Luo, Jing, and Walid F Gellad. (2023) 2023. “Electronic Prior Authorization for Prescription Drugs - Challenges and Opportunities for Reform.”. The New England Journal of Medicine 388 (10): 867-70. https://doi.org/10.1056/NEJMp2214620.
Publications
2023
Yan, C H, C C Hubbard, T A Lee, L K Sharp, C T Evans, G S Calip, S A Rowan, J C McGregor, W F Gellad, and K J Suda. (2023) 2023. “Impact of Hydrocodone Rescheduling on Dental Prescribing of Opioids.”. JDR Clinical and Translational Research 8 (4): 402-12. https://doi.org/10.1177/23800844221102830.
INTRODUCTION: In the United States, dentists frequently prescribe hydrocodone. In October 2014, the US Drug Enforcement Administration rescheduled hydrocodone from controlled substance schedule III to II, introducing more restricted prescribing and dispensing regulations, which may have changed dental prescribing of opioids.
OBJECTIVE: The study aim was to evaluate the impact of the hydrocodone rescheduling on dental prescribing of opioids in the United States.
METHODS: This was a cross-sectional study of opioids prescribed by dentists between October 2012 and October 2016, using the IQVIA Longitudinal Prescription Dataset. Monthly dentist-based opioid prescribing rate (opioid prescription [Rx]/1,000 dentists) and monthly average opioid dosages per prescription (mean morphine milligram equivalent per day [MME/d]) were measured in the 24 mo before and after hydrocodone rescheduling in October 2014 (index or interruption). An interrupted time-series analysis was conducted using segmented ordinary least square regression models, with Newey-West standard errors to handle autocorrelation.
RESULTS: Dentists prescribed 50,412,942 opioid prescriptions across the 49 mo. Hydrocodone was the most commonly prescribed opioid pre- and postindex (74.9% and 63.8%, respectively), followed by codeine (13.8% and 21.6%), oxycodone (8.1% and 9.5%), and tramadol (2.9% and 4.8%). At index, hydrocodone prescribing immediately decreased by -834.8 Rx/1,000 dentists (95% confidence interval [CI], -1,040.2 to -629.4), with increased prescribing of codeine (421.9; 95% CI, 369.7-474.0), oxycodone (85.3; 95% CI, 45.4-125.2), and tramadol (111.8; 95% CI, 101.4-122.3). The mean MME increased at index for all opioids except for hydrocodone, and dosages subsequently decreased during the postindex period.
CONCLUSION: Following the rescheduling, dentist prescribing of hydrocodone declined while prescribing of nonhydrocodone opioids increased. Understanding the impact of this regulation informs strategies to ensure appropriate prescribing of opioids for dental pain.
KNOWLEDGE TRANSFER STATEMENT: The study findings can be used by policy makers to make informed decisions in developing future risk mitigation strategies aimed to regulate opioid prescribing behaviors. Furthermore, dentist-specific resources and guidelines are needed subsequent to these policies in order to meet the dental population needs.
McDermott, Annie, Nadejda Kim, Leslie R M Hausmann, Jared W Magnani, Chester B Good, Terrence M A Litam, Maria K Mor, et al. (2023) 2023. “Association of Neighborhood Disadvantage and Anticoagulation for Patients With Atrial Fibrillation in the Veterans Health Administration: The REACH-AF Study.”. Journal of General Internal Medicine 38 (4): 848-56. https://doi.org/10.1007/s11606-022-07810-z.
BACKGROUND: Atrial fibrillation (AF) is a common arrhythmia, the management of which includes anticoagulation for stroke prevention. Although disparities in anticoagulant prescribing have been well documented for individual socioeconomic factors, less is known about the association of neighborhood-level disadvantage and anticoagulation for AF.
OBJECTIVE: To assess the association between neighborhood disadvantage and anticoagulant initiation for patients with incident AF.
DESIGN: Retrospective cohort study.
PARTICIPANTS: A cohort of patients enrolled in the Veterans Health Administration (VA) with incident AF from January 2014 through December 2020 from the Race, Ethnicity, and Anticoagulant CHoice in Atrial Fibrillation (REACH-AF) Study.
MAIN MEASURES: The primary exposure was neighborhood disadvantage quantified using area deprivation index (ADI), classified by quintiles (Q). The outcomes were initiation of any anticoagulant therapy (warfarin or direct oral anticoagulant, DOAC) within 90 days of AF diagnosis and DOAC use among initiators. We used mixed effects logistic regression to assess the association between ADI and anticoagulant therapy, incorporating a fixed effect for treatment site and baseline patient, provider, and facility covariates.
KEY RESULTS: Among 161,089 patients, 105,489 (65.5%) initiated any anticoagulant therapy, and 78,903 (74.8%) used DOACs. Any anticoagulant therapy increased 3.2 percentage points (63.0% to 66.2%; p<.001) from Q1 to Q5, whereas DOAC use decreased 8.2 percentage points (79.4% to 71.2%; p<.0001) across quintiles. The adjusted odd ratios of any anticoagulant therapy were non-significantly different for Q2-Q5 than Q1. The adjusted odds of DOAC use decreased progressively from 0.89 (95% CI, 0.84-0.94) in Q2 to 0.77 (95% CI, 0.73-0.83) in Q5 compared to Q1 (p<.0001).
CONCLUSIONS: Among Veterans with incident AF, we observed similar initiation of any anticoagulant, though neighborhood deprivation was associated with decreased DOAC use among anticoagulant initiators. Future interventions to improve pharmacoequity in anticoagulant prescribing for AF should consider the role of neighborhood-level determinants of health inequities.
2022
Kianmehr, Hamed, Ping Zhang, Jing Luo, Jingchuan Guo, Meda E Pavkov, Kai McKeever Bullard, Edward W Gregg, et al. (2022) 2022. “Potential Gains in Life Expectancy Associated With Achieving Treatment Goals in US Adults With Type 2 Diabetes.”. JAMA Network Open 5 (4): e227705. https://doi.org/10.1001/jamanetworkopen.2022.7705.
IMPORTANCE: Improvements in control of factors associated with diabetes risk in the US have stalled and remain suboptimal. The benefit of continually improving goal achievement has not been evaluated to date.
OBJECTIVE: To quantify potential gains in life expectancy (LE) among people with type 2 diabetes (T2D) associated with lowering glycated hemoglobin (HbA1c), systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), and body mass index (BMI) toward optimal levels.
DESIGN, SETTING, AND PARTICIPANTS: In this decision analytical model, the Building, Relating, Assessing, and Validating Outcomes (BRAVO) diabetes microsimulation model was calibrated to a nationally representative sample of adults with T2D from the National Health and Nutrition Examination Survey (2015-2016) using their linked short-term mortality data from the National Death Index. The model was then used to conduct the simulation experiment on the study population over a lifetime. Data were analyzed from January to October 2021.
EXPOSURE: The study population was grouped into quartiles on the basis of levels of HbA1c, SBP, LDL-C, and BMI. LE gains associated with achieving better control were estimated by moving people with T2D from the current quartile of each biomarker to the lower quartiles.
MAIN OUTCOMES AND MEASURES: Life expectancy.
RESULTS: Among 421 individuals, 194 (46%) were women, and the mean (SD) age was 65.6 (8.9) years. Compared with a BMI of 41.4 (mean of the fourth quartile), lower BMIs of 24.3 (first), 28.6 (second), and 33.0 (third) were associated with 3.9, 2.9, and 2.0 additional life-years, respectively, in people with T2D. Compared with an SBP of 160.4 mm Hg (fourth), lower SBP levels of 114.1 mm Hg (first), 128.2 mm Hg (second), and 139.1 mm Hg (third) were associated with 1.9, 1.5, and 1.1 years gained in LE in people with T2D, respectively. A lower LDL-C level of 59 mg/dL (first), 84.0 mg/dL (second), and 107.0 mg/dL (third) were associated with 0.9, 0.7, and 0.5 years gain in LE, compared with LDL-C of 146.2 mg/dL (fourth). Reducing HbA1c from 9.9% (fourth) to 7.7% (third) was associated with 3.4 years gain in LE. However, a further reduction to 6.8% (second) was associated with only a mean of 0.5 years gain in LE, and from 6.8% to 5.9% (first) was not associated with LE benefit. Overall, reducing HbA1c from the fourth quartile to the first is associated with an LE gain of 3.8 years.
CONCLUSIONS AND RELEVANCE: These findings can be used by clinicians to motivate patients in achieving the recommended treatment goals and to help prioritize interventions and programs to improve diabetes care in the US.
Shao, Hui, Dawei Guan, Jingchuan Guo, Tianze Jiao, Yongkang Zhang, Jing Luo, Lizheng Shi, Vivian Fonseca, and Joshua D Brown. (2022) 2022. “Projected Impact of the Medicare Part D Senior Savings Model on Diabetes-Related Health and Economic Outcomes Among Insulin Users Covered by Medicare.”. Diabetes Care 45 (8): 1814-21. https://doi.org/10.2337/dc21-2601.
OBJECTIVE: The Medicare Part D Senior Savings Model (SSM) took effect on 1 January 2021. In this study we estimated the number of beneficiaries who would benefit from SSM and the long-term health and economic consequences of implementing this new policy.
RESEARCH DESIGN AND METHODS: Data for Medicare beneficiaries with diabetes treated with insulin were extracted from the 2018 Medical Expenditure Panel Survey. A validated diabetes microsimulation model estimated health and economic impacts of the new policy for the 5-year initial implementation period and a 20-year extended policy horizon. Costs were estimated from a health system perspective.
RESULTS: Of 4.2 million eligible Medicare beneficiaries, 1.6 million (38.3%) would benefit from the policy, and out-of-pocket (OOP) costs per year per beneficiary would decrease by 61% or $500 on average. Compared with non-White subgroups, the White population subgroups would have a higher proportion of SSM enrollees (29.6% vs. 43.7%) and a higher annual OOP cost reduction (reduction of $424 vs. $531). Among the SSM enrollees, one-third (605,125) were predicted to have improved insulin adherence due to lower cost sharing and improved health outcomes. In 5 years, the SSM would 1) avert 2,014 strokes, 935 heart attacks, 315 heart failure cases, and 344 end-stage renal disease cases; 2) gain 3,220 life-years and 3,381 quality-adjusted life-years (QALY); and 3) increase insulin cost and total medical cost by $3.5 billion and $2.8 billion. In 20 years, the number of avoided clinical outcomes, number of life-years and QALY gained, and the total and insulin cost would be larger.
CONCLUSIONS: The Medicare SSM may reduce the OOP costs for approximately one-third of the Medicare beneficiaries treated with insulin, improving health outcomes via increased insulin adherence. However, the SSM will also increase overall Medicare spending for insulin and overall medical costs, which may impact future premiums and benefits. Our findings can inform policy makers about the potential impact of the new Medicare SSM.
Macha, Vandana, Rahi Abouk, and Coleman Drake. (2022) 2022. “Association of Recreational Cannabis Legalization With Alcohol Use Among Adults in the US, 2010 to 2019.”. JAMA Health Forum 3 (11): e224069. https://doi.org/10.1001/jamahealthforum.2022.4069.
IMPORTANCE: In the US, cannabis use has nearly doubled during the past decade, in part because states have implemented recreational cannabis laws (RCLs). However, it is unclear how legalization of adult-use cannabis may affect alcohol consumption.
OBJECTIVE: To estimate the association between implementation of state RCLs and alcohol use among adults in the US.
DESIGN, SETTINGS, AND PARTICIPANTS: This was a cross-sectional study of 4.2 million individuals who responded to the Behavioral Risk Factor Surveillance System in 2010 to 2019. A difference-in-differences approach with demographic and policy controls was used to estimate the association between RCLs and alcohol use, overall and by age, sex, race and ethnicity, and educational level. Data analyses were performed from June 2021 to March 2022.
EXPOSURES: States with RCLs, as reported by the RAND-University of Southern California Schaeffer Opioid Policy Tools and Information Center.
MAIN OUTCOMES AND MEASURES: Past-month alcohol use, binge drinking, and heavy drinking.
RESULTS: Of 4.2 million respondents (median age group, 50-64 years; 2 476 984 [51.7%] women; 2 978 467 [58.3%] non-Hispanic White individuals) in 2010 through 2019, 321 921 individuals lived in state-years with recreational cannabis laws. Recreational cannabis laws were associated with a 0.9 percentage point (95% CI, 0.1-1.7; P = .02) increase in any alcohol drinking but were not significantly associated with binge or heavy drinking. Increases in any alcohol use were primarily among younger adults (18-24 years) and men, as well as among non-Hispanic White respondents and those without any college education. A 1.4 percentage point increase (95% CI, 0.4-2.3; P = .006) in binge drinking was also observed among men, although this association diminished over time.
CONCLUSIONS AND RELEVANCE: This cross-sectional study and difference-in-differences analysis found that recreational cannabis laws in the US may be associated with increased alcohol use, primarily among younger adults and men.
Zupa, Margaret, Robert Feldman, and Jing Luo. (2022) 2022. “Trends in Out-of-Pocket Cost of Glucagon, 2010-2020.”. JAMA Network Open 5 (8): e2229428. https://doi.org/10.1001/jamanetworkopen.2022.29428.
This cross-sectional study investigates trends in out-of-pocket costs for unmixed and novel glucagon formulations among patients with Medicare Advantage and commercial insurance from 2010 to 2020.
Macha, Vandana, Rahi Abouk, and Coleman Drake. (2022) 2022. “Association of Recreational Cannabis Legalization With Alcohol Use Among Adults in the US, 2010 to 2019.”. JAMA Health Forum 3 (11): e224069. https://doi.org/10.1001/jamahealthforum.2022.4069.
IMPORTANCE: In the US, cannabis use has nearly doubled during the past decade, in part because states have implemented recreational cannabis laws (RCLs). However, it is unclear how legalization of adult-use cannabis may affect alcohol consumption.
OBJECTIVE: To estimate the association between implementation of state RCLs and alcohol use among adults in the US.
DESIGN, SETTINGS, AND PARTICIPANTS: This was a cross-sectional study of 4.2 million individuals who responded to the Behavioral Risk Factor Surveillance System in 2010 to 2019. A difference-in-differences approach with demographic and policy controls was used to estimate the association between RCLs and alcohol use, overall and by age, sex, race and ethnicity, and educational level. Data analyses were performed from June 2021 to March 2022.
EXPOSURES: States with RCLs, as reported by the RAND-University of Southern California Schaeffer Opioid Policy Tools and Information Center.
MAIN OUTCOMES AND MEASURES: Past-month alcohol use, binge drinking, and heavy drinking.
RESULTS: Of 4.2 million respondents (median age group, 50-64 years; 2 476 984 [51.7%] women; 2 978 467 [58.3%] non-Hispanic White individuals) in 2010 through 2019, 321 921 individuals lived in state-years with recreational cannabis laws. Recreational cannabis laws were associated with a 0.9 percentage point (95% CI, 0.1-1.7; P = .02) increase in any alcohol drinking but were not significantly associated with binge or heavy drinking. Increases in any alcohol use were primarily among younger adults (18-24 years) and men, as well as among non-Hispanic White respondents and those without any college education. A 1.4 percentage point increase (95% CI, 0.4-2.3; P = .006) in binge drinking was also observed among men, although this association diminished over time.
CONCLUSIONS AND RELEVANCE: This cross-sectional study and difference-in-differences analysis found that recreational cannabis laws in the US may be associated with increased alcohol use, primarily among younger adults and men.
Pickering, Aimee N, Xinhua Zhao, Florentina E Sileanu, Elijah Z Lovelace, Liam Rose, Aaron L Schwartz, Allison H Oakes, et al. (2022) 2022. “Assessment of Care Cascades Following Low-Value Prostate-Specific Antigen Testing Among Veterans Dually Enrolled in the US Veterans Health Administration and Medicare Systems.”. JAMA Network Open 5 (12): e2247180. https://doi.org/10.1001/jamanetworkopen.2022.47180.
IMPORTANCE: Older US veterans commonly receive health care outside of the US Veterans Health Administration (VHA) through Medicare, which may increase receipt of low-value care and subsequent care cascades.
OBJECTIVE: To characterize the frequency, cost, and source of low-value prostate-specific antigen (PSA) testing and subsequent care cascades among veterans dually enrolled in the VHA and Medicare and to determine whether receiving a PSA test through the VHA vs Medicare is associated with more downstream services.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used VHA and Medicare administrative data from fiscal years (FYs) 2017 to 2018. The study cohort consisted of male US veterans dually enrolled in the VHA and Medicare who were aged 75 years or older without a history of prostate cancer, elevated PSA, prostatectomy, radiation therapy, androgen deprivation therapy, or a urology visit. Data were analyzed from December 15, 2020, to October 20, 2022.
EXPOSURES: Receipt of low-value PSA testing.
MAIN OUTCOMES AND MEASURES: Differences in the use and cost of cascade services occurring 6 months after receipt of a low-value PSA test were assessed for veterans who underwent low-value PSA testing in the VHA and Medicare compared with those who did not, adjusted for patient- and facility-level covariates.
RESULTS: This study included 300 393 male US veterans at risk of undergoing low-value PSA testing. They had a mean (SD) age of 82.6 (5.6) years, and the majority (264 411 [88.0%]) were non-Hispanic White. Of these veterans, 36 459 (12.1%) received a low-value PSA test through the VHA, which was associated with 31.2 (95% CI, 29.2 to 33.2) additional cascade services per 100 veterans and an additional $24.5 (95% CI, $20.8 to $28.1) per veteran compared with the control group. In the same cohort, 17 981 veterans (5.9%) received a PSA test through Medicare, which was associated with 39.3 (95% CI, 37.2 to 41.3) additional cascade services per 100 veterans and an additional $35.9 (95% CI, $31.7 to $40.1) per veteran compared with the control group. When compared directly, veterans who received a PSA test through Medicare experienced 9.9 (95% CI, 9.7 to 10.1) additional cascade services per 100 veterans compared with those who underwent testing within the VHA.
CONCLUSIONS AND RELEVANCE: The findings of this cohort study suggest that US veterans dually enrolled in the VHA and Medicare commonly experienced low-value PSA testing and subsequent care cascades through both systems in FYs 2017 and 2018. Care cascades occurred more frequently through Medicare compared with the VHA. These findings suggest that low-value PSA testing has substantial downstream implications for patients and may be especially challenging to measure when care occurs in multiple health care systems.
Radomski, Thomas R, Xinhua Zhao, Elijah Z Lovelace, Florentina E Sileanu, Liam Rose, Aaron L Schwartz, Loren J Schleiden, et al. (2022) 2022. “Use and Cost of Low-Value Health Services Delivered or Paid for by the Veterans Health Administration.”. JAMA Internal Medicine 182 (8): 832-39. https://doi.org/10.1001/jamainternmed.2022.2482.
IMPORTANCE: Within the Veterans Health Administration (VA), the use and cost of low-value services delivered by VA facilities or increasingly by VA Community Care (VACC) programs have not been comprehensively quantified.
OBJECTIVE: To quantify veterans' overall use and cost of low-value services, including VA-delivered care and VA-purchased community care.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study assessed a national population of VA-enrolled veterans. Data on enrollment, sociodemographic characteristics, comorbidities, and health care services delivered by VA facilities or paid for by the VA through VACC programs were compiled for fiscal year 2018 from the VA Corporate Data Warehouse. Data analysis was conducted from April 2020 to January 2022.
MAIN OUTCOMES AND MEASURES: VA administrative data were applied using an established low-value service metric to quantify the use of 29 potentially low-value tests and procedures delivered in VA facilities and by VACC programs across 6 domains: cancer screening, diagnostic and preventive testing, preoperative testing, imaging, cardiovascular testing and procedures, and other procedures. Sensitive and specific criteria were used to determine the low-value service counts per 100 veterans overall, by domain, and by individual service; count and percentage of each low-value service delivered by each setting; and estimated cost of each service.
RESULTS: Among 5.2 million enrolled veterans, the mean (SD) age was 62.5 (16.0) years, 91.7% were male, 68.0% were non-Hispanic White, and 32.3% received any service through VACC. By specific criteria, 19.6 low-value services per 100 veterans were delivered in VA facilities or by VACC programs, involving 13.6% of veterans at a total cost of $205.8 million. Overall, the most frequently delivered low-value service was prostate-specific antigen testing for men aged 75 years or older (5.9 per 100 veterans); this was also the service with the greatest proportion delivered by VA facilities (98.9%). The costliest low-value services were spinal injections for low back pain ($43.9 million; 21.4% of low-value care spending) and percutaneous coronary intervention for stable coronary disease ($36.8 million; 17.9% of spending).
CONCLUSIONS AND RELEVANCE: This cross-sectional study found that among veterans enrolled in the VA, more than 1 in 10 have received a low-value service from VA facilities or VACC programs, with approximately $200 million in associated costs. Such information on the use and costs of low-value services are essential to guide the VA's efforts to reduce delivery and spending on such care.