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BACKGROUND: Despite extensive research, significant gaps remain in understanding racial disparity among individuals with cardiovascular diseases (CVD). These disparities, influenced by factors such as access to care and comorbid conditions, necessitate further investigation to develop targeted interventions. AIM: To evaluate the factors contributing to racial and ethnic disparities in healthcare resource utilization and total healthcare expenditure among individuals with CVD. METHODS: Using data from the Medical Expenditure Panel Survey spanning 2014-2021, total healthcare expenditure and having a CVD visit were compared among Hispanic, Black, and White adults with CVD. Descriptive analysis, linear regression, and logistic regression models were used to compare the results. Multivariable models were used to evaluate the effect of demographic and socioeconomic factors on total healthcare expenditure and the likelihood of having a CVD visit among different races. RESULTS: With a weighted sample of 17,722,706, the study found that Hispanic and Black cohorts had 23% and 11% lower healthcare expenditures (both p < 0.001). Hispanic and Black cohorts also had lower odds of having a CVD visit (odds ratio [OR] = 0.61, 95% confidence interval [CI]:0.55-0.68; OR = 0.58, 95% CI: 0.52-0.65, respectively) compared to the White cohort. Key predictors included physical and cognitive limitations, insurance status, income, region, and the year of data collection. CONCLUSION: This study highlights the need for targeted interventions to address healthcare disparities and promote health equity among minority populations with CVD.
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During the COVID-19 pandemic, tele-mental health (TMH) was a viable approach for providing accessible mental and behavioral health (MBH) services. This study examines the sociodemographic disparities in TMH utilization and its effects on healthcare resource utilization (HCRU) and medical expenditures in Mississippi. Utilizing a cohort of 6787 insured adult patients at the University of Mississippi Medical Center and its affiliated sites between January 2020 and June 2023, including 3065 who accessed TMH services, we observed sociodemographic disparities between TMH and non-TMH cohorts. The TMH cohort was more likely to be younger, female, White/Caucasian, using payment methods other than Medicare, Medicaid, or commercial insurers, residing in rural areas, and with higher household income compared to the non-TMH cohort. Adjusting for sociodemographic factors, TMH utilization was associated with a 190% increase in MBH-related outpatient visits, a 17% increase in MBH-related medical expenditures, and a 12% decrease in all-cause medical expenditures (all p < 0.001). Among rural residents, TMH utilization was associated with a 205% increase in MBH-related outpatient visits and a 19% decrease in all-cause medical expenditures (both p < 0.001). This study underscores the importance of addressing sociodemographic disparities in TMH services to promote equitable healthcare access while reducing overall medical expenditures.
Subject(s)
COVID-19 , Health Expenditures , Health Services Accessibility , Telemedicine , Humans , COVID-19/epidemiology , COVID-19/economics , Mississippi/epidemiology , Female , Male , Health Expenditures/statistics & numerical data , Health Services Accessibility/statistics & numerical data , Health Services Accessibility/economics , Middle Aged , Adult , Telemedicine/statistics & numerical data , Telemedicine/economics , Mental Health Services/statistics & numerical data , Mental Health Services/economics , Healthcare Disparities/economics , Healthcare Disparities/statistics & numerical data , Aged , Pandemics/economics , SARS-CoV-2 , Young AdultABSTRACT
Objective: Investigate the association between Telemental Health (TMH) uptake and sociodemographic characteristics, and how TMH uptake relates to health care resource utilization and Medicaid expenditures among Mississippi Medicaid enrollees with major depression. Methods: A retrospective cohort study was conducted (2019-2020), comparing those who utilized TMH and those who did not. Results: Among the 21,239 identified enrollees, 806 (3.79%) utilized TMH. The TMH cohort was more likely to be of older age, non-Hispanic White, comprehensive managed care organization enrollees, rural residents, and from areas with a higher area deprivation index, and have higher Charlson comorbidity index scores. The TMH cohort also exhibited higher mental health-related and all-cause outpatient and emergency department utilization, along with higher Medicaid expenditures. Conclusion: As the first study investigating telehealth utilization among Mississippi Medicaid enrollees, this study highlights sociodemographic disparities in telehealth adoption. Addressing barriers hindering telehealth adoption among vulnerable populations and ensuring the availability of quality data are vital for future research.
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Background: Telemental health (TMH) offers a promising approach to managing major depressive disorder (MDD). The objective of our work was to evaluate TMH usage among a vulnerable population of MDD Medicare beneficiaries and its association with health care utilization and expenditures. Methods: This cohort study analyzed 2019 Mississippi Medicare fee-for-service data for adult beneficiaries with MDD. Subjects were matched by the use of TMH following 1:1 propensity score matching. Comparisons between TMH and non-TMH cohorts were made on health care utilization and expenditure outcomes, adjusting for provider types postmatching. Results: Among 7,673 identified beneficiaries, 551 used TMH and 7,122 did not. Prematching, TMH cohort showed greater proportions of dual beneficiaries, rural residents, subjects with income below $40,000, those with disability entitlement, and higher Charlson comorbidity index scores, compared to the non-TMH cohort (all p < 0.001). Moreover, the TMH cohort had fewer outpatient visits, but more inpatient admissions, emergency department (ED) visits, and higher medical, pharmacy, and total expenditures (all p < 0.001). Postmatching, TMH was associated with a 25% reduction in outpatient visits (p < 0.001) and a 20% reduction in pharmacy expenditures (p = 0.01), with no significant effect on inpatient admissions, ED visits, medical expenditures, or total expenditures. Conclusions: These results underscore the potential of TMH in enhancing accessible health care services for vulnerable populations and affordable services for Medicare. Our results provide a robust baseline for future policy discussions concerning TMH. Future studies should consider identifying barriers to TMH use among vulnerable populations and ensuring equitable and high-quality patient care.
Subject(s)
Depressive Disorder, Major , Health Expenditures , Medicare , Patient Acceptance of Health Care , Propensity Score , Telemedicine , Humans , United States , Medicare/statistics & numerical data , Medicare/economics , Female , Male , Aged , Health Expenditures/statistics & numerical data , Patient Acceptance of Health Care/statistics & numerical data , Telemedicine/economics , Telemedicine/statistics & numerical data , Depressive Disorder, Major/therapy , Depressive Disorder, Major/economics , Mississippi , Aged, 80 and over , Middle Aged , Vulnerable Populations/statistics & numerical data , Cohort Studies , Mental Health TeletherapyABSTRACT
BACKGROUND: The rapid expansion of telehealth services, driven by the COVID-19 pandemic, necessitates systematic evaluation to guarantee the quality, effectiveness, and cost-effectiveness of telehealth services and programs in the United States. While numerous evaluation frameworks have emerged, crafted by various stakeholders, their comprehensiveness is limited, and the overall state of telehealth evaluation remains unclear. OBJECTIVE: The overarching goal of this scoping review is to create a comprehensive overview of telehealth evaluation, incorporating perspectives from multiple stakeholder categories. Specifically, we aim to (1) map the existing landscape of telehealth evaluation, (2) identify key concepts for evaluation, (3) synthesize existing evaluation frameworks, and (4) identify measurements and assessments considered in the United States. METHODS: We will conduct this scoping review in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews and in line with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). This scoping review will consider documents, including reviews, reports, and white papers, published since January 1, 2019. It will focus on evaluation frameworks and associated measurements of telehealth services and programs in the US health care system, developed by telehealth stakeholders, professional organizations, and authoritative sources, excluding those developed by individual researchers, to collect data that reflect the collective expertise and consensus of experts within the respective professional group. RESULTS: The data extracted from selected documents will be synthesized using tools such as tables and figures. Visual aids like Venn diagrams will be used to illustrate the relationships between the evaluation frameworks from various sources. A narrative summary will be crafted to further describe how the results align with the review objectives, facilitating a comprehensive overview of the findings. This scoping review is expected to conclude by August 2024. CONCLUSIONS: By addressing critical gaps in telehealth evaluation, this scoping review protocol lays the foundation for a comprehensive and multistakeholder assessment of telehealth services and programs. Its findings will inform policy makers, health care providers, researchers, and other stakeholders in advancing the quality, effectiveness, and cost-effectiveness of telehealth in the US health care system. TRIAL REGISTRATION: OSF Registries osf.io/aytus; https://osf.io/aytus. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/55209.
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Background: Bevacizumab-awwb (MVASI®) was the first U.S. Food and Drug Administration-approved biosimilar to Avastin® (reference product [RP]) for the treatment of several different types of cancers, including metastatic colorectal cancer (mCRC), an indication approved based on extrapolation. Objectives: Evaluate treatment outcomes in mCRC patients who received first-line (1L) bevacizumab-awwb at treatment initiation or as continuing bevacizumab therapy (switched from RP). Design: A retrospective chart review study. Methods: Adult patients who had a confirmed diagnosis of mCRC (initial presentation of CRC on or after 01 January 2018) and initiated 1L bevacizumab-awwb between 19 July 2019 and 30 April 2020 were identified from the ConcertAI Oncology Dataset. A chart review was conducted to evaluate patient baseline clinical characteristics and effectiveness and tolerability outcomes during the follow-up. Study measures were reported stratified by prior use of RP: (1) naïve patients and (2) switchers (patients who switched to bevacizumab-awwb from RP without advancing the line of therapy). Results: At the end of study period, naïve patients (n = 129) had a median 1L progression-free survival (PFS) of 8.6 months [95% confidence interval (CI), 7.6-9.9] and a 12-month overall survival (OS) probability of 71.4% (95% CI, 61.0-79.5%). Switchers (n = 105) had a median 1L PFS of 14.1 months (95% CI, 12.1-15.8) and a 12-month OS probability of 87.6% (95% CI, 79.1-92.8%). During treatment with bevacizumab-awwb, 20 events of interest (EOIs) were reported in 18 naïve patients (14.0%) and 4 EOIs reported in 4 switchers (3.8%), of which the most commonly reported events were thromboembolic and hemorrhagic events. Most EOIs resulted in emergency department visit and/or treatment hold/discontinuation/switch. None of the EOIs resulted in death. Conclusion: In this real-world cohort of mCRC patients who were treated 1L with a bevacizumab biosimilar (bevacizumab-awwb), the clinical effectiveness and tolerability data were as expected and consistent with previously published findings from real-world studies of bevacizumab RP in mCRC patients.
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OBJECTIVE: Patients with persistent, recurrent, or metastatic cervical cancer have poor prognosis. While recent advances have expanded treatment options, real-world data on treatment patterns and outcomes in this population are lacking. METHODS: This retrospective study identified adult females with persistent, recurrent, or metastatic cervical cancer from the ConcertAI Oncology Dataset who received systemic therapy on or after August 15, 2014. Patients were followed from persistent, recurrent, or metastatic diagnosis through third-line (3 L) therapy, death, end of record, or study end (June 2021). Data collection included patient characteristics, treatment patterns, and clinical outcomes. Kaplan-Meier methods were used for the three most common first-line (1 L) regimens to analyze real-world time on treatment (rwToT), real-world progression-free survival (rwPFS), and real-world overall survival (rwOS). Analyses were stratified by bevacizumab receipt by treatment line. RESULTS: 307 patients were included (mean [standard deviation] age 51.5 [13.2] years, 70.7% White). 91.2% of patients had metastatic disease, 8.5% had persistent disease, and <1% had recurrent disease. The most common 1 L regimen was carboplatin+paclitaxel+bevacizumab (40.7%) with median (95% confidence interval [CI]) rwToT of 3.5 (2.9-4.4) months. 57.0% of patients proceeded to second line (2 L), and 25.7% went to 3 L. Median (95% CI) rwPFS was 7.2 (6.4-8.1) months, and median (95% CI) rwOS was 16.5 (14.2-19.9) months, from initiation of 1 L. CONCLUSIONS: 1 L regimens received in patients with persistent, recurrent, or metastatic cervical cancer generally followed clinical guidelines, and the rwOS agrees with clinical trials. This study highlights the burden of disease and unmet need for specific treatments in these patients.
Subject(s)
Uterine Cervical Neoplasms , Adult , Female , Humans , United States , Middle Aged , Uterine Cervical Neoplasms/drug therapy , Uterine Cervical Neoplasms/pathology , Bevacizumab/adverse effects , Paclitaxel/therapeutic use , Retrospective Studies , Progression-Free SurvivalABSTRACT
OBJECTIVE: To estimate the effects of inadequate type 2 diabetes mellitus (T2D) care on health outcomes, utilizing a model that incorporates patient, physician, and health-system factors. METHODS: The most recently available (years 2016-2018) Medical Expenditure panel survey longitudinal data was used to identify adults with type 2 diabetes who had received inadequate diabetes care. American Diabetes Association Standards of Diabetes guidelines were used to define inadequate care, resulting in five categories: lifestyle management, immunization, pharmacologic therapy, physical examination, and laboratory evaluation. For each of the five categories, propensity score 1:1 matching was used to match individuals who received inadequate care to similar individuals who did not. After matching, cohorts were followed for one year. The cohorts were compared by total healthcare expenditure change from baseline, total emergency healthcare visits change from baseline, total newly developed diabetes-related complications, and total days absent from school or work change from baseline. RESULTS: 1,619 adults with T2D, representing 15,781,346 individuals met study inclusion criteria, of which 22.60%, 22.80%, 49.21%, 23,93%, and 23,45% received inadequate lifestyle management, immunizations, pharmacologic therapies, physical examinations, and laboratory tests, respectively. After propensity score matching, those who had received inadequate care had increased healthcare expenditure change from baseline and more new diabetes-related complications in the following year. After adjusting for residual covariate imbalance, those that had received inadequate pharmacologic therapies had approximately 0.20 increased instances of emergency healthcare utilization and 0.10 increase in new diabetes-related complications. Those that had received inadequate laboratory tests had 0.26 additional increased instances emergency healthcare utilization. CONCLUSION: Inadequate T2D care is an extensive issue that may have substantial economic burden and may lead to increased diabetes-related complications. Those who did not receive medications or laboratory tests that were consistent with ADA guidelines had significantly increased emergency healthcare utilization in the following year. These findings highlight the importance of careful monitoring of T2D.
Subject(s)
Diabetes Complications , Diabetes Mellitus, Type 2 , Adult , Diabetes Mellitus, Type 2/complications , Diabetes Mellitus, Type 2/epidemiology , Diabetes Mellitus, Type 2/therapy , Health Expenditures , Humans , Patient Acceptance of Health Care , United States/epidemiologyABSTRACT
BACKGROUND: Palliative care aims to improve or maintain quality of life for patients with life-limiting or life-threatening diseases. Limited research shows that palliative care is associated with reduced intensive care unit length of stay and use of high-cost resources. METHODS: This was an observational, non-experimental comparison group study on all patients 18 years or older admitted to any intensive care unit (ICU) at Memorial Hermann - Texas Medical Center for 7 to 30 days from August 2013 to December 2015. Length of stay (LOS) and hospital costs were compared between the treatment group of patients with palliative care in the ICU and the control group of patients with usual care in the ICU. To adjust for confounding of the palliative care consultation on LOS and hospital cost, an inverse probability of treatment weighted method was conducted. Generalized linear models using gamma distribution and log link were estimated. All costs were converted to 2015 US dollars. RESULTS: Mean LOS was 13 days and mean total hospital costs were USD 58,378. In adjusted and weighted analysis, LOS for the treatment group was 8% longer compared to the control group. The mean total hospital cost was estimated to decrease by 21% for the treatment group versus the control group. We found a reduction of USD 33,783 in hospital costs per patient who died in the hospital and reduction of USD 9113 per patient discharged alive. CONCLUSION: Palliative care consultation was associated with a reduction in the total cost of hospital care for patients with life-limiting or life-threatening diseases.
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Acute and chronic graft-versus-host disease (aGVHD/cGVHD) are serious conditions occurring after allogeneic hematopoietic cell transplantation (HCT). Steroids are the most common first-line therapy; however, they are frequently associated with numerous morbid complications. To describe the healthcare resource utilization (HCRU) and costs of steroid-related complications in patients receiving systemic steroids for GVHD. This retrospective study used medical and pharmacy claims from the Optum Research database. Eligible patients were diagnosed with GVHD (aGVHD, cGVHD, or both) after HCT and were treated with systemic steroids between July 1, 2010, and August 31, 2019. The index date was the date of the first claim for systemic steroids after GVHD diagnosis. The baseline period was the 6 months before the index date, and the follow-up period was 2 years after the index date. Outcome variables included HCRU and costs associated with steroid complications, grouped into 4 categories: bone/muscle, gastrointestinal, infection, and metabolic/endocrine. A multivariate analysis was used to assess the cost ratio associated with the presence of each steroid complication; the linear model was adjusted for baseline patient characteristics and types of steroid conditions identified during follow-up. Another multivariate analysis assessed the hazard ratio for hospitalization associated with each steroid complication using a Cox proportional hazards regression model adjusted for the time-varying presence of each complication category. A total of 689 patients were studied (median age, 55 years; male, 60%); 22% had aGVHD only, 21% had cGVHD only, and 39% had both types of GVHD. After 2 years of follow-up, 97% had at least 1 steroid-associated complication. The most common complication category was infection (79.5%), followed by metabolic/endocrine (32.4%), gastrointestinal (29.2%), and bone/muscle conditions (19.7%). About two thirds (66%) of patients with any steroid complication had ≥1 hospitalization requiring a median (interquartile range [IQR]) of 20 (8-43) hospital days. Patients with an infection experienced the highest hospitalization rate (72%) and thus the highest associated costs. The total mean (median [IQR]) healthcare cost potentially related to steroid complications was $164,787 ($50,834 [$8865-$182,693]), and the largest expense was hospitalization (mean [median {IQR}], $140,637 [$26,782 {$0-$141,398}]). Of the different steroid complications, infections were associated with the highest cost (mean [median {IQR}], $167,473 [$57,680 {$16,261-$178,698}]). In addition, a significantly higher total adjusted cost was associated with the presence of an infection, gastrointestinal complication, or bone/muscle complication in patients with GVHD versus the absence of each complication (all P < .001). Complications occurring after steroid treatment for GVHD may add substantially to the HCRU and costs associated with GVHD management. Infections in particular required inpatient care and were associated with the highest economic burden.
Subject(s)
Graft vs Host Disease , Hematopoietic Stem Cell Transplantation , Graft vs Host Disease/drug therapy , Hematopoietic Stem Cell Transplantation/adverse effects , Humans , Male , Middle Aged , Patient Acceptance of Health Care , Retrospective Studies , SteroidsABSTRACT
BACKGROUND: Hepatocellular carcinoma (HCC) is an aggressive form of liver cancer with increasing incidence and mortality worldwide. For metastatic disease, systemic treatment is recommended. In addition to tumor characteristics, adverse events (AEs) may influence regimen choice. AIM: To analyze healthcare burden among patients with advanced HCC, by treatment type and AEs observed. METHODS: Included were adult commercial and Medicare Advantage enrollees with ≥2 non-diagnostic claims coded for HCC (the first setting the index date); ≥1 claim for systemic treatment of advanced/metastatic HCC; and continuous enrollment for a 6-month pre-index baseline period to ≥1 month post-index (follow-up). Patients were excluded by lack of systemic treatment; incomplete demographic information; pregnancy, liver transplant, other cancers during baseline or clinical trial participation. We describe patient characteristics, common AEs, overall survival, and healthcare burden in 2017 USD up to 12 months after initiation of tyrosine kinase inhibitor (TKI) monotherapy; immune checkpoint inhibitor (ICI) monotherapy; or FOLFOX combination therapy. RESULTS: The analytic sample consisted of 322 patients (median age 65.8 years, 76% male) who had 12 months' (unless death occurred prior) available follow-up, with median follow-up of 9 months. Among these, 241 (75%) had TKI monotherapy, 23 (7%) had ICI monotherapy, and 58 had FOLFOX (18%) first-line treatment. Overall, patients had a high burden of AEs (mean 3.2), with the most prevalent being pain (75%), infection (39%), ascites (34%), and bleeding (29%). After adjusting for covariates, infection ($50 374), fever ($47 443), and diarrhea ($29 912) imposed the highest incremental annual costs versus patients without the AE. Up to 90% of costs were attributable to inpatient admissions, with 56% to 60% involving intensive care. Median 1-year survival was 32%. CONCLUSIONS: This real-world study demonstrated AE burden in alignment with previous clinical studies. Regardless of regimen used, AEs are associated with substantial healthcare costs due to inpatient care.
Subject(s)
Carcinoma, Hepatocellular , Liver Neoplasms , Adult , Aged , Carcinoma, Hepatocellular/therapy , Female , Health Care Costs , Humans , Liver Neoplasms/therapy , Male , Medicare , Protein Kinase Inhibitors , Retrospective Studies , United States/epidemiologyABSTRACT
Immune thrombocytopenia (ITP) may occur in isolation (primary) or in association with a predisposing condition (secondary ITP [sITP]). Eltrombopag is a well-studied treatment for primary ITP, but evidence is scarce for sITP. We evaluated real-world use of eltrombopag for sITP using electronic health records. Eligible patients had diagnoses of ITP and a qualifying predisposing condition, and eltrombopag treatment. We described patient characteristics, treatment patterns, platelet counts, and thrombotic and bleeding events. We identified 242 eligible patients; the most common predisposing conditions were hepatitis C and systemic lupus erythematosus. Average duration of eltrombopag treatment was 6.1 months. Most (81.4%) patients achieved a platelet count ≥ 30,000/µL at a mean of 0.70 months, 70.2% reached ≥ 50,000/µL at a mean of 0.95 months, and 47.1% achieved a complete response of > 100,000/µL at a mean of 1.43 months after eltrombopag initiation. At eltrombopag discontinuation, 105 patients (43%) experienced a treatment-free period for a mean 3.3 months. Bleeding events occurred with similar frequency before and during eltrombopag treatment whereas thrombotic events were less frequent during eltrombopag treatment. Our results suggest similar rates of platelet response with eltrombopag in patients with sITP as compared with primary ITP. In addition, a treatment-free period is possible for a substantial minority of patients.
Subject(s)
Benzoates/therapeutic use , Hydrazines/therapeutic use , Purpura, Thrombocytopenic, Idiopathic/drug therapy , Pyrazoles/therapeutic use , Adult , Aged , Female , Hemorrhage/etiology , Humans , Male , Middle Aged , Platelet Count , Purpura, Thrombocytopenic, Idiopathic/complications , Receptors, Thrombopoietin/agonists , Retrospective Studies , Thrombosis/etiology , Treatment OutcomeABSTRACT
BACKGROUND: We investigated the association between adverse events (AEs) suspected to be immune-related and health care resource utilization, costs, and mortality among patients receiving programmed cell death 1/programmed cell death ligand 1 immune checkpoint inhibitor (ICI) monotherapy for urothelial carcinoma, renal cell carcinoma, non-small cell lung cancer, or Merkel cell carcinoma. PATIENTS AND METHODS: We conducted a retrospective cohort study using medical and pharmacy claims and enrollment information from U.S. commercial and Medicare Advantage with Part D enrollees in the Optum Research Database from March 1, 2014, through April 30, 2019. Claims were linked with mortality data from the Social Security Death Index and the National Death Index. Eligible patients had at least one ICI claim between September 1, 2014, and April 30, 2019. RESULTS: After adjusting for potential confounding variables, we found patients with AEs had more than double the risk of an inpatient stay (hazard ratio [HR], 2.2; 95% confidence interval [CI], 1.9-2.5) and an 80% higher risk of an emergency visit (HR, 1.8; 95% CI, 1.6-2.1) than patients without AEs. Adjusted 6-month total costs were $24,301 higher among patients with an AE versus those without ($99,037 vs. $74,736; 95% CI, $18,828-29,774; p < .001). Mean ± SD AE-related medical costs averaged $2,359 ± $7,496 per patient per month, driven by inpatient visits, which accounted for 89.9% of AE-related costs. Adjusted risk of mortality was similar in patients with and without AEs. CONCLUSION: Patients with AEs had higher risks of hospitalizations, emergency room visits, and higher health care costs, driven by inpatient stays, than patients without AEs. The adjusted risk of mortality was similar between the two cohorts. IMPLICATIONS FOR PRACTICE: Patients taking immune checkpoint inhibitors (ICIs) who had adverse events (AEs) had significantly higher health care costs and utilization, driven by inpatient stays, compared with patients who did not. Given this high cost associated with AEs and the differences in the side effect profile of ICIs versus traditional chemotherapy, it is important for physicians to be cognizant of these differences when treating patients with ICIs. Ongoing evaluation, earlier recognition, and more effective, multidisciplinary management of AEs may improve patient outcomes and reduce the need for costly inpatient stays.
Subject(s)
Carcinoma, Non-Small-Cell Lung , Carcinoma, Transitional Cell , Lung Neoplasms , Urinary Bladder Neoplasms , Aged , Carcinoma, Non-Small-Cell Lung/drug therapy , Health Care Costs , Humans , Immune Checkpoint Inhibitors , Lung Neoplasms/drug therapy , Medicare , Retrospective Studies , United StatesABSTRACT
BACKGROUND: Chronic graft-versus-host disease (cGVHD) is the most serious non-relapse complication affecting long-term allogeneic hematopoietic cell transplantation (HCT) survivors. We describe healthcare resource utilization (HCRU) and costs in patients with steroid-resistant (SR) cGVHD versus no GVHD up to 360 and 720 days post-HCT. METHODS: Claims from the Optum Research Database were used to identify patients aged ≥12 years who underwent allogeneic HCT (index date) in the United States from 01 January 2010 to 31 August 2016 with diagnosis of cGVHD (within the study period or unspecified GVHD beyond 120 days post-HCT [SR defined as additional therapy ≥7 days after initiation of systemic steroids]) or no GVHD at any time. All-cause HCRU and costs were compared in patients with SR cGVHD (1-year analysis, n = 296; 2-year analysis, n = 178) versus no GVHD (1-year analysis, n = 227; 2-year analysis, n = 158). RESULTS: Most patients with SR cGVHD (75%) received ≥4 lines of therapy during follow-up. Patients with SR cGVHD had significantly more median office visits (49 vs. 27), outpatient visits (69 vs. 24), emergency department visits (1 vs. 0), and inpatient admissions (2 vs. 1) within 1 year post-HCT versus patients with no GVHD (all p<.001); HCRU was also higher in the 2-year period. Median total all-cause costs were significantly higher (p<.001) for patients with SR cGVHD versus no GVHD in the 1-year ($372,254 vs. $219,593) and 2-year ($532,673 vs. $252,909) follow-up periods. CONCLUSIONS: Patients with SR cGVHD required multiple lines of therapy and used significantly more outpatient and inpatient resources resulting in higher costs versus patients with no GVHD.
Subject(s)
Graft vs Host Disease , Hematopoietic Stem Cell Transplantation , Chronic Disease , Hematopoietic Stem Cell Transplantation/adverse effects , Humans , Patient Acceptance of Health Care , Retrospective Studies , Steroids , United States/epidemiologyABSTRACT
OBJECTIVE: To evaluate the sequences of tumor necrosis factor inhibitors (TNFi) and non-TNFi used by rheumatoid arthritis (RA) patients whose initial TNFi therapy has failed, and to evaluate effectiveness and costs. METHODS: Using the Truven Health MarketScan Research database, we analyzed claims of commercially insured adult patients with RA who switched to their second biologic or targeted disease-modifying antirheumatic drug between January 2008 and December 2015. Our primary outcome was the frequency of treatment sequences. Our secondary outcomes were the time to therapy discontinuation, drug adherence, and drug and other health care costs. RESULTS: Among 10,442 RA patients identified, 36.5% swapped to a non-TNFi drug, most commonly abatacept (54.2%). The remaining 63.5% cycled to a second TNFi, most commonly adalimumab (41.2%). For subsequent switches of therapy, non-TNFi were more common. Patients who swapped to a non-TNFi were significantly older and had more comorbidities than those who cycled to a TNFi (P < 0.001). Survival analysis showed a longer time to discontinuation for non-TNFi than for TNFi (median 605 days compared with 489 days; P < 0.001) when used after initial TNFi discontinuation, but no difference in subsequent switches of therapy. Although non-TNFi were less expensive for adherent patients, cycling to a TNFi was associated with lower costs overall. CONCLUSION: Even though patients are more likely to cycle to a second TNFi than swap to a non-TNFi, those who swap to a non-TNFi are more likely to persist with the therapy. However, cycling to a TNFi is the less costly strategy.
Subject(s)
Arthritis, Rheumatoid/drug therapy , Drug Substitution , Tumor Necrosis Factor Inhibitors/administration & dosage , Adult , Aged , Arthritis, Rheumatoid/diagnosis , Arthritis, Rheumatoid/economics , Arthritis, Rheumatoid/immunology , Cost Savings , Cost-Benefit Analysis , Databases, Factual , Drug Administration Schedule , Drug Costs , Drug Substitution/adverse effects , Drug Substitution/economics , Female , Humans , Male , Middle Aged , Retrospective Studies , Time Factors , Treatment Outcome , Tumor Necrosis Factor Inhibitors/adverse effects , Tumor Necrosis Factor Inhibitors/economics , United StatesABSTRACT
BACKGROUND: Second-line treatment for immune thrombocytopenia (ITP) is not well reported for patients treated in real-world clinical settings. OBJECTIVE: The purpose of this study was to compare outcomes of four second-line treatments for ITP. PATIENTS/METHODS: Included adult patients had at least two medical records containing ITP diagnoses and second-line eltrombopag, romiplostim, rituximab, or splenectomy. Date of treatment initiation or splenectomy was set as index date, between July 1, 2008, and March 31, 2017. Patients had first-line corticosteroid or intravenous immune globulin treatment and continuous database activity from 6 months before to 12 months after index. Patient characteristics, treatment patterns, platelet counts, bleeding-related episodes (BREs), and thrombotic events (TEs) were compared by second-line treatment cohort. RESULTS: The sample included 3332 patients (mean age, 60.5 years; 52.3% female): eltrombopag (5.8%), romiplostim (9.9%), rituximab (73.3%), and splenectomy (11.0%). Patients having splenectomy were younger, more likely female and commercially insured, and less likely to require a third line of treatment than medical regimen cohorts. Proportions of patients having treatment-free (≥180 days with no second-line index or rescue agent) periods varied significantly (P = .01) by regimen: 33% for eltrombopag, 23% for romiplostim, 26% for rituximab, and 17% for splenectomy. All regimens significantly improved platelet counts, while TE and BRE rates differed significantly (P = .03 and P = .01, respectively) when all treatment groups were compared. CONCLUSIONS: Over an average 7-year follow-up, all second-line regimens improved platelet counts, but eltrombopag yielded the highest proportion of patients with completely treatment-free periods of at least 180 days.
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BACKGROUND: The Institute of Medicine reported that more than 1.5 million preventable adverse drug events occur annually in the United States. Comprehensive Medication Management (CMM) is the medication review process to improve clinical outcomes, enhance patient adherence, reduce drug therapy problems and reduce health care costs. University of Texas (UT) Physicians implemented a CMM program in several community-based clinics. We evaluated the effectiveness of CMM to reduce drug therapy problems and achieve medical cost savings. METHODS: This was a retrospective, observational study of CMM participants from October 2015 to September 2016. Program participants included patients aged 18 years or older who had taken more than 4 prescribed medications and were diagnosed with at least one of the following chronic diseases: hypertension, congestive heart failure, chronic obstructive pulmonary disease, asthma or diabetes. Under the CMM program, a clinical pharmacist reviewed patients' electronic health records and created action plans to resolve identified drug problems. As part of the evaluation of the clinical process, two independent physicians conducted peer review on the recommendations issued by the pharmacist in order to establish inter-rater reliability of drug therapy problems and potential consequent medical services. The drug therapy problems were identified and classified into four categories: indication, effectiveness, safety and/or compliance. The average cost of avoided medical services was obtained based on cost extrapolations from the literature, combined with hospital discharge data. Potential medical services avoided were linked to the average cost of those services to calculate the total cost savings of the program from the payers' perspective. RESULTS: By reviewing electronic health records of 3280 patients, the pharmacist identified 301 drug therapy problems and resolved 49.8% of these problems with collaboration from the patient's primary care physician or care team. The most commonly identified drug problems were related to potentially adverse drug reactions or inappropriate drug dosage. The CMM program resulted in potential cost savings of $1,143,015. CONCLUSIONS: The CMM program resolved medication therapy problems among program participants and achieved significant health care cost savings.
Subject(s)
Chronic Disease/drug therapy , Medication Therapy Management/organization & administration , Primary Health Care/organization & administration , Adolescent , Adult , Aged , Aged, 80 and over , Female , Health Care Reform , Health Services Research , Humans , Male , Middle Aged , Program Evaluation , Reimbursement, Incentive/organization & administration , Retrospective Studies , Texas , Young AdultABSTRACT
BACKGROUND: The optimal timing for tracheostomy among patients with acute heart failure (AHF) exacerbation has been controversial, despite multiple studies assessing the utility of early tracheostomy. Our objective was to assess the trend of utilization and outcomes of early tracheostomy among patients with AHF exacerbation in the United States. METHODS AND RESULTS: A retrospective cohort study using the National Inpatient Sample from 2005 to 2014 was conducted. Among those who were admitted with AHF exacerbation (n = 1,390,356), 0.26% of patients underwent tracheostomy (n = 2,571), and among them, 19.4% received early tracheostomy (n = 496). There was no significant shift in the percentage of early tracheostomy from 2008 to 2014. We used propensity score matching to compare the clinical and economic outcomes between the early tracheostomy group and late tracheostomy group. In-hospital mortality did not show any difference between the two groups (13.97% in early group vs. 18.04% in late group; p =0.163). The median total hospital cost ($53,466), total hospital length of stay (19 days), and length of stay after intubation (16 days) in the early tracheostomy group were significantly lower than in the late tracheostomy group ($73,680; 26 days; 23 days, respectively). CONCLUSION: Early tracheostomy showed economic benefit with lower hospital costs and shorter length of stay, without a difference in in-hospital mortality compared to late tracheostomy.
Subject(s)
Heart Failure , Tracheostomy , Hospital Mortality , Humans , Length of Stay , Respiration, Artificial , Retrospective Studies , United States/epidemiologyABSTRACT
BACKGROUND: Pancreatic cancer represents the third leading cause of US cancer deaths, with median survival <1 year. The goal of this study was to describe systemic treatments, healthcare utilization and costs, and overall survival among patients with unresectable/metastatic disease. METHODS: This study used healthcare claims for commercial and Medicare Advantage enrollees diagnosed with pancreatic adenocarcinoma (at index date) during January 01 2010 to 31 May 2017. Included patients were aged ≥18 years, with continuous 6-month preindex enrollment. Patients were excluded by resectable disease, another primary cancer, or pregnancy. Cohorts were based on first-line (LOT1) chemotherapy regimen. RESULTS: Overall, 12 978 patients (mean age 70 years, 51% male) were included, among which 5610 (43%) received chemotherapy. Of those, 23% received gemcitabine monotherapy, 22% gemcitabine-nab paclitaxel, 22% FOLFIRINOX, 3% FOLFOX, and 29% received other regimens. Mean LOT1 duration was 112 days; 60% did not undergo subsequent lines of therapy. Moreover, 50% of patients had an emergency room visit and 45% were hospitalized during LOT1. Among treated and untreated patients, mean total 6-month costs were $52 101. We found that patients receiving FOLFIRINOX had the highest costs, whereas those who received gemcitabine monotherapy had the lowest. Median overall survival (mOS) was 335 days with any first-line treatment. FOLFIRINOX-treated patients had the highest mOS (492 days), whereas gemcitabine monotherapy-treated patients had the lowest (223 days). CONCLUSIONS: A large proportion (57%) of patients with unresectable/metastatic pancreatic cancer did not receive chemotherapy. Healthcare costs were higher for fluorouracil-based regimens, while lower for gemcitabine-based regimens. Survival rates were within expectations for advanced pancreatic cancer.
Subject(s)
Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Carcinoma, Pancreatic Ductal/drug therapy , Health Care Costs , Pancreatic Neoplasms/drug therapy , Aged , Aged, 80 and over , Albumins/administration & dosage , Ambulatory Care/economics , Ambulatory Care/statistics & numerical data , Antineoplastic Combined Chemotherapy Protocols/economics , Carcinoma, Pancreatic Ductal/economics , Carcinoma, Pancreatic Ductal/pathology , Deoxycytidine/administration & dosage , Deoxycytidine/analogs & derivatives , Duration of Therapy , Emergency Service, Hospital/economics , Emergency Service, Hospital/statistics & numerical data , Female , Fluorouracil/therapeutic use , Hospitalization/economics , Hospitalization/statistics & numerical data , Humans , Insurance, Health , Irinotecan/therapeutic use , Leucovorin/therapeutic use , Male , Medicare Part C , Middle Aged , Organoplatinum Compounds/therapeutic use , Oxaliplatin/therapeutic use , Paclitaxel/administration & dosage , Pancreatic Neoplasms/economics , Pancreatic Neoplasms/pathology , Retrospective Studies , Survival Rate , Treatment Outcome , United States , GemcitabineABSTRACT
OBJECTIVE: To systematically review the modeling approaches and quality of economic analyses comparing cycling tumor necrosis factor inhibitors (TNFi) to swapping to a therapy with a different mode of action in patients with rheumatoid arthritis whose initial TNFi failed. METHODS: We searched electronic databases, gray literature, and references of included publications until July 2017. Two reviewers independently screened citations. Reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Data regarding modeling methodology were extracted. RESULTS: We included 7 articles comprising 19 comparisons. Three studies scored ≥16 of 24 on the CHEERS checklist. Most models used a lifetime horizon, took a payer perspective, employed a 6-month cycle length, and measured treatment efficacy in terms of the American College of Rheumatology improvement criteria. We noted possible sources of bias in terms of transparency and study sponsorship. In the cost-utility comparisons, the median incremental cost-effectiveness ratio was US $70,332 per quality-adjusted life-year for swapping versus cycling strategies. Rituximab was more effective and less expensive than TNFi in 7 of 11 comparisons. Abatacept (intravenous) compared to TNFi was less cost-effective than rituximab. Common influential parameters in sensitivity analyses were the rituximab dosing schedule, assumptions regarding disease progression, and the estimation of utilities. CONCLUSION: Differences in the design, key assumptions, and model structure chosen had a major impact on the individual study conclusions. Despite the existence of multiple reporting standards, there continues to be a need for more uniformity in the methodology reported in economic evaluations of cycling versus swapping strategies after TNFi in patients with rheumatoid arthritis.