Administrative Health Care Research Articles

Real-world Prescription Pattern, Discontinuation and Costs of Ibrutinib-Naïve Patients with Chronic Lymphocytic Leukemia: An Italian Healthcare Administrative Database Analysis.

In order to integrate the existing and inconsistent information from clinical trials and real-world practice on chronic lymphocytic leukemia (CLL) treated with ibrutinib, this analysis aimed to describe the prescription pattern of new users of ibrutinib affected by CLL, focusing on discontinuation, severe adverse events (AEs) and change of treatment, and to assess the integrated healthcare expenditure from the Italian National Health System (INHS) perspective. Starting from the ReS database, adults with at least a supply of ibrutinib (ATC code L01XE27) were selected from 01/01/2016 to 12/31/2017. Those without any ibrutinib supply in the year before the index prescription were considered new users. Out of them, only patients with at least a primary or secondary in-hospital diagnosis of CLL (ICD-9-CM code 204.1*) from 01/01/2013 to 12/31/2018 were further broken down according to the ibrutinib's line treatment (first line-FL; second or later line-SLL) and analysed. They were characterized by sex and age in the selection period. Mean annual consumption (defined daily doses [DDD]), treatment discontinuation, changes of therapy, interruptions and healthcare costs in charge of the INHS were assessed during two follow-up years. Out of more than 5 million inhabitants of the ReS database, 69 new ibrutinib users and diagnosed with CLL in 2016 (incidence: 1.6 × 100,000) and 41 in 2017 (incidence: 0.9 × 100,000) were selected. Of these, 21 (19.1%) were FL ibrutinib users and 89 (80.9%) were SLL ones, mostly males and with mean ages (±SD) of 65±14 and 70±10, respectively. The mean annual consumption among FL users decreased from 222.2 DDD per patient treated to 216.0 DDD, while increased among SLL patients from 238.6 DDD to 260.1 DDD, in the first and second follow-up year, respectively. The discontinuation rate was about 40% in the first year, similarly among FL and SLL users. SLL patients discontinued more frequently (52.8% vs 20.0%) in the second year. Very few AEs were recorded. The 62.5% of FL and 55.6% of SLL users discontinuing ibrutinib in 1-year follow-up, while one SLL patient (5.3%) in the second year changed therapy. The 20.0% and 15.9% of all new users in first and second year interrupted ibrutinib. The total integrated cost of FL patients was €55,732 reducing by about €15,000, while it was €58,716 for SLL ones decreasing by €6,000, respectively, in the first and in the second year. Pharmaceuticals were the key cost driver (ibrutinib accounted for more than 77%). This analysis on Italian administrative data provided results about prescription patterns of ibrutinib FL and SLL new users with CLL, focusing on discontinuation, treatment change and healthcare costs over 2-year follow-up, and contributed to improve the knowledge on this hard-to-treat disease.

Estimates of epidemiology, mortality and disease burden associated with progressive fibrosing interstitial lung disease in France (the PROGRESS study)

BackgroundThere is a paucity of data on the epidemiology, survival estimates and healthcare resource utilisation and associated costs of patients with progressive fibrosing interstitial lung disease (PF-ILD) in France. An algorithm for extracting claims data was developed to indirectly identify and describe patients with PF-ILD in the French national administrative healthcare database.MethodsThe French healthcare database, the Système National des Données de Santé (SNDS), includes data related to ambulatory care, hospitalisations and death for 98.8% of the population. In this study, algorithms based on age, diagnosis and healthcare consumption were created to identify adult patients with PF-ILD other than idiopathic pulmonary fibrosis between 2010 and 2017. Incidence, prevalence, survival estimates, clinical features and healthcare resource usage and costs were described among patients with PF-ILD.ResultsWe identified a total of 14,413 patients with PF-ILD. Almost half of them (48.1%) were female and the mean (± standard deviation) age was 68.4 (± 15.0) years. Between 2010 and 2017, the estimated incidence of PF-ILD ranged from 4.0 to 4.7/100,000 person-years and the estimated prevalence from 6.6 to 19.4/100,000 persons. The main diagnostic categories represented were exposure-related ILD other than hypersensitivity pneumonitis (n = 3486; 24.2%), idiopathic interstitial pneumonia (n = 3113; 21.6%) and rheumatoid arthritis-associated ILD (n = 2521; 17.5%). Median overall survival using Kaplan–Meier estimation was 3.7 years from the start of progression. During the study, 95.2% of patients had ≥ 1 hospitalisation for respiratory care and 34.3% were hospitalised in an intensive care unit. The median (interquartile range) total specific cost per patient during the follow-up period was €25,613 (10,622–54,287) and the median annual cost per patient was €18,362 (6856–52,026), of which €11,784 (3003–42,097) was related to hospitalisations. Limitations included the retrospective design and identification of cases through an algorithm in the absence of chest high-resolution computed tomography scans and pulmonary function tests.ConclusionsThis large, real-world, longitudinal study provides important insights into the characteristics, epidemiology and healthcare resource utilisation and costs associated with PF-ILD in France using a comprehensive and exhaustive database, and provides vital evidence that PF-ILD represents a high burden on both patients and healthcare services.Trial registration ClinicalTrials.gov, NCT03858842. ISRCTN, ISRCTN12345678. Registered 3 January 2019—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03858842

Trends in new cancer treatments with targeted molecular therapies before and during the COVID-19 outbreak in Veneto, Italy: A real-world, population-based study.

e18734 Background: The COVID-19 outbreak has had a huge impact on health care services worldwide. Previous studies projected delays in cancer diagnoses and excess mortality for cancer patients as a result of the pandemic. Little is known, however, on the impact of the pandemic on the functioning of cancer services. We aimed to fill this gap by using a region-wide, population-based administrative health care data repository. Methods: We obtained data for patients initiating a targeted molecular therapy during 2017-2020 (January-September, by quarter) in Veneto. Eligible treatments were those with lapatinib, pertuzumab, TDM-1 and trastuzumab for breast cancer; with afatinib, alectinib, crizotinib, erlotinib, gefitinib and osimertinib for lung cancer; with cobimetinib, dabrafenib, trametinib and vemurafenib for melanoma; and with niraparib, olaparib and rucaparib for ovarian cancer. Patients starting more than one targeted molecular therapy in a given calendar year were included only once. We estimated the normalised difference between the number of patients for a given quarter in 2020 and the mean number of patients for the corresponding quarter during 2017-2019. Statistical significance was calculated assuming a type I error probability of 5%. Results: The study included 3,180 patients. In 2020, patients starting a targeted molecular therapy were 361 in the first quarter, 260 in the second quarter and 268 in the third quarter. The normalised difference between the number of treatments in 2020 and the mean number of treatments during 2017-2019 for all cancer types combined was statistically significant only for the first quarter, with more therapies in 2020 than in 2017-2019. In a breakdown by cancer type, differences were unremarkable for breast, lung or ovarian cancer, while there were significantly more treatments for melanoma for all the three quarters in 2020 compared to 2017-2019. Conclusions: We chose to use the rate of initiation of targeted molecular therapies as a proxy for the effectiveness of oncology services in managing cancer patients, because these therapies require that at least pathology and diagnostic facilities are fully operational. The study covered a population of nearly five million people, in a region where universal health coverage is available and where cancer care has been prioritised, by law, over non-cancer related health care services during the COVID-19 outbreak. Our findings suggest that provision of oncology care has not been substantially impacted by the pandemic in Veneto. Of note, label indications were unchanged for these drugs in 2020. The findings are also in line with the priority-based, adapted European Society for Medical Oncology recommendations. Further research is needed to assess whether delays at earlier stages of the route to cancer diagnosis (e.g. GP referrals for specialist care) may have occurred.

Using administrative health data for palliative and end of life care research in Ireland: potential and challenges

Background: This study aims to examine the potential of currently available administrative health and social care data for palliative and end-of-life care (PEoLC) research in Ireland. Objectives include to i) identify data sources for PEoLC research ii) describe the challenges and opportunities of using these and iii) evaluate the impact of recent health system reforms and changes to data protection laws. Methods: The 2017 Health Information and Quality Authority catalogue of health and social care datasets was cross-referenced with a recognised list of diseases with associated palliative care needs. Criteria to assess the datasets included population coverage, data collected, data dictionary and data model availability, and mechanisms for data access. Results: Nine datasets with potential for PEoLC research were identified, including death certificate data, hospital episode data, pharmacy claims data, one national survey, four disease registries (cancer, cystic fibrosis, motor neurone and interstitial lung disease) and a national renal transplant registry. The ad hoc development of the health system in Ireland has resulted in i) a fragmented information infrastructure resulting in gaps in data collections particularly in the primary and community care sector where much palliative care is delivered, ii) ill-defined data governance arrangements across service providers, many of whom are not part of the publically funded health service and iii) systemic and temporal issues that affect data quality. Initiatives to improve data collections include introduction of i) patient unique identifiers, ii) health entity identifiers and iii) integration of the Eircode postcodes. Recently enacted general data protection and health research regulations will clarify legal and ethical requirements for data use. Conclusions: Ongoing reform initiatives and recent changes to data privacy laws combined with detailed knowledge of the datasets, appropriate permissions, and good study design will facilitate future use of administrative health and social care data for PEoLC research in Ireland.

Incidence of diabetes mellitus in Italy in year 2018. A nationwide population-based study of the ARNO Diabetes Observatory

Backgrounds and aimsTo assess incidence of diabetes in Italy in 2018 by the use of administrative claims from several million residents. Differences in rates in men and women across decades of age were investigated. Incident rates of insulin or noninsulin treated subjects were also examined. Methods and resultsWe analyzed administrative healthcare claims of 11,300,750 subjects monitored by the ARNO Diabetes Observatory. Incident cases of diabetes were identified by glucose lowering drug prescriptions, disease-specific co-payment exemptions and hospital discharge codes related to diabetes occurring in 2018 but not in 2017.We identified 697,208 subjects with ascertained diabetes. Incident cases were 65,932, with a rate of 5.83 per 1000 person-years (p-y). Incidence of drug-treated diabetes (n = 60,271) was 5.33 per 1000 p-y. Subjects receiving only insulin prescriptions were 5652 (rate 0.50 per 1000 p-y) and those receiving only prescriptions of noninsulin medications were 51,085 (rate 4.52 per 1000 p-y). Incidence rates progressively increased across decades until age 80 and then dropped by 25–30%. Overall, incident rates were generally higher in women aged 11–40 and in men aged ≥51. ConclusionsRecent cases represented ~10% of the population of diabetic subjects. Incidence of noninsulin-treated diabetes was almost 10-fold higher than incidence of insulin-treated diabetes. Substantial differences in incidence rates were observed in men and women of several decades of age: women more affected in adolescence and young adult age, men more affected in mature and advanced age. These data provide further understanding on the epidemiological burden of the disease in Italy.

Diagnostic Accuracy of Health Care Administrative Diagnosis Codes to Identify Nontuberculous Mycobacteria Disease: A Systematic Review.

BackgroundHealth care administrative database research frequently uses standard medical codes to identify diagnoses or procedures. The aim of this review was to establish the diagnostic accuracy of codes used in administrative data research to identify nontuberculous mycobacterial (NTM) disease, including lung disease (NTMLD).MethodsWe searched Ovid Medline, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from inception to April 2019. We included studies assessing the diagnostic accuracy of International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM) diagnosis codes to identify NTM disease and NTMLD. Studies were independently assessed by 2 researchers, and the Quality Assessment of Diagnostic Accuracy Studies 2 tool was used to assess bias and quality.ResultsWe identified 5549 unique citations. Of the 96 full-text articles reviewed, 7 eligible studies of moderate quality (3730 participants) were included in our review. The diagnostic accuracy of ICD-9-CM diagnosis codes to identify NTM disease varied widely across studies, with positive predictive values ranging from 38.2% to 100% and sensitivity ranging from 21% to 93%. For NTMLD, 4 studies reported diagnostic accuracy, with positive predictive values ranging from 57% to 64.6% and sensitivity ranging from 21% to 26.9%.ConclusionsDiagnostic accuracy measures of codes used in health care administrative data to identify patients with NTM varied across studies. Overall the positive predictive value of ICD-9-CM diagnosis codes alone is good, but the sensitivity is low; this method is likely to underestimate case numbers, reflecting the current limitations of coding systems to capture NTM diagnoses.

Trends in postpartum opioid prescribing: A time series analysis

Objectives To examine whether a highly-publicized 2006 case report questioning the safety of codeine during lactation was associated with changes in postpartum opioid prescribing. Methods We conducted a time series analysis of all publicly-funded prescriptions for opioids to postpartum women in Ontario, Canada from April 1, 2000 to March 31, 2017 using linked administrative healthcare databases. We used autoregressive integrated moving average models to examine the change in the percentage of postpartum opioid prescriptions over time. The intervention was the publication of the case report in 2006 attributing the death of a breastfeeding neonate to maternal codeine use. Results We identified 167,426 postpartum women who were opioid-naive, and 22,255 (13.3%) received an opioid prescription following delivery. In the third quarter of 2006 (immediately prior to case report publication), 17.5% of postpartum women received an opioid, with codeine representing 89.8% of all such prescriptions. By the fourth quarter of 2010, only 12.2% of postpartum women received an opioid, representing a decline of 30% (p Conclusions A highly-publicized case report questioning the safety of maternal codeine use during breastfeeding was associated with significant changes in opioid prescribing to postpartum women, including a decline in overall opioid prescribing and a shift from codeine to stronger opioids.

Association between type of opioid prescribed postpartum and persistent opioid use: a population-based cohort study

Objectives To examine whether postpartum treatment with oxycodone is associated with an increased risk of new persistent opioid use relative to codeine. Methods Population-based retrospective cohort study of opioid-naive women who gave birth in Ontario, Canada between September 1, 2012 and March 31, 2018. Using linked administrative healthcare databases, women prescribed oxycodone postpartum were compared to those prescribed codeine postpartum. The primary outcome was persistent opioid use at 90 days following the initial postpartum prescription, with codeine as the reference exposure. Persistent use at 90 days was defined as any filled prescription in the 28-days (76-104 days), and 56-days (62-118 days) surrounding the 90-day mark. Relative risks (aRR) were adjusted for maternal, delivery, and prescription characteristics. Results We identified 21,365 postpartum women newly prescribed codeine and 43,767 newly prescribed oxycodone. Compared to codeine, an initial prescription for oxycodone was not associated with persistent opioid use at 90 days, whether a 28-day (aRR 1.12; 95%CI 0.92-1.36) or 56-day (aRR 1.06; 95%CI 0.91-1.24) window around the 90-day outcome was considered. Results were unchanged in a propensity-score matched analysis. A prescription containing greater than 225 milligrams of morphine equivalents was associated with an increased risk of persistent use (aRR 1.87; 95%CI 1.43-2.44), as was an initial prescription duration longer than 7 days (aRR 1.59; 95%CI 1.26-2.03). Conclusions The risk of new, persistent opioid use after delivery was similar for oxycodone and codeine. Limiting the volume and duration of the initial opioid prescription may be important interventions to reduce the risk of persistent opioid use in postpartum women.

Differences in Health-Related Quality of Life After Gastric Bypass Surgery: a Cross-Sectional Study

BackgroundGastric bypass (GBP) is a surgical method with good evidence of sustainable weight loss, reduced obesity-related comorbidities, and improved health-related quality of life (HRQoL). However, long-term data post-GBP is scarce on HRQoL related to other factors than weight loss, such as impact of socio-economic, age, and gender.AimTo investigate long-term HRQoL in GBP patients.MethodsThe study was conducted as a cross-sectional study covering 3 to 9 years post-GBP measuring HRQoL using RAND-36. Association to weight loss, time since surgery, gender, educational level, occupation, and age was analyzed. The participants were included on the basis that they had received a GBP that was performed by Region Skåne, the southernmost administrative healthcare region in Sweden. Recruitment to the study was by mail invitation for an online survey.ResultsOf the total population of 5310 persons receiving the questionnaire, 1339 of the 1372 responders fulfilled the inclusion criteria. Those with low educational level, unemployed, persons on sick leave or disability support, and those with less weight loss reported the lowest HRQoL. The longer time since surgery, the lower the HRQoL.ConclusionLess weight loss, longer time since GBP, lower educational level, and lower degree of employment all affect HRQoL negatively after GBP surgery.Graphical abstract

Risk of Total Hip Arthroplasty After Acetabular Fracture Fixation: The Importance of Age

BackgroundGeriatric patients are the most rapidly growing cohort of patients sustaining acetabular fractures (AFs). The purpose of this study was to examine the risk of a secondary total hip arthroplasty (THA) in older patients (>60 year old) with a prior AF open reduction internal fixation (ORIF) compared with younger patients (<60 year old) with an AF ORIF on a large population level. MethodsUsing administrative health care data from 1996 to 2010 inclusive of all 202 hospitals in Ontario, Canada, all adult patients with an AF ORIF and a minimum of two year follow-up were identified and included. The risk of THA was examined using a Cox proportional hazards model adjusting for patient risk factors. Secondary outcomes included surgical complications and all-cause mortality. ResultsA total of 1725 patients had an AF ORIF; 1452 (84.2%, mean age of 38.3 ± 12.1 years) aged <60 years (“younger”) and 273 (15.8%, mean age of 69.9 ± 7.8 years) > 60 years (“older”). The mean (SD) follow-up time for all patients was 6.9 (4.2) years. In older patients, 19.4% (53 of 273) went on to receive a secondary THA with a median time to event of 3.9 years, compared with 12.9% (187 of 1452) in the younger patient cohort with a median time of 6.9 years (HR 1.7, 95% CI: 1.2-2.3). As expected, older patients had a higher 90-day mortality rate compared with younger patients (7.7% vs. 0.7%, respectively; HR 9.2, 95% CI: 4.3-19.9; P < .001). ConclusionOlder patients with an AF ORIF are at a significantly higher risk for a secondary THA than younger patients with an AF ORIF.

Common and Unique Barriers to the Exchange of Administrative Healthcare Data in Environmental Public Health Tracking Program.

CDC’s National Environmental Public Health Tracking Program (Tracking Program) receives administrative data annually from 25–30 states to track potential environmental exposures and to make data available for public access. In 2019, the CDC Tracking Program conducted a cross-sectional survey among principal investigators or program managers of the 26 funded programs to improve access to timely, accurate, and local data. All 26 funding recipients reported having access to hospital inpatient data, and most states (69.2%) regularly update data user agreements to receive the data. Among the respondents, 15 receive record-level data with protected health information (PHI) and seven receive record-level data without PHI. Regarding geospatial resolution, approximately 50.0% of recipients have access to the street address or census tract information, 34.6% have access to ZIP code, and 11.5% have other sub-county geographies (e.g., town). Only three states receive administrative data for their residents from all border states. The survey results will help the Tracking Program to identify knowledge gaps and perceived barriers to the use and accessibility of administrative data for the CDC Tracking Program. The information collected will inform the development of resources that can provide solutions for more efficient and timely data exchange.

Alpha-1 Antitrypsin Deficiency-Associated Clinical Manifestations and Healthcare Resource Use in the United States

Pulmonary events (PEs) associated with alpha-1 antitrypsin deficiency (AATD) can have a severe clinical course and increase healthcare resource use (HRU). However, AATD-associated HRU and healthcare costs have not been extensively described. This study describes and compares real-world HRU and healthcare costs among US patients with severe (requiring hospitalization after AATD-related PE) versus nonsevere AATD clinical course. Administrative healthcare claims for patients with a second primary AATD diagnosis between 6/1/2008 and 12/31/2017 were analyzed from 2 databases (requiring continuous enrollment 6 months preceding diagnosis). Patient baseline characteristics and AATD-associated PE incidence rates, HRU, and healthcare costs during follow-up were compared in patients with severe versus nonsevere AATD. Of 5109 patients with a second AATD diagnosis, 2674 (severe, n = 711 [26.6%]; nonsevere, n = 1963 [73.4%]) had ≥1 AATD-associated PE. PE incidence per 100 person-years was higher in patients with severe versus nonsevere AATD. Annual incidences (mean ± SD) of emergency department (1.2 ± 5.7 vs. 0.4 ± 1.2), inpatient (1.3 ± 2.5 vs. 0.1 ± 0.5), and outpatient (10.3 ± 15.9 vs. 5.7 ± 13.2) visits were higher in patients with severe versus nonsevere AATD. Median (interquartile range) annual costs were also higher for patients with severe versus nonsevere AATD for emergency department ($185 [$0–$1665] vs. $0 [$0–$264]), inpatient ($16,038 [$2968–$70,941] vs. $0 [$0–$0]), and outpatient ($2663 [$412–$10,277] vs. $1114 [$134–$4195]) visits. Higher percentages of patients with severe AATD were prescribed augmentation therapy, antibiotics, or corticosteroids. These findings suggest that patients with severe AATD have higher incidence of AATD-associated PEs, as well as higher HRU and healthcare costs.

Real-world propensity score comparison of treatment effectiveness of peginterferon beta-1a vs. subcutaneous interferon beta-1a, glatiramer acetate, and teriflunomide in patients with relapsing-remitting multiple sclerosis

BackgroundMultiple disease-modifying therapies (DMTs) have been approved by the U.S. Food & Drug Administration for the treatment of relapsing-remitting multiple sclerosis (RRMS). In separately conducted clinical trials, peginterferon beta-1a, subcutaneous interferon beta-1a (SC IFN beta-1a), glatiramer acetate (GA), and teriflunomide have demonstrated efficacy for reducing relapses. No head-to-head phase III clinical trials have directly compared the treatment efficacy of peginterferon beta-1a with these other DMTs. ObjectivesA propensity score-based comparison was conducted of the treatment effectiveness of peginterferon beta-1a vs. SC IFN beta-1a, GA, and teriflunomide among patients with RRMS identified from a large U.S. administrative healthcare claims database. MethodsAdult patients (18-65 years of age) who had ≥1 claim for an MS diagnosis between November 2013 and June 2017 and ≥1 claim for peginterferon beta-1a, SC IFN beta-1a, GA, or teriflunomide between November 1, 2014, and March 31, 2017 were identified from the IBM® MarketScan® Commercial database. The index date was the first claim of a patient's DMT initiated. Only patients who had ≥12 months of insurance enrollment pre-index (baseline period) and ≥90 days post-index (variable length follow-up period) were included. Patients were grouped into cohorts according to the index DMT. Patient demographics and clinical characteristics were evaluated. Propensity score matching (PSM) was separately conducted for pairwise comparisons of treatment effectiveness between peginterferon beta-1a and the other DMT cohorts. During the post-index follow-up period, annualized relapse rate (ARR; relapse defined as hospitalization or outpatient visit with subsequent treatment), annualized number and length of inpatient stays, and the number of claims for durable medical equipment were evaluated. ResultsWith PSM, there were 325 patients (mean age: 46.0 years) in the peginterferon beta-1a cohort compared to 967 (mean age: 46.9 years) in the SC IFN beta-1a cohort; likewise there were 564 patients (mean age: 47.4 years) in the peginterferon beta-1a and 1688 (mean age: 47.6 years) in the GA cohort; and finally there were 584 patients (mean age: 49.1 years) in the peginterferon beta-1a cohort and 1742 (mean age: 49.0 years) in the teriflunomide cohort. During the post-index follow-up period, the ARR did not significantly differ between the peginterferon beta-1a and SC IFN beta-1a cohorts; the ARR was lower among patients treated with peginterferon beta-1a than among those treated with GA (Least squares mean [LSM] estimate: 0.25 vs. 0.31; LSM ratio: 0.809; P=0.027) or teriflunomide (LSM estimate: 0.26 vs. 0.37; LSM ratio: 0.704; P<0.001). The annualized mean number and length of inpatient stays and the mean number of claims for durable medical equipment during the post-index follow-up did not differ between the matched peginterferon beta-1a and GA cohorts nor the peginterferon beta-1a and teriflunomide cohorts. ConclusionIn this real-world comparative analysis of patients with similar patient characteristics, treatment with peginterferon beta-1a was associated with lower ARRs than treatment with either GA or teriflunomide; ARRs did not differ among patients treated with SC IFN beta-1a. Also, all other measured secondary outcomes did not differ between study cohorts. These real-world data may help support decision-making in the treatment of patients with RRMS.

Looking beyond Administrative Health Care Data: The Role of Socioeconomic Status in Predicting Future High-cost Patients with Mental Health and Addiction.

Introduction:Previous research has shown that the socioeconomic status (SES)–health gradient also extends to high-cost patients; however, little work has examined high-cost patients with mental illness and/or addiction. The objective of this study was to examine associations between individual-, household- and area-level SES factors and future high-cost use among these patients.Methods:We linked survey data from adult participants (ages 18 and older) of 3 cycles of the Canadian Community Health Survey to administrative health care data from Ontario, Canada. Respondents with mental illness and/or addiction were identified based on prior mental health and addiction health care use and followed for 5 years for which we ascertained health care costs covered under the public health care system. We quantified associations between SES factors and becoming a high-cost patient (i.e., transitioning into the top 5%) using logistic regression models. For ordinal SES factors, such as income, education and marginalization variables, we measured absolute and relative inequalities using the slope and relative index of inequality.Results:Among our sample, lower personal income (odds ratio [OR] = 2.11, 95% confidence interval [CI], 1.54 to 2.88, for CAD$0 to CAD$14,999), lower household income (OR = 2.11, 95% CI, 1.49 to 2.99, for lowest income quintile), food insecurity (OR = 1.87, 95% CI, 1.38 to 2.55) and non-homeownership (OR = 1.34, 95% CI, 1.08 to 1.66), at the individual and household levels, respectively, and higher residential instability (OR = 1.72, 95% CI, 1.23 to 2.42, for most marginalized), at the area level, were associated with higher odds of becoming a high-cost patient within a 5-year period. Moreover, the inequality analysis suggested pro-high-SES gradients in high-cost transitions.Conclusions:Policies aimed at high-cost patients with mental illness and/or addiction, or those concerned with preventing individuals with these conditions from becoming high-cost patients in the health care system, should also consider non-clinical factors such as income as well as related dimensions including food security and homeownership.

Safe Linkage of Cohort and Population-Based Register Data in a Genomewide Association Study on Health Care Expenditure.

There are research questions whose answers require record linkage of multiple databases that may be characterized by limited options for full data sharing. For this purpose, the Open Data Infrastructure for Social Science and Economic Innovations (ODISSEI) consortium has supported the development of the ODISSEI Secure Supercomputer (OSSC) platform that allows researchers to link cohort data to data from Statistics Netherlands and run large-scale analyses in a high-performance computing (HPC) environment. Here, we report a successful record linkage genomewide association (GWA) study on expenditure for total health, mental health, primary and hospital care, and medication. Record linkage for genotype data from 16,726 participants from the Netherlands Twin Register (NTR) with data from Statistics Netherlands was accomplished in the secure OSSC platform, followed by gene-based tests and estimation of total and single nucleotide polymorphism (SNP)-based heritability. The total heritability of expenditure ranged between 29.4% (SE 0.8) and 37.5% (SE 0.8), but GWA analyses did not identify SNPs or genes that were genomewide significantly associated with health care expenditure. SNP-based heritability was between 0.0% (SE 3.5) and 5.4% (SE 4.0) and was different from zero for mental health care and primary care expenditure. We conclude that successfully linking genotype data to administrative health care expenditure data from Statistics Netherlands is feasible and demonstrates a series of analyses on health care expenditure. The OSSC platform offers secure possibilities for analyzing linked data in large scale and realizing sample sizes required for GWA studies, providing invaluable opportunities to answer many new research questions.

The Hike in BPJS Kesehatan’s Premiums based on The principle of Justice in Service Regulation of Healthcare Insurance

There have been a lot of complaints regarding the service received by the members of Healthcare and Social Security Administrative Body, or so called BPJS Kesehatan. This situation has been worsened with the hike in premiums of BPJS Kesehatan’s independent members stipulated in Presidential Regulations Number 75 / 2019 and The Amendment of Presidential regulation Number 82/2018 on Health insurance. After announcing the hike of BPJS Kesehatan premiums, the government must also improve the healthcare service to all the independent participants of BPJS Kesehatan. This study aimed to examine juridical review on the hike in BPJS’s Premiums based on the principle of justice on the policies of healthcare and social security. This study was conducted by applying normative juridical research method using statue approach and secondary data. According to the result of the research, Regulation Number 40 Year 2004 concerning National Social Insurance and Regulation Number 24 Year 2011 on the implementing agency of social insurance have applied the principle of justice in their policies. However, Presidential Regulation Number 75 Year 2019 “Presidential Regulation Number 82 Year 2018 on Health Insurance” has not implemented or reflected the principle of justice in its policies. In addition, the government reason to increase the payment of BPJS Kesehatan is that BPJS has been in financial deficit. In order to solve this problem, one of the solutions that the government can offer is to seek for other financial sources instead of putting the burden on the members of the social health insurance program.

Data linkage and pain medication in people with cerebral palsy: a cross-sectional study.

To explore data linkage and pain medication as a proxy for pain, to assess differences in pain medication between the cerebral palsy (CP) and the general populations, and to identify factors associated with pain medication in CP. This cross-sectional study linked the Northern Ireland CP Register and two administrative health care databases for people resident in Northern Ireland born between 1981 and 2008. Pain medication as a proxy was validated by replicating analyses from the Study of Participation of Children with Cerebral Palsy Living in Europe (SPARCLE) studies. Logistic regression compared pain medication in the CP and general populations. Multi-level regression models assessed factors associated with pain medication in the CP cohort. The sample size was 701075, of whom 1430 (0.2%) were people with CP. There were 358969 males and 340677 females in the general population, and 810 males and 620 females in the CP population, with an age range of 4 to 31years in both groups. The validation exercise produced results similar to the SPARCLE studies. More people with CP received pain medication (61% vs 50.9%) and had twice the odds of being prescribed opioid analgesics (odds ratio [OR]=2.81, 95% confidence interval [CI] 2.32-3.40). Among those with CP, the odds of being prescribed pain medication were higher for: females (OR=1.34, 95% CI 1.06-1.70), younger age (OR=1.60, 95% CI 1.02-2.51), Gross Motor Function Classification System level V (OR=2.60, 95% CI 1.52-4.47), seizures (OR=2.55, 95% CI 1.68-3.87), and higher deprivation score (OR=2.06, 95% CI 1.41-3.24). Pain medication is an effective proxy for pain. More people with CP were prescribed pain medication than the general population. Pain medication for people with CP is not only dependent on physiological and clinical characteristics, but also environmental factors. What this paper adds Data linkage using pain medication as a proxy for experiencing pain is a valid method. People with cerebral palsy (CP) are more likely to experience pain than the general population. People with CP have over twice the odds of receiving opioids compared to the general population. The odds of being prescribed pain medication were higher for females with CP. Prescription of pain medication among those with CP is not only dependent on clinical characteristics, but also environmental factors.

Reduction in unplanned hospitalizations associated with a physician focused intervention to reduce potentially inappropriate medication use among older adults: a population-based cohort study

BackgroundA multimodal general practitioner-focused intervention in the Local Health Authority (LHA) of Parma, Italy, substantially reduced the prevalence of potentially inappropriate medication (PIM) use among older adults. Our objective was to estimate changes in hospitalization rates associated with the Parma LHA quality improvement initiative that reduced PIM use.MethodsThis population-based longitudinal cohort study was conducted among older residents (> 65 years) using the Parma LHA administrative healthcare database. Crude and adjusted unplanned hospitalization rates were estimated in 3 periods (pre-intervention: 2005–2008, intervention: 2009–2010, post-intervention: 2011–2014). Multivariable negative binomial models estimated trends in quarterly hospitalization rates among individuals at risk during each period using a piecewise linear spline for time, adjusted for time-dependent and time-fixed covariates.ResultsThe pre-intervention, intervention, and post-intervention periods included 117,061, 107,347, and 121,871 older adults and had crude hospitalization rates of 146.2 (95% CI: 142.2–150.3), 146.8 (95% CI: 143.6–150.0), and 140.8 (95% CI: 136.9–144.7) per 1000 persons per year, respectively. The adjusted pre-intervention hospitalization rate was declining by 0.7% per quarter (IRR = 0.993; 95% CI: 0.991–0.995). The hospitalization rate declined more than twice as fast during the intervention period (1.8% per quarter, IRR = 0.982; 95% CI: 0.979–0.985) and was nearly constant post-intervention (IRR: 0.999; 95% CI: 0.997–1.001). Contrasting model predictions for the intervention period (Q1 2009 to Q4 2010), the intervention was associated with 1481 avoided hospitalizations.ConclusionIn a large population of older adults, a multimodal general practitioner-focused intervention to decrease PIM use was associated with a decline in the unplanned hospitalization rate. Such interventions to reduce high risk medication use among older adults warrant consideration by health systems seeking to improve health outcomes and reduce high-cost acute care utilization.

Effectiveness and safety of direct oral anticoagulants in patients with cancer associated venous thromboembolism

IntroductionReal-world evidence on the effects of direct oral anticoagulants (DOACs) in patients with cancer associated venous thromboembolism (VTE) is limited. Thus, our population-based cohort study aimed to assess the effectiveness and safety of DOACs compared to the standard of care low-molecular-weight heparin (LMWH) in this vulnerable population. Materials and methodsUsing linked administrative healthcare databases from the province of Québec, Canada, we identified patients with incident VTE from 2012 to 2015 and a cancer diagnosis in the year before the VTE, who initiated treatment with anticoagulants within 30 days after the VTE. Using an active comparator new-user design with an as-treated exposure definition, we compared use of DOACs with use of LMWH. Cox proportional hazards models estimated adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of recurrent VTE, major bleeding, and all-cause mortality. In secondary analyses, we stratified by age and sex. ResultsOverall, 4438 patients with cancer associated VTE initiated treatment with anticoagulants (513 DOACs, 2698 LMWH). During a median follow-up of 0.3 years, and compared with LMWH, DOACs were associated with a decreased risk of recurrent VTE (HR, 0.54; 95% CI, 0.36–0.82) and major bleeding (HR, 0.54; 95% CI, 0.31–0.96). We also observed a decreased risk of all-cause mortality with DOACs compared with LMWH (HR, 0.14; 95% CI, 0.09–0.22). Age and sex did not modify the associations. ConclusionsDOACs were associated with improved effectiveness and safety compared with LMWH in patients with cancer related VTE. Unmeasured confounding probably contributed to our findings on all-cause mortality.

Statin use and the reoperation rates in glaucoma filtration surgery - population-based cohort study.

To examine the association of systemic statin therapy and reoperation rate after glaucoma filtration surgery (GFS). This is a population-based, historic cohort study of 2705 eyes undergoing GFS in Finland between July 2009 and December 2016. GFSs were identified from national administrative healthcare registers. Baseline sociodemographic and health characteristics were documented. Reoperation rates of GFS subgroups were analysed, with statin users compared to non-users. The outcomes were modelled using a Poisson regression model adjusted for age, sex, education, statin use, chronic comorbidities, and cataract surgery with incident rate ratios (IRR) as the main outcome measure. The cohort contained 2263 subjects with open-angle glaucoma (OAG), 823 men and 1440 women. Surgery was performed on 2705 eyes. First documented procedures: deep sclerectomy (DS) (n = 1601), trabeculectomy (TRE) (799) and glaucoma drainage device (GDD) implantation (305) respectively. In total, 438 secondary operations were performed during the 7.5-year (median 2.25 years) follow-up period. The reoperation rates were 19% after DS, 12% after TRE, and 13% after GDD. Of the surgical procedures, 32% were performed on eyes of patients receiving statin therapy. Statin users showed no difference in reoperation rates (IRR 1.06, CI 0.82-1.37). In subgroups, no difference was observed in the reoperation rates adjusted with statin use after filtration surgery (DS, TRE) (IRR 1.06, CI 0.8-1.40) or GDD implantation (0.57, CI 0.20-1.63). Systemic statin therapy among surgically treated OAG patients had no impact on secondary surgery rates following DS, TRE or GDD implantation.