American Journal of Managed Care最新文献

Objective: Obesity affects more than 40% of US adults, increasing risks for cardiovascular disease and type 2 diabetes. Glucagon-like peptide 1 receptor agonists (GLP-1 RAs), initially indicated for diabetes, show promise in weight loss but face coverage issues, high costs, and premature prescribing from physicians. Research is needed to assess prescribing patterns, especially in patients without diabetes.

Study design: We conducted a retrospective, population-based, observational study using the Merative MarketScan Commercial Database and the Merative MarketScan Medicare Supplemental Database, which capture person-specific clinical utilization and expenditures. We analyzed GLP-1 RA prescribing rates from 2018 to 2023, comparing semaglutide with other GLP-1 RAs and stratifying by diabetes and overweight/obesity indications.

Methods: The study included individuals 18 years or older with 12 months of continuous enrollment from 2018 to 2023, categorizing GLP-1 RA users into 4 groups based on diabetes and obesity/overweight diagnosis codes within a year of their index date.

Results: Prescribing of GLP-1 RA medications, particularly semaglutides, increased notably over the years, whereas dulaglutide, liraglutide, and exenatide use declined. When investigating possible premature prescribing by examining users with no diabetes indication, the number of prediabetes or abnormal glucose diagnoses increased slightly before the index GLP-1 RA prescribing index date. However, less than 9% received a diabetes or prediabetes diagnosis 30 days after starting a GLP-1 RA.

Conclusions: From 2018 to 2023, GLP-1 RA prescribing increased significantly, with semaglutide approved for weight loss rising to 60% share in the nondiabetic obese/overweight group. Trends showed a notable rise in prescriptions for nondiabetic and obese/overweight patients.

Objective: To assess trends in assigned International Statistical Classification of Diseases, Tenth Revision ( ICD-10 ) codes for patients hospitalized with heart failure (HF) from 2018 to 2022 in 2 large US health systems.

Study design: Retrospective cross-sectional analysis of ICD-10 codes assigned to patients hospitalized with HF in the Providence Health and University of Colorado Health (UCHealth) systems.

Methods: The study included patients discharged from the Providence Health and UCHealth systems between 2018 and 2022 with a primary diagnosis of HF. ICD-10 codes analyzed included systolic HF (I50.2), diastolic HF (I50.3), combined systolic and diastolic HF (I50.4), hypertensive heart disease with HF (I11.0), and hypertensive heart disease with HF and chronic kidney disease (CKD) (I13.0, I13.2). Hospitalization data were analyzed separately for each health system due to privacy policies.

Results: Between 2018 and 2022, 61,238 HF hospitalizations occurred in the Providence Health system, and 13,576 occurred in UCHealth. Hypertensive heart disease with HF and CKD was the most common diagnosis, accounting for 42% to 56% of HF hospitalizations, followed by hypertensive heart disease with HF (34%-42%). Together, these diagnoses represented 85% to 90% of HF hospitalizations. Systolic, diastolic, and combined HF codes accounted for only 9% to 18% of hospitalizations. Significant variability in hypertension prevalence (ie, 100% in Providence Health and 38%-39% in UCHealth) was observed between the 2 health systems in patients with codes I13.0 and I13.2.

Conclusions: The study highlighted a significant shift in HF diagnosis codes, with hypertensive heart disease with HF with and without CKD now predominant. The findings highlight the need for standardized coding practices across health systems for quality improvement initiatives and health services research.

Objective: To assess trends in insulin out-of-pocket (OOP) costs, use, and disparities among commercially insured patients from 2008 to 2021.

Study design: Retrospective time series from a national insurance database, with members in all US states, including data from 2008 to 2021.

Methods: Insulin OOP costs and 30-day equivalent fills per year were quantified among insulin users aged 12 to 64 years, stratified by income (low- vs high-poverty zip code) and health plan type (high-deductible health plans with savings options [HDHP/SO] vs not). Participants were commercially insured insulin users aged 12 to 64 years with at least 1 full enrollment year. Characteristics of interest for disparities analysis included income level (low- vs high-poverty zip code) and health plan type (HDHP/SO vs non-HDHP/SO plan).

Results: After increases in adjusted mean annual insulin OOP costs from 2008 ($221 per non-HDHP/SO member and $313 per HDHP/SO member) to 2014 ($280 and $496, respectively), HDHP/SO members had persistent relative reductions in insulin use. In 2014, HDHP/SO members had 0.17 fewer annual fills, a disparity that increased until 2019 (0.79) before decreasing slightly by 2021 (-0.55). Lower-income members consistently had fewer insulin fills.

Conclusions: Insulin OOP cost reduction policies would be more efficient if they targeted HDHP/SO plan members and low-income patients.

Objectives: There are well-known racial/ethnic differences in colorectal cancer (CRC) screening in the US. This study aimed to assess whether racial/ethnic differences in CRC screening persisted in 2021 and how demographic and socioeconomic factors contributed to these differences.

Study design: Population-based study.

Methods: All adults aged 50 to 75 years in the 2021 National Health Interview Survey were included. The rate of CRC screening was calculated for non-Hispanic White, Black/African American, Hispanic, and Asian individuals. Multivariate logistic regression was used to examine racial/ethnic differences in CRC screening, controlling for age, sex, immigrant status (vs born in the US), college education (vs no college education), and insured status (vs uninsured status).

Results: The rate of CRC screening was highest in the non-Hispanic White group (74.4%), followed by the Black/African American (70.9%), Hispanic (61.7%), and Asian (59.5%) groups (P < .01). In multivariate logistic regression, there was no significant racial/ethnic difference in CRC screening after controlling for age (OR, 1.07; 95% CI, 1.06-1.08), female sex (OR, 1.08; 95% CI, 0.997-1.18), immigrant status (OR, 0.62; 95% CI, 0.54-0.70), college education (OR, 1.65; 95% CI, 1.52-1.80), and insured status (OR, 4.38; 95% CI, 3.67-5.23). Sensitivity analysis on colonoscopy use confirmed these findings, except for less colonoscopy use in Asian individuals (OR, 0.73; 95% CI, 0.60-0.89).

Conclusions: Racial/ethnic differences in CRC screening in the US were due to differences in demographic and socioeconomic factors, except for persistently low colonoscopy use in Asian individuals.

Objectives: Corticosteroid use can lead to serious adverse events even with short-term use. Data suggest that corticosteroid premedication prior to infliximab (IFX) administration is ineffective at preventing infusion reactions. Therefore, we examined corticosteroid premedication practices in inflammatory bowel disease (IBD), which represent an opportunity for reducing corticosteroid overuse.

Study design: National cohort study of patients with IBD receiving IFX using 2015-2021 Truven (now Merative) MarketScan data.

Methods: We examined corticosteroid premedication as an outcome of interest using descriptive statistics and identified associated patient-level factors using bivariate analyses. We also explored differences in corticosteroid premedication for first IFX infusions (ie, no opportunity for a prior reaction) and subsequent IFX infusions.

Results: We identified 19,637 patients with IBD who received IFX and met the inclusion criteria. Corticosteroid premedication use declined from 27.4% in 2015 to 20.4% in 2020. During this time, 38.7% of the 4639 patients who received IFX premedication were premedicated for more than 90% of their infusions. Overall, those who received corticosteroid premedication were younger (median age, 30 vs 33 years), more often female (51.6% vs 47.7%), and more likely to have 1 or more comorbidities (21.7% vs 18.8%) than patients who were not premedicated, but the groups had similar rates of diabetes (4.1% vs 4.2%), cataracts (1.4% vs 1.3%), and osteoporosis (1.4% for both). Among patients receiving corticosteroid premedication, 62.5% received it with their first IFX infusion, suggesting routine practice rather than a strategy for those who had a prior infusion reaction.

Conclusions: Corticosteroid premedication for IFX remains unnecessarily common. Corticosteroid premedicating is a common low-value practice that could be targeted to reduce corticosteroid overuse in IBD.

This commentary explains why comparing a launch price with a value-based price from a cost-effectiveness analysis requires further examination.

Objectives: To evaluate the effects of formulary-related rejections of initial adjunctive cariprazine (Vraylar) claims on health care resource utilization (HCRU) among patients with major depressive disorder (MDD).

Study design: Retrospective claims-based analysis.

Methods: Using data from Symphony Health Integrated Dataverse from March 2015 through October 2020, we identified adults with MDD who were being treated with antidepressants and had an initial cariprazine claim that was either rejected for a formulary-related reason (eg, noncoverage, prior authorization requirement, step therapy requirement) or approved; rejected patients were required to receive a subsequent atypical antipsychotic (which helps balance the health status across cohorts but may induce bias and affect generalizability). Rejected and approved cohorts were matched (1:2) using propensity scores. Outcomes included all-cause and mental health (MH)-related HCRU (hospitalizations, emergency department [ED] visits, outpatient visits) and treatment patterns. HCRU was compared between cohorts using rate ratios (RRs), with 95% CIs and P values. Treatment patterns were analyzed using descriptive statistics.

Results: The rejected cohort comprised 566 patients, with 1132 matched patients in the approved cohort. All-cause and MH-related hospitalization rates were 61% and 89% higher, respectively, for the rejected vs approved cohort (all-cause: RR, 1.61; 95% CI, 1.15-2.32; P = .012; MH related: RR, 1.89; 95% CI, 1.18-2.89; P = .016). ED and outpatient visit rates were similar. Patients in the rejected cohort often never received cariprazine (68.4%), and those who did received it after a 6-month delay on average.

Conclusions: Patients with MDD who had an initial adjunctive cariprazine claim rejected for a formulary-related reason and subsequently received an atypical antipsychotic experienced significantly higher hospitalization rates than those with approved initial cariprazine claims, suggesting that formulary restrictions on adjunctive cariprazine may be associated with negative downstream effects.

Objectives: We examine the prevalence of pay-for-performance (P4P) incentives to promote human papillomavirus (HPV) vaccination and eligibility for P4P incentives as reported by clinical staff.

Study design: A 2022 survey of primary care clinical staff in the US who provided HPV vaccination to children aged 9 to 12 years (N = 2527; response rate, 57%).

Methods: The primary outcome was a mutually exclusive categorical variable for the type of P4P quality metrics used in the past year: HPV vaccination, other pediatric vaccinations, other quality metrics, or none. The secondary outcome was an indicator variable for whether the respondent was, or would be, eligible for P4P incentives. We adjusted logistic models for clinical staff and clinic characteristics.

Results: Only 8% (n = 193) of respondents reported use of P4P incentives for HPV vaccination in their clinic. Clinics that were part of a health care system were more likely to have used P4P incentives for HPV vaccination (relative risk ratio [RRR] for respondents in systems of ≥ 5 clinics vs respondents not in systems, 2.06; 95% CI, 1.38-3.08), and clinics that saw more children were more likely to have used P4P incentives for HPV vaccination (RRR for respondents in clinics seeing ≥ 50 children vs clinics seeing 0-9 children per week, 2.64; 95% CI, 1.44-4.82). Physicians were more than twice as likely as other clinical staff to be eligible for P4P incentives (eg: OR for physician assistant, 0.40; 95% CI, 0.28-0.59).

Conclusions: Opportunities exist to extend P4P incentives in primary care to promote HPV vaccination.

Assertive community treatment, a strongly evidence-based practice for delivering care to individuals with schizophrenia and low health care engagement, is applicable to disengaged, medically complex patients.

To mark the 30th anniversary of The American Journal of Managed Care (AJMC), each issue in 2025 includes a special feature: reflections from a thought leader on what has changed-and what has not-over the past 3 decades and what's next for managed care. The July issue features a conversation with David J. Shulkin, MD, a physician and former secretary of the US Department of Veterans Affairs.