Cancer Treatment Before and After Physician-Pharmacy Integration.

Importance: Integration of pharmacies with physician practices, also known as medically integrated dispensing, is increasing in oncology. However, little is known about how this integration affects drug use, expenditures, medication adherence, or time to treatment initiation. Objective: To examine the association of physician-pharmacy integration with oral oncology drug expenditures, use, and patient-centered measures. Design, Setting, and Participants: This cohort study used claims data from a large commercial insurer in the US to analyze changes in outcome measures among patients treated by pharmacy-integrating vs nonintegrating community oncologists in 14 states between January 1, 2011, and December 31, 2019. Commercially insured patients were aged 18 to 64 years with 1 of the following advanced-stage diagnoses: breast cancer, colorectal cancer, kidney cancer, lung cancer, melanoma, or prostate cancer. Data analysis was conducted from May 2023 to March 2024. Exposure: Treatment by a pharmacy-integrating oncologist, ascertained by the presence of an on-site pharmacy or nonpharmacy dispensing site. Main Outcomes and Measures: Oral, intravenous (IV), total, and out-of-pocket drug expenditures for a 6-month episode of care; share of patients prescribed oral drugs; days' supply of oral drugs; medication adherence measured by proportion of days covered; and time to treatment initiation. The association between an oncologist's pharmacy integration and each outcome of interest was estimated using the difference-in-differences estimator. Results: Between 2012 and 2019, 3159 oncologists (745 females [27.1%], 2002 males [72.9%]) treated 23 968 patients (66.4% female; 53.4% aged 55-64 years). Of the 3159 oncologists, 578 (18.3%) worked in practices that integrated with pharmacies (with a low rate in 2011 of 0% and a high rate in 2019 of 31.5%). In the full sample (including all cancer sites), after physician-pharmacy integration, no significant changes were found in oral drug expenditures, IV drug expenditures, or total drug expenditures. There was, however, an increase in days' supply of oral drugs (5.96 days; 95% CI, 0.64-11.28 days; P = .001). There were no significant changes in out-of-pocket expenditures, medication adherence, or time to treatment initiation of oral drugs. In the breast cancer sample, there was an increase in oral drug expenditures ($244; 95% CI, $41-$446; P = .02) and a decrease in IV drug expenditures (-$4187; 95% CI, -$8293 to -$80; P = .05). Conclusions and Relevance: Results of this cohort study indicated that the integration of oncology practices with pharmacies was not associated with significant changes in expenditures or clear patient-centered benefits.

Long term cost outcomes among commercially insured patients undergoing bariatric surgical procedures.

Objective: Bariatric procedures have become safer in recent years, warranting new data on long-term costs. This study examined the impact of bariatric procedures on a person's long-term healthcare costs up to 10 years and if it differed by socio-economic status (SES). Methods: This retrospective observational study compared the downstream health care cost of patients with obesity who had undergone bariatric surgery (BS) between 2009 and 2018 to a 1:1 matched group of members with obesity but no surgery. Results: 167,764 individuals from administrative claims data with an obesity diagnosis were included; 83,882 in the BS group and 83,882 in the non-surgical group. In follow-up years 2-10, the BS group was associated with lower total medical healthcare cost compared to the non-surgical group (cost ratios ranged 0.85-0.93, p values < 0.05). When stratifying the BS group by SES quartiles, there were no significant cost differences by SES (cost ratios ranged from 0.96 to 1.05, most p values > 0.05). Conclusions: BS was associated with lower long-term follow-up medical cost and cost savings appeared similar among the SES quartiles in the BS group. The study results may help policy makers and employers in designing benefits and extending coverage for bariatric surgical procedures.

The association between hypertensive disorders during pregnancy and maternal and neonatal outcomes: a retrospective claims analysis.

BACKGROUND: Hypertensive disorders during pregnancy continue to increase in prevalence and are associated with several adverse outcomes and future cardiovascular risk for mothers. This study evaluated the association of hypertensive disorders compared to no hypertension during pregnancy with neonatal and maternal outcomes. We then evaluated risk factors associated with progression from a less to more severe hypertensive disorder during pregnancy. METHODS: We conducted a propensity-matched retrospective cohort study utilizing Medicaid claims data from a national insurer. The study population consisted of mothers with and without hypertensive disorders who delivered between 7/1/2016-12/31/2018 and their infants. Hypertensive disorders included gestational hypertension, chronic hypertension, preeclampsia, and superimposed preeclampsia. Propensity score matching was used to match mothers without to those with hypertensive disorders. Regression models were used to compare maternal and neonatal outcomes. Stepwise logistic regression was used to determine characteristics associated with the progression of gestational hypertension to preeclampsia or chronic hypertension to superimposed preeclampsia. RESULTS: We observed the highest risk of cesarean delivery (odds ratio [OR]:1.61 and 1.99) in mothers and preterm delivery (OR:2.22 and 5.37), respiratory distress syndrome (OR:2.39 and 4.19), and low birthweight (OR:3.64 and 9.61) in babies born to mothers with preeclampsia or superimposed preeclampsia compared to no hypertension, respectively (p < 0.05 for all outcomes). These outcomes were slightly higher among chronic or gestational hypertension compared to no hypertension, however, most were not statistically significant. Risk of neonatal intensive care unit utilization was higher among more severe hypertensive disorders (OR:2.41 for preeclampsia, OR:4.87 for superimposed preeclampsia). Obesity/overweight and having a history of preeclampsia during a prior pregnancy were most likely to predict progression from gestational/chronic hypertension to preeclampsia/superimposed preeclampsia. CONCLUSION: Mothers and neonates born to mothers with preeclampsia or superimposed preeclampsia experienced more adverse outcomes compared to those without hypertension. Mothers and neonates born to mothers with gestational hypertension had outcomes similar to those without hypertension. Outcomes for those with chronic hypertension fell in between gestational hypertension and preeclampsia. Obesity/overweight and having a history of preeclampsia during a prior pregnancy were strong risk factors for hypertension progression.

One-Year Adverse Outcomes Among US Adults With Post-COVID-19 Condition vs Those Without COVID-19 in a Large Commercial Insurance Database.

Importance: Many individuals experience ongoing symptoms following the onset of COVID-19, characterized as postacute sequelae of SARS-CoV-2 or post-COVID-19 condition (PCC). Less is known about the long-term outcomes for these individuals. Objective: To quantify 1-year outcomes among individuals meeting a PCC definition compared with a control group of individuals without COVID-19. Design, Setting, and Participants: This case-control study with a propensity score-matched control group included members of commercial health plans and used national insurance claims data enhanced with laboratory results and mortality data from the Social Security Administration's Death Master File and Datavant Flatiron data. The study sample consisted of adults meeting a claims-based definition for PCC with a 2:1 matched control cohort of individuals with no evidence of COVID-19 during the time period of April 1, 2020, to July 31, 2021. Exposures: Individuals experiencing postacute sequelae of SARS-CoV-2 using a Centers for Disease Control and Prevention-based definition. Main Outcomes and Measures: Adverse outcomes, including cardiovascular and respiratory outcomes and mortality, for individuals with PCC and controls assessed over a 12-month period. Results: The study population included 13 435 individuals with PCC and 26 870 individuals with no evidence of COVID-19 (mean [SD] age, 51 [15.1] years; 58.4% female). During follow-up, the PCC cohort experienced increased health care utilization for a wide range of adverse outcomes: cardiac arrhythmias (relative risk [RR], 2.35; 95% CI, 2.26-2.45), pulmonary embolism (RR, 3.64; 95% CI, 3.23-3.92), ischemic stroke (RR, 2.17; 95% CI, 1.98-2.52), coronary artery disease (RR, 1.78; 95% CI, 1.70-1.88), heart failure (RR, 1.97; 95% CI, 1.84-2.10), chronic obstructive pulmonary disease (RR, 1.94; 95% CI, 1.88-2.00), and asthma (RR, 1.95; 95% CI, 1.86-2.03). The PCC cohort also experienced increased mortality, as 2.8% of individuals with PCC vs 1.2% of controls died, implying an excess death rate of 16.4 per 1000 individuals. Conclusions and Relevance: This case-control study leveraged a large commercial insurance database and found increased rates of adverse outcomes over a 1-year period for a PCC cohort surviving the acute phase of illness. The results indicate a need for continued monitoring for at-risk individuals, particularly in the area of cardiovascular and pulmonary management.

Clinical Outcomes and Cost Associated With an Intravascular Microaxial Left Ventricular Assist Device vs Intra-aortic Balloon Pump in Patients Presenting With Acute Myocardial Infarction Complicated by Cardiogenic Shock.

Importance: Intravascular microaxial left ventricular assist device (LVAD) compared with intra-aortic balloon pump (IABP) has been associated with increased risk of mortality and bleeding among patients with acute myocardial infarction (AMI) and cardiogenic shock (CS) undergoing percutaneous coronary intervention (PCI). However, evidence on the association of device therapy with a broader array of clinical outcomes, including data on long-term outcomes and cost, is limited. Objective: To examine the association between intravascular LVAD or IABP use and clinical outcomes and cost in patients with AMI complicated by CS. Design, Setting, and Participants: This retrospective propensity-matched cohort study used administrative claims data for commercially insured patients from 14 states across the US. Patients included in the analysis underwent PCI for AMI complicated by CS from January 1, 2015, to April 30, 2020. Data analysis was performed from April to November 2021. Exposures: Use of either an intravascular LVAD or IABP. Main Outcomes and Measures: The primary outcomes were mortality, stroke, severe bleeding, repeat revascularization, kidney replacement therapy (KRT), and total health care costs during the index admission. Clinical outcomes and cost were also assessed at 30 days and 1 year. Results: Among 3077 patients undergoing PCI for AMI complicated by CS, the mean (SD) age was 65.2 (12.5) years, and 986 (32.0%) had cardiac arrest. Among 817 propensity-matched pairs, intravascular LVAD use was associated with significantly higher in-hospital (36.2% vs 25.8%; odds ratio [OR], 1.63; 95% CI, 1.32-2.02), 30-day (40.1% vs 28.3%; OR, 1.71; 95% CI, 1.37-2.13), and 1-year mortality (58.9% vs 45.0%; hazard ratio [HR], 1.44; 95% CI, 1.21-1.71) compared with IABP. At 30 days, intravascular LVAD use was associated with significantly higher bleeding (19.1% vs 14.5%; OR, 1.35; 95% CI, 1.04-1.76), KRT (12.2% vs 7.0%; OR, 1.88; 95% CI, 1.30-2.73), and mean cost (+$51 680; 95% CI, $31 488-$75 178). At 1 year, the association of intravascular LVAD use with bleeding (29.7% vs 24.3%; HR, 1.36; 95% CI, 1.05-1.75), KRT (18.1% vs 10.9%; HR, 1.95; 95% CI, 1.35-2.83), and mean cost (+$46 609; 95% CI, $22 126-$75 461) persisted. Conclusions and Relevance: In this propensity-matched analysis of patients undergoing PCI for AMI complicated by CS, intravascular LVAD use was associated with increased short-term and 1-year risk of mortality, bleeding, KRT, and cost compared with IABP. There is an urgent need for additional evidence surrounding the optimal management of patients with AMI complicated by CS.

Effectiveness, safety and treatment adherence of biosimilar follow-on insulin in diabetes management.

AIM: To assess the change in HbA1c after initiation of biosimilar follow-on insulin (Basaglar) or reference insulin (Lantus) among patients with type 2 diabetes. We also compared treatment adherence, safety events and costs at 1 year after initiation of insulin. MATERIALS AND METHODS: Using claims data from a large US health plan during 2016-2020, we identified adults with type 2 diabetes who initiated either Basaglar or Lantus. Generalized linear regression modelling assessed the differences in outcomes between the two groups. A 0.4% margin was used to determine non-inferiority for HbA1c. RESULTS: The study included 1136 Basaglar users and 6304 Lantus users. Both Lantus and Basaglar groups showed more than 1% reduction in HbA1c over 6 months and over 12 months. Reduction in HbA1c with Basaglar was similar (non-inferior) to that with Lantus, with an adjusted difference of Basaglar to Lantus of 0.14% (95% CI -0.02 to 0.30) over 6 months and 0.17% (95% CI 0.02 to 0.32) over 12 months. Rates of adverse events were similar for both hypoglycaemia and vascular events. The Basaglar group showed higher adherence in terms of proportion of days covered (adjusted difference 0.06, 95% CI 0.04 to 0.08). Medical costs were similar, but the cost of Basaglar was lower (adjusted mean cost difference -$462, 95% CI -$556 to -$363) after adjustment. CONCLUSIONS: In patients with type 2 diabetes, Basaglar provided similar glycaemic control compared with Lantus, had a similar safety profile and lower drug costs, and showed more favourable adherence.

Disparities in health care use among low-salary and high-salary employees.

OBJECTIVES: To examine how health care utilization and spending vary for low-income employees compared with high-income employees enrolled in an employer-sponsored high-deductible health plan (HDHP). STUDY DESIGN: We use commercial medical claims data and administrative human resource data from a large employer between 2014 and 2018. We link the administrative data, which include details on salary and other benefit choices, to each employee in each year with medical claims. Our variables of interest include medical spending and utilization outcomes grouped into different care settings. METHODS: Using multivariate regressions, we estimate the association between salary buckets and health care utilization and spending, controlling for demographic characteristics, comorbidities of employees, human resource health plan benefits, and geography. RESULTS: Employees earning less than $75,000 show lower rates of utilization and spending on preventive measures, such as outpatient visits and prescription drugs, while having higher rates of utilization of preventable and avoidable emergency department visits and inpatient stays, resulting in lower overall health care spending among lower-salary employees. CONCLUSIONS: Low-salary employees enrolled in HDHPs have higher rates of acute care utilization and spending but lower rates of primary care spending compared with high-salary employees. Results suggest that HDHPs discourage routine physician-patient care among low-salary employees.

Drivers of Hospital Length of Stay in Medicaid and Commercially Insured Mother-Infant Pairs With a Diagnosis of Neonatal Abstinence Syndrome.

BACKGROUND: The occurrence of neonatal abstinence syndrome (NAS) mirrors the growing opioid epidemic in the United States. As Medicaid covers a majority of cases, the commercially insured population has largely been ignored for NAS risk. OBJECTIVE: The objective of this study was to examine Medicaid and commercially insured mother-infant pairs to determine demographic and clinical characteristics associated with NAS length of stay (LOS). RESEARCH DESIGN: This observational, descriptive case-series study utilized administrative claims from HealthCore Integrated Research Database to measure maternal characteristics for 6 months before delivery, and neonatal characteristics and health care service utilization for 3 months after NAS diagnosis. Bootstrapped regressions were used to model LOS. RESULTS: The sample included 1807 mother-infant pairs. Most infants (79%) had Medicaid coverage (Medicaid: N=1419; Commercial: N=388). Although all infants had NAS, Medicaid-insured mothers had more prevalent drug abuse (70.8% vs. 41.0%; P<0.0001), but fewer used prescription opioids (45.3% vs. 60.8%; P<0.0001) compared with commercially insured mothers. Commercially insured infants were sicker, with a higher prevalence of complex chronic conditions, and yet Medicaid-insured infants were admitted to neonatal intensive care unit at a much higher rate (91.1% vs. 78.9%; P<0.0001). After adjustment, neonatal intensive care unit admission (+6.7 d, 95% confidence interval: 4.5-9.3) and chronic complex conditions (+5.2 d, 95% confidence interval: 3.8-6.6) contributed most to LOS. CONCLUSION: A re-evaluation of obstetrical management towards a focus on the history of possible opioid and substance use regardless of insurance type and demographic background might inform efforts to reduce LOS.

Association between early-childhood antibiotic exposure and subsequent asthma in the US Medicaid population.

BACKGROUND: Although socioeconomically disadvantaged children have an increased risk of asthma, the association between early-childhood antibiotics and the incidence of asthma among such children has had limited study. OBJECTIVE: To examine the association between antibiotic fills in the first 2 years of life and risk of developing asthma among children enrolled in Medicaid plans. METHODS: This retrospective cohort study of children with continuous medical and pharmacy coverage from birth to 2.5 years of age was performed from July 1, 2012, to November 31, 2018. We excluded children with a diagnosis of asthma before 2.5 years of age. Hazard ratios (HRs) and 95% CIs were estimated from Cox proportional hazards regression models. Covariates included sex, preterm birth, cesarean delivery, and mother's asthma status. RESULTS: There were 79,582 children in the study cohort of whom 29,931 (37.6%) had 0 antibiotic prescriptions filled, 27,403 (34.4%) had 1 or 2 prescriptions filled, and 22,248 (28.0%) had 3 or more prescriptions filled. A total of 2381 new cases of asthma were observed in 89,545 person-years of follow-up. After adjustment, receipt of 1 or 2 antibiotics was associated with an increased risk of developing asthma, relative to 0 antibiotics (HR, 1.34; 95% CI, 1.21-1.49), and receipt of 3 or more antibiotics was associated with greater increased risk relative to 0 antibiotics (HR, 1.71; 95% CI, 1.54-1.90). After adjustment, the absolute risk of developing asthma by age 4.0 years increased from 2.7% (0 antibiotics) to 3.6% (1-2 antibiotics) and 4.5% (≥3 antibiotics). CONCLUSION: Antibiotic prescriptions filled in the first 2 years of life were associated with an increased risk of asthma diagnosis from 2.5 to 5 years of age in a Medicaid population.

Evaluation of value-based insurance design for primary care.

OBJECTIVES: To evaluate the impact of value-based insurance design (VBID), which removed patient cost sharing for primary care visits, on healthcare spending in a large, geographically diverse employer. STUDY DESIGN: Quasi-experimental, difference-in-differences (DID) design, administrative claims-based study. METHODS: Healthcare spending during the preintervention period (2008 and 2009) was compared with the postintervention period (2011 through 2014) to measure the impact of removing primary care cost sharing. The study population included Anthem commercially insured enrollees with continuous medical eligibility from 2008 to 2014 who were younger than 65 years. The VBID cohort included health plan enrollees from a national large employer that implemented the benefit change. The comparison cohort included other Anthem enrollees who did not have a similar benefit change and were propensity score-matched to the VBID cohort. Utilization of various types of healthcare services was also examined. RESULTS: The VBID cohort experienced a $12.0 per member per month relative reduction in overall spending compared with the comparison cohort (P = .02). The trend was driven by reductions in expenditures for emergency department (ED) visits ($1.3 relative reduction; DID, -10.0%; P = .03) and other outpatient services ($7.6 relative reduction; DID, -5.8%; P = .02), which aligned with reduced utilization of ED visits (DID, -4.5%; P = .07) and other outpatient services (DID, -4.1%; P = .004). For physician office visits, the VBID cohort did not experience a significant relative increase compared with the comparison cohort (DID, 0.9%; P = .25). CONCLUSIONS: The attempt to increase primary care access by reducing cost sharing did not produce a negative outcome in terms of total spending for healthcare.

Effect of Controlled Substance Use Management on Prescribing Patterns and Health Outcomes Among High-Risk Users.

BACKGROUND: The misuse of prescription drugs is a serious public health problem. Although controlled substance (CS) prescribing, in particular, opioid analgesics, has recently declined, the volume of prescriptions in 2015 was still 3 times higher than in 1999. To curb the high volume of CS prescribing, a national health plan has implemented a controlled substance utilization management (CSUM) program, a prescriber-focused educational intervention regarding patients at risk for CS misuse. OBJECTIVE: To characterize the effect of the CSUM program on CS prescribing volumes, number of prescribers and other health outcomes (opioid overdoses, all-cause emergency department visits, and all-cause hospitalizations). METHODS: The CSUM program identified patients who received ≥10 CS prescriptions within any 3-month window for noncancer pain as being high risk for CS misuse and mailed patient medication profiles to their CS prescribers. This retrospective study was conducted on patients whose prescribers were contacted by the CSUM program from January 2014 to December 2015. The reference group included patients with carved-out pharmacy benefits who were 1:1 propensity score matched to the program group. CS prescribing volumes, number of CS prescribers, and other health care utilization measures were assessed in the 6-month pre-intervention (baseline) period and 6-month post-intervention (follow-up) period using difference-in-difference (DID) analysis. RESULTS: After matching, each group had 17,295 patients, and there were no differences in baseline demographic and clinical characteristics. During the follow-up period, the CSUM group had 1.1 fewer prescriptions for CS (mean difference [MD] within group -3.2 vs. -2.1 prescriptions), 21 fewer days of supply (MD -27 vs. -6 days), and 0.2 fewer number of CS prescribers (MD -0.8 vs. -0.6 prescribers) per patient when compared with the reference group; all P values were < 0.001. The reductions in CS prescribing volumes and number of prescribers within the CSUM group were mainly driven by opioid analgesics, with minimal differences in benzodiazepines and stimulants between the 2 groups. The CSUM program had no significant effect on the opioid dosage strength but was associated with a lower rate of all-cause emergency department visits. CONCLUSIONS: The CSUM program had a moderate positive effect on reducing CS prescribing volumes and number of CS prescribers compared with a reference group. Beside the focus on patients who have already received 10+ CS prescriptions, there remains a need for more intensive approaches for accelerating targeted declines in CS in general and opioids in particular. DISCLOSURES: Funding for this study was provided by Anthem, which had no role in study design, data interpretation, manuscript development, or the decision to publish. Chen, Ma, Barron, DeVries, and Agiro are employees of HealthCore, a wholly owned subsidiary of Anthem. Horn is an employee of Anthem.

Commercial Claims-Based Comparison of Survival and Toxic Effects of Definitive Radiotherapy vs Primary Surgery in Patients With Oropharyngeal Squamous Cell Carcinoma.

Importance: Definitive radiotherapy (RT) and primary surgery (PS) are considered to be equally viable local therapy modalities for oropharyngeal squamous cell carcinoma (OPSCC). The comparative effectiveness of these therapies is often debated, and treatment decisions are based on a paucity of comparative data. Objective: To examine the differences in overall survival and key toxic effects in patients with OPSCC treated with RT and PS. Design, Setting, and Participants: This retrospective cohort analysis used the HealthCore Integrated Research Database to identify 884 patients diagnosed with OPSCC from January 1, 2007, to December 31, 2014. Patients were categorized as receiving definitive RT (with or without chemotherapy) or PS (with or without adjuvant RT or chemoradiotherapy). Administrative claims data were linked with state cancer registries from California, Connecticut, Georgia, Kentucky, New York, and Ohio. Data analysis was performed from February 29, 2016, to February 6, 2018. Exposures: Definitive RT or PS. Main Outcomes and Measures: Overall survival was analyzed using Cox proportional hazards regression. Risks of gastrostomy dependence, esophageal stricture, and osteoradionecrosis were determined through claims and analyzed using logistic regression. Results: A total of 884 patients (608 [68.8%] in the RT group and 276 [31.2%] in the PS group; mean [SD] age, 61.5 [10.7] years; 727 [82.2%] male; 842 [95.3%] white) were included in this study. The 3-year overall survival was 76% among patients treated with RT and 81% among patients treated with PS (hazard ratio, 0.76; 95% CI, 0.54-1.01). On multivariable analysis, increasing age, female sex, and low income were associated with inferior survival; treatment type was not. Patients treated with RT were more likely to have gastrostomy dependence within the first year (391 [64.3%] vs 127 [46.0%]; adjusted OR, 0.57; 95% CI, 0.42-0.77). After treating chemotherapy as an effect modifier, there was no difference between modalities. Treatment type was not associated with esophageal stricture or osteoradionecrosis risk. Mean costs were approximately $100 000 for payers and $5000 for patients, with no adjusted differences between RT and PS. Conclusions and Relevance: This study suggests that RT and PS are equally viable treatment options for OPSCC; therefore, local therapy decisions may be individualized to each patient. However, the frequent addition of chemotherapy was associated with increased gastrostomy dependence among patients undergoing RT, which may be relevant in clinical decision making.

Untreated Sleep Apnea: An Analysis of Administrative Data to Identify Risk Factors for Early Nonadherence.

STUDY OBJECTIVES: Discontinuation of positive airway pressure (PAP) treatment for obstructive sleep apnea (OSA) is widely reported, but research has not adequately addressed nonadherence with diagnostic testing for sleep disorders and initiation of PAP. This study sought to identify drivers of nonadherence with diagnostic sleep testing and PAP treatment initiation among patients preauthorized for these services. METHODS: This observational cohort study used preauthorization records from a sleep management program and administrative medical claims from a large commercial health insurer. Participants included adults preauthorized for sleep testing and a subset in whom OSA was diagnosed and who were preauthorized for PAP treatment. Outcome measures were nonadherence with diagnostic sleep testing and PAP treatment initiation, identified as lack of a claim for a preauthorized service within 3 months of preauthorization of that service. Risk factors for nonadherence included patient demographics, prescribing factors, signs and symptoms of OSA, comorbidities, and prior health service utilization. RESULTS: Of 51,749 patients preauthorized for diagnostic testing, 23.5% did not undergo testing. Among 19,968 patients preauthorized for PAP treatment, 11.1% did not initiate treatment. Testing and treatment ordered by primary care providers, residence outside the Midwest region, and two or fewer office visits within 6 months before preauthorization were strong predictors of nonadherence. Apnea-hypopnea index score < 30 events/h was also a strong predictor of nonadherence with treatment initiation. CONCLUSIONS: This study adds to existing knowledge about risk factors for nonadherence with sleep testing and treatment initiation following preauthorization. Health plans and providers should develop strategies to better engage patients with higher risk of nonadherence.

Evaluation of a Diabetes Self-Management Program: Claims Analysis on Comorbid Illnesses, Health Care Utilization, and Cost.

BACKGROUND: An estimated 30.3 million Americans have diabetes mellitus. The US Department of Health and Human Services created national objectives via its Healthy People 2020 initiative to improve the quality of life for people who either have or are at risk for diabetes mellitus, and hence, lower the personal and national economic burden of this debilitating chronic disease. Diabetes self-management education interventions are a primary focus of this initiative. OBJECTIVE: The aim of this study was to evaluate the impact of the Better Choices Better Health Diabetes (BCBH-D) self-management program on comorbid illness related to diabetes mellitus, health care utilization, and cost. METHODS: A propensity score matched two-group, pre-post design was used for this study. Retrospective administrative medical and pharmacy claims data from the HealthCore Integrated Research Environment were used for outcome variables. The intervention cohort included diabetes mellitus patients who were recruited to a diabetes self-management program. Control cohort subjects were identified from the HealthCore Integrated Research Environment by at least two diabetes-associated claims (International Classification of Diseases-Ninth Revision, ICD-9 250.xx) within 2 years before the program launch date (October 1, 2011-September 30, 2013) but did not participate in BCBH-D. Controls were matched to cases in a 3:1 propensity score match. Outcome measures included pre- and postintervention all-cause and diabetes-related utilization and costs. Cost outcomes are reported as least squares means. Repeated measures analyses (generalized estimating equation approach) were conducted for utilization, comorbid conditions, and costs. RESULTS: The program participants who were identified in HealthCore Integrated Research Environment claims (N=558) were matched to a control cohort of 1669 patients. Following the intervention, the self-management cohort experienced significant reductions for diabetes mellitus-associated comorbid conditions, with the postintervention disease burden being significantly lower (mean 1.6 [SD 1.6]) compared with the control cohort (mean 2.1 [SD 1.7]; P=.001). Postintervention all-cause utilization was decreased in the intervention cohort compared with controls with -40/1000 emergency department visits vs +70/1000; P=.004 and -5780 outpatient visits per 1000 vs -290/1000; P=.001. Unadjusted total all-cause medical cost was decreased by US $2207 in the intervention cohort compared with a US $338 decrease in the controls; P=.001. After adjustment for other variables through structural equation analysis, the direct effect of the BCBH-D was -US $815 (P=.049). CONCLUSIONS: Patients in the BCBH-D program experienced reduced all-cause health care utilization and costs. Direct cost savings were US $815. Although encouraging, given the complexity of the patient population, further study is needed to cross-validate the results.

Leveraging benefit design for better diabetes self-management and A1C control.

OBJECTIVES: To evaluate the relationship between cost sharing for blood glucose testing strips and glycemic control rates. STUDY DESIGN: A retrospective observational study using medical and pharmacy claims data integrated with laboratory glycated hemoglobin (A1C) values for patients using insulin and testing strips. A new user study design was utilized to identify individuals from 14 commercial US health plans who filled testing strips with assumed intention to monitor blood glucose. METHODS: Patients were divided into low (<20% of annual testing strip cost; n = 3575) and high (≥20%; n = 3580) cost-sharing categories. We compared the likelihood of patients in low and high cost-sharing categories achieving glycemic control (A1C <8.0%) through modified Poisson regression models. RESULTS: Patients with low cost sharing for testing strips had higher rates of control than those with high cost sharing (58.1% vs 50.3%; P <.001). Low cost sharing was associated with greater probability of glycemic control (adjusted risk ratio [aRR], 1.14; 95% CI, 1.09-1.20; P <.0001). Glycemic control was more likely for patients in areas with median household income greater than $60,000 versus less than $40,000 (aRR, 1.16; 95% CI, 1.07-1.25; P <.01) and greater than $80,000 versus less than $40,000 (aRR, 1.18; 95% CI, 1.06-1.32; P <.01). CONCLUSIONS: We found a statistically significant correlation between cost sharing for testing strips and better A1C control for patients using insulin medication. Lower cost sharing for testing strips can remove a barrier to diabetes self-management and may lead to improved glycemic control at the population level. Future efforts should study the potential benefits of reducing diabetic complications and associated cost savings.

Real-World Impact of a Decision Support Tool on Colony-Stimulating Factor Use and Chemotherapy-Induced Febrile Neutropenia Among Patients With Breast Cancer.

Background: White blood cell colony-stimulating factors (CSFs) decrease the incidence of chemotherapy-induced febrile neutropenia (FN). Widespread use of CSFs that is not guideline-concordant has been reported. Among patients with breast cancer receiving chemotherapy, the ability of evidence-based decision support tools to promote risk-appropriate reductions in CSF use without increased incidence of FN has not been examined. Methods: A retrospective cohort design and US commercial claims data were used. The impact of CSF decision support was analyzed among women with breast cancer receiving first-cycle chemotherapy from April 1, 2013, to March 30, 2015. The tool was implemented as part of a prior authorization process in 9 states starting July 1, 2014. Patients were assigned to intervention (ie, states where the decision support tool had been implemented) or nonintervention states (ie, 39 states where the tool had not been implemented). CSF use and subsequent incidence of FN were compared using difference-in-difference (DID) regressions adjusting for baseline differences in FN risk factors such as comorbidities and various infections. Results: The study sample of 7,224 patients (intervention states: pre-implementation, 1,991 and post-implementation, 2,010; nonintervention states: pre-implementation, 1,569 and post-implementation, 1,654) showed no significant difference in risk factors. Before and after implementation, a significant decrease in the proportion of patients with CSF use was observed in the intervention states (75% to 69%) compared with no significant change in the nonintervention (72% to 71%) states (DID, -5.4%; 95% CI, -6.0% to -4.7%; P=.006). No significance increase in FN incidence occurred in intervention (5.0% to 5.5%) and nonintervention (5.4% to 4.8%) states (DID, 0.2%; 95% CI, -0.20 to 0.30; P=.78). Similar results were obtained in subgroups by comorbidities and in sensitivity analyses by claims-based FN definitions. Conclusions: CSF use decreased modestly after implementation of the decision support tool, with no observed changes in FN rates. Such tools can reduce practice variation to improve care standards.

Comparison of Specialty Medication Use for Common Chronic Inflammatory Diseases Among Health Exchange and Other Commercially Insured Members.

BACKGROUND: The Affordable Care Act of 2010 allows the purchase of health insurance through special marketplaces called "health exchanges." The majority of individuals enrolling in the exchanges were previously uninsured, older, and sicker than other commercially insured members. Early evidence also suggests that exchange plan members use more costly specialty drugs compared with other commercially insured members. OBJECTIVES: To (a) examine patient characteristics and specialty drug use for common chronic inflammatory diseases (CIDs) among exchange plan members compared with other commercially insured members and (b) explore variations in specialty drug use within exchange plans by metal tiers (bronze, silver, gold, and platinum), as well as across local markets. METHODS: This analysis included adults aged ≥ 18 years who were enrolled in exchange plans (exchange population) and other commercial health plans (nonexchange population). The primary outcome was the likelihood of using specialty drugs prescribed to treat common CIDs, such as rheumatoid arthritis, ankylosing spondylitis, Crohn's disease, ulcerative colitis, psoriatic arthritis, and psoriasis. The adjusted likelihood of using CID specialty drugs was calculated from logistic regression controlling for prevalence of CIDs and other health risk factors. RESULTS: A total of 931,384 exchange plan members and 2,682,855 nonexchange plan members were included in the analysis. Compared with the nonexchange population, the exchange population was older, more likely to be female, had more comorbid conditions, but filled fewer prescriptions. The 2 groups were similar in terms of CID prevalence. The observed likelihood of CID specialty drug use was 20.0% lower in the exchange versus the nonexchange populations (341 users per 100,000 exchange members vs. 427 users per 100,000 nonexchange members; P < 0.001). Within the exchange population, the observed likelihood of CID specialty drug use was 132 per 100,000 bronze plan members (69.1% lower than nonexchange); 326 per 100,000 silver plan members (23.5% lower than nonexchange); 579 per 100,000 gold plan members (35.6% higher than nonexchange); and 672 per 100,000 platinum plan members (57.5% higher than nonexchange). All differences were statistically significant at P < 0.001. There were also large differences by local market, ranging from 49.1% lower to 75.8% higher CID use in the exchange population than in the nonexchange population. After adjustment, the exchange population was 16.6% less likely to use CID specialty drugs than the nonexchange population (P < 0.001). Large variation in specialty drug use within the exchange plan metal tiers was reduced. After adjustment, the higher use of CID specialty drugs among the exchange population in certain local plans was no longer statistically significant. CONCLUSIONS: Members insured through exchange plans were older and sicker than those with nonexchange plans, but they did not use more CID specialty drugs compared with the nonexchange population. Large variations were seen among the exchange plan metal tiers and by local markets, which were often related to the risk profiles of exchange plan enrollees. DISCLOSURES: Funding for this study was provided by Anthem. Anthem had no role in study design, data interpretation, manuscript development, or the decision to publish. Chen, Gautam, DeVries, and Sylwestrzak are employees of HealthCore, a wholly owned subsidiary of Anthem. Richards is an employee of Anthem. Ruggieri is a former employee of Anthem and a current employee of MedImpact Healthcare Systems. Study concept and design were contributed by Ruggieri, Richards, DeVries, and Sylwestrzak. Chen took the lead in data collection, along with Gautam. Data interpretation was performed by Chen, along with the other authors. The manuscript was written by Chen, Gautam, Sylwestrzak, and DeVries and revised by Chen, Gautam, and Sylwestrzak, along with the other authors.

Lowering Cost Share May Improve Rates of Home Glucose Monitoring Among Patients with Diabetes Using Insulin.

BACKGROUND: Not much is known about the extent to which lower cost share for blood glucose strips is associated with persistent filling. OBJECTIVE: To evaluate the relationship between cost sharing for blood glucose testing strips and continued use of testing strips. METHODS: This is a retrospective observational study using medical and pharmacy claims data integrated with laboratory hemoglobin A1c (A1c) values for patients using insulin and blood glucose testing strips. Diabetic patients using insulin who had at least 1 fill of blood glucose testing strips between 2010 and 2012 were included. Patients were divided into a low cost-share group (out-of-pocket cost percentage of total testing strip costs over a 1-year period from the initial fill < 20%; n = 3,575) and a high cost-share group (out-of-pocket cost percentage ≥ 20%; n = 3,580). We compared the likelihood of continued testing strip fills after the initial fill between the 2 groups by using modified Poisson regression models. RESULTS: Patients with low cost share had higher rates of continued testing strip fills compared with those with high cost share (89% vs. 82%, P < 0.001). Lower cost share was associated with greater probability of continued fills (adjusted risk ratio [aRR] = 1.05, 95% CI = 1.03-1.07, P < 0.001). Other patient characteristics associated with continued fills included type 1 diabetes diagnosis, types of insulin regimens, and health insurance plan type. In a subset analysis of patients whose A1c values at baseline were above the target level (8%) set by the National Committee for Quality Assurance guidelines, we saw a slight increase in magnitude of relationship between cost share and continued fills (RR = 1.06, 95% CI = 1.03-1.10, P < 0.01). CONCLUSIONS: There was a statistically significant association between cost share for testing strips and continued blood glucose self-monitoring. Among patients not achieving A1c control at baseline, there was an increase in the magnitude of relationship. Lowering cost share for testing strips can remove a barrier to persistence in diabetes self-management. DISCLOSURES: Funding for this study was provided by Anthem, which had no role in the study design, data interpretation, or preparation or review of the manuscript. The decision to publish was strictly that of the authors. Xie, Agiro, and DeVries are employees of HealthCore, a wholly owned subsidiary of Anthem. Bowman is an employee of Anthem. Study concept and design were contributed by all the authors. Xie took the lead in data collection, along with Agiro, and data interpretation was performed by all the authors. The manuscript was written by Xie and Agiro, along with DeVries, and revised by Xie, Agiro, and Devries, along with Bowman.