Comparison of healthcare resource utilization and costs in patients with type 2 diabetes initiating dapagliflozin versus sitagliptin.

AIMS: To compare healthcare costs and utilization in patients with type 2 diabetes (T2D) who initiated dapagliflozin (DAPA) with costs and utilization in those who initiated sitagliptin (SITA) in a real-world setting. MATERIALS AND METHODS: This was a retrospective study of health plan enrollees in two US commercial claims databases or Medicare Part D. The study population comprised adult patients with T2D who initiated DAPA or SITA between January 1, 2014 and April 30, 2015. DAPA and SITA initiators were propensity-score-matched, and healthcare utilization and costs during the 1-year follow-up period were compared. Analyses were conducted separately for patients with evidence of oral antidiabetic drug (OAD) monotherapy use at baseline. RESULTS: A total of 2722 patients were included in each matched cohort. Follow-up unadjusted all-cause costs ($16 065 and $17 281; P = 0.135) and diabetes-related costs ($9697 and $9354; P = 0.539) were similar in the DAPA and SITA cohorts. Higher office and outpatient visit costs in the SITA group were offset by higher pharmacy costs in the DAPA group. In the subgroup of 1804 patients with OAD monotherapy use at baseline, patients in the SITA group had higher total all-cause costs compared with those in the DAPA group ($14 884 vs. $12 353; P = 0.026). CONCLUSION: Patients who initiated DAPA or SITA had similar all-cause and diabetes-related healthcare costs over 1 year of follow-up. In the subgroup of patients treated with OAD monotherapy at baseline (84% metformin monotherapy), those who initiated DAPA as add-on therapy had lower costs than patients who added SITA.

Searching for the Smoker's Paradox in Acute Stroke Patients Treated With Intravenous Thrombolysis.

BACKGROUND: Inconsistent evidence supports better outcome in smokers after stroke. Our study examines this association in a large sample of ischemic stroke treated with intravenous thrombolysis. METHOD: Virtual International Stroke Trials Archive (VISTA) database, composed of individual patient data of multiple clinical trials, was queried. The primary outcome was functional independence at 3 months noted by modified Rankin Scale (mRS; a 7-point scale ranging from 0 [no deficit] to 6 [death]) score≤ 2. The secondary outcomes were National Institutes of Health Stroke Scale (NIHSS; stroke severity measure, ranging from 0 [no deficit] to 42 [most severe]) score at 24 hours and the occurrence of symptomatic intractracranial hemorrhage. RESULTS: A total of 5383 patients were included: 1501 current smokers and 3882 nonsmokers. Smokers were younger (60 ± 13 vs. 71 ± 12 years, p < .0001) and had lower median NIHSS score at baseline (12 [8-17] vs. 13 [9-18], p < .0001). The rate of favorable functional outcome (mRS ≤ 2) at 3 months was significantly higher among current smokers (49.7% vs. 39.5%, p < .0001) and with crude ORs of 1.52, 95% CI 1.33-1.72. The association became non-significant after adjusting for age (OR 1.11, 95% CI 0.97-1.27). Subgroup analysis by age/gender strata showed that current smoking was associated with favorable outcome only in women ≥ 65 years. Current smoking was also associated with lower rates of symptomatic intracranial hemorrhage (adjusted OR 0.55, 95% CI 0.39-0.79). CONCLUSION: Smokers experience their first ever stroke 11 years younger than nonsmokers. This age difference explains the association between current smoking and favorable functional outcome. IMPLICATIONS: Smoking is associated with occurrence of first ever stroke at a younger age, therefore, focus should be on smoking prevention and treatment. The decision to treat ischemic stroke patients with intravenous thrombolysis should not be influenced by the patients' smoking status.

Potential Misclassification of Blood Pressure Status in Children and Adolescents With Short or Tall Stature.

Blood pressure (BP) is measured in percentiles that are adjusted for sex, age, and height percentile in children and adolescents. Standard tables for the conversion of BP percentiles do not present exact BP percentile cutoffs for extremes in stature, either short (<5th percentile) or tall (>95th percentile). An algorithm can be used to calculate exact BP percentiles across a range of height z scores. We compared values from standard BP tables with exact calculations of BP percentiles to see which were better at identifying hypertension in more than 5,000 children with either short or tall stature. Study subjects were 3-17-year-old patients within HealthPartners Medical Group, an integrated health care delivery system in Minnesota, at any time between 2007 and 2012. Approximately half of the subjects who met the criteria for hypertension using exact calculation would be misclassified as normal using available thresholds in the published BP tables instead of the recommended algorithm, which was not included in the tables.

A Statewide Effort to Implement Collaborative Care for Depression: Reach and Impact for All Patients With Depression.

BACKGROUND: Little is known about the reach and impact of collaborative care for depression outside of clinical trials. OBJECTIVE: The objective of this study was to examine the effect of a collaborative care intervention for depression on the rates of depression diagnosis, use of specific depression codes, and treatment intensification. RESEARCH DESIGN: Evaluation of a staggered, multiple baseline implementation initiative. SUBJECTS: Patients receiving depression care in primary care clinics throughout Minnesota from February 2008 through March 2011. MEASURES: Data regarding depression diagnosis rates and codes, and measures of antidepressant intensification were provided by health insurers. RESULTS: Depression Improvement Across Minnesota: Offering a New Direction (DIAMOND) affected neither rates of depression recognition nor use of depression diagnostic codes, and the overall reach of DIAMOND was disappointingly small. Patients in DIAMOND had more episodes of treatment intensification than non-DIAMOND patients, but we were unable to account for depression severity in our analysis. CONCLUSIONS: DIAMOND did not affect depression recognition or diagnostic coding, but may have affected treatment intensification. Our results suggest that even strongly evidence-based interventions may have little contamination effects on patients not enrolled in the new care model.

Impact of Chest Wall Modifications and Lung Injury on the Correspondence Between Airway and Transpulmonary Driving Pressures.

OBJECTIVE: Recent interest has arisen in airway driving pressure (DP(AW)), the quotient of tidal volume (V(T)), and respiratory system compliance (C(RS)), which could serve as a direct and easily measured marker for ventilator-induced lung injury risk. We aimed to test the correspondence between DP(AW) and transpulmonary driving pressure (DP(TP))-the quotient of V(T) and lung compliance (C(L)), in response to intra-abdominal hypertension and changes in positive end-expiratory pressure during different models of lung pathology. DESIGN: Well-controlled experimental setting that allowed reversible modification of chest wall compliance (C(CW)) in a variety of models of lung pathology. SETTING: Large animal laboratory of a university-affiliated hospital. SUBJECTS: Ten deeply anesthetized swine. INTERVENTIONS: Application of intra-abdominal pressures of 0 and 20 cm H2O at positive end-expiratory pressure of 1 and 10 cm H2O, under volume-controlled mechanical ventilation in the settings of normal lungs (baseline), unilateral whole-lung atelectasis, and unilateral and bilateral lung injuries caused by saline lavage. MEASUREMENTS AND MAIN RESULTS: Pulmonary mechanics including esophageal pressure and calculations of DP(AW), DP(TP), C(RS), C(L), and C(CW). When compared with normal intra-abdominal pressures, intra-abdominal hypertension increased DP(AW), during both "normal lung conditions" (p < 0.0001) and "unilateral atelectasis" (p = 0.0026). In contrast, DP(TP) remained virtually unaffected by changes in positive end-expiratory pressure or intra-abdominal pressures in both conditions. During unilateral lung injury, both DPA(W) and DP(TP) were increased by the presence of intra-abdominal hypertension (p < 0.0001 and p = 0.0222, respectively). During bilateral lung injury, intra-abdominal hypertension increased both DP(AW) (at positive end-expiratory pressure of 1 cm H2O, p < 0.0001; and at positive end-expiratory pressure of 10 cm H2O, p = 0.0091) and DP(TP) (at positive end-expiratory pressure of 1 cm H2O, p = 0.0510; and at positive end-expiratory pressure of 10 cm H2O, p = 0.0335). CONCLUSIONS: Our data indicate that DP(AW) is influenced by reductions in chest wall compliance and by underlying lung properties. As with other measures of pulmonary mechanics that are based on unmodified P(AW), caution is advised in attempting to attribute hazard or safety to any specific absolute value of DP(AW).

A qualitative study of processes used to implement evidence-based care in a primary care practice.

BACKGROUND: Evidence-based guidelines for care of coronary heart disease patients are not fully implemented. Primary care practices provide most of the care for these patients. OBJECTIVE: To learn how providers and staff in a busy primary care practice implement interventions to provide evidence-based care of coronary heart disease patients. METHODS: We conducted a qualitative analysis of the responses to open-ended questions in nine electronically administered bimonthly surveys of key physicians, clinic staff and managers in the practice. RESULTS: Ten to 16 (mean=12.3) personnel responded to each survey. Nearly 30% were physicians and 40.5% were clinic staff. Four major themes emerged from the qualitative analysis: (i) giving data about not-at-goal patients to providers for care plan development; (ii) developing team roles and defining tasks; (iii) providing patient care and implementing care plans and (iv) providing technology support to generate useful, accurate data. The frequency that the subthemes were mentioned varied from survey to survey, but their mention persisted over the entire time of all nine surveys. CONCLUSIONS: Developing a system for implementing evidence-based care involves considerations of roles and teamwork, technology use to develop a patient registry and obtain needed clinical data, care processes for pre-visit planning, and between-visit care management. A registered nurse care manager is a central figure in implementing and sustaining the process. Implementing evidence-based guidelines is an ongoing process of revision, retraining and reinforcement.

Factors Associated With Adherence to Blood Pressure Measurement Recommendations at Pediatric Primary Care Visits, Minnesota and Colorado, 2007-2010.

INTRODUCTION: Elevated blood pressure in childhood may predict increased cardiovascular risk in young adulthood. The Task Force on the Diagnosis, Evaluation and Treatment of High Blood pressure in Children and Adolescents recommends that blood pressure be measured in children aged 3 years or older at all health care visits. Guidelines from both Bright Futures and the Expert Panel of Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents recommend annual blood pressure screening. Adherence to these guidelines is unknown. METHODS: We conducted a cross-sectional study to assess compliance with blood pressure screening recommendations in 2 integrated health care delivery systems. We analyzed electronic health records of 103,693 subjects aged 3 to 17 years. Probability of blood pressure measurement documented in the electronic health record was modeled as a function of visit type (well-child vs nonwell-child); patient age, sex, race/ethnicity, and body mass index; health care use; insurance type; and type of office practice or clinic department (family practice or pediatrics). RESULTS: Blood pressure was measured at 95% of well-child visits and 69% of nonwell-child outpatient visits. After adjusting for potential confounders, the percentage of nonwell-child visits with measurements increased linearly with patient age (P < .001). Overall, the proportion of children with annual blood pressure measurements was high and increased with age. Family practice clinics were more likely to adhere to blood pressure measurement guidelines compared with pediatric clinics (P < .001). CONCLUSION: These results show good compliance with recommendations for routine blood pressure measurement in children and adolescents. Findings can inform the development of EHR-based clinical decision support tools to augment blood pressure screening and recognition of prehypertension and hypertension in pediatric patients.

Initiation of oral contraceptives and changes in blood pressure and body mass index in healthy adolescents.

OBJECTIVES: To describe changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), and body mass index (BMI) associated with initiation and continued use of combined oral contraceptives (COCs) in healthy adolescents. STUDY DESIGN: This observational, matched cohort study was conducted in 2 large health systems. Utilizing claims and electronic medical records, we identified adolescents 14-17.9 years of age initiating medium-dose COCs (containing 30 or 35 (µg of ethinyl estradiol or equivalent and a progestin) between July 1, 2007 and December 31, 2009 with a baseline and at least 1 follow-up blood pressure (BP) and BMI. COC-users were matched 1:2 by age, race/ethnicity, and site to controls (COC-nonusers). All BPs and BMIs recorded during outpatient visits starting 1 month prior to COC initiation (index date for controls), through December 31, 2010 were collected. Mixed model linear regression with random intercepts and slopes were then used to estimate changes in SBP, DBP, and BMI over time. RESULTS: The 510 adolescent COC-users and 912 controls did not differ significantly by age, race/ethnicity, insurance, and baseline SBP, DBP, or BMI. After adjusting for baseline values, over a median of 18 months follow-up, COC-users had an decrease in SBP of 0.07 mm Hg/mo, and controls had an increase of 0.02 mm Hg/mo (P = .65). Similarly, DBP decreased by 0.007 mm Hg/mo in COC-users vs 0.006 mm Hg/mo in controls (P = .99). BMI increased by 0.04 (kg/m(2))/mo in COC-users vs 0.025 (kg/m(2))/mo in controls (P = .09). CONCLUSIONS: These data should provide reassurance to patients and providers regarding the lack of significant associations between COC-use and BMI or BP changes in adolescents.

Economic Costs of Diabetes in the U.S. in 2022.

OBJECTIVE: This study updates previous estimates of the economic burden of diagnosed diabetes, with calculation of the health resource use and indirect costs attributable to diabetes in 2022. RESEARCH DESIGN AND METHODS: We combine the demographics of the U.S. population in 2022 with diabetes prevalence, from national survey data, epidemiological data, health care cost data, and economic data, into a Cost of Diabetes Economic Model to estimate the economic burden at the population and per capita levels. Health resource use and associated medical costs are analyzed by age, sex, race/ethnicity, comorbid condition, and health service category. Data sources include national surveys (2015-2020 or most recent available), Medicare standard analytic files (2020), and administrative claims data from 2018 to 2021 for a large commercially insured population in the U.S. RESULTS: The total estimated cost of diagnosed diabetes in the U.S. in 2022 is $412.9 billion, including $306.6 billion in direct medical costs and $106.3 billion in indirect costs attributable to diabetes. For cost categories analyzed, care for people diagnosed with diabetes accounts for 1 in 4 health care dollars in the U.S., 61% of which are attributable to diabetes. On average people with diabetes incur annual medical expenditures of $19,736, of which approximately $12,022 is attributable to diabetes. People diagnosed with diabetes, on average, have medical expenditures 2.6 times higher than what would be expected without diabetes. Glucose-lowering medications and diabetes supplies account for ∼17% of the total direct medical costs attributable to diabetes. Major contributors to indirect costs are reduced employment due to disability ($28.3 billion), presenteeism ($35.8 billion), and lost productivity due to 338,526 premature deaths ($32.4 billion). CONCLUSIONS: The inflation-adjusted direct medical costs of diabetes are estimated to rise 7% from 2017 and 35% from 2012 calculations (stated in 2022 dollars). Following decades of steadily increasing prevalence of diabetes, the overall estimated prevalence in 2022 remains relatively stable in comparison to 2017. However, the absolute number of people with diabetes has grown and contributes to increased health care expenditures, particularly per capita spending on inpatient hospital stays and prescription medications. The enormous economic toll of diabetes continues to burden society through direct medical and indirect costs.

Influenza and pertussis vaccination coverage among privately insured women of reproductive age.

An increasing number of vaccines are now designated as maternal vaccines, recommended prior to, during, or immediately following pregnancy. The influenza and pertussis (Tdap) vaccines have the potential to improve the health of women and their offspring. Among privately insured women of reproductive age, goals of this study were to describe influenza and Tdap vaccination coverage and to explore variation in coverage by age and race/ethnicity. This cross-sectional, observational study included women 18-44 years of age with continuous enrollment from 1 January 2007-31 March 2011 in a single, Midwestern health insurance plan and at least one visit to a plan affiliated practice. Data on vaccine coverage came from insurance claims, supplemented by electronic medical record data. Primary outcomes were: receipt of Tdap ever, receipt of Tdap or Tetanus vaccination (Td) in the past 10 years, and receipt of influenza vaccination during the 2010-2011 influenza season. Coverage was compared by race/ethnicity. Among 12,657 women with continuous private insurance, 45.5 % had received Tdap ever, 82.5 % had received Td or Tdap in the past 10 years, and 39.8 % received the influenza vaccine in the 2010-2011 season. Marked disparities in influenza vaccination coverage by race/ethnicity were observed, only 30.0 % of African American women received influenza vaccine compared to 40.7 % of white, non-Hispanic women (p < .0001). Among insured women of reproductive age, there is a need for interventions to increase Tdap and influenza vaccination uptake. Further research is needed to understand and address disparities in influenza vaccination coverage in this population.

The relationship of area-level sociodemographic characteristics, household composition and individual-level socioeconomic status on walking behavior among adults.

Understanding the contextual factors associated with why adults walk is important for those interested in increasing walking as a mode of transportation and leisure. This paper investigates the relationships between neighborhood-level sociodemographic context, individual level sociodemographic characteristics and walking for leisure and transport. Data from two community-based studies of adults (n=550) were used to determine the association between the area-sociodemographic environment (ASDE), calculated from U.S. Census variables, and individual-level SES as potential correlates of walking behavior. Descriptive statistics, mean comparisons and Pearson's correlations coefficients were used to assess bivariate relationships. Generalized estimating equations were used to model the relationship between ASDE, as quartiles, and walking behavior. Adjusted models suggest adults engage in more minutes of walking for transportation and less walking for leisure in the most disadvantaged compared to the least disadvantaged neighborhoods but adding individual level demographics and SES eliminated the significant results. However, when models were stratified for free or reduced cost lunch, of those with children who qualified for free or reduced lunch, those who lived in the wealthiest neighborhoods engaged in 10.7 minutes less of total walking per day compared to those living in the most challenged neighborhoods (p<0.001). Strategies to increase walking for transportation or leisure need to take account of individual level socioeconomic factors in addition to area-level measures.

Role of prices in driving the variation in spending across medical groups.

OBJECTIVE: To understand the relative role of prices versus utilization in the variation in total spending per patient across medical groups. DATA SOURCES: We conducted a cross-sectional analysis of medical claims for commercially insured adults from a large national insurer in 2018. STUDY DESIGN: After assigning patients to a medical group based on primary care visits in 2018, we calculated total medical spending for each patient in that year. Total spending included care provided by clinicians within the medical group and care provided by other providers, including hospitals. It did not include drug spending. We estimated the case mix adjusted spending per patient for each medical group. Within each market, we categorized medical groups into quartiles based on the group's spending per patient. To decompose spending variation into price versus utilization, we compared spending differences between highest and lowest quartile medical groups under two scenarios: (1) using actual prices (2) using a standardized price (same price used for a given service across the nation). PRINCIPAL FINDINGS: In total, 3,921,736 patients were assigned to 7284 medical groups. Per-patient spending in the highest quartile of spending medical groups was $1813 higher than per-patient spending in the lowest spending quartile of medical groups (50% higher relative spending). This overall difference was primarily driven by differences in inpatient care, imaging, and specialty care. In the scenario where we used standardized prices, the difference in spending between medical groups in the top and bottom quartiles decreased to $1425, implying that 79% of the $1813 difference in spending between the top and bottom quartile groups is explained by utilization and the remaining 21% by prices. The likely explanation for the modest impact of prices is that patients cared for by a given medical group receive care across a wide range of providers. CONCLUSIONS: Prices explained a modest fraction of the differences in spending between medical groups.

Treatment modification after initiating second-line medication for type 2 diabetes.

OBJECTIVES: To describe changes in antidiabetic medication (ADM) use and characteristics associated with changes in ADM use after initiation of noninsulin second-line therapy. STUDY DESIGN: Retrospective cohort study. METHODS: This study analyzed private health plan claims for adults with type 2 diabetes who initiated 1 of 5 index ADM classes: sulfonylureas, dipeptidyl peptidase 4 inhibitors (DPP4is), sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RAs), or thiazolidinediones. Analyses evaluated 3 treatment modification outcomes-discontinuation, switching, and intensification-over 12-month follow-up. RESULTS: Of 82,624 included adults, nearly two-thirds (63.6%) experienced any treatment modification. Discontinuation was the most common modification (38.6%), especially among patients prescribed GLP-1 RAs (50.3%). Switching occurred in 5.2% of patients and intensification in 19.8%. In adjusted analysis, compared with patients prescribed sulfonylureas, discontinuation risk was 7% higher (HR, 1.07; 95% CI, 1.04-1.10) among patients prescribed DPP4is and 28% higher (HR, 1.28; 95% CI, 1.23-1.33) among patients prescribed GLP-1 RAs. Compared with sulfonylureas, all other index ADM classes had higher risks of switching and lower risks of intensification. Younger age group and female sex were both associated with higher risks of all modifications. Compared with index ADM prescription by a family medicine or internal medicine physician, index prescription by an endocrinologist was associated with both lower discontinuation risk and higher intensification risk. CONCLUSIONS: Most patients experienced a treatment modification within 1 year. Results highlight the need for new prescribing approaches and patient supports that can maximize medication adherence and reduce health system waste.

Accuracy of heart disease prevalence estimated from claims data compared with an electronic health record.

INTRODUCTION: We developed a decision support tool that can guide the development of heart disease prevention programs to focus on the interventions that have the most potential to benefit populations. To use it, however, users need to know the prevalence of heart disease in the population that they wish to help. We sought to determine the accuracy with which the prevalence of heart disease can be estimated from health care claims data. METHODS: We compared estimates of disease prevalence based on insurance claims to estimates derived from manual health records in a stratified random sample of 480 patients aged 30 years or older who were enrolled at any time from August 1, 2007, through July 31, 2008 (N = 474,089) in HealthPartners insurance and had a HealthPartners Medical Group electronic record. We compared randomly selected development and validation samples to a subsample that was also enrolled on August 1, 2005 (n = 272,348). We also compared the records of patients who had a gap in enrollment of more than 31 days with those who did not, and compared patients who had no visits, only 1 visit, or 2 or more visits more than 31 days apart for heart disease. RESULTS: Agreement between claims data and manual review was best in both the development and the validation samples (Cohen's κ, 0.92, 95% confidence interval [CI], 0.87-0.97; and Cohen's κ, 0.94, 95% CI, 0.89-0.98, respectively) when patients with only 1 visit were considered to have heart disease. CONCLUSION: In this population, prevalence of heart disease can be estimated from claims data with acceptable accuracy.

Obesogenic family types identified through latent profile analysis.

BACKGROUND: Obesity may cluster in families due to shared physical and social environments. PURPOSE: This study aims to identify family typologies of obesity risk based on family environments. METHODS: Using 2007-2008 data from 706 parent/youth dyads in Minnesota, we applied latent profile analysis and general linear models to evaluate associations between family typologies and body mass index (BMI) of youth and parents. RESULTS: Three typologies described most families with 18.8% "Unenriched/Obesogenic," 16.9% "Risky Consumer," and 64.3% "Healthy Consumer/Salutogenic." After adjustment for demographic and socioeconomic factors, parent BMI and youth BMI Z-scores were higher in unenriched/obesogenic families (BMI difference = 2.7, p < 0.01 and BMI Z-score difference = 0.51, p < 0.01, respectively) relative to the healthy consumer/salutogenic typology. In contrast, parent BMI and youth BMI Z-scores were similar in the risky consumer families relative to those in healthy consumer/salutogenic type. CONCLUSIONS: We can identify family types differing in obesity risks with implications for public health interventions.

Variation in spending associated with primary care practices.

OBJECTIVES: To measure variation in spending and inpatient prices associated with the primary care physician (PCP) practice to which patients are attributed. STUDY DESIGN: Cross-sectional analysis of claims data. METHODS: We used random effect models to estimate case mix-adjusted spending across large PCP practices within 3-digit zip codes. We compare inpatient prices for patients in high-spending practices with those in low-spending practices. RESULTS: The physician practice to which a patient was attributed is associated with significant differences in spending after controlling for patient comorbidities and geography. Patients attributed to practices in the top quartile of total medical expenses have about 30% higher spending than patients attributed to practices in the bottom quartile of adjusted spending in their 3-digit zip code. If patients attributed to practices in the top 2 quartiles had spending equivalent to those in the median practice, total spending would drop by 8%. Price variation accounts for a meaningful amount of the variation, with inpatient prices 17% higher in top-quartile vs bottom-quartile practices. We cannot disaggregate the large variation in utilization into practice patterns and unmeasured case mix (including unmeasured differences in patients' socioeconomic status) vs random health shocks, but correlation in spending patterns across years suggests that some persistent differences in spending patterns exist. CONCLUSIONS: There are meaningful opportunities to reduce spending by changing patient PCP selection, encouraging patients to use lower-priced specialists and hospitals, and eliminating wasteful care. Attention must be paid to the best ways to reap these savings.

Costs for commercially insured adults prescribed second-line diabetes medications.

OBJECTIVES: To examine differences in health care costs associated with choice of second-line antidiabetes medication (ADM) for commercially insured adults with type 2 diabetes. STUDY DESIGN: Retrospective cohort study with multiple pretests and posttests. METHODS: Included patients initiated second-line ADM therapy between 2011 and 2015, with variable follow-up through 2017. The 6 index medication classes were sulfonylureas, dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RAs), basal insulin, sodium-glucose cotransporter-2 (SGLT-2) inhibitors, and thiazolidinediones (TZDs). Multivariable regression models compared between-class changes in adjusted quarterly costs after second-line ADM initiation. RESULTS: The study cohort included 34,963 adults. Most were prescribed a sulfonylurea (46.0%) or DPP-4 inhibitor (30.4%). Adjusted quarterly index medication costs were significantly higher for all patients receiving nonsulfonylurea medications, ranging from $108 (95% CI, $99-$118) for TZDs to $742 (95% CI, $720-$765) for GLP-1 RAs. Changes in quarterly total health care costs were significantly higher for all nonsulfonylurea classes. Conversely, changes in quarterly nonpharmacy medical costs were significantly lower for patients receiving DPP-4 inhibitors (-$67; 95% CI, -$92 to -$43), GLP-1 RAs (-$43; 95% CI, -$85 to -$1), and SGLT-2 inhibitors (-$46; 95% CI, -$87 to -$6); changes in all other quarterly costs besides the index medication were significantly lower for patients receiving DPP-4 inhibitors (-$60; 95% CI, -$94 to -$26) and SGLT-2 inhibitors (-$113; 95% CI, -$169 to -$57). CONCLUSIONS: The higher cost of nonsulfonylurea medications was the main driver of relative increases in total costs. Relative decreases in nonpharmacy medical costs among patients receiving newer ADM classes reflect these medications' potential value.

Adolescent primary care visit patterns.

PURPOSE: Many clinical preventive care services are recommended for adolescents. Little is known about whether most adolescents have a sufficient number of preventive care services visits over time to receive those services. We wanted to measure how frequently adolescents who are insured either through private insurance or government programs have preventive vs nonpreventive care visits. METHODS: We conducted a retrospective descriptive analysis based on claims data from a large health plan in Minnesota with about 700,000 members. All study patients were aged 11 to 18 years between January 1, 1998, and December 31, 2007. Our outcome measure was rates of preventive and nonpreventive care visits. RESULTS: One-third of adolescents with 4 or more years of continuous enrollment had no preventive care visits from age 13 through 17 years, and another 40% had only a single such visit. Nonpreventive care visits were more frequent in all age-groups, averaging about 1 per year at age 11 years, climbing to about 1.5 per year at age 17 years. Differences in rates between government insurance and commercial insurance were small. In older adolescence, girls had more preventive care visits and more nonpreventive care visits than did boys. CONCLUSIONS: Most adolescents come in infrequently for preventive care visits but more often for nonpreventive care visits. We recommend using the same approach in adolescence for preventive care that is being used in adults: the no-missed-opportunities paradigm. All visits by adolescents should be viewed as an opportunity to provide preventive care services, and systems should be set up to make that possible, even in busy practices with short encounters with a clinician.

A surveillance source of tobacco use differences among immigrant populations.

INTRODUCTION: Tobacco use disproportionately affects some ethnic minority populations. Important gains in understanding the relationship between acculturation and tobacco use have been hindered by the lack of available data, large samples of specific immigrant groups. This study is among the first to use electronic medical record (EMR) data to examine differences in tobacco use associated with acculturation among various population groups. METHODS: Relevant variables for all medical group patients aged 18 years and older with clinician visits were extracted from the EMR of one large medical group from March 2006 to February 2007. Preferred language and country of origin data from the EMR were used to create distinct cultural groupings. Adjusted prevalences were computed. RESULTS: One hundred thousand [corrected] three hundred [corrected] twenty nine patients reported [corrected] languages as English, Hmong, Vietnamese, Oromo, Amharic, Somali, and Spanish and were categorized as U.S. born or non-U.S. born. After adjusting for age, utilization, and insurance status, more acculturated Mexican and Hmong women were more likely to be tobacco users compared with less acculturated women. Among non-English speaking, current tobacco use was more prevalent among men compared with women. DISCUSSION: Interpreted language and country of origin data collected in a clinical setting were useful for describing tobacco use differences between and within cultural groups. Using preferred language and country of origin as a proxy for acculturation status may help understand some of the within and between cultural differences in tobacco use. These novel data sources have potential usefulness for tobacco surveillance of relatively small cultural groups.

Disparities in tobacco cessation medication orders and fills among special populations.

BACKGROUND: There is considerable interest in measuring and eliminating health care disparities among various special populations, but there is limited understanding of their extent, causes, or potential remedies. To improve this for tobacco cessation, we measured differences in the frequency of receiving and filling cessation medication prescriptions by race, ethnicity, age, language preference, health insurance, and pregnancy. METHODS: The relevant variables for all patients of a Minnesota medical group aged 18 years and older with clinician visits were extracted from the electronic medical records of 1 large medical group from March 2006 to February 2007. This was combined with claims data from 1 insurance plan that covered most of these individuals. Order and fill rates for cessation medications were then adjusted for each of the other variables. RESULTS: There were 32,733 current users of tobacco, 18,047 of whom had both health insurance and pharmacy claims data available. After adjustment, 15.4% overall had received an order for cessation medications during this year, but only 78% had filled it. Groups receiving fewer orders than their comparison groups were aged 18-34 years or older than 65 years, men, pregnant women, Asians and Hispanics, and those with non-English-language preference, on Medicaid, or with fewer visits. The same groups were less likely to fill that prescription, except patients with non-English preference or Medicaid. DISCUSSION: There are disparities in both the receipt of cessation medication orders and the likelihood of filling them for some special populations. The causes are likely to be complex, but this information provides a starting point for learning to improve this problem.