Administrative Health Claims Research Articles

Comorbidities in an Australian sample of chronic and new opioid users.

Mental health disorders and substance abuse are risk factors that both precede and follow chronic opioid use. We predicted that incident opioid users would have lower rates of mental health comorbidities than chronic opioid users, but that incident chronic opioid users would have lower rates of mental health comorbidities than prevalent chronic users. We used administrative health claims data to evaluate differences in lifetime mental health and substance abuse comorbidity profiles of people who were prevalent and incident chronic opioid users, as well as those who used opioids acutely. Results were stratified by age. Over 5,188 people were prevalent chronic opioid users at study entry. Of the 10,079 people who initiated opioids, 10.2 per-cent had a subsequent chronic episode (incident chronic) and the remainder stopped within 90 days (incident acute). In prevalent chronic users compared to incident chronic users, rates of depression and anxiety were higher across all age groups (odds ratio (OR) across age groups range from = 1.60, 95 percent confidence interval (CI) = 1.35,1.89, to OR = 6.66, 95 percent CI = 3.02, 14.69) and prevalence of alcohol abuse was higher in those aged 55 to 74 years (OR = 5.11, 95 percent CI = 1.83, 14.24, p = 0.002). Acute users were less likely than incident chronic users to have depression and anxiety in those aged over 74 years (depression OR = 0.82, 95 per-cent CI = 0.70, 0.95; anxiety OR = 0.82, 95% CI 0.70, 0.98). Mental health morbidities commonly associated with chronic opioid use increase in prevalence as chronic use continues.

Are preoperative depression and anxiety associated with patient-reported outcomes, health care payments, and opioid use after anterior discectomy and fusion?

BACKGROUND CONTEXTDepression and anxiety are common psychiatric conditions among US adults, and anterior cervical discectomy and fusion (ACDF) is one of the most commonly performed spinal surgeries. Mental health conditions can affect physical health, and thus have the potential to contribute to adverse outcomes after spine surgery; however, a comprehensive assessment of long-term outcomes and the additive economic burden of these conditions in patients undergoing ACDF has not been well described. PURPOSEOur goal was to assess the associations between depression/anxiety and adverse outcomes and health-resource utilization after anterior cervical discectomy and fusion (ACDF). STUDY DESIGNRetrospective database study. PATIENT SAMPLEWe retrospectively analyzed a private administrative health claims database to identify patients who underwent ACDF in the United States from 2010 to 2013. A total of 16,306 patients met our inclusion criteria. Mean (± standard deviation) patient age was 50±7.9 years. Approximately 4,800 patients (30%) had a depression diagnosis and 4,000 (25%) had a diagnosis of anxiety. OUTCOME MEASURESThe primary outcomes of interest were intensive care unit admission, multiday hospitalization, discharge disposition, 30- and 90-day hospital readmission, 1- and 2-year rates of revision surgery, and chronic postoperative opioid use. Secondary outcomes were 1- and 2-year total cumulative health care payments and cumulative postoperative opioid consumption. METHODSRegression models controlled for demographic and medical covariates, alpha=0.05. RESULTSA preoperative diagnosis of depression was associated with higher odds of multiday hospitalization (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.01–1.19), 90-day readmission (OR 1.71, 95% CI 1.46–2.02), revision surgery within 2 years (OR 1.43 95% CI 1.16–1.76), and chronic postoperative opioid use (OR 1.58, 95% CI 1.45–1.72) and an increase of $5,915 in adjusted 2-year health care payments (p<.001). Patients with a preoperative diagnosis of anxiety had higher odds of multiday hospitalization (OR 1.15, 95% CI 1.06–1.25), revision surgery within 2 years (OR 1.33, 95% CI 1.07–1.65), and chronic postoperative opioid use (OR 1.62, 95% CI 1.48–1.77) and an increase of $4,471 in adjusted 2-year health care payments (p<.001). Neither anxiety nor depression was associated with intensive care unit admission, discharge disposition, 30-day readmission, revision surgery within 1 year, 1-year cumulative health care payments, or cumulative postoperative opioid consumption. CONCLUSIONSPatients with preoperative diagnoses of depression or anxiety have a greater likelihood of adverse outcomes, increased opioid consumption, and increased cumulative health care payments after ACDF compared with patients without depression or anxiety.

Use of medicines associated with dry mouth and dental visits in an Australian cohort.

Poor recognition of medicine-induced dry mouth can have a number of adverse effects, including difficulties with speech, chewing and swallowing dry foods, gum disease, dental caries and oral candidosis. This study examined the prevalence of use of medicines that cause dry mouth and claims for dental services funded by the Department of Veterans' Affairs (DVA) in an Australian cohort. We used the DVA administrative health claims data to identify persons using medicines that can cause dry mouth at 1st of September 2016 and determine their DVA dental claims in the subsequent year. Results were stratified by gender, residence in community or residential aged cared facility and number of medicines. We identified 50679 persons using medicines known to cause dry mouth. Of these, 72.6% were taking only one medicine that may cause dry mouth, and 21.6% were taking two. Less than half (46.2%) of all people taking at least one of these medicines had a dental claim in the following year. A smaller proportion of women (35.9%) made claims than men (56.9%), χ2 =2248.77, P<0.0001. Targeted interventions raising awareness of the relationship between some medicines and dry mouth, and the importance of dental visits are warranted.

Nonadherence to Standard of Care for Locally Advanced Colon Cancer as a Contributory Factor for High Mortality Rates in Kentucky

Kentucky has one of the highest mortality rates for colon cancer, despite dramatic improvements in screening. The National Comprehensive Cancer Network (NCCN) guidelines recommend operation and adjuvant chemotherapy for locally advanced (stage IIb/c and stage III) colon cancer (LACC). The purpose of this study was to determine the rate of nonadherence with current standard of care (SOC) and associated factors as possible contributors to mortality. The Kentucky Cancer Registry database linked with administrative health claims was queried for individuals (20 years and older) diagnosed with LACC from 2007 to 2012. Bivariate and logistic regression of nonadherence was performed. Survival analysis was performed with Cox regression and Kaplan-Meier plots. A total of 1,404 patients with LACC were included. Approximately 42% of patients with LACC were noted to be nonadherent to SOC, with nearly all (95.7%) failing to receive adjuvant chemotherapy. After adjusting for all significant factors, we found the factors associated with nonadherence included the following: age older than 75 years, stage III colon cancer, high Charlson Comorbidity Index (3+), low poverty level, Medicaid coverage, and disability. Adherence to SOC is associated with a significant improvement in the 5-year survival rate compared with nonadherence (63.0% and 27.4%, respectively; p < 0.0001). Our study identified multiple factors associated with the failure of patients with LACC to receive SOC, particularly adjuvant chemotherapy, suggesting the need to focus on improving adjuvant chemotherapy compliance in specific populations. Nonadherence to LACC SOC is likely a major contributor to the persistently high mortality rates in Kentucky.

Healthcare Resource Utilization and Costs Among Patients With Schizophrenia Switching From Oral Risperidone/Paliperidone to Once-Monthly Paliperidone Palmitate: A Veterans Health Administration Claims Analysis

BackgroundSchizophrenia is associated with high health care resource utilization and treatment costs. ObjectiveThis study compared treatment patterns, health care resource utilization, and medical costs before and after a switch from oral antipsychotic drug (risperidone or paliperidone [RIS/PALI]) therapy to the long-acting injectable once-monthly paliperidone palmitate (PP1M) in patients with schizophrenia. MethodsData for adult patients (aged ≥18 years) with at least 1 diagnosis of schizophrenia who initiated treatment with oral RIS/PALI ≥6 months before switching and had continuous health plan enrollment during the study period before and after the switch were extracted from the Veterans Health Administration database. Treatment patterns, health care resource utilization, and costs were compared between the period 6 or 12 months before and after switching directly from oral RIS/PALI to PP1M. ResultsThe analysis included 676 and 493 patients in the 6-month and 12-month cohorts, respectively. Adherence to oral RIS/PALI during the 12 months preswitch was 11.0% and 22.1% as measured by proportion of days covered and medication possession ratio ≥80%, respectively. During the 12 months postswitch, adherence to PP1M was 27.0% and 35.9%, respectively. Among patients treated with oral RIS/PALI, from 12 months pre- to 12 months post-PP1M switch, fewer all-cause inpatient stays (2.2 vs 1.1, respectively; P < 0.05) and a shorter mean length of inpatient stay (28.1 and 14.0 days, respectively; P < 0.05) were observed. This pattern was similar for both the number of mental health– and schizophrenia-related inpatient stays and length of stay. Compared with 12 months pre-PP1M switch, significantly higher mean numbers of all-cause outpatient visits and pharmacy visits were observed at 12 months postswitch. In line with health care resource utilization findings, at 12 months pre- versus 12 months post-PP1M switch we observed decreases in all-cause inpatient stay costs ($41,886 vs $20,489; P < 0.05) and increases in outpatient visit costs ($22,005 vs $29,069; P < 0.05). Findings for the 6-month cohort followed a similar pattern. ConclusionsPost-PP1M switch, a decrease in total medical costs fully offset an increase in pharmacy costs, resulting in similar total costs. The findings suggest potential economic benefits of switching patients with schizophrenia from oral RIS/PALI to PP1M in the Veterans Health Administration.

Elevated White Blood Cell Levels and Thrombotic Events in Patients With Polycythemia Vera: A Real-World Analysis of Veterans Health Administration Data

BackgroundPatients with polycythemia vera (PV) have a substantial risk of thrombotic events (TEs). The objective of the present analysis was to describe the association between white blood cell (WBC) levels and occurrence of TEs among patients with PV from a large real-world population. Patients and MethodsThe present retrospective analysis using Veterans Health Administration claims data (October 1, 2005, to September 30, 2012) evaluated adult patients assigned to 4 WBC count categories (WBC count < 7.0, 7.0-8.4, 8.5 to < 11.0, and ≥ 11.0 × 109/L) to compare the risk of TEs (reference, WBC count, < 7.0 × 109/L group). Analysis was performed using a Cox proportional hazards model, considering WBC status as a time-dependent covariate. ResultsOf the 1565 patients with PV included in the present analysis, the WBC count was < 7.0 × 109/L for 428 (27.3%), 7.0 to 8.4 × 109/L for 375 (24.0%), 8.5 to < 11.0 × 109/L for 284 (18.1%), and ≥ 11.0 × 109/L for 478 (30.5%). Of the 1565 patients, 390 (24.9%) had experienced a TE during the study period. The mean follow-up ranged from 3.6 to 4.5 years. Compared with the reference group (WBC count < 7.0 ×109/L), the hazard ratio for TEs was 1.10 (95% confidence interval [CI], 0.82-1.48; P = .5395), 1.47 (95% CI, 1.10-1.96; P = .0097), and 1.87 (95% CI, 1.44-2.43; P < .0001) for patients with a WBC count of 7.0 to 8.4, 8.5 to < 11.0, and ≥ 11.0 ×109/L, respectively. ConclusionA positive, significant association between an increased WBC count of ≥ 8.5 ×109/L and the occurrence of TEs was observed in patients with PV. The potential thrombogenic role of WBCs in patients with PV supports the continued inclusion of WBC count control in disease management and evaluation of the response to therapy.

Identifying potential targets for prevention and treatment of amyotrophic lateral sclerosis based on a screen of medicare prescription drugs

Background: Few well-established factors are associated with risk of amyotrophic lateral sclerosis (ALS). We comprehensively evaluate prescription drugs use in administrative health claims from U.S. Medicare beneficiaries in relation to ALS risk to generate hypotheses for further research. Methods: This is a population-based case–control study of 10,450 U.S. Medicare participants (ages 66–89 years) diagnosed with ALS, based on Medicare Parts A and B fee-for-service claims, between 1 January 2008, and 31 December 2014, and 104,500 controls (1:10 ratio) frequency-matched on age, sex, and selection year. Odds ratios (ORs) for the ALS association with 685 prescription drugs were estimated using logistic regression models for both a one- and three-year lag period. Covariates included demographic characteristics and key comorbidities, among other factors. Prescription drug use was based on Medicare Part D claims. We adjusted for multiple comparisons using a Bonferroni correction. Additional a priori analyses of sex hormone drugs were also undertaken. Results: In the large drug screen, we found 10 drugs significantly associated with lower ALS risk after the multiple-testing correction in a one-year and three-year lag analysis. These included several drugs for hypertension, diabetes, and cardiovascular disease. In a separate a priori inquiry of sex hormone drugs, tamoxifen was related to lower ALS risk, and testosterone to a higher risk in women. Conclusions: These associations warrant replication in databases that include information on the severity and duration of medical conditions underlying drug use, and drug use over a longer portion of individuals’ lifespans, to further help evaluate confounding by indication.

PCN325 REAL-WORLD DATA DESCRIBING THE ROLE OF CHEMOTHERAPY IN THE TREATMENT OF HR+/HER2- MBC PATIENTS: DIVERGENCE FROM EVIDENCE-BASED MEDICINE

Randomized controlled trials and published guidelines recommend endocrine therapy, specifically cyclin-dependent kinase 4/6 inhibitors (CDK 4/6i) in combination with either aromatase inhibitors or fulvestrant, as first-line (1L) therapy for hormone receptor-positive (HR+) human epidermal receptor2 negative (HER2-) metastatic breast cancer (mBC). Chemotherapy is reserved for patients in visceral crisis. We aimed to understand the use of 1L chemotherapy in the treatment of HR+/HER2- mBC in the U.S. post-approval of the first CDK 4/6i palbociclib in 2015. Female HR+/HER2- patients diagnosed with mBC (at least one non-diagnostic inpatient/two outpatient claims for breast cancer and one claim for lymph node/distant metastatic disease) initiating 1L treatment between 01/01/2015 and 10/31/2018 were identified in the Symphony Health administrative claims database. Regimes received in 1L were categorized as: single-agent chemotherapy (saChemo), combination chemotherapy (cChemo), and hormonal/targeted (H/T). Patient demographics, frequency of use of agents, comorbidities (Charlson components) at 1L initiation, and the proportion of patients who had not initiated second-line (2L) therapy (proxy for progression-free survival) at 6 months from 1L start of treatment (Kaplan-Meier method) were assessed. 4317 HR+/HER- patients were identified. 1L treatment patterns/mean age: saChemo 18%/64yrs, cChemo 21%/61yrs, H/T 61%/67yrs. Comorbidities >2: saChem=6%, cChemo=4%, H/T=6%. Visceral metastasis: saChemo=23%, cChemo=19%, H/T=58%. The top 3 most frequent saChemo: capecitabine=12%, paclitaxel=11%, nab-paclitaxel=11%; cChemo: cyclophosphamide/doxorubicin=23%, cyclophosphamide/docetaxel=9%, carboplatin/paclitaxel=4%.; H/T: anastrozole=25%, letrozole=23%, fulvestrant=13%. 6-month proportion of patients not initiating 2L, saChemo: paclitaxel=94%, capecitabine=76%, docetaxel=60%; cChemo: carboplatin/nab-paclitaxel=86%, carboplatin/paclitaxel=84%, carboplatin/docetaxel=74%; H/T: letrozole/palbociclib=89%, letrozole=84%, anastrozole=82%. Endocrine therapy is recommended by the NCCN guidelines as the treatment of choice for HR+/HER2- patients. However, chemotherapy still constitutes >40% of 1L choices since the introduction of CDK4/6i. More alarming is the continued use of cChemo for these patients. Further long term follow-up is needed to understand median time to next treatment (proxy for progression-free survival).

Pediatric Urinary Stone Disease in the United States: The Urologic Diseases in America Project

ObjectiveTo examine the recent epidemiology of pediatric urinary stone disease (USD) in the United States. MethodsWe utilized the 2004-2016 Optum© Clinformatics® Data Mart database, a de-identified adjudicated administrative health claims database that includes 15-18 million individuals covered annually by commercial insurance in all 50 US states. The analysis included 12,739,125 children aged 0-18 years. We calculated annual rates of USD, ambulatory visits, and procedures, and the prevalence of prescription fills. ResultsThe 2005-2016 USD rate was 59.5 cases per 100,000 person-years. The annual rate rose gradually from 2005 to a peak of 65.2 cases per 100,000 person-years in 2011. The USD rate increased with increasing age, and was highest among females compared to males, non-Hispanic Whites compared to other race/ethnic groups, and those residing in the South compared to other geographic regions. The overall 2005-2016 rate in the 120 days following a USD episode was 1.9 for ambulatory visits, 0.24 for surgical procedures, and 1.1 for imaging procedures. Ureteroscopy was the most common surgical procedure and CT scan was the most common imaging procedures, although ultrasound utilization increased over time. Medications were filled in 46.9% of cases, and use was lowest among males (43.1%), Asians (34.8%), and in the Northeast (34.3%). Opiate agonists were the most prevalent prescription (39.9%). ConclusionOur study provides one of the most comprehensive examinations of pediatric USD to date, demonstrating shifting rates and treatment patterns over time, as well as differences by age, gender, race/ethnicity, and geographic region.

Persistence with opioids post discharge from hospitalisation for surgery in Australian adults: a retrospective cohort study

ObjectiveTo determine time to opioid cessation post discharge from hospital in persons who had been admitted to hospital for a surgical procedure and were previously naïve to opioids.Design, setting and...

Use of Medicines that May Exacerbate Heart Failure in Older Adults: Therapeutic Complexity of Multimorbidity.

Multimorbidity is common in older patients with heart failure (HF), complicating therapeutic management and increasing the risk of harm. This study sought to examine the prevalence of medicines for the treatment of comorbid conditions potentially associated with harm in older people, before and after HF hospitalization. A retrospective cohort study of older people hospitalized with a primary diagnosis of HF over a 12-month period was conducted using administrative health claims data from the Department of Veterans' Affairs (DVA) Australia. We examined the prevalence of medicines that may exacerbate or worsen HF as defined by the American Heart Association (AHA) and Australian HF clinical guidelines, in the 30days prior and 120days before and after discharge for HF. A total of 4069 older adults were hospitalized for HF during the study period; almost 60% (n = 2435) received at least one medicine associated with an increased risk of harm before hospitalization, with the majority (66.7%, n = 1623) dispensed in the 30days prior. A small but significant reduction after hospitalization was observed, but 56% (n = 1638) received at least one of these medicines after hospitalization (p = 0.001). Over one-quarter received two or more medicines before hospitalization, and this only reduced to 22% post-hospitalization (p < 0.0001). Little change in the prescribing of potentially harmful medicines for HF was observed; 56% of older adults received at least one following hospitalization for HF, highlighting the therapeutic complexity of multimorbidity in HF. Use of the AHA list to facilitate identification of potentially harmful medicines, followed by prioritization of treatment goals and appropriate risk mitigation are needed to facilitate reduction in hospitalization for patients with HF with multimorbidity.

EPR19-069: Opioid Use Among Cancer Patients Undergoing Surgery and Their Associated Risk of Re-admissions and Emergency Department Visits in the 1-Year Postsurgical Period

Background: Prescription opioid use and overdose has steadily increased over the past years, resulting in a dramatic increase in opioid-related emergency department (ED) visits and hospitalizations. Methods: This study used a prospective cohort of cancer patients having undergone surgery in Montreal (Quebec) to describe their post-discharge opioid use and identify potential patterns of unplanned health service use (ED visits, hospitalizations). Provincial health administrative claims were used to measure opioid dispensation as well as hospital re-admissions and ED visits. The hospital warehouse, patient chart and patient interview will be used to further describe patient’s medical profile. Marginal structural models will be used to model the association between use of opioids and risk of ED visits and hospitalizations. Inverse probability of treatment and censoring weights will be constructed to properly adjust for confounders that may be unbalanced between the opioid and non–opioid users as well as to account for competing risk due to mortality. Reasons for the re-admissions will also be presented as part of the analyses. Covariates will include patient comorbidities, medication history, and healthcare system characteristics such as nurse-to-patient and attending physician-to-patient ratios. Results (interim): A total of 821 were included in the study; of these, 73% (n=597) were admitted for a cancer procedure. At postoperative discharge, 605 (74%) of patients had at least one opioid dispensation, of which the majority (67%) were oxycodone with hydromorphone being the second most prescribed (28%). Among those who filled a prescription, mean age was 66 (13.4), 68% had no previous history of opioid use, and 10% have had 3 or more dispensing pharmacies in the year prior to admission, compared to less than 1% for the non–opioid users. Overall, 343 people refilled their opioid prescription at least once and 128 at least twice during the 1-year postoperative period. Among cancer patients who were opioid users, 214 ED visits occurred in the 1 year after surgery compared to only 40 for the non-cancer opioid users. Conclusion: This study will help to identify the risk profile of cancer patients who are most likely to continue using opioids for prolonged periods following surgical procedures as well as quantify the impact of opioid use and its associated burden on the healthcare system in order to identify areas for possible interventions.

Traditional risk factors may not explain increased incidence of myocardial infarction in MS.

To compare the risk of incident acute myocardial infarction (AMI) in the multiple sclerosis (MS) population and a matched population without MS, controlling for traditional vascular risk factors. We conducted a retrospective matched cohort study using population-based administrative (health claims) data in 2 Canadian provinces, British Columbia and Manitoba. We identified incident MS cases using a validated case definition. For each case, we identified up to 5 controls without MS matched on age, sex, and region. We compared the incidence of AMI between cohorts using incidence rate ratios (IRR). We used Cox proportional hazards regression to compare the hazard of AMI between cohorts adjusting for sociodemographic factors, diabetes, hypertension, and hyperlipidemia. We pooled the provincial findings using meta-analysis. We identified 14,565 persons with MS and 72,825 matched controls. The crude incidence of AMI per 100,000 population was 146.2 (95% confidence interval [CI] 129.0-163.5) in the MS population and 128.8 (95% CI 121.8-135.8) in the matched population. After age standardization, the incidence of AMI was higher in the MS population than in the matched population (IRR 1.18; 95% CI 1.03-1.36). After adjustment, the hazard of AMI was 60% higher in the MS population than in the matched population (hazard ratio 1.63; 95% CI 1.43-1.87). The risk of AMI is elevated in MS, and this risk may not be accounted for by traditional vascular risk factors.

Validation of an algorithm for identifying MS cases in administrative health claims datasets

ObjectiveTo develop a valid algorithm for identifying multiple sclerosis (MS) cases in administrative health claims (AHC) datasets.MethodsWe used 4 AHC datasets from the Veterans Administration (VA), Kaiser Permanente Southern California (KPSC), Manitoba (Canada), and Saskatchewan (Canada). In the VA, KPSC, and Manitoba, we tested the performance of candidate algorithms based on inpatient, outpatient, and disease-modifying therapy (DMT) claims compared to medical records review using sensitivity, specificity, positive and negative predictive values, and interrater reliability (Youden J statistic) both overall and stratified by sex and age. In Saskatchewan, we tested the algorithms in a cohort randomly selected from the general population.ResultsThe preferred algorithm required ≥3 MS-related claims from any combination of inpatient, outpatient, or DMT claims within a 1-year time period; a 2-year time period provided little gain in performance. Algorithms including DMT claims performed better than those that did not. Sensitivity (86.6%–96.0%), specificity (66.7%–99.0%), positive predictive value (95.4%–99.0%), and interrater reliability (Youden J = 0.60–0.92) were generally stable across datasets and across strata. Some variation in performance in the stratified analyses was observed but largely reflected changes in the composition of the strata. In Saskatchewan, the preferred algorithm had a sensitivity of 96%, specificity of 99%, positive predictive value of 99%, and negative predictive value of 96%.ConclusionsThe performance of each algorithm was remarkably consistent across datasets. The preferred algorithm required ≥3 MS-related claims from any combination of inpatient, outpatient, or DMT use within 1 year. We recommend this algorithm as the standard AHC case definition for MS.

The prevalence of MS in the United States: A population-based estimate using health claims data.

ObjectiveTo generate a national multiple sclerosis (MS) prevalence estimate for the United States by applying a validated algorithm to multiple administrative health claims (AHC) datasets.MethodsA validated algorithm was applied to private, military, and public AHC datasets to identify adult cases of MS between 2008 and 2010. In each dataset, we determined the 3-year cumulative prevalence overall and stratified by age, sex, and census region. We applied insurance-specific and stratum-specific estimates to the 2010 US Census data and pooled the findings to calculate the 2010 prevalence of MS in the United States cumulated over 3 years. We also estimated the 2010 prevalence cumulated over 10 years using 2 models and extrapolated our estimate to 2017.ResultsThe estimated 2010 prevalence of MS in the US adult population cumulated over 10 years was 309.2 per 100,000 (95% confidence interval [CI] 308.1–310.1), representing 727,344 cases. During the same time period, the MS prevalence was 450.1 per 100,000 (95% CI 448.1–451.6) for women and 159.7 (95% CI 158.7–160.6) for men (female:male ratio 2.8). The estimated 2010 prevalence of MS was highest in the 55- to 64-year age group. A US north-south decreasing prevalence gradient was identified. The estimated MS prevalence is also presented for 2017.ConclusionThe estimated US national MS prevalence for 2010 is the highest reported to date and provides evidence that the north-south gradient persists. Our rigorous algorithm-based approach to estimating prevalence is efficient and has the potential to be used for other chronic neurologic conditions.

A new way to estimate neurologic disease prevalence in the United States: Illustrated with MS.

ObjectiveConsiderable gaps exist in knowledge regarding the prevalence of neurologic diseases, such as multiple sclerosis (MS), in the United States. Therefore, the MS Prevalence Working Group sought to review and evaluate alternative methods for obtaining a scientifically valid estimate of national MS prevalence in the current health care era.MethodsWe carried out a strengths, weaknesses, opportunities, and threats (SWOT) analysis for 3 approaches to estimate MS prevalence: population-based MS registries, national probability health surveys, and analysis of administrative health claims databases. We reviewed MS prevalence studies conducted in the United States and critically examined possible methods for estimating national MS prevalence.ResultsWe developed a new 4-step approach for estimating MS prevalence in the United States. First, identify administrative health claim databases covering publicly and privately insured populations in the United States. Second, develop and validate a highly accurate MS case-finding algorithm that can be standardly applied in all databases. Third, apply a case definition algorithm to estimate MS prevalence in each population. Fourth, combine MS prevalence estimates into a single estimate of US prevalence, weighted according to the number of insured persons in each health insurance segment.ConclusionsBy addressing methodologic challenges and proposing a new approach for measuring the prevalence of MS in the United States, we hope that our work will benefit scientists who study neurologic and other chronic conditions for which national prevalence estimates do not exist.

Smoking and Smoking Cessation Among Persons with Tobacco- and Non-tobacco-Associated Cancers.

To examine smoking and use of smoking cessation aids among tobacco-associated cancer (TAC) or non-tobacco-associated cancer (nTAC) survivors. Understanding when and if specific types of cessation resources are used can help with planning interventions to more effectively decrease smoking among all cancer survivors, but there is a lack of research on smoking cessation modalities used among cancer survivors. Kentucky Cancer Registry data on incident lung, colorectal, pancreatic, breast, ovarian, and prostate cancer cases diagnosed 2007-2011, were linked with health administrative claims data (Medicaid, Medicare, private insurers) to examine the prevalence of smoking and use of smoking cessation aids 1year prior and 1year following the cancer diagnosis. TACs included colorectal, pancreatic, and lung cancers; nTAC included breast, ovarian, and prostate cancers. There were 10,033 TAC and 13,670 nTAC survivors. Smoking before diagnosis was significantly higher among TAC survivors (p < 0.0001). Among TAC survivors, smoking before diagnosis was significantly higher among persons who: were males (83%), aged 45-64 (83%), of unknown marital status (84%), had very low education (78%), had public insurance (89%), Medicaid (85%) or were uninsured (84%). Smoking cessation counseling and pharmacotherapy were more common among TAC than nTAC survivors (p < 0.01 and p = 0.05, respectively). While smoking cessation counseling and pharmacotherapy were higher among TAC survivors, reducing smoking among all cancer survivors remains a priority, given cancer survivors are at increased risk for subsequent chronic diseases, including cancer. Tobacco cessation among all cancer survivors (not just those with TAC) can help improve prognosis, quality of life and reduce the risk of further disease. Health care providers can recommend for individual, group and telephone counseling and/or pharmacotherapy recommendations. These could also be included in survivorship care plans.

Identifying Patients With Inflammatory Bowel Diseases in an Administrative Health Claims Database: Do Algorithms Generate Similar Findings?

Application of selective algorithms to administrative health claims databases allows detection of specific patients and disease or treatment outcomes. This study identified and applied different algorithms to a single data set to compare the numbers of patients with different inflammatory bowel disease classifications identified by each algorithm. A literature review was performed to identify algorithms developed to define inflammatory bowel disease patients, including ulcerative colitis, Crohn’s disease, and inflammatory bowel disease unspecified in routinely collected administrative claims databases. Based on the study population, validation methods, and results, selected algorithms were applied to the Optum Clinformatics® Data Mart database from June 2000 to March 2017. The patient cohorts identified by each algorithm were compared. Three different algorithms were identified from literature review and selected for comparison (A, B, and C). Each identified different numbers of patients with any form of inflammatory bowel disease (323 833; 246 953, and 171 537 patients, respectively). The proportions of patients with ulcerative colitis, Crohn’s disease, and inflammatory bowel disease unspecified were 32.0% to 47.5%, 38.6% to 43.8%, and 8.7% to 26.6% of the total population with inflammatory bowel disease, respectively, depending on the algorithm applied. Only 5.1% of patients with inflammatory bowel disease unspecified were identified by all 3 algorithms. Algorithm C identified the smallest cohort for each disease category except inflammatory bowel disease unspecified. This study is the first to compare numbers of inflammatory bowel disease patients identified by different algorithms from a single database. The differences between results highlight the need for validation of algorithms to accurately identify inflammatory bowel disease patients.

Arterial and Venous Thromboembolic Safety of Bevacizumab in Patients with High Grade Gliomas

INTRODUCTIONBevacizumab, an angiogenesis inhibitor targeting vascular endothelial growth factor A, is used for the treatment of recurrent glioblastoma, the most common primary brain malignancy in adults. Multiple studies demonstrate the efficacy of bevacizumab on progression-free and overall survival of patients with recurrent glioblastoma. However, real world safety data of bevacizumab in patients with glioblastoma is limited on serious adverse outcomes including arterial and venous thrombosis. Our study aimed to evaluate the risk of arterial thromboembolism (ATE) and venous thromboembolism (VTE) in a population-based sample of adult patients with high grade gliomas.METHODWe conducted a nested case-control study within a retrospective cohort of patients receiving treatment for high grade gliomas under the protocol by Stupp, et al. (radiotherapy plus concomitant/adjuvant temezolomide). Patients were sampled from the Truven Health MarketScan® Research Database, containing administrative health claims data of over 40 million commercially insured enrollees and their dependents, between 2009 and 2015. A validated algorithm was used to identify patients with high grade gliomas that underwent craniotomy (index time) with external beam radiation and temozolomide-based treatment occurring within 91 days (cohort entry time). Patients were excluded if they received craniotomy, radiation, temozolomide or bevacizumab during year prior to surgery or had one of our outcomes of interest (ATE or VTE) during the cohort ascertainment period (between index and cohort entry dates). Patients were required to have continuous health plan enrollment during the 12-month baseline and follow up periods (unless died). Surgical procedures and chemotherapy treatments were identified using diagnostic and procedural medical and pharmacy claims data. These data sources were also used to identify VTE risk factors, including medical conditions, procedures and medication use, and to calculate modified Charlson comorbidity index scores at baseline.Cases of ATE and VTE were each identified in the overall cohort using a validated algorithm for administrative claims data. For ATE and VTE separately, each case was matched to up to ten controls on sex, age group, index time and follow-up duration using incidence density sampling with replacement. Exposure to bevacizumab was characterized as any use (yes vs. no) and recent use (last bevacizumab infusion within 30 days prior event or control censoring). We estimated relative risk of ATE and VTE associated with bevacizumab in separate models using conditional logistic regression models to calculate adjusted odds ratios (aOR) and 95% confidence interval (CI). All multivariable models were adjusted for sex, age, and comorbidity index scores; models for risk of VTE were also adjusted for number of baseline VTE risk factors and VTE prophylaxis received.RESULTSOur final study cohort included 2157 patients undergoing treatment for high grade gliomas. We identified 25 ATE cases and 99 VTE cases and matched incidence density-sampled controls (n=170 for ATE; n=819 for VTE) for our nested case-control analysis. A higher proportion of ATE cases received bevacizumab during follow up compared to the controls (28% vs. 17%). In multivariable analyses, no statistically significant increase in ATE risk was observed with bevacizumab overall (aOR 1.51, 95% CI 0.54-4.24), although confidence intervals were wide given the few events observed. Compared to controls in the VTE analysis, cases had a slightly higher proportion of baseline VTE risk factors (2 or more: 17% vs. 13%) and treatment with bevacizumab (13% vs. 9%). However, we found no significant increased risk of VTE associated with bevacizumab overall (aOR 1.40, 95% CI 0.71-2.75) or recent infusion of bevacizumab (aOR 1.40, 95% CI 0.65-3.01).CONCLUSIONSOur findings from this large retrospective cohort of patients undergoing treatment for high grade glioma provide little evidence in support of the increased risk of ATE and VTE reported with use of bevacizumab in other cancer sites. Our study was limited by an overall small number of ATE events observed, and further research is needed to confirm safety of bevacizumab with respect to arterial thrombosis. These population-based estimates show no significant increase in risk of VTE associated with bevacizumab and suggest its safe use in the treatment of high grade gliomas. DisclosuresLee:AbbVie Inc.: Research Funding. Patel:Celgene: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Janssen: Honoraria.

Elevated White Blood Cell Levels and Thrombotic Events in Patients with Polycythemia Vera: A Real-World Analysis of Veterans Health Administration Data

Introduction:Patients with polycythemia vera (PV) have poor overall survival compared with the general population, with arterial and venous thrombotic events (TEs) representing a substantial source of morbidity and mortality. A subanalysis of the Cytoreductive Therapy in Polycythemia Vera (CYTO-PV) study demonstrated a significant correlation between white blood cell (WBC) count ≥11 × 109/L and time-dependent risk of major thrombosis (hazard ratio, 3.9; 95% CI, 1.24-12.3). The objective of this analysis was to describe the association between WBC levels and occurrence of TEs among patients with PV from a large, real-world population.Methods:This was a retrospective, observational study using Veterans Health Administration claims data collected between 10/1/05, and 9/30/12. Patients with ≥2 claims for PV (ICD-9-CM code 238.4) ≥30 days apart during the identification period (10/1/06 to 9/30/07) were eligible for analysis. The earliest date for a PV claim within the identification period was designated as the index date. All patients were ≥18 years of age, had no TEs before the index date, and had continuous health plan enrollment with medical and pharmacy benefits ≥12 months pre-index. Patients were followed up until death, disenrollment, or end of study period, whichever occurred first. Patients with ≥3 WBC values per year on average during the follow-up period and, for patients with a TE, ≥1 WBC value before the TE were included in the analysis. Based on the last measurement before the TE or end of follow-up, patients were assigned to one of the following WBC categories: WBC <7.0, 7.0-8.4, 8.5-<11.0, and ≥11.0 × 109/L. A univariate Cox proportional hazards model was used to compare the risk of TEs between WBC categories using <7.0 × 109/L as the reference group.Results:A total of 1565 US veterans with PV were included in the analysis (WBC [× 109/L] <7.0, n=428 [27.3%]; 7.0-8.4, n=375 [24.0%]; 8.5-<11.0, n=284 [18.1%]; ≥11.0, n=478 [30.5%]). Patient demographics were similar across groups (Table 1). The mean Charlson Comorbidity Index and Chronic Disease Scores were similar across groups and ranged from 1.11-1.45 and 6.15-6.76, respectively. Hypertension was the most common comorbid condition among patients across all WBC categories (65.1%-71.5%). Mean follow-up times across groups ranged from 3.6 to 4.5 years. Rates of cytoreductive treatment, including phlebotomy, were similar across WBC groups and ranged from 77.3% to 78.2% (any cytoreductive treatment) and 56.9% to 65.9% (phlebotomy). The mean number of phlebotomies per patient per year was 2.6, 2.6, 4.7, and 3.0 among patients with WBC counts <7.0, 7.0-8.4, 8.5-<11.0, and ≥11.0 × 109/L, respectively. Overall, 390 patients (24.9%) experienced a TE during the study period, including 85 patients (19.9%) with WBC <7.0 × 109/L, 91 patients (24.3%) with WBC 7.0-8.4 × 109/L, 73 patients (25.7%) with WBC 8.5-<11.0 × 109/L, and 141 patients (29.5%) with WBC ≥11.0 × 109/L (Figure 1). Compared with the WBC <7.0 × 109/L reference group, the hazard ratios (95% CI) for TEs were 1.22 (0.91-1.64; P=0.1835), 1.39 (1.02-1.90; P=0.0401), and 1.81 (1.39-2.38; P<0.0001) among patients with WBC counts 7.0-8.4, 8.5-<11.0, and ≥11.0 × 109/L, respectively (Table 1).Conclusion:A significant, positive association between increased WBC counts and occurrence of TEs in patients with PV was observed in this study. Patients with WBC counts ≥8.5 × 109/L had a significantly increased risk of TE, and those with counts ≥11.0 × 109/L were at greatest risk. Effective control of WBC counts is an important component of disease management and may reduce risk of TEs in patients with PV. [Display omitted] DisclosuresParasuraman:Incyte: Employment, Equity Ownership. Yu:Incyte Corporation: Employment, Equity Ownership. Paranagama:Incyte: Employment, Equity Ownership. Shrestha:STATinMED Research: Employment, Equity Ownership. Wang:STATinMED Research: Employment, Equity Ownership. Baser:STATinMED Research: Employment, Equity Ownership. Scherber:Gilead: Honoraria.