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1.
J Asthma ; : 1-9, 2020 Mar 27.
Artigo em Inglês | MEDLINE | ID: mdl-32162561

RESUMO

Introduction: Enhancing Care for Patients with Asthma is a multi-state, multi-center quality improvement program developed to augment guideline-based practice among health care providers through Plan-Do-Study-Act cycle. This study examined the association between the implementation of the guideline-based quality improvement program and subsequent changes in asthma-related emergency room visits and hospitalizations.Methods: This retrospective, interrupted time-series study used administrative claims data from a private insurer that provided coverage to patients receiving care from participating health centers (15 centers in New Mexico, Oklahoma, Texas, and Illinois). The 12-month implementation period started in January 2013 for centers in Cohort 1 and October 2013 for centers in Cohort 2. The claims of 1,828 patients with asthma from January 2012 to May 2015 were analyzed. The data included 12-month pre-program implementation, 12-month program implementation, and 5-month post-program completion periods.Results: The average number of asthma-related emergency room visits and hospitalizations decreased from 2.22 to 1.38 and 1.97 to 1.04 per 100 patients per month, respectively, in the 12-month pre-implementation period as compared to 12-month implementation period. The results of three-level generalized linear mixed models found that during the 12-month implementation period, patients had 37.7% and 47.1% lower rates of emergency room visits and hospitalizations, respectively, compared to the 12-month pre-implementation period (p < 0.001 in both comparisons).Conclusions: Enhancing Care for Patients with Asthma is an effective quality improvement program that was successfully executed in diverse geographical states and associated with reductions in potentially preventable health events. The findings support the widespread use of the program in other settings.

2.
Health Aff (Millwood) ; 38(11): 1887-1892, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31682491

RESUMO

In 2015 the Food and Drug Administration approved filgrastim-sndz (Zarxio), the first US biosimilar. Following rapid uptake, by March 2018 filgrastim-sndz accounted for 47 percent of filgrastim administrations among commercially insured and 42 percent among Medicare Advantage beneficiaries. The initial cost difference between the originator and biosimilar was 31 percent in the former population but negligible in the latter.

3.
J Manag Care Spec Pharm ; 25(11): 1201-1217, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31663461

RESUMO

BACKGROUND: The boxed warning (also known as "black box warning") is one of the FDA's strongest safety actions for pharmaceuticals. After the FDA issues black box warnings for drugs, prescribing changes have been inconsistent. Formulary management may provide an opportunity to restrict access to drugs with serious safety concerns. OBJECTIVE: To examine Medicare prescription drug plan formulary changes after new FDA postmarket black box warnings and major updates to preexisting black box warnings. METHODS: In this cohort study, we identified each drug that received a new FDA postmarket black box warning or a major update to a preexisting black box warning from January 2008 through June 2015 and examined its formulary coverage. The main outcome measure was the proportion of Medicare prescription drug plan formularies providing unrestrictive coverage immediately before the black box warning, at least 1 year after the warning and at least 2 years after the warning. Unrestrictive formulary coverage was defined as coverage of a drug without prior authorization or step-therapy requirements. RESULTS: Of 101 new black box warnings and major updates to preexisting warnings affecting 68 unique drug formulations, the mean percentage of formularies providing unrestrictive coverage changed from 65.4% (95% CI = 59.6%-71.2%) prewarning; 62.6% (95% CI = 56.3%-68.9%, P = 0.04) at least 1 year postwarning; and 61.9% (95% CI = 55.4%-68.5%, P = 0.10) at least 2 years postwarning. CONCLUSIONS: The mean percentage of Medicare prescription drug plan formularies providing unrestrictive coverage decreased modestly by approximately 3 percentage points after drugs received postmarket FDA black box warnings. Formulary restrictions may present an underused mechanism to reduce use of potentially unsafe medications. DISCLOSURES: This study was supported by a student research grant received by Solotke and provided by the Yale School of Medicine Office of Student Research under National Institutes of Health training grant award T35DK104689. Karaca-Mandic, Shah, and Ross acknowledge support from Agency for Healthcare Research and Quality (AHRQ) grant R01 HS025164, which studies factors associated with de-adoption of drug therapies shown to be ineffective or unsafe. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors assume full responsibility for the accuracy and completeness of the ideas presented. Ross has received support from the following: the U.S. Food and Drug Administration (FDA) as part of the Centers for Excellence in Regulatory Science and Innovation (CERSI) program; Johnson and Johnson through Yale University to develop methods of clinical trial data sharing; Medtronic and the FDA to develop methods for postmarket surveillance of medical devices; the Blue Cross Blue Shield Association to better understand medical technology evaluation; the Centers for Medicare & Medicaid Services (CMS) to develop and maintain performance measures that are used for public reporting; the AHRQ to examine community predictors of health care quality; and the Laura and John Arnold Foundation, which established the Collaboration for Research Integrity and Transparency at Yale University. Shah has received support from the FDA as part of the CERSI program. In addition, he has received support through the Mayo Clinic from CMS, AHRQ, National Science Foundation, and Patient-centered Outcomes Research Institute. Karaca-Mandic has provided consulting services to Precision Health Economics and Tactile Medical for work unrelated to this manuscript. Dhruva and Solotke have no conflicts of interest to report.

4.
JAMA Netw Open ; 2(8): e198325, 2019 Aug 02.
Artigo em Inglês | MEDLINE | ID: mdl-31373650

RESUMO

Importance: The Centers for Disease Control and Prevention guidelines in 2016 recommended avoiding concurrent use of opioids and benzodiazepines. Objective: To determine whether the release of the guidelines was associated with changes in coprescription of opioids and benzodiazepines. Design, Setting, and Participants: This retrospective cohort study used claims data obtained from a US national database of medical and pharmacy claims for 3 598 322 adult commercially insured patients and 1 299 142 Medicare Advantage (MA) beneficiaries with no recent history of cancer, sickle cell disease, or hospice care who ever used prescribed opioids during the study period, January 1, 2014, through March 31, 2018. Exposures: Overlapping opioid and benzodiazepine prescriptions filled. Main Outcomes and Measures: The extent (proportion of person-months with any overlapping days of prescription of opioids and benzodiazepines) and intensity (proportion of days with opioids prescribed where benzodiazepines were also available) of coprescription. Results: Of 4 897 464 patients (with 13.4 million person-months of opioid use), the total number of unique commercially insured individuals was 3 598 322 (1 974 731 women [54.9%]), and the total number of unique MA beneficiaries was 1 299 142 (770 256 women [59.3%]). Among 128 576 participants experiencing chronic pain episodes, more than one-half of person-months of long-term opioid use occurred in women (52.7% of person-months among those with commercial insurance and 62.4% of person-months among MA beneficiaries). The median (interquartile range) age of the participants was 51 (41-58) years for patients in the commercial insurance group and 70 (61-77) years for those in the MA group. The mean (SE) extent of coprescription was 23.0% (0.18%) for the commercial insurance group and 25.7% (0.18%) for the MA group. The extent of coprescription decreased in the targeted guideline population-individuals with long-term opioid use-after the guideline release (postguideline slope, -0.95 percentages point per year [95% CI, -1.44 to -0.46 percentage points per year] for the commercial insurance group and -1.06 percentage points per year [95% CI, -1.49 to -0.63 percentage points per year] for the MA group). Nontargeted short-term episodes of opioid use were associated with no change or small declines in trend (for the MA group, postguideline slope of 0.47 percentage point per year [95% CI, 0.35-0.59 percentage point per year]; for the commercial insurance group, postguideline slope of -0.05 percentage point per year [95% CI, -0.12 to 0.02 percentage point per year]). High coprescribing intensity was seen, with 79.3% (95% CI, 78.9%-79.6%) of opioid prescription days in the commercial insurance group and 83.9% (95% CI, 83.7%-84.2%) in the MA group overlapping with benzodiazepines. There was no change in the intensity of coprescribing. Intensity of coprescription was higher when the same clinician prescribed opioids and benzodiazepines. Conclusion and Relevance: This study observed a reduction in the extent but not intensity of coprescribing of benzodiazepines for patients with long-term opioid use.

5.
Diabetes Technol Ther ; 21(12): 702-712, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31418588

RESUMO

Background: High-quality diabetes care is evidence-based, timely, and equitable. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are the most recently approved class of glucose-lowering medications with additional cardio- and renal-protective benefits and low risk of hypoglycemia. Cardiovascular and kidney disease are among the most common chronic diabetes complications, whereas hypoglycemia is the most prevalent adverse effect of glucose-lowering therapy. We examine the sociodemographic and clinical factors associated with early SGLT2i initiation and appropriateness of use based on contemporaneous scientific evidence. Materials and Methods: Retrospective analysis of medical and pharmacy claims data from OptumLabs® Data Warehouse for commercially insured and Medicare Advantage adult beneficiaries with diabetes types 1 and 2, who filled any glucose-lowering medication between January 1, 2013 and December 31, 2016. Demographic (age, sex, race, income), clinical (comorbidities), and insurance-related factors affecting first prescription for a SGLT2i were examined using multivariable logistic regression. Results: Among 1,054,727 adults with pharmacologically treated diabetes, 7.2% (n = 75,500) initiated a SGLT2i. Patients with prior myocardial infarction (MI) (odds ratio [OR]: 0.94, 95% confidence interval [CI]: 0.91-0.96), heart failure (HF) (OR: 0.93, 95% CI: 0.91-0.94), kidney disease (OR: 0.80, 95% CI: 0.78-0.81), and severe hypoglycemia (OR: 0.96, 95% CI: 0.94-0.98) were all less likely to start a SGLT2i; P < 0.001 for all. SGLT2i were also less likely to be started by patients ≥75 years (OR: 0.57, 95% CI: 0.55-0.59, vs. 18-44 years), Black patients (OR: 0.93, 95% CI: 0.91-0.95, vs. White), and those with Medicare Advantage insurance (OR: 0.63, 95% CI: 0.62-0.64, vs. commercial). Conclusions: Younger, healthier, non-Black patients with commercial health insurance were most likely to start taking SGLT2i. Patients with MI, HF, kidney disease, and prior hypoglycemia were less likely to use SGLT2i, despite evidence supporting their preferential use in these patients. Efforts to address this treatment-risk paradox may help improve health outcomes among patients with type 2 diabetes.

6.
Am J Manag Care ; 25(8): 379-386, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31419095

RESUMO

OBJECTIVES: To date, breakthrough chimeric antigen receptor (CAR) T-cell therapies, such as tisagenlecleucel, indicated for pediatric acute lymphoblastic leukemia (pALL) and diffuse large B-cell lymphoma (DLBCL), and axicabtagene ciloleucel, indicated for DLBCL, although clinically effective, have been limited by treatment delays. Our study measured the social value of CAR T-cell therapy (CAR T) for relapsed or refractory pALL and DLBCL in the United States and quantified social value lost due to treatment delays. STUDY DESIGN: We used an economic framework for therapy valuation, measuring social value as the sum of consumer surplus and manufacturer profit. Consumer surplus is the difference between the value of health gains from a therapy and its incremental cost, while accounting for indirect costs and benefits to patients. METHODS: For 20 incident cohorts of pALL (n = 20 × 400 = 8000) and DLBCL (n = 20 × 5902 = 118,040), we quantified patient value, calculated as the value of additional quality-adjusted life-years gained with CAR T, minus the incremental cost of CAR T compared with standard of care (SOC). We calculated manufacturer profits using a range of production costs given uncertainties in the production process. Patient value and manufacturer profits were summed to obtain total social value. We measured social value lost from treatment delays, assuming that patients received the SOC while awaiting CAR T-cell treatment. RESULTS: Depending on production costs, as much as $6.5 billion and $34.8 billion in social value was generated for patients with pALL and DLBCL, respectively. However, with 1, 2, or 6 months of treatment delay (assuming $200,000 production costs), the pALL population lost 9.8%, 36.2%, and 67.3% of social value, respectively, whereas the DLBCL population lost 4.2%, 11.5%, and 46.0%, relative to no delay. CONCLUSIONS: The social value of CAR T is significantly limited by treatment delays. Efficient payment mechanisms, adequate capital, and payment policy reform are urgently needed to increase patient access and maximize the value of CAR T.

7.
J Vasc Surg ; 69(2): 571-580, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-29914829

RESUMO

OBJECTIVE: Phlebolymphedema (chronic venous insufficiency-related lymphedema) is a common and costly condition. Nevertheless, there is a dearth of evidence comparing phlebolymphedema therapeutic interventions. This study sought to examine the medical resource utilization and phlebolymphedema-related cost associated with Flexitouch (FLX; Tactile Medical, Minneapolis, Minn) advanced pneumatic compression devices (APCDs) relative to conservative therapy (CONS) alone, simple pneumatic compression devices (SPCDs), and other APCDs in a representative U.S. population of phlebolymphedema patients. METHODS: This was a longitudinal matched case-control analysis of deidentified private insurance claims. The study used administrative claims data from Blue Health Intelligence for the complete years 2012 through 2016. Patients were continuously enrolled for at least 18 months, diagnosed with phlebolymphedema, and received at least one claim for CONS either alone or in addition to pneumatic compression (SPCDs or APCDs). The main outcomes included direct phlebolymphedema- and sequelae-related medical resource utilization and costs. RESULTS: After case matching, the study included 86 patients on CONS (87 on FLX), 34 on SPCDs (23 on FLX), and 69 on other APCDs (67 on FLX). Compared with CONS, FLX was associated with 69% lower per patient per year total phlebolymphedema- and sequelae-related costs net of any pneumatic compression device-related costs ($3839 vs $12,253; P = .001). This was driven by 59% fewer mean annual hospitalizations (0.13 vs 0.32; P < .001) corresponding to 82% lower inpatient costs and 55% lower outpatient hospital costs. FLX was also associated with 52% lower outpatient physical therapy and occupational therapy costs and 56% lower other outpatient-related costs. Compared with SPCDs, FLX was associated with 85% lower total costs ($1153 vs $7449; P = .008) driven by 93% lower inpatient costs ($297 vs $4215; P = .002), 84% lower outpatient hospital costs ($368 vs $2347; P = .020), and 85% lower other outpatient-related costs ($353 vs $2313; P = .023). Compared with APCDs, FLX was associated with 53% lower total costs ($3973 vs $8436; P = .032) because of lower outpatient costs and lower rates of cellulitis (22.4% vs 44.9% of patients; P = .02). CONCLUSIONS: This analysis indicates significant benefits attributable to FLX compared with alternative compression therapies that can help reduce the notable economic burden of phlebolymphedema.


Assuntos
Custos de Cuidados de Saúde , Dispositivos de Compressão Pneumática Intermitente/economia , Linfedema/economia , Linfedema/terapia , Insuficiência Venosa/economia , Insuficiência Venosa/terapia , Demandas Administrativas em Assistência à Saúde , Adolescente , Adulto , Idoso , Assistência Ambulatorial/economia , Estudos de Casos e Controles , Criança , Pré-Escolar , Tratamento Conservador/economia , Análise Custo-Benefício , Feminino , Custos Hospitalares , Humanos , Lactente , Recém-Nascido , Estudos Longitudinais , Linfedema/diagnóstico , Linfedema/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Insuficiência Venosa/diagnóstico , Insuficiência Venosa/fisiopatologia , Adulto Jovem
8.
Arch Phys Med Rehabil ; 100(2): 307-314, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30291827

RESUMO

OBJECTIVE: To investigate differences in facility characteristics, patient characteristics, and outcomes between skilled nursing facilities (SNFs) that participated in Medicare's voluntary Bundled Payments for Care Improvement (BPCI) initiative and nonparticipants, prior to BPCI. DESIGN: Retrospective, cross-sectional comparison of BPCI participants and nonparticipants. SETTING: SNFs. PARTICIPANTS: All Medicare-certified SNFs (N=15,172) and their 2011-2012 episodes of care for chronic obstructive pulmonary disease, congestive heart failure, femur and hip/pelvis fracture, hip and femur procedures, lower extremity joint replacement, and pneumonia (N=873,739). INTERVENTIONS: Participation in a bundled payment program that included taking financial responsibility for care within a 90-day episode. MAIN OUTCOME MEASURES: This study investigates the characteristics of bundled payment participants and their patient characteristics and outcomes relative to nonparticipants prior to BPCI, to understand the implications of a broader implementation of bundled payments. RESULTS: SNFs participating in BPCI were more likely to be in urban areas (80.8%-98.4% vs 69.5%) and belong to a chain or system (73.8%-85.5% vs 55%), and were less likely to be located in the south (13.1%-20.2% vs 35.4%). Quality performance was similar or higher in most cases for SNFs participating in BPCI relative to nonparticipants. In addition, BPCI participants admitted higher socioeconomic status patients with similar clinical characteristics. Initial SNF length of stay was shorter and hospital readmission rates were lower for BPCI patients compared to nonparticipant patients. CONCLUSIONS: We found that SNFs participating in the second financial risk-bearing phase of BPCI represented a diversity of SNF types, regions, and levels of quality and the results may provide insight into a broader adoption of bundled payment for postacute providers.


Assuntos
Medicare/estatística & dados numéricos , Qualidade da Assistência à Saúde/organização & administração , Mecanismo de Reembolso/estatística & dados numéricos , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Fatores Etários , Estudos Transversais , Gastos em Saúde/estatística & dados numéricos , Humanos , Tempo de Internação , Readmissão do Paciente/estatística & dados numéricos , Melhoria de Qualidade/organização & administração , Melhoria de Qualidade/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde , Qualidade da Assistência à Saúde/normas , Características de Residência/estatística & dados numéricos , Estudos Retrospectivos , Fatores Sexuais , Instituições de Cuidados Especializados de Enfermagem/organização & administração , Fatores Socioeconômicos , Resultado do Tratamento , Estados Unidos
9.
Health Serv Res ; 53(6): 4886-4905, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30112827

RESUMO

OBJECTIVE: To determine whether skilled nursing facilities (SNFs) chosen by health systems to participate in preferred provider networks exhibited differences in quality, costs, and patient outcomes relative to other SNFs after accounting for differences in case mix. DATA SOURCES: Medicare provider and claims data, 2012 and 2013. STUDY DESIGN: We compared SNFs included in preferred networks relative to other SNFs in the same market, prior to the establishment of preferred provider networks. DATA EXTRACTION METHODS: We linked the SNFs in our sample to facility characteristics and quality data. We identified SNF admissions and hospitalizations in claims data and limited the analysis to patients discharged from the hospitals in our sample. We obtained patient characteristics from Medicare summary files and the preceding hospital stay. PRINCIPAL FINDINGS: Preferred SNFs exhibited better performance across publicly reported quality measures. Patients admitted to preferred SNFs exhibited shorter stays, lower Medicare payments, and lower probability of SNF readmission relative to nonpreferred SNFs. CONCLUSIONS: Our results imply that health systems selected SNFs with lower resource use and better performance on quality measures. Thus, the trend toward preferred provider networks could have implications for Medicare spending and patient health.


Assuntos
Gastos em Saúde , Medicare/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Encaminhamento e Consulta , Instituições de Cuidados Especializados de Enfermagem , Continuidade da Assistência ao Paciente , Hospitais/estatística & dados numéricos , Humanos , Revisão da Utilização de Seguros , Medicare/economia , Alta do Paciente/estatística & dados numéricos , Instituições de Cuidados Especializados de Enfermagem/economia , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Estados Unidos
10.
Health Aff (Millwood) ; 37(6): 956-963, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29863916

RESUMO

The effectiveness of health insurance advertising has gained renewed attention following the Trump administration's decision to reduce the marketing budget for the federal Marketplace. Yet there is limited evidence on the relationship between advertising and enrollment behavior. This study combined survey data from the 2014 National Health Interview Survey on adults ages 18-64 with data on volumes of televised advertisements aired in respondents' counties of residence during the 2013-14 open enrollment period. We found that people living in counties with higher numbers of ads sponsored by the federal government were significantly more likely to shop for and enroll in a Marketplace plan. In contrast, people living in counties with higher numbers of ads from political sponsors opposing the Affordable Care Act (ACA) were less likely to shop or enroll. These findings add to the evidence base around advertising in the ACA context.


Assuntos
Setor de Assistência à Saúde/organização & administração , Cobertura do Seguro/estatística & dados numéricos , Meios de Comunicação de Massa , Patient Protection and Affordable Care Act/legislação & jurisprudência , Adulto , Idoso , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estados Unidos , Adulto Jovem
11.
J Perinatol ; 38(6): 645-652, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29453436

RESUMO

OBJECTIVES: To quantify drive distances to hospital obstetric services and advanced neonatal care and to examine such disparities by residential rurality and insurance type. STUDY DESIGN: Data for all-payer maternal childbirth hospitalizations in 2002 (N = 661,240) and 2013 (N = 634,807) from nine geographically dispersed states were linked with the American Hospital Association annual surveys to identify maternal residence zip codes and the addresses of hospitals with obstetric services or advanced neonatal care. RESULTS: The uneven geographic distribution of hospital obstetric and advanced neonatal care increased between 2002 and 2013, varying by maternal residential rurality and insurance type. Women in rural non-core areas, with Medicaid or no insurance, and living in counties with lower income and educational attainment, had to travel farther to the nearest hospital with obstetric services or neonatal care than their counterparts. CONCLUSIONS: Women in communities that are already socioeconomically disadvantaged face increasing and substantial travel distances to access perinatal care.


Assuntos
Acesso aos Serviços de Saúde/estatística & dados numéricos , Unidade Hospitalar de Ginecologia e Obstetrícia/estatística & dados numéricos , Cuidado Pós-Natal/normas , Pobreza , Tempo para o Tratamento , Estudos Transversais , Bases de Dados Factuais , Feminino , Pesquisas sobre Serviços de Saúde , Disparidades em Assistência à Saúde , Humanos , Recém-Nascido , Masculino , Medicaid/economia , Medicaid/estatística & dados numéricos , Cuidado Pós-Natal/tendências , Gravidez , População Rural , Fatores Socioeconômicos , Estados Unidos , População Urbana
12.
J Allergy Clin Immunol Pract ; 6(5): 1568-1577.e4, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-28958746

RESUMO

BACKGROUND: Utilization trends of omalizumab, a first-in-its-class asthma biologic approved in 2003 for individuals not controlled by inhaled corticosteroids (ICSs), may reveal lessons in patient selection. OBJECTIVE: To describe utilization patterns for omalizumab since its introduction in 2003, with a focus on patient-level characteristics of patients for whom omalizumab was initiated. METHODS: Using a large US database of administrative claims, we identified privately insured and Medicare Advantage beneficiaries with asthma between 2003 and 2015. Characteristics of incident (no omalizumab use in the previous 12 months) and prevalent users of omalizumab for asthma were described and omalizumab use trends graphed. A comparison cohort (1:5 matching proportion) of nonomalizumab users was compared with incident omalizumab users on demographic characteristics, medication adherence (medication possession ratio [MPR]) for ICSs and/or ICS/long-acting ß-agonist (ICS-LABA), exacerbation frequency, and asthma control in the 6 months before omalizumab initiation. RESULTS: We identified 7,658 prevalent and 3,399 incident omalizumab users. Omalizumab incidence peaked in the second quarter of 2004 at 0.65 per 1,000 individuals with asthma, whereas prevalence peaked in the fourth quarter of 2006 at 3.22; as of fourth quarter 2015, rates were 0.14 and 1.96, respectively. In the 12 months before omalizumab initiation, 72.5% had low adherence (MPR ≤ 0.75) and 48.6% had very low adherence (MPR ≤ 0.5) to ICSs and/or ICS-LABA. In the period 2003 to 2015, the mean number of exacerbations in the 12 months before incident use ranged from 1.50 to 2.11 and the proportion that had poor asthma control (≥3 rescue inhalers dispensed) ranged from 54% to 67%. Incident omalizumab users were less likely to have good asthma control than the matched cohort of nonusers (adjusted odds ratio, 0.53 [0.48-0.59]). CONCLUSIONS: Omalizumab use for asthma has been gradually decreasing following a peak shortly after its market availability. Many omalizumab users have low or very low adherence rates for ICSs and/or ICS-LABA in the 12 months before omalizumab initiation.


Assuntos
Antiasmáticos/uso terapêutico , Asma/tratamento farmacológico , Uso de Medicamentos/estatística & dados numéricos , Adesão à Medicação/estatística & dados numéricos , Omalizumab/uso terapêutico , Adolescente , Agonistas Adrenérgicos beta/uso terapêutico , Adulto , Idoso , Asma/epidemiologia , Criança , Pré-Escolar , Estudos de Coortes , Progressão da Doença , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
13.
J Health Polit Policy Law ; 43(6): 961-989, 2018 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-31091327

RESUMO

Television advertising has been a primary method for marketing new health plans available under the Affordable Care Act (ACA) to consumers. Data from Kantar Media's Campaign Media Analysis Group were used to analyze advertising content during three ACA open enrollment periods (fall 2013 to spring 2016). Few advertisement airings featured people who were elderly, disabled, or receiving care in a medical setting, and over time airings increasingly featured children, young adults, and people exercising. The most common informational messages focused on plan choice and availability of low-cost plans, but messages shifted over open enrollment cycles to emphasize avoidance of tax penalties and availability of financial assistance. Over the three open enrollment periods, there was a sharp decline in explicit mentions of the ACA or Obamacare in advertisements. Overall, television advertisements have increasingly targeted young, healthy consumers, and informational appeals have shifted toward a focus on financial factors in persuading individuals to enroll in marketplace plans. These advertising approaches make sense in the context of pressures to market plans to appeal to a sufficiently large, diverse group. Importantly, dramatic declines over time in explicit mention of the law mean that citizens may fail to understand the connection between the actions of government and the benefits they are receiving.


Assuntos
/estatística & dados numéricos , Trocas de Seguro de Saúde , Patient Protection and Affordable Care Act , Televisão , Humanos , Estados Unidos
14.
Am J Manag Care ; 23(9): e310-e315, 2017 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-29087169

RESUMO

OBJECTIVES: To assess whether Medicare formularies restrict access to drugs receiving new FDA black box warnings for which safer drug alternatives are available. STUDY DESIGN: A retrospective analysis using Medicare Prescription Drug Plan Formulary files to determine formulary changes for drugs receiving FDA black box warnings between 2007 and 2013. METHODS: We identified all FDA-approved medications available in tablet or capsule formulation that received a black box warning between 2007 and 2013 related to death and/or cardiovascular risk. We then determined formulary coverage of these drugs pre-black box warning, 1 year after, and 2 years after. For each formulary, we identified formulary restrictiveness, defined as: unrestrictive coverage (no prior authorization or step therapy), restrictive coverage (prior authorization or step therapy required), or no coverage. RESULTS: Nine drugs with at least 1 FDA-approved safer drug alternative received 10 new black box warnings for death and/or cardiovascular risk between 2007 and 2013. In response to FDA black box warnings, overall formulary restrictiveness increased for 40% (n = 4) of drugs at 1 year, and for 50% (n = 5) at 2 years. However, for the majority of drugs (n = 7), most formularies remained unrestrictive 2 years after a new black box warning. CONCLUSIONS: Medicare formularies became more restrictive for half of the drugs that recently received new FDA black box warnings for death and/or cardiovascular risk and for which safer drug alternatives are available. However, a substantial proportion of formularies remained unrestrictive, suggesting inconsistent responses to new safety information to curtail the use of these medications.


Assuntos
Formulários Farmacêuticos como Assunto , Medicare/organização & administração , United States Food and Drug Administration , Formulários Farmacêuticos como Assunto/normas , Humanos , Medicamentos sob Prescrição/normas , Estudos Retrospectivos , Estados Unidos , United States Food and Drug Administration/normas
16.
Jt Comm J Qual Patient Saf ; 43(1): 41-48, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-28334585

RESUMO

BACKGROUND: The gap between publishing and implementing guidelines differs based on practice setting, including hospital geography and teaching status. On March 31, 2006, a Practice Bulletin published by the American College of Obstetricians and Gynecologists (ACOG) recommended against the routine use of episiotomy and urged clinicians to make judicious decisions to restrict the use of the procedure. OBJECTIVE: This study investigated changes in trends of episiotomy use before and after the ACOG Practice Guideline was issued in 2006, focusing on differences by hospital geographic location (rural/urban) and teaching status. METHODS: In a retrospective analysis of discharge data from the Nationwide Inpatient Sample (NIS)-a 20% sample of US hospitals-5,779,781 hospital-based births from 2002 to 2011 (weighted N = 28,067,939) were analyzed using multivariable logistic regression analysis to measure odds of episiotomy and trends in episiotomy use in vaginal deliveries. RESULTS: The overall episiotomy rate decreased from 20.3% in 2002 to 9.4% in 2011. Across all settings, a comparatively larger decline in episiotomy rates preceded the issuance of the ACOG Practice Guideline (34.0% decline), rather than following it (23.9% decline). The episiotomy rate discrepancies between rural, urban teaching, and urban nonteaching hospitals remained steady prior to the guideline's release; however, differences between urban nonteaching and urban teaching hospitals narrowed between 2007 and 2011 after the guideline was issued. CONCLUSION: Teaching status was a strong predictor of odds of episiotomy, with urban nonteaching hospitals having the highest rates of noncompliance with evidence-based practice. Issuance of clinical guidelines precipitated a narrowing of this discrepancy.


Assuntos
Parto Obstétrico , Episiotomia , Fidelidade a Diretrizes , Feminino , Hospitais de Ensino , Hospitais Urbanos , Humanos , Gravidez , Estudos Retrospectivos , Estados Unidos
17.
Health Aff (Millwood) ; 36(4): 747-754, 2017 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-28298432

RESUMO

The launch of the Affordable Care Act was accompanied by major insurance information campaigns by government, nonprofit, political, news media, and private-sector organizations, but it is not clear to what extent these efforts were associated with insurance gains. Using county-level data from the Census Bureau's American Community Survey and broadcast television airings data from the Wesleyan Media Project, we examined the relationship between insurance advertisements and county-level health insurance changes between 2013 and 2014, adjusting for other media and county- and state-level characteristics. We found that counties exposed to higher volumes of local insurance advertisements during the first open enrollment period experienced larger reductions in their uninsurance rates than other counties. State-sponsored advertisements had the strongest relationship with declines in uninsurance, and this relationship was driven by increases in Medicaid enrollment. These results support the importance of strategic investment in advertising to increase uptake of health insurance but suggest that not all types of advertisements will have the same effect on the public.


Assuntos
Cobertura do Seguro/estatística & dados numéricos , Meios de Comunicação de Massa/estatística & dados numéricos , Patient Protection and Affordable Care Act , Adulto , Censos , Acesso aos Serviços de Saúde , Humanos , Seguro Saúde/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , Estados Unidos
18.
Health Aff (Millwood) ; 36(1): 91-100, 2017 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-28069851

RESUMO

Traditional fee-for-service (FFS) Medicare's prospective payment systems for postacute care provide little incentive to coordinate care or control costs. In contrast, Medicare Advantage plans pay for postacute care out of monthly capitated payments and thus have stronger incentives to use it efficiently. We compared the use of postacute care in skilled nursing and inpatient rehabilitation facilities by enrollees in Medicare Advantage and FFS Medicare after hospital discharge for three high-volume conditions: lower extremity joint replacement, stroke, and heart failure. After accounting for differences in patient characteristics at discharge, we found lower intensity of postacute care for Medicare Advantage patients compared to FFS Medicare patients discharged from the same hospital, across all three conditions. Medicare Advantage patients also exhibited better outcomes than their FFS Medicare counterparts, including lower rates of hospital readmission and higher rates of return to the community. These findings suggest that payment reforms such as bundling in FFS Medicare may reduce the intensity of postacute care without adversely affecting patient health.


Assuntos
Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Medicare Part C/estatística & dados numéricos , Cuidados Semi-Intensivos/métodos , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Substituição/reabilitação , Artroplastia de Substituição/estatística & dados numéricos , Planos de Pagamento por Serviço Prestado/economia , Feminino , Insuficiência Cardíaca/reabilitação , Humanos , Masculino , Medicare Part C/economia , Readmissão do Paciente , Acidente Vascular Cerebral/terapia , Cuidados Semi-Intensivos/economia , Estados Unidos
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