A comparison of healthcare utilization and outcomes following skin vs. serum-specific IgE allergy testing.

OBJECTIVE: To compare the cost, healthcare utilization, and outcomes between skin and serum-specific IgE (sIgE) allergy testing. METHODS: This retrospective cohort study used IBM® MarketScan claims data, from which commercially insured individuals who initiated allergy testing between January 1 and December 31, 2018 with at least 12 months of enrollment data before and after index testing date were included. Cost of allergy testing per patient was estimated by testing pattern: skin only, sIgE only, or both. Multivariable linear regression was used to compare healthcare utilization and outcomes, including office visits, allergy and asthma-related prescriptions, and emergency department (ED) and urgent care (UC) visits between skin and sIgE testing at 1-year post testing (α = 0.05). RESULTS: The cohort included 168,862 patients, with a mean (SD) age of 30.8 (19.5) years; 100,666 (59.7%) were female. Over half of patients (56.4%, n = 95,179) had skin only testing, followed by 57,291 patients with sIgE only testing and 16,212 patients with both testing. The average cost of allergy testing per person in the first year was $430 (95% CI $426-433) in patients with skin only testing, $187 (95% CI $183-190) in patients with sIgE only testing, and $532 (95% CI $522-542) in patients with both testing. At 1-year follow-up post testing, there were slight increases in allergy and asthma-related prescriptions, and notable decreases in ED visits by 17.0-17.4% and in UC visits by 10.9-12.6% for all groups (all p < 0.01). Patients with sIgE-only testing had 3.2 fewer allergist/immunologist visits than patients with skin-only testing at 1-year follow-up (p < 0.001). Their healthcare utilization and outcomes were otherwise comparable. CONCLUSIONS: Allergy testing, regardless of the testing method used, is associated with decreases in ED and UC visits at 1-year follow-up. sIgE allergy testing is associated with lower testing cost and fewer allergist/immunologist visits, compared to skin testing.

Cost of Serum Versus Skin Allergy Testing Among Medicare Fee-for-Service Beneficiaries in the United States.

Background: Testing for allergic sensitization can be achieved similarly via skin or serum specific immunoglobulin E (sIgE) testing, although the costs of each method differ. Objective: This study compared cost and utilization of allergy testing utilizing skin vs sIgE testing and whether equal access (parity) to both testing methods affects overall allergy testing costs among Medicare fee-for-service beneficiaries in the United States. Methods: Allergy test utilization and payment data were analyzed using 100% 2019 Medicare fee-for-service claims data. Beneficiaries with any sIgE test, skin prick test, or intradermal skin test associated with ICD-10 codes of allergic rhinitis, asthma, and food allergy were included. Aggregate and per-beneficiary testing cost, number of allergens tested, and number of allergy-related specialist visits incurred were estimated by the testing patterns of sIgE only, skin prick only, intradermal only, skin prick and intradermal, and sIgE plus prick and/or intradermal. Medicare Administrative Contractors (MACs) with parity for all allergy tests and those which restricted sIgE testing were compared. Multivariate linear regression was performed on the association between testing patterns and each cost and utilization measure, controlling for parity, age, sex, race/ethnicity, and dual-eligible status. Results: We analyzed 270 831 patients and 327 263 allergy-related claims. Total payment for all allergy tests was $71 380 866, including $15 903 954 for sIgE tests, $42 223 930 for skin prick tests, and $13 252 982 for intradermal tests. Beneficiaries receiving sIgE tests had only 1.8 fewer allergist visits than those with skin prick tests only (0.8 vs 2.6). Cost of testing per beneficiary was also lower in sIgE testing only compared with skin prick tests only ($161 vs $247). Multivariable regression results showed per-beneficiary payments for allergy testing were on average $22 lower in MACs with parity compared with MACs without parity. Discussion: Serum specific IgE testing is associated with lower costs and fewer allergy specialist visits compared with skin testing. Insurance coverage with parity toward sIgE and skin testing is associated with lower overall costs of allergy testing. Conclusion: Among Medicare fee-for-service beneficiaries in the United States, sIgE testing may be more cost effective compared with skin testing in the management of allergic disease.

Does electronic prescribing of controlled substances deter controlled substance prescribing in emergency departments?

Objective: To examine the association between electronic prescribing of controlled substances (EPCS) and controlled substance prescription patterns in U.S. emergency departments (ED). Materials and methods: We conducted cross-sectional analysis at both the ED level and visit level, using the 2016-2017 National Hospital Ambulatory Medical Care Surveys. Results: The sample included 24,296 visits to 316 EDs, 45% of which utilized EPCS. Pain-related visits were associated with significantly higher odds of prescriptions for any controlled substances (OR = 1.52; 95% CI: 1.32-1.75; p < 0.001) and Schedule II substances (OR = 2.13; 95% CI: 1.80-2.52; p < 0.001). Conditional on pain-related visits, EPCS was significantly associated with higher odds of any (OR 1.31; 95% CI: 1.08-1.59; p = 0.006) and Schedule III (OR 1.38; 95% CI: 1.03-1.85; p = 0.031) controlled substance prescriptions. For non-pain related visits, EPCS was not associated with changes in controlled substance prescriptions. Discussion: While EPCS transmits prescriptions directly to pharmacies in order to reduce drug diversion problems, the results indicated no significant association between EPCS use and prescriptions for Schedule II drugs which include opioids. As many states move towards mandating EPCS use in order to curb the opioid epidemic, future studies should examine the barriers to the effective implementation of EPCS, in the context of other systems such as Prescription Drug Monitoring Programs. Conclusion: EPCS does not appear to deter Schedule II controlled substances prescription including opioids in an ED visit. It may facilitate any and Schedule III controlled substance prescriptions when pain was involved in an ED visit.

Dementia and readmission risk in patients with heart failure participating in a transitional care program.

BACKGROUND: Cognitive impairment is prevalent in patients hospitalized for heart failure (HF). We aimed to generate further evidence on the value of dementia screening in hospitalized HF patients by examining whether and when dementia would be an independent risk factor for 30-day readmission while modeling permutations of known risk factors such as patient demographics, disease burden, prior utilization, and index hospitalization characteristics. METHODS AND RESULTS: A retrospective cohort study was employed, consisting of 26,128 patients (2,075 or 7.9% with dementia) in a transitional care program post HF hospitalization. The overall 30-day all-cause readmission rate was 18.1%. Patients with dementia had higher unadjusted rates of readmission (22.0 vs 17.8%) and death (4.5 vs. 2.2%) within 30 days post hospitalization, compared to those without dementia. Hierarchical multivariable proportional hazards regression results showed that dementia independently predicted readmission when both patient demographics and disease burden variables were controlled for (HR=1.15, p=0.02). However, the association between dementia and readmission was attenuated in the full model when prior utilization and index hospitalization characteristics were added (HR=1.04, p=0.55). For dementia patients, Charlson comorbidity index, prior ED visits, and length of stay were significant risk factors of readmission. CONCLUSIONS: The presence of dementia and the predictors of 30-day readmission in those with dementia may help identify this subset of high-risk HF patients for potential efforts to improve their prognosis.

Persistent airflow obstruction in inner-city children with asthma.

Background: Airway remodeling has been shown to be persistent in patients with asthma despite treatment with controller medications. Patients with early airflow obstruction may continue to experience poor lung function despite treatment. Objectives: To determine whether early airflow obstruction in inner-city children with asthma persists despite guideline-based asthma care. Methods: In a retrospective study that used a cohort of inner-city children with asthma treated by using an asthma-specific disease management system, the patients were stratified into "low" or "high" lung function groups at the time of the initial visit (high, forced expiratory volume in the first second of expiration [FEV1] % predicted and FEV1/forced vital capacity [FVC] ≥ 80%; and low, FEV1% predicted and FEV1/FVC < 80%). These patients then received National Heart, Lung, and Blood Institute guideline-based asthma treatment at regular follow-up intervals with spirometry performed at these visits as part of regular care. FEV1% predicted and FEV1/FVC were followed up for up to 10 years for both the high and low cohorts. Results: Over 10 years, the patients initially in the "high" group maintained FEV1% predicted and FEV1/FVC at values similar to the initial visit (94 to 96% and 87 to 89%, respectively), whereas those in the low group had only slight increases of FEV1% predicted and FEV1/FVC over the same time (77 to 82% and 78 to 82%, respectively). Low FEV1% predicted and FEV1/FVC at the time of the first visit was significantly associated with an increased risk of low values of these lung functions over the next 3-5 years despite treatment. African American ethnicity and male gender were also associated with lower lung function over time. Conclusion: Early airflow obstruction in inner city children asthma is associated with poor lung function in later life despite guideline-based asthma care. Current asthma therapy may not affect pathways and leads to airway remodeling in children with asthma.

Role of provider encouragement on patient engagement via online portals.

OBJECTIVE: The study sought to examine whether provider encouragement is associated with improvements in engaging patients with their healthcare processes using online portals. MATERIALS AND METHODS: Using the Health Information National Trends Survey 2017 (N = 2, 670), we conducted an exploratory factor analysis with varimax orthogonal rotation and derived 3 outcome variables on patient engagement: (1) information access score, (2) care convenience score, and (3) patient engagement score. Multivariable linear regression on each outcome variable was conducted with provider encouragement as the main predictor, controlling for patient demographics. RESULTS: Women (60%), white participants (69%), and those with a college degree (49%) were more likely to report receiving provider encouragement. Those who were encouraged to use patient portals scored higher on all 3 outcome measures compared with those who were not encouraged (B = 0 .80 vs B = 0.11 for information access, B = 1.13 vs B = 0.13 for care convenience, and B = 0.44 vs B = 0.05 for patient engagement; all P < .001). For every additional 100 patients receiving encouragement, 65 more information access tasks, 94 more care convenience tasks, and 40 more patient engagement tasks would be performed. DISCUSSION: Provider encouragement was most influential concerning care convenience tasks and least influential on complex decision-making tasks. This may be due to portal design and the content available to patients, which merit consideration in future studies. CONCLUSIONS: Provider encouragement is associated with more patient engagement, as indicated by significantly higher utilization of patient portals for accessing information, participating in routine care processes, and making complex healthcare decisions.