OBJECTIVETo describe the use of and adherence to 17-alpha hydroxyprogesterone caproate (17-OHPC), explore factors associated with its utilization and adherence, and to investigate the outcomes of ...17-OHPC in a real-world setting. METHODSThe Decision Resources Group (DRG) database (1 January 2012-31 December 2017) was used to identify women with diagnosis of "history of preterm labor", aged 16-50 years old, had a singleton gestation, were continuously enrolled for at least 6 months and 9 months before and after the index date, respectively, and had a delivery outcome recorded. Adequate adherence was defined and compared using two approaches: (1) patients receiving at least 10 injections of 17-OHPC; (2) number of received injections/eligible number of injections ≥0.7. The outcome of 17-OHPC was evaluated by the incidence rate of preterm birth (PTB). Bivariate tests compared patients' characteristics with their use of and adherence to 17-OHPC, and examined the associations between 17-OHPC utilization and incidence of diabetes or hypertension. Stepwise logistic regression was conducted to assess the effect of adherence on the delivery outcome. RESULTSOf 28,339 patients meeting study criteria, 2585 (9.1%) had ≥1 claim for 17-OHPC. An increasing trend of utilization was observed from 2012 to 2017 (7.6-13.1%). The utilization rate was highest in the Southwest US (13.8%) (p < .001). Commercial insurance patients (9.6%) were more likely to use 17-OHPC than Medicaid patients (7.9%) (p < .001). Patients with higher Charlson Comorbidity Index (CCI) scores were less likely to use 17-OHPC. Of women prescribed 17-OHPC, 792 (30.6%) and 424 (16.4%) were adherent using two definitions, respectively. No difference in PTB rate was observed between adherers and non-adherers (definition 1: aOR = 0.97, 95% CI = 0.81-1.16; definition 2: aOR = 1.18, 95% CI = 0.95-1.48). No association was found between 17-OHPC and incidence of diabetes (p = .96); however, use of 17-OHPC was associated with a lower incidence rate of hypertension (p = .002). CONCLUSIONS17-OHPC utilization and adherence rates remain low. Insurance type and geographic region were associated with both utilization and adherence. There was no association between 17-OHPC adherence and effectiveness. More evidence is needed to determine if the use of 17-OHPC is advantageous in a sub-group of patients.
Objective:
To compare healthcare utilization, costs, and incidence of diabetes-specific adverse events (ie, hyperglycemia, diabetic ketoacidosis, and hypoglycemia) in type 1 diabetes adult patients ...using real-time continuous glucose monitoring (rtCGM) versus traditional blood glucose monitoring (BG).
Methods:
Adult patients (≥18 years old) with type 1 diabetes in a large national administrative claims database between 2013 and 2015 were identified. rtCGM patients with 6-month continuous health plan enrollment and ≥1 pharmacy claim for insulin during pre-index and post-index periods were propensity-score matched with BG patients. Healthcare utilization associated with diabetic adverse events were examined. A difference-in-difference (DID) method was used to compare the change in costs between rtCGM and BG cohorts.
Results:
Six-month medical costs for rtCGM patients (N = 153) increased from pre- to post-index period, while they decreased for matched BG patients (N = 153). DID analysis indicated a $2,807 (P = .062) higher post-index difference in total medical costs for rtCGM patients. Pharmacy costs for both cohorts increased. DID analysis indicated a $1,775 (P < .001) higher post-index difference in pharmacy costs for rtCGM patients. The incidence of hyperglycemia for both cohorts increased minimally from pre- to post-index period. The incidence of hypoglycemia for rtCGM patients decreased, while it increased marginally for BG patients. Inpatient hospitalizations for rtCGM and BG patients increased and decreased marginally, respectively.
Conclusions:
rtCGM users had non-significantly higher pre-post differences in medical costs but significantly higher pre-post differences in pharmacy costs (mostly due to the rtCGM costs themselves) compared to BG users. Changes in adverse events were minimal.
Abstract Purpose This study aimed to assess how pneumonia incidence, health care resource utilization, costs, and hospital length of stay differ by age category in the United States. Methods A ...retrospective cross-sectional analysis of the Medical Expenditure Panel Survey database was conducted from 2007 to 2011 for patients with pneumonia. Study outcomes were pneumonia incidence, annual health care utilization, and expenditures across 5 age groups. Early trends of outcomes in the period after introduction of the 13-valent pneumococcal conjugate vaccine (PCV13) (2011) were compared with the pre-PCV13 period (2007–2009). Findings Pneumonia incidence rates for the 1790 patients ranged from 9.2 to 33.0 per 1000 patients. Patients <5 years old had the highest incidence rate at 33.0 per 1000 patients, followed by patients ≥65 years old (27.2 per 1000 patients) and patients ≥45 to <65 years old (14.4 per 1000 patients). The percentages of patients with pneumonia-related hospitalization were 26%, 7%, 15%, 24%, and 46%, respectively ( P < 0.0001). Mean (SD) days in hospital stay were 1.73 (0.08), 0.31 (0.50), 0.58 (0.10), 1.86 (0.29), and 3.05 (0.33), respectively ( P < 0.05), for patients <5, ≥5 to < 18, ≥18 to <45, ≥45 to <65, and ≥65 years old. Mean total pneumonia-related medical costs in patients aged <5 years ($3376; P = 0.009), ≥45 to ≤65 years ($4726; P < 0.0001), and >65 years ($7206; P < 0.0001) were significantly higher compared with patients ≥5 to <18 years old ($1175) after controlling for covariates. Compared with the pre-PCV13 period (2007–2009; n = 1075), a 16% decrease in incidence, a 27% decrease length of stay in hospital, and a 22% decrease in medical costs were observed in the post-PCV13 period (2011; n = 382), although these differences were not statistically significant ( P > 0.05). Implications Pneumonia remains a disease with significant burden in the United States, and clinical and economic outcomes varied widely by age. Hospitalization for pneumonia has a considerable effect on economic burden, particularly for the very young (<5 years old), middle-aged (≥45 to <65 years old), and elderly (≥65 years old) populations. A trend toward reductions in pneumonia incidence and associated medical costs was observed after the PCV13 was introduced, although these findings were not statistically significant.
BACKGROUND:
An up-to-date assessment of dipeptidyl peptidase-4 (DPP-4) inhibitors is needed to include newly available data.
OBJECTIVE:
To assess the efficacy and safety of DPP-4 inhibitors, ...including sitagliptin, saxagliptin, vildagliptin, and linagliptin, in type 2 diabetes.
METHODS:
We conducted a search of MEDLINE for randomized controlled trials (RCTs) of DPP-4 inhibitors in type 2 diabetes through November 2011, using the key terms sitagliptin, saxagliptin, vildagliptin, and linagliptin. We also searched for completed, but unpublished, trials at relevant web sites. RCTs were selected for meta-analysis if they (1) compared DPP-4 inhibitors with placebo or an antihyperglycemic agent; (2) had study duration of 12 or more weeks; (3) had 1 or more baseline and posttreatment efficacy and/or safety outcome; and (4) were published in English.
RESULTS:
In 62 evaluated articles, DPP-4 inhibitors lowered hemoglobin A1c (A1C) significantly more than placebo (weighted mean difference WMD −0.76%; 95% CI −0.83 to −0.68); however, heterogeneity was substantial (I2 = 82%). Exclusion of Japanese trials (n = 7) resulted in a reduction of heterogeneity (I2 = 59%). In the non-Japanese RCTs (n = 55), DPP-4 inhibitors were associated with a reduction in A1C (WMD −0.65%; 95% CI −0.71 to −0.60) but higher risk of hypoglycemia (odds ratio OR 1.30; 95% CI 1.00 to 1.68) compared to placebo. The 7 Japanese-specific RCTs showed a greater reduction in A1C (WMD −1.67%; 95% CI −1.89 to −1.44) and a nonsignificant increase in risk of hypoglycemia (OR 1.41; 95% CI 0.51 to 3.88) with DPP-4 inhibitors versus placebo. When comparing DPP-4 inhibitors to active comparators, the I2 was still high after deleting Japanese studies. In these 17 active comparator trials, there was no significant difference in A1C reduction (WMD 0.04%; 95% CI −0.09 to 0.16) or risk of hypoglycemia (OR 0.60; 95% CI 0.22 to 1.61) for DPP-4 inhibitors compared to other antihyperglycemics. There were similar odds of any or serious adverse events with DPP-4 inhibitors compared to placebo, but a decreased risk compared to other antihyperglycemics.
CONCLUSIONS:
DPP-4 inhibitors were associated with a reduction in A1C with comparable safety profiles compared to placebo, but no significant difference in A1C compared to other hyperglycemics. Differences in efficacy and safety were observed between Japanese and non-Japanese patients.
Objectives
To compare medication use and health resource utilization between migraineurs with evidence of opioid use at emergency department visit versus no opioid use at emergency department visit, ...and to examine predictors of opioid use among migraineurs at emergency department visits.
Methods
This was a retrospective study using REACHnet electronic health records (December 2013 to April 2017) from Baylor Scott & White Health Plan. The index date was defined as the first migraine-related emergency department visit after ≥6 months of enrollment. Adult patients with a migraine diagnosis and ≥6 months of continuous enrollment before and after their index dates were included. Descriptive statistics and bivariate analyses were used to compare medication use and health resource utilization between opioid users and non-opioid users. Multivariable logistic regression was used to examine predictors of opioid use at emergency department visits.
Results
A total of 788 migraineurs met eligibility criteria. Over one-third (n = 283, 35.9%) received ≥1 opioid medication during their index date emergency department visit. Morphine (n = 103, 13.1%) and hydromorphone (n = 85, 10.8%) were the most frequently used opioids. Opioid users had more hospitalizations and emergency department visits during their pre-index period (both p < 0.05). Significant (p < 0.05) predictors of opioid use at emergency department visits included past migraine-related opioid use (2–4 prescriptions, Odds Ratio = 1.66; 5–9 prescriptions, Odds Ratio = 2.12; ≥10 prescriptions, Odds Ratio = 4.43), past non-migraine-related opioid use (≥10 prescriptions, Odds Ratio = 1.93), past emergency department visits (1–3 visits, Odds Ratio = 1.84), age (45–64 years, Odds Ratio = 1.45), and sleep disorder (Odds Ratio = 1.43), controlling for covariates.
Conclusion
Opioids were commonly given to migraineurs at emergency departments. Previous opioid use, health resource utilization, age, and specific comorbidities might be used to identify migraineurs with a high risk of opioid use.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
This study examined the extent to which chronic comorbidities contribute to excess health care expenditures between older adults with dementia and propensity score (PS)-matched nondementia controls.
...This was a retrospective, cross-sectional, PS-matched case (dementia): control (nondementia) study of older adults (65 y or above) using alternative years data from pooled 2005 to 2015 Medical Expenditure Panel Surveys (MEPS). Chronic comorbidities were identified based on Clinical Classifications System or ICD-9-CM codes. Ordinary least squares regression was utilized to quantify the impact of chronic comorbidities on the excess expenditures with logarithmic transformation. Expenditures were expressed as 2019 US dollars. All analyses accounted for the complex survey design of MEPS.
The mean yearly home health care expenditures were particularly higher among older adults with dementia and co-occurring anemia, eye disorders, hyperlipidemia, and hypertension compared with PS-matched controls. Ordinary least squares regression models revealed that home health care expenditures were 131% higher (β=0.837, P <0.001) among older adults with dementia compared with matched nondementia controls before adjusting for chronic comorbidities. When additionally adjusting for chronic comorbidities, the percentage increase, while still significant ( P <0.001) decreased from 131% to 102%.
The excess home health care expenditures were partially explained by chronic comorbidities among community-dwelling older adults with dementia.
Adherence to asthma long-term controller medications is one of the key drivers to improve asthma management among patients with persistent asthma. While suboptimal use of controller medications has ...been found to be associated with more frequent use of oral corticosteroids (OCS), few studies exist regarding the relationship between adherence to controller therapy and the use of short-acting beta2-agonists (SABAs). A better understanding of the association between adherence to asthma controller agents and use of reliever medications will help health care providers and decision makers enhance asthma management.
To determine if there is a relationship between asthma controller adherence, risk of exacerbation requiring OCS, and use of asthma rescue agents.
Texas Medicaid claims data from January 1, 2008, to August 31, 2011, were retrospectively analyzed. Continuously enrolled patients aged 5-63 years with a primary diagnosis of asthma (ICD-9-CM code 493) and with 4 or more prescription claims for any asthma medication in 1 year (persistent asthma) were included. The index date was the date of the first asthma controller prescription, and patients were followed for 1 year. The primary outcome variables were SABA (dichotomous: less than 6 vs. ≥ 6) and OCS (continuous) use. The primary independent variable was adherence (proportion of days covered PDC) to asthma long-term controller medications. Covariates included demographics and nonstudy medication utilization. Multivariate logistic and linear regression analyses were employed to address the study objective.
The study sample (n = 32,172) was aged 15.0 ± 14.5 years, and adherence to controller therapy was 32.2% ± 19.7%. The mean number of SABA claims was 3.7 ± 3.1, with most patients having 1-5 claims (73.2%), whereas 19.4% had ≥ 6 SABA claims. The mean number of OCS claims was 1.0 ± 1.4. Adherent (PDC ≥ 50%) patients were 96.7% (OR = 1.967; 95% CI = 1.826-2.120) more likely to have ≥ 6 SABA claims when compared with nonadherent (PDC less than 50%) patients (P less than 0.001). As for OCS use, adherent patients had 0.11 fewer claims compared with nonadherent patients (P less than 0.001). Importantly, patients with ≥ 6 SABA claims had 0.7 more OCS claims compared with patients with less than 6 claims for SABA (P less than 0.001). The odds of having ≥ 6 SABA claims were higher for concurrent dual therapy users, older age, males, African Americans and higher number of nonstudy medications (P less than 0.001). Dual therapy users, younger age, Hispanic ethnicity, and higher number of nonstudy medications were associated with an increase in OCS use (P less than 0.005).
Adherence to long-term controller medications was suboptimal among patients with asthma. Adherent patients had fewer OCS claims, indicating that adherence to controller therapy is critical in preventing asthma exacerbations requiring OCS use. Although there was a positive relationship between adherence to long-term controller medication and SABA use, increased SABA use served as a predictor of increased OCS use, which indicates poor asthma control. Health care providers should be aware of OCS and SABA use among patients who are both adherent and nonadherent to asthma controller medications.
What is known and objective
Metastatic renal cell carcinoma (mRCC) is the most common type of kidney cancers. Disease‐specific survival for mRCC has been significantly improved with the introduction ...of new targeted agents since 2005. However, there is a lack of head‐to‐head clinical trials comparing the efficacy between therapies. This study compared indirectly progression‐free survival (PFS) and overall survival (OS) among first‐line and second‐line therapies in patients with mRCC using network meta‐analysis (NMA).
Methods
The PubMed, MEDLINE, Cochrane Library and Web of Science were searched to identify phase II or phase III randomized controlled trials (RCTs) of targeted and biological therapies in patients with mRCC published between January 2000 and June 2020. The Bayesian fixed‐effect NMA was performed to evaluate relative PFS and OS of first‐line and second‐line therapies of axitinib, bevacizumab, cabozantinib, everolimus, lenvatinib, nivolumab, ipilimumab, pazopanib, sorafenib, sunitinib, temsirolimus, tivozanib, avelumab and pembrolizumab, which were approved by the Food and Drug Administration or European Medicines Agency. End points were compared using hazard ratio (HR) and 95% credible interval (CrI). The surface under the cumulative ranking curve (SUCRA) was estimated to assess the probability of being the best treatment.
Results and discussion
A total of 26 RCTs (first line: 19, second line: 9) with 13 893 patients were included in the NMA. For the first‐line therapy, cabozantinib was associated with the highest improved PFS (HR = 0.26, 95% CrI = 0.14‐0.44) followed by avelumab + axitinib and pembrolizumab + axitinib (HR = 0.27, SUCRA = 90%). Pembrolizumab + axitinib had a high likelihood of being the preferred treatment when using OS as the outcome measure (HR = 0.41, 95% CrI = 0.16‐0.85). Avelumab + axitinib had the lowest HR compared with placebo + interferon on discontinuations due to AE (HR = 1.04, 95% CrI = 0.54‐1.86). For second‐line therapy, cabozantinib was identified as the most effective treatment option when assessing PFS (HR = 0.17, 95% CrI = 0.12‐0.24). Axitinib had the lowest HR of OS and discontinuation due to AE (HR = 0.54, 95% CrI = 0.40‐0.71; HR = 0.98, 95% CrI = 0.42‐1.97, respectively). Pazopanib was the second choice in terms of OS (HR = 0.56, 95% CrI = 0.28‐1.00; SUCRA = 76%) compared with placebo.
What is new and conclusion
With respect to PFS and OS improvement, cabozantinib, avelumab + axitinib and pembrolizumab + axitinib are likely to be the preferred options for the first‐line therapy and cabozantinib and axitinib for the second‐line therapy in the management of mRCC. Regarding safety, avelumab + axitinib and temsirolimus were considered preferred treatment options in first‐line and second‐line therapies. More future research is needed to establish subgroup analyses, allowing evaluation of the impact of some of the differences in patient characteristics, including treatment effect modifiers.
This study compared indirectly progression‐free survival (PFS) and overall survival among first‐line and second‐line therapies in patients with metastatic renal cell carcinoma using network meta‐analysis. For the first‐line therapy, cabozantinib was associated with the highest improved PFS (HR = 0.26, 95% CrI = 0.14‐0.44) followed by avelumab + axitinib and pembrolizumab + axitinib (HR = 0.27, 95% CrI = 0.17‐0.42). Cabozantinib was identified as the most effective treatment option when assessing PFS (HR = 0.17, 95% CrI = 0.12‐0.24) in the second‐line therapy.
Objective
The purpose of this study was to evaluate the subsequent health resource utilization (HRU) between patients with migraine who received opioid medications at their emergency department (ED) ...visits (“opioid recipients”) versus patients with migraine who did not receive opioid medications at their ED visits (“non‐recipients”).
Background
Previous studies have found that opioid use is common among patients with migraine at emergency settings. Medication overuse, especially the use of opioids, is associated with migraine progression, which can ultimately lead to substantial health resource use and costs. There is limited evidence on opioid use specifically in emergency settings and its impact on future HRU among people with migraine.
Method
This retrospective cohort study used electronic health record data from the Baylor Scott & White Health between December 2013 and April 2017. Adult patients who had at least 6 months of continuous enrollment before (baseline or pre‐index) and after (follow‐up) the first date they had an ED visit with a diagnosis of migraine (defined as index date) were enrolled in the study. Opioid use and HRU during follow‐up period between opioid recipients and non‐recipients were summarized and compared.
Results
A total of 788 patients met the eligibility criteria and were included in this study. During the 6‐month follow‐up period, compared to patients with migraine who were non‐recipients at their index ED visits, opioid recipients had significantly more all‐cause (3.6 SD = 6.3 vs. 1.9 SD = 4.8, p < 0.0001) and migraine‐related (1.6 SD = 4.2 vs. 0.6 SD = 2.1, p < 0.0001) opioid prescriptions (RXs), and more all‐cause (2.6 SD = 4.3 vs. 1.6 SD = 2.6, p = 0.002) and migraine‐related (0.6 SD = 1.4 vs. 0.3 SD = 0.8, p = 0.001) ED visits. In addition, opioid recipients had higher risk of future migraine‐related ED visits controlling for covariates (HR = 1.49, 95% CI = 1.09–2.03, p = 0.013). Factors that were significantly (p < 0.05) related to future migraine‐related ED visits include previous opioid use (HR = 2.12, 95% CI = 1.24–3.65, p = 0.007), previous ED visits (HR = 2.38, 95% CI = 1.23–4.58, p = 0.010), hypertension (HR = 1.46, 95% CI = 1.07–2.00, p = 0.017), age between 45 and 64 years (HR = 0.68, 95% CI = 0.48–0.97, p = 0.033), female sex (HR = 1.82, 95% CI = 1.12–2.86, p = 0.015), and tobacco use disorder (HR = 1.45, 95% CI = 1.07–1.97, p = 0.017). Sub‐analyses were restricted to the group of patients who were opioid naïve at baseline (n = 274, defined as having ≤1 opioid RXs during the 6‐month pre‐index period). Patients who were baseline opioid naïve but received opioids during their index ED visits were more likely to have future migraine‐related ED visits compared to patients who were baseline opioid naïve and did not receive any opioids during their index ED visits, controlling for covariates (HR = 2.90, 95% CI = 1.54–5.46, p = 0.001).
Conclusion
Opioid use among patients with migraine presenting to the ED is associated with increased future HRU, which highlights the need for optimizing migraine management in emergency settings.
Hypertension affects approximately one‐third of the US adults. This study investigated antihypertensive utilization patterns among hypertensive patients who were prescribed treatment, yet still ...experienced uncontrolled hypertension. Data from the Decision Resources Group Real World Evidence Data Repository US database (2015‐2016) were used to construct a cohort of uncontrolled hypertension patients to observe antihypertensive utilization patterns. Results for 5059 patients, with an average age of 57.8 (SD = 13.7), who had, on average 2.4 agents prescribed. Approximately half (51.9%) were female, and most were White (86.8%). More than one‐third (N = 1877; 37.1%) of patients were diagnosed with diabetes mellitus (DM) or chronic kidney disease (CKD) that could independently contribute to increased cardiovascular complications. Overall, the most common treatments prescribed, as percent of agents and as percent of patients, respectively, were diuretics (24.9%; 59.6%), followed by angiotensin‐converting enzyme inhibitors (ACEIs) (23.8%; 56.9%), beta‐blockers (BBs) (18.7%; 44.8%), calcium channel blockers (CCBs) (15.4%; 36.8%), and angiotensin II receptor blockers (ARBs) (13.5%; 32.3%). Approximately one‐tenth (10.5%) of the prescriptions were written for fixed‐dose combination therapies. Among patients diagnosed with DM and CKD (N = 200), the order of the most common agents was the same as the overall cohort. Only 5.6% of prescriptions written for these patients were fixed‐dose combination therapy. Based on clinical guidelines, which suggest using ACEIs, ARBs, or CCBs as first‐line therapy, and fixed‐dose combination therapy to increase adherence, this indicates over‐prescribing of BBs and under‐prescribing of fixed‐dose combination therapy. These findings illustrate the need to further investigate challenges faced by patients and providers in treatment decision‐making.
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