Masking for COVID-19 Is Associated with Decreased Emergency Department Utilization for Non-COVID Viral Illnesses and Respiratory Conditions in Maryland.

BACKGROUND: Masking, which is known to decrease the transmission of respiratory viruses, was not widely practiced in the United States until the coronavirus disease 2019 (COVID-19) pandemic. This provides a natural experiment to determine whether the percentage of community masking was associated with decreases in emergency department (ED) visits due to non-COVID viral illnesses (NCVIs) and related respiratory conditions. METHODS: In this observational study of ED encounters in a 11-hospital system in Maryland during 2019-2020, year-on-year ratios for all complaints were calculated to account for "lockdowns" and the global drop in ED visits due to the pandemic. Encounters for specific complaints were identified using the International Classification of Diseases, version 10. Encounters with a positive COVID test were excluded. Linear regression was used to determine the association of publicly available masking data with ED visits for NCVI and exacerbations of asthma and chronic obstructive pulmonary disease (COPD), after adjusting for patient age, sex, and medical history. RESULTS: There were 285,967 and 252,598 ED visits across the hospital system in 2019 and 2020, respectively. There was a trend toward an association between the year-on-year ratio for all ED visits and the Maryland stay-at-home order (parameter estimate = -0.0804, P = .10). A 10% percent increase in the prevalence of community masking was associated with a 17.0%, 8.8%, and 9.4% decrease in ED visits for NCVI and exacerbations of asthma exacerbations and chronic obstructive pulmonary disease, respectively (P < .001 for all). CONCLUSIONS: Increasing the prevalence of masking is associated with a decrease in ED visits for viral illnesses and exacerbations of asthma and COPD. These findings may be valuable for future public health responses, particularly in future pandemics with respiratory transmission or in severe influenza seasons.

Alcohol Control and Foster Care.

Parental alcohol consumption is often associated with an increased likelihood of child abuse. As consumption is related to price, the purpose of this paper is to investigate the propensity for increases in the full price of alcohol to influence entry rates and the length of time spent in foster care. Using alcoholic beverage prices and a measure of availability in combination with data on foster care cases, we find that higher alcohol prices are not effective in reducing foster care entry rates; however, once in foster care, the duration of stay may be shortened by higher prices and reduced availability.

Do strict formularies replicate failure for patients with schizophrenia?

OBJECTIVES: We measure the impact of Medicaid formulary restrictions (FRs) on the rate at which patients who previously failed a drug therapy for schizophrenia are returned to that therapy. STUDY DESIGN: We collect drug-level information on FRs in state Medicaid programs and examine claims of noninstitutionalized Medicaid enrollees with schizophrenia. METHODS: A difference-in-differences technique is used to compute the change in the probability of adverse outcomes before and after a state adopts an FR. This change is compared with the change in failure probabilities in states with no FRs. RESULTS: Regardless of FRs, patients tend to resume the same drug after an adverse medical event. In 2005, 69% of inpatient mental health-related admissions resulted in patients resuming the same therapy within 6 months of the event, and 63% of patients resumed the same drug after a mental health-related emergency department admission. In states where FRs limit access to all atypicals, the likelihood of a patient resuming the same atypical after having ceased treatment for at least 30 days increases by 20.1% relative to patients in states without restrictions. Additionally, patients in states that impose FRs on all atypicals are 11.6% more likely to discontinue all treatments. CONCLUSIONS: FR may increase the likelihood that patients will return to failed treatments or cease treatment altogether. Although formularies are designed to reduce drug spending, an unintended consequence may be an increase in the use of other services needed to treat patients with schizophrenia.

The impact of insulin type on severe hypoglycaemia events requiring inpatient and emergency department care in patients with type 2 diabetes.

AIMS: To evaluate the risk from different insulin types on severe hypoglycaemia (SHG) events requiring inpatient (IP) or emergency department (ED) care in patients with type 2 diabetes. METHODS: Type 2 diabetes patients newly started on insulin in a large commercial claims database were evaluated for SHG events. Patients were classified into an insulin group based on their most frequently used insulin type. Multivariable Cox models assessed the association between insulin type and the risk of SHG events. RESULTS: We identified 8626 patients (mean age 53.5 years; 55% female) with type 2 diabetes followed for an average of 4.0 years after insulin initiation. Of these, 161 (1.9%) had a SHG event at an average of 3.1y after insulin initiation. Patients with SHG events were slightly older (56.4 vs. 53.4 years), used a similar number of OADs (1.1 vs. 1.2) but had more co-morbidities compared with those without SHG events. In multivariate Cox models, premixed insulin (HR 2.12; p<0.01), isophane insulin (NPH) (HR 2.02; p<0.01), and rapid acting insulin (HR 2.75; p<0.01) had significantly higher risks of SHG events compared with glargine. No statistically significant difference in SHG events was seen with detemir (HR 1.20; p=0.73). CONCLUSIONS: Among patients with type 2 diabetes, the use of newer basal insulin analogues was associated with lower rates of SHG events requiring IP or ED care compared with users of other insulin formulations. Future research should examine the impact of hypoglycaemia events of different severity levels.

Expenditures for medicaid patients treated with exenatide compared with other diabetes management regimens.

OBJECTIVE: To compare Medicaid spending among patients with type 2 diabetes mellitus (T2DM) receiving exenatide or other add-on therapies. STUDY DESIGN: Medicaid data in patients with T2DM were compared among those who initiated exenatide, thiazolidinediones, dipeptidyl peptidase-4 inhibitors, or basal insulin. Patients were on a regimen of metformin and/or sulfonylurea for 30 days and continued the next-line therapy for at least 90 days. METHODS: Total inpatient, outpatient, prescription, and total annual health expenditures were compared for 1 year following treatment initiation. Regression analyses were conducted to compare spending; analyses controlled for patient characteristics, year of initiation, and prior therapy. Propensity score matching was used to match patients receiving exenatide with those receiving other therapies, and analyses were repeated with matched cohorts. RESULTS: Of 23,966 eligible patients, 1345 initiated exenatide and 22,621 initiated other therapies. In the unmatched analysis, medical spending was significantly lower in those given exenatide compared with those given other therapies for inpatient ($1945 vs $3893), prescription ($4505 vs $5714), and total costs ($11,830 vs $15,459) (P <.01 for all); outpatient spending was not significantly different ($5380 vs $5853, P = .15). In the matched analysis (n = 1345 for exenatide, n = 1345 non-exenatide), patients receiving exenatide had significantly lower spending in all 4 categories: inpatient ($1945 vs $4242), outpatient ($5380 vs $6826), prescription ($4505 vs $5878), and total ($11,830 vs $16,945) (P <.01 for all). CONCLUSION: Patients with T2DM receiving exenatide had lower annual Medicaid claims costs compared with patients receiving other therapies.