Hernandez, Inmaculada, Alvaro San-Juan-Rodriguez, Chester B Good, and Walid F Gellad. (2021) 2021. “Estimating Discounts for Top Spending Drugs in Medicare Part D.”. Journal of General Internal Medicine 36 (8): 2503-5. https://doi.org/10.1007/s11606-020-06194-2.
Publications
2021
Essien, Utibe R, Nadejda Kim, Leslie R M Hausmann, Maria K Mor, Chester B Good, Jared W Magnani, Terrence M A Litam, Walid F Gellad, and Michael J Fine. (2021) 2021. “Disparities in Anticoagulant Therapy Initiation for Incident Atrial Fibrillation by Race/Ethnicity Among Patients in the Veterans Health Administration System.”. JAMA Network Open 4 (7): e2114234. https://doi.org/10.1001/jamanetworkopen.2021.14234.
IMPORTANCE: Atrial fibrillation is a common cardiac rhythm disturbance causing substantial morbidity and mortality that disproportionately affects racial/ethnic minority groups. Anticoagulation reduces stroke risk in atrial fibrillation, yet studies show it is underprescribed in racial/ethnic minority patients.
OBJECTIVE: To compare initiation of anticoagulant therapy by race/ethnicity for patients in the Veterans Health Administration (VA) system with atrial fibrillation.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included 111 666 patients within the VA system with incident atrial fibrillation between January 1, 2014, and December 31, 2018. Data were analyzed between December 1, 2019, and March 31, 2020.
EXPOSURES: Any anticoagulation was defined as receipt of warfarin or direct-acting oral anticoagulants, apixaban, dabigatran, edoxaban, or rivaroxaban.
MAIN OUTCOMES AND MEASURES: Initiation of any anticoagulation (or direct-acting oral anticoagulant therapy in those who initiated any anticoagulation) was examined within 90 days of an index atrial fibrillation diagnosis.
RESULTS: Our final cohort comprised 111 666 patients (109 386 men [98.0%] and 95 493 White patients [85.5%]; mean [SD] age, 72.9 [10.4] years). A total of 69 590 patients (62.3%) initiated any anticoagulant therapy, varying 10.5 percentage points by race/ethnicity (P < .001); initiation was lowest in Asian (52.2% [n = 676]) and Black (60.3% [n = 6177]) patients and highest in White patients (62.7% [n = 59 881]). Among anticoagulant initiators, 45 381 (65.2%) used direct-acting oral anticoagulants, varying 7.2 percentage points by race/ethnicity (P < .001); initiation was lowest in Hispanic (58.3% [n = 1470]), American Indian/Alaska Native (59.8% [n = 201]), and Black (60.9% [n = 3763]) patients and highest in White patients (66.0% [n = 39 502). Compared with White patients, the odds of initiating any anticoagulant therapy were significantly lower for Asian (adjusted odds ratio [aOR], 0.82; 95% CI, 0.72-0.94) and Black (aOR, 0.90; 95% CI 0.85-0.95) patients. Among initiators, the adjusted odds of direct-acting oral anticoagulant initiation were significantly lower for Hispanic (aOR, 0.79; 95% CI, 0.70-0.89), American Indian/Alaska Native (aOR, 0.75; 95% CI, 0.57-0.99), and Black (aOR, 0.74; 95% CI 0.69-0.80) patients.
CONCLUSIONS AND RELEVANCE: This cohort study found that in patients with incident atrial fibrillation managed in the VA system, race/ethnicity was independently associated with initiating any anticoagulant therapy and direct-acting oral anticoagulant use among anticoagulant initiators. Understanding the reasons for these treatment disparities is essential to improving equitable atrial fibrillation management and outcomes among racial/ethnic minority patients treated in the VA system.
Rogal, Shari, Ada Youk, Olufunso Agbalajobi, Hongwei Zhang, Walid Gellad, Michael J Fine, Pamela Belperio, Timothy Morgan, Chester B Good, and Kevin Kraemer. (2021) 2021. “Medication Treatment of Active Opioid Use Disorder in Veterans With Cirrhosis.”. The American Journal of Gastroenterology 116 (7): 1406-13. https://doi.org/10.14309/ajg.0000000000001228.
INTRODUCTION: Although opioid use disorder (OUD) is common in patients with cirrhosis, it is unclear how medication treatment for OUD (MOUD) is used in this population. We aimed to assess the factors associated with MOUD and mortality in a cohort of Veterans with cirrhosis and OUD.
METHODS: Within the Veterans Health Administration Corporate Data Warehouse, we developed a cohort of Veterans with cirrhosis and active OUD, using 2 outpatient or 1 inpatient International Classification of Diseases, ninth revision codes from 2011 to 2015 to define each condition. We assessed MOUD initiation with methadone or buprenorphine over the 180 days following the first OUD International Classification of Diseases, ninth revision code in the study period. We fit multivariable regression models to assess the association of sociodemographic and clinical factors with receiving MOUD and the associations between MOUD and subsequent clinical outcomes, including new hepatic decompensation and mortality.
RESULTS: Among 5,600 Veterans meeting criteria for active OUD and cirrhosis, 722 (13%) were prescribed MOUD over 180 days of follow-up. In multivariable modeling, MOUD was significantly, positively associated with age (adjusted odds ratio [AOR] per year: 1.04, 95% confidence interval (CI): 1.01-1.07), hepatitis C virus (AOR = 2.15, 95% CI = 1.37-3.35), and other substance use disorders (AOR = 1.47, 95% CI = 1.05-2.04) negatively associated with alcohol use disorder (AOR = 0.70, 95% CI = 0.52-0.95), opioid prescription (AOR = 0.51, 95% CI = 0.38-0.70), and schizophrenia (AOR = 0.59, 95% CI = 0.37-0.95). MOUD was not significantly associated with mortality (adjusted hazards ratio = 1.20, 95% CI = 0.95-1.52) or new hepatic decompensation (OR = 0.57, CI = 0.30-1.09).
DISCUSSION: Few Veterans with active OUD and cirrhosis received MOUD, and those with alcohol use disorder, schizophrenia, and previous prescriptions for opioids were least likely to receive these effective therapies.
Hernandez, Inmaculada, Deanna Rowe, Walid F Gellad, and Chester B Good. (2021) 2021. “Trends in the Use of Conventional and New Pharmaceuticals for Hemophilia Treatments Among Medicaid Enrollees, 2005-2020.”. JAMA Network Open 4 (6): e2112044. https://doi.org/10.1001/jamanetworkopen.2021.12044.
This cohort study used Medicaid data to examine trends in the use of and spending for hemophilia pharmaceuticals from 2005 to 2020.
Good, Chester B, and Inmaculada Hernandez. (2021) 2021. “Decomposition of Expenditures for Insulins Across the Distribution Chain-Insights Into Rising Prices?”. JAMA Health Forum 2 (11): e212258. https://doi.org/10.1001/jamahealthforum.2021.2258.
Swart, Elizabeth C S, Douglas Mager, Natasha Parekh, Rock A Heyman, Rochelle Henderson, Kiraat Munshi, Gail Bridges, and Chester B Good. (2021) 2021. “Infection Incidence and Management in Multiple Sclerosis Patients After Initiating Disease-Modifying Therapy.”. Multiple Sclerosis and Related Disorders 56: 103285. https://doi.org/10.1016/j.msard.2021.103285.
Disease-modifying therapies for multiple sclerosis (MS) are effective, but frequently cost $70,000+/year and can predispose patients to serious infections. This retrospective cohort analysis (N = 3,204) compared rates of infections over a 24-month period by MS medication route of administration and antimicrobial use. Infection rates were: 38.7% (oral), 37.3% (infused), and 36.8% (injectable). Of those infections, antimicrobials were prescribed in 86.5% (oral), 84.3% (infused), and 85.5% (injectable) cases. We found differences within bacterial and herpes zoster infection rates (and antimicrobial use) among new users by medication route of administration. Our findings suggest that pharmacovigilance may inform the shared-decision processes when choosing MS medications.
Neilson, Lynn M, Caroline Swift, Elizabeth C S Swart, Yan Huang, Natasha Parekh, Kiraat D Munshi, Rochelle Henderson, and Chester B Good. (2021) 2021. “Impact of Marijuana Legalization on Opioid Utilization in Patients Diagnosed With Pain.”. Journal of General Internal Medicine 36 (11): 3417-22. https://doi.org/10.1007/s11606-020-06530-6.
BACKGROUND: Given efforts to reduce opioid use, and because marijuana potentially offers a lower-risk alternative for treating chronic pain, there is interest in understanding the public health impact of marijuana legalization on opioid-related outcomes.
OBJECTIVE: Assess the impact of recreational and medical marijuana legalization on opioid utilization among patients receiving pharmacotherapy for pain.
DESIGN: Retrospective claims-based study of commercially insured patients continuously eligible for pharmacy and medical benefits from July 8, 2014 to June 30, 2017. Index pain prescription period was defined between January 8, 2015 and June 30, 2015, and longer-term opioid use examined during 2-year follow-up. Marijuana state policy on July 1, 2015, was assigned: none; medical only; or medical and recreational.
PARTICIPANTS: Patients aged 18-62 without cancer diagnosis.
MAIN MEASURES: Patient receiving (1) opioid at index; (2) > 7 days' supply of index opioid; (3) opioid during follow-up; and (4) ≥ 90 days' opioid supply during follow-up. Multivariable regression assessed associations between opioid utilization and state marijuana policy, adjusting for age, gender, overall disease burden, mental health treatment, concomitant use of benzodiazepine or muscle relaxant, and previous pain prescription.
KEY RESULTS: Of 141,711 patients, 80,955 (57.1%) resided in states with no policy; 56,494 (39.9%) with medical-only; and 4262 (3.0%) with medical and recreational. Patients in states with both policies were more likely to receive an index opioid (aOR = 1.72, 95% CI = 1.61-1.85; aOR = 1.90, 95% CI = 1.77-2.03; P < 0.001) but less likely to receive > 7 days' index supply (aOR = 0.84, 95% CI = 0.77-0.91; aOR = 0.76, 95% CI = 0.70-0.83; P < 0.001) than patients in states with no policy or medical-only, respectively. Those in states with both policies were more likely to receive a follow-up opioid (aOR = 1.87, 95% CI = 1.71-2.05; aOR = 2.20, 95% CI = 2.01-2.42; P < 0.001) than those in states with no policy or medical-only, respectively, and more likely to receive ≥ 90 cumulative follow-up opioid days' supply (aOR = 1.18, 95% CI = 1.07-1.29; P < 0.001) than those in states with no policy.
CONCLUSIONS: Our analysis does not support the supposition that access to marijuana lowers use of chronic opioids for pain.
Neilson, Lynn M, Kiraat D Munshi, Samuel K Peasah, Yan Huang, Elizabeth C S Swart, Rochelle Henderson, Chronis Manolis, and Chester B Good. (2021) 2021. “Changes in Type 2 Diabetes Medication Utilization and Costs in the United States, 2014-2019.”. Medical Care 59 (9): 789-94. https://doi.org/10.1097/MLR.0000000000001597.
OBJECTIVE: The objective of this study was to describe national changes in utilization and associated costs of antidiabetic medications in the United States from 2014 to 2019, across different drug classes and insurance plans.
RESEARCH DESIGN AND METHODS: This retrospective, cross-sectional study examined administrative claims from a large national pharmacy benefits manager from January 1, 2014, to December 31, 2019. Patients aged 18 years and above enrolled in commercial, Medicare, or Medicaid health plans who filled ≥1 prescription claim for an antidiabetic medication(s) during the 6-year period were included. Utilization was examined as the total number of 30-day adjusted prescription fills per user per month (PUPM). Gross costs were calculated as the sum of plan costs (net of rebates) and member out-of-pocket costs. Differences in mean utilization and costs PUPM between 2014 and 2019 for each medication class were calculated.
RESULTS: The final analytic sample increased from 745,290 patients in 2014 to 1,596,006 in 2019. Antidiabetic medication utilization increased by 8.8% from 2014 to 2019, driven by increases in sodium-glucose cotransporter 2 inhibitor (48.7%; P<0.001), glucagon-like peptide 1 receptor agonist (11.8%; P<0.001), insulin (8.1%; P<0.001), and metformin (2.9%; P<0.05) utilization. Average costs PUPM rose 47.5% (P<0.001), from $126.52 in 2014 to $186.58 in 2019. Sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, and combination drugs contributed significantly to these increased costs, with 6-year cost differences of 57.3%, 46.9%, and 47.2%, respectively (all P<0.001).
CONCLUSION: Our study demonstrates a shift in antidiabetic medication class utilization from 2014 to 2019, where associated costs net of rebates significantly increased to a disproportionately greater extent than the significant increase in utilization PUPM.
Arnold, Jonathan, Xinhua Zhao, John P Cashy, Florentina E Sileanu, Maria K Mor, Patience Moyo, Carolyn T Thorpe, et al. (2021) 2021. “An Interrupted Time-Series Evaluation of the Association Between State Laws Mandating Prescriber Use of Prescription Drug Monitoring Programs and Discontinuation of Chronic Opioid Therapy in US Veterans.”. Medical Care 59 (12): 1042-50. https://doi.org/10.1097/MLR.0000000000001643.
BACKGROUND: Most states have recently passed laws requiring prescribers to use prescription drug monitoring programs (PDMPs) before prescribing opioid medications. The impact of these mandates on discontinuing chronic opioid therapy among Veterans managed in the Veterans Health Administration (VA) is unknown. We assess the association between the earliest of these laws and discontinuation of chronic opioid therapy in Veterans receiving VA health care.
METHODS: We conducted a comparative interrupted time-series study in the 5 states mandating PDMP use before August 2013 (Ohio, West Virginia, Kentucky, New Mexico, and Tennessee), adjusting for trends in the 17 neighboring control states without such mandates. We modeled 25 months of prescribing for each state centered on the month the mandate became effective. We included Veterans prescribed long-term outpatient opioid therapy (305 of the preceding 365 d). Our outcomes were discontinuation of chronic opioid therapy (primary outcome) and the average daily quantity of opioids per Veteran over the following 6 months (secondary outcome).
RESULTS: We included 250 monthly cohorts with 225,665 unique Veterans and 3.4 million Veteran-months. Baseline discontinuation rates before the PDMP mandates were 0.4%-2.7% per month. Kentucky saw a discontinuation increase of 1 absolute percentage point following its PDMP mandate which decreased over time. The other 4 states had no significant association between their mandates and change in opioid discontinuation. There was no evidence of decreasing opioid quantities following PDMP mandates.
CONCLUSION: We did not find consistent evidence that state laws mandating provider PDMP use were associated with the discontinuation of chronic opioid therapy within the VA for the time period studied.
Berenbrok, Lucas A, Lauren Ciemniecki, Amanda A Cremeans, Robin Albright, and Elaine Mormer. (2021) 2021. “Pharmacist Competencies for Over-the-Counter Hearing Aids: A Delphi Study.”. Journal of the American Pharmacists Association : JAPhA 61 (4): e255-e262. https://doi.org/10.1016/j.japh.2021.01.039.
BACKGROUND: The 2017 Food and Drug Administration Reauthorization Act established a new category of hearing aids to be available over the counter to increase accessibility and affordability of hearing aid devices. To prepare for increased consumer demand, pharmacists must be ready to meet the needs of the millions of adults eligible to seek over-the-counter hearing aids at the community pharmacy. To date, no organization has proposed competency statements to describe a pharmacist with the knowledge, skills, and abilities aligning with safe and effective use of over-the-counter hearing aids to be sold at community pharmacies.
OBJECTIVES: The objective of this study was to establish competencies needed for pharmacists to safely and effectively assist patients seeking over-the-counter hearing aids at the community pharmacy.
METHODS: The Delphi technique was selected to achieve group consensus for competency statements. The project began with a kickoff meeting in July 2019 and continued with a brainstorming round followed by 3 rounds of surveys ending in March 2020. Each survey presented competency statements for panelists to review, rate their agreement, and offer revisions. Statements that reached consensus to accept (≥80% agreement) were advanced to the final list. Statements that did not reach consensus were advanced to subsequent survey rounds.
RESULTS: A total of 14 individuals representing pharmacy, audiology, hearing aid manufacturers, and persons with hearing loss participated. In total, 26 competency statements were accepted by consensus, 2 statements were rejected by consensus, and 11 statements did not reach consensus. All 26 accepted statements were mapped to the Pharmacists' Patient Care Process before final approval by the stakeholder panel.
CONCLUSION: Pharmacists will likely play new interprofessional roles in the delivery of hearing health care as over-the-counter hearing aids come to market. With professional competency statements, pharmacists will have a framework for the knowledge, skills, and abilities needed to safely assist patients seeking over-the-counter hearing aids at the community pharmacy.