Neighborhood Disadvantage and Prostate Tumor RNA Expression of Stress-Related Genes.

Importance: African American men experience greater prostate cancer incidence and mortality than White men. Growing literature supports associations of neighborhood disadvantage, which disproportionately affects African American men, with aggressive prostate cancer; chronic stress and downstream biological impacts (eg, increased inflammation) may contribute to these associations. Objective: To examine whether several neighborhood disadvantage metrics are associated with prostate tumor RNA expression of stress-related genes. Design, Setting, and Participants: This cross-sectional study leveraged prostate tumor transcriptomic data for African American and White men with prostate cancer who received radical prostatectomy at the University of Maryland Medical Center between August 1992 and January 2021. Data were analyzed from May 2023 to April 2024. Exposures: Using addresses at diagnosis, 2 neighborhood deprivation metrics (Area Deprivation Index [ADI] and validated bayesian Neighborhood Deprivation Index) as well as the Racial Isolation Index (RI) and historical redlining were applied to participants' addresses. Self-reported race was determined using electronic medical records. Main Outcomes and Measures: A total of 105 stress-related genes were evaluated with each neighborhood metric using linear regression, adjusting for race, age, and year of surgery. Genes in the Conserved Transcriptional Response to Adversity (CTRA) and stress-related signaling genes were included. Results: A total of 218 men (168 [77%] African American, 50 [23%] White) with a median (IQR) age of 58 (53-63) years were included. African American participants experienced greater neighborhood disadvantage than White participants (median [IQR] ADI, 115 [100-130] vs 92 [83-104]; median [IQR] RI, 0.68 [0.34-0.87] vs 0.11 [0.06-0.14]). ADI was positively associated with expression for 11 genes; HTR6 (serotonin pathway) remained significant after multiple-comparison adjustment (ß = 0.003; SE, 0.001; P < .001; Benjamini-Hochberg q value = .01). Several genes, including HTR6, were associated with multiple metrics. We observed higher expression of 5 proinflammatory genes in the CTRA with greater neighborhood disadvantage (eg, CXCL8 and ADI, ß = 0.008; SE, 0.003; P = .01; q value = .21). Conclusions and Relevance: In this cross-sectional study, the expression of several stress-related genes in prostate tumors was higher among men residing in disadvantaged neighborhoods. This study is one of the first to suggest associations of neighborhood disadvantage with prostate tumor RNA expression. Additional research is needed in larger studies to replicate findings and further investigate interrelationships of neighborhood factors, tumor biology, and aggressive prostate cancer to inform interventions to reduce disparities.

Costs and health care resource utilization among Medicare beneficiaries diagnosed with chronic lymphocytic leukemia.

BACKGROUND: Chronic lymphocytic leukemia (CLL) is the most common type of leukemia. However, published studies of CLL have either only focused on costs among individuals diagnosed with CLL without a non-CLL comparator group or focused on costs associated with specific CLL treatments. An examination of utilization and costs across different care settings provides a holistic view of utilization associated with CLL. OBJECTIVE: To quantify the health care costs and resource utilization types attributable to CLL among Medicare beneficiaries and identify predictors associated with each of the economic outcomes among beneficiaries diagnosed with CLL. METHODS: This retrospective study used a random 20% sample of the Medicare Chronic Conditions Data Warehouse (CCW) database covering the 2017-2019 period. The study population consisted of individuals with and without CLL. The CLL cohort and non-CLL cohort were matched using a 1:5 hard match based on baseline categorical variables. We characterized economic outcomes over 360 days across cost categories and places of services. We estimated average marginal effects using multivariable generalized linear regression models of total costs and across type of services. Total cost was compared between CLL and non-CLL cohorts using the matched sample. We used generalized linear models appropriate for the count or binary outcome to identify factors associated with various categories of health care resource utilization, such as inpatient admissions, emergency department (ED) visits, and oncologist/hematologist visits. RESULTS: A total of 2,736 beneficiaries in the CLL cohort and 13,571 beneficiaries in the non-CLL matched cohort were identified. Compared with the non-CLL cohort, the annual cost for the CLL cohort was higher (CLL vs non-CLL, mean [SD]: $22,781 [$37,592] vs $13,901 [$24,725]), mainly driven by health care provider costs ($6,535 vs $3,915) and Part D prescription drug costs ($5,916 vs $2,556). The main categories of health care resource utilization were physician evaluation/management visits, oncologist/hematologist visits, and laboratory services. Compared with beneficiaries aged 65-74 years, beneficiaries aged 85 years or older had lower use and cost in maintenance services (ie, oncologist visits, hospital outpatient costs, and prescription drug cost) but higher use and cost in acute services (ie, ED). Compared with residency in a metropolitan area, living in a nonmetropolitan area was associated with fewer physician visits but higher ED visits and hospitalizations. CONCLUSIONS: The cooccurrence of lower utilization of routine care services, along with higher utilization of acute care services among some individuals, has implications for patient burden and warrants further study.

Design and rationale of the Botswana Smoking Abstinence Reinforcement Trial: a protocol for a stepped-wedge cluster randomized trial.

BACKGROUND: With expanded and sustained availability of HIV treatment resulting in substantial improvements in life expectancy, the need to address modifiable risk factors associated with leading causes of death among people living with HIV/AIDS (PLWH), such as tobacco smoking, has increased. Tobacco use is highly prevalent among PLWH, especially in southern Africa, where HIV is heavily concentrated, and many people who smoke would like to quit but are unable to do so without assistance. SBIRT (Screening, Brief Intervention and Referral to Treatment) is a well-established evidence-based approach successful at supporting smoking cessation in a variety of settings. Varenicline is efficacious in supporting smoking cessation. We intend to assess the effectiveness of SBIRT and varenicline on smoking cessation among PLWH in Botswana and the effectiveness of our implementation. METHODS: BSMART (Botswana Smoking Abstinence Reinforcement Trial) is a stepped-wedge, cluster randomized, hybrid Type 2 effectiveness-implementation study guided by the RE-AIM framework, to evaluate the effectiveness and implementation of an SBIRT intervention consisting of the 5As compared to an enhanced standard of care. SBIRT will be delivered by trained lay health workers (LHWs), followed by referral to treatment with varenicline prescribed and monitored by trained nurse prescribers in a network of outpatient HIV care facilities. Seven hundred and fifty people living with HIV who smoke daily and have been receiving HIV care and treatment at one of 15 health facilities will be recruited if they are up to 18 years of age and willing to provide informed consent to participate in the study. DISCUSSION: BSMART tests a scalable approach to achieve and sustain smoking abstinence implemented in a sustainable way. Integrating an evidence-based approach such as SBIRT, into an HIV care system presents an important opportunity to establish and evaluate a modifiable cancer prevention strategy in a middle-income country (MIC) setting where both LHW and non-physician clinicians are widely used. The findings, including the preliminary cost-effectiveness, will provide evidence to guide the Botswanan government and similar countries as they strive to provide affordable smoking cessation support at scale. CLINICAL TRIAL REGISTRATION: NCT05694637 Registered on 7 December 2022 on clinicaltrials.gov, https://clinicaltrials.gov/search?locStr=Botswana&country=Botswana&cond=Smoking%20Cessation&intr=SBIRT.

Disparity in treatment patterns among Medicare beneficiaries diagnosed with chronic lymphocytic leukemia: an analysis of patient and contextual factors.

This study characterizes the patterns and timing of CLL treatment and, to our knowledge, is the first to identify social vulnerability factors associated with CLL treatment receipt in the Medicare population. A total of 3508 Medicare beneficiaries diagnosed with CLL from 2017 to 2019 were identified. We reported the proportion of individuals who received CLL treatment and the time until the first CLL treatment receipt after the first observed claim with a CLL diagnosis. Logistic regression and time-to-event models provided adjusted odds ratios and hazard ratios associated with baseline individual-level and county-level factors. Sixteen percent of individuals received CLL treatment, and the median follow-up time was 540 d. The median time to receipt of CLL treatment was 61 d. Older age and residence in a county ranked high in social vulnerability (as defined by minority status and language) were negatively associated with treatment receipt and time to treatment receipt.

Direct Medical Costs of COPD in the USA: An Analysis of the Medical Expenditure Panel Survey 2017-2018.

AIM: In this study, we aimed to provide a nationally representative estimate of the economic burden of chronic obstructive pulmonary disease (COPD) by examining direct medical costs among individuals aged 45 years and older in the USA. METHODS: Medical Expenditure Panel Survey (2017-2018) data were used to estimate the direct medical costs associated with COPD. All-cause (unadjusted) cost and COPD-specific (adjusted) cost were determined for the various service categories using a regression-based approach among patients with COPD. We developed a weighted two-part model and adjusted for various demographic, socioeconomic, and clinical characteristics. RESULTS: The study sample consisted of 23,590 patients, of which 1073 had COPD. Patients with COPD had a mean age of 67.4 years (standard error (SE): 0.41), and the total all-cause mean medical cost per patient per year (PPPY) was 2018 US $19,449 (SE: US $865), of which US $6145 (SE: US $295) was for prescription drugs. Using the regression approach, the mean total COPD-specific cost was US $4322 (SE: US $577) PPPY, with prescription drugs contributing US $1887 (SE: 216) PPPY. These results represented an annual total COPD-specific cost of US $24.0 billion, with prescription drugs contributing US $10.5 billion. The mean annual out-of-pocket spending accounted for 7.5% (mean: US $325) of the total COPD-specific cost; for COPD-specific prescription drug cost, 11.3% (mean: US $212) was out-of-pocket cost. CONCLUSION: COPD poses a significant economic burden on healthcare payers and patients 45 years of age and older in the USA. While prescription drugs accounted for almost half of the total cost, more than 10% of the prescription drug cost was out-of-pocket.

Association of individual low-income status and area deprivation with mortality in multiple myeloma.

INTRODUCTION: Lower individual-level socioeconomic status (SES) and area-level SES have each been associated with poor survival outcomes among patients with multiple myeloma (MM). A body of literature suggests that individual-level SES may be differentially associated with mortality depending on area-level SES, and vice versa. This study assessed the effect of the cross-level interaction between individual low-income status and area deprivation on mortality among patients with MM. MATERIALS AND METHODS: This retrospective cohort study used the Surveillance, Epidemiology, and End Results (SEER)-Medicare data (2006-2016). Individuals were defined as having low income if they were dually eligible for Medicare and Medicaid and/or if they received the Low-Income Subsidy. The county-level Social Deprivation Index (SDI) was linked to individual-level SEER-Medicare data and categorized into quintiles, from the least deprived (Quintile 1) to the most deprived (Quintile 5). Adjusted hazard ratios (HRs) for the associations between low-income status, area deprivation, and all-cause mortality were estimated from a mixed-effects Cox proportional-hazards (PH) model. RESULTS: The mortality hazard was higher for individuals with low income than individuals without low income in all quintiles of area deprivation, with the exception of Quintile 5 (Quintile 1: HR 1.53 [95% confidence interval [CI]: 1.32-1.77]; Quintile 2: HR 1.17 [95%CI: 1.01-1.36]; Quintile 3: HR 1.34 [95%CI: 1.18-1.53]; Quintile 4: HR 1.33 [95%CI: 1.17-1.52]; Quintile 5: HR 1.09 [95%CI: 0.96-1.23]). Among individuals without low income, individuals residing in the most deprived area had a higher mortality hazard than individuals residing in the least deprived area (HR: 1.22 [95%CI: 1.03-1.45]). In contrast, among individuals with low income, residing in a more deprived area, Quintile 2, was associated with a lower hazard of death than residing in the least deprived area, Quintile 1 (HR: 0.82 [95%CI: 0.67-0.99]), and there was no statistically significant difference between Quintile 1 and Quintiles 3, 4, and 5. DISCUSSION: In this analysis, there was a statistically significant cross-level interaction between individual low-income status and area deprivation on mortality. More research is needed to fully understand the mechanism behind these associations, but the findings show that patients and their health should be considered in the context of where they live.

The impact of an interprofessional care transitions clinic on readmission rates and costs.

The objective of this study was to assess the effectiveness of the Interprofessional Care Transitions Clinic (ICTC) in reducing preventable readmissions and their associated costs among Medicare/Medicaid patients. A prospective cohort study was conducted among adults who were discharged from the University of Maryland Prince George's Hospital Center to assess the comparative effectiveness of a clinic-based intervention in terms of readmission events, potentially avoidable utilization, length of stay, and hospital charges. Outcomes were evaluated at 1 month, 3 months, and 6 months post-discharge. There were statistically significant differences in the following outcomes (follow-up period): proportion of readmissions (3 months), potentially avoidable utilization (1 month), and mean medical charges for ICTC patients compared to non-ICTC patients (1 month). This program was aimed at testing the impact of having an interprofessional team focused on providing holistic patient-centered care.

The impact of automatic physician review of prescription drug monitoring program data on opioid prescribing in a Maryland statewide hospital system.

BACKGROUND AND AIMS: Prescription drug monitoring programs (PDMPs) were implemented to decrease dangerous opioid prescribing but have had variable results. This report details how automatic PDMP review changed opioid prescribing across a statewide medical system. DESIGN: An observational study. SETTING: Fourteen hospital networks in the United States. CASES: Healthcare encountered from July 1, 2016 to June 30, 2019. INTERVENTION: Starting from July 1, 2018, the patient's PDMP data would be displayed automatically to providers in the unified electronic medical record (EMR) whenever the provider began to write for an opioid prescription. MEASUREMENTS: Outcomes were prescriptions per encounter (PPE) and the morphine milligram equivalents (MME) per prescription. Outcomes were stratified by practice location, medication prescribed, and diagnosis. All data, including whether the prompt was triggered for a given encounter and whether a prescription was given, were extracted from the EMR. An interrupted timeseries analysis was used to determine how PPE and MME changed in response to the implementation of automatic PDMP review. FINDINGS: Of the 624,488 encounters examined, 18.37 percent (n = 114,710) were in emergency departments, 56.79 percent were admissions (n = 354,634), and 24.84 percent (n = 155,144) were outpatient visits. Opioid prescriptions were started and then canceled 24 percent of the time after the PDMP was shown. There was a decline in MME (ßOverall + Policy Trends = -3.17, p = <0.0001), which was driven by inpatient (ßOverall + Policy Trends = -2.10, p < 0.0001) and outpatient providers (ßOverall + Policy Trends = -3.24, p < 0.01). A decline in MME was seen in all medication categories (-1.72 < ßOverall + Policy Trends < -5.87, p < 0.01). There were no changes in these trends after excluding encounters for severe and acute pain. CONCLUSIONS: Automated PDMP review is associated with fewer prescriptions and smaller doses without decreasing appropriate use.

Utility of a Clinically Guided Data-Driven Approach for Predicting Breast Cancer Complications: An Application Using a Population-Based Claims Data Set.

PURPOSE: With earlier detection and an increasing number of breast cancer (BCa) survivors, more women are living with side effects of BCa treatment. A predictive approach to studying treatment-related adverse events (AEs) may generate proactive strategies; however, many studies are descriptive in nature. Focusing on short-term AEs, we determine the performance of prediction models of disease- or treatment-related AEs among women diagnosed with BCa. METHODS: We used administrative claims data from the Blue Health Intelligence National Data Repository. The study sample included female individuals age 18 years and older who were diagnosed with BCa and received cancer-directed treatment between January 1, 2014, and August 1, 2019. Using the information available in the claims data, we constructed longitudinal patient histories and identified disease- and treatment-related AEs occurring within 6 months of treatment. The following prediction models were developed: logistic regression, Lasso regression, gradient boosted tree (GBT), and random forest (RF). We compared models using the area under the receiver operating characteristic curve and its CI, among other metrics. RESULTS: Data were extracted for 267,473 members meeting study inclusion criteria. The area under the curve for the logistic regression model was 0.82 (0.82-0.86), compared with 0.89 (0.87-0.90) for the Lasso, 0.91 (0.89-0.93) for the GBT, and 0.90 (0.93-0.89) for the RF models. The sensitivity was 0.96 for the GBT, Lasso, and RF models, whereas the specificity was 0.42, 0.44, and 0.39 for the GBT, Lasso, and RF models, respectively. Positive predictive values were 0.96 across all three models. CONCLUSION: Prediction models developed using big data methods and grounded in a clinically guided framework have the potential to reliably predict short-term treatment-related AEs among women diagnosed with BCa.

Economic burden of interstitial lung disease in a commercially insured population with Sjögren syndrome in the United States.

BACKGROUND: Patients with Sjögren syndrome (SjS) have substantial cost burden on the health care system; among these patients, those who develop interstitial lung disease (ILD) experience poorer quality of life and have a higher mortality risk. However, the economic burden of ILD has not been documented. OBJECTIVE: To estimate the direct health care costs associated with ILD among patients with SjS in a representative sample of the commercially insured population in the United States. METHODS: Individuals with a diagnosis of SjS between January 1, 2006, and September 30, 2015, with and without a diagnosis of ILD, were identified from the PharMetrics Plus for Academics database. The index date was defined as the later date of the first claim with a diagnosis of SjS or the first claim with a diagnosis of ILD for individuals with SjS and ILD (SjS-ILD), and the first claim with a diagnosis of SjS for SjS-only controls. All baseline variables were measured in the 180 days preindex period. A 5:1 propensity score matching was applied to controls for baseline demographic and geographic variables. The cost ratio and average marginal effect for total direct medical costs comparing SjS patients with and without ILD were estimated using a generalized linear model. Costs per health care resource utilization category were also reported. All costs were represented from a health plan payer perspective and inflated to 2020 US dollars. RESULTS: After applying the inclusion criteria, 815 SjS-ILD cases were identified and matched to 4,075 SjS-only controls based on the 5:1 propensity score matching procedure. The 180-day total cost of SjS-ILD cases was about 2 times higher compared with that of SjS-only controls (adjusted cost ratio = 1.95; 95% CI = 1.76-2.15). The average difference in total cost between patients with and without ILD was $8,814 (95% CI = $7,149-$10,479). Costs were mainly contributed from outpatient services other than physician office visit (such as radiological and pathological tests), inpatient services, and outpatient pharmacy cost components for both groups (39.4%, 38.8%, and 16.3% for SjS-ILD cases; 43.7%, 22.6%, and 22.9% for SjS-only controls, respectively). CONCLUSIONS: Total direct health care cost was substantially higher in patients with SjS and ILD compared with patients with SjS without ILD. Our findings provide the foundation for further economic evaluation for preventive strategies to reduce the clinical and economic burden imposed by ILD among patients with SjS.

Cost-effectiveness of concurrent radiation with cetuximab or chemotherapy in older patients with oropharyngeal cancer.

Aim: To assess the cost-effectiveness of definitive therapies for nonmetastatic oropharyngeal cancer (OPC). Materials & methods: Using the Surveillance, Epidemiology and End Results-Medicare dataset, patients diagnosed between 2000 and 2011 were identified. The cost-effectiveness of chemoradiation (CRT) versus radiotherapy (RT), cetuximab plus RT (cetuximab-RT) versus RT and cetuximab-RT versus CRT were estimated. Results: The incremental cost-effectiveness ratio for CRT compared with RT from 2000 to 2005 was US$56,650 (95% CI: US$4,522-$288,688) per additional year of survival. CRT was dominated by RT from 2006 to 2011. Cetuximab-RT was dominated by RT and CRT. Conclusion: CRT had a favorable value from 2000 to 2005 but was dominated by RT from 2006 to 2011. The value of cetuximab-RT compared with RT/CRT was not favorable with similar/inferior survival and substantial incremental costs.

Direct medical and indirect absenteeism costs among working adult ADHD patients in the United States.

OBJECTIVE: This study investigated the direct medical and indirect (i.e. absenteeism) costs among working adults diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD) in the United States. METHODS: This study utilized 2017-2018 Medical Expenditure Panel Survey data. Attribution and regression-based incremental cost approaches were utilized to estimate direct medical costs, i.e. prescription drug costs and total costs. The regression-based approach was utilized to estimate absenteeism cost. RESULTS: The study sample consisted of 32,222 observations (weighted: 187,207,896). Of these, 459 (weighted: 3,175,033) had ADHD. The mean annual per person ADHD-attributable prescription drug cost was 2018 US $1,248 (standard error (SE): 97) and the ADHD-attributable total cost was $2,031 (SE: 371). This contributed to a mean overall annual spending of $3.96 (SE: 0.42) billion on ADHD-attributable prescription drugs and $6.45 (SE: 1.26) billion on ADHD-attributable total direct medical costs among adult ADHD patients. Based on the regression-based approach, the mean annual incremental cost for ADHD was $1,641 (SE: 164) and $4,328 (SE: 862) per person for prescription medication costs and total costs, respectively. The mean indirect cost of ADHD was estimated at $512 (SE: 91) per year, per person among working adults with ADHD in the United States. CONCLUSIONS: There is a significant direct and indirect economic burden on working adults with ADHD. EXPERT OPINION: There is a significant economic burden of ADHD in terms of direct medical (including out-of-pocket) cost as well as indirect absenteeism cost. The per person annual costs estimated using a regression approach were approximately twice as much as the costs using the sum disease-specific approach, suggesting a potential role for 'spillover' costs among working adults with ADHD. Prescription drug costs were top-ranked contributors to the direct medical costs. As a group, working adults with ADHD are relatively understudied and more research is needed to better understand the burden of ADHD in this group.

The economic burden of Parkinson disease among Medicare beneficiaries.

BACKGROUND: The progressive nature of Parkinson disease (PD), together with a lack of curative treatments, contributes to its economic burden. OBJECTIVE: To estimate the longitudinal incremental costs attributable to PD among Medicare beneficiaries. METHODS: In this retrospective cohort study, we used data from the Chronic Conditions Data Warehouse to identify Medicare beneficiaries with and without PD-related claims identified from 2006 to 2014 with follow-up until 2015. We grouped PD cases and controls based on their survival profiles using a grouping algorithm that used the following baseline measures: age, race, sex, and comorbidity. We identified 3 survival groups and used them to stratify the descriptive annual cost estimates in the 9 years after the index date. We estimated the incremental 1-, 3-, and 5-year costs of PD using generalized linear models (GLM) that controlled for baseline factors. RESULTS: We identified 27,394 cases and controls who were grouped into 3 survival groups. The mean age of the full study sample was 73 years. No material differences were found in the incremental cost of PD across the survival groups. Based on the multivariable GLM, the 1-year incremental cost of PD was $9,625 (95% CI, $9,054-$10,197). The 3-year incremental cost of PD was $20,832 (95% CI, $19,390-$22,274). The 5-year incremental cost of PD was $27,466 (95% CI, 25,088-$29,844). CONCLUSIONS: Among Medicare beneficiaries, PD is associated with excess costs compared with controls. We did not identify substantial differences in the incremental cost of PD across the survival groups. DISCLOSURES:This study was funded by Pfizer Inc. The funding agreement did not impact the authors' independence in designing the study, collecting the data, interpreting the data, writing the manuscript, and submitting the manuscript for publication. Dr Onukwugha reports grants from Pfizer Inc for the conduct of this study and is an employee of University of Maryland, Baltimore, which received financial support from Pfizer Inc in connection with the development of this manuscript; Dr Shulman reports research funding from Pfizer Inc related to the current work, is an employee of University of Maryland, Baltimore, which received financial support from Pfizer Inc in connection with the development of this manuscript, and reports research funding from the NIH, The Rosalyn Newman Foundation, and the Eugenia and Michael Brin family unrelated to the current work and royalties from Oxford University Press and Johns Hopkins University Press; Ms Myers and Dr Alvir are employees and stockholders of Pfizer Inc; Dr Gray was an employee and stockholder of Pfizer Inc at the time of analysis.

Adverse Discharge Outcomes Associated With the Medicare Hospital Readmissions Reduction Program Among Commercially Insured Adults.

ABSTRACT: It is unknown if changes in the rate of discharges against medical advice (DAMA) are related to the implementation of the Medicare Hospital Readmissions Reduction Program (HRRP). We performed an interrupted time series analysis of monthly DAMA rates per 1,000 discharges of all enrolled individuals 18-64 years old with a hospitalization between January 1, 2006, and December 31, 2015, in a commercially insured population. We performed a segmented linear regression with two interruptions: (1) April 2010 to coincide with the passage of the HRRP and (2) October 2012 to coincide with the implementation of HRRP penalties. There were 1,087,812 discharges representing 668,823 individuals over 120 months. The downward trend in monthly DAMA rates was reversed significantly after April 2010 with a sustained 0.1 increase in the monthly rate that continued after the implementation of penalties in October 2012. Allowing for the two interruptions, there was a statistically significant positive trend (0.10; 0.06-0.13, p < .01) in April 2010. Relative to the first interruption, there was no statistically significant change in the slope in October 2012; the estimated slope was -0.04 (-0.08 to 0.002). Monthly DAMA rates increased in anticipation of and after HRRP implementation, suggesting a potential relationship between the HRRP and DAMA.

Economic burden of comorbidities among COPD Patients hospitalized for acute exacerbations: an analysis of a commercially insured population.

INTRODUCTION: This study quantifies costs associated with comorbid conditions among adults diagnosed with chronic obstructive pulmonary disease (COPD) who experience acute exacerbations (AECOPD) needing inpatient hospitalization. METHODS: This retrospective cohort study used 2006-2015 IQVIA PharMetrics® Plus data, a health plan claims database. Patients aged 40-64 years, with AECOPD, defined as an inpatient hospitalization for a COPD-related diagnosis were included. The impact of comorbidities on AECOPD costs (costs of the COPD-related inpatient stay plus healthcare services used 30 days post-discharge) was determined using multivariable regression. The models adjusted for clinical complications, previous utilization, age, sex, region, year, length of hospitalization, and season of admission. RESULTS: Among these COPD patients, 89.5% had at least 1 comorbidity. The mean cost for AECOPD was 2015 US $19,687 (SD: 27,035, median: 11,539). Congestive heart failure, lipid disorders, cancer, and presence of any of the 10 most frequent comorbidities were associated with $1,921 (95% confidence interval (CI): 977-2,866), $1,619 (95% CI: 967-2,272), $8,347 (95% CI: 7,236-9,458), and $4,433 (95% CI: 3,598-5,268) higher costs, respectively than corresponding individuals without these comorbid conditions. Patients with depressive disorders were associated with $1,592 (95% CI: 828-2,355) lower costs compared to those without depressive disorders. CONCLUSION: COPD comorbidity imposes a significant economic burden on AECOPD.

Discharges against medical advice and 30-day healthcare costs: an analysis of commercially insured adults.

Aim: Prior literature detailing the consequences of a discharge against medical advice (DAMA) has not focused on costs. We examine costs following a DAMA. Materials & methods: This retrospective cohort study utilized the IQVIA PharMetrics® Plus database to identify adults hospitalized during 2007-2015. We compared 30-day postdischarge healthcare costs between matched DAMA and routinely discharged groups. Results: Thirty-day healthcare costs for the DAMA group were US$1078 (95% CI: US$434-1730) higher, driven by inpatient readmissions (US$979; 95% CI: US$415-1543) and emergency department visits (US$79; 95% CI: US$56-102). Costs due to prescription drug fills were lower in the DAMA group. Conclusion: A DAMA was associated with higher 30-day postdischarge healthcare costs compared with routine discharges.

Valuing diversity in value assessment: introducing the PhRMA Foundation Health Disparities Challenge Award.

DISCLOSURES:: No funding supported the writing of this article. The author has received grants from BeiGene, Ltd., and Pfizer, Inc., and advisory board fees from PhRMA Foundation.

Valuing diversity in value assessment: introducing the PhRMA Foundation Health Disparities Challenge Award.

DISCLOSURES:: No funding supported the writing of this article. The author has received grants from BeiGene, Ltd., and Pfizer, Inc., and advisory board fees from PhRMA Foundation.

Why the Gap in Evaluating the Social Constructs and the Value of Medicines?

The compounding effects of occupying two or more social identities, such as being "Black" and "female" have been described in intersectionality theory. Intersectionality, a term coined by legal scholar and activist Kimberlé Crenshaw, is a framework to consider race and other social identities as overlapping, dynamic, and interdependent identities. Since its inception, intersectionality has made significant in-roads to inform the conceptualization and empirical investigations of race, gender, and other social identities in sociology, critical race theory, anthropology, feminist theory, and other disciplines. However, to date, cost effectiveness research has not systematically examined race intersecting with other social identities in the valuation of medicines using social theory, such as intersectionality. Consequently, cost effectiveness analysis, which is a method to study the value of medicines in diverse populations, has not been subject to sufficient examination through an intersectionality framework. In the US context, the racial injustices experienced and documented within diverse communities highlight that health outcomes cannot be examined in a vacuum; overlapping social identities such as race and class in relation to context have real effects on health behaviors, measured preferences, and economic costs. Failure to examine the effects of overlapping social identities on heterogeneity in benefits and costs can result in inadequate information for decision makers to evaluate the value of treatments. Without consideration of the overlapping social identities in diverse populations, there is a risk that cost effectiveness analysis results will not accurately reflect the value of treatments in socially disadvantaged populations. In this Current Opinion, we provide an outline for conducting socially conscious cost effectiveness analyses, using intersectionality as one example.

Health Care Resource Utilization Associated With Parkinson Disease Among Medicare Beneficiaries.

OBJECTIVE: To compare differences in health care resource utilization (HcRU) over time between Medicare beneficiaries with and without Parkinson disease (PD). METHODS: This retrospective observational study used the Chronic Conditions Data Warehouse (5% Medicare sample) between 2005 and 2015. In a propensity score-matched (age, sex, race, and comorbidity adjusted) sample of beneficiaries with and without PD, we examined all-cause HcRU due to inpatient admissions, emergency department (ED) admissions, skilled nursing facility (SNF) admissions, health care provider encounters, neurologist visits, rehabilitation service visits, and non-PD medication fills. Relative to beneficiaries without PD, we reported adjusted incidence rate ratios (IRRs) and 95% confidence intervals (CIs) for beneficiaries with PD using generalized linear models with log link and negative binomial variance functions. RESULTS: A total of 467,064 Medicare enrollees (unmatched sample) met the inclusion criteria. Of these, 3.3% had PD. In the matched sample and relative to beneficiaries without PD, beneficiaries with PD displayed higher rates of inpatient admissions (IRR 1.29, 95% CI 1.24-1.34), ED admissions (IRR 1.31, 95% CI 1.27-1.34), SNF admissions (IRR 2.00, 95% CI 1.92-2.09), health care provider encounters (IRR 1.18, 95% CI 1.16-1.20), neurologist visits (IRR 5.57, 95% CI 5.35-5.78), rehabilitation service visits (IRR 1.47, 95% CI 1.41-1.53), and non-PD medication fills (IRR 1.10, 95% CI 1.08-1.11) over time. CONCLUSION: These results reflect patterns of medical care among Medicare beneficiaries with PD. The findings can help clinicians, payers, and policy makers make evidence-based decisions for the allocation of scarce health care resources for PD management. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that Medicare beneficiaries with PD use more health care resources than matched controls without PD.