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1.
BMJ Open ; 10(1): e031203, 2020 Jan 06.
Artigo em Inglês | MEDLINE | ID: mdl-31911513

RESUMO

OBJECTIVE: Access to highly priced anticancer medications usually requires insurance coverage. A first step towards coverage of such medications is their inclusion in reimbursement lists. We assessed listing for reimbursement in China between 2009 and 2018 of anticancer medications on the WHO's Essential Medicines List. SETTING AND STUDY DESIGN: Using publicly available data, we assessed which anticancer medications listed in the 20th WHO Model List of Essential Medicines (EML) were included in China's National Reimbursement Drug List (NRDL). For five targeted anticancer medications on the WHO EML, we also assessed inclusion in the 31 Chinese Provincial Reimbursement Drug Lists (PRDLs). Logistic regression was used to test whether inclusion of targeted anticancer medications was associated with provincial economic levels. PRIMARY OUTCOME MEASURES: Inclusion of five targeted anticancer medications in the NRDL and PRDLs before and after 2017. RESULTS: The 2017 NRDL included all anticancer medications on the WHO EML (except for one not approved in China at the time), and by 2018, all 31 PRDLs listed the targeted anticancer medications except for nilotinib; four provinces had covered all five targeted medications before the 2017 NRDL coverage mandate. Provincial economic level and regional incidence of specific cancers seemed unrelated to the inclusion of five targeted anticancer medications in PRDLs. CONCLUSION: Our findings suggest that by including medications in the national and provincial reimbursement lists, China has taken an important first step in promoting access to targeted anticancer medications. Further research is needed to determine whether inclusion in PRDLs improved the availability, appropriate use and affordability of highly priced targeted anticancer medications in China.

2.
Radiology ; 294(2): 342-350, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31891320

RESUMO

Background Trends in noninvasive diagnostic imaging (NDI) utilization rates have predominantly been reported in Medicare enrollees. To the authors' knowledge, there has been no prior direct comparison of utilization rates between Medicare and commercially insured patients. Purpose To analyze trends in NDI utilization rates by modality, comparing Medicare fee-for-service and commercially insured enrollees. Materials and Methods This study was a retrospective trend analysis of NDI performed between 2003 and 2016 as reported in claims databases for all adults enrolled in fee-for-service Medicare and for roughly 9 million commercially insured patients per year. The commercially insured patients were divided into two populations: those aged 18-44 years and those aged 45-64 years. The same procedure code definitions for NDI were applied to both Medicare and commercial claims, rates were calculated per 1000 enrollees, and trends were reported over time in aggregate followed by modality (CT, MRI, nuclear imaging, echocardiography, US, radiography). Join-point regression was used to model annual rates and to identify statistically significant (P < .05) changes in trends. Results In almost all instances, Medicare enrollees had the highest utilization rate for each modality, followed by commercially insured patients aged 45-64 years, then aged 18-44 years. All three populations showed utilization growth through the mid to late 2000s (images per 1000 enrollees per year for Medicare: 91 [95% confidence interval {CI}: 34, 148]; commercially insured patients aged 45-64 years: 158 [95% CI: 130, 186]; aged 18-44 years: 83 [95% CI: 69, 97]), followed by significant declining trends from the late 2000s through early 2010s (images per 1000 enrollees per year for Medicare: -301 [95% CI: -510, -92]; commercially insured patients aged 45-64 years: -54 [95% CI: -69, -39]; aged 18-44 years: -26 [95% CI: -31, -21]) coinciding with code-bundling events instituted by Medicare (CT, nuclear imaging, echocardiography). There were significant trend changes in modalities without code bundling (MRI, radiography, US), although flat trends mostly were exhibited. After the early 2010s, there were significant trend changes largely showing flat utilization growth. The notable exception was a significant trend change to renewed growth of CT imaging among commercially insured patients aged 45-64 years and Medicare enrollees after 2012, although at half the prior rate (images per 1000 enrollees per year for Medicare: 17 [95% CI: 6, 28]; commercially insured patients aged 45-64 years: 11 [95% CI: 2, 20]). Conclusion Noninvasive diagnostic imaging utilization trends among commercially insured individuals are similar to those in Medicare enrollees, although at lower rates. Earlier rapid growth has ceased and, except for CT, utilization has stabilized since the early 2010s. © RSNA, 2019 See also the editorial by Hentel and Wolk in this issue.

3.
BMC Public Health ; 20(1): 24, 2020 Jan 08.
Artigo em Inglês | MEDLINE | ID: mdl-31914972

RESUMO

BACKGROUND: Increasing medicines availability and affordability is a key goal of Brazilian health policies. "Farmácia Popular" (FP) Program is one of the government's key strategies to achieve this goal. Under FP, antihypertension (HTN) and antiglycemic (DM) medicines have been provided at subsidized prices in private retail settings since 2006, and free of charge since 2011. We aim to assess the impact of sequential changes in FP benefits on patient affordability and government expenditures for HTN and DM treatment under the FP, and examine their implications for public financing mechanisms and program sustainability. METHODS: Longitudinal, retrospective study using interrupted time series to analyze: HTN and DM treatment coverage; total and per capita expenditure; percentage paid by MoH; and patient cost sharing. Analyzes were conducted in the dispensing database of the FP program (from 2006 to 2012). RESULTS: FP has increased its coverage over time; by December 2012 FP covered on average 13% of DM and 11.5% of HTN utilization, a growth of over 600 and 1500%, respectively. The overall cost per treatment to the MoH declined from R$36.43 (R$ = reais, the Brazilian currency) to 18.74 for HTN and from R$33.07to R$15.05 for DM over the period analyzed, representing a reduction in per capita cost greater than 50%. The amount paid by patients for the medicines covered increased over time until 2011, but then declined to zero. We estimate that to treat all patients in need for HTN and DM in 2012 under FP, the Government would need to expend 97% of the total medicines budget. CONCLUSIONS: FP rapidly increased its coverage in terms of both program reach and proportion of cost subsidized during the period analyzed. Costs of individual HTN and DM treatments in FP were reduced after 2011 for both patients (free) and government (better negotiated prices). However, overall FP expenditures by MoH increased due to markedly increased utilization. The FP is sustainable as a complementary policy but cannot feasibly substitute for the distribution of medicines by the SUS.

4.
BMJ Open ; 9(11): e031658, 2019 Nov 28.
Artigo em Inglês | MEDLINE | ID: mdl-31784440

RESUMO

BACKGROUND: In October 2012, the Chinese government established maximum retail prices for specific products, including 30 antineoplastic medications. Three years later, in June 2015, the government abolished price regulation for most medications, including all antineoplastic medications. This study examined the impacts of regulation and subsequent deregulation of prices of antineoplastic medications in China. METHODS: Using hospital procurement data and an interrupted time series with comparison series design, we examined the impacts of the policy changes on relative purchase prices (Laspeyres price index) and volumes of and spending on 52 antineoplastic medications in 699 hospitals. We identified three policy periods: prior to the initial price regulation (October 2011 to September 2012); during price regulation (October 2012 to June 2015); and after price deregulation (July 2015 to June 2016). RESULTS: During government price regulation, compared with price-unregulated cancer medications (n=22, mostly newer targeted products), the relative price of price-regulated medications (n=30, mostly chemotherapeutic products) decreased significantly (ß=-0.081, p<0.001). After the government price deregulation, no significant price change occurred. Neither government price regulation nor deregulation had a significant impact on average volumes of or average spending on all antineoplastic medications immediately after the policy changes or in the longer term (p>0.05). CONCLUSION: Compared with unregulated antineoplastics, the prices of regulated antineoplastic medications decreased after setting price caps and did not increase after deregulation. To control the rapid growth of oncology medication expenditures, more effective measures than price regulation through price caps for traditional chemotherapy are needed.

6.
JAMA Netw Open ; 2(12): e1917603, 2019 Dec 02.
Artigo em Inglês | MEDLINE | ID: mdl-31851344

RESUMO

Importance: There are few nationwide studies comparing the risk of reintervention after contemporary bariatric procedures. Objective: To compare the risk of intervention after Roux-en-Y gastric bypass (RYGB) vs vertical sleeve gastrectomy (VSG). Design, Setting, and Participants: This cohort study used a nationwide US commercial insurance claims database. Adults aged 18 to 64 years who underwent a first RYGB or VSG procedure between January 1, 2010, and June 30, 2017, were matched on US region, year of surgery, most recent presurgery body mass index (BMI) category (based on diagnosis codes), and baseline type 2 diabetes. The prematch pool included 4496 patients undergoing RYGB and 8627 patients undergoing VSG, and the final weighted matched sample included 4476 patients undergoing RYGB and 8551 patients undergoing VSG. Exposures: Bariatric surgery procedure type (RYGB vs VSG). Main Outcomes and Measures: The primary outcome was any abdominal operative intervention after the index procedure. Secondary outcomes included the following subtypes of operative intervention: biliary procedures, abdominal wall hernia repair, bariatric conversion or revision, and other abdominal operations. Nonoperative outcomes included endoscopy and enteral access. Time to first event was compared using multivariable Cox proportional hazards regression modeling. Results: Among 13 027 patients, the mean (SD) age was 44.4 (10.3) years, and 74.1% were female; 13.7% had a preoperative BMI between 30 and 39.9, 45.8% had a preoperative BMI between 40 and 49.9, and 24.2% had a preoperative BMI of at least 50. Patients were followed up for up to 4 years after surgery (median, 1.6 years; interquartile range, 0.7-3.2 years), with 41.9% having at least 2 years of follow-up and 16.3% having at least 4 years of follow-up. Patients undergoing VSG were less likely to have any subsequent operative intervention than matched patients undergoing RYGB (adjusted hazard ratio [aHR], 0.80; 95% CI, 0.72-0.89) and similarly were less likely to undergo biliary procedures (aHR, 0.77; 95% CI, 0.67-0.90), abdominal wall hernia repair (aHR, 0.60; 95% CI, 0.47-0.75), other abdominal operations (aHR, 0.71; 95% CI, 0.61-0.82), and endoscopy (aHR, 0.54; 95% CI, 0.49-0.59) or have enteral access placed (aHR, 0.58; 95% CI, 0.39-0.86). Patients undergoing VSG were more likely to undergo bariatric conversion or revision (aHR, 1.83; 95% CI, 1.19-2.80). Conclusions and Relevance: In this nationwide study, patients undergoing VSG appeared to be less likely than matched patients undergoing RYGB to experience subsequent abdominal operative interventions, except for bariatric conversion or revision procedures. Patients considering bariatric surgery should be aware of the increased risk of subsequent procedures associated with RYGB vs VSG as part of shared decision-making around procedure choice.

7.
Am J Manag Care ; 25(12): e379-e387, 2019 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-31860232

RESUMO

OBJECTIVES: New direct-acting antivirals (DAAs), introduced in late 2013, are effective for treating chronic hepatitis C virus (HCV) infection but may pose substantial financial burden on patients and health insurers. We examined HCV medication use and costs in a commercially insured population. STUDY DESIGN: Retrospective cohort study. METHODS: We used claims data for 3091 individuals with HCV infection (2012-2015). Outcomes included HCV medication use, inflation-adjusted out-of-pocket (OOP) and health plan spending, and predictors of receiving new DAAs. RESULTS: Cumulatively, 9% of members with a diagnosis of HCV were treated with HCV medications in 2012 and this increased to 32% in 2015. Of 3091, 589 received new DAAs and 80% (n = 465) completed a 12-week treatment regimen. After new DAAs became available, average annual health plan spending on HCV medications increased from $2869 to $16,504 per HCV-diagnosed member (relative change, 475%; 95% CI, 352%-598%), and OOP spending increased from $41 to $94 (relative change, 131%; 95% CI, 15%-247%). Age (being aged 50-64 years [adjusted odds ratio (aOR), 2.13; 95% CI, 1.29-3.53] and being ≥65 years [aOR, 2.01; 95% CI, 1.14-3.55] compared with being <30 years) and having liver cirrhosis (aOR, 3.34; 95% CI, 2.64-4.21) were positively associated with receiving new DAAs, and a diagnosis of alcohol abuse (aOR, 0.70; 95% CI, 0.53-0.92) was negatively associated with receiving new DAAs. CONCLUSIONS: The proportion of a commercially insured population with HCV infection who were treated with HCV medications doubled within 2 years following availability of new DAAs. Member OOP spending was kept low while the health plan bore 99% of the cost of HCV medications. During our 2-year follow-up, we did not observe financial benefits to the health plan of the cure of HCV infection by new DAAs.

8.
Artigo em Inglês | MEDLINE | ID: mdl-31879829

RESUMO

BACKGROUND: Inappropriate prescribing is an important health system problem in China. Several studies have identified critical factors influencing prescription quality, but the impact of physicians' working hours remains unknown. In China, tertiary hospitals face ever-increasing outpatient volumes. Physicians are asked to work long hours and the impact of shift duration on prescription quality is unknown. OBJECTIVE: We aimed to investigate the association between consecutive working hours and the quality of physicians' prescriptions in a Chinese tertiary hospital. METHODS: We obtained all outpatient electronic health records from the hospital information system (HIS) of a tertiary hospital in Beijing, China from 1 July to 30 November 2015. Prescriptions made during two periods were analyzed: a morning shift from 7:30 to 12:30, and an afternoon shift from 13:30 to 18:30. The time when a physician issued the first prescription was considered the beginning of the work shift and prescriptions within the next 4 consecutive hours were included. Potentially inappropriate prescriptions were based on the Rational Drug Use (RDU) system that was developed and validated for this study. We used multivariable logistic regression to examine the impact of shift duration and other clinical and physician factors on potentially inappropriate prescribing. RESULTS: Of the total 560,529 prescriptions, 15.3% were classified as inappropriate by the RDU system. Physicians' inappropriate prescribing increased in the last hour in each work shift (odds ratio (OR) for the fourth hour compared to the first = 1.12 (95% CI, 1.09-1.15)). We also found that physicians who worked all day had a higher rate of inappropriate prescribing than those who only worked half a day (OR = 1.05 (95% CI, 1.04-1.07)). CONCLUSIONS: Longer working hours are a risk factor for inappropriate prescribing. Relevant interventions are urgently needed to establish working hour limits in China to reduce the likelihood of inappropriate prescribing by physicians.

9.
Rev Saude Publica ; 53: 94, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31644724

RESUMO

OBJECTIVE: To evaluate trends in the use of generic and non-generic medicines to treat hypertension and diabetes under the Farmácia Popular Program (FP) and its impact on generic medicines sales volume and market share in the Brazilian pharmaceutical market. METHODS: This longitudinal, retrospective study used interrupted time series design to analyze changes in monthly sales volume and proportion of medicines sales (market share) for oral antidiabetic and antihypertensive medicines for generic versus non-generic products. Analyses were conducted in a combined dataset that aggregate monthly sales volumes from the Farmácia Popular program and from the QuintilesIMS™ (IQVIA) national market sales data from January 2007 to December 2012. The Farmácia Popular program phases analyzed included: a) 2009 reductions in medicines reference prices (AFP-II) and b) 2011 implementation of free medicines program for hypertension and diabetes, the Saúde não tem preço (SNTP - Health has no price). RESULTS: Patterns of use for FP-covered antidiabetic and antihypertensive medicines were similar to their use in the market in general. After one year of the decreases in government subsidies in April 2010, market share of antidiabetic and antihypertensive medicines experienced relative declines of -54.5% and -59.9%, respectively. However, when FP-covered medicines were made free to patients, overall market volume for antidiabetic and antihypertensive generics increased dramatically, with 242.6% and 277.0% relative increases by February 2012, as well as non-generics with relative increase of 209.7% and 279% for antidiabetic and antihypertensive medicines, respectively. CONCLUSIONS: Ministry of Health policies on the amount of patient cost sharing and on the choice of medicines on coverage lists have substantial impacts on overall generic sales volume in retail pharmacies.


Assuntos
Anti-Hipertensivos/uso terapêutico , Comércio/tendências , Serviços Comunitários de Farmácia/tendências , Medicamentos Genéricos/uso terapêutico , Hipoglicemiantes/uso terapêutico , Programas Nacionais de Saúde/tendências , Brasil , Comércio/estatística & dados numéricos , Serviços Comunitários de Farmácia/estatística & dados numéricos , Diabetes Mellitus/tratamento farmacológico , Política de Saúde , Humanos , Hipertensão/tratamento farmacológico , Análise de Séries Temporais Interrompida , Estudos Longitudinais , Programas Nacionais de Saúde/estatística & dados numéricos , Farmácias/estatística & dados numéricos , Farmácias/tendências , Avaliação de Programas e Projetos de Saúde , Valores de Referência , Estudos Retrospectivos , Fatores de Tempo
10.
Lancet Infect Dis ; 19(12): 1345-1354, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31588042

RESUMO

BACKGROUND: Non-prescription dispensing of antibiotics at community pharmacies is a major driver of antimicrobial resistance. China has regarded curbing non-prescription sales of antibiotics at community pharmacies as an important task for tackling antibiotics resistance and planned to eliminate this practice nationwide before 2020. We aimed to quantify non-prescription dispensing of antibiotics cross-sectionally at community pharmacies in China in 2017, and longitudinally (2011-17) in a single province. METHODS: A simulated client method was used to measure non-prescription antibiotic dispensing based on scenarios about paediatric diarrhoea and adult acute upper respiratory tract infection (URTI), which were presented at each pharmacy. We collected cross-sectional data for 2423 community pharmacies from 221 counties or districts in six provinces in different regions of China, in 2017. We also assessed 213 community pharmacies in Shaanxi province with a baseline survey in 2011 and subsequent follow-up surveys every 2 years until 2017. In the cross-sectional analysis, multivariate binary logistic regression with random-intercepts was used to evaluate the factors associated with non-prescription dispensing of antibiotics. We also estimated unadjusted period effects of non-prescription antibiotic dispensing using generalised estimated equations. FINDINGS: After excluding invalid interactions within 12 community pharmacies, the study included 4822 simulated interactions within 2411 community pharmacies. Non-prescription antibiotic dispensing was observed during 1169 (48·5% [95% CI 46·5-50·5]) of 2411 diarrhoea interactions and 1690 (70·1% [68·2-71·9]) of 2411 adult URTI interactions. Non-prescription antibiotic dispensing was more prevalent in rural areas and the central and western provinces, and was negatively associated with the presence of a pharmacist on-site (odds ratio 0·66 [0·56-0·78], p<0·0001) and being part of a chain pharmacy (0·75 [0·62-0·89], p=0·0012). In Shaanxi province, significant decreases of non-prescription antibiotic dispensing occurred in paediatric cases (from 154 [72·3%] of 213 community pharmacies to 107 [50·2%], p<0·0001) and adult cases (from 204 [95·8%] to 148 [69·5%], p<0·0001) between 2011 and 2017. INTERPRETATION: Non-prescription dispensing of antibiotics at community pharmacies was still prevalent nationwide in China in 2017, although a decrease was observed in Shaanxi Province since 2011. Multifaceted measures, including regulatory interventions, professional training, and public health education are needed. FUNDING: Young Talent Support Plan and High Achiever Plan of Health Science Center, Xi'an Jiaotong University, Central University Basic Research Fund, Early Career Research Start-up Plan of Xi'an Jiaotong University.

12.
J Pharm Policy Pract ; 12: 18, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31417682

RESUMO

Objectives: To describe changes in the private market for selected originators, branded generics ('similares'), and generic products during the 10 years following passage of the Brazilian Generics Law. Methods: We analyzed longitudinal data collected by IQVIA® on quarterly sales by wholesalers to retail pharmacies in Brazil from 1998 through 2010, grouped by originators, branded generics, and generic products in three therapeutic classes (antibiotics, antidiabetics, and antihypertensives). Outcomes included market share (proportion of the total private market volume), sales volume per capita, prices and number of manufacturers by group. Results: In the private market share, generics became dominant in each therapeutic class but the speed of uptake varied. Originators consistently lost most market share while branded generics varied over time. By the end of the study period, generics were the most sold product type in all classes, followed by branded generics. The number of generic manufacturers increased in all classes, while branded generics increased just after the policy but then decreased slowly through the end of 2010. For approximately 50% of the antibiotics analyzed, branded generics and generics had lower prices than originators. For antidiabetics, branded generic and generic prices were quite similar during the period analyzed. Price trends for the various subclasses of antihypertensive exhibited very different patterns over time. Conclusion: Sales of branded generics and originators decreased substantially in the three therapeutic classes analysed following the introduction of the generics policy in Brazil, but the time to market dominance of generics varied by class.

13.
J Healthc Qual ; 2019 Aug 22.
Artigo em Inglês | MEDLINE | ID: mdl-31453829

RESUMO

High-risk hospitalized younger adults (age ≤60) have 30-day readmission rates comparable to Medicare fee-for-service patients. This younger cohort has a high incidence of comorbid mental health and substance use disorders, which increases the complexity of their postdischarge care. Although few care transition studies have enrolled younger adult patients, findings from our previous work suggest that these patients have postdischarge needs requiring different approaches than those serving elderly patients. Our current pilot study, situated in a safety-net system, targets this younger population, employing a social worker as the Transition Coach (TC). Social workers are explicitly trained to address psychosocial complexities, and we evaluated whether our TC intervention could improve hospital-to-home transitions by assisting patients with medication management, attending follow-up appointments, and addressing medical, psychiatric, and psychosocial needs. Primary outcomes were Patient Activation Measure scores on admission and 30-days postdischarge; outpatient follow-up at 7 and 30 days; and all-cause, in-network 30-, 60-, and 90-day readmissions. At 30 and 60 days, no differences were observed in the primary outcomes; at 90 days, intervention patients demonstrated a trend toward readmission reduction. A social worker-led transitional care program shows promise in reducing readmissions over 90 days among high-risk, lower socioeconomic, nonelderly adult patients.

14.
PLoS One ; 14(5): e0217617, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31150458

RESUMO

BACKGROUND: Health care provider (HCP) performance in low- and middle-income countries (LMICs) is often inadequate. The Health Care Provider Performance Review (HCPPR) is a comprehensive systematic review of the effectiveness and cost of strategies to improve HCP performance in LMICs. We present the HCPPR's methods, describe methodological and contextual attributes of included studies, and examine time trends of study attributes. METHODS: The HCPPR includes studies from LMICs that quantitatively evaluated any strategy to improve HCP performance for any health condition, with no language restrictions. Eligible study designs were controlled trials and interrupted time series. In 2006, we searched 15 databases for published studies; in 2008 and 2010, we completed searches of 30 document inventories for unpublished studies. Data from eligible reports were double-abstracted and entered into a database, which is publicly available. The primary outcome measure was the strategy's effect size. We assessed time trends with logistic, Poisson, and negative binomial regression modeling. We were unable to register with PROSPERO (International Prospective Register of Systematic Reviews) because the protocol was developed prior to the PROSPERO launch. RESULTS: We screened 105,299 citations and included 824 reports from 499 studies of 161 intervention strategies. Most strategies had multiple components and were tested by only one study each. Studies were from 79 countries and had diverse methodologies, geographic settings, HCP types, work environments, and health conditions. Training, supervision, and patient and community supports were the most commonly evaluated strategy components. Only 33.6% of studies had a low or moderate risk of bias. From 1958-2003, the number of studies per year and study quality increased significantly over time, as did the proportion of studies from low-income countries. Only 36.3% of studies reported information on strategy cost or cost-effectiveness. CONCLUSIONS: Studies have reported on the efficacy of many strategies to improve HCP performance in LMICs. However, most studies have important methodological limitations. The HCPPR is a publicly accessible resource for decision-makers, researchers, and others interested in improving HCP performance.


Assuntos
Pessoal de Saúde/tendências , Programas Nacionais de Saúde , Pobreza/economia , Assistência à Saúde/economia , Assistência à Saúde/tendências , Países em Desenvolvimento/economia , Pessoal de Saúde/economia , Humanos , Revisão da Pesquisa por Pares
15.
Ann Surg ; 2019 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-31205064

RESUMO

MINI: We used commercial insurance claims data to compare vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB) with respect to diabetes treatment outcomes. In matched cohorts of patients, RYGB patients were more likely than patients with VSG to come off all diabetes medications up to 2 years after surgery, and had greater decreases in cumulative medication dosing. OBJECTIVE: The aim of the study was to compare diabetes outcomes following vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB). BACKGROUND: There are few comparative studies on diabetes outcomes after VSG and RYGB. METHODS: We used a US-wide commercial insurance claims database to identify adults with diabetes undergoing VSG or RYGB in 2010 to 2016. We matched patients on baseline insulin use, total diabetes medication burden, age, presence of diabetes complications, and follow-up duration, and used adjusted Cox proportional hazards models to compare diabetes medication discontinuation between procedures. We used difference-in-differences analyses to compare changes in medication use intensity up to 2 years after surgery. RESULTS: The matched cohort included 1111 VSG and 922 RYGB patients: 16% were younger than 40 years, 11% were 60 years or older, 67% were women, 67% had a body mass index of 40 kg/m or higher, and 23% were on insulin at the time of surgery. Thirteen percent were lost to follow-up at 1 year, and 30% at 2 years after surgery. Patients with VSG were less likely than matched RYGB patients to discontinue all diabetes medications (hazard ratio 0.80, 95% confidence interval 0.72-0.88). Although both groups had substantial decreases in medication use after surgery, RYGB patients had an 86% (32%, 140%) lower total diabetes medication dose than VSG by the second half of postoperative year 2. CONCLUSIONS: In a large claims-based, nationwide cohort of bariatric patients with diabetes, those undergoing RYGB were more likely to come off all medications than those undergoing VSG. Patients with diabetes should consider this potential benefit of RYGB when making informed decisions about obesity treatments.

16.
Prim Care Diabetes ; 13(6): 549-555, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31097343

RESUMO

OBJECTIVE: Innovative mobile health technologies (mHealth) may facilitate self-management of blood glucose. This study evaluates uptake, use, and predictors of uptake and long-term use of a diabetes mHealth intervention, which comprises an FDA-approved mobile glucometer and nurse coaching, in a real-world setting. METHODS: n = 4438 commercially-insured adults with diabetes were recruited from 2014 to 2015 via an opt-in, phone-based process. In this post-only study, we obtained data on recruitment, glucometer use, demographics, and insurance and employer characteristics. We calculated percent uptake and reasons for unsuccessful recruitment. We used logistic regression to model predictors of uptake and survival analysis to examine duration of testing and predictors of discontinuation. RESULTS: Of the recruited members, 556 (12.5%) signed up for the mHealth program and 324 (7.3%) began testing. Of those who did not sign up, the majority (70.6%) were unable to be reached by phone. Male (OR = 1.60, 95% CI: 1.25, 2.03) and Spanish-speaking (OR = 8.34, 95% CI: 5.40, 12.88) members were more likely to start testing. Two-thirds (66.2%) of those who started testing had a first test value that indicated hyperglycemia; 97% tested more than once and the median time between first and last test was 407 days. Older age was the only significant predictor of long-term use. CONCLUSIONS: Although uptake of the mHealth program was low, most members who started testing had initial glucose values that indicated a need for better glucose management and the majority of patients engaged with the program for over a year. Male and Spanish-speaking members were more likely to initiate the program.

17.
Health Aff (Millwood) ; 38(3): 408-415, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30830830

RESUMO

The effects of high-deductible health plans (HDHPs) on breast cancer diagnosis and treatment among vulnerable populations are unknown. We examined time to first breast cancer diagnostic testing, diagnosis, and chemotherapy among a group of women whose employers switched their insurance coverage from health plans with low deductibles ($500 or less) to plans with high deductibles ($1,000 or more) between 2004 and 2014. Primary subgroups of interest comprised 54,403 low-income and 76,776 high-income women continuously enrolled in low-deductible plans for a year and then up to four years in HDHPs. Matched controls had contemporaneous low-deductible enrollment. Low-income women in HDHPs experienced relative delays of 1.6 months to first breast imaging, 2.7 months to first biopsy, 6.6 months to incident early-stage breast cancer diagnosis, and 8.7 months to first chemotherapy. High-income HDHP members had shorter delays that did not differ significantly from those of their low-income counterparts. HDHP members living in metropolitan, nonmetropolitan, predominantly white, and predominantly nonwhite areas also experienced delayed breast cancer care. Policies may be needed to reduce out-of-pocket spending obligations for breast cancer care.

18.
Pediatrics ; 143(2)2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30647089

RESUMO

BACKGROUND: Timely contraceptive initiation is increasingly common, yet population trends by method and among subgroups with increased risk of unintended pregnancy are not well described. The impact of timing and type of contraceptive initiation on risk of unwanted pregnancy is unknown. METHODS: We used nationally representative cross-sectional data from 4 cycles of the National Survey of Family Growth, 2002-2015. We calculated outcomes from self-reported dates of sexual debut, contraceptive initiation, and unwanted pregnancy. We compared trends in timely contraceptive initiation (within 1 month of sexual debut) by method and by race and/or ethnicity and income. Using multivariable regression, we identified predictors of delayed contraceptive initiation. We compared the risk of unwanted pregnancy for delayed versus timely contraceptive initiation. RESULTS: We analyzed responses from 26 359 women with sexual debuts in 1970-2014. One in 5 overall and 1 in 4 African American, Hispanic, or low-income respondents reported delayed contraceptive initiation, which was associated with unwanted pregnancy within 3 months of sexual debut (adjusted risk ratio 3.7 versus timely contraceptive initiation; 99.9% confidence interval: 2.3-5.9; P < .001). Timely contraceptive initiation with less effective versus effective methods was not associated with unwanted pregnancy within 3 months. CONCLUSIONS: Delayed contraceptive initiation is more common among African American, Hispanic, and low-income women and is strongly associated with short-term risk of unwanted pregnancy. Pediatricians play a key role in making timely contraception available to adolescents at or before sexual debut. More research is needed to understand the importance of early contraceptive methods on pregnancy risk.


Assuntos
Preservativos/tendências , Anticoncepção/tendências , Anticoncepcionais/administração & dosagem , Resultado da Gravidez/epidemiologia , Comportamento Sexual , Adolescente , Adulto , Anticoncepção/métodos , Estudos Transversais , Feminino , Humanos , Masculino , Gravidez , Autorrelato , Comportamento Sexual/efeitos dos fármacos , Inquéritos e Questionários , Fatores de Tempo , Estados Unidos/epidemiologia , Adulto Jovem
19.
Rev. saúde pública (Online) ; 53: 94, jan. 2019. tab, graf
Artigo em Inglês | LILACS-Express | ID: biblio-1043318

RESUMO

ABSTRACT OBJECTIVE To evaluate trends in the use of generic and non-generic medicines to treat hypertension and diabetes under the Farmácia Popular Program (FP) and its impact on generic medicines sales volume and market share in the Brazilian pharmaceutical market. METHODS This longitudinal, retrospective study used interrupted time series design to analyze changes in monthly sales volume and proportion of medicines sales (market share) for oral antidiabetic and antihypertensive medicines for generic versus non-generic products. Analyses were conducted in a combined dataset that aggregate monthly sales volumes from the Farmácia Popular program and from the QuintilesIMS™ (IQVIA) national market sales data from January 2007 to December 2012. The Farmácia Popular program phases analyzed included: a) 2009 reductions in medicines reference prices (AFP-II) and b) 2011 implementation of free medicines program for hypertension and diabetes, the Saúde não tem preço (SNTP - Health has no price). RESULTS Patterns of use for FP-covered antidiabetic and antihypertensive medicines were similar to their use in the market in general. After one year of the decreases in government subsidies in April 2010, market share of antidiabetic and antihypertensive medicines experienced relative declines of -54.5% and -59.9%, respectively. However, when FP-covered medicines were made free to patients, overall market volume for antidiabetic and antihypertensive generics increased dramatically, with 242.6% and 277.0% relative increases by February 2012, as well as non-generics with relative increase of 209.7% and 279% for antidiabetic and antihypertensive medicines, respectively. CONCLUSIONS Ministry of Health policies on the amount of patient cost sharing and on the choice of medicines on coverage lists have substantial impacts on overall generic sales volume in retail pharmacies.

20.
Popul Health Manag ; 22(3): 248-254, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30204544

RESUMO

Public and private insurers increasingly use quality payment programs as a tool to improve quality of care in primary care settings. However, little is known about primary care providers' perspectives on whether and how quality payment programs improve diabetes quality of care. In this qualitative study, the authors conducted semi-structured interviews and focus groups with 23 providers from March to June 2015. Transcripts were analyzed to identify key themes using the immersion-crystallization method. Almost all of the providers believed that insurers play a meaningful role in improving quality of care for diabetes patients. Most thought that insurers' efforts are more effective when channeled through providers and delivery systems rather than directed at patients. Providers generally believed that quality payment programs have had a positive impact on quality of diabetes care, although provider views were not evidence based. Providers in practices in which quality payment programs were believed to have had a positive impact stated that the programs provided financial incentives and resources for improved population health management systems and additional staff. Conversely, most providers did not believe that quality payment programs have had any impact via direct financial incentives to individual physicians. A few providers were skeptical about the impact of quality payment programs and noted negative consequences that they had observed. Providers recommended strategies to improve quality payment programs (eg, refine quality measures, provide regular feedback on quality and costs) and additional strategies that insurers could consider to address provider- and patient-level barriers to high-quality diabetes care.

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