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

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

Psychotherapy and Psychiatry Visits in the United States: A Study of MEPS, 2017-2019.

BACKGROUND: Rates of individuals with a psychotherapy visit has not been well studied, and recent reports lack granularity by age. METHODS: The 2017-2019 Medical Expenditure Panel Survey (MEPS) was used to investigate rates and associations of psychotherapy and psychiatry visits by age/sex and antidepressant/antipsychotic use. RESULTS: The study included all 90,853 individuals, of which 5.2% (95% CI, 4.9-5.4) reported any psychotherapy (excluding psychiatry visits) visit during a year, while 3.6% (95% CI, 3.4-3.8) reported a visit with a psychiatrist. Females were more likely to have a psychotherapy visit than males after 15 years of age. The highest rates of females with a psychotherapy visit were between 15 and 30 years of age, while rates among males were highest between 10 to 25 years of age. For psychiatry visits, males had higher rates than females during preteen years, similar rates through teen years, lower rates though adulthood, and similar rates after 60 years of age. Rates of a psychiatry visit did not vary as much by age as a psychotherapy visit. Among antidepressant or antipsychotic medication users, the rate of either a psychotherapy visit or a psychiatry visit during a year was markedly higher at younger ages and decreased as age advanced. CONCLUSION: Psychotherapy and psychiatry utilization have differences in population level patterns with use being highest among females between 15 to 30 years of age and higher among younger (compared with older) individuals who reported antidepressants or antipsychotics.

Psychiatric Medication Users by Age and Sex in the United States, 1999-2018.

PURPOSE: This study aimed to determine the rates of psychiatric medication users in the United States between 1999 to 2018 for different medication categories by age and sex. METHODS: The 1999 to 2002, 2006 to 2009, and 2015 to 2018 Medical Expenditure Panel Surveys (MEPS) were used for the analysis. All individuals with a valid age were included. Any antidepressant, benzodiazepine, attention deficit hyperactivity disease (ADHD) medication, antipsychotics, and mood stabilizer report use was defined as a medication user. Separate multivariable logistic regression predicted medication users by age with restricted cubic splines by sex, medication category, and year category (1999 to 2002, 2006 to 2009, and 2015 to 2018). In addition, the rate of prescribing to males and females at different ages was determined for medication categories. RESULTS: Rates of any psychiatric medication users increased during the study period. Females had higher rates of medication users around 20 years of age. Rates of antidepressant users increased over time and were higher for females after earlier adolescence. Rates of benzodiazepine users were higher for females, increased after 1999 to 2002, and had consistent patterns of use over time. Antipsychotic and mood stabilizer user rates were lower than other categories. Adolescent antipsychotic users markedly decreased between 2006 to 2009 and 2015 to 2018. Rates of ADHD medication users increased over time, particularly among younger adults between 25 and 50 years of age. CONCLUSION: The rates of individuals reporting the use of any psychiatric medications increased over the last few decades. Rates and patterns of medication users have large variations by medication category, age, and sex, but these patterns of use were stable for most medication categories.

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

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

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

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

The cardiovascular outcomes, heart failure and kidney disease trials tell that the time to use Sodium Glucose Cotransporter 2 inhibitors is now.

Sodium glucose contrasporter 2 inhibitors (SGLT2i) were initially introduced as a novel class of modestly effective antiglycemics. Over the last 5 years, multiple members of this class have been examined for their cardiovascular safety, effects on heart failure with reduced ejection fraction (HFrEF) and chronic kidney disease (CKD) in diverse populations with or without diabetes type 2. The plethora of studies and outcomes examined make it difficult for the practitioner to track the entirety of the evidence. SGLT2i improve cardiorenal outcomes and have a beneficial risk benefit ratio across populations with cardiovascular disease, HFrEF and kidney disease. In this quantitative review, we synthesize the data from the large outcomes trials about the benefits and risks of SGLT2i. SGLT2i reduce all cause, cardiovascular mortality, heart failure hospitalizations, need for dialysis and acute kidney injury as a class effect across a broad range of populations with diabetes Type 2 at risk for cardiovascular disease, patients with HFrEF or CKD with or without diabetes. While certain adverse events for example, diabetic ketoacidosis and genital mycotic infections are reproducibly increased by SGLT2i, the absolute increase in the risk of these complications is smaller than the absolute risk reductions conferred by SGLT2i. Other complications such as amputations, fractures and urinary tract infections are increased to a lesser degree, or not at all (e.g., hypoglycemia). Overall, SGLT2is appear to have a favorable safety profile and thus should be used by cardiologists, nephrologists, endocrinologists, primary care physicians when managing the cardiorenal risk of their patients.

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

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

Thyroid Hormone Use in the United States, 1997-2016.

BACKGROUND: Thyroid disorders are among the most commonly treated conditions by the United States health care system. The number of patients reporting thyroid hormone use has increased in recent years, but it is unknown if there have been differential increases in the number of treated individuals within different demographic groups. Previous research has also not evaluated how expenditures for different thyroid hormone medications have changed in recent years. METHODS: Using data from the 1997 through 2016 Medical Expenditure Panel Survey, we calculated the proportion of adults reporting thyroid hormone prescriptions by 3 demographic variables (age, sex, and race) and determined expenditures from thyroid hormone prescriptions by medication type (overall, generic, Synthroid or Cytomel, and other brand). RESULTS: Between 1997 and 2016, the proportion of adults who reported thyroid hormone use increased from 4.1% (95% CI, 3.7-4.4) to 8.0% (95% CI, 7.5-8.5). Most of the growth in thyroid hormone use occurred among adults aged >65, and use was also more common among females and non-Hispanic whites. Expenditures from thyroid hormones increased from $1.1 billion (95% CI, 0.9-1.3) in 1997 to $3.2 billion dollars (95% CI, 2.9-3.6) in 2016. Generic thyroid hormone prescriptions comprised 18.1% of all thyroid hormone prescriptions in 2004 (95% CI, 15.8-20.4) and 80.8% of all thyroid hormone prescriptions (95% CI, 78.4-83.2) in 2016. CONCLUSIONS: Thyroid hormone use nearly doubled over the last 20 years, and increased use was associated with being older, female, and non-Hispanic white. During the same time period, thyroid hormone expenditures almost tripled.

Anti-Hypertensive Medication Combinations in the United States.

BACKGROUND: Examining the anti-hypertensive regimens of individuals with different comorbidities may offer insights into how we can improve hypertension management. METHODS: The Medical Expenditure Panel Survey (2013-2015) was used to describe the most common single-, two-, three-, and four-drug hypertension regimens among hypertensive adults in four different comorbidity groups: 1. Hypertension only; 2. Hypertension and diabetes; 3. Hypertension and cardiovascular disease (coronary heart disease or stroke history); and 4. Hypertension, diabetes, and cardiovascular disease. RESULTS: 15,901 adults with hypertension taking anti-hypertensive medications were included in the study. 58.6% (95% CI: 57.3-59.8) took multiple anti-hypertensive medications, but the proportion of adults taking multiple anti-hypertensives varied by comorbidity group. Regimens including an ACE-inhibitor/ARB were the most prevalent regimens among individuals taking ≥2 anti-hypertensive medications. The most common two-drug regimen for both the hypertension-only and hypertension-diabetes groups was an ACE-inhibitor/ARB with thiazide. The most prevalent regimen for the two cardiovascular disease groups was an ACE-inhibitor/ARB with beta-blocker. CONCLUSIONS: Most individuals with hypertension use between 2-5 medications and the medications comprising these regimens vary by comorbidity. The ACCOMPLISH trial suggested that certain combinations may lead to superior cardiovascular outcomes. Research comparing the efficacy of different hypertension medication combinations among individuals with different comorbidities could lead to better patient hypertensionrelated outcomes.

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

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

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

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