Update to Gabapentinoid Use in the United States, 2002-2021.

Gabapentinoids are commonly used medications for numerous off-label conditions. The 2002-2021 Medical Expenditure Panel Survey (MEPS) was used to investigate the proportion of the adult population who were gabapentinoid users, the ages of these users, medications and diagnoses associated with users, and the likelihood of starting, stopping, or continuing gabapentinoids. Gabapentinoid users continued to increase since our last publication from 4.0% in 2015 to 4.7% in 2021. Gabapentinoid use was much more likely among individuals who used other medications used in chronic pain. Between 2017-2021, numerous chronic pain conditions were associated with gabapentinoid use. New gabapentinoid users clearly outnumbered gabapentinoid stoppers between 2011-2012 and 2017-2018, but this difference decreased in the most recent cohorts.

Cardiac injury in children with COVID-19.

BACKGROUND: There is little known about the spectrum of cardiac injury in acute COVID-19 infection in children. METHODS: A single-centre, retrospective chart analysis was performed. The protocol was deemed IRB exempt. All patients under the age of 21 years admitted from 20 March, 2020 to 22 June, 2021 for acute symptomatic COVID-19 infection or clinical suspicion of multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 were included. Past medical history, lab findings, echocardiogram and electrocardiogram/telemetry findings, and clinical outcomes were reviewed. RESULTS: Sixty-six patients with MIS-C and 178 with acute COVID-19 were reviewed. Patients with MIS-C had more cardiac testing than those with acute COVID-19. Inflammatory markers were more likely elevated, and function was more likely abnormal on echocardiogram in those with MIS-C with testing performed. Among patients with MIS-C, 17% had evidence of coronary dilation versus 0% in the acute COVID-19 group. One (0.6%) patient with acute COVID-19 had clinically significant electrocardiogram or telemetry findings, and this was in the setting of prior arrhythmias and CHD. Four (6%) patients with MIS-C had clinically significant findings on electrocardiogram or telemetry. Among patients with acute COVID-19, extracorporeal membrane oxygenation support was required in 0.6% of patients with acute COVID-19, and there was a 2.8% mortality. There were no deaths in the setting of MIS-C. CONCLUSIONS: Patients with acute COVID-19 and clinical suspicion of cardiac injury had a lower incidence of abnormal laboratory findings, ventricular dysfunction, or significant arrhythmia than those with MIS-C.

Quantifying side effects and caregiver burdens of pediatric pulmonary hypertension therapies.

BACKGROUND AND OBJECTIVES: Pulmonary hypertension (PH) is a rare, but serious disease among children. However, PH has been primarily evaluated among adults. Consequently, treatment therapies have not been fully evaluated among pediatric populations and are used in an 'off label' manner. The purpose of this study was to estimate the side effect profiles of the most commonly prescribed pediatric PH therapies and to understand the burdens placed upon families caring for children living with PH. METHODS: Participants were recruited online through the "Families of children with pulmonary hypertension" Facebook group and asked to complete a survey about PH treatments. RESULTS: A total of 139 parents of a child living with PH completed the survey. Almost all children used ≥ 1 medication to treat PH, with 52% using ≥ 3 medications. The highest average number of side effects was reported by users of Treprostinil, Selexipag and type-5 phosphodiesterase (PDE5) inhibitors. The most common side effects were skin flushing, headache, nasal congestion, joint/muscle pain, and nausea. In terms of accessing care, 81% travel ≥ 20 miles and 68% travel for ≥ 60 min to receive care. CONCLUSIONS: We found an array of treatment combinations employed to mitigate symptoms of PH in children, with a wide range of side effects. We also found a large, unseen economic, emotional, and time burden of caring for a child living with PH. Further research is warranted to understand the clinical implications of these side effects to move towards labeled usage of these therapies rather than post-hoc off-label usage.

Preventative practices and effects of the COVID-19 pandemic on caregivers of children with pediatric pulmonary hypertension.

BACKGROUND: Pulmonary hypertension (PH) is a serious and life-threatening disease characterized by elevated mean arterial pressure and pulmonary vascular resistance. COVID-19 may exacerbate PH, as evidenced by higher mortality rates among those with PH. The objective of this study was to understand the unique burdens that the COVID-19 pandemic has placed upon families of children living with PH. METHODS: Participants were recruited online through the "Families of children with pulmonary hypertension" Facebook group and asked to complete a survey about their experiences during the COVID-19 pandemic. RESULTS: A total of 139 parents/caregivers of children living with PH completed the online survey. Almost all (85.6%) of parents/caregivers had received the COVID-19 vaccine, though only 59.7% reported a willingness to vaccinate their child with PH against COVID-19. Over 75% of parents/caregivers felt that they practiced preventative measures (e.g., wearing a facemask, social distancing, and avoiding gatherings) more than those in the community where they live. They also reported several hardships related to caring for their child with PH during the pandemic such as financial duress, loss of work, and affording treatment costs. CONCLUSIONS: These findings indicate that parents/caregivers of children at higher risk for COVID-19 complications may be more willing to act on clinical recommendations themselves as proxy for protecting those at high risk. The economic, emotional and social impacts of COVID-19 are significantly greater for high-risk individuals.

The Ecology of Antihypertensives in the United States, 1997-2017.

OBJECTIVE: Antihypertensives are the most used medication type in the USA, yet there remains uncertainty about the use of different antihypertensives. We sought to characterize use of antihypertensives by and within medication class(es) between 1997 and 2017. PATIENTS AND METHODS: A repeated cross-sectional study of 493,596 adult individuals using the 1997-2017 Medical Expenditure Panel Survey (MEPS). The Orange Book was used for adjunctive information. The primary outcome was the estimated use by and within antihypertensive medication class(es). RESULTS: The proportion of individuals taking any antihypertensive during a year increased from 1997 to the early 2010s and then remained stable. The proportion of adults using angiotensin II receptor blockers (ARBs) and dihydropyridine calcium channel blockers (CCBs) increased during the study period, while angiotensin-converting enzyme inhibitors (ACE-Is) increased until 2010 after which rates remained stable. Beta-blocker use was similar to that of ACE-Is with an earlier decline starting in 2012. Thiazide diuretic use increased from 1997 to 2007, leveled off until 2014, and declined from 2015 to 2017. Non-dihydropyridine CCB use declined throughout the study. ACE-Is, ARBs, CCBs, thiazide diuretics, and loop diuretics all had one dominant in-class medication. There was a clear increase in the use of losartan within ARBs, lisinopril within ACE-Is, and amlodipine within CCBs following generic conversion. Furosemide and hydrochlorothiazide started with and maintained a dominant position in their classes. Metoprolol use increased throughout the study and became the dominant beta-blocker. CONCLUSIONS: Antihypertensive classes appear to have a propensity to equilibrate to an individual medication, despite a lack of outcomes-based research to compare medications within a class.

Decreasing Use of Primary Care: A Repeated Cross-Sectional Study of MEPS 2007-2017.

We sought to describe the proportion of patients in contact with a primary care physician, as well as the total number of primary care contacts over a 2-year period, using the 2002-2017 Medical Expenditure Panel Survey. The rate of any contact with a primary care physician for patients in the population decreased by 2.5% over the study period (adjusted odds ratio [aOR] = 0.99 per panel, 95% CI, 0.98-0.99; P <.001). The number of contacts with a primary care physician decreased among individuals with any contact by 0.5 contacts over 2 years (aOR = -0.04 per panel, 95% CI, -0.04 to -0.03, P <.001). The decreases were observed across all age groups at varying rates. The results of this study suggest that the driver for the previously reported decreases in primary care visits is secondary to fewer contacts per patient.

Trends in Total and Out-of-Pocket Expenditures for Visits to Primary Care Physicians, by Insurance Type, 2002-2017.

PURPOSE: Total and out-of-pocket visit expenditures for primary care physician visits may affect how primary care is delivered. We determined trends in these expenditures for visits to US primary care physicians. METHODS: Using the 2002-2017 Medical Expenditure Panel Survey, we ascertained changes in total and out-of-pocket visit expenditures for primary care visits for Medicare, Medicaid, and private insurance. We calculated mean values for each insurer using a generalized linear model and a 2-part model, respectively. RESULTS: Analyses were based on 750,837 primary care visits during 2002-2017. Over time, the proportion of primary care visits associated with private insurance or no insurance decreased, while Medicare- or Medicaid-associated visits increased. The proportion of visits with $0 out-of-pocket expenditure increased, primarily from an increase in $0 private insurance visits. Total expenditure per visit increased for private insurance and Medicare visits, but did not notably change for Medicaid visits. Out-of-pocket expenditures rose primarily from increases in private insurance visits with higher expenditures of this type. Medicare and Medicaid had minimal change in out-of-pocket expenditure per visit. CONCLUSIONS: Between 2002 and 2017, mean total expenditures and out-of-pocket expenditures increased for primary care visits, but at notably lower rates than those previously documented for emergency department visits. A rise in total expenditure per visit was identified for private insurance and Medicare, but not for Medicaid. Out-of-pocket expenditures increased marginally related to changes in out-of-pocket expenditures for private insurance visits. We would expect increasing difficulty with primary care physician access, particularly for Medicaid patients, if the current trends continue.

The Ecology of Medical Care Before and After the Affordable Care Act: Trends From 2002 to 2016.

BACKGROUND: The initial ecology of medical care study was published in 1961, offering a framework by which to investigate individuals' contact with the medical system. We studied changes in the framework around the implementation of the Patient Protection and Affordable Care Act (ACA) within longer-term trends. METHODS: The 2002-2016 Medical Expenditure Panel Survey was used to determine rates of visit/contact per 1,000 individuals per month for physicians, primary care physicians, specialty physicians, emergency departments, inpatient hospitalizations, dental visits, and home health visits for the overall population and by age group, poverty category, health status, and race/ethnicity. Adjusted Wald tests were used to investigate differences between the pre-ACA (2012-2013) and post-ACA (2014-2015) periods. Multivariable linear regression was used to determine trends over the study period (2002-2016). RESULTS: The survey included 525,804 person-years. The uninsured rate decreased from 12.8% (95% CI, 12.0%-13.7%) in 2013 to 7.6% (95% CI, 7.0%-8.3%) in 2016. From 2002 to 2016, the numbers of individuals in a month who had contact with primary care physicians, dental care, and inpatient hospitalizations decreased. Primary care physician contact decreased most among the elderly and those reporting fair/poor health. After ACA implementation, few significant changes were identified in the overall population or by age, poverty category, race/ethnicity, or health status. CONCLUSIONS: The medical ecology framework was not notably altered 2 years after implementation of the ACA. The long-term decrease in primary care contact does not appear to have been interrupted after implementation of the ACA, was observed across income and age categories, and was most evident among the elderly and individuals reporting fair/poor health.

Emergency Department Out-of-Pocket Expenditures by Insurance, 1999 to 2016.

STUDY OBJECTIVE: Per visit, emergency department (ED) expenditures have increased more for private insurance than Medicare and Medicaid during the past 20 years, but it is unknown whether ED out-of-pocket expenditures show a similar pattern of increase. We compare increases in per-visit ED out-of-pocket expenditures over time for visits that did not result in hospitalization or observation admissions for private insurance, Medicare, and Medicaid. METHODS: This repeated cross-sectional analysis of out-of-pocket expenditures used data from the 1999 to 2016 Medical Expenditure Panel Survey, a nationally representative survey of the noninstitutionalized US civilian population. We used 2-part models-logistic regression followed by a generalized linear model with a γ distribution and a log link function-to compare per-visit out-of-pocket expenditures over time among different payers. Models contained insurance type, year, an interaction between year and insurance type, region of country, sex, and 5 visit-level variables (magnetic resonance imaging/computed tomography scans, ultrasonography, surgical procedures, radiographs, and ECGs). RESULTS: In our sample of 107,519 ED visits, mean annual per-visit out-of-pocket expenditures increased $7.31 a year (95% confidence interval $6.22 to $8.41) for private insurance and did not increase for Medicare or Medicaid. Most private insurance and Medicare visits had out-of-pocket expenditures less than $100 and nearly all Medicaid visits had no out-of-pocket expenditures. There was no strong evidence suggesting that out-of-pocket expenditures at different total expenditure amounts increased appreciably for private insurance. CONCLUSION: Per-visit out-of-pocket expenditure increases for private insurance ED visits were predominantly related to overall increases in per-visit total expenditure.

Combination therapy for severe portopulmonary hypertension in a child allows for liver transplantation.

Severe PPHTN is a contraindication to liver transplantation and predicts an abysmal 5-year outcome. It is defined as a resting mPAP >45 mm Hg with a mean pulmonary artery wedge pressure of <15 mm Hg and pulmonary vascular resistance of >3 wood units in the setting of portal hypertension. There have been limited reports of successful treatment of PPHTN leading to successful liver transplantation in adults, and one reported use of monotherapy as a bridge to successful liver transplant in pediatrics. To our knowledge, we describe the first use of combination therapy as a successful bridge to liver transplantation in a pediatric patient with severe PPHTN. This report adds to the paucity of data in pediatrics on the use of pulmonary vasodilator therapy in patients with severe PPHTN as a bridge to successful liver transplantation. Early diagnosis in order to mitigate or avoid the development of irreversible pulmonary vasculopathy that would preclude candidacy for liver transplantation is crucial, but our report demonstrates that combination therapy can be administered safely, quickly, and may allow for successful liver transplantation in patients with severe PPHTN.

Safety of enteral sildenafil in hemodynamically unstable children.

BACKGROUND: Enteral sildenafil may be used in the intensive care unit for treatment of pulmonary arterial hypertension. We aimed to determine if initial enteral sildenafil dosing is safe in children receiving concurrent vasoactive infusions. METHODS: We performed a single-centre retrospective chart review that included patients less than 2 years of age in paediatric and cardiovascular intensive care units at an academic medical centre from 1 January, 2010 to 30 November, 2016. Included patients received concomitant enteral sildenafil and a continuously infused vasoactive agent. Exclusion criteria consisted of mechanical circulatory support, any form of dialysis, or a suspicion of septic shock at the time of sildenafil initiation. We sought to identify patients who developed worsening hemodynamic instability after initiation of enteral sildenafil defined as one or more of the following observations within 24 hours of sildenafil initiation: sildenafil discontinuation, total fluid bolus receipt >10 ml/kg, increased vasoactive support, epinephrine intravenous push administration, and/or the initiation of mechanical circulatory support. RESULTS: Worsening hemodynamic instability was identified in 35% of the 130-patient cohort. Patients younger than 4 months were at increased risk of further hemodynamic instability compared with older patients (56% versus 44%, p = 0.0003) despite receiving lower median doses (1.28 mg/kg/day versus 1.78 mg/kg/day, p = 0.01). CONCLUSIONS: Critically ill children receiving vasoactive infusions may be at increased risk for further hemodynamic instability after initiation of enteral sildenafil, particularly in younger patients. This population may benefit from lower starting enteral sildenafil doses of 0.25 mg/kg/dose or less every 8 hours to avoid further hemodynamic compromise.

Comparing Medical Ecology, Utilization, and Expenditures Between 1996-1997 and 2011-2012.

PURPOSE: This study compared ecology (number of individuals using a service), utilization (number of services used), and expenditures (dollars spent) for various categories of medical services between primarily 1996-1997 and 2011-2012. METHODS: A repeated cross-sectional study was performed using nationally representative data mainly from the 1996, 1997, 2011, and 2012 Medical Expenditure Panel Survey (MEPS). These data were augmented with the 2002-2003 MEPS as well as the 1999-2000 and 2011-2012 National Heath and Nutrition Examination Survey. Individuals (number per 1,000 people), utilization, and expenditures during an average month in 1996-1997 and 2011-2012 were determined for 15 categories of services. RESULTS: The number of individuals who used various medical services was unchanged for many categories of services (total, outpatient, outpatient physician, users of prescribed medications, primary care and specialty physicians, inpatient hospitalization, and emergency department). It was, however, increased for others (optometry/podiatry, therapy, and alternative/complementary medicine) and decreased for a few (dental and home health). The number of services used (utilization) largely mirrored the findings for individual use, with the exception of an increase in the number of prescribed medications and a decrease in number of primary care physician visits. There were large increases in dollars spent (expenditures) in every category with the exception of primary care physician and home health; the largest absolute increases were in prescribed medications, specialty physicians, emergency department visits, and likely inpatient hospitalizations. CONCLUSIONS: Although the number of individuals with visits during an average month and the total utilization of medical services were largely unchanged between the 2 time periods, total expenditures increased markedly. The increases in expenditure varied dramatically by category.

Impact of Medicare Part D on out-of-pocket drug costs and medical use for patients with cancer.

BACKGROUND: Medicare Part D was designed to reduce out-of-pocket (OOP) costs for Medicare beneficiaries, but to the authors' knowledge the extent to which this occurred for patients with cancer has not been measured to date. The objective of the current study was to examine the impact of Medicare Part D eligibility on OOP cost for prescription drugs and use of medical services among patients with cancer. METHODS: Using the Medical Expenditure Panel Survey (MEPS) for the years 2002 through 2010, a differences-in-differences analysis estimated the effects of Medicare Part D eligibility on OOP pharmaceutical costs and medical use. The authors compared per capita OOP cost and use between Medicare beneficiaries (aged ≥65 years) with cancer to near-elderly patients aged 55 years to 64 years with cancer. Statistical weights were used to generate nationally representative estimates. RESULTS: A total of 1878 near-elderly and 4729 individuals with Medicare were included (total of 6607 individuals). The mean OOP pharmaceutical cost for Medicare beneficiaries before the enactment of Part D was $1158 (standard error, ±$52) and decreased to $501 (standard error, ±$30), a decline of 43%. Compared with changes in OOP pharmaceutical costs for nonelderly patients with cancer over the same period, the implementation of Medicare Part D was associated with a further reduction of $356 per person. Medicare Part D appeared to have no significant impact on the use of medications, hospitalizations, or emergency department visits, but was associated with a reduction of 1.55 in outpatient visits. CONCLUSIONS: Medicare D has reduced OOP prescription drug costs and outpatient visits for seniors with cancer beyond trends observed for younger patients, with no major impact on the use of other medical services noted.