Mortality Due to Hyperglycemic Crises in the US, 1999-2022.

This study analyzes trends in US mortality attributed to both diabetic ketoacidosis and hyperosmolar hyperglycemic state from 1999-2022.

Change in Epidemiology of Creutzfeldt-Jakob Disease in the US, 2007-2020.

This cross-sectional study uses Centers for Disease Control and Prevention multiple cause of death data to examine recent US trends in Creutzfeldt-Jakob disease.

Reduced racial disparity in receipt of optimal locoregional treatment for women with early-stage breast cancer.

INTRODUCTION: Racial disparities in breast cancer treatment contribute to Black women having the worst breast cancer survival rates in the U.S. We investigated whether differences in receipt of optimal locoregional treatment (OLT), defined as receipt of mastectomy, breast-conserving surgery, or no surgery when contraindicated, existed between Black and White women with early-stage breast cancer from 2008-2018. METHODS: In this retrospective cohort study, data from the Surveillance, Epidemiology, and End Results (SEER) Program Incidence Database was utilized to identify tumor cases from Black and White women aged 20-64 years old with stage I-II breast cancer. Logistic regression analyses were used to evaluate the associations between race and receipt of OLT as well as potential effect modification by tumor characteristics, and year of diagnosis. RESULTS: Among 177,234 women diagnosed with early-stage breast tumors, disparities in OLT between Black and White women were present from 2008-2010 (2008: 82.1% Black vs. 85.7% White, p<0.001; 2009: 82.1% Black vs. 85.8% White, p<0.001; 2010: 82.2% Black vs. 87.2% White, p<0.001). This disparity was eliminated between 2010-2011 (86.3% Black vs. 87.5% White, p = 0.15), and did not reoccur during the remainder of the study period. From 2010-2011, more Black women received radiation therapy following breast-conserving surgery (43.4% to 48.9%; p = 0.001), which accounted for an overall increased receipt of OLT. CONCLUSION: Increased receipt of radiation therapy with breast-conserving surgery appeared to drive a substantial increase in OLT for Black women from 2010-2011 that lasted throughout the study period. Further research on the underlying mechanisms that reduced this disparity is warranted.

Insulin Fills by Medicare Enrollees and Out-of-Pocket Caps Under the Inflation Reduction Act.

This study uses data from IQVIA's National Prescription Audit to assess the association of the Inflation Reduction Act's cap on cost sharing with insulin fills by Medicare beneficiaries.

Association between use of ß2-adrenergic receptor agonists and incidence of Parkinson's disease: Retrospective cohort analysis.

INTRODUCTION: Previous observational studies assessing ß2-agonist/-antagonist use on PD risk have yielded conflicting results. We evaluated the relationship between ß2-agonist use and the incidence of Parkinson's disease in patients with chronic lung disease. METHODS: We performed a retrospective cohort analysis on a 20% random sample abstracted from a traditional (fee-for-service) Medicare program in the United States. Inclusion criteria were individuals over 65 years old diagnosed with asthma, COPD, and/or bronchiectasis who were enrolled in a prescription drug (standalone Part D) plan over 2007-2010 and alive through 2014. The main outcome measure was a diagnosis of Parkinson's disease over the period 2011-2014, in relation to the number of 30-day-equivalent drug claims over 2007-2010. Logistic regression analysis was performed on a sample including 236,201 Medicare beneficiaries. RESULTS: The sample was 68% female, 80% white, and on average 77 years old as of 2010. Compared to non-users, ß2-agonist users were more likely to be younger (76.3y versus 78.0y), smokers (40.4% versus 31.1%) and asthmatic (62.4% versus 28.3%). The odds ratio for a ß2-agonist claim on PD development was 0.986 (95% CI 0.977-0.995) after adjusting for demographics, smoking history, respiratory exacerbations, comorbidities, and other drug use. Risk reductions were larger for males than females (0.974 versus 0.994, P = 0.032), and for individuals with COPD compared to those with asthma (0.968 versus 0.998, P = 0.049). Reverse causality was addressed with a Cox analysis that allowed ß2-agonist use to vary from medication initiation to disease onset. By the end of the follow-up period, ß2-agonist use was shown to be associated with a true protective effect against PD onset. DISCUSSION: ß2-agonist use is associated with decreased risk of PD incidence. Further investigation, possibly including clinical trials, is warranted to strengthen the evidence base supporting clinical decision-makers looking to repurpose pharmaceuticals to prevent neurodegenerative disease onset.

What do nonprofit hospitals reward? An examination of CEO compensation in nonprofit hospitals.

Nonprofit hospital chief executive officer (CEO) compensation has received considerable attention in light of nonprofits' tax-favored status as well as the high costs of hospital care. Past studies have found that hospital financial performance is a significant determinant of CEO pay but nonprofit performance, including quality and charity care, are not. Using post-ACA data, we re-examine whether a variety of hospital performance measures are important determinants of nonprofit hospital CEO compensation. We found mixed evidence with respect to the significance of the association between financial performance and uncompensated care and CEO compensation. Among the other nonprofit performance measures, patient satisfaction was significantly associated with CEO compensation, but other measures were not significant determinants of CEO compensation. Our results suggest nonprofit hospitals balance their financial health against their mission when setting CEO incentives. Additional policy targeting transparency in hospital CEO compensation may be warranted to help policymakers understand the specific factors used by hospital boards to incentivize CEOs.

Association of cash payment with intensity of opioid prescriptions.

BACKGROUND: It is difficult to track use and outcomes in patients who pay cash for their prescriptions at the pharmacy. In Texas, 14% of all opioid prescriptions are paid with cash, often by uninsured patients and pharmacy shoppers. OBJECTIVE: To evaluate the association of cash payment with intensity of opioid prescriptions. METHODS: Using a prescription drug monitoring program and the U.S. Census data for the 2019 calendar year, this cross-sectional descriptive study analyzed more than 4 million opioid prescriptions in Texas residents aged 18-64 years. The payment type was coded as insurance if the prescription was paid in whole or in part by a health plan and as cash otherwise. Daily morphine milligram equivalent (MME) dose was used to compare the intensity of opioid prescriptions. The association of uninsured rates with mean daily MME and the number of opioid prescriptions paid with cash per 100,000 persons were assessed at a county level. RESULTS: Cash payment was associated with 30% higher mean daily MME (59 vs. 45; P < 0.001) than insurance payment. This difference was driven by the prescriptions for patients aged 25-34 years and from the highest decile of prescribers based on the percentage of opioid prescriptions paid by cash. For instance, cash payment was associated with 82% higher mean daily MME (91 vs. 50; P < 0.001) when patients aged 25-34 years obtained their prescriptions from the highest decile of prescribers. At a county level, uninsured rates were not associated with mean daily MMEs or the number of opioid prescriptions paid with cash. CONCLUSION: Cash payment was associated with a higher intensity of opioid prescriptions, mirroring the rates of drug overdose deaths across the patient age groups. Further research and policy actions need to address unmet pain management needs in uninsured patients and potential pharmacy shopping with cash payment and fraudulent identifications.

Reporting of Infectious Diseases in the United States During the Coronavirus Disease 2019 (COVID-19) Pandemic.

Reporting of infectious diseases other than COVID-19 has been greatly decreased throughout the COVID-19 pandemic. We find this decrease varies by routes of transmission, reporting state, and COVID-19 incidence at the time of reporting. These results underscore the need for continual investment in routine surveillance efforts despite pandemic conditions.

Disparities In County COVID-19 Vaccination Rates Linked To Disadvantage And Hesitancy.

We analyzed trends in adult COVID-19 vaccine coverage over time based on COVID-19 vaccine hesitancy and social vulnerability. We found that each of these variables carries an independent association with disparities across counties in COVID-19 vaccine coverage. Counties that score high on both hesitancy and vulnerability are especially likely to have lower COVID-19 vaccination rates compared with the rest of the country.

Trends in the quality and cost of inpatient surgical procedures in the United States, 2002-2015.

OBJECTIVES: This study documents trends in risk-adjusted quality and cost for a variety of inpatient surgical procedures among Medicare beneficiaries from 2002 through 2015, which can provide valuable insight on future strategies to improve public health and health care. METHODS: We focused on 11 classes of inpatient surgery, defined by the Agency for Health Research and Quality's (AHRQ's) Clinical Classification System. The surgical classes studied included a wide range of surgeries, including tracheostomy, heart valve procedures, colorectal resection, and wound debridement, among others. For each surgical class, we assessed trends in treatment costs and quality outcomes, as defined by 30-day survival without unplanned readmissions, among Medicare beneficiaries receiving these procedures during hospital stays. Quality and costs were adjusted for patient severity based on demographics, comorbidities, and community context. We also explored surgical innovations of these 11 classes of inpatient surgery from 2002-2015. RESULTS: We found significant improvements in quality for 7 surgical classes, ranging from 0.08% (percutaneous transluminal coronary angioplasty) to 0.74% (heart valve procedures) per year. Changes in cost varied by surgery, the significant decrease in cost ranged from -2.59% (tracheostomy) to -0.34% (colorectal resection) per year. Treatment innovation occurred with respect to surgical procedures utilized for heart valve procedures and colorectal resection, which may be associated with the decrease in surgical cost. CONCLUSIONS: Our results suggest that there was significant quality improvement for 7 surgery categories over the 14-year study period. Costs decreased significantly for 6 surgery categories, and increased significantly for 3 other categories.

Access to the 340B Drug Pricing Program: is there evidence of strategic hospital behavior?

OBJECTIVE: The 340B Drug Pricing Program allows hospitals to purchase covered drugs at a discount and potentially generate profit if they are reimbursed at rates that exceed 340B acquisition prices. Disproportionate share hospitals (DSH) are eligible to participate in 340B if their DSH adjustment-a measure that identifies hospitals that treat a disproportionate share of low income Medicare or Medicaid patients-is above 11.75%. To assess whether hospitals behave strategically to gain access to the program, we examined data on the number of hospitals just above versus below the DSH adjustment threshold for 340B eligibility and conducted McCrary density tests to assess statistical significance. RESULTS: In 2014-2016, the number of hospitals increases by 41% just above the 340B eligibility threshold. McCrary density tests found this increase to be statistically significant across a range of bandwidths in 2014-2016 (p < 0.01). From 2011-2013, the findings are sensitive to the bandwidth around the threshold, but insignificant in 2008-2010. We found no comparable change among hospitals ineligible for the 340B program. These data are consistent with the hypothesis that some hospitals adjust their DSH to gain 340B eligibility. Our findings support recent calls from the Government Accountability Office to improve oversight of the 340B program.

Measuring the Value Healthy Individuals Place on Generous Insurance Coverage of Severe Diseases: A Stated Preference Survey of Adults Diagnosed With and Without Lung Cancer.

OBJECTIVES: To compare the ex ante willingness to pay (WTP) of healthy individuals for generous insurance coverage of novel lung cancer treatments to the WTP for coverage of such treatment among individuals with lung cancer. METHODS: A survey was administered to 2 cohorts of US adults: (1) healthy individuals without cancer and (2) individuals diagnosed with lung cancer. A multiple random staircase survey design was used to elicit respondent WTP for coverage of novel lung cancer therapy associated with survival gains. RESULTS: Of the 84 937 healthy individuals invited, 300 completed the survey. Of the 36 249 in the lung cancer cohort invited, 250 completed the survey. Mean age by cohort was 50.0 (SD 14.6) and 48.4 (SD 16.8) years, and 55.2% and 47.2% were female, respectively. Respondents in the healthy and lung cancer cohorts were willing to pay $97.52 (95% confidence interval (CI) $89.89-$105.15) and $22 304 (95% CI $20 194-$24 414) per month, respectively, for coverage of a novel therapy providing 5-year survival of 15% versus standard-of-care therapy with a 5-year survival of 4%. After accounting for the likelihood that healthy individuals are diagnosed with lung cancer in the future, we estimated that 89.8% of the total value of new lung cancer treatments comes from the WTP healthy individuals place on generous insurance coverage. CONCLUSIONS: Total societal willingness to pay for lung cancer is much higher than conventionally thought, as most healthy individuals are risk-averse and highly value having lung cancer treatments available to them in the future.

Comparison of Direct Oral Anticoagulants Versus Warfarin in Patients With Atrial Fibrillation and Bioprosthetic Heart Valves.

There are limited data regarding direct oral anticoagulants (DOACs) for stroke prevention in patients with bioprosthetic heart valves (BHVs) and atrial fibrillation (AF). The objectives of this study were to evaluate the ambulatory utilization of DOACs and to compare the effectiveness and safety of DOACs versus warfarin in patients with AF and BHVs. We conducted a retrospective cohort study at a large integrated health care delivery system in California. Patients with BHVs and AF treated with warfarin, dabigatran, rivaroxaban, or apixaban between September 12, 2011 and June 18, 2020 were identified. Inverse probability of treatment-weighted comparative effectiveness and safety of DOACs compared with warfarin were determined. Use of DOACs gradually increased since 2011, with a significant upward in trend after a stay-at-home order related to COVID-19. Among 2,672 adults with BHVs and AF who met the inclusion criteria, 439 were exposed to a DOAC and 2233 were exposed to warfarin. For the primary effectiveness outcome of ischemic stroke, systemic embolism and transient ischemic attack, no significant association was observed between use of DOACs compared with warfarin (HR 1.19, 95% CI 0.96 to 1.48, p = 0.11). Use of DOACs was associated with lower risk of the primary safety outcome of intracranial hemorrhage, gastrointestinal bleeding, and other bleed (HR 0.69, 95% CI 0.56 to 0.85, p < 0.001). Results were consistent across multiple subgroups in the sensitivity analyses. These findings support the use of DOACs for AF in patients with BHVs.

Association between exenatide use and incidence of Alzheimer's disease.

INTRODUCTION: Recent developments suggest that insulin-sensitizing agents used to treat type II diabetes (T2DM) may also prove useful in reducing the risk of Alzheimer's disease (AD). The objective of this study is to analyze the association between exenatide use among Medicare beneficiaries with T2DM and the incidence of AD. METHODS: We performed a retrospective cohort analysis on claims data from a 20% random sample of Medicare beneficiaries with T2DM from 2007 to 2013 (n = 342,608). We compared rates of incident AD between 2009 and 2013 according to exenatide use in 2007-2008, measured by the number of 30-day-equivalent fills. We adjusted for demographics, comorbidities, and use of other drugs. Unmeasured confounding was assessed with an instrumental variables approach. RESULTS: The sample was mostly female (65%), White (76%), and 74 years old on average. Exenatide users were more likely to be male (38% vs. 35%), White (87% vs. 76%), and younger (by 4.2 years) than non-users. Each additional 30-day-equivalent claim was associated with a 2.4% relative reduction in incidence (odds ratio 0.976; 95% confidence interval 0.963-0.989; P < .001). There was no evidence of unmeasured confounding. DISCUSSION: Exenatide use is associated with a reduced incidence of AD among Medicare beneficiaries aged 65 years or older with T2DM. The association shown in this study warrants consideration by clinicians prescribing insulin sensitizing agents to patients.

New Evidence on the Compensation of Chief Executive Officers at Nonprofit U.S. Hospitals.

Chief executive officer (CEO) compensation is highly scrutinized, with nonprofit organizations often receiving additional attention due to their tax-exempt status. Understanding hospital CEO compensation is of increasing importance as health care costs remain high and strong leadership is required to implement new health policies. This study documents CEO compensation at nonprofit hospitals in the United States for 2010 and 2015. We compare hospital CEO compensation with CEO compensation in other institution types, including nonhospital health care. We also explore changes in hospital CEO compensation over time and differences across states. We find CEOs at hospitals earn substantially less than CEOs of publicly traded companies though more than presidents of nonprofit institutions of higher education. Additionally, we find that the relationship between CEO compensation and hospital size was weaker in 2015 than in 2010, and substantial variation in CEO compensation exists across states.