Health Care Resource Utilization and Total Costs of Care for Adult Patients With Relapsed or Refractory Acute Lymphoblastic Leukemia in the United States: A Retrospective Claims Analysis.

PURPOSE: Although immunotherapies such as blinatumomab and inotuzumab have led to improved outcomes, financial burden and health resource utilization (HRU) have increased for adult patients with relapsed or refractory B-cell acute lymphoblastic leukemia (R/R B-ALL). This study assessed real-world HRU and costs of care among adult patients with R/R B-ALL by line of therapy (LoT) in the United States. METHODS: We selected patients from the MarketScanⓇ Database (January 1, 2016 through December 31, 2020) as follows: ≥1 claims of ALL-indicated first-line (1L) therapies, ≥1 diagnosis of ALL before the index date (1L initiation date), 6-month continuous enrollment before the index date, second-line (2L) therapy initiation, ≥18 years old at 2L, no clinical trial enrollment, no diagnosis of other forms of non-Hodgkin's lymphoma, and no claim for daratumumab or nelarabine during the study period. Outcome measures included claim-based time to next treatment (TTNT), all-cause and adverse event (AE)-related HRU, and all-cause and AE-related costs. FINDINGS: The R/R B-ALL cohort (N = 203) was 60% male, median age of 41 years, and median Charlson Comorbidity Index score of 3.0. Mean (SD) follow-up was 17.8 (11.8) months. Of those who received 2L, 55.7% (113/203) required 3L, and 15% (30/203) initiated 4L+. Patients relapsed quickly, with a median TTNT of 170 days, 169 days, and 205 days for 2L, 3L, and 4L+, respectively. Hospitalization rates were high across each LoT (2L, 88%; 3L, 73%; 4L+, 73%), and the mean (SD) inpatient length of stay increased by LoT as follows: 8.6 (6.8) days for 2L, 10.6 (13.3) for 3L, and 11.6 (13.6) for 4L+. Mean (SD) overall costs were substantial within each LoT at $513,279 ($599,209), $340,419 ($333,555), and $390,327 ($332,068) for 2L, 3L, and 4L+, respectively. The mean (SD) overall/per-patient-per-month AE-related costs were $358,676 ($497,998) for 2L, $202,621 ($272,788) for 3L, and $210,539 ($267,814) for 4L+. Among those receiving blinatumomab or inotuzumab within each LoT, the mean (SD) total costs were $566,373 ($621,179), $498,070 ($376,260), and $512,908 ($159,525) for 2L, 3L, and 4L+, respectively. IMPLICATIONS: These findings suggest that adult patients with R/R B-ALL relapse frequently with standard of care and incur a substantial HRU and cost burden with each LoT. Those treated with blinatumomab or inotuzumab incurred higher total costs within each LoT compared with the overall R/R B-ALL cohort. Alternative therapies with longer duration of remission are urgently needed, and HRU should be considered for future studies examining the optimal sequencing of therapy.

Association between cervical artery dissection and spinal manipulative therapy -a medicare claims analysis.

BACKGROUND: Cervical artery dissection and subsequent ischemic stroke is the most serious safety concern associated with cervical spinal manipulation. METHODS: We evaluated the association between cervical spinal manipulation and cervical artery dissection among older Medicare beneficiaries in the United States. We employed case-control and case-crossover designs in the analysis of claims data for individuals aged 65+, continuously enrolled in Medicare Part A (covering hospitalizations) and Part B (covering outpatient encounters) for at least two consecutive years during 2007-2015. The primary exposure was cervical spinal manipulation; the secondary exposure was a clinical encounter for evaluation and management for neck pain or headache. We created a 3-level categorical variable, (1) any cervical spinal manipulation, 2) evaluation and management but no cervical spinal manipulation and (3) neither cervical spinal manipulation nor evaluation and management. The primary outcomes were occurrence of cervical artery dissection, either (1) vertebral artery dissection or (2) carotid artery dissection. The cases had a new primary diagnosis on at least one inpatient hospital claim or primary/secondary diagnosis for outpatient claims on at least two separate days. Cases were compared to 3 different control groups: (1) matched population controls having at least one claim in the same year as the case; (2) ischemic stroke controls without cervical artery dissection; and (3) case-crossover analysis comparing cases to themselves in the time period 6-7 months prior to their cervical artery dissection. We made each comparison across three different time frames: up to (1) 7 days; (2) 14 days; and (3) 30 days prior to index event. RESULTS: The odds of cervical spinal manipulation versus evaluation and management did not significantly differ between vertebral artery dissection cases and any of the control groups at any of the timepoints (ORs 0.84 to 1.88; p > 0.05). Results for carotid artery dissection cases were similar. CONCLUSION: Among Medicare beneficiaries aged 65 and older who received cervical spinal manipulation, the risk of cervical artery dissection is no greater than that among control groups.

Comparison of real-world clinical and economic outcomes in patients receiving oral anticoagulants: A retrospective claims analysis.

BACKGROUND: Direct oral anticoagulants (DOACs) have become widely used for the prevention of stroke in nonvalvular atrial fibrillation (AF) and for the treatment of venous thromboembolism (VTE). Warfarin, the standard of care prior to DOACs, requires monitoring and dose adjustment to ensure patients remain appropriately anticoagulated. DOACs do not require monitoring but are significantly more expensive. We sought to examine real-world effectiveness and costs of DOACs and warfarin in patients with AF and VTE. OBJECTIVE: To examine clinical and economic outcomes. The clinical objectives were to determine the bleeding and thrombotic event rates associated with DOACs vs warfarin. The economic objectives were to determine the cost associated with these events, as well as the all-cause medical and pharmacy costs associated with DOACs vs warfarin. METHODS: This analysis was an observational, propensity-matched comparison of retrospective medical and pharmacy claims data for members enrolled in an integrated health plan between October 1, 2015, and September 30, 2020. Members who were older than 18 years of age with at least 1 30-day supply of warfarin or a DOAC filled within 30 days of a new diagnosis of VTE or nonvalvular AF were eligible for the analysis. Cox hazard ratios were used to compare differences in clinical outcomes, where paired t-tests were used to evaluate economic outcomes. RESULTS: After matching, there were 893 patients in each group. Among matched members, warfarin was associated with increased risk of nonmajor bleeds relative to apixaban (hazard ratio [HR] = 1.526; P = 0.0048) and increased risk of pulmonary embolism relative to both DOACs (apixaban: HR = 1.941 [P = 0.0328]; rivaroxaban: HR = 1.833 [P = 0.0489]). No statistically significant difference was observed in hospitalizations or in length of stay between warfarin and either DOAC. The difference-in-difference (DID) in total costs of care per member per month for apixaban and rivaroxaban relative to warfarin were $801.64 (P = 0.0178) and $534.23 (P = 0.0998) more, respectively. DID in VTE-related cost for apixaban was $177.09 less, relative to warfarin (P = 0.0098). DID in all-cause pharmacy costs for apixaban and rivaroxaban relative to warfarin were $342.47 (P < 0.0001) and $386.42 (P < 0.001) more, respectively. CONCLUSIONS: Warfarin use was associated with a significant decrease in total cost of care despite a significant increase in VTE-related costs vs apixaban. Warfarin was also associated with a significant increase in other nonmajor bleeds relative to apixaban, as well as a significant increase in pulmonary embolism relative to both DOACs. Warfarin was associated with a significant reduction in all-cause pharmacy cost compared with either DOAC. DISCLOSURES: The authors of this study have nothing to disclose.

Relationship between continuity of care and clinical outcomes in patients with dyslipidemia in Korea: a real world claims database study.

Dyslipidemia is a risk factor for atherosclerotic cardiovascular disease and requires proactive management. This study aimed to investigate the association between care continuity and the outcomes of patients with dyslipidemia. We conducted a retrospective cohort study on patients with dyslipidemia by employing the Korea National Health Insurance claims database during the period 2007-2018. The Continuity of Care Index (COCI) was used to measure continuity of care. We considered incidence of atherosclerotic cardiovascular disease as a primary outcome. A Cox's proportional hazards regression model was used to quantify risks of primary outcome. There were 236,486 patients newly diagnosed with dyslipidemia in 2008 who were categorized into the high and low COC groups depending on their COCI. The adjusted hazard ratio for the primary outcome was 1.09 times higher (95% confidence interval: 1.06-1.12) in the low COC group than in the high COC group. The study shows that improved continuity of care for newly-diagnosed dyslipidemic patients might reduce the risk of atherosclerotic cardiovascular disease.

Improving Stroke Risk Prediction in the General Population: A Comparative Assessment of Common Clinical Rules, a New Multimorbid Index, and Machine-Learning-Based Algorithms.

BACKGROUND: There are few large studies examining and predicting the diversified cardiovascular/noncardiovascular comorbidity relationships with stroke. We investigated stroke risks in a very large prospective cohort of patients with multimorbidity, using two common clinical rules, a clinical multimorbid index and a machine-learning (ML) approach, accounting for the complex relationships among variables, including the dynamic nature of changing risk factors. METHODS: We studied a prospective U.S. cohort of 3,435,224 patients from medical databases in a 2-year investigation. Stroke outcomes were examined in relationship to diverse multimorbid conditions, demographic variables, and other inputs, with ML accounting for the dynamic nature of changing multimorbidity risk factors, two clinical risk scores, and a clinical multimorbid index. RESULTS: Common clinical risk scores had moderate and comparable c indices with stroke outcomes in the training and external validation samples (validation-CHADS2: c index 0.812, 95% confidence interval [CI] 0.808-0.815; CHA2DS2-VASc: c index 0.809, 95% CI 0.805-0.812). A clinical multimorbid index had higher discriminant validity values for both the training/external validation samples (validation: c index 0.850, 95% CI 0.847-0.853). The ML-based algorithms yielded the highest discriminant validity values for the gradient boosting/neural network logistic regression formulations with no significant differences among the ML approaches (validation for logistic regression: c index 0.866, 95% CI 0.856-0.876). Calibration of the ML-based formulation was satisfactory across a wide range of predicted probabilities. Decision curve analysis demonstrated that clinical utility for the ML-based formulation was better than that for the two current clinical rules and the newly developed multimorbid tool. Also, ML models and clinical stroke risk scores were more clinically useful than the "treat all" strategy. CONCLUSION: Complex relationships of various comorbidities uncovered using a ML approach for diverse (and dynamic) multimorbidity changes have major consequences for stroke risk prediction. This approach may facilitate automated approaches for dynamic risk stratification in the significant presence of multimorbidity, helping in the decision-making process for risk assessment and integrated/holistic management.

Substitution of Nonpharmacologic Therapy With Opioid Prescribing for Pain During the COVID-19 Pandemic.

Importance: During the pandemic, access to medical care unrelated to COVID-19 was limited because of concerns about viral spread and corresponding policies. It is critical to assess how these conditions affected modes of pain treatment, given the addiction risks of prescription opioids. Objective: To assess the trends in opioid prescription and nonpharmacologic therapy (ie, physical therapy and complementary medicine) for pain management during the COVID-19 pandemic in 2020 compared with the patterns in 2019. Design, Setting, and Participants: This retrospective, cross-sectional study used weekly claims data from 24 million US patients in a nationwide commercial insurance database (Optum's deidentified Clinformatics Data Mart Database) from January 1, 2019, to September 31, 2020. Among patients with diagnoses of limb, extremity, or joint pain, back pain, and neck pain for each week, patterns of treatment use were identified and evaluated. Data analysis was performed from April 1, 2021, to September 31, 2021. Main Outcomes and Measures: The main outcomes of interest were weekly rates of opioid prescriptions, the strength and duration of related opioid prescriptions, and the use of nonpharmacologic therapy. Transition rates between different treatment options before the outbreak and during the early months of the pandemic were also assessed. Results: A total of 21 430 339 patients (mean [SD] age, 48.6 [24.0] years; 10 960 507 [51.1%] female; 909 061 [4.2%] Asian, 1 688 690 [7.9%] Black, 2 276 075 [10.6%] Hispanic, 11 192 789 [52.2%] White, and 5 363 724 [25.0%] unknown) were enrolled during the first 3 quarters in 2019 and 20 759 788 (mean [SD] age, 47.0 [23.8] years; 10 695 690 [51.5%] female; 798 037 [3.8%] Asian; 1 508 023 [7.3%] Black, 1 976 248 [9.5%] Hispanic, 10 059 597 [48.5%] White, and 6 417 883 [30.9%] unknown) in the first 3 quarters of 2020. During the COVID-19 pandemic, the proportion of patients receiving a pain diagnosis was smaller than that for the same period in 2019 (mean difference, -15.9%; 95% CI, -16.1% to -15.8%). Patients with pain were more likely to receive opioids (mean difference, 3.5%; 95% CI, 3.3%-3.7%) and less likely to receive nonpharmacologic therapy (mean difference, -6.0%; 95% CI, -6.3% to -5.8%), and opioid prescriptions were longer and more potent during the early pandemic in 2020 relative to 2019 (mean difference, 1.07 days; 95% CI, 1.02-1.17 days; mean difference, 0.96 morphine milligram equivalents; 95% CI, 0.76-1.20). Analysis of individuals' transitions between treatment options for pain found that patients were more likely to transition out of nonpharmacologic therapy, replacing it with opioid prescriptions for pain management during the COVID-19 pandemic than in the year before. Conclusions and Relevance: Nonpharmacologic therapy is a benign treatment for pain often recommended instead of opioid therapy. The decrease in nonpharmacologic therapy and increase in opioid prescription during the COVID-19 pandemic found in this cross-sectional study, especially given longer days of prescription and more potent doses, may exacerbate the US opioid epidemic. These findings suggest that it is imperative to investigate the implications of limited medical access on treatment substitution, which may increase patient risk, and implement policies and guidelines to prevent those substitutions.

Utilization of a Colorectal Cancer Screening Test Among Individuals With Average Risk.

Importance: Colorectal cancer (CRC) screening reduces CRC incidence and mortality. It is important to examine screening patterns over time, including after the introduction of new screening modalities. Objective: To compare use of CRC screening tests before and after the availability of the multitarget stool DNA (mt-sDNA) test, given that endorsed options have changed. Design, Setting, and Participants: This longitudinal cohort study used administrative claims data to examine CRC screening use in 2 discrete periods: before (August 1, 2011, to July 31, 2014) and after (August 1, 2016, to July 31, 2019) the mt-sDNA test became available. The MarketScan Commercial and Medicare Supplemental databases were queried for individuals aged 45 to 75 years between August 1, 2011, and July 31, 2019, with average risk of CRC and with continuous enrollment in the databases from August 1, 2001, to July 31, 2019. Main Outcomes and Measures: The proportion of individuals up to date or not due for CRC screening during each measurement year and the type of screening test used among individuals due for screening. Data were reported overall and among individuals aged 45 to 49 or 50 years and older on August 1, 2011. Results: A total of 97 776 individuals with average risk were identified. Individuals had a mean (SD) age of 50.8 (3.5) years, and 54 227 (55.5%) were women. The proportion of individuals with average risk aged 50 to 75 years with commercial or Medicare supplemental insurance who were up to date with CRC screening increased from 50.4% in 2011 (30 605 of 60 770) to 69.7% in 2019 (42 367 of 60 770). Among individuals due for screening and screened, the use of high-sensitivity fecal occult blood test (FOBT) decreased between 2011 (1088 of 6241 eligible individuals [17.7%]) and 2019 (195 of 2943 eligible individuals [6.6%]), and the use of mt-sDNA increased between 2016 (58 of 3014 eligible individuals [1.9%]) and 2019 (418 of 2943 eligible individuals [14.2%]). No consistent trends were observed with fecal immunochemical test (FIT) or screening colonoscopy. Computed tomography colonography, double-contrast barium enema, and flexible sigmoidoscopy were rarely performed. Conclusions and Relevance: In this cohort study, the proportion of individuals with average risk who were up to date with CRC screening increased between 2011 and 2019 but remained suboptimal. There were no substantial changes in the use of the colonoscopy or FIT; however, there was an increase in the adoption of mt-sDNA and a decrease in the use of FOBT during the study period.

Real-World Claims Analyses of Comorbidity Burden, Treatment Pattern, Healthcare Resource Utilization, and Costs in Pediatric Psoriasis.

INTRODUCTION: There are limited real-world data on treatment patterns, comorbidities, and healthcare burden in pediatric patients with psoriasis. We examined patient demographics, comorbidity burden, treatment patterns, and healthcare use and costs in pediatric psoriasis. METHODS: A retrospective, real-world, exploratory study was conducted using US claims databases. Pediatric patients aged < 18 years with newly diagnosed psoriasis (index date) were selected from IBM® MarketScan® databases (2016-2018). Patients were enrolled continuously for ≥ 12 months pre- and post-index date. Pre-index demographics, comorbidity, treatment drug classes prescribed, and post-index healthcare resource utilization and costs were studied. Study measures are reported for total population and by severity (categorized as mild and moderate-to-severe psoriasis). Variables were compared using t-test (continuous) or chi-square and Fisher's exact test (categorical). RESULTS: Overall, 4754 pediatric patients with psoriasis (58.3% females) met the selection criteria and were included in the study. Mean and standard deviation (SD) age was 12.6 (3.7) years on index date, with 13.4% patients having moderate-to-severe psoriasis. The mean (SD) Deyo-Charlson Comorbidity Index was 0.14 (0.40); anxiety (6.6%), depression (4.1%), and obesity (3.9%) were the most prevalent comorbidities observed. Topical treatments were prescribed to most patients as first-line treatment of mild (79.1%) and moderate-to-severe (52.0%) psoriasis. Other first-line therapies prescribed in moderate-to-severe cases included non-biologic systemics (21.0%), phototherapy (15.0%), and biologics (9.2%). Healthcare use and costs increased with psoriasis severity during the post-index period. Mean annual total all-cause costs per patient were higher for patients with moderate-to-severe psoriasis compared with mild psoriasis ($27,541 vs. $5,034; P < 0.001). CONCLUSIONS: Psychiatric, metabolic, and inflammatory disorders were observed comorbidities in pediatric patients with psoriasis. For moderate-to-severe psoriasis, topicals, phototherapy, and biologics were a common first-, second-, and third-line treatment sequence. Higher unadjusted healthcare costs by severity were driven by outpatient prescription costs.

The effects of vertically integrated care on health care use and outcomes in inpatient rehabilitation facilities.

OBJECTIVE: To understand the effects of receiving vertically integrated care in inpatient rehabilitation facilities (IRFs) on health care use and outcomes. DATA SOURCES: Medicare enrollment, claims, and IRF patient assessment data from 2012 to 2014. STUDY DESIGN: We estimated within-IRF differences in health care use and outcomes between IRF patients admitted from hospitals vertically integrated with the IRF (parent hospital) vs patients admitted from other hospitals. For hospital-based IRFs, the parent hospital was defined as the hospital that owned the IRF and co-located with the IRF. For freestanding IRFs, the parent hospital(s) was defined as the hospital(s) that was in the same health system. We estimated models for freestanding and hospital-based IRFs and for fee-for-service (FFS) and Medicare Advantage (MA) patients. Dependent variables included hospital and IRF length of stay, functional status, discharged to home, and hospital readmissions. DATA EXTRACTION METHODS: We identified Medicare beneficiaries discharged from a hospital to IRF. PRINCIPAL FINDINGS: In adjusted models with hospital fixed effects, our results indicate that FFS patients in hospital-based IRFs discharged from the parent hospital had shorter hospital (-0.7 days, 95% CI: -0.9 to -0.6) and IRF (-0.7 days, 95% CI: -0.9 to -0.6) length of stay were less likely to be readmitted (-1.6%, 95% CI: -2.7% to -0.5%) and more likely to be discharged to home care (1.4%, 95% CI: 0.7% to 2.0%), without worse patient clinical outcomes, compared to patients discharged from other hospitals and treated in the same IRFs. We found similar results for MA patients. However, for patients in freestanding IRFs, we found little differences in health care use or patient outcomes between patients discharged from a parent hospital compared to patients from other hospitals. CONCLUSIONS: Our results indicate that receiving vertically integrated care in hospital-based IRFs shortens institutional length of stay while maintaining or improving health outcomes.

Analysis of Pediatric Surgery Using the National Healthcare Insurance Service Database in Korea: How Many Pediatric Surgeons Do We Need in Korea?

BACKGROUND: In the past, general surgeons (GSs) without a pediatric surgical subspecialty often performed surgery on children and, even now, GSs are performing many pediatric surgeries. We aimed to investigate the involvement of pediatric surgeons (PSs) and GSs in pediatric surgery, compare the outcomes of surgery in the neonatal intensive care unit (NICU), and estimate the appropriate PS workforce in Korea. METHODS: We used surgical data from the National Health Insurance Service database that was collected from patients under the age of 19 years in hospitals nationwide from January 2002 to December 2017. In this database, we found 37 hospitals where PSs worked by using the index operation (congenital diaphragmatic hernia, esophageal atresia, hypertrophic pyloric stenosis, Hirschsprung's disease, abdominal wall defect, jejunoileal atresia, malrotation, anorectal malformation, and biliary atresia). It was assumed that the surgery in the 37 hospitals was performed by PS and that the surgery in other hospitals was performed by GS. Mortality was analyzed to compare the outcomes of acute abdominal surgery in the NICU. We estimated the number of PS currently needed in Korea for each situation under the assumption that PS would perform all operations for the index operation, main pediatric diseases (index operation + gastroesophageal reflux disease, choledochal cyst, inguinal hernia, and appendicitis), acute abdominal surgery in the NICU, and all pediatric surgeries. Additionally, we estimated the appropriate number of PS required for more advanced pediatric surgery in the future. RESULTS: The number of pediatric surgeries from 2002 to 2017 increased by 124%. Approximately 10.25% of the total pediatric surgeries were performed by PSs, and the percentage of the surgery performed by PSs increased from 8.32% in 2002 to 15.92% in 2017. The percentage of index operations performed by PSs annually was 62.44% in average. It was only 47.81% in 2002, and increased to 88.79% in 2017. During the last 5 years of the study period, the average annual number of surgeries for main pediatric diseases was approximately 33,228. The ratio of the number of surgeries performed by PS vs. GS steadily increased in main pediatric diseases, however, the ratio of the number of surgery performed by PS for inguinal hernia and appendicitis remained low in the most recent years. The percentage of the number of acute abdominal surgery performed by PS in the NICU was 44% in 2002, but it had recently risen to 89.7%. After 30 days of birth, mortality was significantly lower in all groups that were operated on by PS, rather than GS, during the last 5 years. In 2019, 49 PSs who were under the age of 65 years were actively working in Korea. Assuming that all pediatric surgeries of the patients under the age of 19 years should be performed by PS, the minimum number of PS currently required was about 63 if they perform all of the index operations, the main pediatric surgery was about 209, the NICU operation was about 63, and the all pediatric surgeries was about 366. Additionally, it was determined that approximately 165 to 206 PS will be appropriate for Korea to implement more advanced pediatric surgery in the future. CONCLUSION: The proportion of the pediatric surgery performed by PS rather than GS is increasing in Korea, but it is still widely performed by GS. PSs have better operative outcomes for acute abdominal surgery in the NICU than GSs. We believe that at least the index operation or the NICU operation should be performed by PS for better outcome, and that a minimum of 63 PSs are needed in Korea to do so. In addition, approximately 200 PSs will be required in Korea in order to manage main pediatric diseases and to achieve more advanced pediatric surgery in the future.

Incidence and Direct Medical Cost of Acute Stress Disorder and Post-traumatic Stress Disorder in Korea: Based on National Health Insurance Service Claims Data from 2011 to 2017.

BACKGROUND: We aimed to investigate the annual incidence of trauma and stress-related mental disorder including acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) using the National Health Insurance Service Database. In addition, we estimated direct medical cost of ASD and PTSD in Korea. METHODS: To examine the incidence, we selected patients who had at least one medical claim containing a 10th revision of the International Statistical Classification of Diseases and Related Health Problems code for ASD (F43.0) and PTSD (F43.1) and had not been diagnosed in the previous 360 days, from 2010 to 2017. We estimated annual incidence and the number of newly diagnosed patients of ASD and PTSD. Annual prevalence and direct medical cost of ASD and PTSD were also estimated. RESULTS: The number of newly diagnosed cases of ASD and PTSD from 2011 to 2017 totaled 38,298 and 21,402, respectively. The mean annual incidence of ASD ranged from 8.4 to 13.7 per 100,000 population and that of PTSD ranged from 4.2 to 8.3 per 100,000 population, respectively. The incidence of ASD was found more in females and was highest among the 70-79 years of age group and the self-employed individuals group. The incidence of PTSD was also more common in the female group. However, the incidence of PTSD was highest in the 60-69 years of age group and in the medical aid beneficiaries group. The annual estimated medical cost per person of ASD ranged from 104 to 149 US dollars (USD). In addition, that of PTSD ranged from 310 to 426 USD. CONCLUSION: From 2011 to 2017, the annual incidence and direct medical cost of ASD and PTSD in Korea were increased. Proper information on ASD and PTSD will not only allows us to accumulate more knowledge about these disorders themselves but also lead to more appropriate therapeutic interventions by improving the ability to cope with these trauma related psychiatric sequelae.

The association of vertically integrated care with health care use and outcomes.

OBJECTIVE: To determine whether vertically integrated hospital and skilled nursing facility (SNF) care is associated with more efficient use of postdischarge care and better outcomes. DATA SOURCES: Medicare provider, beneficiary, and claims data from 2012 to 2014. STUDY DESIGN: We compared facility characteristics, quality of care, and health care use for hospital-based SNFs and "virtually integrated" SNFs (defined as freestanding SNFs with close referral relationships with a single hospital) relative to nonintegrated freestanding SNFs. Among patients admitted to integrated SNFs, we estimated differences in health care use and outcomes for patients originating from the parent hospital (ie, receiving vertically integrated care) versus other hospitals using linear regressions that included SNF fixed effects. We estimated bounds for our main estimates that incorporated potential omitted variables bias. DATA EXTRACTION METHODS: We identified hospital-based SNFs based on provider data. We defined virtually integrated SNFs based on patient flows between hospitals and SNFs. We identified SNF episodes, preceding hospital stays, patient characteristics, health care use, and patient outcomes using Medicare data. PRINCIPAL FINDINGS: Consistent with prior research, integrated SNFs performed better on quality measures and health care use relative to nonintegrated SNFs (eg, hospital-based SNFs had 11-day shorter stays compared with nonintegrated SNFs adjusting for patient characteristics, P < .001). Stroke patients admitted to hospital-based SNFs from the parent hospital had shorter preceding hospital stays (adjusted difference: -1.2 days, P = .001) and shorter initial SNF stays (adjusted difference: -2.7 days, P = .049); estimates were attenuated but still robust accounting for potential omitted variables bias. For stroke patients, associations between vertically integrated care and other outcomes were either statistically insignificant or not robust to accounting for potential omitted variables bias. CONCLUSIONS: Vertically integrated hospital and SNF care was associated with shorter hospital and SNF stays. However, there were few beneficial associations with other outcomes, suggesting limited coordination benefits from vertical integration.

Development of a predictive model for integrated medical and long-term care resource consumption based on health behaviour: application of healthcare big data of patients with circulatory diseases.

BACKGROUND: Medical costs and the burden associated with cardiovascular disease are on the rise. Therefore, to improve the overall economy and quality assessment of the healthcare system, we developed a predictive model of integrated healthcare resource consumption (Adherence Score for Healthcare Resource Outcome, ASHRO) that incorporates patient health behaviours, and examined its association with clinical outcomes. METHODS: This study used information from a large-scale database on health insurance claims, long-term care insurance, and health check-ups. Participants comprised patients who received inpatient medical care for diseases of the circulatory system (ICD-10 codes I00-I99). The predictive model used broadly defined composite adherence as the explanatory variable and medical and long-term care costs as the objective variable. Predictive models used random forest learning (AI: artificial intelligence) to adjust for predictors, and multiple regression analysis to construct ASHRO scores. The ability of discrimination and calibration of the prediction model were evaluated using the area under the curve and the Hosmer-Lemeshow test. We compared the overall mortality of the two ASHRO 50% cut-off groups adjusted for clinical risk factors by propensity score matching over a 48-month follow-up period. RESULTS: Overall, 48,456 patients were discharged from the hospital with cardiovascular disease (mean age, 68.3 ± 9.9 years; male, 61.9%). The broad adherence score classification, adjusted as an index of the predictive model by machine learning, was an index of eight: secondary prevention, rehabilitation intensity, guidance, proportion of days covered, overlapping outpatient visits/clinical laboratory and physiological tests, medical attendance, and generic drug rate. Multiple regression analysis showed an overall coefficient of determination of 0.313 (p < 0.001). Logistic regression analysis with cut-off values of 50% and 25%/75% for medical and long-term care costs showed that the overall coefficient of determination was statistically significant (p < 0.001). The score of ASHRO was associated with the incidence of all deaths between the two 50% cut-off groups (2% vs. 7%; p < 0.001). CONCLUSIONS: ASHRO accurately predicted future integrated healthcare resource consumption and was associated with clinical outcomes. It can be a valuable tool for evaluating the economic usefulness of individual adherence behaviours and optimising clinical outcomes.

Screening Medications for Association with Progression to Wet Age-Related Macular Degeneration.

PURPOSE: There is an urgent need for treatments that prevent or delay development to advanced age-related macular degeneration (AMD). Drugs already on the market for other conditions could affect progression to neovascular AMD (nAMD). If identified, these drugs could provide insights for drug development targets. The objective of this study was to use a novel data mining method that can simultaneously evaluate thousands of correlated hypotheses, while adjusting for multiple testing, to screen for associations between drugs and delayed progression to nAMD. DESIGN: We applied a nested case-control study to administrative insurance claims data to identify cases with nAMD and risk-set sampled controls that were 1:4 variable ratio matched on age, gender, and recent healthcare use. PARTICIPANTS: The study population included cases with nAMD and risk set matched controls. METHODS: We used a tree-based scanning method to evaluate associations between hierarchical classifications of drugs that patients were exposed to within 6 months, 7 to 24 months, or ever before their index date. The index date was the date of first nAMD diagnosis in cases. Risk-set sampled controls were assigned the same index date as the case to which they were matched. The study was implemented using Medicare data from New Jersey and Pennsylvania, and national data from IBM MarketScan Research Database. We set an a priori threshold for statistical alerting at P ≤ 0.01 and focused on associations with large magnitude (relative risks ≥ 2.0). MAIN OUTCOME MEASURES: Progression to nAMD. RESULTS: Of approximately 4000 generic drugs and drug classes evaluated, the method detected 19 distinct drug exposures with statistically significant, large relative risks indicating that cases were less frequently exposed than controls. These included (1) drugs with prior evidence for a causal relationship (e.g., megestrol); (2) drugs without prior evidence for a causal relationship, but potentially worth further exploration (e.g., donepezil, epoetin alfa); (3) drugs with alternative biologic explanations for the association (e.g., sevelamer); and (4) drugs that may have resulted in statistical alerts due to their correlation with drugs that alerted for other reasons. CONCLUSIONS: This exploratory drug-screening study identified several potential targets for follow-up studies to further evaluate and determine if they may prevent or delay progression to advanced AMD.

Dilemmas Within the Korean Health Insurance System.

The health insurance system in Korea is well-established and provides benefits for the entire national population. In Korea, when patients are treated at a hospital, the hospital receives a partial payment for the treatment from the patient, and the remaining amount is provided by the health insurance service. The Health Insurance Review and Assessment Service (HIRA) assesses whether the treatment was appropriate. If HIRA deems the treatment appropriate, the doctor can receive payment from the health insurance service. However, this system has several drawbacks. In this study, we aimed to provide examples of the problems that can occur in relation to HIRA assessments in Korea through actual clinical cases.

The usage of over-the-counter products by private insured patients in Germany - a claims data analysis with focus on complementary medicine.

BACKGROUND: An important contribution to well-being of human beings can be observed by the use of self-medication products that is reflected in the constantly growing volume of over-the-counter (OTC) drugs. The aim of the current study was to extend the measurement concept for OTCs by exploring the relevance of the peripheral assortment provided by the widely accepted framework of the Anatomical Therapeutical and Chemical (ATC) classification of the WHO. METHODS: The focus was on the prescriptions and drug-related receipts submitted by privately insured persons to 18 private health insurers (PHIs) in Germany from the year 2016. The age- and gender-specific average claims amount per risks of outpatient drug expenditure were used as weights to scale up the relative distributions of the item amounts. The ATC-classification defines the commodity groups and discriminates between the main and the peripheral assortment. A descriptive analysis assessed the OTC frequencies and sum scores of the product groups within the main and peripheral assortment whereby the study group explored and assessed the relevance of each category independently according to the OTCs and integrative medicines. RESULTS: The analysis included 22.1 Mio. packages from the main assortment and examined 10.1 Mio. packages from the peripheral assortment. The latter was examined thoroughly and the commodity groups "Pharmaceutical food products", "Medicinal products for special therapy options" and particular "Hygiene and body care products" meet the defined requirements for OTCs relevant for integrative medicines. A high proportion of OTC products from the peripheral assortment was associated with the categories "medicinal products for special therapy options". Homeopathy and anthroposophy present two special therapy options, which are relevant for the extended OTC measurement. CONCLUSIONS: The analysis of OTC drugs is feasible when the main and the peripheral assortment is available and enable to integrate about 18% of all OTCs, which are neglected by the common ATC-based approach. The presented extended approach may help to identify potential users of OTCs or people in need of OTC use. In case of the highly disputed homeopathy and anthroposophy products, more research among interactions with prescriptions drugs (Rx), nutrition's and other potentially harmful exposures is recommended.

Real-World Experience With Apremilast in the Treatment of Adults With Moderate to Severe Plaque Psoriasis in Québec: A Claims-Based Analysis of Drug Utilization and Healthcare Resource Utilization.

BACKGROUND: In Québec, targeted biologic therapies for moderate to severe plaque psoriasis are restricted to patients who have not responded to phototherapy or conventional systemic treatment, primarily due to high drug costs. Apremilast, an oral treatment for plaque psoriasis, was added to the Québec provincial health insurance plan (Régie de l'assurance maladie du Québec; RAMQ) formulary in 2015, making this the only province in Canada with public drug plan reimbursement for apremilast. OBJECTIVES: The aim of this study is to describe patients' characteristics, treatment patterns, healthcare resource utilization (HCRU), and associated costs and to measure real-world budget impact of using apremilast before biologics in plaque psoriasis. METHODS: This study was performed using RAMQ drug claims and medical services data. Patients diagnosed with psoriasis between January 2015 and December 2017 were identified. Medical services and prescription claims were categorized as all-cause and psoriasis-related. Using RAMQ database estimates, a 3-year budget impact analysis was developed comparing treatment cost with and without the addition of apremilast to the formulary. RESULTS: In all, 540 patients were identified (apremilast: n = 92; biologics: n = 448). Comorbidity burden and treatment persistence and adherence were comparable between apremilast and biologic users. The year following the index date, all-cause HCRU was lower for apremilast versus biologic users (CAN$19 763 vs CAN$28 025; P < .01), mainly driven by drug cost. Using apremilast before biologics resulted in an estimated RAMQ net savings of CAN$49 290 (2015), CAN$746 856 (2016), and CAN$1 216 512 (2017), and a total savings of CAN$2 012 658 since apremilast's addition to the formulary. CONCLUSION: Adding apremilast to the drug formulary of other Canadian provinces could result in significant healthcare savings.

Assessing the Population-Level Correlation of Medication Regimen Complexity and Adherence Indices Using Electronic Health Records and Insurance Claims.

BACKGROUND: Nonadherence to medication regimens can lead to adverse health care outcomes and increasing costs. OBJECTIVES: To (a) assess the level of medication complexity at an outpatient setting using population-level electronic health record (EHR) data and (b) evaluate its association with medication adherence measures derived from medication-dispensing claims. METHODS: We linked EHR data with insurance claims of 70,054 patients who had an encounter with a U.S. midwestern health system between 2012 and 2013. We constructed 3 medication-derived indices: medication regimen complexity index (MRCI) using EHR data; medication possession ratio (MPR) using insurance pharmacy claims; and prescription fill rates (PFR; 7 and 30 days) using both data sources. We estimated the partial correlation between indices using Spearman's coefficient (SC) after adjusting for age and sex. RESULTS: The mean age (SD) of 70,054 patients was 37.9 (18.0) years, with an average Charlson Comorbidity Index of 0.308 (0.778). The 2012 data showed mean (SD) MRCI, MPR, and 30-day PFR of 14.6 (17.8), 0.624 (0.310), and 81.0 (27.0), respectively. Patients with previous inpatient stays were likely to have high MRCI scores (36.3 [37.9], P < 0.001) and were less adherent to outpatient prescriptions (MPR = 50.3 [27.6%], P < 0.001; 30-day PFR = 75.7 [23.6%], P < 0.001). However, MRCI did not show a negative correlation with MPR (SC = -0.31, P < 0.001) or with 30-day PFR (SC = -0.17, P < 0.001) at significant levels. CONCLUSIONS: Medication complexity and adherence indices can be calculated on a population level using linked EHR and claims data. Regimen complexity affects patient adherence to outpatient medication, and strength of correlations vary modestly across populations. Future studies should assess the added values of MRCI, MPR, and PFR to population health management efforts. DISCLOSURES: No outside funding supported this study. The authors have nothing to disclose. The abstract of this work was presented at INFORMS Healthcare Conference, held on July 27-29, 2019, in Cambridge, MA.

Association of Systemic Hypertension With Primary Open-angle Glaucoma: A Population-based Case-Control Study.

PURPOSE: To examine the association between systemic hypertension (HTN) and primary open-angle glaucoma (POAG) using Taiwan's nationwide health insurance claims data. DESIGN: A case-control study. METHODS: Data for this case-control study were retrieved from the Taiwan National Health Insurance Research Database for all 112,929 newly diagnosed patients with POAG from January 2010 through December 2015 (cases), and 449,840 propensity score-matched controls from Taiwan's National Health Insurance system. We performed multiple logistic regression analysis to estimate the odds (ORs) of prior HTN among cases vs controls. RESULTS: Of total 562,300 study patients, 296,975 (52.81%) had HTN prior to the index date, 63,528 (56.49%) among cases and 233,447 (51.90%) among controls (P < .001). POAG was significantly associated with prior HTN (OR 1.31, 95% CI 1.29-1.33) after adjusting for age, sex, monthly income, geographic location and residential urbanization level, hyperlipidemia, diabetes, coronary heart disease, migraine, hypotension, and obstructive sleep apnea syndrome. CONCLUSIONS: POAG is associated with pre-existing HTN, suggesting that internal medicine/family medicine physicians should refer patients with hypertension periodically for regular ophthalmological examinations and ophthalmologists should alert patients with glaucoma to have their blood pressure regularly monitored.