logistic regression, this study examined the association between the ADI, rurality, and completion of cancer screening after adjusting for age, Charlson Comorbidity Index, race, and sex (for colorectal cancer only). Main Outcomes and Measures: Completion of recommended breast, cervical, and colorectal cancer screening. Results: The study cohorts were composed of 78 302 patients eligible for breast cancer screening (mean [SD] age, 61.8 [7.1] years), 126 731 patients eligible for cervical cancer screening (mean [SD] age, 42.6 [13.2] years), and 145 550 patients eligible for colorectal cancer screening (mean [SD] age, 62.4 [7.0] years; 52.9% [77 048 of 145 550] female). The odds of completing recommended screening were decreased for individuals living in the most deprived (highest ADI) census block group quintile compared with the least deprived (lowest ADI) quintile: the odds ratios were 0.51 (95% CI, 0.46-0.57) for breast cancer, 0.58 (95% CI, 0.54-0.62) for cervical cancer, and 0.57 (95% CI, 0.53-0.61) for colorectal cancer. Individuals living in rural areas compared with urban areas also had lower rates of cancer screening: the odds ratios were 0.76 (95% CI, 0.72-0.79) for breast cancer, 0.81 (95% CI, 0.79-0.83) for cervical cancer, and 0.93 (95% CI, 0.91-0.96) for colorectal cancer. Conclusions and Relevance: Individuals living in areas of greater deprivation and rurality had lower rates of recommended cancer screening, signaling the need for effective intervention strategies that may include improved community partnerships and patient engagement to enhance access to screening in highest-risk populations.

Utilization of Cardiac Surveillance Tests in Survivors of Breast Cancer and Lymphoma After Anthracycline-Based Chemotherapy.

BACKGROUND: The National Comprehensive Cancer Network and American Society of Clinical Oncology recommend consideration of the use of echocardiography 6 to 12 months after completion of anthracycline-based chemotherapy in at-risk populations. Assessment of BNP (B-type natriuretic peptide) has also been suggested by the American College of Cardiology/American Heart Association/Heart Failure Society of America for the identification of Stage A (at risk) heart failure patients. The real-world frequency of the use of these tests in patients after receipt of anthracycline therapy, however, has not been studied previously. METHODS AND RESULTS: In this retrospective study, using administrative claims data from the OptumLabs Data Warehouse, we identified 31 447 breast cancer and lymphoma patients (age ≥18 years) who were treated with an anthracycline in the United States between January 1, 2008 and January 31, 2018. Continuous medical and pharmacy coverage was required for at least 6 months before the initial anthracycline dose and 12 months after the final dose. Only 36.1% of patients had any type of cardiac surveillance (echocardiography, BNP, or cardiac imaging) in the year following completion of anthracycline therapy (29.7% echocardiography). Surveillance rate increased from 37.5% in 2008 to 42.7% in 2018 (25.6% in 2008 to 40.5% echocardiography in 2018). Lymphoma patients had a lower likelihood of any surveillance compared with patients with breast cancer (odds ratio, 0.79 [95% CI, 0.74-0.85]; P<0.001). Patients with preexisting diagnoses of coronary artery disease and arrhythmia had the highest likelihood of cardiac surveillance (odds ratio, 1.54 [95% CI, 1.39-1.69] and odds ratio, 1.42 [95% CI, 1.3-1.53]; P<0.001 for both), although no single comorbidity was associated with a >50% rate of surveillance. CONCLUSIONS: The majority of survivors of breast cancer and lymphoma who have received anthracycline-based chemotherapy do not undergo cardiac surveillance after treatment, including those with a history of cardiovascular comorbidities, such as heart failure.

Development and Implementation of a Team-Based, Primary Care Delivery Model: Challenges and Opportunities.

In this article, we describe the implementation of a team-based care model during the first 2 years (2016-2017) after Mayo Clinic designed and built a new primary care clinic in Rochester, Minnesota. The clinic was configured to accommodate a team-based care model that included complete colocation of clinical staff to foster collaboration, designation of a physician team manager to support a physician to advanced practice practitioner ratio of 1:2, expanded roles for registered nurses, and integration of clinical pharmacists, behavioral health specialists, and community specialists; this model was designed to accommodate the growth of nonvisit care. We describe the implementation of this team-based care model and the key metrics that were tracked to assess performance related to the quadruple aim of improving population health, improving patient experience, reducing cost, and supporting care team's work life.

Care Transitions Program for High-Risk Frail Older Adults is Most Beneficial for Patients with Cognitive Impairment.

BACKGROUND: Although posthospitalization care transitions programs (CTP) are highly diverse, their overall program thoroughness is most predictive of their success. OBJECTIVE: To identify components of a successful homebased CTP and patient characteristics that are most predictive of reduced 30-day readmissions. DESIGN: Retrospective cohort. PATIENTS: A total of 315 community-dwelling, hospitalized, older adults (≥60 years) at high risk for readmission (Elder Risk Assessment score ≥16), discharged home over the period of January 1, 2011 to June 30, 2013. SETTING: Midwest primary care practice in an integrated health system. INTERVENTION: Enrollment in a CTP during acute hospitalization. MEASUREMENTS: The primary outcome was all-cause readmission within 30 days of the first CTP evaluation. Logistic regression was used to examine independent variables, including patient demographics, comorbidities, number of medications, completion, and timing of program fidelity measures, and prior utilization of healthcare. RESULTS: The overall 30-day readmission rate was 17.1%. The intensity of follow-up varied among patients, with 17.1% and 50.8% of the patients requiring one and ≥3 home visits, respectively, within 30 days. More than half (54.6%) required visits beyond 30 days. Compared with patients who were not readmitted, readmitted patients were less likely to exhibit cognitive impairment (29.6% vs 46.0%; P = .03) and were more likely to have high medication use (59.3% vs 44.4%; P = .047), more emergency department (ED; 0.8 vs 0.4; P = .03) and primary care visits (4.0 vs 3.0; P = .018), and longer cumulative time in the hospital (4.6 vs 2.5 days; P = .03) within 180 days of the index hospitalization. Multivariable analysis indicated that only cognitive impairment and previous ED visits were important predictors of readmission. CONCLUSIONS: No single CTP component reliably predicted reduced readmission risk. Patients with cognitive impairment and polypharmacy derived the most benefit from the program.

Renal Outcomes in Anticoagulated Patients With Atrial Fibrillation.

BACKGROUND: Lifelong oral anticoagulation, either with warfarin or a non-vitamin K antagonist oral anticoagulant (NOAC), is indicated for stroke prevention in most patients with atrial fibrillation (AF). Emerging evidence suggests that NOACs may be associated with better renal outcomes than warfarin. OBJECTIVES: This study aimed to compare 4 oral anticoagulant agents (apixaban, dabigatran, rivaroxaban, and warfarin) for their effects on 4 renal outcomes: ≥30% decline in estimated glomerular filtration rate (eGFR), doubling of the serum creatinine level, acute kidney injury (AKI), and kidney failure. METHODS: Using a large U.S. administrative database linked to laboratory results, the authors identified 9,769 patients with nonvalvular AF who started taking an oral anticoagulant agent between October 1, 2010 and April 30, 2016. Inverse probability of treatment weighting was used to balance more than 60 baseline characteristics among patients in the 4 drug cohorts. Cox proportional hazards regression was performed in the weighted population to compare oral anticoagulant agents. RESULTS: The cumulative risk at the end of 2 years for each outcome was 24.4%, 4.0%, 14.8%, and 1.7% for ≥30% decline in eGFR, doubling of serum creatinine, AKI, and kidney failure, respectively. When the 3 NOACs were pooled, they were associated with reduced risks of ≥30% decline in eGFR (hazard ratio [HR]: 0.77; 95% confidence interval [CI]: 0.66 to 0.89; p < 0.001), doubling of serum creatinine (HR: 0.62; 95% CI: 0.40 to 0.95; p = 0.03), and AKI (HR: 0.68; 95% CI: 0.58 to 0.81; p < 0.001) compared with warfarin. When comparing each NOAC with warfarin, dabigatran was associated with lower risks of ≥30% decline in eGFR and AKI; rivaroxaban was associated with lower risks of ≥30% decline in eGFR, doubling of serum creatinine, and AKI; however, apixaban did not have a statistically significant relationship with any of the renal outcomes. CONCLUSIONS: Renal function decline is common among patients with AF treated with oral anticoagulant agents. NOACs, particularly dabigatran and rivaroxaban, may be associated with lower risks of adverse renal outcomes than warfarin.

Effects of Different Models of Dialysis Care on Patient-Important Outcomes: A Systematic Review and Meta-Analysis.

Ongoing payment reform in dialysis necessitates better patient outcomes and lower costs. Suggested improvements to processes of care for maintenance dialysis patients are abundant; however, their impact on patient-important outcomes is unclear. This systematic review included comparative randomized controlled trials or observational studies with no restriction on language, published from 2000 to 2014, involving at least 5 adult dialysis patients who received a minimum of 6 months of follow-up. The effect size was pooled and stratified by intervention strategy (multidisciplinary care [MDC], home dialysis, alternate dialysis settings, and electronic health record implementation). Heterogeneity (I2) was used to assess the variability in study effects related to study differences rather than chance. Of the 1988 articles screened, 25 international studies with 74,833 maintenance dialysis patients were included. Interventions with MDC or home dialysis were associated with a lower mortality (hazard ratio [HR] = 0.72, 95% confidence interval [CI] 0.61, 0.84, I2 = 41.6%; HR = 0.57, 95% CI 0.41, 0.81, I2 = 89.0%; respectively) and hospitalizations (incidence rate ratio [IRR] = 0.68, 95% CI 0.51, 0.91, I2 = NA; IRR = 0.88, 95% CI 0.64, 1.20, I2 = 79.6%; respectively). Alternate dialysis settings also were associated with a reduction in hospitalizations (IRR = 0.41, 95% CI 0.25, 0.69, I2 = 0.0%). This systematic review underscores the importance of multidisciplinary care, and also the value of telemedicine as a means to increase access to providers and enhance outcomes for those dialyzing at home or in alternate settings, including those with limited access to nephrology expertise because of travel distance.

Direct Comparison of Dabigatran, Rivaroxaban, and Apixaban for Effectiveness and Safety in Nonvalvular Atrial Fibrillation.

BACKGROUND: The introduction of non-vitamin K antagonist oral anticoagulants (NOACs) has been a major advance for stroke prevention in atrial fibrillation (AF). Patients and clinicians now have a choice between different NOACs, but there is no direct comparative effectiveness evidence to guide decision-making. We aimed to compare the effectiveness and safety of dabigatran, rivaroxaban, and apixaban in clinical practice. METHODS: Using a large US administrative claims database, we created three one-to-one propensity-score-matched cohorts of patients with nonvalvular AF who were users of dabigatran, rivaroxaban, or apixaban between October 1, 2010 and February 28, 2015 (rivaroxaban vs dabigatran, n = 31,574; apixaban vs dabigatran, n = 13,084; and apixaban vs rivaroxaban, n = 13,130). The primary outcomes were stroke and systemic embolism (effectiveness) and major bleeding (safety) that occurred during treatment. Cox proportional hazards models were used to compare outcomes in propensity-score-matched cohorts. RESULTS: We found no differences between the three NOACs in the risk of stroke or systemic embolism (hazard ratio [HR], 1.00; 95% CI, 0.75-1.32 for rivaroxaban vs dabigatran; HR, 0.82; 95% CI, 0.51-1.31 for apixaban vs dabigatran; and HR, 1.05; 95% CI, 0.64-1.72 for apixaban vs rivaroxaban). Apixaban was associated with a lower risk of major bleeding (HR, 0.50; 95% CI, 0.36-0.70; P < .001 vs dabigatran and HR, 0.39; 95% CI, 0.28-0.54; P < .001 vs rivaroxaban). Rivaroxaban was associated with an increased risk of major bleeding (HR, 1.30; 95% CI, 1.10-1.53; P < .01) and intracranial bleeding (HR, 1.79; 95% CI, 1.12-2.86; P < .05) compared with dabigatran. CONCLUSIONS: Dabigatran, rivaroxaban, and apixaban appear to have similar effectiveness, although apixaban may be associated with a lower bleeding risk and rivaroxaban may be associated with an elevated bleeding risk.

Disparities in Treatment of Patients With High-risk Prostate Cancer: Results From a Population-based Cohort.

OBJECTIVE: To assess the variation in primary treatment of high-risk prostate cancer (PCa) by different hospital characteristics in the United States. MATERIALS AND METHODS: We used the National Cancer Data Base to identify patients diagnosed with pretreatment high-risk PCa from 2004 to 2011. The primary outcomes were different forms of primary therapy or watchful waiting (WW) across different types of hospitals (community, comprehensive cancer community, and academic hospitals). Multivariable logistic regression analyses were used to test for differences in treatment by hospital type. RESULTS: During the study period, we identified 102,701 men diagnosed with high-risk PCa. Overall, the most common treatment was radical prostatectomy (37.0%) followed by radiation therapy (33.2%) and WW (8.5%). Compared with white men with high-risk PCa, black men had lower adjusted odds ratios (OR) for surgery at comprehensive community (OR: 0.64; P <.001) and academic (OR: 0.62; P <.001) hospitals. Similarly, black men were also more likely to be managed with WW at community (OR: 1.49; P <.001), comprehensive cancer community (OR: 1.24; P <.001), and academic (OR: 1.55; P <.001) hospitals, as well as with radiation therapy at comprehensive cancer community (OR: 1.27; P <.001) and academic hospitals (OR: 1.23; P <.001). CONCLUSION: Disparities in the use of WW and different primary treatments among patients with high-risk PCa persisted across different types of hospitals and over time. Our findings highlight a significant racial disparity in the use of curative therapy for high-risk PCa that should be urgently addressed to ensure that all men with PCa receive appropriate care across all racial groups and cancer care facilities.

The Method for Performance Measurement Matters: Diabetes Care Quality as Measured by Administrative Claims and Institutional Registry.

OBJECTIVES: Performance measurement is used by health care providers, payers, and patients. Historically accomplished using administrative data, registries are used increasingly to track and improve care. We assess how measured diabetes care quality differs when calculated using claims versus registry. DATA SOURCES/STUDY SETTING: Cross-sectional analysis of administrative claims and electronic health records (EHRs) of patients in a multispecialty integrated health system in 2012 (n = 368,883). STUDY DESIGN: We calculated percent of patients attaining glycohemoglobin <8.0 percent, LDL cholesterol <100 mg/dL, blood pressure <140/90 mmHg, and nonsmoking (D4) in cohorts, identified by Medicare Accountable Care Organization/Minnesota Community Measures (ACO-MNCM; claims-based), Healthcare Effectiveness Data and Information Set (HEDIS; claims-based), and registry (EHR-based). DATA COLLECTION/EXTRACTION METHODS: Claims were linked to EHR to create a dataset of performance-eligible patients. PRINCIPAL FINDINGS: ACO-MNCM, HEDIS, and registry identified 6,475, 6,989, and 6,425 measurement-eligible patients. Half were common among the methods; discrepancies were due to attribution, age restriction, and encounter requirements. D4 attainment was lower in ACO-MNCM (36.09 percent) and HEDIS (37.51 percent) compared to registry (43.74 percent) cohorts. CONCLUSIONS: Registry- and claims-based performance measurement methods identify different patients, resulting in different rates of quality metric attainment with implications for innovative population health management.

Cost-effectiveness of proton beam therapy for intraocular melanoma.

PURPOSE: Proton beam therapy is a commonly accepted treatment for intraocular melanomas, but the literature is lacking in descriptions of patient preferences of clinical outcomes and economic impact. In addition, no economic evaluations have been published regarding the incremental cost-effectiveness of proton beam therapy compared with enucleation or plaque brachytherapy, typical alternative treatments. We, therefore, conducted a cost-utility analysis of these three approaches for the treatment of intraocular melanomas. MATERIALS AND METHODS: A Markov model was constructed. Model parameters were identified from the published literature and publicly available data sources. Cost-effectiveness of each treatment was calculated in 2011 US Dollars per quality-adjusted life-year. Incremental cost-effectiveness ratios were calculated assuming enucleation as reference. One-way sensitivity analyses were conducted on all model parameters. A decision threshold of $50,000/quality-adjusted life-year was used to determine cost-effectiveness. RESULTS: Enucleation had the lowest costs and quality-adjusted life-years, and plaque brachytherapy had the highest costs and quality-adjusted life-years. Compared with enucleation, the base-case incremental cost-effectiveness ratios for plaque brachytherapy and proton beam therapy were $77,500/quality-adjusted life-year and $106,100/quality-adjusted life-year, respectively. Results were highly sensitive to multiple parameters. All three treatments were considered optimal, and even dominant, depending on the values used for sensitive parameters. CONCLUSION: Base-case analysis results suggest enucleation to be optimal. However, the optimal choice was not robust to sensitivity analyses and, depending on the assumption, both plaque brachytherapy and proton beam therapy could be considered cost-effective. Future clinical studies should focus on generating further evidence with the greatest parameter uncertainty to inform future cost-effectiveness analyses.

The net value of health care for patients with type 2 diabetes, 1997 to 2005.

BACKGROUND: The net economic value of increased health care spending remains unclear, especially for chronic diseases. OBJECTIVE: To assess the net value of health care for patients with type 2 diabetes. DESIGN: Economic analysis of observational cohort data. SETTING: Mayo Clinic, Rochester, Minnesota, a not-for-profit integrated health care delivery system. PATIENTS: 613 patients with type 2 diabetes. MEASUREMENTS: Changes in inflation-adjusted annual health care spending and in health status between 1997 and 2005 (with health status defined as 10-year cardiovascular risk), holding age and diabetes duration constant across the observation period ("modifiable risk"), and simulated outcomes for all diabetes complications based on the UKPDS (United Kingdom Perspective Diabetes Study) Outcomes Model. Net value was estimated as the present discounted monetary value of improved survival and avoided treatment spending for coronary heart disease minus the increase in annual spending per patient. RESULTS: Assuming that 1 life-year is worth $200,000 and accounting for changes in modifiable cardiovascular risk, the net value of changes in health care for patients with type 2 diabetes was $10,911 per patient (95% CI, -$8480 to $33,402) between 1997 and 2005, a positive dollar value that suggests the value of health care has improved despite increased spending. A second approach based on diabetes complications yielded a net value of $6931 per patient (CI, -$186,901 to $211,980). LIMITATION: The patient population was homogeneous and small, and the wide CIs of the estimates are compatible with a decrease as well as an increase in value. CONCLUSION: The economic value of improvements in health status for patients with type 2 diabetes seems to exceed or equal increases in health care spending, suggesting that those increases were worth the extra cost. However, the possibility that society is getting less value for its money could not be statistically excluded, and there is opportunity to improve the value of diabetes-related health care. PRIMARY FUNDING SOURCE: None.

Projecting future drug expenditures--2006.

PURPOSE: Drug expenditure trends in 2004 and 2005, projected drug expenditures for 2006, and factors likely to influence drug costs are discussed. SUMMARY: Various factors are likely to affect drug costs, including drug prices, drugs in development, and generic drugs. In 2004 there was a continued moderation of the increase in drug expenditures. Drug expenditures increased by 8.7% from 2003 to 2004. Through the first nine months of 2005, expenditures increased by only 8.1% compared with 2004. This moderation can be attributed to several factors, including the continued trend toward higher prescription drug cost sharing for insured consumers, growing availability of generic drugs, and lack of "blockbuster" new drugs in recent years. Drug expenditures in 2006 will likely be influenced by similar factors, with few costly new products reaching the market, increased concern over product safety slowing the diffusion of those new agents that do reach the market, and several important patent expirations, leading to slower growth in expenditures. CONCLUSION: Forecasting and managing rising drug expenditures remains a challenge. Pharmacy managers must remain vigilant in monitoring drug costs in their health system and take a proactive role in pursuing efficient drug utilization. The dynamic health policy environment further complicates drug budgeting and must be considered, especially in integrated health systems responsible for managing inpatient, outpatient, and clinic drug costs. The comparison of health-system-specific data and trends with the national information presented in this article may provide a useful context when presenting institutional drug costs to senior management.