Lower total cost of care in patients with diabetes on a SGLT2 vs GLP1 +/- metformin

BACKGROUND: Diabetes is the leading cost driver in nonspecialty spend for clients accounting for more than 14% of total drug spend. National treatment guidelines recommend metformin as the preferred initial first-line agent for patients with type 2 diabetes. Patients should be continued on metformin for as long as it is tolerated and not contraindicated. Guidelines suggest either a GLP1 or SGLT2 as second line agents for patients unable to reach glucose control after reaching maximally tolerated metformin. While both GLP1 and SGLT2 agents are recommended by ADA Guidelines for patients with ASCVD or indicators of high risk, and for patients to help minimize weight gain/promote weight loss, GLP1 agents have a higher monthly cost than SGLT2s. OBJECTIVE(S): To identify total cost of care in patients with diabetes on GLP1 vs SGLT2 +/- metformin. METHOD(S): A retrospective analysis using a subset of medical paid claims data of a large self-insured employer from 1.1.21 to 12.31.21 for patients either on GLP1, SGLT2, +/- metformin agents and diagnosis for diabetes was performed. Members continuously enrolled in the plan and at least 18 years of age, with 2 or more fills of either GLP1 or SGLT2 +/- metformin were included in the analysis. Total cost of care included medical and pharmacy claims. Patients with COVID or Oncology related hospitalizations were excluded and deemed outliers for total cost of care. A student's t-test was performed to compare mean total cost of care between SGLT2 +/- metformin only and GLP1 +/- metformin with significance level of 0.05. Effect size was determined used Cohen's d. RESULT(S): A total of 105 patients were identified. There were 54 patients (51%), 36 (67%) on metformin, and 34 male (63%) on SGLT2. There were 51 patients (49%), 45 (88%) on metformin, and 14 male (27%) on GLP1. Both groups had an average age of 54. The total cost of care for SGLT2 was $12,345, 95% CI [$8,560, $16,100] and GLP1 was $18,383, 95% CI [$14,600, $22,200], P < 0.05. Effect size was moderate, with Cohen's d value of 0.43. CONCLUSION(S): While GLP1 agents are considered to have beneficial effects on weight loss and slightly higher improvements in lowering A1c that may reduce total cost of care, a review of patients on either GLP1 or SGLT2 + /- metformin showed a significantly lower average total cost of care for patients on SGLT2. Diabetes is typically the number one non-specialty cost driver for plan sponsors. Selection of second-line agent in patients with diabetes should take into account the increased drug costs of GLP1 vs SGLT2, because GLP1 increased drug costs may not offset medical costs.

Small bowel obstruction caused by a fibrotic bow-string appendix: a consequence of non-operative management of acute appendicitis.

A 73-year-old woman presented with small bowel obstruction that failed to settle with conservative management. Over the previous 2 years she had presented twice with computed tomography scan-proven acute appendicitis with localised perforation of the appendix tip. In view of medical comorbidities, she was treated non-operatively with clinical and radiological resolution on each occasion, but on the third presentation laparoscopy was undertaken for non-resolving small bowel obstruction and the non-inflamed appendix itself was identified as a fibrous band causing compression of the distal ileum and complete small bowel obstruction. Following division and appendicectomy, the patient made an uneventful recovery. This case illustrates the potential consequence of repeated appendiceal inflammation and non-operative management and may be seen increasingly as this approach is widely adopted during the COVID-19 pandemic.

Inequality in mortality between Black and White Americans by age, place, and cause, and in comparison to Europe, 1990-2018

Although there is a large gap between Black and White American life expectancies, the gap fell 48.9% between 1990-2018, mainly due to mortality declines among Black Americans. We examine age-specific mortality trends and racial gaps in life expectancy in rich and poor U.S. areas and with reference to six European countries. Inequalities in life expectancy are starker in the U.S. than in Europe. In 1990 White Americans and Europeans in rich areas had similar overall life expectancy, while life expectancy for White Americans in poor areas was lower. But since then even rich White Americans have lost ground relative to Europeans. Meanwhile, the gap in life expectancy between Black Americans and Europeans decreased by 8.3%. Black life expectancy increased more than White life expectancy in all U.S. areas, but improvements in poorer areas had the greatest impact on the racial life expectancy gap. The causes that contributed the most to Black mortality reductions included: Cancer, homicide, HIV, and causes originating in the fetal or infant period. Life expectancy for both Black and White Americans plateaued or slightly declined after 2012, but this stalling was most evident among Black Americans even prior to the COVID-19 pandemic. If improvements had continued at the 1990-2012 rate, the racial gap in life expectancy would have closed by 2036. European life expectancy also stalled after 2014. Still, the comparison with Europe suggests that mortality rates of both Black and White Americans could fall much further across all ages and in both rich and poor areas.

Adapting to COVID19: Can virtual burn camp be as impactful as last year's in-person camp?

Introduction: Skin is not the only casualty following a burn accident. Many children suffer long term, debilitating emo-tional effects from their burn injury (Abdullah et al. 1994;Kornhaber et al. 2018). Armstrong-James et al. (2018) and Maslow and Lobato (2010) found that summer camps explic-itly designed for burn survivor children can positively impact children's adaptability to stares and comments and improve a summer camp for burn survivors for the past 25+ years. When the COVID19 pandemic closed many businesses, we decided to transition our in-person camp to 100% online. Researchers demonstrated the positive effects of summer camp for burn survivors (Maslow & Lobato, 2010;Bakker et al. 2011). However, the effects of a 100% online camp are not known. Our concern was, are we able to transition and be as impactful as it is face to face at camp? What will the schedule and activities look like in this new format? How will we ensure all children participating will have access to online and the supplies necessary?Methods: We opted to select a three-week format with two sessions a day divided into two age groups. We ensured every child had internet access then mailed out a “camp in the box.” It contained all the things needed for each planned activity. The critical question remained, however, will we be as impactful? The current research looks at quantitative and qualitative measures of self-esteem, happiness, and satisfac-tion following participation in a three-week summer program held in July 2020. We make comparisons to previous years' results. The authors expected that self-esteem, happiness, and satisfaction levels matched or exceeded last years' levels.Results: We collected data from 42 campers and 22 volun-teer camp counselors. Results show that campers were able to receive the support they needed, not only from the staff but also from their peers.Conclusions: The delivery method was indeed different this year, but the positive effect on our campers remained the same.

CLINICAL ORAL ABSTRACTS: Comparison of clinical outcomes among patients who did and did not have screening ultrasound or pelvic exam before obtaining medication abortion via direct-to-patient telemedicine and mail

Until recently, standard guidelines for provision of medication abortion (MA) required an ultrasound or pelvic exam be done prior to treatment to confirm intrauterine pregnancy and that the gestational age is within the recommended timeframe for outpatient MA. However, requiring these tests can introduce financial and logistical obstacles for patients. During the COVID-pandemic, use of "no test medication abortion" (NTMA) became more common, including in the TelAbortion study, a multicenter trial that provides MA by direct-to-patient telemedicine and mail. We compared clinical outcomes among study patients who had NTMA or who had an ultrasound or pelvic exam prior to MA. This prospective, observational study examined the association between use of screening ultrasound or pelvic exam and the occurrence of selected clinical events after MA. We included all participants in the TelAbortion study who were enrolled from March 25 to September 15, 2020 and who received services from a participating site that provided at least 2 NTMAs during the analysis period. The primary outcome was procedure abortion or ongoing pregnancy after MA. Other outcomes included a composite outcome of hospitalization and/or blood transfusion, ongoing pregnancy after MA, diagnosis of ectopic pregnancy after shipment of abortion medications, and receipt of clinical care after abortion medications were mailed. We compared outcomes for the 2 groups by calculating adjusted odds ratios (aORs) and corresponding 95% confidence intervals (CIs) using a logistic regression model with inverse probability weighting according to the propensity score and incorporating generalized estimating equations to adjust for clustering by study site. Propensity score weighting was done to increase comparability of the study groups with respect to age, race/ethnicity, prior pregnancies (any versus none), patient residence ≥150 miles from the study site, gestational age by date of last menstrual period, and whether patient used insurance to pay for the abortion service. We included 5 of the 9 participating TelAbortion sites. We analyzed outcomes among 384 TelAbortion patients, including 278 who had NTMA and 106 who had a screening ultrasound or pelvic exam before shipment of abortion medications. A procedure abortion or ongoing pregnancy after MA was reported for 16/278 (5.8%) NTMA patients compared to 2/106 (1.9%) patients who had screening ultrasound or pelvic exam (aOR = 3.23, 95% CI: 0.58–17.97). There were no diagnoses of ectopic pregnancy in either study group. Hospitalization and/or blood transfusion occurred in 2/276 (0.7%) and 1/106 (0.9%) of patients who had NTMA and screening ultrasound or pelvic exam, respectively (aOR = 1.13, 95% CI: 0.48–2.65). Ongoing pregnancy after MA was detected in 4/278 (1.4%) and 2/106 (1.9%) of patients who had NTMA and screening ultrasound or pelvic exam, respectively (aOR = 0.76, 95% CI: 0.08–7.16). More NTMA patients had unplanned clinical encounters after shipment of abortion medication (33/276, 12.0%) compared to patients who had screening ultrasound or pelvic exam (6/106, 5.7%, aOR = 2.91, 95% CI: 1.72–4.91). Of 264 patients who answered questions related to satisfaction, all 183 NTMA patients and 81 patients who had a screening ultrasound or pelvic exam reported being satisfied or very satisfied with the MA service. Individuals who obtain NTMA may be more likely to have a procedure abortion or ongoing pregnancy and have unplanned clinical encounters following MA compared to individuals who obtain a screening ultrasound or pelvic exam. However, NTMA was not associated with an increased risk of ongoing pregnancy or of hospitalization and/or blood transfusion. Moreover, more than 94% of NTMA patients had complete abortion without a procedural intervention. NTMA could increase access to MA without serious consequences for patient safety or satisfaction. [ABSTRACT FROM AUTHOR] Copyright of Contraception is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The Mental Health Effects of the First Two Months of Lockdown during the COVID-19 Pandemic in the UK*

In this paper, we estimate the effects of the COVID-19 pandemic on mental health in the UK. We use longitudinal micro data for the UK over the period 2009–20 to control for pre-existing trends in mental health and construct individual-specific counterfactual predictions for April 2020, against which the COVID-19 mental health outcomes can be assessed. Our analysis reveals substantial effects at the population level, approximately equal in magnitude to the pre-pandemic differences between the top and bottom quintiles of the income distribution. This overall effect was not distributed equally in the population – the pandemic had much bigger effects for young adults and for women, which are groups that already had lower levels of mental health before COVID-19. Hence inequalities in mental health have been increased by the pandemic. Even larger effects are observed for measures of mental health that capture the number of problems reported or the fraction of the population reporting any frequent or severe problems, which more than doubled. Pre-existing health vulnerabilities had no predictive power for subsequent changes in mental health. © 2020 The Authors. Fiscal Studies published by John Wiley & Sons Ltd. on behalf of Institute for Fiscal Studies