Disease Burden and Health-Related Quality of Life (HRQoL) of Chronic Obstructive Pulmonary Disease (COPD) in the US - Evidence from the Medical Expenditure Panel Survey (MEPS) from 2016-2019.

Purpose: Chronic obstructive pulmonary disease (COPD) is a progressive disease associated with reduced life expectancy, increased morbidity, mortality, and cost. This study characterized the US COPD burden, including socioeconomic and health-related quality of life (HRQoL) outcomes. Study Design and Methods: In this retrospective, cross-sectional study using nationally representative estimates from Medical Expenditures Survey (MEPS) data (2016-2019), adults (≥18 years) living with and without COPD were identified. Adults living without COPD (control cohort) and with COPD were matched 5:1 on age, sex, geographic region, and entry year. Demographics, clinical characteristics, socioeconomic, and generic HRQoL measures were examined to include a race-stratified analysis of people living with COPD. Results: A total of 4,135 people living with COPD were identified; the matched dataset represented a weighted non-institutionalized population of 11.3 million with and 54.2 million people without COPD. Among people living with COPD, 66.3% had ≥1 COPD-related condition; 62.7% had ≥1 cardiovascular condition, compared to 33.5% and 50.5% without COPD. More people living with COPD were unemployed (56.2% vs 45.3%), unable to work due to illness/disability (30.1% vs 12.1%), had problems paying bills (16.1% vs 8.8%), reported poorer perceived health (fair/poor: 36.2% vs 14.4%), missed more working days due to illness/injury per year (median, 2.5 days vs 0.0 days), and had limitations in physical functioning (40.1% vs 19.4%) (all P<0.0001). In race-stratified analyses for people living with COPD, people self-reporting as Black had higher prevalence of cardiovascular-risk conditions, poorer socioeconomic and HRQoL outcomes, and higher healthcare expenses than White or Other races. Conclusion: Adults living with COPD had higher clinical disease burden, lower socioeconomic status, and reduced HRQoL than those without, with greater disparities among Black people living with COPD compared to White and other races. Understanding the characteristics of patients helps address care disparities and access challenges.

Risk of Death and Cardiovascular Events Following an Exacerbation of COPD: The EXACOS-CV US Study.

Purpose: This study estimated the magnitude and duration of risk of cardiovascular events and mortality following acute exacerbations of chronic obstructive pulmonary disease (AECOPD), and whether risks varied by number and severity of exacerbation in a commercially insured population in the United States. Methods: This was a retrospective cohort study of newly diagnosed COPD patients ≥40 years old in the Healthcare Integrated Research Database from 2012 to 2019. Patients experiencing exacerbations comprised the "exacerbation cohort". Moderate exacerbations were outpatient visits with contemporaneous antibiotic or glucocorticoid administration; severe exacerbations were emergency department visits or hospitalizations for AECOPD. Follow-up started on the exacerbation date. Distribution of time between diagnosis and first exacerbation was used to assign index dates to the "unexposed" cohort. Cox proportional hazards models estimated risks of a cardiovascular event or death following an exacerbation adjusted for medical and prescription history and stratified by follow-up time, type of cardiovascular event, exacerbation severity, and rank of exacerbation (first, second, or third). Results: Among 435,925 patients, 170,236 experienced ≥1 exacerbation. Risk of death was increased for 2 years following an exacerbation and was highest during the first 30 days (any exacerbation hazard ratio (HR)=1.79, 95% CI=1.58-2.04; moderate HR=1.22, 95% CI=1.04-1.43; severe HR=5.09, 95% CI=4.30-6.03). Risks of cardiovascular events were increased for 1 year following an AECOPD and highest in the first 30-days (any exacerbation HR=1.34, 95% CI=1.23-1.46; moderate HR=1.23 (95% CI 1.12-1.35); severe HR=1.93 (95% CI=1.67-2.22)). Each subsequent AECOPD was associated with incrementally higher rates of both death and cardiovascular events. Conclusion: Risk of death and cardiovascular events was greatest in the first 30 days and rose with subsequent exacerbations. Risks were elevated for 1-2 years following moderate and severe exacerbations, highlighting a sustained increased cardiopulmonary risk associated with exacerbations.

National and Local Direct Medical Cost Burden of COPD in the United States From 2016 to 2019 and Projections Through 2029.

BACKGROUND: Despite the significant burden posed by COPD to health care systems, there is a lack of up-to-date information quantifying the general COPD burden, costs, and long-term projections to various stakeholders in the United States. RESEARCH QUESTION: What are the updated state-specific and nationwide estimates of the COPD disease burden and direct costs in 2019, along with projections of COPD-attributable medical costs through 2029? STUDY DESIGN AND METHODS: A cross-sectional, retrospective study design using the 2016 to 2019 Medical Expenditure Panel Survey, 2019 American Community Survey, and 2019 Behavioral Risk Factor Surveillance System data was applied to generate COPD-attributable expenditure estimates. Cost projections for the years 2020 to 2029 were based on 2017 national population projections reported by the US Census Bureau, and all costs were adjusted to 2019 US dollars. RESULTS: In total, 4,135 people living with COPD were included; a higher proportion had other concurrent conditions such as cardiovascular-related conditions compared with people without COPD (n = 86,021). Overall, in 2019, COPD-attributable medical costs after adjusting for demographic characteristics and 19 concurrent conditions (including COPD-related and non-COPD-related conditions) were estimated at $31.3 billion, with state-specific cost estimates reporting wide variation, from $44.8 million in Alaska to $3.1 billion in Florida. Nationwide COPD-attributable medical costs borne by payer type were as follows: private insurance, $11.4 billion; Medicare, $10.8 billion; and Medicaid, $3.0 billion. Projections of national medical costs attributable to COPD are reported to increase to $60.5 billion in 2029. INTERPRETATION: Understanding the current disease and economic burden of COPD in the United States, along with the projected costs attributable to COPD in the next decade, will highlight unmet needs and gaps in care that help inform health care decision-makers in planning future actions to alleviate this disease burden.

Complications Associated With Use of Long-Term Central Venous Catheters Among Commercially Insured Women With Breast Cancer.

PURPOSE: Despite some advantages to their use, long-term central venous catheters (CVCs) are associated with complications for patients who require chemotherapy. Understanding of these risks in commercially insured populations is limited. This information can inform medical policies that ensure the appropriate use of venous access devices. This study's objectives were to assess the extent of variation in use of long-term CVCs in a cohort of commercially insured women with breast cancer, and to assess risks of associated complications. METHODS: Retrospective cohort analysis was conducted using health insurance claims between January 2006 and October 2013. The cohort included commercially insured women age ≥ 18 years diagnosed with breast cancer who received infusion chemotherapy (N = 31,047). We conducted matched and case-mix adjusted Cox proportional hazard modeling to assess differences in bloodstream infections and thrombovascular complications between patients using long-term CVCs and those using temporary intravenous catheters. RESULTS: Approximately two thirds of the cohort had a long-term CVC, although rates varied across regions (57% to 75%), health plans (65% to 70%), and insurance coverage (63% to 68%). After propensity score matching, the adjusted hazard ratio for infection was 2.70 (95% CI, 2.31 to 3.16) and thrombovascular complications, 2.61 (95% CI, 2.33 to 2.93) in patients with long-term CVCs compared with those with temporary intravenous catheters. CONCLUSION: Although long-term CVCs may have benefits, they are associated with increased morbidity. Regional and health plan variation in long-term CVC insertion suggests that some of their use reflects provider- or institution-driven variation in practice. Evidence-based guidelines and tools may help decrease discretionary use of long-term CVCs.

Identifying health outcomes in healthcare databases.

PURPOSE: The purpose of this review is to assist researchers in developing, using, and interpreting case-identifying algorithms in electronic healthcare databases. METHODS: We review clinical characteristics of health outcomes, data settings and informatics, and epidemiologic and statistical methods aspects as they pertain to the development and use of case-identifying algorithms. RESULTS: We offer a framework for thinking critically about the use of electronic health insurance data and electronic health records to identify the occurrence of health outcomes. Accuracy of case ascertainment in database research depends on many factors, including clinical and behavioral aspects of the health outcome, and details of database construction as it pertains to completeness and reliability of database content. Existing methods for diagnostic and screening tests, misclassification, validation studies, and predictive modelling can be usefully applied to improve case ascertainment in database research. CONCLUSIONS: Good case-identifying algorithms are based on a sound understanding of care-seeking behavior and patterns of clinical diagnosis and treatment in the study population and details about the construction and characteristics of the database. Researchers should use quantitative bias analyses to take into account the performance characteristics of case-identifying algorithms and their impact on study results.

The relationship between patient-reported tolerability issues with oral antidiabetic agents and work productivity among patients having type 2 diabetes.

OBJECTIVE: To investigate the association between reported oral antidiabetic tolerability issues and work productivity, activity impairment, and indirect costs. METHODS: Data were collected from the 2006 to 2008 US National Health and Wellness Survey and the Lightspeed Research, using an Internet-based questionnaire (N = 2074). RESULTS: Absenteeism, presenteeism, overall work impairment, and activity impairment increased as the number of tolerability issues increased. Similar results were observed using a diabetes-specific productively measure. Total annual adjusted indirect costs (absenteeism and presenteeism costs summed) were $2759, $5533, $7537, and $8405 for patients with 1, 2, 3, and 4 or more tolerability issues, respectively. CONCLUSIONS: The consideration of tolerability profiles of oral antidiabetic agents may lead to improved productivity among treated patients. Furthermore, targeted educational programs regarding risks and management of these issues to employees with type 2 diabetes mellitus may benefit both employers and patients.

Effects of hypoglycemia on health-related quality of life, treatment satisfaction and healthcare resource utilization in patients with type 2 diabetes mellitus.

AIMS: To quantify patient-reported rates of hypoglycemia and its association with health-related quality of life (HRQL), treatment satisfaction, and healthcare resource utilization. METHODS: Data were collected from 2006 to 2008 US National Health and Wellness Survey and the Ailment Panel of Lightspeed Online Research, an internet-based questionnaire. Adults (≥ 18 years) with type 2 diabetes taking ≥ 1 oral antidiabetic agent (OAD), but not insulin, were included (n=2074). Multivariate analyses included logistic regression and generalized linear models. RESULTS: Overall, patients who reported experiencing hypoglycemia symptoms (n=286; 13.78%) were significantly more likely to have a lower HRQL on several parameters including: increased limitations on mobility (b=0.66, OR=1.93, p<0.0001) and usual activities (b=0.58, OR=1.78, p<0.0001), increased pain/discomfort (b=0.69, OR=2.00, p<0.0001) and anxiety/depression (b=0.84, OR=2.31, p<0.0001). They also had a lower total treatment satisfaction score as measured by the DiabMedSat tool (b=-7.66, p<0.0001). Self-reported rates of diabetes-related emergency room (b=0.98, p=0.004) and physician visits (b=0.30, p<0.0001) were also higher among these patients. CONCLUSION: Among OAD-treated type 2 diabetes patients, symptoms of hypoglycemia tend to be correlated with significantly lower HRQL, lower treatment satisfaction and higher levels of healthcare resource utilization.

Patient-reported tolerability issues with oral antidiabetic agents: Associations with adherence; treatment satisfaction and health-related quality of life.

AIMS: The study's aim was to quantify prevalence of tolerability issues among patients with T2DM currently treated with OADs and to assess its association with treatment adherence, satisfaction and health-related quality of life (HRQL). METHODS: Data were collected from the 2006-2008 US National Health and Wellness Survey and the Ailment Panel of Lightspeed Online Research, an internet-based questionnaire. Participants (N=2074) self-reported a diagnosis of T2DM, were >18 years of age and currently taking >1 OADs but not insulin, and spoke English. RESULTS: The majority (71.7%) experienced at least 1 tolerability issue in the past 2 weeks; 49.7% experienced >2. Tolerability issues included signs/symptoms of hypoglycemia (57.2%), constipation/diarrhea (28%), headaches (25.6%), weight gain (22.9%) and water retention (21.0%). There was a significant association between the number of tolerability issues and both the likelihood of non-adherence (r=0.20, p<0.01) and reduced treatment satisfaction (r=-0.42, p<0.01). Each additional tolerability issue was associated with 28% greater likelihood of medication non-adherence. Constipation/diarrhea (b=-0.02, p<0.01) and symptoms of hypoglycemia (b=-0.08, p<0.01) were significantly associated with lower HRQL scores. CONCLUSIONS: Optimizing OAD therapy of T2DM by improving tolerability may increase patient satisfaction, medication adherence and HRQL, and may increase the likelihood of attaining treatment goals.

Costs of severely ill members and specialty medication use in a commercially insured population.

This study examines the overall profile and costs associated with severely ill commercially insured people. We found severely ill members to have the highest costs, from both the insurer and member perspective. Even for the most costly members where specialty medication use was highest, biologics represented less than one-third of the pharmacy spending and 6.6 percent of overall spending. Out-of-pocket spending rose dramatically when medications were paid for under the pharmacy benefit rather than the medical benefit. The advantages of paying for specialty medications under the pharmacy benefit should be evaluated in conjunction with the potential consequences of increased out-of-pocket burden.

Association between short-term effectiveness of statins and long-term adherence to lipid-lowering therapy.

PURPOSE: The relationship between low-density lipoprotein (LDL) cholesterol reduction in the first 3 months of statin therapy and medication adherence during a 33-month follow-up period was studied. METHODS: A retrospective cohort study was conducted among enrollees in a Southeastern managed care plan who started therapy with atorvastatin, fluvastatin, lovastatin, pravastatin, or simvastatin between October 1999 and August 2001, were enrolled for > or =12 months before and > or =6 months after treatment initiation, and had at least one LDL cholesterol measurement in the year before and 4-12 weeks after the start of therapy. Patients were followed up via electronic pharmacy and medical records for up to 33 more months. The follow-up period was divided into 3-month intervals; patients were considered adherent if statin therapy was available > or =80% of the time. A generalized linear model for repeated measures quantified the association between change in LDL cholesterol at 4-12 weeks and medication adherence in subsequent intervals, adjusting for demographic, clinical, and health-service-use variables. RESULTS: The final sample consisted of 9510 patients. Medication adherence decreased significantly over time: 59%, 40%, 34%, and 21% of patients were adherent at 3, 6, 12, and 36 months, respectively. Mean +/- S.D. LDL cholesterol reduction at 12 weeks was 28.9% +/- 19.9%. The relative LDL cholesterol reduction at 12 weeks was significantly and independently associated with subsequent medication adherence: Compared with subjects in the first quartile of LDL cholesterol reduction, those in quartiles 2, 3, and 4 were more likely to be adherent in any subsequent interval (adjusted odds ratio [95% confidence interval], 1.26 [1.12-1.42], 1.25 [1.11-1.40], and 1.15 [1.02-1.29], respectively). Other independent predictors of adherence in months 4-36 included adherence during the initial three months of therapy, age, and recent history of coronary revascularization. CONCLUSION: Greater reduction in LDL cholesterol levels during the first three months of statin therapy was associated with greater adherence to lipid-lowering drug therapy.