Publications by authors named "Pinar Karaca-Mandic"

75 Publications

Physician Network Connections Associated With Faster De-Adoption of Dronedarone for Permanent Atrial Fibrillation.

Circ Cardiovasc Qual Outcomes 2021 Sep 24:CIRCOUTCOMES121008040. Epub 2021 Sep 24.

National Bureau of Economic Research, Cambridge, MA (A.J., P.K.-M.).

Background: Physicians' professional networks are an important source of new medical information and have been shown to influence the adoption of new treatments, but it is unknown how physician networks impact the de-adoption of harmful practices.

Methods: We analyzed changes in physicians' use of dronedarone after the PALLAS trial (Palbociclib Collaborative Adjuvant Study; November 2011) showed that dronedarone increased the risk of death from cardiovascular events among patients with permanent atrial fibrillation. Deidentified administrative claims from the OptumLabs Data Warehouse were combined with physicians' demographic information from the Doximity database and publicly available data on physicians' patient-sharing relationships compiled by the Centers for Medicare and Medicaid Services. We used a linear probability model with an interrupted linear time trend specification to model the impact of the PALLAS trial on physicians' dronedarone usage between 2009 and 2014.

Results: Before the PALLAS trial, the use of dronedarone was increasing by 0.22 percentage points per quarter (95% CI, 0.19-0.25) in our Medicare Advantage sample (N=343 429 patient-quarter observations) and 0.63 percentage points per quarter (95% CI, 0.52-0.75) in our commercially insured sample (N=44 402 patient-quarter observations). After the PALLAS trial and subsequent United States Food and Drug Administration black box warning, physicians in the Medicare Advantage sample with an above-median number of network connections to other physicians decreased their quarterly usage of dronedarone by 0.12 percentage points more per quarter (95% CI, -0.20 to -0.04; =0.031) than physicians with equal to or below the median number of network connections. Similar patterns existed in the commercially insured sample (=0.0318).

Conclusions: After controlling for a wide range of patient, physician, and geographic characteristics, physicians with a greater number of network connections were faster de-adopters of dronedarone for patients with permanent atrial fibrillation after the PALLAS trial and subsequent United States Food and Drug Administration black box warning detailed the harmfulness of dronedarone for these patients. Policies for improving physicians' responsiveness to new medical information should consider utilizing the influence of these important professional network relationships.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.121.008040DOI Listing
September 2021

Site of care potentially limits cost savings from biosimilars.

Am J Manag Care 2021 08 1;27(8):e287-e289. Epub 2021 Aug 1.

Mayo Clinic, 200 First St SW, Rochester, MN 55905. Email:

Objectives: The first FDA-approved biosimilar was launched in 2015: filgrastim-sndz (Zarxio), a biosimilar for the reference drug filgrastim (Neupogen). Filgrastim is a granulocyte colony-stimulating factor used to prevent and treat neutropenia. In this study, we examined the association between site of care and drug cost across reference filgrastim, tbo-filgrastim (Granix; a version of filgrastim approved as a biosimilar in Europe and as a new drug in the United States), and biosimilar filgrastim administrations among the commercially insured.

Study Design: Retrospective study using administrative claims data.

Methods: We used OptumLabs Data Warehouse to identify the site of care of each short-acting filgrastim administration among commercial enrollees between January 1, 2014, and December 31, 2019.

Results: For each filgrastim product, model-adjusted median drug costs were higher in the outpatient hospital setting than for the same drug administered in the office setting. Comparing drug costs within the same setting, in the office setting, costs of biosimilar and tbo-filgrastim were $103.61 and $94.07 lower than reference filgrastim, respectively (P < .001 for each comparison). In the outpatient hospital setting, adjusted median costs for tbo-filgrastim were lower than those for reference filgrastim (-$132.90; P < .001), but adjusted median costs of the biosimilar were slightly higher ($20.50; P = .025).

Conclusions: Although previous work has found lower costs for biosimilar filgrastim compared with reference filgrastim, here we found that site of care can change this calculus, reducing savings. After adjusting for patient characteristics and geography, we found that drug cost savings for biosimilar filgrastim were limited to the office setting, with no savings in the outpatient hospital setting.
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http://dx.doi.org/10.37765/ajmc.2021.88730DOI Listing
August 2021

Uptake of evidence by physicians: De-adoption of erythropoiesis-stimulating agents after the TREAT trial.

BMC Nephrol 2021 Aug 21;22(1):284. Epub 2021 Aug 21.

National Bureau of Economic Research and OptumLabs Visiting Fellow, University of Minnesota Carlson School of Management, 321 19th Avenue South, Minneapolis, MN, 55455, USA.

Background: Variation in de-adoption of ineffective or unsafe treatments is not well-understood. We examined de-adoption of erythropoiesis-stimulating agents (ESA) in anemia treatment among patients with chronic kidney disease (CKD) following new clinical evidence of harm and ineffectiveness (the TREAT trial) and the FDA's revision of its safety warning.

Method: We used a segmented regression approach to estimate changes in use of epoetin alfa (EPO) and darbepoetin alfa (DPO) in the commercial, Medicare Advantage (MA) and Medicare fee-for-service (FFS) populations. We also examined how changes in both trends and levels of use were associated with physicians' characteristics.

Results: Use of DPO and EPO declined over the study period. There were no consistent changes in DPO trend across insurance groups, but the level of DPO use decreased right after the FDA revision in all groups. The decline in EPO use trend was faster after the TREAT trial for all groups. Nephrologists were largely more responsive to evidence than primary care physicians. Differences by physician's gender, and age were not consistent across insurance populations and types of ESA.

Conclusions: Physician specialty has a dominant role in prescribing decision, and that specializations with higher use of treatment (nephrologists) were more responsive to new evidence of unsafety and ineffectiveness.
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http://dx.doi.org/10.1186/s12882-021-02491-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8379779PMC
August 2021

Second-Line Therapy for Type 2 Diabetes Management: The Treatment/Benefit Paradox of Cardiovascular and Kidney Comorbidities.

Diabetes Care 2021 Aug 4. Epub 2021 Aug 4.

Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN.

Objective: To examine whether glucagon-like peptide 1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2i) are preferentially initiated among patients with cardiovascular disease, heart failure (HF), or nephropathy, where these drug classes have established benefit, compared with dipeptidyl peptidase 4 inhibitors (DPP-4i), for which corresponding benefits have not been demonstrated.

Research Design And Methods: We retrospectively analyzed claims of adults with type 2 diabetes included in OptumLabs Data Warehouse, a deidentified database of commercially insured and Medicare Advantage beneficiaries, who first started GLP-1RA, SGLT2i, or DPP-4i therapy between 2016 and 2019. Using multinomial logistic regression, we examined the relative risk ratios (RRR) of starting GLP-1RA and SGLT2i compared with DPP-4i for those with a history of myocardial infarction (MI), cerebrovascular disease, HF, and nephropathy after adjusting for demographic and other clinical factors.

Results: We identified 75,395 patients who started GLP-1RA, 58,234 who started SGLT2i, and 91,884 who started DPP-4i. Patients with prior MI, cerebrovascular disease, or nephropathy were less likely to start GLP-1RA rather than DPP-4i compared with patients without these conditions (RRR 0.83 [95% CI 0.78-0.88] for MI, RRR 0.77 [0.74-0.81] for cerebrovascular disease, and RRR 0.87 [0.84-0.91] for nephropathy). Patients with HF or nephropathy were less likely to start SGLT2i (RRR 0.83 [0.80-0.87] for HF and RRR 0.57 [0.55-0.60] for nephropathy). Both medication classes were less likely to be started by non-White and older patients.

Conclusions: Patients with cardiovascular disease, HF, and nephropathy, for whom evidence suggests a greater likelihood of benefiting from GLP-1RA and/or SGLT2i therapy, were less likely to start these drugs. Addressing this treatment/benefit paradox, which was most pronounced in non-White and older patients, may help reduce the morbidity associated with these conditions.
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http://dx.doi.org/10.2337/dc20-2977DOI Listing
August 2021

Clinical Evaluation of a Novel Wearable Compression Technology in the Treatment of Lymphedema, an Open-Label Controlled Study.

Lymphat Res Biol 2021 Jul 2. Epub 2021 Jul 2.

Ellis Fischel Cancer Center, University of Missouri, Columbia, Missouri, USA.

A diagnosis of lymphedema comes with a lifetime requirement for careful self-care and treatment to control skin deterioration and the consequences of excessive fluid and protein buildup leading to abnormal limb volume and an increased risk of infection. The burden of care and psychosocial aspects of physical disfiguration and loss of function are associated with compromised quality of life (QoL). The current standard therapeutic intervention is complex decongestive therapy with manual lymph drainage and frequent wearing of compression garments. With insurance limitations on therapy visits and the time and travel required, additional home treatment options are needed. Pneumatic compression pumps that mimic the manual massage pressure and pattern are sometimes prescribed, but these are bulky, difficult to apply, and require immobility during treatment. An open-label pilot study in 40 subjects was performed to evaluate the QoL and limb volume maintenance efficacy of a novel wearable compression system (Dayspring™) that is low profile, easy to use, and allows for mobility during treatment. After 28 days of use, subjects had a statistically significant 18% ( < 0.001) improvement in overall QoL as measured by the Lymphedema Quality-of-Life Questionnaire compared with baseline. Individual QoL domains, and limb volume improved with therapy. Adherence was 98% over the course of the study. Results of the clinical evaluation suggest the Dayspring wearable compression device is safe and effective and improves QoL and limb volume. The novel, low-profile device is easy to use and allows for mobility during treatment, addressing a potential barrier to adherence with pneumatic compression devices.
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http://dx.doi.org/10.1089/lrb.2020.0126DOI Listing
July 2021

How do insurance firms respond to financial risk sharing regulations? Evidence from the Affordable Care Act.

Health Econ 2021 Jun 1;30(6):1443-1460. Epub 2021 Apr 1.

Department of Finance, Carlson School of Management, University of Minnesota, Minneapolis, Minnesota, USA.

Many insurance markets have reinstated premium stabilization programs to ensure financial protection from market volatility. In this paper, we focus on one such regulation-risk corridors (RCs)-in the context of the Health Insurance Marketplaces established under the Affordable Care Act. We develop a model to show how the program provided incentives for some insurers to lower their premiums. The RCs program was defunded unexpectedly for coverage year 2016, before its legislated end in 2016. Consistent with the model, we find that making a RCs claim before the program ended is associated with higher premium growth after the program's demise. The model and empirical evidence are consistent with the view that the end of the RCs program contributed to premium growth in the Marketplaces.
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http://dx.doi.org/10.1002/hec.4252DOI Listing
June 2021

Translational Effect of Provider-Focused, Multi-State, Multi-Clinic Asthma Care Quality Improvement Program on Patient-Level Health Care Costs.

J Prim Care Community Health 2021 Jan-Dec;12:21501327211000246

Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA.

Introduction/objectives: Enhancing Care for Patients with Asthma (ECPA), a year-long provider-focused, multi-state, multi-clinic quality improvement program, decreased avoidable utilizations among patients with asthma, but its effects on health care expenditures were not determined. This study examined the translational and sustainable effects of improved care through ECPA on individual-level total health care costs due to asthma.

Methods: We conducted a retrospective pretest-posttest quasi-experimental study in which attributed 1683 patients in a 12-month pre-ECPA implementation period served as their own control. We constructed the total annual asthma-related health care costs per patient occurred during pre-ECPA implementation, ECPA implementation, and post-ECPA completion. We used 3-level generalized linear mixed models (GLMMs) to estimate the ECPA effect on the annual health care costs and account for correlation between the repeated outcome measures for each patient and nested clinic. All costs were adjusted for inflation to 2014 U.S. dollars, the last year of program observation.

Results: Total asthma-related health care costs among the 1683 included patients decreased from an average of $7033 to $3237 per person-year (pre-ECPA implementation vs implementation). Using the cost data from the 12-month pre-ECPA implementation period as a reference, GLMMs found that the ECPA implementation was associated with a reduction in total annual asthma-related health care costs by 56.4% (95% CI -60.7%, -51.8%). During the 12-months after ECPA completion period, health care costs were also found to be significantly lower, experiencing a 57.3% reduction.

Conclusions: The economic benefits of ECPA provide a justification to adopt this quality improvement initiative to more primary care clinics at a national level.
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http://dx.doi.org/10.1177/21501327211000246DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7983490PMC
June 2021

The association of vertically integrated care with health care use and outcomes.

Health Serv Res 2021 Mar 17. Epub 2021 Mar 17.

Schaeffer Center for Health Policy and Economics, Sol Price School of Public Policy, University of Southern California, Los Angeles, California, USA.

Objective: To determine whether vertically integrated hospital and skilled nursing facility (SNF) care is associated with more efficient use of postdischarge care and better outcomes.

Data Sources: Medicare provider, beneficiary, and claims data from 2012 to 2014.

Study Design: We compared facility characteristics, quality of care, and health care use for hospital-based SNFs and "virtually integrated" SNFs (defined as freestanding SNFs with close referral relationships with a single hospital) relative to nonintegrated freestanding SNFs. Among patients admitted to integrated SNFs, we estimated differences in health care use and outcomes for patients originating from the parent hospital (ie, receiving vertically integrated care) versus other hospitals using linear regressions that included SNF fixed effects. We estimated bounds for our main estimates that incorporated potential omitted variables bias.

Data Extraction Methods: We identified hospital-based SNFs based on provider data. We defined virtually integrated SNFs based on patient flows between hospitals and SNFs. We identified SNF episodes, preceding hospital stays, patient characteristics, health care use, and patient outcomes using Medicare data.

Principal Findings: Consistent with prior research, integrated SNFs performed better on quality measures and health care use relative to nonintegrated SNFs (eg, hospital-based SNFs had 11-day shorter stays compared with nonintegrated SNFs adjusting for patient characteristics, P < .001). Stroke patients admitted to hospital-based SNFs from the parent hospital had shorter preceding hospital stays (adjusted difference: -1.2 days, P = .001) and shorter initial SNF stays (adjusted difference: -2.7 days, P = .049); estimates were attenuated but still robust accounting for potential omitted variables bias. For stroke patients, associations between vertically integrated care and other outcomes were either statistically insignificant or not robust to accounting for potential omitted variables bias.

Conclusions: Vertically integrated hospital and SNF care was associated with shorter hospital and SNF stays. However, there were few beneficial associations with other outcomes, suggesting limited coordination benefits from vertical integration.
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http://dx.doi.org/10.1111/1475-6773.13642DOI Listing
March 2021

Physician variation in the de-adoption of ineffective statin and fibrate therapy.

Health Serv Res 2021 Feb 10. Epub 2021 Feb 10.

University of Minnesota, Minneapolis, Minnesota, USA.

Objective: To describe physicians' variation in de-adopting concurrent statin and fibrate therapy for type 2 diabetic patients following a reversal in clinical evidence.

Data Sources: We analyzed 2007-2015 claims data from OptumLabs Data Warehouse, a longitudinal, real-world data asset with de-identified administrative claims and electronic health record data.

Study Design: We modeled fibrate use among Medicare Advantage and commercially insured type 2 diabetic statin users before and after the publication of the ACCORD lipid trial, which found statins and fibrates were no more effective than statins alone in reducing cardiovascular events among type 2 diabetic patients. We modeled fibrate use trends with physician random effects and physician characteristics such as age and specialty.

Data Extraction: We identified patient-year-quarters with one year of continuous insurance enrollment, type 2 diabetes diagnoses, and fibrate use. We designated the physician most responsible for patients' diabetes care based on evaluation and management visits and prescriptions of glucose-lowering drugs.

Principal Findings: Fibrate use increased by 0.12 percentage points per quarter among commercial patients (95% CI, 0.10 to 0.14) and 0.17 percentage points per quarter among Medicare Advantage patients (95% CI, 0.13 to 0.20) before the trial and then decreased by 0.16 percentage points per quarter among commercial patients (95% CI, -0.18 to -0.15) and 0.05 percentage points per quarter among Medicare Advantage patients (95% CI, -0.06 to -0.03) after the trial. However, 45% of physicians treating commercial patients and 48% of physicians treating Medicare Advantage patients had positive trends in prescribing following the trial. Physicians' characteristics did not explain their variation (pseudo R  = 0.000).

Conclusion: On average, physicians decreased fibrate prescribing following the ACCORD lipid trial. However, many physicians increased prescribing following the trial. Observable physician characteristics did not explain variations in prescribing. Future research should examine whether physicians vary similarly in other de-adoption settings.
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http://dx.doi.org/10.1111/1475-6773.13630DOI Listing
February 2021

Comparison of Diabetes Medications Used by Adults With Commercial Insurance vs Medicare Advantage, 2016 to 2019.

JAMA Netw Open 2021 02 1;4(2):e2035792. Epub 2021 Feb 1.

Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota.

Importance: Glucagonlike peptide-1 receptor agonists (GLP-1RA), sodium-glucose cotransporter-2 inhibitors (SGLT2i), and dipeptidyl peptidase-4 inhibitors (DPP-4i) are associated with low rates of hypoglycemia, and postmarketing trials of GLP-1RA and SGLT2i demonstrated that these medications improved cardiovascular and kidney outcomes.

Objective: To compare trends in initiation of treatment with GLP-1RA, SGLT2i, and DPP-4i by older adults with type 2 diabetes insured by Medicare Advantage vs commercial health plans.

Design, Setting, And Participants: This retrospective cohort study used administrative claims data from a deidentified database of commercially insured and Medicare Advantage beneficiaries. Adults aged 58 to 66 years with type 2 diabetes who filled any medication prescription to lower glucose levels from January 1, 2016, to December 31, 2019, were compared between groups.

Exposure: Enrollment in a Medicare Advantage or commercial health insurance plan.

Main Outcomes And Measures: The odds of initiating GLP-1RA, SGLT2i, and DPP-4i treatment were examined for Medicare Advantage vs commercial insurance beneficiaries using 3 separate logistic regression models adjusted for year and demographic and clinical factors. These models were used to calculate adjusted annual rates of medication initiation by health plan.

Results: A total of 382 574 adults with pharmacologically treated type 2 diabetes (52.9% men; mean [SD] age, 62.4 [2.7] years) were identified, including 172 180 Medicare Advantage and 210 394 commercial beneficiaries. From 2016 to 2019, adjusted rates of initiation of GLP-1RA, SGLT2i, and DPP-4i treatment increased among all beneficiaries, from 2.14% to 20.02% for GLP-1RA among commercial insurance beneficiaries and from 1.50% to 11.44% among Medicare Advantage beneficiaries; from 2.74% to 18.15% for SGLT2i among commercial insurance beneficiaries and from 1.57% to 8.51% among Medicare Advantage beneficiaries; and from 3.30% to 11.71% for DPP-4i among commercial insurance beneficiaries and from 2.44% to 7.68% among Medicare Advantage beneficiaries. Initiation rates for all 3 drug classes were consistently lower among Medicare Advantage than among commercial insurance beneficiaries. Within each calendar year, the odds of initiating GLP-1RA treatment ranged from 0.28 (95% CI, 0.26-0.29) to 0.70 (95% CI, 0.65-0.75) for Medicare Advantage and commercial insurance beneficiaries, respectively; SGLT2i, from 0.21 (95% CI, 0.20-0.22) to 0.57 (95% CI, 0.53-0.61), respectively; and DPP-4i, from 0.37 (95% CI, 0.34-0.39) to 0.73 (95% CI, 0.69-0.78), respectively (P < .001 for all). The odds of starting GLP-1RA and SGLT2i increased with income; for an income of $200 000 and higher vs less than $40 000, the odds ratio for GLP-1RA was 1.23 (95% CI, 1.15-1.32) and for SGLT2i was 1.16 (95% CI, 1.09-1.24).

Conclusions And Relevance: These findings suggest that Medicare Advantage beneficiaries may be less likely than commercially insured beneficiaries to be treated with newer medications to lower glucose levels, with greater disparities among lower-income patients. Better understanding of nonclinical factors contributing to treatment decisions and efforts to promote greater equity in diabetes management appear to be needed.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.35792DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7851726PMC
February 2021

Trends in Pediatric Hospitalizations for Coronavirus Disease 2019.

JAMA Pediatr 2021 04;175(4):415-417

Department of Finance, Medical Industry Leadership Institute, University of Minnesota Carlson School of Management, Minneapolis.

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http://dx.doi.org/10.1001/jamapediatrics.2020.5535DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802004PMC
April 2021

The Effects of Market Competition on Cardiologists' Adoption of Transcatheter Aortic Valve Replacement.

Med Care 2020 11;58(11):996-1003

Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania.

Background: For decades, the prevailing assumption regarding the diffusion of high-cost medical technologies has been that competitive markets favor more aggressive adoption of new treatments by health care providers (ie, the "Medical Arms Race"). However, novel regulations governing the adoption of transcatheter aortic valve replacement (TAVR) may have disrupted this paradigm when TAVR was introduced.

Objective: The objective of this study was to assess the relationship between the market concentration of physician group practices and the adoption of TAVR in its first years of use.

Research Design: This was a retrospective cohort study.

Subjects: Physician group practices (n=5116) providing interventional cardiology services in the United States from May 1, 2012, to December 31, 2014.

Measures: The first use of TAVR as indicated by a fee-for-service Medicare claim. Covariates including characteristics of the physician groups (ie, case volume, hospital affiliation, mean patient risk) as well as county-level and market-level characteristics.

Results: By the close of 2014, 9.3% of practices had adopted TAVR. Cox proportional hazards models revealed a hazard ratio of 1.26 (95% confidence interval: 1.16-1.37, P<0.001) per 1000 point increase in the physician group practice Herfindahl-Hirschman Index, indicating each 1000 point increase in group practice Herfindahl-Hirschman Index was associated with a 26% relative increase in the rate of TAVR adoption.

Conclusions: Adoption of TAVR by physician groups in concentrated markets was potentially a consequence of the unique regulations governing TAVR reimbursement, which favored the adoption of TAVR by physician groups with greater market power. These findings have important implications for how future regulations may shape patterns of technology adoption.
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http://dx.doi.org/10.1097/MLR.0000000000001391DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7572719PMC
November 2020

Association of COVID-19-Related Hospital Use and Overall COVID-19 Mortality in the USA.

J Gen Intern Med 2020 Aug 19. Epub 2020 Aug 19.

Departments of Pharmacy, Health Services, and Economics University of Washington, Seattle, WA, USA.

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http://dx.doi.org/10.1007/s11606-020-06084-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7437636PMC
August 2020

Assessment of COVID-19 Hospitalizations by Race/Ethnicity in 12 States.

JAMA Intern Med 2021 01;181(1):131-134

Carlson School of Management, Department of Information & Decision Sciences, University of Minnesota, Minneapolis.

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http://dx.doi.org/10.1001/jamainternmed.2020.3857DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7432276PMC
January 2021

Patient and provider-level factors associated with changes in utilization of treatments in response to evidence on ineffectiveness or harm.

Int J Health Econ Manag 2020 Sep 30;20(3):299-317. Epub 2020 Apr 30.

National Bureau of Economic Research, Cambridge, MA, USA.

High-quality health care not only includes timely access to effective new therapies but timely abandonment of therapies when they are found to be ineffective or unsafe. Little is known about changes in use of medications after they are shown to be ineffective or unsafe. In this study, we examine changes in use of two medications: fenofibrate, which was found to be ineffective when used with statins among patients with Type 2 diabetes (ACCORD lipid trial); and dronedarone, which was found to be unsafe in patients with permanent atrial fibrillation (PALLAS trial). We examine the patient and provider characteristics associated with a decline in use of these medications. Using Medicare fee-for-service claims from 2008 to 2013, we identified two cohorts: patients with Type 2 diabetes using statins (7 million patient-quarters), and patients with permanent atrial fibrillation (83 thousand patient-quarters). We used interrupted time-series regression models to identify the patient- and provider-level characteristics associated with changes in medication use after new evidence emerged for each case. After new evidence of ineffectiveness emerged, fenofibrate use declined by 0.01 percentage points per quarter (95% CI - 0.02 to - 0.01) from a baseline of 6.9 percent of all diabetes patients receiving fenofibrate; dronedarone use declined by 0.13 percentage points per quarter (95% CI - 0.15 to - 0.10) from a baseline of 3.8 percent of permanent atrial fibrillation patients receiving dronedarone. For dronedarone, use declined more quickly among patients dually-enrolled in Medicare and Medicaid compared to Medicare-only patients (P < 0.001), among patients seen by male providers compared to female providers (P = 0.01), and among patients seen by cardiologists compared to primary care providers (P < 0.001).
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http://dx.doi.org/10.1007/s10754-020-09282-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7725279PMC
September 2020

Reducing potentially preventable health events among patients with asthma through multi-state, multi-center quality improvement program.

J Asthma 2021 Jul 27;58(7):874-882. Epub 2020 Mar 27.

Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA.

Introduction: Enhancing Care for Patients with Asthma is a multi-state, multi-center quality improvement program developed to augment guideline-based practice among health care providers through Plan-Do-Study-Act cycle. This study examined the association between the implementation of the guideline-based quality improvement program and subsequent changes in asthma-related emergency room visits and hospitalizations.

Methods: This retrospective, interrupted time-series study used administrative claims data from a private insurer that provided coverage to patients receiving care from participating health centers (15 centers in New Mexico, Oklahoma, Texas, and Illinois). The 12-month implementation period started in January 2013 for centers in Cohort 1 and October 2013 for centers in Cohort 2. The claims of 1,828 patients with asthma from January 2012 to May 2015 were analyzed. The data included 12-month pre-program implementation, 12-month program implementation, and 5-month post-program completion periods.

Results: The average number of asthma-related emergency room visits and hospitalizations decreased from 2.22 to 1.38 and 1.97 to 1.04 per 100 patients per month, respectively, in the 12-month pre-implementation period as compared to 12-month implementation period. The results of three-level generalized linear mixed models found that during the 12-month implementation period, patients had 37.7% and 47.1% lower rates of emergency room visits and hospitalizations, respectively, compared to the 12-month pre-implementation period ( < 0.001 in both comparisons).

Conclusions: Enhancing Care for Patients with Asthma is an effective quality improvement program that was successfully executed in diverse geographical states and associated with reductions in potentially preventable health events. The findings support the widespread use of the program in other settings.
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http://dx.doi.org/10.1080/02770903.2020.1741611DOI Listing
July 2021

Biosimilar Filgrastim Uptake And Costs Among Commercially Insured, Medicare Advantage.

Health Aff (Millwood) 2019 11;38(11):1887-1892

Molly Moore Jeffery is a research associate in the Department of Health Care Policy and Research and scientific director of research in emergency medicine, Mayo Clinic, in Rochester.

In 2015 the Food and Drug Administration approved filgrastim-sndz (Zarxio), the first US biosimilar. Following rapid uptake, by March 2018 filgrastim-sndz accounted for 47 percent of filgrastim administrations among commercially insured and 42 percent among Medicare Advantage beneficiaries. The initial cost difference between the originator and biosimilar was 31 percent in the former population but negligible in the latter.
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http://dx.doi.org/10.1377/hlthaff.2019.00253DOI Listing
November 2019

Medicare Prescription Drug Plan Formulary Restrictions After Postmarket FDA Black Box Warnings.

J Manag Care Spec Pharm 2019 Nov;25(11):1201-1217

Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Medical Center, and University of California, San Francisco, School of Medicine, San Francisco, California.

Background: The boxed warning (also known as "black box warning") is one of the FDA's strongest safety actions for pharmaceuticals. After the FDA issues black box warnings for drugs, prescribing changes have been inconsistent. Formulary management may provide an opportunity to restrict access to drugs with serious safety concerns.

Objective: To examine Medicare prescription drug plan formulary changes after new FDA postmarket black box warnings and major updates to preexisting black box warnings.

Methods: In this cohort study, we identified each drug that received a new FDA postmarket black box warning or a major update to a preexisting black box warning from January 2008 through June 2015 and examined its formulary coverage. The main outcome measure was the proportion of Medicare prescription drug plan formularies providing unrestrictive coverage immediately before the black box warning, at least 1 year after the warning and at least 2 years after the warning. Unrestrictive formulary coverage was defined as coverage of a drug without prior authorization or step-therapy requirements.

Results: Of 101 new black box warnings and major updates to preexisting warnings affecting 68 unique drug formulations, the mean percentage of formularies providing unrestrictive coverage changed from 65.4% (95% CI = 59.6%-71.2%) prewarning; 62.6% (95% CI = 56.3%-68.9%, = 0.04) at least 1 year postwarning; and 61.9% (95% CI = 55.4%-68.5%, = 0.10) at least 2 years postwarning.

Conclusions: The mean percentage of Medicare prescription drug plan formularies providing unrestrictive coverage decreased modestly by approximately 3 percentage points after drugs received postmarket FDA black box warnings. Formulary restrictions may present an underused mechanism to reduce use of potentially unsafe medications.

Disclosures: This study was supported by a student research grant received by Solotke and provided by the Yale School of Medicine Office of Student Research under National Institutes of Health training grant award T35DK104689. Karaca-Mandic, Shah, and Ross acknowledge support from Agency for Healthcare Research and Quality (AHRQ) grant R01 HS025164, which studies factors associated with de-adoption of drug therapies shown to be ineffective or unsafe. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors assume full responsibility for the accuracy and completeness of the ideas presented. Ross has received support from the following: the U.S. Food and Drug Administration (FDA) as part of the Centers for Excellence in Regulatory Science and Innovation (CERSI) program; Johnson and Johnson through Yale University to develop methods of clinical trial data sharing; Medtronic and the FDA to develop methods for postmarket surveillance of medical devices; the Blue Cross Blue Shield Association to better understand medical technology evaluation; the Centers for Medicare & Medicaid Services (CMS) to develop and maintain performance measures that are used for public reporting; the AHRQ to examine community predictors of health care quality; and the Laura and John Arnold Foundation, which established the Collaboration for Research Integrity and Transparency at Yale University. Shah has received support from the FDA as part of the CERSI program. In addition, he has received support through the Mayo Clinic from CMS, AHRQ, National Science Foundation, and Patient-centered Outcomes Research Institute. Karaca-Mandic has provided consulting services to Precision Health Economics and Tactile Medical for work unrelated to this manuscript. Dhruva and Solotke have no conflicts of interest to report.
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http://dx.doi.org/10.18553/jmcp.2019.25.11.1201DOI Listing
November 2019

Factors Associated with Psychiatrist Opt-out from US Medicare: an Observational Study.

J Gen Intern Med 2019 11 16;34(11):2460-2466. Epub 2019 Aug 16.

Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA.

Background: Concerns exist about availability and access to psychiatric services in the USA. For Medicare beneficiaries, one impediment to psychiatric services is the extent to which psychiatrists have opted out of the Medicare program.

Objective: This study describes geographic variation in rates that psychiatrists opt out of Medicare, and assesses physician-level and geographic-level predictors of opt-out.

Design: Retrospective cross-sectional analysis of data describing psychiatrists' opt-out status as of March 2017 linked to data on psychiatrist location, psychiatrist characteristics (obtained from a comprehensive US physician database), and market area-level characteristics.

Participants: 27,838 psychiatrists in the USA MAIN MEASURES: Whether a psychiatrist had opted out of Medicare as of March 2017.

Key Results: Overall, 7.0% of psychiatrists (1940/27,838) opted out of Medicare as of March 2017. Opt-out rates varied substantially across states and within states. Physician-level factors independently associated with opt-out included: older age (psychiatrists > 65 years were 2.6 percentage points more likely to opt vs. psychiatrists < 35 years old, p = 0.03), greater years of experience, female gender (female psychiatrists were 2.6 percentage points more likely to opt out than male psychiatrists, p < 0.001), graduation from a top-20 ranked medical school (1.7 percentage points more likely to opt out of Medicare, p < 0.001), and domestic medical graduate (domestic graduates were 7.3 percentage points more likely to opt out of Medicare vs. foreign graduates, p < 0.001). Adjusting for other individual- and geographic-level factors, psychiatrists who practiced in areas with more psychiatrists per Medicare beneficiary were less likely to opt out (p < 0.001).

Conclusions: The overall likelihood that psychiatrists opt out of Medicare is significant and varies considerably across regions and by characteristics of psychiatrists.
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http://dx.doi.org/10.1007/s11606-019-05246-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6848419PMC
November 2019

The potential impact of CAR T-cell treatment delays on society.

Am J Manag Care 2019 08;25(8):379-386

Precision Health Economics, 1999 Harrison St, Ste 1420, Oakland, CA 94612. Email:

Objectives: To date, breakthrough chimeric antigen receptor (CAR) T-cell therapies, such as tisagenlecleucel, indicated for pediatric acute lymphoblastic leukemia (pALL) and diffuse large B-cell lymphoma (DLBCL), and axicabtagene ciloleucel, indicated for DLBCL, although clinically effective, have been limited by treatment delays. Our study measured the social value of CAR T-cell therapy (CAR T) for relapsed or refractory pALL and DLBCL in the United States and quantified social value lost due to treatment delays.

Study Design: We used an economic framework for therapy valuation, measuring social value as the sum of consumer surplus and manufacturer profit. Consumer surplus is the difference between the value of health gains from a therapy and its incremental cost, while accounting for indirect costs and benefits to patients.

Methods: For 20 incident cohorts of pALL (n = 20 × 400 = 8000) and DLBCL (n = 20 × 5902 = 118,040), we quantified patient value, calculated as the value of additional quality-adjusted life-years gained with CAR T, minus the incremental cost of CAR T compared with standard of care (SOC). We calculated manufacturer profits using a range of production costs given uncertainties in the production process. Patient value and manufacturer profits were summed to obtain total social value. We measured social value lost from treatment delays, assuming that patients received the SOC while awaiting CAR T-cell treatment.

Results: Depending on production costs, as much as $6.5 billion and $34.8 billion in social value was generated for patients with pALL and DLBCL, respectively. However, with 1, 2, or 6 months of treatment delay (assuming $200,000 production costs), the pALL population lost 9.8%, 36.2%, and 67.3% of social value, respectively, whereas the DLBCL population lost 4.2%, 11.5%, and 46.0%, relative to no delay.

Conclusions: The social value of CAR T is significantly limited by treatment delays. Efficient payment mechanisms, adequate capital, and payment policy reform are urgently needed to increase patient access and maximize the value of CAR T.
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August 2019

Adoption of New Glucose-Lowering Medications in the U.S.-The Case of SGLT2 Inhibitors: Nationwide Cohort Study.

Diabetes Technol Ther 2019 12 9;21(12):702-712. Epub 2019 Oct 9.

Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota.

High-quality diabetes care is evidence-based, timely, and equitable. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are the most recently approved class of glucose-lowering medications with additional cardio- and renal-protective benefits and low risk of hypoglycemia. Cardiovascular and kidney disease are among the most common chronic diabetes complications, whereas hypoglycemia is the most prevalent adverse effect of glucose-lowering therapy. We examine the sociodemographic and clinical factors associated with early SGLT2i initiation and appropriateness of use based on contemporaneous scientific evidence. Retrospective analysis of medical and pharmacy claims data from OptumLabs Data Warehouse for commercially insured and Medicare Advantage adult beneficiaries with diabetes types 1 and 2, who filled any glucose-lowering medication between January 1, 2013 and December 31, 2016. Demographic (age, sex, race, income), clinical (comorbidities), and insurance-related factors affecting first prescription for a SGLT2i were examined using multivariable logistic regression. Among 1,054,727 adults with pharmacologically treated diabetes, 7.2% ( = 75,500) initiated a SGLT2i. Patients with prior myocardial infarction (MI) (odds ratio [OR]: 0.94, 95% confidence interval [CI]: 0.91-0.96), heart failure (HF) (OR: 0.93, 95% CI: 0.91-0.94), kidney disease (OR: 0.80, 95% CI: 0.78-0.81), and severe hypoglycemia (OR: 0.96, 95% CI: 0.94-0.98) were all less likely to start a SGLT2i;  < 0.001 for all. SGLT2i were also less likely to be started by patients ≥75 years (OR: 0.57, 95% CI: 0.55-0.59, vs. 18-44 years), Black patients (OR: 0.93, 95% CI: 0.91-0.95, vs. White), and those with Medicare Advantage insurance (OR: 0.63, 95% CI: 0.62-0.64, vs. commercial). Younger, healthier, non-Black patients with commercial health insurance were most likely to start taking SGLT2i. Patients with MI, HF, kidney disease, and prior hypoglycemia were less likely to use SGLT2i, despite evidence supporting their preferential use in these patients. Efforts to address this treatment-risk paradox may help improve health outcomes among patients with type 2 diabetes.
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http://dx.doi.org/10.1089/dia.2019.0213DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7207017PMC
December 2019

Rates of Physician Coprescribing of Opioids and Benzodiazepines After the Release of the Centers for Disease Control and Prevention Guidelines in 2016.

JAMA Netw Open 2019 08 2;2(8):e198325. Epub 2019 Aug 2.

National Bureau of Economic Research, Cambridge, Massachusetts.

Importance: The Centers for Disease Control and Prevention guidelines in 2016 recommended avoiding concurrent use of opioids and benzodiazepines.

Objective: To determine whether the release of the guidelines was associated with changes in coprescription of opioids and benzodiazepines.

Design, Setting, And Participants: This retrospective cohort study used claims data obtained from a US national database of medical and pharmacy claims for 3 598 322 adult commercially insured patients and 1 299 142 Medicare Advantage (MA) beneficiaries with no recent history of cancer, sickle cell disease, or hospice care who ever used prescribed opioids during the study period, January 1, 2014, through March 31, 2018.

Exposures: Overlapping opioid and benzodiazepine prescriptions filled.

Main Outcomes And Measures: The extent (proportion of person-months with any overlapping days of prescription of opioids and benzodiazepines) and intensity (proportion of days with opioids prescribed where benzodiazepines were also available) of coprescription.

Results: Of 4 897 464 patients (with 13.4 million person-months of opioid use), the total number of unique commercially insured individuals was 3 598 322 (1 974 731 women [54.9%]), and the total number of unique MA beneficiaries was 1 299 142 (770 256 women [59.3%]). Among 128 576 participants experiencing chronic pain episodes, more than one-half of person-months of long-term opioid use occurred in women (52.7% of person-months among those with commercial insurance and 62.4% of person-months among MA beneficiaries). The median (interquartile range) age of the participants was 51 (41-58) years for patients in the commercial insurance group and 70 (61-77) years for those in the MA group. The mean (SE) extent of coprescription was 23.0% (0.18%) for the commercial insurance group and 25.7% (0.18%) for the MA group. The extent of coprescription decreased in the targeted guideline population-individuals with long-term opioid use-after the guideline release (postguideline slope, -0.95 percentages point per year [95% CI, -1.44 to -0.46 percentage points per year] for the commercial insurance group and -1.06 percentage points per year [95% CI, -1.49 to -0.63 percentage points per year] for the MA group). Nontargeted short-term episodes of opioid use were associated with no change or small declines in trend (for the MA group, postguideline slope of 0.47 percentage point per year [95% CI, 0.35-0.59 percentage point per year]; for the commercial insurance group, postguideline slope of -0.05 percentage point per year [95% CI, -0.12 to 0.02 percentage point per year]). High coprescribing intensity was seen, with 79.3% (95% CI, 78.9%-79.6%) of opioid prescription days in the commercial insurance group and 83.9% (95% CI, 83.7%-84.2%) in the MA group overlapping with benzodiazepines. There was no change in the intensity of coprescribing. Intensity of coprescription was higher when the same clinician prescribed opioids and benzodiazepines.

Conclusion And Relevance: This study observed a reduction in the extent but not intensity of coprescribing of benzodiazepines for patients with long-term opioid use.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.8325DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6681551PMC
August 2019

Assessing the Content of Television Health Insurance Advertising during Three Open Enrollment Periods of the ACA.

J Health Polit Policy Law 2018 12;43(6):961-989

University of Minnesota.

Television advertising has been a primary method for marketing new health plans available under the Affordable Care Act (ACA) to consumers. Data from Kantar Media's Campaign Media Analysis Group were used to analyze advertising content during three ACA open enrollment periods (fall 2013 to spring 2016). Few advertisement airings featured people who were elderly, disabled, or receiving care in a medical setting, and over time airings increasingly featured children, young adults, and people exercising. The most common informational messages focused on plan choice and availability of low-cost plans, but messages shifted over open enrollment cycles to emphasize avoidance of tax penalties and availability of financial assistance. Over the three open enrollment periods, there was a sharp decline in explicit mentions of the ACA or Obamacare in advertisements. Overall, television advertisements have increasingly targeted young, healthy consumers, and informational appeals have shifted toward a focus on financial factors in persuading individuals to enroll in marketplace plans. These advertising approaches make sense in the context of pressures to market plans to appeal to a sufficiently large, diverse group. Importantly, dramatic declines over time in explicit mention of the law mean that citizens may fail to understand the connection between the actions of government and the benefits they are receiving.
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http://dx.doi.org/10.1215/03616878-7104392DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521724PMC
December 2018

Skilled Nursing Facility Participation in Medicare's Bundled Payments for Care Improvement Initiative: A Retrospective Study.

Arch Phys Med Rehabil 2019 02 4;100(2):307-314. Epub 2018 Oct 4.

Sol Price School of Public Policy, University of Southern California, Los Angeles, CA. Electronic address:

Objective: To investigate differences in facility characteristics, patient characteristics, and outcomes between skilled nursing facilities (SNFs) that participated in Medicare's voluntary Bundled Payments for Care Improvement (BPCI) initiative and nonparticipants, prior to BPCI.

Design: Retrospective, cross-sectional comparison of BPCI participants and nonparticipants.

Setting: SNFs.

Participants: All Medicare-certified SNFs (N=15,172) and their 2011-2012 episodes of care for chronic obstructive pulmonary disease, congestive heart failure, femur and hip/pelvis fracture, hip and femur procedures, lower extremity joint replacement, and pneumonia (N=873,739).

Interventions: Participation in a bundled payment program that included taking financial responsibility for care within a 90-day episode.

Main Outcome Measures: This study investigates the characteristics of bundled payment participants and their patient characteristics and outcomes relative to nonparticipants prior to BPCI, to understand the implications of a broader implementation of bundled payments.

Results: SNFs participating in BPCI were more likely to be in urban areas (80.8%-98.4% vs 69.5%) and belong to a chain or system (73.8%-85.5% vs 55%), and were less likely to be located in the south (13.1%-20.2% vs 35.4%). Quality performance was similar or higher in most cases for SNFs participating in BPCI relative to nonparticipants. In addition, BPCI participants admitted higher socioeconomic status patients with similar clinical characteristics. Initial SNF length of stay was shorter and hospital readmission rates were lower for BPCI patients compared to nonparticipant patients.

Conclusions: We found that SNFs participating in the second financial risk-bearing phase of BPCI represented a diversity of SNF types, regions, and levels of quality and the results may provide insight into a broader adoption of bundled payment for postacute providers.
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http://dx.doi.org/10.1016/j.apmr.2018.08.186DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6348124PMC
February 2019

Do Skilled Nursing Facilities Selected to Participate in Preferred Provider Networks Have Higher Quality and Lower Costs?

Health Serv Res 2018 12 15;53(6):4886-4905. Epub 2018 Aug 15.

Sol Price School of Public Policy, Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA.

Objective: To determine whether skilled nursing facilities (SNFs) chosen by health systems to participate in preferred provider networks exhibited differences in quality, costs, and patient outcomes relative to other SNFs after accounting for differences in case mix.

Data Sources: Medicare provider and claims data, 2012 and 2013.

Study Design: We compared SNFs included in preferred networks relative to other SNFs in the same market, prior to the establishment of preferred provider networks.

Data Extraction Methods: We linked the SNFs in our sample to facility characteristics and quality data. We identified SNF admissions and hospitalizations in claims data and limited the analysis to patients discharged from the hospitals in our sample. We obtained patient characteristics from Medicare summary files and the preceding hospital stay.

Principal Findings: Preferred SNFs exhibited better performance across publicly reported quality measures. Patients admitted to preferred SNFs exhibited shorter stays, lower Medicare payments, and lower probability of SNF readmission relative to nonpreferred SNFs.

Conclusions: Our results imply that health systems selected SNFs with lower resource use and better performance on quality measures. Thus, the trend toward preferred provider networks could have implications for Medicare spending and patient health.
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http://dx.doi.org/10.1111/1475-6773.13027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6232398PMC
December 2018

Health and economic benefits of advanced pneumatic compression devices in patients with phlebolymphedema.

J Vasc Surg 2019 02 15;69(2):571-580. Epub 2018 Jun 15.

Division of Cardiovascular Medicine, Stanford University School of Medicine, Falk Cardiovascular Research Center, Stanford, Calif. Electronic address:

Objective: Phlebolymphedema (chronic venous insufficiency-related lymphedema) is a common and costly condition. Nevertheless, there is a dearth of evidence comparing phlebolymphedema therapeutic interventions. This study sought to examine the medical resource utilization and phlebolymphedema-related cost associated with Flexitouch (FLX; Tactile Medical, Minneapolis, Minn) advanced pneumatic compression devices (APCDs) relative to conservative therapy (CONS) alone, simple pneumatic compression devices (SPCDs), and other APCDs in a representative U.S. population of phlebolymphedema patients.

Methods: This was a longitudinal matched case-control analysis of deidentified private insurance claims. The study used administrative claims data from Blue Health Intelligence for the complete years 2012 through 2016. Patients were continuously enrolled for at least 18 months, diagnosed with phlebolymphedema, and received at least one claim for CONS either alone or in addition to pneumatic compression (SPCDs or APCDs). The main outcomes included direct phlebolymphedema- and sequelae-related medical resource utilization and costs.

Results: After case matching, the study included 86 patients on CONS (87 on FLX), 34 on SPCDs (23 on FLX), and 69 on other APCDs (67 on FLX). Compared with CONS, FLX was associated with 69% lower per patient per year total phlebolymphedema- and sequelae-related costs net of any pneumatic compression device-related costs ($3839 vs $12,253; P = .001). This was driven by 59% fewer mean annual hospitalizations (0.13 vs 0.32; P < .001) corresponding to 82% lower inpatient costs and 55% lower outpatient hospital costs. FLX was also associated with 52% lower outpatient physical therapy and occupational therapy costs and 56% lower other outpatient-related costs. Compared with SPCDs, FLX was associated with 85% lower total costs ($1153 vs $7449; P = .008) driven by 93% lower inpatient costs ($297 vs $4215; P = .002), 84% lower outpatient hospital costs ($368 vs $2347; P = .020), and 85% lower other outpatient-related costs ($353 vs $2313; P = .023). Compared with APCDs, FLX was associated with 53% lower total costs ($3973 vs $8436; P = .032) because of lower outpatient costs and lower rates of cellulitis (22.4% vs 44.9% of patients; P = .02).

Conclusions: This analysis indicates significant benefits attributable to FLX compared with alternative compression therapies that can help reduce the notable economic burden of phlebolymphedema.
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http://dx.doi.org/10.1016/j.jvs.2018.04.028DOI Listing
February 2019

TV Advertising Volumes Were Associated With Insurance Marketplace Shopping And Enrollment In 2014.

Health Aff (Millwood) 2018 06;37(6):956-963

Pinar Karaca-Mandic is an associate professor in the Finance Department and academic director of the Medical Industry Leadership Institute, Carlson School of Management, University of Minnesota.

The effectiveness of health insurance advertising has gained renewed attention following the Trump administration's decision to reduce the marketing budget for the federal Marketplace. Yet there is limited evidence on the relationship between advertising and enrollment behavior. This study combined survey data from the 2014 National Health Interview Survey on adults ages 18-64 with data on volumes of televised advertisements aired in respondents' counties of residence during the 2013-14 open enrollment period. We found that people living in counties with higher numbers of ads sponsored by the federal government were significantly more likely to shop for and enroll in a Marketplace plan. In contrast, people living in counties with higher numbers of ads from political sponsors opposing the Affordable Care Act (ACA) were less likely to shop or enroll. These findings add to the evidence base around advertising in the ACA context.
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http://dx.doi.org/10.1377/hlthaff.2017.1507DOI Listing
June 2018

Enhancing guideline-based asthma care processes through a multi-state, multi-center quality improvement program.

J Asthma 2019 Apr 11;56(4):440-450. Epub 2018 May 11.

a Department of Pharmaceutical Care & Health Systems, College of Pharmacy , University of Minnesota , Minneapolis , Minnesota , USA.

Objective: This study investigated the effectiveness of Enhancing Care for Patients with Asthma (ECPA)-a collaborative quality improvement program implemented in 65 community health centers that serve asthma patients in four states-on clinic-based asthma performance measures consistent with national guidelines.

Methods: This study utilized a pretest-posttest quasi-experimental design. Six clinic-based performance measures of each center were collected from a retrospective chart review at time points: before the ECPA implementation; at the end of the 12-month long ECPA program; and 6 months after program completion. The effectiveness of the ECPA was assessed using generalized linear mixed models with a Poisson distribution and log link by evaluating the change in each measure from baseline to program completion, from baseline to 6-month post-program completion and from program completion to 6-month post-program completion.

Results: The ECPA implementation was positively associated with improvement in all measures from baseline to program completion: documentation of asthma severity (rate ratio (RR) 1.314; 95% confidence interval (CI) 1.206, 1.432); Asthma Control Test (RR 3.625; 95% CI 3.185, 4.124); pulmonary function testing (RR 1.771; 95% CI 1.527, 2.054), asthma education (RR 2.246; 95% CI 2.018, 2.501), asthma action plan (RR 2.335; 95% CI 2.070, 2.634) and controller medication (RR 1.961; 95% CI 1.504,2.556). Improvement was sustained for all six measures at the 6-month post-program completion time point.

Conclusion: This study demonstrated the favorable effect of the ECPA program on evidence-based asthma quality measures. This program could be considered a model worth replication on a broader scale.
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http://dx.doi.org/10.1080/02770903.2018.1463378DOI Listing
April 2019

Rural-urban differences in access to hospital obstetric and neonatal care: how far is the closest one?

J Perinatol 2018 06 16;38(6):645-652. Epub 2018 Feb 16.

Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA.

Objectives: To quantify drive distances to hospital obstetric services and advanced neonatal care and to examine such disparities by residential rurality and insurance type.

Study Design: Data for all-payer maternal childbirth hospitalizations in 2002 (N = 661,240) and 2013 (N = 634,807) from nine geographically dispersed states were linked with the American Hospital Association annual surveys to identify maternal residence zip codes and the addresses of hospitals with obstetric services or advanced neonatal care.

Results: The uneven geographic distribution of hospital obstetric and advanced neonatal care increased between 2002 and 2013, varying by maternal residential rurality and insurance type. Women in rural non-core areas, with Medicaid or no insurance, and living in counties with lower income and educational attainment, had to travel farther to the nearest hospital with obstetric services or neonatal care than their counterparts.

Conclusions: Women in communities that are already socioeconomically disadvantaged face increasing and substantial travel distances to access perinatal care.
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http://dx.doi.org/10.1038/s41372-018-0063-5DOI Listing
June 2018
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