JAMA Health Forum最新文献

Importance: Hospitals are major stakeholders in US health policy yet receive less scholarly attention than other health care industries, such as pharmaceuticals and health professionals. Understanding their federal lobbying activity is critical to evaluating how hospitals shape health policy.

Objective: To characterize federal lobbying by the hospital industry in 2024, including health systems and hospital associations, and to examine the concentration of spending and use of internal vs external lobbyists.

Design, setting, and participants: This descriptive cross-sectional study used 2024 federal lobbying disclosure data filed under the Lobbying Disclosure Act of 1995, compiled by OpenSecrets, a nonprofit website that standardizes and publishes data on political spending. and included all organizations categorized as hospitals or hospital associations that reported federal lobbying activity in 2024, along with their affiliated lobbying firms.

Exposure: Organization type (nonprofit, for-profit, and private equity-owned).

Main outcomes and measures: The primary outcomes were total and mean lobbying expenditures, and use of internal vs external lobbyists. Lobbying firm outcomes included total hospital industry earnings and clients and the share of total earnings and clients attributable to the hospital industry.

Results: In 2024, 355 hospital-related organizations reported $116.13 million in federal lobbying expenditures. Hospitals and health systems accounted for $70.56 million (60.7%), with the remainder from hospital associations. Eighteen organizations spent more than $1 million, including 12 health systems and 6 hospital associations. For-profit and private equity-owned systems comprised 8.5% of all lobbying health systems but 27.8% of the highest spenders (5 of 18 organizations). However, overall for-profit and nonprofit spending mirrored their share of US community hospitals. Nearly all hospitals and health systems (283 of 295 organizations [94.9%]) employed external lobbying firms. Lobbying by for-profit systems was highly concentrated among a few large organizations, while nonprofit lobbying was diffuse.

Conclusions and relevance: This cross-sectional study found that hospitals and affiliated organizations are major participants in federal health policy lobbying, relying on a small number of professional firms, with large health systems often outspending their state hospital associations. These patterns suggest lobbying influence is concentrated among well-resourced organizations and that not all hospitals have an equal voice in federal policymaking.

Importance: Buprenorphine is the most commonly prescribed medication for opioid use disorder, but rates of retention in treatment remain low. Prior authorization (PA) has been identified as a barrier to the administration of buprenorphine, and patients may need multiple PAs to continue treatment; thus, many states have passed laws to prohibit the use of PA for buprenorphine in private insurance.

Objective: To examine the association between PA prohibitions and buprenorphine treatment retention overall and by branded vs generic drug status.

Design, setting, and participants: This cross-sectional study used a difference-in-differences design and private insurance claims data from 49 states and the District of Columbia with no PA prohibition for buprenorphine as of January 1, 2015. Patients aged 18 to 64 years who started a new buprenorphine treatment between January 1, 2015, and June 1, 2022, were included in the study. Data were analyzed from June 3, 2024, to December 31, 2025.

Exposure: Prior authorization prohibitions, defined as state laws barring private insurers from using PA for any buprenorphine product.

Main outcomes and measures: The main outcome was buprenorphine treatment retention, measured by a dichotomous variable indicating whether the buprenorphine treatment episode lasted 180 days or longer.

Results: The sample included 22 946 patients (67.7% male) who started buprenorphine treatment; 54.3% started buprenorphine treatment with generic buprenorphine. A total of 30.4% of patients reached the 180-day treatment retention threshold. Adopting PA prohibitions was not associated with significant changes in buprenorphine treatment retention (effect estimate, 0.007; 95% CI, -0.044 to 0.059; P = .78). Stratified analysis by branded vs generic status of buprenorphine at the start of the treatment episode showed no significant association between PA prohibitions and treatment retention among patients receiving either branded (effect estimate, -0.018; 95% CI, -0.075 to 0.040; P = .55) or generic (effect estimate, 0.041; 95% CI, -0.036 to 0.118; P = .30) buprenorphine.

Conclusions and relevance: This cross-sectional study found that state laws prohibiting PA for buprenorphine were not associated with significant changes in buprenorphine treatment retention among privately insured patients. Prior authorization prohibition alone may not be effective in improving buprenorphine treatment retention. Additional interventions appear to be needed to address gaps in opioid use disorder treatment for privately insured patients.

Importance: The Global Burden of Disease (GBD) reports widely used estimates of mortality and disability-adjusted life-years (DALYs) and related risk factors. However, the overall reliability of these estimates between GBD iterations has not been assessed.

Objective: To evaluate the instability and inconsistency of GBD risk factor estimates for mortality and DALYs across GBD iterations.

Data sources: GBD risk factor collaboration estimates extracted from the published tables of GBD iterations and the Institute for Health Metrics and Evaluation repository.

Study selection: GBD risk factor collaboration publications published for 2010 through 2023.

Data extraction and synthesis: Death and DALY estimates were manually extracted by 1 reviewer with independent validation of a random sample of 100 by another with no discrepancies. Risk factor naming was harmonized across iterations to ensure comparability; those with inconsistent definitions were excluded.

Main outcomes and measures: Fluctuations were calculated for numbers of deaths and DALYs for each risk factor across GBD iterations during the study period (2010-2023) and between the original and subsequently revised estimates for each year (1990-2021). Differences were expressed as a ratio of the minimum to maximum range to the mean (R:M) and coefficient of variation. Detail analyses assessed diet and low physical activity. Point estimates were compared to the previous iterations' estimates 95% uncertainty intervals (95% UI) for GBD 2019, 2021, and 2023.

Results: Across GBD iterations from 2010 to 2023, the median (range) R:M was 0.8 (0-3.8) for deaths, and 0.7 (0.1-3.3) for DALYs. Level 2 dietary and child and maternal malnutrition death estimates showed high instability (R:M >1 for 9 of 16 and 4 of 8 risks, respectively). When comparing original estimates with GBD 2019, 2021, and 2023 estimates for the same years, the median R:M was 0.4 (0-2.9) for both deaths and DALYs. The coefficient of variation was greater than 0.2 for 336 of 675 death estimates (50%). Specifically, 70% to 96% of point estimates for red meat, sugar-sweetened beverages, fruits, vegetables, and seafood omega-3 fatty acids in GBD 2021 fell outside the GBD 2019 95% UI. In GBD 2023, only diet high in trans fats had more than half of point estimates outside the GBD 2021 95% UI.

Conclusions and relevance: This meta-epidemiological assessment indicates that GBD estimates are substantially unstable, particularly for behavioral risks, making them unlikely to simply reflect genuine changes over time, and warranting caution in interpretation.

Importance: The US has faced a nationwide shortage of attention-deficit/hyperactivity disorder (ADHD) medications since 2022, yet the underlying causes remain unclear. Public debate has largely centered on prescribing trends and Drug Enforcement Administration (DEA) quotas, although evidence suggests that quotas were not binding. A sound policy response requires a clear understanding of the drivers behind the shortage.

Objective: To examine descriptive evidence on the potential causes of the shortage.

Setting and design: In this economic evaluation, we use time series data (2015-2025) from multiple sources, such as Symphony Health and the DEA's Automation of Reports and Consolidated Orders System (ARCOS) summary reports, to characterize US production, consumption, and trade of amphetamine-based and other stimulants, including manufacturer-level production volumes, before and during the shortage period.

Findings: The sharp, simultaneous production cutbacks across several medium-sized and smaller manufacturers in late 2022 and early 2023 coincided with a steep contraction in US imports of raw amphetamines and more modest declines in phenylacetone, a key precursor.

Conclusions and relevance: These patterns align with manufacturers' reports to the US Food and Drug Administration citing a shortage of the active ingredient as the cause of backorders. More broadly, this economic evaluation reframes the discussion of ADHD medication shortages beyond DEA quotas, highlighting the vulnerability of US pharmaceutical manufacturing to international supply chain disruptions and underscoring the need for policies that strengthen supply chain resilience.