Dispensing of Ivermectin From Veterans Administration Pharmacies During the COVID-19 Pandemic.

This cohort study compares changes in ivermectin dispensing during the COVID-19 pandemic between the Veterans Administration (VA) and retail pharmacy settings and examines the association of the VA national formulary restriction with ivermectin dispensing.

Out-of-pocket spending for health care after COVID-19 hospitalization.

OBJECTIVES: Many patients report financial stress following hospitalization for COVID-19. Although many COVID-19 survivors require extensive care after discharge, the degree to which this care contributes to financial stress is unclear. Using national data, we assessed out-of-pocket spending during the 180 days after discharge among patients hospitalized for COVID-19. STUDY DESIGN: Retrospective cohort analysis of Optum's deidentified Clinformatics Data Mart, a national database of medical and pharmacy claims. METHODS: Among privately insured and Medicare Advantage patients hospitalized for COVID-19 between March and June 2020, we calculated median out-of-pocket spending during the 180 days after discharge. For comparison, we repeated this calculation among patients hospitalized for pneumonia. RESULTS: Of 7932 patients with COVID-19 included in analyses, 2061 (26.0%) had private insurance. Among privately insured and Medicare Advantage patients, median (25th-75th percentile) out-of-pocket spending after discharge was $287 ($59-$842) and $271 ($63-$783), respectively. Out-of-pocket spending exceeded $2000 for 10.9% and 9.3% of these patients, respectively. Among privately insured and Medicare Advantage patients hospitalized for pneumonia, median (25th-75th percentile) out-of-pocket spending after discharge was $276 ($62-$836) and $570 ($181-$1466). Out-of-pocket spending exceeded $2000 for 12.1% and 17.2% of these patients, respectively. CONCLUSIONS: For most patients hospitalized for COVID-19, postdischarge care may not be a major source of financial stress. Although this is reassuring, our findings also suggest that a sizable minority of COVID-19 survivors have substantial out-of-pocket spending after discharge. These survivors could be particularly vulnerable to financial toxicity if they also receive bills for the hospitalization owing to the expiration of insurer cost-sharing waivers. Insurers should consider this possibility when deciding whether to reinstate cost-sharing waivers for COVID-19 hospitalizations.

Association Between Default Number of Opioid Doses in Electronic Health Record Systems and Opioid Prescribing to Adolescents and Young Adults Undergoing Tonsillectomy.

Importance: In prior studies, decreasing the default number of doses in opioid prescriptions written in electronic health record systems reduced opioid prescribing. However, these studies did not rigorously assess patient-reported outcomes, and few included pediatric patients. Objective: To evaluate the association between decreasing the default number of doses in opioid prescriptions written in electronic health record systems and opioid prescribing and patient-reported outcomes among adolescents and young adults undergoing tonsillectomy. Design, Setting, and Participants: This nonrandomized clinical trial included adolescents and young adults aged 12 to 50 years undergoing tonsillectomy from October 1, 2019, through July 31, 2021, at a tertiary medical center. The treatment group comprised patients from a pediatric otolaryngology service (mostly aged 12-21 years) and the control group comprised patients from a general otolaryngology service (mostly aged 18-25 years). Interventions: Data on patient-reported opioid consumption and outcomes were collected via a survey on postoperative day 14. Based on opioid consumption among pediatric otolaryngology patients before the intervention, the default number of opioid doses was decreased from 30 to 12 in a tonsillectomy order set. This change occurred only for pediatric otolaryngology patients. Main Outcomes and Measures: Proportion of patients with 12 doses in the discharge opioid prescription, number of doses in this prescription, and refills and pain-related visits within 2 weeks of surgery. In a secondary analysis of patients completing the postoperative survey, patient-reported opioid consumption, pain control, sleep disturbance, anxiety, and depression were assessed. Linear or log-linear difference-in-differences models were fitted, adjusting for patients' demographic characteristics and presence of a mental health or substance use disorder. Results: The study included 237 patients (147 female patients [62.0%]; mean [SD] age, 17.3 [3.6] years). Among 131 pediatric otolaryngology patients, 1 of 70 (1.4%) in the preintervention period and 27 of 61 (44.3%) in the postintervention period had 12 doses in the discharge opioid prescription (differential change, 45.5 percentage points; 95% CI, 32.2-58.8 percentage points). Among pediatric otolaryngology patients, the mean (SD) number of doses prescribed in the preintervention period was 22.3 (7.4) and in the postintervention period was 16.1 (6.5) (differential percentage change, -29.2%; 95% CI, -43.2% to -11.7%). The intervention was not associated with changes in refills or pain-related visits. The secondary analysis included 150 patients. The intervention was not associated with changes in patient-reported outcomes except for a 3.5-point (95% CI, 1.5-5.5 points) differential increase in a sleep disturbance score that ranged from 4 to 20, with higher scores indicating poorer sleep quality. Conclusions and Relevance: This nonrandomized clinical trial suggests that evidence-based default dosing settings may decrease perioperative opioid prescribing among adolescents and young adults undergoing tonsillectomy, without compromising analgesia. Trial Registration: ClinicalTrials.gov Identifier: NCT04066829.

Out-of-Pocket Spending for Health Care After COVID-19 Hospitalization

Objectives: Many patients report financial stress following hospitalization for COVID-19. Although many COVID-19 survivors require extensive care after discharge, the degree to which this care contributes to financial stress is unclear. Using national data, we assessed out-of-pocket spending during the 180 days after discharge among patients hospitalized for COVID-19. Study Design: Retrospective cohort analysis of Optum's deidentified Clinformatics Data Mart, a national database of medical and pharmacy claims. Methods: Among privately insured and Medicare Advantage patients hospitalized for COVID-19 between March and June 2020, we calculated median out-of-pocket spending during the 180 days after discharge. For comparison, we repeated this calculation among patients hospitalized for pneumonia. Results: Of 7932 patients with COVID-19 included in analyses, 2061 (26.0%) had private insurance. Among privately insured and Medicare Advantage patients, median (25th-75th percentile) out-of-pocket spending after discharge was $287 ($59-$842) and $271 ($63-$783), respectively. Out-of-pocket spending exceeded $2000 for 10.9% and 9.3% of these patients, respectively. Among privately insured and Medicare Advantage patients hospitalized for pneumonia, median (25th-75th percentile) out-of-pocket spending after discharge was $276 ($62-$836) and $570 ($181-$1466). Out-of-pocket spending exceeded $2000 for 12.1% and 17.2% of these patients, respectively. Conclusions: For most patients hospitalized for COVID-19, postdischarge care may not be a major source of financial stress. Although this is reassuring, our findings also suggest that a sizable minority of COVID-19 survivors have substantial out-of-pocket spending after discharge. These survivors could be particularly vulnerable to financial toxicity if they also receive bills for the hospitalization owing to the expiration of insurer cost-sharing waivers. Insurers should consider this possibility when deciding whether to reinstate cost-sharing waivers for COVID-19 hospitalizations.

Dispensing of HIV and Hepatitis C Antivirals During COVID-19: An Interrupted Time-Series Analysis of U.S. National Data.

INTRODUCTION: Little is known about the potential changes in the dispensation of life-saving hepatitis C virus (HCV) and HIV antivirals after the initial U.S. outbreak of COVID-19. The objective of this study was to describe the immediate and 1-year impacts of the U.S. outbreak of COVID-19 on monthly dispensing of HIV and HCV antivirals, specifically direct-acting antivirals (DAA) to treat HCV, antiretroviral therapy (ART) to treat HIV, and pre-exposure prophylaxis (PrEP) to prevent HIV. METHODS: Authors used interrupted time-series analysis, examining IQVIA National Prescription Audit (includes 92% of U.S. retail pharmacies and 70% of U.S. mail order and long-term care pharmacies) for changes in monthly dispensed prescriptions, 2 years before and 1 year after the initial U.S. COVID-19 outbreak. Fitted linear segmented regression models were used to assess immediate level and slope changes, excluding data from April 2020 as a washout period. Authors stratified analyses by new/refill, age group, payer type, and delivery channel. RESULTS: After the initial outbreak, DAA prescription dispensing declined by almost one third. The COVID-19 outbreak was associated with an immediate-level decrease in total DAA prescriptions, followed by a slope increase in monthly dispensing. However, by April 2021, monthly DAA dispensing had not recovered to prepandemic levels. In contrast, ART and PrEP dispensing changed little over the same time period. CONCLUSIONS: U.S. dispensing of DAAs to treat HCV fell at the start of the U.S. COVID-19 outbreak and has yet to fully recover to prepandemic levels. Addressing barriers to care is crucial to reaching national HIV and hepatitis C elimination goals.

Assessment of Out-of-Pocket Spending for COVID-19 Hospitalizations in the US in 2020.

Importance: Many insurers waived cost sharing for COVID-19 hospitalizations during 2020. Nonetheless, patients may have been billed if their plans did not implement waivers or if waivers did not capture all hospitalization-related care. Assessment of out-of-pocket spending for COVID-19 hospitalizations in 2020 may show the financial burden that patients may experience if insurers allow waivers to expire, as many chose to do during 2021. Objective: To estimate out-of-pocket spending for COVID-19 hospitalizations in the US in 2020. Design, Setting, and Participants: This cross-sectional study used data from the IQVIA PharMetrics Plus for Academics Database, a national claims database representing 7.7 million privately insured patients and 1.0 million Medicare Advantage patients, regarding COVID-19 hospitalizations for privately insured and Medicare Advantage patients from March to September 2020. Main Outcomes and Measures: Mean total out-of-pocket spending, defined as the sum of out-of-pocket spending for facility services billed by hospitals (eg, accommodation charges) and professional and ancillary services billed by clinicians and ancillary providers (eg, clinician inpatient evaluation and management, ambulance transport). Results: Analyses included 4075 hospitalizations; 2091 (51.3%) were for male patients, and the mean (SD) age of patients was 66.8 (14.8) years. Of these hospitalizations, 1377 (33.8%) were for privately insured patients. Out-of-pocket spending for facility services, professional and ancillary services, or both was reported for 981 of 1377 hospitalizations for privately insured patients (71.2%) and 1324 of 2968 hospitalizations for Medicare Advantage patients (49.1%). Among these hospitalizations, mean (SD) total out-of-pocket spending was $788 ($1411) for privately insured patients and $277 ($363) for Medicare Advantage patients. In contrast, out-of-pocket spending for facility services was reported for 63 hospitalizations for privately insured patients (4.6%) and 36 hospitalizations for Medicare Advantage patients (1.3%). Among these hospitalizations, mean (SD) total out-of-pocket spending was $3840 ($3186) for privately insured patients and $1536 ($1402) for Medicare Advantage patients. Total out-of-pocket spending exceeded $4000 for 2.5% of privately insured hospitalizations compared with 0.2% of Medicare Advantage hospitalizations. Conclusions and Relevance: In this cross-sectional study, few patients hospitalized for COVID-19 in 2020 were billed for facility services provided by hospitals, suggesting that most were covered by insurers with cost-sharing waivers. However, many patients were billed for professional and ancillary services, suggesting that insurer cost-sharing waivers may not have covered all hospitalization-related care. High cost sharing for patients who were billed by facility services suggests that out-of-pocket spending may be substantial for patients whose insurers have allowed waivers to expire.

Prescription Drug Dispensing to US Children During the COVID-19 Pandemic.

BACKGROUND: After the US coronavirus disease 2019 outbreak, overall prescription dispensing declined but then rebounded. Whether these same trends occurred for children is unknown. METHODS: Using the IQVIA National Prescription Audit, which contains monthly dispensing counts from 92% of US retail pharmacies, we assessed changes in the monthly number of prescriptions dispensed to US children aged 0 to 19 years during 2018-2020. We compared dispensing totals in April to December 2020 and April to December 2019 overall, by drug class, and among drug classes that typically treat acute infections (eg, antibiotics) or chronic diseases (eg, antidepressants). RESULTS: Between January 2018 and February 2020, the median monthly number of prescriptions dispensed to children was 25 744 758. Dispensing totals declined from 25 684 219 to 16 742 568 between March and April 2020, increased to 19 657 289 during October 2020, and decreased to 15 821 914 during December 2020. Dispensing totals during April to December 2020 (160 630 406) were 27.1% lower compared with April to December 2019 (220 284 613). Among the 3 drug classes accounting for the most prescriptions in 2019, the corresponding percentage changes were -55.6% for antibiotics, -11.8% for attention-deficit/hyperactivity disorder medications, and 0.1% for antidepressants. Among drug classes that typically treat acute infections and chronic diseases, percentage changes were -51.3% and -17.4%, respectively. CONCLUSIONS: Prescription dispensing to children declined by one-quarter in April to December 2020 compared with April to December 2019. Declines were greater for infection-related drugs than for chronic disease drugs. Decreased dispensing of the latter is potentially concerning and warrants further investigation. Whether reductions in dispensing of infection-related drugs are temporary or sustained will be important to monitor going forward.

Views on COVID-19 and Use of Face Coverings Among U.S. Youth.

PURPOSE: Little is known about the views of U.S. youth on COVID-19 or their use of face coverings. Closing this gap could facilitate messaging to promote COVID-19 risk mitigation behaviors. METHODS: In July 2020, a five-question text message survey was sent to 1,087 youth aged 14-24 years. Questions assessed youths' perceptions regarding the likelihood of contracting COVID-19, the potential impact of contracting COVID-19 on their lives, the possibility of spreading COVID-19 to others, and their use of face coverings around others with whom they do not live. Coding was conducted to assign responses to discrete categories and to identify common themes. RESULTS: Of 1,087 eligible participants, 797 (73.3%) were included in analyses. Of these participants, 27.3% believed they would likely contract COVID-19 in the next few months, 90.3% believed contracting COVID-19 would have a moderate or significant impact on their lives, 86.0% were moderately or very concerned about spreading COVID-19, and 89.2% reported wearing face coverings all or most of the time. Factors affecting face covering use included the desire to avoid contracting and spreading COVID-19, peer influence, and policy mandates. CONCLUSIONS: Youths' perceptions regarding the risk of contracting COVID-19 varied, but most believed their lives would be adversely impacted if this occurred. Most youth were concerned about spreading COVID-19 and wore face coverings, but many made exceptions to face covering use when around close contacts. Public health campaigns may be most effective if they leverage positive peer influence and appeal to youths' desire not to spread COVID-19 to others.

Out-of-Pocket Spending for Influenza Hospitalizations in Medicare Advantage.

INTRODUCTION: Although many Medicare Advantage plans have waived cost sharing for COVID-19 hospitalizations, these waivers are voluntary and may be temporary. To estimate the magnitude of potential patient cost sharing if waivers are not implemented or are allowed to expire, this study assesses the level and predictors of out-of-pocket spending for influenza hospitalizations in 2018 among elderly Medicare Advantage patients. METHODS: Using the Optum De-Identified Clinformatics DataMart, investigators identified Medicare Advantage patients aged ≥65 years hospitalized for influenza in 2018. For each hospitalization, out-of-pocket spending was calculated by summing deductibles, coinsurance, and copays. The mean out-of-pocket spending and the proportion of hospitalizations with out-of-pocket spending exceeding $2,500 were calculated. A 1-part generalized linear model with a log link and Poisson variance function was fitted to model out-of-pocket spending as a function of patient demographic characteristics, plan type, and hospitalization characteristics. Coefficients were converted to absolute changes in out-of-pocket spending by calculating average marginal effects. RESULTS: Among 14,278 influenza hospitalizations, the mean out-of-pocket spending was $987 (SD=$799). Out-of-pocket spending exceeded $2,500 for 3.0% of hospitalizations. The factors associated with higher out-of-pocket spending included intensive care use, greater length of stay, and enrollment in a preferred provider organization plan (average marginal effect=$634, 95% CI=$631, $636) compared with enrollment in an HMO plan. CONCLUSIONS: In this analysis of elderly Medicare Advantage patients, the mean out-of-pocket spending for influenza hospitalizations was almost $1,000. Federal policymakers should consider passing legislation mandating insurers to eliminate cost sharing for COVID-19 hospitalizations. Insurers with existing cost-sharing waivers should consider extending them indefinitely, and those without such waivers should consider implementing them immediately.

Factors Associated With School Attendance Plans and Support for COVID-19 Risk Mitigation Measures Among Parents and Guardians.

OBJECTIVE: To determine which factors are associated with plans for in-person school attendance during the 2020-2021 school year and with support for 15 school-based COVID-19 risk mitigation measures among parents and guardians. METHODS: In June 2020, we conducted an online survey of parents and guardians of public school children in Illinois, Michigan, and Ohio. In a child-level analysis, we used linear regression to assess which demographic factors, health-related concerns, and parent/guardian views were associated with plans for in-person school attendance. In a respondent-level analysis, we used linear regression to assess factors associated with the number of risk mitigation measures supported. RESULTS: Among 2202 children in the child-level analysis, in-person school attendance was planned for 71.0%. Such plans were less likely among children of Black respondents (-14.1 percentage points, 95% confidence interval [CI]: -25.7, -2.6) and Asian respondents (-16.8, 95% CI: -31.3, -2.2), and among children with perceived high-risk health conditions (-9.7, 95% CI: -15.8, -3.6). Among 1,126 respondents in the respondent-level analysis, the mean number of measures supported was 8.0 (SD 4.4). Several factors were associated with support, but the magnitude of associations was generally modest. CONCLUSIONS: During the COVID-19 pandemic, families of children with health conditions or who are of Black or Asian race/ethnicity may be less likely to opt for in-person learning. For these families, addressing barriers to remote education is critical. As schools plan for the 2020-2021 school year and beyond, they should respond to the desire among parents and guardians to implement substantial numbers of risk mitigation measures.