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1.
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 Health Serv Res ; 19(1): 422, 2019 Jun 25.
Artigo em Inglês | MEDLINE | ID: mdl-31238950

RESUMO

BACKGROUND: Medication non-adherence is a major contributor to poor outcomes in diabetes. Previous research has shown an association between use of mail order pharmacy delivery and better medication adherence, but little is known about the barriers and facilitators to mail order pharmacy use in diabetes patients. This qualitative study examined factors related to mail order pharmacy use versus traditional "brick and mortar" pharmacies to refill prescriptions. METHODS: We conducted four 90-min focus groups in 2016 among 28 diabetes patients in the Hawaii and Northern California regions of Kaiser Permanente, a large integrated health care delivery system. We queried participants on their preferred mode for refilling prescriptions and perceived barriers and facilitators of mail order pharmacy use. One researcher independently coded each focus group transcript, with two of these transcripts double-coded by a second researcher to promote reliability. We employed thematic analysis guided by the Capability, Opportunity, Motivation, and Behavior (COM-B) framework using NVivo 11 software. RESULTS: A total of 28 diabetes patients participated. Participants' average age was 64.1 years; 57% were female; and racial/ethnic backgrounds included Asian/Native Hawaiian/Pacific Islander (36%), Black/African-American (21%) Hispanic/Latino (7%), and non-Hispanic White (36%). Analysis uncovered 26 themes related to the decision to use mail order pharmacy, with each theme representing a barrier or facilitator mapped to the COM-B framework. Most themes (20/26) fell into the COM-B category of 'Opportunity.' Opportunity barriers to mail order pharmacy use included unpredictability of medication delivery date, concerns about mail security, and difficulty coordinating refill orders for multiple prescriptions. In contrast, facilitators included greater access and convenience (e.g., no need to wait in line or arrange transportation) compared to traditional pharmacies. Motivational facilitators to mail order pharmacy use included receiving a pharmacy benefit plan incentive of a free one-month supply of prescriptions. CONCLUSIONS: This study found that while patients with diabetes may benefit from mail order pharmacy use, they perceive numerous barriers to using the service. These findings will inform the design of interventions and quality improvement initiatives to increase mail order pharmacy use, which in turn may improve medication adherence and outcomes in diabetes patients, across health care systems.


Assuntos
Diabetes Mellitus/tratamento farmacológico , Hipoglicemiantes/uso terapêutico , Assistência Farmacêutica/estatística & dados numéricos , Serviços Postais/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , California , Feminino , Grupos Focais , Hawaii , Humanos , Masculino , Adesão à Medicação/estatística & dados numéricos , Pessoa de Meia-Idade , Pesquisa Qualitativa
4.
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.

5.
Med Care ; 57(4): 245-255, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30807450

RESUMO

BACKGROUND: Decades-long efforts to require parity between behavioral and physical health insurance coverage culminated in the comprehensive federal Mental Health Parity and Addiction Equity Act. OBJECTIVES: To determine the association between federal parity and changes in mental health care utilization and spending, particularly among high utilizers. RESEARCH DESIGN: Difference-in-differences analyses compared changes before and after exposure to federal parity versus a comparison group. SUBJECTS: Commercially insured enrollees aged 18-64 with a mental health disorder drawn from 24 states where self-insured employers were newly subject to federal parity in 2010 (exposure group), but small employers were exempt before-and-after parity (comparison group). A total of 11,226 exposure group members were propensity score matched (1:1) to comparison group members, all of whom were continuously enrolled from 1 year prepolicy to 1-2 years postpolicy. MEASURES: Mental health outpatient visits, out-of-pocket spending for these visits, emergency department visits, and hospitalizations. RESULTS: Relative to comparison group members, mean out-of-pocket spending per outpatient mental health visit declined among exposure enrollees by $0.74 (1.40, 0.07) and $2.03 (3.17, 0.89) in years 1 and 2 after the policy, respectively. Corresponding annual mental health visits increased by 0.31 (0.12, 0.51) and 0.59 (0.37, 0.81) per enrollee. Difference-in-difference changes were larger for the highest baseline quartile mental health care utilizers [year 2: 0.76 visits per enrollee (0.14, 1.38); relative increase 10.07%] and spenders [year 2: $-2.28 (-3.76, -0.79); relative reduction 5.91%]. There were no significant difference-in-differences changes in emergency department visits or hospitalizations. CONCLUSIONS: In 24 states, commercially insured high utilizers of mental health services experienced modest increases in outpatient mental health visits 2 years postparity.


Assuntos
Gastos em Saúde , Cobertura do Seguro/legislação & jurisprudência , Seguro Saúde/legislação & jurisprudência , Serviços de Saúde Mental/legislação & jurisprudência , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adulto , Feminino , Humanos , Masculino , Transtornos Mentais
6.
Hum Vaccin Immunother ; 15(7-8): 1708-1714, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30735462

RESUMO

Background. Health insurers are well-positioned to address low HPV vaccination coverage in the US through initiatives such as provider assessment and feedback. However, little is known about the feasibility of using administrative claims data to assess provider performance on vaccine delivery. Methods. We used administrative claims data from a regional health plan to estimate provider performance on the 2013-2015 Healthcare Effectiveness Data and Information Set (HEDIS) measure for HPV vaccine. This measure required that a girl receive three doses of HPV vaccine by age 13. Providers who administered ≥1 dose in a HEDIS-consistent series received credit for meeting the goal. Results. From January 2008-April 2015, 1,975 (8.5%) of 11-12 year-old girls in our sample received a HEDIS-consistent HPV vaccine series. Our sample of providers consisted of 1,236 who had ≥10 well-visits with different female patients, and 94% of these were pediatricians. A substantial minority of providers (39.4%) did not administer any HEDIS-consistent HPV vaccine doses. Only 5.5% of providers administered HPV vaccine doses that were part of a HEDIS-consistent series to at least one-quarter of their patients. These estimates did not vary by provider sex or age. Doses in a HEDIS-consistent vaccine series were often attributed to multiple providers. Conclusions. In a regional health plan, only 5.5% of providers in our sample administered doses that were part of a complete, three-dose HPV vaccine series to at least one-quarter of their 11-12 year-old female patients.


Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Pessoal de Saúde/estatística & dados numéricos , Planejamento em Saúde/estatística & dados numéricos , Vacinas contra Papillomavirus/administração & dosagem , Criança , Feminino , Humanos , Esquemas de Imunização , Masculino , Vacinação/estatística & dados numéricos
7.
Am J Emerg Med ; 37(6): 1037-1043, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30177266

RESUMO

OBJECTIVES: To describe recent trends in advanced imaging and hospitalization of emergency department (ED) syncope patients, both considered "low-value", and examine trend changes before and after the publication of American College Emergency Physician (ACEP) syncope guidelines in 2007, compared to conditions that had no changes in guideline recommendations. METHODS: We analyzed 2002-2015 National Hospital Ambulatory Medical Care Survey data using an interrupted-time series with comparison series design. The primary outcomes were advanced imaging among ED visits with principal diagnosis of syncope and headache and hospitalization for ED visits with principal diagnosis of syncope, chest pain, dysrhythmia, and pneumonia. We adjusted annual imaging and hospitalization rates using survey-weighted multivariable logistic regression, controlling for demographic and visit characteristics. Using adjusted outcomes as datapoints, we compared linear trends and trend changes of annual imaging and hospitalization rates before and after 2007 with aggregate-level multivariable linear regression. RESULTS: From 2002 to 2007, advanced imaging rates for syncope increased from 27.2% to 42.1% but had no significant trend after 2007 (trend change: -3.1%; 95%CI -4.7, -1.6). Hospitalization rates remained at approximately 37% from 2002 to 2007 but declined to 25.7% by 2015 (trend change: -2.2%; 95%CI -3.0, -1.4). Similar trend changes occurred among control conditions versus syncope, including advanced imaging for headache (difference in trend change: -0.6%; 95%CI -2.8, 1.6) and hospitalizations for chest pain, dysrhythmia, and pneumonia (differences in trend changes: 0.1% [95%CI -1.9, 2.0]; -0.9% [95%CI -3.1, 1.3]; and -1.2% [95%CI -5.3, 2.9], respectively). CONCLUSIONS: Before and after the release of 2007 ACEP syncope guidelines, trends in advanced imaging and hospitalization for ED syncope visits had similar changes compared to control conditions. Changes in syncope care may, therefore, reflect broader practice shifts rather than a direct association with the 2007 ACEP guideline. Moreover, utilization of advanced imaging remains prevalent. To reduce low-value care, policymakers should augment society guidelines with additional policy changes such as reportable quality measures.


Assuntos
Diagnóstico por Imagem/tendências , Síncope/diagnóstico , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Diagnóstico por Imagem/métodos , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/normas , Tratamento de Emergência/estatística & dados numéricos , Tratamento de Emergência/tendências , Feminino , Guias como Assunto , Hospitalização/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Qualidade da Assistência à Saúde/normas , Qualidade da Assistência à Saúde/estatística & dados numéricos , Síncope/terapia , Estados Unidos
8.
J Clin Gastroenterol ; 53(10): e424-e430, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30148764

RESUMO

BACKGROUND: Hepatitis B virus (HBV) screening during pregnancy is standard of care to prevent vertical transmission to infants, yet the mothers themselves may not receive appropriate follow-up. GOALS: Using a national database, we sought to determine rates of maternal peripartum follow-up with a HBV specialist and identify factors associated with a lack of follow-up. MATERIALS AND METHODS: We identified women who delivered in 2000 to 2012 and were diagnosed with HBV according to International Classification of Diseases-9 codes using a national database (Optum) derived from commercial insurance claims with ∼46 million members ages 0 to 64 in all 50 states. Our primary outcome was follow-up during or after pregnancy with a HBV specialist (gastroenterology/infectious diseases). RESULTS: The prevalence of HBV was 0.27% (2558/959,747 pregnancies), and median follow-up was 45 months. Only 21% of women had peripartum HBV specialist follow-up. On multivariable regression, predictors of peripartum follow-up at 1-year included younger age [odds ratio (OR), 0.97/y; 95% confidence interval (CI), 0.94, 0.99], Asian race/ethnicity (OR, 1.56 vs. white; 95% CI, 1.13, 2.17), and residing in the Northeast (OR, 1.70; 95% CI, 1.09, 2.66) and Midwest (OR, 1.73; 95% CI, 1.07, 2.81) versus West. Predictors of testing for HBV DNA and alanine aminotransferase at 1 year included Asian race (OR, 1.72; 95% CI, 1.23, 2.41), a primary care physician visit within 2 years of delivery (OR, 1.63; 95% CI, 1.19, 2.22), and peripartum HBV specialist follow-up within 1 year (OR, 15.68; 95% CI, 11.38, 21.60). CONCLUSIONS: Maternal HBV specialist follow-up rates were extremely low in this large, diverse cohort representing all United States regions. Referral to a HBV specialist was the strongest predictor of appropriate postpartum HBV laboratory testing. Follow-up rates may be even lower in uninsured populations.

9.
Ann Intern Med ; 169(12): 845-854, 2018 12 18.
Artigo em Inglês | MEDLINE | ID: mdl-30458499

RESUMO

Background: Little is known about the long-term effects of high-deductible insurance on care for chronic medical conditions. Objective: To determine whether a transition from low-deductible to high-deductible insurance is associated with delayed medical care for macrovascular complications of diabetes. Design: Observational longitudinal comparison of matched groups. Setting: A large national health insurer during 2003 to 2012. Participants: The intervention group comprised 33 957 persons with diabetes who were continuously enrolled in low-deductible (≤$500) insurance plans during a baseline year followed by up to 4 years in high-deductible (≥$1000) plans. The control group included 294 942 persons with diabetes who were enrolled in low-deductible plans contemporaneously with matched intervention group members. Intervention: Employer-mandated transition to a high-deductible plan. Measurements: The number of months it took for persons in each study group to seek care for their first major macrovascular symptom, have their first major diagnostic test for macrovascular disease, and have their first major procedure-based treatment was determined. Between-group differences in time to reach a midpoint event rate were then calculated. Results: No baseline differences were found between groups. During follow-up, the delay for the high-deductible group was 1.5 months (95% CI, 0.8 to 2.3 months) for seeking care for the first major symptom, 1.9 months (CI, 1.4 to 2.3 months) for the first diagnostic test, and 3.1 months (CI, 0.5 to 5.8 months) for the first procedure-based treatment. Limitation: Health outcomes were not examined. Conclusion: Among persons with diabetes, mandated enrollment in a high-deductible insurance plan was associated with delays in seeking care for the first major symptoms of macrovascular disease, the first diagnostic test, and the first procedure-based treatment. Primary Funding Source: National Institute of Diabetes and Digestive and Kidney Diseases.


Assuntos
Aterosclerose/terapia , Dedutíveis e Cosseguros , Angiopatias Diabéticas/terapia , Seguro Saúde/economia , Tempo para o Tratamento/economia , Adulto , Feminino , Humanos , Estudos Longitudinais , Masculino , Aceitação pelo Paciente de Cuidados de Saúde
10.
Health Aff (Millwood) ; 37(6): 964-974, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29863921

RESUMO

State prescription drug monitoring programs (PDMPs) aim to reduce risky controlled-substance prescribing, but early programs had limited impact. Several states implemented robust features in 2012-13, such as mandates that prescribers register with the program and regularly check its registry database. Some states allow prescribers to fulfill the latter requirement by designating delegates to check the registry. The effects of robust PDMP features have not been fully assessed. We used commercial claims data to examine the effects of implementing robust PDMPs in four states on overall and high-risk opioid prescribing, comparing those results to trends in similar states without robust PDMPs. By the end of 2014 the absolute mean morphine-equivalent dosages that providers dispensed declined in a range of 6-77 mg per person per quarter in the four states, relative to comparison states. Only in one of the four states, Kentucky, did the percentage of people who filled opioid prescriptions decline versus its comparator state, with an absolute reduction of 1.6 percent by the end of 2014. Robust PDMPs may be able to significantly reduce opioid dosages dispensed, percentages of patients receiving opioids, and high-risk prescribing.


Assuntos
Analgésicos Opioides/provisão & distribução , Uso de Medicamentos/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Padrões de Prática Médica , Programas de Monitoramento de Prescrição de Medicamentos/legislação & jurisprudência , Feminino , Humanos , Revisão da Utilização de Seguros , Cobertura do Seguro/economia , Kentucky , Estudos Longitudinais , Masculino , Missouri , New Mexico , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Medicamentos sob Prescrição/provisão & distribução , Desenvolvimento de Programas , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Tennessee , Estados Unidos
11.
Breast Cancer Res Treat ; 171(2): 449-459, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29855813

RESUMO

PURPOSE: High-deductible health plan (HDHP) enrollment is expanding rapidly and might substantially increase out-of-pocket (OOP) payment burden. We examined trends in total and OOP health service expenditures overall and by insurance coverage type among women with metastatic breast cancer. METHODS: We used a longitudinal time series design to examine measures among 5364 women with metastatic breast cancer insured by a large US health insurer from 2004 to 2011. We measured outcomes during the 12 months after a first identified metastatic breast cancer diagnosis and required women to have at least 6 months of prior enrollment. We plotted enrollment measures and adjusted total and OOP spending. We fit trend lines using linear autoregressive models. RESULTS: Between 2004 and 2011, the percentage of women with metastatic breast cancer enrolled in employer-mandated HDHPs increased from 8 to 23% while the percentage enrolled in employer-mandated low-deductible plans (LDHPs) decreased from 69 to 37%. Over the same time period, estimated annual inflation-adjusted total health service spending among women with metastatic breast cancer whose employers only offered HDHPs or LDHPS increased from $96,899 to $104,688 (increase of $1197 per year; 95% confidence interval [CI]: $47,$2,348). Corresponding OOP spending values among these women with employer-mandated deductible levels were $4,496 and $5,151 ($91 per year trend; 95% CI -$13,$195). From 2004-2011, women in HDHPs and LDHPs had unchanged annual OOP spending, estimated at of $6642 (95% CI $6,268,$7016) and $4,247 (95% CI $3956,$4538), respectively. Thus, women in HDHPs experienced 55% (44%, 66%) more OOP spending than women in LDHP. CONCLUSIONS: OOP spending among women with metastatic breast cancer and employer-mandated deductible levels was 55% higher among HDHP than LDHP members, and employer-mandated HDHP enrollment increased substantially from 2004 to 2011. Stakeholders and policymakers should design health plans that protect financially vulnerable cancer patients from high OOP costs.


Assuntos
Neoplasias da Mama/epidemiologia , Dedutíveis e Cosseguros , Gastos em Saúde , Cobertura do Seguro , Adulto , Idoso , Neoplasias da Mama/patologia , Custos e Análise de Custo , Feminino , Humanos , Seguro Saúde , Pessoa de Meia-Idade , Vigilância em Saúde Pública
12.
Breast Cancer Res Treat ; 171(1): 235-242, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29754304

RESUMO

OBJECTIVE: High-deductible health plans (HDHPs) have become the predominant commercial health insurance arrangement in the US. HDHPs require substantial out-of-pocket (OOP) costs for most services but often exempt medications from high cost sharing. We examined effects of HDHPs on OOP costs and utilization of adjuvant hormonal therapy (AHT), which are fundamental care for patients with breast cancer. METHODS: This controlled quasi-experimental study used claims data (2003-2012) from a large national health insurer. We included 986 women with incident early-stage breast cancer, age 25-64 years, insured by employers that mandated a transition from low-deductible (≤ $500/year) to high-deductible (≥ $1000/year) coverage, and 3479 propensity score-matched controls whose employers offered only low-deductible plans. We examined AHT utilization and OOP costs per person-year before and after the HDHP switch. RESULTS: At baseline, the OOP costs for AHT were $40.41 and $36.55 per person-year among the HDHP and control groups. After the HDHP switch, the OOP costs for AHT were $91.76 and $72.98 per person-year among the HDHP and control groups, respectively. AHT OOP costs increased among HDHP members relative to controls but the change was not significant (relative change 13.72% [95% CI - 9.25, 36.70%]). AHT use among HDHP members did not change compared to controls (relative change of 2.73% [95% CI - 14.01, 19.48%]); the change in aromatase inhibitor use was - 11.94% (95% CI - 32.76, 8.88%) and the change in tamoxifen use was 20.65% (95% CI - 8.01, 49.32%). CONCLUSION: We did not detect significant changes in AHT use after the HDHP switch. Findings might be related to modest increases in overall AHT OOP costs, the availability of low-cost generic tamoxifen, and patient awareness that AHT can prolong life and health. Minimizing OOP cost increases for essential medications might represent a feasible approach for maintaining medication adherence among HDHP members with incident breast cancer.


Assuntos
Neoplasias da Mama/epidemiologia , Dedutíveis e Cosseguros , Aceitação pelo Paciente de Cuidados de Saúde , Adulto , Idoso , Antineoplásicos Hormonais/uso terapêutico , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/tratamento farmacológico , Quimioterapia Adjuvante , Feminino , Gastos em Saúde , Humanos , Seguro Saúde , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Vigilância em Saúde Pública
14.
J Clin Oncol ; 36(11): 1121-1127, 2018 04 10.
Artigo em Inglês | MEDLINE | ID: mdl-29489428

RESUMO

Purpose High-deductible health plans (HDHPs) require substantial out-of-pocket spending and might delay crucial health services. Breast cancer treatment delays of as little as 2 months are associated with adverse outcomes. Methods We used a controlled prepost design with survival analysis to assess timing of breast cancer care events among 273,499 women age 25 to 64 years without evidence of breast cancer before inclusion. Women were included if continuously enrolled for 1 year in a low-deductible ($0 to $500) plan followed by up to 4 years in a HDHP (at least $1,000 deductible) after an employer-mandated switch. Study inclusion was on a rolling basis, and members were followed between 2003 and 2012. The comparison group comprised 2.4 million contemporaneously matched women whose employers offered only low-deductible plans. Measures were times to first diagnostic breast imaging (diagnostic mammogram, breast ultrasound, or breast magnetic resonance imaging), breast biopsy, incident early-stage breast cancer diagnosis, and breast cancer chemotherapy. Outcomes were analyzed by using Cox models and adjusted for age-group, morbidity score, poverty level, US region, index date, and employer size. Results After the index date, HDHP members experienced delays in receipt of diagnostic imaging (adjusted hazard ratio [aHR], 0.95; 95% CI, 0.94 to 0.96), biopsy (aHR, 0.92; 95% CI, 0.89 to 0.95), early-stage breast cancer diagnosis (aHR, 0.83; 0.78 to 0.90), and chemotherapy initiation (aHR, 0.79; 95% CI, 0.72 to 0.86) compared with the control group. Conclusion Women switched to HDHPs experienced delays in diagnostic breast imaging, breast biopsy, early-stage breast cancer diagnosis, and chemotherapy initiation. Additional research should determine whether such delays cause adverse health outcomes, and policymakers should consider selectively reducing out-of-pocket costs for key breast cancer services.


Assuntos
Neoplasias da Mama/economia , Neoplasias da Mama/terapia , Dedutíveis e Cosseguros/economia , Custos de Cuidados de Saúde , Gastos em Saúde , Cobertura do Seguro/economia , Seguro Saúde/economia , Tempo para o Tratamento/economia , Adulto , Biópsia/economia , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/mortalidade , Diagnóstico Tardio/economia , Detecção Precoce de Câncer/economia , Feminino , Humanos , Mamografia/economia , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Valor Preditivo dos Testes , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
15.
Curr Diab Rep ; 18(2): 8, 2018 02 05.
Artigo em Inglês | MEDLINE | ID: mdl-29399715

RESUMO

PURPOSE OF REVIEW: Diabetes incidence is rising among vulnerable population subgroups including minorities and individuals with limited education. Many diabetes-related programs and public policies are unevaluated while others are analyzed with research designs highly susceptible to bias which can result in flawed conclusions. The Natural Experiments for Translation in Diabetes 2.0 (NEXT-D2) Network includes eight research centers and three funding agencies using rigorous methods to evaluate natural experiments in health policy and program delivery. RECENT FINDINGS: NEXT-D2 research studies use quasi-experimental methods to assess three major areas as they relate to diabetes: health insurance expansion; healthcare financing and payment models; and innovations in care coordination. The studies will report on preventive processes, achievement of diabetes care goals, and incidence of complications. Some studies assess healthcare utilization while others focus on patient-reported outcomes. NEXT-D2 examines the effect of public and private policies on diabetes care and prevention at a critical time, given ongoing and rapid shifts in the US health policy landscape.


Assuntos
Complicações do Diabetes/prevenção & controle , Diabetes Mellitus/prevenção & controle , Política de Saúde , Pesquisa Médica Translacional , Animais , Humanos , Seguro Saúde/economia , Estados Unidos
16.
Diabetes Care ; 41(5): 940-948, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29382660

RESUMO

OBJECTIVE: High-deductible health plans (HDHPs) are now the predominant commercial health insurance benefit in the U.S. We sought to determine the effects of HDHPs on emergency department and hospital care, adverse outcomes, and total health care expenditures among patients with diabetes. RESEARCH DESIGN AND METHODS: We applied a controlled interrupted time-series design to study 23,493 HDHP members with diabetes, aged 12-64, insured through a large national health insurer from 2003 to 2012. HDHP members were enrolled for 1 year in a low-deductible (≤$500) plan, followed by 1 year in an HDHP (≥$1,000 deductible) after an employer-mandated switch. Patients transitioning to HDHPs were matched to 192,842 contemporaneous patients whose employers offered only low-deductible coverage. HDHP members from low-income neighborhoods (n = 8,453) were a subgroup of interest. Utilization measures included emergency department visits, hospitalizations, and total (health plan plus member out-of-pocket) health care expenditures. Proxy health outcome measures comprised high-severity emergency department visit expenditures and high-severity hospitalization days. RESULTS: After the HDHP transition, emergency department visits declined by 4.0% (95% CI -7.8, -0.1), hospitalizations fell by 5.6% (-10.8, -0.5), direct (nonemergency department-based) hospitalizations declined by 11.1% (-16.6, -5.6), and total health care expenditures dropped by 3.8% (-4.3, -3.4). Adverse outcomes did not change in the overall HDHP cohort, but members from low-income neighborhoods experienced 23.5% higher (18.3, 28.7) high-severity emergency department visit expenditures and 27.4% higher (15.5, 39.2) high-severity hospitalization days. CONCLUSIONS: After an HDHP switch, direct hospitalizations declined by 11.1% among patients with diabetes, likely driving 3.8% lower total health care expenditures. Proxy adverse outcomes were unchanged in the overall HDHP population with diabetes, but members from low-income neighborhoods experienced large, concerning increases in high-severity emergency department visit expenditures and hospitalization days.


Assuntos
Dedutíveis e Cosseguros , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/economia , Gastos em Saúde/estatística & dados numéricos , Seguro Saúde , Adolescente , Adulto , Criança , Estudos de Coortes , Dedutíveis e Cosseguros/economia , Dedutíveis e Cosseguros/estatística & dados numéricos , Diabetes Mellitus/epidemiologia , Diabetes Mellitus/terapia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Seguro Saúde/economia , Seguro Saúde/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pobreza , Características de Residência/estatística & dados numéricos , Adulto Jovem
17.
PLoS Med ; 14(11): e1002427, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-29135978

RESUMO

BACKGROUND: The 2012 Health and Social Care Act (HSCA) in England led to among the largest healthcare reforms in the history of the National Health Service (NHS). It gave control of £67 billion of the NHS budget for secondary care to general practitioner (GP) led Clinical Commissioning Groups (CCGs). An expected outcome was that patient care would shift away from expensive hospital and specialist settings, towards less expensive community-based models. However, there is little evidence for the effectiveness of this approach. In this study, we aimed to assess the association between the NHS reforms and hospital admissions and outpatient specialist visits. METHODS AND FINDINGS: We conducted a controlled interrupted time series analysis to examine rates of outpatient specialist visits and inpatient hospitalisations before and after the implementation of the HSCA. We used national routine hospital administrative data (Hospital Episode Statistics) on all NHS outpatient specialist visits and inpatient hospital admissions in England between 2007 and 2015 (with a mean of 26.8 million new outpatient visits and 14.9 million inpatient admissions per year). As a control series, we used equivalent data on hospital attendances in Scotland. Primary outcomes were: total, elective, and emergency hospitalisations, and total and GP-referred specialist visits. Both countries had stable trends in all outcomes at baseline. In England, after the policy, there was a 1.1% (95% CI 0.7%-1.5%; p < 0.001) increase in total specialist visits per quarter and a 1.6% increase in GP-referred specialist visits (95% CI 1.2%-2.0%; p < 0.001) per quarter, equivalent to 12.7% (647,000 over the 5,105,000 expected) and 19.1% (507,000 over the 2,658,000 expected) more visits per quarter by the end of 2015, respectively. In Scotland, there was no change in specialist visits. Neither country experienced a change in trends in hospitalisations: change in slope for total, elective, and emergency hospitalisations were -0.2% (95% CI -0.6%-0.2%; p = 0.257), -0.2% (95% CI -0.6%-0.1%; p = 0.235), and 0.0% (95% CI -0.5%-0.4%; p = 0.866) per quarter in England. We are unable to exclude confounding due to other events occurring around the time of the policy. However, we limited the likelihood of such confounding by including relevant control series, in which no changes were seen. CONCLUSIONS: Our findings suggest that giving control of healthcare budgets to GP-led CCGs was not associated with a reduction in overall hospitalisations and was associated with an increase in specialist visits.


Assuntos
Reforma dos Serviços de Saúde/tendências , Planejamento em Saúde/tendências , Hospitalização/tendências , Análise de Séries Temporais Interrompida/tendências , Medicina/tendências , Medicina Estatal/tendências , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Inglaterra/epidemiologia , Feminino , Reforma dos Serviços de Saúde/métodos , Planejamento em Saúde/métodos , Humanos , Lactente , Recém-Nascido , Análise de Séries Temporais Interrompida/métodos , Masculino , Medicina/métodos , Pessoa de Meia-Idade , Reino Unido/epidemiologia , Adulto Jovem
18.
JAMA Intern Med ; 177(11): 1577-1585, 2017 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-28973068

RESUMO

Importance: Clinicians who order unnecessary radiographic imaging may cause financial harm to patients who have increasing levels of cost sharing. Clinician predictors of low-value imaging are largely unknown. Objective: To characterize clinician predictors of low-value imaging for acute uncomplicated back pain and headache, including clinicians who saw both conditions. Design, Setting, and Participants: Multivariate logistic regression modeling of imaging rates after acute uncomplicated back pain and headache visits as indicated by January 2010 to December 2014 commercial insurance claims and demographic data from a large US health insurer. Participants included 100 977 clinicians (primary care physicians, specialist physicians, and chiropractors). Main Outcomes and Measures: Imaging after acute uncomplicated back pain and headache visits was recorded. We identified whether the clinician's prior patient received imaging, whether the clinician was an owner of imaging equipment, and the varying impact by clinician specialty. We then used high rates of low-value back imaging as a predictor for low-value headache imaging. Results: Clinicians conducted 1 007 392 visits for 878 720 adults ages 18 to 64 years with acute uncomplicated back pain; 52 876 primary care physicians conducted visits for 492 805 adults ages 18 to 64 years with acute uncomplicated headache; 34 190 primary care clinicians conducted 405 721 visits for 344 991 adults ages 18 to 64 years with headache and had also conducted at least 4 visits from patients with back pain. If a primary care physician's prior patient received low-value back imaging, the patient had 1.81 higher odds of low-value imaging (95% CI, 1.77-1.85). This practice effect was larger for chiropractors (odds ratio [OR], 2.80; 95% CI, 2.74-2.86) and specialists (OR, 2.98; 95% CI, 2.88-3.07). For headache, a prior low-value head image predicted 2.00 higher odds of a subsequent head imaging order (95% CI, 1.95-2.06). Clinician ownership of imaging equipment was a consistent independent predictor of low-value imaging (OR, 1.65-7.76) across clinician type and imaging scenario. Primary care physicians with the highest rates of low-value back imaging also had 1.53 (95% CI, 1.45-1.61) higher odds of ordering low-value headache imaging. Conclusions and Relevance: Clinician characteristics such as ordering low-value imaging on a prior patient, high rates of low-value imaging in another clinical scenario, and ownership of imaging equipment are strong predictors of low-value back and headache imaging. Findings should inform policies that target potentially unnecessary and financially burdensome care.


Assuntos
Diagnóstico por Imagem/economia , Cefaleia/diagnóstico por imagem , Dor Lombar/diagnóstico por imagem , Padrões de Prática Médica/estatística & dados numéricos , Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Melhoria de Qualidade , Estados Unidos
19.
JAMA Pediatr ; 171(8): 747-755, 2017 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-28628701

RESUMO

Importance: Opioid use disorder (OUD) frequently begins in adolescence and young adulthood. Intervening early with pharmacotherapy is recommended by major professional organizations. No prior national studies have examined the extent to which adolescents and young adults (collectively termed youth) with OUD receive pharmacotherapy. Objective: To identify time trends and disparities in receipt of buprenorphine and naltrexone among youth with OUD in the United States. Design, Setting, and Participants: A retrospective cohort study was conducted using deidentified data from a national commercial insurance database. Enrollment and complete health insurance claims of 9.7 million youth, aged 13 to 25 years were analyzed, identifying individuals who received a diagnosis of OUD between January 1, 2001, and June 30, 2014, with final follow-up date December 31, 2014. Analysis was conducted from April 25 to December 31, 2016. Time trends were identified and multivariable logistic regression was used to determine sociodemographic factors associated with medication receipt. Exposures: Sex, age, race/ethnicity, neighborhood education and poverty levels, geographic region, census region, and year of diagnosis. Main Outcomes and Measures: Dispensing of a medication (buprenorphine or naltrexone) within 6 months of first receiving an OUD diagnosis. Results: Among 20 822 youth diagnosed with OUD (0.2% of the 9.7 million sample), 13 698 (65.8%) were male and 17 119 (82.2%) were non-Hispanic white. Mean (SD) age was 21.0 (2.5) years at the first observed diagnosis. The diagnosis rate of OUD increased nearly 6-fold from 2001 to 2014 (from 0.26 per 100 000 person-years to 1.51 per 100 000 person-years). Overall, 5580 (26.8%) youth were dispensed a medication within 6 months of diagnosis, with 4976 (89.2%) of medication-treated youth receiving buprenorphine and 604 (10.8%) receiving naltrexone. Medication receipt increased more than 10-fold, from 3.0% in 2002 (when buprenorphine was introduced) to 31.8% in 2009, but declined in subsequent years (27.5% in 2014). In multivariable analyses, younger individuals were less likely to receive medications, with adjusted probability for age 13 to 15 years, 1.4% (95% CI, 0.4%-2.3%); 16 to 17 years, 9.7% (95% CI, 8.4%-11.1%); 18 to 20 years, 22.0% (95% CI, 21.0%-23.0%); and 21 to 25 years, 30.5% (95% CI, 30.0%-31.5%) (P < .001 for difference). Females (7124 [20.3%]) were less likely than males (13 698 [24.4%]) to receive medications (P < .001), as were non-Hispanic black (105 [14.8%]) and Hispanic (1165 [20.0%]) youth compared with non-Hispanic white (17 119 [23.1%]) youth (P < .001). Conclusions and Relevance: In this first national study of buprenorphine and naltrexone receipt among youth, dispensing increased over time. Nonetheless, only 1 in 4 commercially insured youth with OUD received pharmacotherapy, and disparities based on sex, age, and race/ethnicity were observed.


Assuntos
Buprenorfina/uso terapêutico , Naltrexona/uso terapêutico , Tratamento de Substituição de Opiáceos/tendências , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Adolescente , Estudos de Coortes , Feminino , Humanos , Masculino , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Prevalência , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
20.
Health Aff (Millwood) ; 36(4): 671-679, 2017 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-28373333

RESUMO

Choosing Wisely was launched by the American Board of Internal Medicine in April 2012 as a patient- and clinician-targeted campaign to reduce potentially unnecessary "low-value" medical services. The campaign's impact on low- and high-value care beyond its first year is unknown; furthermore, it is unknown whether some patients such as members of consumer-directed health plans and people residing in different US regions have responded more than others. To evaluate the impact of Choosing Wisely, we used commercial insurance claims to track changes in the use of low-value imaging (x-ray, computed tomography, and magnetic resonance imaging) for back pain before and after the campaign began, a period running from 2010 to 2014. We selected back pain imaging because it is a prominent target of Choosing Wisely, which considers it low value except in a minority of cases, because of its relatively high out-of-pocket expense, and the large volume of low back pain visits nationally. We found only a 4 percent relative reduction in low-value back imaging 2.5 years after the start of the campaign and some differences in regional trends, but no differences associated with enrollment in consumer-directed health plans. Our findings highlight the ongoing challenge of reducing unnecessary medical care, even when patients have "skin in the game" under consumer-directed health plans.


Assuntos
Dor nas Costas/diagnóstico por imagem , Comportamento de Escolha , Sobremedicalização/estatística & dados numéricos , Sobremedicalização/tendências , Adolescente , Adulto , Dor nas Costas/economia , Assistência à Saúde/economia , Feminino , Gastos em Saúde/tendências , Humanos , Masculino , Medicare , Pessoa de Meia-Idade , Estados Unidos
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