American Health and Drug Benefits最新文献

Background: An enhanced recovery pathway using individualized multimodal pain management with scheduled nonopioid and opioid regimens previously enabled reproducible same-day discharge of Medicare beneficiaries and commercially insured patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) procedures in the hospital or in ambulatory surgery center settings.

Objective: To analyze the migration trends for TKA and THA procedures from a hospital to an ambulatory surgery center facility and to assess perioperative outcomes before and after incorporating liposomal bupivacaine into a multimodal pain management regimen for these procedures.

Methods: This retrospective medical chart review study included patients undergoing THA or TKA with an enhanced recovery pathway in a hospital or an ambulatory surgery center between 2013 and 2019. The outcome measures included length of stay at the hospital or the ambulatory center, and opioid consumption. We compared the outcomes before and after the addition of liposomal bupivacaine to surgeon-applied periarticular intraoperative local anesthetic field blocks between in-hospital patients who received and patients who did not receive liposomal bupivacaine in 2013 and 2014, and the impact of liposomal bupivacaine use in the hospital versus the ambulatory center from 2015 to 2019.

Results: In 2013 and 2014, the addition of liposomal bupivacaine increased the same-day hospital discharge rate to 32% versus 4% without liposomal bupivacaine (odds ratio, 14.3; 95% confidence interval, 5.9-33.3; P <.0001); the same-day hospital discharge rates increased to 73% in 2015. From 2015 through 2019, 89% of all patients were discharged on the same day from the hospital. In-hospital opioid use was 22% lower in the liposomal bupivacaine cohort than in the patients who did not receive this medication (P = .0035). In 2018 and 2019, same-day discharge from the hospital or the ambulatory surgery center rates were 96% and 100%, respectively, and 84% of the patients used postsurgical opioid prescriptions of 30 or fewer tablets. The complication rates and healthcare resource utilization did not increase with the incorporation of liposomal bupivacaine into the enhanced recovery pathway and increased same-day discharge rates.

Conclusion: An enhanced recovery pathway using individualized, scheduled multimodal pain management protocol in patients undergoing THA or TKA facilitated reproducible, high same-day discharge rates and low postoperative opioid consumption. These results suggest that the use of liposomal bupivacaine for intraoperative field blocks supports predictable same-day discharge rates after THA or TKA. This protocol could facilitate same-day hospital discharge and the migration of THA and TKA procedures from the hospital to lower-cost ambulatory surgery centers.

Background: Substantial research has documented inequalities between US minorities and whites in meeting the eligibility criteria for the Medicare Part D medication therapy management (MTM) program. Even though the Centers for Medicare & Medicaid Services attempted to relax the eligibility criteria, a critical barrier to effective MTM reform is a lack of stronger evidence about the effects of MTM on minorities' health outcomes.

Objective: To examine the effects of comprehensive medication review (CMR), an MTM core component, on racial and ethnic disparities in adherence to diabetes, hypertension, and hyperlipidemia medications among Medicare beneficiaries aged ≥65 years.

Methods: This study used full-year 2017 Medicare Parts A, B, and D claims data, including MTM data, linked to the Area Health Resources Files. Racial and ethnic disparities in nonadherence to diabetes, hypertension, and hyperlipidemia medications were compared between CMR recipients and nonrecipients matched by their propensity scores. To determine the changes in racial and ethnic disparities after receiving CMR, a difference-in-differences framework was applied, by including in logistic regression analyses interaction terms between dummy variables for CMR receipt and each racial or ethnic minority group.

Results: Compared with CMR nonrecipients, CMR recipients had significantly lower racial and ethnic disparities across the 3 outcome measures, with the exception of the difference between whites and blacks in nonadherence to diabetes medications. For example, compared with CMR nonrecipients, among CMR recipients the differences in the odds of nonadherence to hypertension medications were reduced, respectively, by 8% (95% confidence interval [CI], 0.88-0.96) between whites and blacks; by 18% (95% CI, 0.78-0.86) between whites and Hispanics; by 16% (95% CI, 0.77-0.91) between whites and Asians; and by 9% (95% CI, 0.85-0.98) between whites and other racial and ethnic groups.

Conclusion: Receiving a CMR reduced the racial and ethnic disparities in adherence to diabetes, hypertension, and hyperlipidemia medications among Medicare beneficiaries aged ≥65 years. These findings provide critical empirical evidence that may inform the future design of the Medicare Part D MTM program, which is valuable for improving pharmacotherapy outcomes and could further realize its potential when additional people from racial and ethnic minorities are enrolled.

Background: Health plans and health systems need to understand the demand for common healthcare services to ensure adequate access to care. Utilization of cardiac catheterization is of particular interest, because it is relatively common and has the potential for variation across subpopulations, similar to the level of geographical variation in heart disease in the United States.

Objectives: To illustrate how the utilization of cardiac catheterization has changed over time in a US population with commercial and Medicare Advantage health plans, and how it differs between subpopulations.

Methods: Cardiac catheterization claims data from 2012 to 2018 were extracted from the database of a national healthcare organization offering commercial and Medicare Advantage health plans. Contemporaneous health plan enrollment data and government data were used to determine the patients' characteristics. Annual catheterizations per 1000 patients for the population as a whole and for subpopulations were determined using claims data. Spearman's rank-order correlation was used to assess the monotonicity of trends. Catheterization utilization for each subpopulation was compared with that of the population average. A second, patient-level analysis was used to determine the factors predictive of patients' catheterization utilization in 2018.

Results: Across the overall population, the rate of cardiac catheterization was stable from 2012 to 2018. An adjusted analysis of 2018 data showed that catheterization utilization was significantly associated with older age, male sex, residence in a rural zip code, residence in a lower-income zip code, and residence in a state with a high obesity rate. The trendlines of the relative utilization of catheterization in subpopulations over time revealed similar patterns.

Conclusion: Marked differences were observed in the rates of cardiac catheterization utilization between the subpopulations in our study. Overall, these data show a direct correlation between geographic residence, obesity level, wealth, and the rate of cardiac catheterization utilization. To ensure adequate access to care, health plans and health systems should explore the implications of disproportionately high demand for cardiac catheterization in populations from lower-income areas, higher obesity rate states, rural patients, and older patients.

Background: Much of the literature about the costs of metastatic pancreatic cancer is focused on the Medicare population, but the cost in the commercially insured population is not well-documented. Differences in treatment patterns between commercially insured and Medicare patients with metastatic pancreatic cancer can provide insights into healthcare utilization and the total cost of care.

Objective: To compare the total cost of care for commercially insured versus Medicare patients with metastatic pancreatic cancer who are receiving National Comprehensive Cancer Network (NCCN)-recommended treatment regimens.

Methods: We identified 3904 patients (mean age at diagnosis, 56 years) with metastatic pancreatic cancer using International Classification of Diseases, Ninth/Tenth Revision diagnosis codes in claims data in the 2014-2018 MarketScan commercial database and 28,063 patients (mean age at diagnosis, 73 years) with metastatic pancreatic cancer in the 2014-2017 Medicare Parts A, B, and D 100% research identifiable data files. We calculated the total cost of care and resource utilization by NCCN-recommended (category 1) treatment regimen, including 5-fluorouracil, leucovorin, oxaliplatin, and irinotecan (FOLFIRINOX); gemcitabine plus nab-paclitaxel; gemcitabine monotherapy; and liposomal irinotecan. All patients had ≥2 claims with a pancreatic cancer diagnosis more than 30 days apart and ≥1 subsequent claims with a secondary malignancy diagnosis for metastatic disease.

Results: The mean total cost of care was 186% higher in the commercially insured cohort than in the Medicare cohort. Excluding gemcitabine monotherapy, the total cost of care for patients with metastatic pancreatic cancer was similar between the regimens used in each cohort, ranging from $95,426 to $116,325 in the commercial insurance group and from $39,777 to $40,390 in the Medicare group. The components of hospital-based inpatient and outpatient costs varied between similar regimens in both cohorts. The inpatient admission patterns of patients' regimens were consistent across the 2 cohorts, with patients receiving gemcitabine monotherapy or liposomal irinotecan having the lowest overall number of admissions in each cohort.

Conclusions: The treatment patterns varied across the regimens but were largely consistent between the commercially insured and the Medicare patients who received the same regimen for metastatic pancreatic cancer; the ratio of total cost of care was 3:1 (commercially insured to Medicare). The total costs of care were similar across the regimens in each cohort, but the components of the total cost varied. These results can inform clinical guidelines and pathways for pancreatic cancer therapy as new evidence and treatment options emerge, and in the context of increasing value-based care models.

Background: Several nonpharmacologic and pharmacologic treatments are available for the management of knee osteoarthritis (OA)-related pain and for improving functionality; however, clinical guideline recommendations vary on their use.

Objective: To compare the treatment patterns in a real-world setting versus the guideline recommendations for the treatment of newly diagnosed patients with knee OA.

Methods: This retrospective analysis used data from the electronic health records of the Geisinger Health System between January 1, 2010, and December 2018 to identify adults with newly diagnosed knee OA who had not received previous therapy with intra-articular corticosteroids, opioids, intra-articular hyaluronic acid, or prescription nonsteroidal anti-inflammatory drugs (NSAIDs). Eligible patients were evaluated for the mutually exclusive treatment categories after diagnosis, including prescription NSAIDs, intra-articular corticosteroids, intra-articular hyaluronic acid (specifically an intra-articular bioengineered hyaluronic acid), opioids, physical therapy, bracing, and total knee arthroplasty. These 7 treatment categories were evaluated for utilization patterns in the real-world setting.

Results: A total of 8776 patients with a new diagnosis of knee OA were identified; 88.2% of them received 1 of the 7 evaluated treatments. The most frequently prescribed first treatment was intra-articular corticosteroids (26%), followed by opioids (17.6%), and intra-articular bioengineered hyaluronic acid (14.9%). The most often prescribed second treatment was opioids (15.8%), followed by physical therapy (14%), NSAIDs (11.8%), and intra-articular bioengineered hyaluronic acid (9.6%). Of note, 22.9% of the patients received only 1 evaluated therapy during the study period and did not receive a second treatment.

Conclusions: Real-world treatment patterns in patients with newly diagnosed knee OA indicate that prescribers are using the spectrum of the available therapies that, at times, are different from the current treatment guideline recommendations.

Background: Statin Therapy for Patients with Cardiovascular Disease (SPC) is a Centers for Medicare & Medicaid Services Star measure added to Medicare Part C (Medicare Advantage) plans in 2019 to incentivize statin use for secondary prevention of cardiovascular disease (CVD). The measure assesses statin dispensing and adherence in patients with atherosclerotic CVD (ASCVD). Clinical pharmacists are well-positioned to affect positively a health system's performance on the SPC measure.

Objective: To assess the effect of telephone outreach by clinical pharmacists on moderate- or high-intensity statin prescribing in patients with ASCVD.

Methods: Patients in managed care health plans who meet the SPC measure criteria and are not currently receiving a moderate- to high-intensity statin therapy were contacted by a clinical pharmacist through telephone outreach. If appropriate, they were prescribed a statin by a clinical pharmacist. The primary outcome measure was the proportion of patients who meet the SPC measure classification and had 1 confirmed prescription fill for a moderate- or high-intensity statin after intervention by a clinical pharmacist.

Results: A total of 84 patients were identified for review and outreach, of whom 35 (41.7%) met the SPC measure criteria. Of these 35 patients, 16 (45.7%) were female and the mean age was 66 years. A total of 22 (62.9%) patients agreed to a statin prescription, and 16 (72.7%) of these patients picked up the prescription within 10 days of prescribing. An additional 4 patients, for a total of 20 (57.1%) of the 35 eligible patients, were eventually dispensed a statin. Healthcare Effectiveness Data and Information Set (HEDIS) vendor data available after the intervention showed a larger SPC measure population than was captured with the health plan's internal report. HEDIS data showed an increase in statin prescribing for patients meeting the SPC measure classification from 24.7% to 56.6% during the study period (P <.001). The mean time spent per patient for chart review and/or outreach by the clinical pharmacist was 27.7 (standard deviation, 9) minutes.

Conclusion: These results indicate that clinical pharmacists who conduct a telephonic population health intervention can achieve a high rate of success in initiating a moderate- to high-intensity statin therapy in patients with ASCVD.