Publications

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.

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.

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.

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.

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.

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.

BACKGROUND: Low-value prescribing may result in adverse patient outcomes and increased medical expenditures. Clinicians' baseline strategies for navigating patient encounters involving low-value prescribing remain poorly understood, making it challenging to develop acceptable deprescribing interventions. Our objective was to characterize primary care physicians' (PCPs) approaches to reduce low-value prescribing in older adults through qualitative analysis of clinical scenarios.

METHODS: As part of an overarching qualitative study on low-value prescribing, we presented two clinical scenarios involving potential low-value prescribing during semi-structured interviews of 16 academic and community PCPs from general internal medicine, family medicine and geriatrics who care for patients aged greater than or equal to 65. We conducted a qualitative analysis of their responses to identify salient themes related to their approaches to prescribing, deprescribing, and meeting patients' expectations surrounding low-value prescribing.

RESULTS: We identified three key themes. First, when deprescribing, PCPs were motivated by their desire to mitigate patient harms and follow medication safety and deprescribing guidelines. Second, PCPs emphasized good communication with patients when navigating patient encounters related to low-value prescribing; and third, while physicians emphasized the importance of shared decision-making, they prioritized patients' well-being over satisfying their expectations.

CONCLUSIONS: When presented with real-life clinical scenarios, PCPs in our cohort sought to reduce low-value prescribing in a guideline-concordant fashion while maintaining good communication with their patients. This was driven primarily by a desire to minimize the potential for harm. This suggests that barriers other than clinician knowledge may be driving ongoing use of low-value medications in clinical practice.

BACKGROUND: Delays in advancing to biologic therapies are associated with adverse outcomes in inflammatory bowel disease (IBD). Insurer-mandated prior authorizations have been linked to prolonged medication initiation times. We hypothesized that prior authorizations are associated with prolonged biologic initiation time and increased IBD-related healthcare utilization among children with IBD.

METHODS: We performed a retrospective cohort study of 190 pediatric patients with IBD initiating biologics at a tertiary care hospital to measure the association between prior authorization, biologic initiation time (physician recommendation to first dose), and healthcare utilization (hospitalization, surgery, or emergency department visit). Demographic, insurance, and disease severity-related covariables were collected. Multivariable linear regression was used to measure the association between prior authorization and biologic initiation time. Propensity score methods were used to measure the associations between prior authorization and IBD-related healthcare utilization within 180 days and corticosteroid dependence at 90 days, with adjustment for insurance type, demographics, and disease severity-related characteristics.

RESULTS: Median biologic initiation time was 21 days. Prior authorization and complicated prior authorizations (requiring appeal, step therapy, or peer-to-peer review) were associated with 10.2-day (95% confidence interval [CI] 8.2 to 12.3) and 24.6-day (95% CI 16.4 to 32.8) increases in biologic initiation time, respectively. Prior authorizations increased the likelihood of IBD-related healthcare utilization within 180 days by 12.9% (95% CI 2.5 to 23.4) and corticosteroid dependence at 90 days by 14.1% (95% CI 3.3 to 24.8).

CONCLUSIONS: Prior authorizations are associated with prolonged biologic initiation time and increased IBD-related healthcare utilization. Minimizing prior authorization-related delays may expedite biologic delivery and reduce the risk of IBD-related healthcare utilization.

BACKGROUND & AIMS: Identification of postendoscopy esophageal adenocarcinoma (PEEC) among Barrett's esophagus (BE) patients presents an opportunity to improve survival of esophageal adenocarcinoma (EAC). We aimed to estimate the proportion of PEEC within the first year after BE diagnosis.

METHODS: Multiple databases (Medline, Embase, Scopus, and Cochrane databases) were searched until September 2020 for original studies with at least 1-year follow-up evaluation that reported EAC and/or high-grade dysplasia (HGD) in the first year after index endoscopy in nondysplastic BE, low-grade dysplasia, or indefinite dysplasia. The proportions of PEEC defined using EAC alone and EAC+HGD were calculated by dividing EAC or EAC+HGD in the first year over the total number of EAC or EAC+HGD, respectively.

RESULTS: We included 52 studies with 145,726 patients and a median follow-up period of 4.8 years. The proportion of PEEC (EAC) was 21% (95% CI, 13-31) and PEEC (EAC+HGD) was 26% (95% CI, 19-34). Among studies with nondysplastic BE only, the PEEC (EAC) proportion was 17% (95% CI, 11-23) and PEEC (EAC+HGD) was 14% (95% CI, 8-19). Among studies with 5 or more years of follow-up evaluation, the PEEC (EAC) proportion was 10% and PEEC (EAC+HGD) was 19%. Meta-regression analysis showed a strong inverse relationship between PEEC and incident EAC (P < .001). The PEEC (EAC) proportion increased from 5% in studies published before 2000 to 30% after 2015. Substantial heterogeneity was observed for most analyses.

CONCLUSIONS: PEEC accounts for a high proportion of HGD/EACs and is proportional to reduction in incident EAC. Using best endoscopic techniques now and performing future research on improving neoplasia detection through implementation of quality measures and educational tools is needed to reduce PEEC.

BACKGROUND: Patients with recent hematopoietic cell transplantation (HCT) are considered high risk for gastrointestinal endoscopy due to the potential for procedural bacterial translocation. Prior studies investigating these risks do not account for the higher baseline rate of infectious complications among those who are immunocompromised. We performed a retrospective cohort study of patients with recent HCT who underwent endoscopy and their matched controls who did not undergo endoscopy.

METHODS: We identified patients who underwent HCT followed by upper and/or lower endoscopy at the University of Pennsylvania from 2000 to 2018. Individuals were matched 1:1 by age, sex, and type of HCT to controls who underwent HCT without subsequent endoscopy. Infectious adverse events were assessed by Sepsis-3 and Sepsis-2 criteria. Factors associated with infectious adverse events after endoscopy/index date were assessed using multivariable conditional logistic regression.

RESULTS: We identified 149 patients who underwent HCT and endoscopy and 149 matched controls who underwent HCT without endoscopy. Sepsis-3 infectious adverse events occurred in 3.4% of patients in each group. Sepsis-2 infectious adverse events occurred in 20.1% of patients who underwent endoscopy compared to 19.5% of controls. There was no association between endoscopy and Sepsis-2 infectious adverse events in the multivariable regression analysis (adjusted odds ratio 1.65, 95% CI 0.51-5.26).

CONCLUSIONS: When compared to controls with similar immune statuses, patients who underwent endoscopy after HCT did not have a higher risk of infectious adverse events. These results may inform clinical decision making regarding the risks and benefits of endoscopic management after HCT.