A Cost Analysis of Phosphodiesterase Type 5 Inhibitors in the United States.

OBJECTIVE: To perform a cost analysis of generic and brand-name Phosphodiesterase Type 5 (PDE5) inhibitors at different dosages and pharmacies across the US. METHODS: Using an all-payer retail pharmacy-claims database, we analyzed prescription drug data for three generic and six brand-name oral PDE5 inhibitors at different dosages across US chain and independent pharmacies in 2019. RESULTS: We obtained cash price data from 60,186 pharmacies (35,976 chain and 24,210 independent). The nationwide mean cash price per unit (PPU) ranged from $8.6 ± 5.2 (sildenafil 20 mg at chain pharmacies) to $107.1 ± 71 (Adcirca 20 mg at independent pharmacies) equal to 1145.3% difference. Chain pharmacies provided significantly lower average prices for one brand-name and six generic PDE5 inhibitors. Tadalafil PPU was cheaper at higher quantities, however, PPU increased with quantity prescribed for sildenafil. Looking at the top 10 metropolitan statistical areas, the highest PPUs were observed for tadalafil (Cialis) 10 mg and sildenafil (Viagra) 50 mg in Atlanta ($67.4 ± 8.7) and Los Angeles ($50.3 ± 24.0), while New York ($9.7 ± 2.6) and Miami ($27.9 ± 16.4) had the lowest PPUs for tadalafil (Cialis) 5 mg and sildenafil (Viagra) 100 mg, respectively. CONCLUSION: A substantial variability in PDE5 inhibitor cash prices exists across manufacturer, dosage, quantity, pharmacy type, and location. In addition, the pricing does not necessarily correlate with the regional socioeconomic factors. This highlights the importance of provider awareness and patient counseling on drug price including potentially assisting patients in identifying opportunities for cost savings.

Trends in price for topical corticosteroids from 2017 to 2021 and the opportunity for cost savings identifiable at the point of care: A retrospective cross-sectional study.

BACKGROUND: Topical corticosteroids possess numerous generics and similar-strength substitutes. Affordability can impact obtaining the medication prescribed. OBJECTIVE: To determine recent trends in topical corticosteroid pricing and potential for cost saving. METHODS: A retrospective cross-sectional study analyzing all prescriptions dispensed for topical corticosteroids from January 1, 2017 through December 31, 2021, using a US all-payer pharmacy-claims database and commercial coupon dataset, was performed. RESULTS: Two hundred thirty-seven unique drug products (≥1 claim) were identified. Factors that predicted for higher cost (P < .05) were branded products (105% more expensive than generics) and ultrapotent class (55% more expensive than low potency) while ointments predicted for lower cost (19% less expensive than creams). Cash prices remained relatively stable, except for ultrapotent branded topical corticosteroids (63% increase). Cost savings were available for both brand-to-generic ($14.75 per unit) and generic-to-generic ($6.82 per unit) switching. Coupon prices were consistently lower than cash prices (r = 0.89). LIMITATIONS: Contracted rates through insurance plans were not included. CONCLUSIONS: Topical corticosteroid prices over the past 5 years have stabilized, the exception being branded ultrapotent corticosteroids. Savings from switching among similar-strength substitutes remain significant despite price stabilization. Coupon prices mirror the hierarchy of cash prices and can help assess real-time costs.

Pharmacy and neighborhood-level variation in cash price of diabetes medications in the United States.

BACKGROUND: Diabetes medications place significant financial burden on patients but less is known about factors affecting cost variation. OBJECTIVE: To examine pharmacy and neighborhood factors associated with cost variation for diabetes drugs in the US. RESEARCH DESIGN, SUBJECTS AND MEASURES: We used all-payer US pharmacy data from 45,874 chain and independent pharmacies reflecting 7,073,909 deidentified claims. We divided diabetes drugs into insulins, non-insulin generic medications, and brand name medications. Generalized linear models, stratified by pharmacy type, identified pharmacy and neighborhood factors associated with higher or lower cash price-per-unit (PPU) for each set of drugs. RESULTS: Cash PPU was highest for brand name therapies ($149.4±203.2), followed by insulins ($42.4±25.0), and generic therapies ($1.3±4.4). Pharmacy-level price variation was greater for non-insulin generic therapies than insulins or brand name therapies. Chain pharmacies had both lower prices and lesser variation compared with independent pharmacies. CONCLUSIONS: Cash prices for diabetes medications in the US can vary considerably and that the greatest degree of price variation occurs in non-insulin generic therapies.

Trends and determinants of retail prescription drug costs.

OBJECTIVE: To characterize price trends and variation for US generic and branded drugs at the retail level as they relate to pharmacy acquisition costs and local market factors. DATA SOURCES: Drug pricing data consisting of US pharmacy claims from 2014 to 2019 collected and licensed by GoodRx, an online tool for comparing drug prices. STUDY DESIGN: Time trends of median drug prices and coefficients of variation were measured for generic and branded drugs, including subgroups based on clinical condition (i.e., diabetes and cancer). Pharmacy competition was measured using the Herfindahl-Hirschman Index (HHI) at the zip-code level. Multivariable linear regression analysis assessed the impact of local market-level factors on drug prices and variation. DATA COLLECTION: US drug pricing data consisting of claims filled through a mix of public and private insurance at 58,332 chain and independent pharmacies across 14,421 zip codes in all 50 states. PRINCIPAL FINDINGS: From 2014 to 2019, pharmacy retail markets trended towards greater competition: average HHI by zip code decreased by 15.0% (p < 0.001). Median cash price increased significantly for both generic (6.58%, p < 0.001) and branded (84.10%, p < 0.001) drugs. When normalized to acquisition costs, cash prices for generic drugs rose 22.03% (p < 0.001) while those of branded drugs decreased by 2.31% (p < 0.001). Diabetes drugs showed higher baseline overall markup of cash prices relative to acquisition costs (10.54, Interquartile range (IQR) 3.28-18.43) than cancer drugs (1.88, IQR 1.36-3.08). Neither local pharmacy competition nor median income significantly predicted drug price or variation. CONCLUSION: Measures of generic drug price and price variation are high despite decreased costs earlier in the pharmaceutical supply chain, defying expectations of what would happen in a competitive market. Efforts to bypass the pharmacy benefit model for generic drugs may offer consumers an opportunity for substantial savings.

Prescription Filling Patterns of Evidence-Based Medical Therapies for Heart Failure During the COVID-19 Pandemic in the United States.

BACKGROUND: Maintaining a steady medication supply during a public health crisis is a major health priority. We leveraged a large U.S. pharmacy-claims database to understand the use of evidence-based therapies in heart failure (HF) care during the coronavirus disease-2019 (COVID-19) pandemic. METHODS: We analyzed 27,027,650 individual claims from an all-payer pharmacy-claims database across 56,155 chain, independent and mail-order pharmacies in 14,164 zip codes in 50 states. Prescriptions dispensed (in 2-week intervals) of evidence-based HF therapies in 2020 were indexed to comparable timeframes in 2019. We normalized these year-to-year changes in HF medical therapies relative to those observed with a stable basket of drugs. RESULTS: Fills of losartan, lisinopril, carvedilol, and metoprolol all peaked in the weeks of March 2020 and demonstrated trajectories thereafter that were relatively consistent with the reference set of drugs. Fills of spironolactone (+4%) and eplerenone (+18%) showed modest trends toward increased relative use during 2020. Fills of empagliflozin (+75%), dapagliflozin (+65%) and sacubitril/valsartan (+61%) showed striking longitudinal increases throughout 2020 that deviated substantially from year-to-year trends of the overall basket of drugs. For all 3 therapies, fills of all quantity sizes increased relatively throughout 2020. For both generic and brand-name therapies, prescription fill patterns from mail-order pharmacies increased substantially over expected trends beginning in March 2020 CONCLUSION: Prescription fills of most established generic therapies used in HF care were maintained, whereas those of sacubitril/valsartan and the sodium-glucose cotransporter-2 inhibitors steeply increased during the COVID-19 pandemic. These nationwide pharmacy claims data provide reassurance about therapeutic access, during a public health crisis, to evidence-based medications used in HF care.

To drive or not to drive? A study of travel behavior for a recent drinking occasion.

Despite decades of education and enforcement campaigns, alcohol-impaired driving persists as a social problem in the U.S. Are there other factors influencing decisions to drive after alcohol consumption that may be amenable to change? We conducted a roadside survey in California in 2012 to assess whether residential accessibility, travel attitudes (indicated by ratings of convenience and safety for travel options), and perceptions of arrest risk affect travel choices made subsequent to alcohol consumption. We conducted hybrid choice modeling for 580 participants. Mode-specific travel attitudes were valid constructs and predictive of travel behavior. Perceived level of service (speed) increased the utility for taxi and getting a ride. Perceiving high risk of arrest affected mode choice through travel attitudes. Not everyone assessed their mode options in the same way. For example, frequent binge drinkers appear to be more willing to consider taxis, men had stronger preferences towards active modes, and younger drivers were less pro-driving in this context. Past drinking and driving behavior affected one's attitude towards driving, while the number of drinks was related to mode choice. While our accessibility measure was not significantly related to attitudes or choice, decreasing urbanicity corresponded with stronger preferences for driving. This pilot study suggests that improving level of service (speed), convenience, and overall safety are considerations for public health in terms of promoting alternatives to drinking and driving. This line of research also has implications for emerging options, such as ride hailing, and how these might be optimized for specific segments of the population.

Measuring the Effects of Screening Programs in Asymptomatic Employees: Detection of Hypertension Through Worksite Screenings.

OBJECTIVE: To evaluate the effectiveness of workplace screenings on identification, subsequent follow-up, and treatment of patients with undiagnosed hypertension. METHODS: Claims data and screening values for 31,281 individuals from 21 self-insured employer groups were combined with zip code-level information and analyzed using multilevel logit models. RESULTS: Up to 17.6% of individuals without a previous indication of hypertension in the administrative data exhibited high blood pressure (140/90 or greater) at screening. In the month following workplace screening, significant increases were noted, using administrative claims, in the number of new diagnoses for hypertension (odds ratio: 1.81; P < 0.0001) and new prescriptions for antihypertensive drugs (odds ratio: 2.27; P < 0.0001), primarily among individuals with high blood pressure at screening. CONCLUSIONS: Workplace screening programs offer a potential approach to identify undiagnosed hypertension in employees and ensuing therapeutic management.

The Interaction Between an Individual's Acculturation and Community Factors on Physical Inactivity and Obesity: A Multilevel Analysis.

OBJECTIVES: We examined whether the interactions between primarily speaking English at home and community-level measures (median household income and immigrant composition) are associated with physical inactivity and obesity. METHODS: We pooled the 2005 and 2007 Los Angeles County Health Survey data to construct a multilevel data set, with community-level median household income and immigrant density as predictors at the community level. After controlling for individual-level demographic variables, we included the respondent's perceived community safety as a covariate to test the hypothesis that perceived public safety mediates the association between acculturation and health outcomes. RESULTS: The interaction between community median household income and primarily speaking English at home was associated with lower likelihoods of physical inactivity (odds ratio [OR] = 0.644; 95% confidence interval [CI] = 0.502, 0.825) and obesity (OR = 0.674; 95% CI = 0.514, 0.882). These odds remained significant after we controlled for perceived community safety. CONCLUSIONS: Resources in higher-income areas may be beneficial only to residents fully integrated into the community. Future research could focus on understanding how linguistic isolation affects community-level social learning and access to resources and whether this differs by family-level acculturation.

Does neighbourhood composition modify the association between acculturation and unhealthy dietary behaviours?

OBJECTIVE: Studies have shown that immigrants' acculturation is associated with numerous unhealthy behaviours. Yet, the role of environmental factors in modifying the effect of acculturation on health behaviours has received little attention. This study aims to create a more nuanced understanding of the health effects of acculturation by examining how neighbourhood immigrant composition modifies the association between individuals' eating patterns and acculturation. METHODS: Cross-sectional Data from Los Angeles County Health Survey 2007 adult sample were linked to data on retail food establishments and US Census 2000 neighbourhood characteristics. Acculturation was measured by language spoken at home and years stayed in the US. Eating fast food more than once per week and eating zero serving of fruit or vegetables during the previous day were used as proxy indicators for unhealthy dietary behaviour. Multilevel logistic regression models were performed in the full sample and in the sample with only Latino adults. RESULTS: Immigrants' lack of acculturation and living in a neighbourhood with a high percentage immigrants were associated with healthier dietary behaviour. We also identified that lack of acculturation conveyed a significantly stronger protective effect on regular fast-food consumption for immigrants living in neighbourhoods with higher percentage immigrants (OR: 0.34, 95% CI: 0.12 to 0.93). CONCLUSIONS: Among immigrants in Los Angeles County, living in a neighbourhood with a high density of other immigrants attenuates the negative effects of acculturation on healthy eating behaviours. Healthy eating promotion efforts should build on this protective effect in outreach to acculturating immigrant communities.

Comparative effectiveness of shock wave lithotripsy and ureteroscopy for treating patients with kidney stones.

IMPORTANCE: Shock wave lithotripsy (SWL) and ureteroscopy (URS) account for more than 90% of procedural interventions for kidney stones, which affect 1 in 11 persons in the United States. Efficacy data for SWL are more than 20 years old. Advances in URS, along with emerging evidence of reduced efficacy of modern lithotripters, have created uncertainty regarding the comparative effectiveness of these 2 treatment options. OBJECTIVE: To compare the effectiveness of SWL and URS to fragment or remove urinary stones in a large private payer cohort. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective cohort study of privately insured beneficiaries who had an emergency department visit for a kidney stone and subsequently underwent SWL or URS. Using an instrumental variable approach to control for observed and unobserved differences between the 2 groups, we created a bivariate probit model to estimate the probability of repeat intervention following an initial procedure. MAIN OUTCOMES AND MEASURES: A second procedure (SWL or URS) within 120 days of an initial intervention to fragment or remove or a kidney stone. RESULTS: Following an acute care visit for a kidney stone, 21 937 patients (45.8%) underwent SWL and 25 914 patients (54.2%) underwent URS to fragment or remove the stone. After the initial URS, 4852 patients (18.7%) underwent an additional fragmentation or removal procedure compared with 5186 patients (23.6%) after the initial SWL (P < .001). After adjusting for observed and unobserved variables, the estimated probabilities of repeat intervention were 11.0%(95%CI, 10.9-11.1) following SWL and 0.3%(95%CI, 0.325-0.329) following URS. CONCLUSIONS AND RELEVANCE: Among privately insured beneficiaries requiring procedural intervention to remove a symptomatic stone, repeat intervention is more likely following SWL. For the marginal patient (as opposed to the average patient), the probability of repeat intervention is substantially higher.

Long-term effects of health factor modification in Milwaukee County.

We use the UCLA Health Forecasting Tool to forecast the 2011-2050 health trends in Milwaukee County. We first simulate a baseline scenario (S-1) that assumes no health behavior change, and compare this with three simulated intervention scenarios: expansion of Quitline reach to enhance smoking cessation (S-2), an increased penetration of diabetes screening (S-3) and construction of additional recreational facilities (S-4). We compared the disease-free life years (DFLY) gained from each intervention scenario by 2050 on a year-by-year and cumulative basis. Simulation results show that increasing access to recreational facilities achieves the greatest gain in DFLYs for every year from 2011 to 2050. By 2050, the cumulative DFLY gain is 22 393, 5956 and 41 396 for S-2, S-3, and S-4, respectively. The cost-effectiveness ratios for Quitline expansion, diabetes screening, and recreational facility construction are $1802, $1285, and $1322, per DFLY gained, respectively.

Trends in recreational computer use among Latino children in California.

In this study we examine differential trends in recreational computer use among Latino and white children in California. We analyzed data from the children's sample (age 4-11) of the 2001 and 2009 California Health Interview Survey. Multivariate analysis was used to estimate the impact of language spoken at home, income and parental education, on recreational computer use. Latino children had substantially lower recreational computer use in 2001, compared to whites, but by 2009 the gap had almost disappeared. Among Latinos, compared to families where English is spoken exclusively, recreational computer use was substantially lower in families where Spanish is spoken exclusively. Parental education and income were significantly associated with recreational computer use, but only among Latinos, and the association with parental education changed from 2001 to 2009, explaining some of the difference in trend between Latino and white children.

Estimating benefits of past, current, and future reductions in smoking rates using a comprehensive model with competing causes of death.

INTRODUCTION: Despite years of declining smoking prevalence, tobacco use is still the leading preventable contributor to illness and death in the United States, and the effect of past tobacco-use control efforts has not fully translated into improvements in health outcomes. The objective of this study was to use a life course model with multiple competing causes of death to elucidate the ongoing benefits of tobacco-use control efforts on US death rates. METHODS: We used a continuous-time life course simulation model for the US population. We modeled smoking initiation and cessation and 20 leading causes of death as competing risks over the life span, with the risk of death for each cause dependent on past and current smoking status. Risk parameters were estimated using data from the National Health Interview Survey that were linked to follow-up mortality data. RESULTS: Up to 14% (9% for men, 14% for women) of the total gain in life expectancy since 1960 was due to tobacco-use control efforts. Past efforts are expected to further increase life expectancy by 0.9 years for women and 1.3 years for men. Additional reduction in smoking prevalence may eventually yield an average 3.4-year increase in life expectancy in the United States. Coronary heart disease is expected to increase as a share of total deaths. CONCLUSION: A dynamic individual-level model with multiple causes of death supports assessment of the delayed benefits of improved tobacco-use control efforts. We show that past smoking reduction efforts will translate into further increases in life expectancy in the coming years. Smoking will remain a major contributor to preventable illness and death, worthy of continued interventions.

Forecasting diabetes prevalence in California: a microsimulation.

INTRODUCTION: Setting a goal for controlling type 2 diabetes is important for planning health interventions. The purpose of this study was to explore what may be a feasible goal for type 2 diabetes prevention in California. METHODS: We used the UCLA Health Forecasting Tool, a microsimulation model that simulates individual life courses in the population, to forecast the prevalence of type 2 diabetes in California's adult population in 2020. The first scenario assumes no further increases in average body mass index (BMI) for cohorts entering adolescence after 2003. The second scenario assumes a gradual BMI decrease for children entering adolescence after 2010. The third scenario builds on the second by extending the same BMI decrease to people aged 12 to 65 years. The fourth scenario builds on the third by eliminating racial/ethnic disparities in physical activity. RESULTS: We found the predicted diabetes prevalence of the first, second, third, and fourth scenarios in 2020 to be 9.93%, 9.91%, 9.76%, and 9.77%, respectively. We found obesity prevalence for type 2 diabetes patients in 2020 to be 34.2%, 34.0%, 25.7%, and 25.6% for the 4 scenarios. Life expectancy in the third (80.56 y) and fourth (80.94 y) scenarios compared favorably with that of the first (80.32 y) and second (80.32 y) scenarios. CONCLUSION: For the next 10 years, behavioral risk factor modifications are more likely to affect obesity prevalence and life expectancy in the general population and obesity prevalence among diabetic patients than to alter type 2 diabetes prevalence in the general population. We suggest setting more specific goals for reducing the prevalence of diabetes, such as reducing obesity-related diabetes complications, which may be more feasible and easier to evaluate than the omnibus goal of lowering overall type 2 diabetes prevalence by 2020.

Substantial decline in sugar-sweetened beverage consumption among California's children and adolescents.

INTRODUCTION: Few studies have looked at changes among risk factors that might help explain why childhood obesity prevalence in the US has leveled off in recent years. We present an analysis of the California Health Interview Survey (CHIS) that examines trends in childhood and adolescent obesity as well as trends in sugar-sweetened beverage (SSB) consumption. METHOD: We compared 3 separate cross-sectional samples (2003, 2005, and 2007) from biennial CHIS for 3 age groups, age 2-5, age 6-11 and age 12-17. We calculated the prevalence of high SSB consumption (defined as having more than one SSB during the previous day). 2 measures of obesity were used - weight-for-age at or above the 95th percentile on national growth charts for children aged 2-11, and body mass index for age at or above the 95th percentile on national growth charts for adolescents aged 12-17. Logistic regression analysis is used to estimate adjusted odds ratios of high SSB consumption in 2005 and 2007 compared with the baseline year of 2003. RESULTS: From 2003 to 2007, each age group experienced a substantial decline in high SSB consumption (16.4%-5.0% for age 2-5, P < 0.001; 22.5%-9.9% for age 6-11, P < 0.001; 35.7%-25.7% for age 12-17, P < 0.001). Declines in the prevalence of children's obesity were significant among children age 2-5 (P < 0.001) and age 6-11 (P < 0.05) but not among adolescents (P = 0.42). Children and teenagers in 2005 and 2007 were significantly less likely than those surveyed in 2003 to have high SSB consumption after adjusting for gender, age, race/ethnicity, poverty level, and parental education (P < 0.001). CONCLUSION: Policy actions may have impacted the prevalence of SSB consumption in the population. Further research is needed to examine the contribution of declining SSB consumption on the leveling off of obesity trends and the extent to which these declines are attributable to new policies and programs.

Assessing and forecasting population health: integrating knowledge and beliefs in a comprehensive framework.

A comprehensive population health-forecasting model has the potential to interject new and valuable information about the future health status of the population based on current conditions, socioeconomic and demographic trends, and potential changes in policies and programs. Our Health Forecasting Model uses a continuous-time microsimulation framework to simulate individuals' lifetime histories by using birth, risk exposures, disease incidence, and death rates to mark changes in the state of the individual. The model generates a reference forecast of future health in California, including details on physical activity, obesity, coronary heart disease, all-cause mortality, and medical expenditures. We use the model to answer specific research questions, inform debate on important policy issues in public health, support community advocacy, and provide analysis on the long-term impact of proposed changes in policies and programs, thus informing stakeholders at all levels and supporting decisions that can improve the health of populations.