Estimating and Rewarding the Value of Healthcare Interventions Beyond the Healthcare Sector: A Conceptual Framework.

BACKGROUND: Evaluating healthcare interventions for their impacts beyond health outcomes may result in recognition of changes in human capital, income level, tax revenue, and government spending, which could affect economic growth and population health. In this paper, we document instances where current health technology assessment (HTA) practices fail to account for the impacts of healthcare interventions on broader society beyond the healthcare sector. METHODS: We propose a novel conceptual framework, highlighting its three components (distributional cost-effectiveness analysis [DCEA], input-output model, and voting scheme) and their contributions to capturing the economic and societal ripple effects of healthcare interventions. This manuscript also outlines a case study in which the framework is applied to the reassessment of a previously evaluated digital health therapeutic for the treatment of opioid use disorder (OUD) compared with standard of care, demonstrating its practical application. RESULTS: The DCEA health value metric indicates that digital therapeutic is more equitable, favoring socioeconomically disadvantaged groups, while standard of care exacerbates health inequality by benefiting the already advantaged. Additionally, digital therapeutic shows potential for boosting productivity, raising income, and creating jobs, supporting its consideration by employer-sponsored health plans to optimize resource allocation for treating OUD. CONCLUSION: The conceptual framework provides insights for enhancing HTAs to incorporate the broader economic and societal impacts of healthcare interventions. By integrating DCEA, extended HTA analysis with input-output modeling, and a voting scheme, decision makers can make informed choices aligned with societal priorities, although further research and validation are necessary for practical implementation across diverse healthcare contexts.

Review on epidemiology, disease burden, and treatment patterns of IgA nephropathy in select APAC countries.

BACKGROUND: Immunoglobulin type A (IgA) nephropathy is the most common primary glomerulonephritis (GN) worldwide with higher rates in East and Pacific Asia compared to North America and Europe. Despite high reported prevalence of IgAN in these countries, the overall disease prevalence across Asia is not available. Treatment patterns of IgAN patients across Asian countries have also not been summarized. The aim of this study was to review and summarize evidence on IgA nephropathy prevalence, treatment patterns, and humanistic and economic burden in mainland China, Taiwan, South Korea, Japan, and Australia. METHODS: A targeted literature review was conducted in PubMed and local databases in China (including Taiwan), South Korea, Japan, and Australia between January 2010-December 2021. Website literature searches were conducted using Google Scholar and Baidu. RESULTS: Sixty-nine publications and 3 clinical guidelines were included. Incidence ranged from 0 to 10.7 per 100 000 people per year in Australia, Japan, and Taiwan, and ranged from 6.3 to 24.70% among patients who underwent renal biopsy in mainland China. Prevalence and diagnosis rates ranged from 0 to 72.1% in mainland China, South Korea, Taiwan, Japan, and Australia. Mortality rates in mainland China, South Korea, and Japan varied widely. The top 3 commonly used therapies were angiotensin-converting enzyme inhibitor/angiotensin receptor blockers (0.9-99.6%), corticosteroids (3.5-100%), and immunosuppressants (1.6-85.5%) in Japan, mainland China, and South Korea. Patient quality of life was measured by different tools, and annual hospitalization costs ranged from $1 284.73 to $2 252.12 (2015-2018) in China. CONCLUSIONS: The prevalence of IgA nephropathy among the general population in select countries/regions is not commonly available, despite evidence from studies and clinical guidelines. In addition, it is observed across geographic regions that heterogeneity exists in prevalence rates, and large variations exist in treatment patterns. There is need to fill in these gaps to understand the contributing factors behind the differences through population-based, multi-center, and real-world studies.

Insights into insurance coverage for digital therapeutics: A qualitative study of US payer perspectives.

BACKGROUND: In the last decade there has been an increase in the development and marketing of digital therapeutic (DTx) products aiming to prevent, manage, or treat a medical disorder or disease. Health insurance coverage for these products is not well established, and payers are facing increasing pressure to include these products as a covered benefit. OBJECTIVE: To examine factors and characteristics that could drive health insurance coverage of DTx products from US payers' and coverage decision-makers' perspectives. METHODS: This was a qualitative noninterventional, cross-sectional study conducted from August 2022 to October 2022. Virtual focus group meetings with pharmacy benefit managers/directors or medical directors representing a range of health insurance organizations were held following a semistructured interview guide. Convenience and snowball sampling techniques were used to identify participants. Transcripts were coded and analyzed with Atlas.ti software to identify common themes and subthemes. RESULTS: Five focus group meetings and 1 individual interview were held from August to October 2022. Participants (n = 22) were mostly pharmacists (n = 18, 85%) with more than 15 years of experience (n = 18, 85%). Some participants indicated that DTx products for diabetes (n = 6, 29%), mental/behavioral health (n = 3, 14%), and substance abuse disorders (n = 3, 14%) were already covered by their organizations. The topics generating the most comments grouped by code were issues around the evidence for DTx (67 unique comments) and barriers for coverage (60 unique comments). Participants indicated they want to have evidence of effectiveness that is similar to traditional pharmaceutical products. Barriers for coverage included a need to revise benefit policies, exclusion of nonprescription products, and mechanisms for billing. DTx products with an indication for mental/behavioral health were viewed as most likely to be reimbursed. Coverage of DTx products may occur under either the pharmacy or medical benefit. CONCLUSIONS: Health care payers stated that evidence of effectiveness was a necessary condition for health insurance coverage of DTx products. Given these are relatively new in health care, payers had more questions than answers regarding how these products will be integrated into health benefits.

The effects of early initiation of aripiprazole once-monthly on healthcare resource utilization and healthcare costs in individuals with schizophrenia: real-world evidence from US claims data.

AIM: To evaluate the impact of timing of aripiprazole once-monthly (AOM) initiation on healthcare resource utilization (HCRU), risk of hospitalization, and healthcare costs in patients with schizophrenia. METHODS: A retrospective cohort study was conducted using data from the Merative MarketScan database (01/01/2013-12/31/2019). Adults aged ≥18 years with a new episode of care for schizophrenia and an AOM claim were included. Patients were classified into two cohorts based on the time between the first schizophrenia diagnosis and the first AOM claim (early cohort: ≤1 year; late cohort: >1 year). All-cause and psychiatric-specific HCRU, risk of hospitalization, and healthcare costs were evaluated over 1-year post-AOM initiation. The relationship between the timing of AOM initiation and HCRU was evaluated using negative binomial regression, and healthcare costs using generalized linear models (log-link with gamma distribution). Logistic regression was used to estimate the likelihood of hospitalization during the follow up period for both all-cause and psychiatric-specific hospitalization. RESULTS: A total of 945 patients were included (early cohort: n = 525; late cohort: n = 420). At baseline, the early cohort had lower mean age, a greater proportion of males, and a lower mean Charlson Comorbidity Index score than the late cohort (all p < .05). After adjusting for baseline demographic and clinical characteristics, all-cause and psychiatric-specific hospitalization during the 1-year follow-up period were statistically significantly higher for the late cohort versus the early cohort (all-cause: incident rate ratio [IRR] = 1.63, 95% confidence interval [CI]: 1.28-2.07, p < .01; psychiatric-specific: IRR = 1.93, 95% CI: 1.46-2.55, p < .01). The early cohort had statistically significantly lower adjusted all-cause ($21,686 versus $29,033; p = .0002) and psychiatric-specific ($24,414 versus $32,461; p = .0002) healthcare costs versus the late cohort. LIMITATIONS: This study utilized claims data, which are intended for administrative purposes rather than for research. CONCLUSIONS: This analysis extends previous evidence for the benefits of AOM in patients with new episodes of schizophrenia, by demonstrating lower HCRU, risk of hospitalization, and healthcare costs with early AOM initiation compared with later initiation.

Schizophrenia is a costly disease that impacts patients, caregivers, and the healthcare system. Antipsychotic medications are an important component of schizophrenia treatment. These medications reduce symptom severity, improve functioning and reduce costs. Aripiprazole once-monthly (AOM) is a long-acting injectable antipsychotic used to treat schizophrenia. This study evaluates whether starting AOM early in the disease course improves outcomes for people with schizophrenia. Outcomes include healthcare resource utilization, risk of hospitalization, and healthcare costs. The study team found that hospitalization and costs were lower for people who started AOM early in the disease course as opposed to later. This study points to the importance of early treatment to improve outcomes for people with schizophrenia.

Economic value of knowing BRCA status: BRCA testing for prostate cancer prevention and optimal treatment.

BACKGROUND: We aimed to estimate the incremental lifetime effects, costs, and net-monetary-benefit (NMB) of knowing BRCA information by testing of patients with low-risk localized prostate cancer (PCa) in the US and guiding subsequent screening and treatment, and the cumulative savings or losses of yearly cohort testing over 16 years. We compared two strategies: (1)'with BRCA information' and (2)'without BRCA information.' We also estimated the expected value of perfect information. METHODS: The incremental NMB (INMB) quantified the monetized benefit per person of knowing BRCA status. The net-monetized-value of knowing BRCA information was estimated by multiplying the INMB with the eligible population. RESULTS: The INMBs of knowing BRCA information were $43,357 (payer) and $43,487 (society). in payer and societal perspectives, respectively. Escalated to the eligible patients in 2020, knowing BRCA status resulted in net monetized lifetime value of $1.7 billion (payer and society) for the 2020 cohort; and yielded accumulated net-monetized-value of $28.0 billion (payer) and $28.1 billion (society) over 16 yearly cohorts of eligible PCa patients. CONCLUSIONS: The economic value of knowing BRCA status for all low-risk localized PCa patients in the US provides short-term and long-term evidence for BRCA testing to screen early and optimize treatment.

The economic value of knowing BRCA status: BRCA testing for optimizing treatment in recurrent epithelial ovarian cancer.

BACKGROUND: This study aimed to estimate the incremental lifetime effects, costs, and net monetary benefit (NMB) of knowing BRCA information for recurrent ovarian cancer (ROC) patients in a given year and the cumulative savings of yearly hypothetical cohort testing over 16 years. We compared two strategies: (1) 'with BRCA information' and (2) 'without BRCA information.' METHODS: Incremental NMB (INMB) was calculated as the average net monetized benefit of knowing BRCA status. The net monetized value (cumulative INMB) of knowing BRCA information was estimated by multiplying the INMB with the eligible ROC patients in year 2020 and extended for potential ROC patients over 16 yearly hypothetical cohorts of ROC patients. RESULTS: Knowing BRCA information for ROC patients provided an additional monetized value of $3,528 in (payer) and $3,194 (society). Escalated to all ROC patients in the U.S. and future incidence ROC estimates, knowing BRCA information resulted in a lifetime cumulative INMB of $35.6 million (payer) and $32.2 million (society) for the 2020 cohort; and yielded an accumulated value of $97.3 million (payer) and $88.0 million (society) over 16 yearly hypothetical cohorts of ROC patients. CONCLUSIONS: The economic value of knowing BRCA status of all U.S. ROC patients provides short-term and long-term evidence for optimizing treatment.

The economic value of knowing BRCA status: universal BRCA testing for breast cancer prevention.

BACKGROUND: This study aimed to estimate the incremental lifetime effects, costs, and net monetary benefit (NMB) of knowing BRCA information by universal genetic testing of all US women without breast cancer turning 40 in a given year, and the cumulative savings or losses of yearly cohort testing over 16 years. We compared two strategies: (1) 'with BRCA information' and (2) 'without BRCA information.' METHODS: Incremental NMB (INMB) was calculated as the monetized benefit per person of knowing BRCA status. The net monetized value (cumulated INMB) of knowing BRCA information was estimated by multiplying the INMB with the eligible population or the year 2020 cohort of US women age 40 and extended for a total of 16 yearly cohorts. RESULTS: Universal testing of the female population at the age of 40 in a given year provided aan INMB of $663/person (payer) and $1,006/person (society).Escalated to the U.S. population of women age 40 , knowing BRCA status resulted in lifetime cumulated INMB of $1.3 billion (payer) and $2.0 billion (society) for the 2020 cohort; and yielded accumulated monetized value of $18.3 billion (payer) and $27.6 billion (society) over 16 yearly cohorts of 40-year-old women. CONCLUSIONS: The universal testing for BRCA status of all US women at age 40 provides compelling short-term and long-term economic value.

Work productivity loss among adults aged 18-64 years with Multiple Sclerosis in the United States: A propensity score matched study.

BACKGROUND: Scarce data exists regarding United States (US) national-level work productivity loss among adults with Multiple Sclerosis (MS). OBJECTIVE: To address this significant knowledge gap, we examined the national-level productivity loss among adults (18≤ age ≤64 years) with MS compared to propensity score matched non-MS controls. METHODS: We adopted a retrospective, cross-sectional, matched cohort study design with pooled data from alternate years (2005/2007/2009/2011/2013/2015) of the Medical Expenditure Panel Survey (MEPS). We included adults who were employed and alive during the calendar year. Clinical Classification System code of "80" was used to identify individuals with MS. We matched adults with MS to non-MS adults utilizing propensity scores generated based on age, gender, and race/ethnicity using a greedy matching algorithm (8:1-digit matching). Missed workdays measured productivity loss of MEPS respondents. We selected Negative Binomial Regression (NBR) analysis as the count data model for this study. Analyses were conducted using SAS 9.4 and STATA 15.0 and accounted for the complex survey design of MEPS to generate US national-level estimates. RESULTS: The final propensity-score matched sample consisted of 104 and 312 (unweighted) adults with and without MS, respectively. US national-level mean [Standard Error (SE)] annual missed workdays among individuals with MS [8.94 (SE:1.59)] was significantly higher (p = 0.001) compared to propensity score matched non-MS controls [3.15 (SE:0.40)]. After adjusting for several factors, NBR showed an approximately two-fold higher rate of missed work days among individuals with MS compared to propensity score matched non-MS controls (Incidence Rate Ratio: 1.98, 95% Confidence Interval: 1.18-3.33). Severity of pain, marital status, region, and hypertension also negatively impacted work productivity in this sample. CONCLUSIONS: Individuals with MS in the US experience significantly higher productivity loss compared to propensity score matched non-MS controls. Interventions (e.g., improved management of MS symptoms) are warranted to reduce productivity loss among individuals with MS.

Impact of the COVID-19 Pandemic on Healthcare Resource Utilization in Individuals with Major Depressive Disorder.

Objective: To estimate the impact COVID-19 pandemic on healthcare resource utilization (HCRU) among individuals with major depressive disorder (MDD). Method: A retrospective cohort study was conducted to compare HCRU in the twelve months prior to and six months following pandemic onset among 1,318,709 individuals with MDD and propensity-score matched controls. Outcomes were monthly rates of all-cause and MDD-specific outpatient, inpatient, and prescription medication HCRU. Piecewise random effects models were used to adjust for patient-level clustering, trends over time, and pre-pandemic factors. Results: In the first month following onset, outpatient HCRU declined with primary care visits down 25.1%. Following this initial decline, outpatient HCRU increased, exceeding pre-pandemic rates within three months. By April 2020, three quarters of all psychotherapy sessions were delivered by telehealth, followed by psychiatry (62.3%), and primary care visits (30.1%). The use of telehealth remained highest for psychotherapy and psychiatry (representing 67.6% and 54.2% of visits, respectively, in September 2020). All-cause partial-day hospitalizations declined 50.5% and remained depressed through July 2020 (down 18.3%). Beginning in the first month post-onset, prescription medication HCRU increased for all antidepressant and antipsychotic medication classes: serotonin modulators ( + 11.8%), bupropion ( + 10.4%), SSRIs ( + 9.0%), SNRIs ( + 8.6%), and atypical antipsychotics ( + 7.5%). Conclusions: Following pandemic onset, individuals with MDD realized an immediate, but short-lived, reduction in primary care HCRU. Telehealth use remained elevated through the first six months. The most significant and sustained reduction in HCRU was noted for partial-day hospitalizations and all-cause ED visits.

Economic Burden of Chronic Comorbidities Among Community-Dwelling Older Adults With Dementia: A Propensity Score Matched National-Level Study.

OBJECTIVE: This study examined the extent to which chronic comorbidities contribute to excess health care expenditures between older adults with dementia and propensity score (PS)-matched nondementia controls. METHODS: This was a retrospective, cross-sectional, PS-matched case (dementia): control (nondementia) study of older adults (65 y or above) using alternative years data from pooled 2005 to 2015 Medical Expenditure Panel Surveys (MEPS). Chronic comorbidities were identified based on Clinical Classifications System or ICD-9-CM codes. Ordinary least squares regression was utilized to quantify the impact of chronic comorbidities on the excess expenditures with logarithmic transformation. Expenditures were expressed as 2019 US dollars. All analyses accounted for the complex survey design of MEPS. RESULTS: The mean yearly home health care expenditures were particularly higher among older adults with dementia and co-occurring anemia, eye disorders, hyperlipidemia, and hypertension compared with PS-matched controls. Ordinary least squares regression models revealed that home health care expenditures were 131% higher (ß=0.837, P <0.001) among older adults with dementia compared with matched nondementia controls before adjusting for chronic comorbidities. When additionally adjusting for chronic comorbidities, the percentage increase, while still significant ( P <0.001) decreased from 131% to 102%. CONCLUSIONS: The excess home health care expenditures were partially explained by chronic comorbidities among community-dwelling older adults with dementia.

Association of low-income subsidy, medicaid dual eligibility, and disability status with high-risk medication use among Medicare Part D beneficiaries.

BACKGROUND: Low-income subsidy/dual eligibility (LIS/DE) status and disability status may be associated with high-risk medication (HRM) use but are not usually accounted for in medication-use quality measures. OBJECTIVE: To examine the association of: 1) LIS/DE status and HRM use; and 2) disability status and HRM use, while controlling for both health plan level effects and patient characteristics for Medicare beneficiaries enrolled in Medicare Advantage Prescription Drug Plans (MA-PD) and stand-alone Prescription Drug Plans (PDP). METHODS: This retrospective cross-sectional study used 2013 Medicare data to determine if LIS/DE status and disability status were independently associated with HRM use (using the Pharmacy Quality Alliance HRM measure) in MA-PDs and PDPs. Multivariable generalized linear mixed models assessed the association of LIS/DE and HRM use, and disability and HRM use, after adjusting for health plan effect and patient-level confounders for MA-PD and PDP beneficiaries. RESULTS: Of 520,019 MA-PD beneficiaries, 88,693 (17.1%) were LIS/DE and 48,997 (9.4%) were disabled. Of 881,264 PDP beneficiaries, 213,096 (24.2%) were LIS/DE, and 83,593 (9.5%) were disabled. LIS/DE beneficiaries had a higher percent of HRM users compared to non-LIS/DE MA-PD (13.3% vs. 9.7%, p < 0.001) and PDP (17.1% vs. 13.2%, p < 0.001) beneficiaries. Disabled beneficiaries had a higher percent of HRM users compared to non-disabled MA-PD (17.0% vs. 9.6%, p < 0.001) and PDP (22.9% vs. 13.2%, p < 0.001) beneficiaries. Multivariable analyses showed LIS/DE (adjusted odds ratio [AOR] = 1.07; 95% CI = 1.04, 1.10) and disability (AOR = 1.38; 95% CI = 1.34, 1.42) were associated with HRM use among MA-PD and PDP beneficiaries (LIS/DE AOR = 1.14; 95% CI = 1.12, 1.16; disability AOR = 1.37; 95% CI = 1.34, 1.40). CONCLUSIONS: The association of LIS/DE and disability with higher HRM use in both MA-PD and PDP beneficiaries, when controlling for health plan effects and patient characteristics, suggests these factors should be considered when comparing health plan performance on HRM measures.

A conceptual framework for evaluation of community pharmacy pay-for-performance programs.

BACKGROUND: Recent interest in initiating pay-for-performance (P4P) programs indicates an underlying belief that economic incentives will have a direct impact on health care quality and efficiency. Evaluations of the impact of P4P programs on health care organizations and providers have been presented in the literature; however, none have focused on the impact of an incentive targeting community pharmacies. OBJECTIVE: To propose a theory-derived conceptual framework of how a financial incentive might work in a community pharmacy. METHODS: Studies from the fields of economics (agency theory), psychology (intrinsic and extrinsic motivators; expectancy theory), and organizational theory (ownership, institutional layers, organizational culture, and change management; quality improvement) were reviewed to inform the framework's components. This proposed conceptual framework also integrated and expanded on previous health care-related P4P models. RESULTS: P4P programs inherently use financial incentives to catalyze change; however, elements from psychology and organizational theories along with economic theory were identified as important considerations in how a financial incentive may operate when targeting a community pharmacy. Through the incorporation of these theories along with other P4P frameworks in health care, a conceptual framework was derived comprising 4 domains: incentive, pharmacy, other influencing factors, and P4P program measures. Hypothesized relationships among these domains were depicted. CONCLUSION: As focus on improving the quality of health care provision develops, opportunities for pharmacists to provide patient care services beyond dispensing will continue to advance, along with expanded reimbursement mechanisms extending beyond traditional product dispensing. The proposed theory-derived conceptual framework serves to depict how the integration of P4P and other factors may affect the pharmacy environment and subsequently affect a pharmacy's capability to perform well on medication-related quality measures. This framework may be used as a foundation on which to design studies to investigate the association between community pharmacy factors and performance in a P4P program.

Influence of Comorbidities on Healthcare Expenditures and Perceived Physical and Mental Health Status Among Adults with Multiple Sclerosis: A Propensity Score-Matched US National-Level Study.

OBJECTIVE: To evaluate the effect of comorbidities on healthcare expenditures and perceived physical and mental health status among adults with multiple sclerosis (MS) compared to propensity score-matched non-MS controls. METHODS: A retrospective, cross-sectional, matched cohort study was conducted using Medical Expenditure Panel Survey (2005-2015) data. The base study sample consisted of adults (age ≥18 years) who were alive and had positive total healthcare expenditures during the survey calendar year. Adults with MS were propensity-matched (1:1) to non-MS controls based on age, gender, and race/ethnicity using greedy matching algorithm. Healthcare expenditures consisted of total and subtypes of expenditures. Health status consisted of perceived physical and mental health status. Comorbidities were identified using ICD-9-CM and Clinical Classification System codes. Ordinary least squares regression and multinomial logistic regression were used to analyze the healthcare expenditures and health status variables, respectively. RESULTS: Final study sample consisted of 541 adults in each MS and non-MS control groups after propensity score matching. After adjusting for potential confounders, individuals with MS had greater total and subtypes of expenditures compared to non-MS controls, and several comorbidities (eg, depression, hypertension) were significantly associated with increased healthcare expenditures. Yearly average total expenditures (expressed in 2018 US$) were significantly (p<0.001) higher for adults with MS ($29,396) than propensity score-matched non-MS adults ($7875). Moreover, after adjusting for all individual-level factors, adults with MS experienced 363% (p<0.001) higher total expenditures compared to propensity score-matched non-MS controls. Individuals with MS were more likely to report poorer physical and good mental health status compared to propensity score-matched non-MS controls, and several comorbidities (eg, anxiety, depression) were significant independent predictors of poorer health status. For example, adults with MS were four times more likely (OR: 4.10, 95% CI: 2.42-6.96) to report fair/poor physical health status compared to excellent/very good physical health status compared with non-MS controls. Adults with MS were 42% (OR: 1.42, 95% CI: 1.01-1.99) more likely than propensity score-matched non-MS controls to report good rather than very good or excellent mental health status. However, there was no difference between adults with MS and propensity score-matched non-MS controls in terms of reporting fair or poor than very good or excellent mental health status. CONCLUSION: Findings from this study indicate substantial economic and health status burdens among adults with MS at the US national-level that are significantly influenced by comorbidities.

Janus Kinase Inhibitors and Risk of Venous Thromboembolism: A Systematic Review and Meta-analysis.

OBJECTIVE: To assess the risk of venous thromboembolism (VTE) in patients treated with Janus kinase (JAK) inhibitors in clinical trials. PATIENTS AND METHODS: We performed a literature search of Ovid MEDLINE and ePub Ahead of Print, In-Process & Other Non-Indexed Citations, and Daily; Ovid EMBASE; Ovid Cochrane Central Register of Controlled Trials; Ovid Cochrane Database of Systematic Reviews; and Scopus, from inception to December 4, 2019, for randomized, placebo-controlled trials with JAK inhibitors as an intervention and reported adverse events. Odds ratio with 95% CI was calculated to estimate the VTE risk using a random effects model. Two independent reviewers screened and extracted data. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to assess certainty in estimated VTE risk. RESULTS: We included 29 trials (13,910 patients). No statistically significant association was found between use of JAK inhibitors and risk of VTE (odds ratio, 0.91; 95% CI, 0.57 to 1.47; P=.70; I2=0; low certainty because of serious imprecision). Results using Bayesian analysis were consistent with those of the primary analysis. Results of stratified and meta-regression analyses suggested no interaction by dose of drug, indication for treatment, or length of follow-up. CONCLUSION: We found insufficient evidence to support an increased risk of JAK inhibitor-associated VTE based on currently available data.

Association Between Dual Trajectories of Opioid and Gabapentinoid Use and Healthcare Expenditures Among US Medicare Beneficiaries.

OBJECTIVES: Little is known about relationships between opioid- and gabapentinoid-use patterns and healthcare expenditures that may be affected by pain management and risk of adverse outcomes. This study examined the association between patients' opioid and gabapentinoid prescription filling/refilling trajectories and direct medical expenditures in US Medicare. METHODS: This cross-sectional study included a 5% national sample (2011-2016) of fee-for-service beneficiaries with fibromyalgia, low back pain, neuropathy, or osteoarthritis newly initiating opioids or gabapentinoids. Using group-based multitrajectory modeling, this study identified patients' distinct opioid and gabapentinoid (OPI-GABA) dose and duration patterns, based on standardized daily doses, within a year of initiating opioids and/or gabapentinoids. Concurrent direct medical expenditures within the same year were estimated using inverse probability of treatment weighted multivariable generalized linear regression, adjusting for sociodemographic and health status factors. RESULTS: Among 67 827 eligible beneficiaries (mean age ± SD = 63.6 ± 14.8 years, female = 65.8%, white = 77.1%), 11 distinct trajectories were identified (3 opioid-only, 4 gabapentinoid-only, and 4 concurrent OPI-GABA trajectories). Compared with opioid-only early discontinuers ($13 830, 95% confidence interval = $13 643-14 019), gabapentinoid-only early discontinuers and consistent low-dose and moderate-dose gabapentinoid-only users were associated with 11% to 23% lower health expenditures (adjusted mean expenditure = $10 607-$11 713). Consistent low-dose opioid-only users, consistent high-dose opioid-only users, consistent low-dose OPI-GABA users, consistent low-dose opioid and high-dose gabapentinoid users, and consistent high-dose opioid and moderate-dose gabapentinoid users were associated with 14% to 106% higher healthcare expenditures (adjusted mean expenditure = $15 721-$28 464). CONCLUSIONS: Dose and duration patterns of concurrent OPI-GABA varied substantially among fee-for-service Medicare beneficiaries. Consistent opioid-only users and all concurrent OPI-GABA users were associated with higher healthcare expenditures compared to opioid-only discontinuers.

Health-related risk behaviors among myocardial infarction survivors in the United States: A propensity score matched study.

BACKGROUND: According to the American College of Cardiology/the American Heart Association (ACC/AHA) recommendations, health-related risk behaviors for secondary prevention of myocardial infarction (MI) are critical to determine. OBJECTIVE: This study aimed to compare health-related risk behaviors between MI survivors and propensity-score-matched non-MI controls using nationally representative data. METHODS: This cross-sectional, matched case-control study used publicly available Behavioral Risk Factor Surveillance System (BRFSS) 2017 data. Older adults with MI were propensity-score-matched to their non-MI controls. The 10 dependent variables included body mass index (BMI), smoking status, heavy alcohol consumption, influenza vaccine, length of time since last routine and cholesterol checkup, alcohol consumption, fruit and vegetable consumption, and physical activity. Chi-square tests and binomial logistic regression were used to examine the health-related risk behaviors differences between MI survivors and propensity-score-matched non-MI controls. RESULTS: The final study sample consisted of 18,021 MI survivors and 54,063 non-MI controls after propensity score matching. Multivariable logistic regression analysis showed significant differences between MI survivors and matched non-MI controls in terms of cholesterol checkup, smoking status, and alcohol consumption. For example, multivariate analysis of health-related risk behaviors showed MI survivors were more likely to be smokers (AOR = 1.46, 95% CI: 1.28-1.68). CONCLUSION: Based on this national survey of adults, MI survivors were more likely to be smokers but less likely to consume alcohol compared to their propensity-score-matched controls. Moreover, MI survivors were more likely to have their cholesterol checkup within the past 2 years compared to matched non-MI controls. Although lower alcohol consumption and greater chances of cholesterol checkups are reassuring health-related behaviors, interventions are needed to minimize the chances of smoking in this population.

Facility and state-level factors associated with telemental health (TMH) adoption among mental health facilities in the United States.

INTRODUCTION: Telemental health (TMH) is a promising approach to increase access to mental healthcare. This study examined the TMH adoption rates and associations with facility- and state-level factors among US mental health (MH) facilities. METHODS: This retrospective, cross-sectional study used linked data for 2016 from the National Mental Health Services Survey (N = 11,833), Area Health Resources File, and national reports for broadband access and telehealth policies. The associations of facility and state-level characteristics with TMH adoption were examined with multi-level logistic regressions. RESULTS: Overall, 25.9% had used TMH. Having veteran affiliation [Adjusted Odds Ratio (AOR) = 18.53, 95% Confidence Interval (95%CI): 10.66-32.21] and greater Information Technology (IT) capacity [AOR(95%CI): 2.89(2.10-3.98)] were the strongest correlates of TMH adoption. Other facility characteristics associated with higher likelihood of TMH adoption were: public ownership, high patient volumes, having comprehensive MH treatments or Quality Improvement practices, having private or non-Medicaid public payers, and treating elderly patients (AORs: 1.16-2.41). TMH adoption was less likely among facilities treating more African Americans or patients with substance abuse disorders. TMH adoption varied substantially across states, with adoption more likely in states issuing special telehealth licences and those with more rural counties. DISCUSSION: One in four MH facilities adopted TMH in 2016. TMH adoption varied by multiple facility- and state-level factors. Our findings suggest that: legal/regulatory burden and lower facility IT capacity may discourage TMH adoption; significant racial disparities exist in TMH adoption; and there is a need to increase TMH use for substance abuse disorders.

Dual-trajectories of opioid and gabapentinoid use and risk of subsequent drug overdose among Medicare beneficiaries in the United States: a retrospective cohort study.

BACKGROUND AND AIMS: Little is known about opioid and gabapentinoid (OPI-GABA) use duration and dose patterns' associations with adverse outcome risks. We examined associations between OPI-GABA dose and duration trajectories and subsequent drug overdose. DESIGN: Retrospective cohort study. SETTING: US Medicare. PARTICIPANTS: Using a 5% sample (2011-16), we identified 71 005 fee-for-service Medicare beneficiaries with fibromyalgia, low back pain, neuropathy and/or osteoarthritis initiating OPIs and/or GABAs [mean age ± standard deviation (SD) = 65.5 ± 14.5 years, female = 68.1%, white = 76.8%]. MEASUREMENTS: Group-based multi-trajectory models identified distinct OPI-GABA use patterns during the year of OPI and/or GABA initiation, based on weekly average standardized daily dose (i.e. OPIs = morphine milligram equivalent, GABAs = minimum effective daily dose). We estimated models with three to 12 trajectories and selected the best model based on Bayesian information criterion (BIC) and Nagin's criteria. We estimated risk of time to first drug overdose diagnosis within 12 months following the index year, adjusting for socio-demographic and health factors using inverse probability of treatment weighted multivariable Cox proportional hazards models. FINDINGS: We identified 10 distinct trajectories (BIC = -1 176 954; OPI-only = 3, GABA-only = 3, OPI-GABA = 4). Compared with OPI-only early discontinuers (40.6% of the cohort), 1-year drug overdose risk varied by trajectory group: consistent low-dose OPI-only users [16.6%; hazard ratio (HR) = 1.47, 95% confidence interval (CI) = 1.19-1.82], consistent high-dose OPI-only users (1.8%; HR = 4.57, 95% CI = 2.99-6.98), GABA-only early discontinuers (12.5%; HR = 1.39, 95% CI = 1.09-1.77), consistent low-dose GABA-only users (11.0%; HR = 1.44, 95% CI = 1.12-1.85), consistent high-dose GABA-only users (3.1%; HR = 1.43, 95% CI = 0.94-2.17), early discontinuation of OPIs and consistent low-dose GABA users (6.9%; HR = 1.24, 95% CI = 0.90-1.69), consistent low-dose OPI-GABA users (3.4%; HR = 2.49, 95% CI = 1.76-3.52), consistent low-dose OPI and high-dose GABA users (3.2%; HR = 2.46, 95% CI = 1.71-3.53) and consistent high-dose OPI and moderate-dose GABA users (0.9%; HR = 7.22, 95% CI = 4.46-11.69). CONCLUSIONS: Risk of drug overdose varied substantially among US Medicare beneficiaries on different use trajectories of opioids and gabapentinoids. High-dose opioid-only users and all consistent opioid and gabapentinoid users (regardless of doses) had more than double the risk of subsequent drug overdose compared with opioid-only early discontinuers.

Health Outcomes Associated with Adherence to Antidepressant Use during Acute and Continuation Phases of Depression Treatment among Older Adults with Dementia and Major Depressive Disorder.

OBJECTIVES: To examine health outcomes associated with adherence to Healthcare Effectiveness Data and Information Set (HEDIS) antidepressant medication management (AMM) during acute and continuation phases of depression treatment among older adults with dementia and major depressive disorder (MDD). DESIGN: Retrospective cohort study. SETTING: Medicare 5% sample data (2011-2013). PARTICIPANTS: Older adults (aged 65 years or older) with dementia and MDD. MEASUREMENTS: The first antidepressant prescription claim from 1 May 2011 through 30 April 2012 was considered the index prescription start date (IPSD). Adherence during acute- and continuation-phase AMM was based on HEDIS guidelines. Study outcomes included all-cause mortality, all-cause hospitalization, and falls/factures (with mortality being the competing event for hospitalization and falls/fractures) during follow-up from end of acute-/continuation-phase AMM adherence. Due to the proportionality assumption violation of Cox models, fully non-parametric approaches (Kaplan-Meier and modified Gray's test) were used for time-to-event analysis adjusting for the inverse probability of treatment weights. RESULTS: Final study samples consisted of 4330 (adherent (N) = 3114 (71.92%)) and 3941 (adherent (N) = 2407 (61.08%)) older adults with dementia and MDD during acute- and continuation-phase treatments, respectively. No significant difference (p > 0.05) between adherent and non-adherent groups was observed for all-cause mortality and falls/fractures in both the acute and continuation phases. There was a significant difference in time to all-cause hospitalization during acute-phase treatment (p = 0.018), with median times of 530 (95% CI: 499-587) and 425 (95% CI: 364-492) days for adherent and non-adherent groups, respectively. CONCLUSIONS: Acute-phase adherence to HEDIS AMM was associated with reductions in all-cause hospitalization risk among older adults with dementia and MDD.