Claims-based Dataset Research Articles

Trends in Radiation Therapy for Bone Metastases, 2015 to 2017: Choosing Wisely in the Era of Complex Radiation

Guidelines recommend short-course (≤10 fractions) external-beam radiation therapy (EBRT) for bone metastases. Stereotactic body radiation therapy (SBRT) may also improve outcomes; however, routine use is not recommended outside clinical trials. We assessed national radiation therapy trends in complex techniques for bone metastases and associated expenditures. Using a claims-based Medicare data set covering 84% of beneficiaries, we assessed the relative proportion of all radiation episodes represented by bone metastases. We then evaluated use of short-course and long-course (>10 fractions) EBRT, intensity modulated radiation therapy (IMRT), and SBRT for bone metastases in hospital-affiliated outpatient (OPD) or freestanding (FREE) facilities. We assessed differences using χ2d or Wilcoxon rank sum tests for categorical and continuous variables, respectively. We identified associations with modality, fractionation, and expenditures using multivariable logistic/linear regression. Among 467,781 radiation episodes for 17 cancer diagnoses, the overall proportion of episodes dedicated to bone metastases (9.4%) was stable from 2015 to 2017, although treatments were increasing in the hospital-affiliated outpatient setting (P < .005). We identified 40,993 episodes for bone metastases, of which 63% were short-course EBRT, 24% were long-course EBRT, 7% were SBRT, and 6% were IMRT. Techniques more common in the hospital-affiliated outpatient setting included short-course EBRT (OPD, 69%, vs FREE, 56%) and SBRT (OPD, 9%, vs FREE, 5%). Techniques more common among free-standing centers included long-course EBRT (OPD, 19%, vs FREE, 31%) and IMRT (OPD, 4%, vs FREE, 9%). From 2015 to 2017, long-course EBRT decreased by an absolute 8%; short-course EBRT, SBRT, and IMRT increased by 4%, 2.5%, and 1%, respectively. The SBRT/IMRT uptake did not differ by setting (P = .4). Differences in expenditures between SBRT and short-course EBRT decreased by a relative 8% in professional and 12% in technical fees. Approximately 1 in 4 patients received long-course EBRT, with small reductions in use largely replaced by complex treatment modalities. However, expenditures for complex modalities also decreased over time. As alternative payment models take effect, quality metrics are needed to ensure appropriate, effective, and safe delivery of complex technologies.

Real-World Utilization of Midostaurin Among Patients with Systemic Mastocytosis (SM)

Introduction: Systemic Mastocytosis (SM) is a rare neoplasm of myeloid origin characterized by an accumulation of abnormal mast cells in the bone marrow, liver, spleen, and skin and has a molecular signature of the KITD816V mutation, detectable in &gt;90% of patients. Clinical findings include cytopenias, liver-function abnormalities, hypoalbuminemia, weight loss, ascites, and osteolytic bone lesions due to infiltration of various organs by the malignant mast cells. The indolent and smoldering subtypes of SM can have a long natural history but aggressive systemic mastocytosis (aSM), SM with associated hematological neoplasm (SMHN), and mast cell leukemia (MCL) subtypes are associated with poor prognosis at a median survival of 3.5 years, 2 years and 6 months respectively. In April 2017, the FDA approved midostaurin, a multitargeted kinase inhibitor for the treatment of adults with aSM, SMHN and MCL at a dose of 100mg twice daily based on achievement of response rate endpoint noted in an open label trial of midostaurin (Gotlib et al, NEJM 2016). Pre-midostaurin, the treatment options for aSM, SMHN and MCL were imatinib, cladribine, interferon or allogeneic stem cell transplant (ASCT). The objective of this retrospective study was to assess the uptake and utilization of midostaurin in patients with aSM, SMHN and MCL. Methods: Patients with at least 1 claim for midostaurin (index date) between April 1, 2017 and October 31, 2018 and who had at least 1 claim with a diagnosis of SM (ICD 10 code C96.2x or C94.3x) in the 6-month pre-index period were identified from Symphony Health's Integrated Dataverse (IDV), a large US claims database containing linked longitudinal prescription, medical, and hospital claims. The IDV contains claims for 280 million active unique patients representing over 73% of specialty prescriptions, 58% of medical claims, and 30% of hospital claims volume in the US. Patients included in the study cohort had a 6-month pre-index period with no claims with a diagnosis of SM, were at least 18 years old at initiation of midostaurin, and no evidence of participation in a clinical trial. Patient characteristics and treatment patterns were summarized using descriptive statistics. Median and 95% confidence interval (CI) for duration of midostaurin were calculated using Kaplan-Meier estimates. Results: Of the 38 patients with SM treated with midostaurin, 33 had a diagnosis of aSM and 5 had a diagnosis of MCL. The majority were female (61%) with a median age of 63 years (range 27-79) at diagnosis; 42% of these patients were 65 years or older (Table). The majority (66%) of patients had commercial insurance, and patients resided in all 4 US regions (34% South, 34% West, 18% Midwest, 11% Northeast). Nearly two-thirds (63%) of midostaurin use was in the first line setting, 32% was given in second line, and 5% was given in third line. Among the 14 patients with therapy prior to midostaurin, cladribine was most common (n=4, 29%), followed by hydroxyurea, interferon alfa-2b, brentuximab vedotin, and others (each n=2, 14%). Over two-thirds (68%) had an average daily dose of 200mg on the first fill, 5% treated at 100mg daily, and 26% with average daily doses &lt;100mg. Two thirds (22 of 33) patients with aSM and 4 of 5 with MCL were prescribed the 200mg/day recommended dose. With a median follow-up of 13.4 months from midostaurin initiation, the median duration of midostaurin 2.4 months (95% CI 1.1-4.6). Conclusions: In this retrospective claims based study, there is evidence of early uptake of midostaurin use in SM. Midostaurin was used in the first line setting in the majority of patients. The median duration of midostaurin treatment was short at 2.4 months especially when compared to a median treatment duration of 11.5 months in the pivotal trial. It is noteworthy that almost a third of patients were started on a lower than recommended dose which may compromise efficacy. The relatively short follow up may be another reason for the observed duration of response. Potential barriers to the appropriate use of midostaurin in SM such as lack of awareness, access, cost or delay in diagnosis due to its rarity will need further exploration. While the current claims-based dataset does not provide us the information, early, accurate diagnosis of SM is essential to timely utilization of midostaurin in the real-world setting. Further research and education may be needed to optimize the use of novel therapeutics in such orphan diseases. Disclosures Gajra: Cardinal Health: Employment. Klink:Cardinal Health: Employment. Chopra:Cardinal Health: Employment. Feinberg:Cardinal Health: Employment.

Changes in Oral Anticoagulation Therapy over One Year in 51,000 Atrial Fibrillation Patients at Risk for Stroke: A Practice-Derived Study.

This study assessed changes in anticoagulation therapy over time in patients with atrial fibrillation (AF). Analyses were performed on a claims-based dataset of 4 million health-insured individuals. The study population consisted of patients newly initiating a non-vitamin-K oral anticoagulants (NOACs) or vitamin K antagonist (VKA) for AF between 2013 and 2016. The study outcomes consisted of the proportion of patients who had (1) discontinued OAC treatment, (2) switched from VKA to NOAC, (3) switched from NOAC to VKA or (4) switched from one NOAC to another. Predictors of discontinuation or switching of OAC treatment were determined by Cox proportional hazards regression models with time-independent and time-dependent covariates. The study population comprised 51,606 AF patients initiating VKA (n = 21,468, 41.6%), apixaban (n = 8,832, 17.1%), dabigatran (n = 3,973, 7.7%) or rivaroxaban (n = 17,333, 33.6%). After 1 year, 29.9% of VKA and 29.5% of NOAC patients had discontinued OAC treatment without switching to another anticoagulant. A total of 10.7% of VKA patients switched to NOACs within 1 year, whereas 4.9% NOAC patients had switched to VKA. Of AF patients who were initiated on a NOAC, 5.2% switched to another NOAC. Treatment changes among NOAC starters were strongly associated with occurrence of stroke, myocardial infarction and gastrointestinal bleeding after treatment initiation. For VKA starters switching to a NOAC, stroke and bleeding events were associated with an increased likelihood of switching. Overall discontinuation rates of VKA and NOACs are comparable over the first year of therapy, while switching from VKA to NOAC was more common than from NOAC to VKA. The majority of treatment changes were associated with clinical events.

Uptake in antithrombotic treatment and its association with stroke incidence in atrial fibrillation: insights from a large German claims database.

Underuse of oral anticoagulation (OAC) for stroke prevention in atrial fibrillation (AF) results in thousands of preventable strokes in Germany each year. This study aimed to assess changes in antithrombotic therapy in AF patients after increased use of direct oral anticoagulants (DOACs) in Germany and to evaluate whether the adoption of DOAC therapy was associated with changes in AF-related stroke and bleeding over time. Analyses were carried out on a large claims-based dataset of 4million health-insured Germans. The study population consisted of 601,261 prevalent AF patients between 2011 and 2016 who were assigned to one of the following four treatment groups: DOAC, VKA, antiplatelets or no antithrombotic treatment. Treatment patterns were descriptively analysed and represented by cohort and CHA2DS2-VASc score. Clinical outcomes before and after the adoption of DOAC therapy were assessed using Poisson regression models. Use of OAC increased from 42 to 61% between 2011 and 2016, mainly due to more frequent prescription of DOACs. However, some underuse of OAC therapy remained even in high risk AF patients. In parallel with the increased prescription rate of OAC, there was an overall 24% incidence reduction in stroke between 2011 and 2016 which was mainly driven by reductions in ischemic strokes. Over the same time period the risk for major bleeding remained unchanged. Between 2011 and 2016, the use of guideline-conform antithrombotic therapy in Germany has significantly increased. This was associated with a significant decline in strokes without an increased incidence of bleeding complications.

Outcomes After Use of Standard- and Low-Dose Non-Vitamin K Oral Anticoagulants in Asian Patients With Atrial Fibrillation.

Background and Purpose- Limited data are available describing the relative effectiveness, safety, and optimal dosing of non-vitamin K antagonist oral anticoagulants (NOACs) for treatment of nonvalvular atrial fibrillation in East Asian patients. We tried to compare effectiveness and safety outcomes of standard- and low-dose NOACs and warfarin in this population. Methods- Using nationwide administrative claims-based datasets from the Korean National Health Insurance Service Database (July 1, 2015, to December 31, 2016), this study comprised 56 504 anticoagulation-naive nonvalvular atrial fibrillation patients with high thromboembolic risk (CHA2DS2-VASc score, ≥2) treated with oral anticoagulants. Main study outcomes included thromboembolic events (ischemic stroke or systemic embolism), major bleeding, and mortality. Results- Among the study patients, 10 409 (18.4%) received warfarin and 46 095 (81.6%) were treated with NOACs: dabigatran (n=12 593; 22.3%), rivaroxaban (n=21 000; 37.2%), and apixaban (n=12 502; 22.1%). Low-dose NOAC (75.1% dabigatran, 59.7% rivaroxaban, and 62.7% apixaban) was more frequently used than standard-dose NOAC. During median follow-up of 15.0 months, each NOAC was associated with significantly lower risk of thromboembolic events (hazard ratio [HR], 0.76; 95% CI, 0.75-0.81 for dabigatran; HR, 0.74; 95% CI, 0.65-0.83 for rivaroxaban; and HR, 0.68; 95% CI, 0.59-0.78 for apixaban). Regarding safety outcomes, dabigatran (HR, 0.81; CI, 0.69-0.95) and apixaban (HR, 0.67; CI, 0.56-0.79) were associated with lower risk of major bleeding but not with rivaroxaban (HR, 0.96; CI, 0.84-1.11). Among adults <75 years of age without chronic kidney disease, use of low-dose apixaban did not demonstrate clinical benefit over warfarin with respect to thromboembolic events (HR, 0.99; CI, 0.76-1.28) and mortality (HR, 0.85; CI, 0.62-1.16). Conclusions- In this cohort of East Asian patients with nonvalvular atrial fibrillation, NOACs were associated with better effectiveness and safety outcomes versus warfarin. Lower NOAC doses were more often used, but an unjustified underdosing of apixaban seems to result in lower clinical benefit.

Adverse Events Among Patients with Hairy Cell Leukemia Treated with Purine Nucleoside Analogs in the United States

Introduction: Purine nucleoside analogs (PNAs) are the recommended first-line treatment in patients with hairy cell leukemia (HCL) owing to their efficacy. However, because of the rarity of this disease, little is known about clinically significant adverse events (AEs) outside of previously performed clinical trials. This retrospective claims-based study of patients treated in the current era of improved supportive care assessed the incidence and prevalence rates of AEs associated with PNA use and healthcare resource utilization (HRU) among patients with HCL enrolled in the Truven MarketScan Commercial Claims and Encounters and the Medicare Supplemental databases.Methods: Adults (≥18 years old) diagnosed with HCL (≥2 medical claims ≥30 days apart) between January 1, 2006 and December 31, 2015 were included in the study. All patients had ≥1 claim for PNA therapy (cladribine or pentostatin ± rituximab) after the HCL diagnosis date and the 1st prescription claim was defined as the index date. Continuous health plan enrollment for ≥6 months pre- (baseline period) and ≥12 months post-index date (follow-up period) was required. Patients treated with a PNA during the baseline period were excluded. Incidence rate was defined as the number of new cases of an AE during the follow-up period divided by the number of patients at risk (patients without any evidence of the adverse event in the 6-month baseline period). Prevalence rate was defined as the number of all AEs (existing cases during the baseline period and new cases during the follow-up period) divided by the total number of patients. Incidence and prevalence rates were calculated as rate per 1000 patient-years at risk. To evaluate the HRU, PNA-treated patients with HCL were categorized based on occurrence of highest AE during the follow-up period. Generalized linear model (GLM) compared HRU during the 12-month follow-up, adjusting for demographic, clinical characteristics, and baseline total healthcare costs.Results: In total, 647 PNA-treated patients with HCL were identified. Mean age (standard deviation) was 57.1 (12.2) years. Most patients were men (81.5%) and resided in the southern USA (32.2%). Over the 12-month follow-up period, 87.2% of the PNA-treated patients developed at least one AE. PNA-related AEs with the highest incidence rate were myelosuppression, anemia, and skin toxicities. The prevalence rate showed a similar trend for PNA-related AEs. Infectious complications including opportunistic infections were seen at a high rate (Table 1). The incidence and prevalence of infectious complications overall were 23.5% and 39.3% (235 and 393 per 1000 patient-years), respectively. Patients who developed myelosuppression had a higher rate of hospitalization compared with those who did not (47.4% vs 12.2%; p<0.0001) and had a longer inpatient length of stay (LOS) (3.4 vs 0.8 [days]; p=0.001). A higher proportion of patients who developed opportunistic infections were hospitalized compared with those who did not (53.7% vs 30.8%; p=0.025) and had a longer inpatient LOS (5.4 vs 2.4 [days]), although this was not statistically significant (p=0.138).Conclusion: This large claims-based dataset of patients with HCL treated with PNAs shows that a substantial proportion of patients developed AEs, including myelosuppression (most frequent) and infectious complications. Because of the nature of the data set, information regarding mortality is not currently available. However, infections due to myelo- and immunosuppression are known to be the most frequent causes of death in this patient population. These findings indicate a need for larger studies evaluating the outcomes of patients with HCL treated with approved therapies to understand better their short- and long-term toxicities, as well as for the development of therapies with lower risks of myelo- and immunosuppression. DisclosuresPavilack:AstraZeneca: Employment. Olufade:AstraZeneca: Equity Ownership; AstraZeneca: Employment. Bashyal:STATinMED: Employment. Li:STATinMED: Employment. Andritsos:HCLF: Membership on an entity's Board of Directors or advisory committees; AstraZeneca: Consultancy.

PCV24 - SAFETY AND EFFECTIVENESS OF CONTEMPORARY P2Y12 INHIBITORS IN EAST ASIAN PATIENTS WITH ACUTE CORONARY SYNDROMES: A NATIONWIDE POPULATION-BASED COHORT STUDY

To evaluate the safety and effectiveness of potent P2Y12 inhibitors ticagrelor and prasugrel compared to clopidogrel in East Asian patients with acute coronary syndromes (ACS). In an observational national cohort study using administrative claims-based datasets, we compared safety and effectiveness outcomes in patients with ACS who initiated P2Y12 inhibitors between January 1, 2013, and November 30, 2015. The primary safety outcomes were any bleeding and major bleeding, and the primary effectiveness outcomes were major cardiovascular events (a composite of cardiovascular death, myocardial infarction or stroke) and all-cause mortality. Among 70,715 eligible patients with ACS, 56,216 (79.5%) used clopidogrel, 11,402 (16.1%) used ticagrelor, and 3,097 (4.4%) used prasugrel. The median follow-up period was 18.0 months (interquartile range, 9.6–26.4 months). In a propensity-matched cohort, as compared with clopidogrel, ticagrelor was associated with a higher risk of any bleeding (hazard ratio [HR] 1.30, 95% confidence interval [CI] 1.21–1.41) and major bleeding (HR 1.25, 95% CI 1.04–1.51), but a similar risk of major cardiovascular events (HR 0.98, 95% CI 0.90–1.07) and a lower risk of mortality (HR 0.80, 95% CI 0.67–0.96). Prasugrel, as compared with clopidogrel, was associated with a higher risk of any bleeding (HR 1.22, 95% CI 1.05–1.42), but a borderline benefit of major cardiovascular events (HR 0.84, 95% CI 0.71–1.00) and a similar risk of major bleeding and mortality. There was no significant difference between ticagrelor and prasugrel in terms of any safety or effectiveness outcomes. In a contemporary clinical-practice of East Asian patients with ACS, compared to clopidogrel, ticagrelor was associated with an increased risk of bleeding but a decreased risk of mortality. Prasugrel was associated with an increase of any bleeding but a borderline clinical benefit for reduction of major cardiovascular events. The risks of bleeding and ischemic events were similar between ticagrelor and prasugrel.

Development of an Algorithm to Distinguish Smoldering Versus Symptomatic Multiple Myeloma in Claims-Based Data Sets.

The distinction of patients with symptomatic multiple myeloma (MM) from those with smoldering MM poses a challenge for researchers who use administrative databases. Historically, researchers either have included all patients or used treatment receipt as the distinguishing factor; both methods have drawbacks. We present an algorithm for distinguishing between symptomatic and smoldering MM using ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes for the classic defining events of symptomatic MM commonly referred to as the CRAB criteria (hypercalcemia, renal impairment, anemia, and bone lesions). SEER-Medicare-linked data from 4,187 patients with MM diagnosed between 2007 and 2011 were used for this analysis. Eighty-four percent had ICD-9-CM codes consistent with CRAB criteria, whereas only 57% received treatment. Overall survival of patients with symptomatic MM defined as receipt of treatment was 32.3 months versus 26.6 months for the overall population and 22.9 months for patients with symptomatic MM defined by CRAB criteria. Conceptually, removal of patients with smoldering MM should result in a reduction in overall survival; however, the cohort of patients who received treatment tended to be younger and healthier than the overall population, which could have skewed the results. The algorithm we present resulted in a larger and more representative sample than classification by treatment status and reduced potential bias that could result from including all patients with smoldering MM in the analysis. Although this study was performed using the SEER-Medicare database, the methodology was broad enough that the algorithm could be extended to additional claims-based data sets with relative ease.

Trends in antipsychotic prescriptions for Japanese outpatients during 2006-2012: a descriptive epidemiological study.

This study aimed to assess the trends in antipsychotic prescriptions for outpatients in Japan, where a community-based approach to mental healthcare is emphasized. This descriptive epidemiological study used claims data from 1038 community pharmacies across Japan. Outpatients who were ≥18years old and receiving their initial antipsychotic prescription during 2006-2012 were evaluated. The annual trends were reported for monotherapies, polypharmacy, antipsychotic doses, and the concurrent prescription of psychotropic medications. The 152592 outpatients included 101133 (66%) adults (18-64years old) and 51459 (34%) older adults (≥65years old). Among the adults, second-generation antipsychotic monotherapy prescriptions increased from 49% in 2006 to 71% in 2012, first-generation antipsychotic monotherapy prescriptions decreased from 29 to 14%, and antipsychotic polypharmacy decreased from 23 to 15%, respectively. Among the older adults, second-generation antipsychotic monotherapy prescriptions increased from 64 to 82%, first-generation antipsychotic monotherapy prescriptions decreased from 29 to 12%, and antipsychotic polypharmacy decreased from 7 to 6%, respectively. During the study period, >80% of the adults and >90% of the older adults received antipsychotics at risperidone-equivalent doses of <6mg/day. Anxiolytics/hypnotics, antidepressants, antiparkinson agents, mood stabilizers, and anti-dementia agents were concurrently prescribed with antipsychotics for 70, 33, 20, 20, and 0.3% of the adults and for 43, 16, 19, 8, and 16% of the older adults, respectively. The present study evaluated large-scale claims-based datasets and found that high-dose prescriptions and antipsychotic polypharmacy among Japanese outpatients were not as prevalent as has been previously thought. Copyright © 2017 John Wiley & Sons, Ltd.

Outcomes of Sacral Neuromodulation in a Privately Insured Population

In this study, we analyzed claims data from the Ingenix data base to analyze outcomes of sacral neuromodulation with respect to both provider and patient factors. We used the Ingenix (I3) data base to determine demographic, diagnosis, and procedure success information for years 2002-2007 for privately insured patients. Demographic information was obtained, as were the diagnoses given and procedures performed, based on ICD-9 diagnosis codes and Current Procedural Terminology procedure codes. Multivariate analysis was performed to identify specific predictors of success, as measured by progression to implantation of a pulse generator. Overall success, as defined by battery placement, was 49.1%. Fifty-one percent of staged procedures were followed by battery placement compared with 24.1% of percutaneous cases (p < 0.0001). Among the patient variables analyzed, women were more likely than men to progress to battery placement. After Stage I testing, patients treated by urologists were overall more likely than gynecologists to proceed to battery placement (I3: 54% vs. 47%, p < 0.0001). Unlike previous findings in other claims-based data sets, we did not observe a provider-volume relationship in the i3 data set. Success of sacral neuromodulation, as defined by proceeding to battery placement, was much better after formal staged procedures, which leads us to question the utility of percutaneous techniques. Outcomes were also better among female patients and among those treated by a urologist. Specialty differences will likely diminish over time as more gynecologists adopt sacral neuromodulation.

Estimating the Economic Burden of Rheumatoid Arthritis in Taiwan Using the National Health Insurance Database.

BackgroundRheumatoid arthritis (RA) is a chronic autoimmune disease characterized by inflammation and destruction of the joints.ObjectivesThis research aims to estimate the economic burden of RA in Taiwan.MethodsThe National Health Insurance Research Database (NHIRD), a claims-based dataset encompassing 99 % of Taiwan’s population, was applied. We used a micro-costing approach for direct healthcare costs and indirect social costs by estimating the quantities and prices of cost categories. Direct costs included surgeries, hospitalizations, medical devices and materials, laboratory tests, and drugs. The costs and quantities of the direct economic burden were calculated based on 2011 data of NHIRD. We identified RA patients and a control cohort matched 1:4 on demographic and clinical covariates to calculate the incremental cost related to RA. Indirect costs were evaluated by missed work (absenteeism) and worker productivity (presenteeism). For the indirect burden, we estimated the rate of absenteeism and presenteeism from a patient survey. Costs were presented in US dollars (US$1 = 30 TWD).ResultsA total of 41,269 RA patients were included in the database with incremental total direct cost of US$86,413,971 and indirect cost of US$138,492,987. This resulted in an average incremental direct cost of US$2050 per RA patient. Within direct costs, the largest burdens were associated with drugs (US$73,028,944), laboratory tests (US$6,132,395), and hospitalizations (US$3,208,559). For indirect costs, absenteeism costs and presenteeism costs were US$16,059,681 and US$114,291,687, respectively.ConclusionsThe economic burden of RA in Taiwan is driven by indirect healthcare costs, most notably presenteeism.Electronic supplementary materialThe online version of this article (doi:10.1007/s40801-016-0063-8) contains supplementary material, which is available to authorized users.

PMS34 - Disease Burden of Psoriatic Arthritis In Taiwan: A Population-Based Analysis

Psoriatic arthritis (PsA) is an inflammatory arthritis associated with skin psoriasis. PsA causes swelling, stiffness and pain in joints, it may also affect the spine, ankles and wrists. It is also associated with decreased quality-of-life in its patients. Treatment of PsA includes both pharmacological and non-pharmacological treatments. The research aims to estimate the economic burden of PsA in Taiwan. The National Health Insurance Research Database (NHIRD), a claims-based dataset encompassing 99% of Taiwan’s population, was applied. The database measures direct costs to the healthcare system and does not take into account indirect costs such as absenteeism or loss of productivity. We used a micro-costing approach for direct health care costs by estimating the quantities and prices of cost categories. Direct costs included surgeries, ward usage, medical devices and materials, lab tests, PUVA therapy and medications. The costs and quantities of the direct economic burden were calculated based on 2011 data of NHIRD. We identified PsA patients and a control cohort matched 1:4 on demographic and clinical covariates to calculate the incremental cost related to PsA. A total of 4,053 PsA patients were included in the database with incremental total direct cost of $13,282,615. This resulted in an average incremental direct cost of $3,277 per PsA patient. Direct costs were mostly influenced by medication costs ($11,991,479; 90.28%), while lab tests ($576,403; 4.34%), PUVA therapy ($348,741; 2.63%), surgery ($150,471; 1.13%), ward usage ($130,978; 0.99%) and medical devices/materials ($84,543; 0.64%) made up the balance. Within medication costs, biologic and tablet disease-modifying anti-rheumatic drugs accounted for 45% and 22% of all medication costs, respectively. Our findings highlight the significant economic burden PsA places on Taiwan’s economy. The direct costs of PsA in Taiwan are driven by medication costs and lab tests. Efficient management of PsA could reduce the economic impact of the disease.

Validity of a Claims-Based Diagnosis of Obesity Among Medicare Beneficiaries.

Population-level data on obesity are difficult to obtain. Claims-based data sets are useful for studying public health at a population level but lack physical measurements. The objective of this study was to determine the validity of a claims-based measure of obesity compared to obesity diagnosed with clinical data as well as the validity among older adults who suffer from chronic disease. This study used data from the National Health and Nutrition Examination Survey 1999-2004 for adults aged ≥ 65 successfully linked to 1999-2007 Medicare claims (N = 3,554). Sensitivity, specificity, positive and negative predictive values, κ statistics as well as logistic regression analyses were computed for the claims-based diagnosis of obesity versus obesity diagnosed with body mass index. The claims-based diagnosis of obesity underestimates the true prevalence in the older Medicare population with a low sensitivity (18.4%). However, this method has a high specificity (97.3%) and is accurate when it is present. Sensitivity was improved when comparing the claim-based diagnosis to Class II obesity (34.2%) and when used in combination with chronic conditions such as diabetes, congestive heart failure, chronic obstructive pulmonary disease, or depression. Understanding the validity of a claims-based obesity diagnosis could aid researchers in understanding the feasibility of conducting research on obesity using claims data.

Non-Adherence And Non-Persistence Related To Glp-1 Therapy In Patients With Diabetes Mellitus Type 2 (T2dm): Analysis of A Large German Claims-Based Dataset And Comparison To Oral Anti-Diabetics.

Non-Adherence And Non-Persistence Related To Glp-1 Therapy In Patients With Diabetes Mellitus Type 2 (T2dm): Analysis of A Large German Claims-Based Dataset And Comparison To Oral Anti-Diabetics.

Real life anticoagulation treatment of patients with atrial fibrillation in Germany: extent and causes of anticoagulant under-use.

Oral anticoagulation (OAC) with either new oral anticoagulants (NOACs) or Vitamin-K antagonists (VKAs) is recommended by guidelines for patients with atrial fibrillation (AF) and a moderate to high risk of stroke. Based on a claims-based data set the aim of this study was to quantify the stroke-risk dependent OAC utilization profile of German AF patients and possible causes of OAC under-use. Our claims-based data set was derived from two German statutory health insurance funds for the years 2007-2010. All prevalent AF-patients in the period 2007-2009 were included. The OAC-need in 2010 was assumed whenever a CHADS2- or CHA2DS2-VASC-score was >1 and no factor that disfavored OAC use existed. Causes of OAC under-use were analyzed using multivariate logistic regression. 108,632 AF-prevalent patients met the inclusion criteria. Average age was 75.43 years, average CHA2DS2-VASc-score was 4.38. OAC should have been recommended for 56.1/62.9 % of the patients (regarding factors disfavouring VKA/NOAC use). For 38.88/39.20 % of the patient-days in 2010 we could not observe any coverage by anticoagulants. Dementia of patients (OR 2.656) and general prescription patterns of the treating physician (OR 1.633) were the most important factors increasing the risk of OAC under-use. Patients who had consulted a cardiologist had a lower risk of being under-treated with OAC (OR 0.459). OAC under-use still seems to be one of the major challenges in the real-life treatment of AF patients. Our study confirms that both patient/disease characteristics and treatment environment/general prescribing behaviour of physicians may explain the OAC under-use in AF patients.

Weekly and holiday-related patterns of panic attacks in panic disorder: a population-based study.

BackgroundWhile chronobiological studies have reported seasonal variation in panic attacks (PA) episodes, information on the timing of PA by week-days may enable better understanding of the triggers of PA episodes and thereby provide pointers for suitable interventional approaches to minimize PA attacks. This study investigated weekly variation in potential PA admissions including associations with holidays using a population-based longitudinal, administrative claims-based dataset in an Asian population.MethodsThis study used ambulatory care data from the “Longitudinal Health Insurance Database 2000. We identified 993 patients with panic disorder (PD), and they had 4228 emergency room (ER) admissions for potential PA in a 3-year period between 1 January 2009 and 31 December 2011. One-way analysis of variance (ANOVA) was used to examine associations between the potential PA admissions and holidays/weekend days/work-days of the week.ResultsThe daily mean number of potential PA admissions was 3.96 (standard deviation 2.05). One-way ANOVA showed significant differences in potential PA admissions by holiday and day of the week (p<0.001). Daily frequencies showed a trough on Wednesday-Thursday, followed by a sharp increase on Saturday and a peak on Sunday. Potential PA admissions were higher than the daily mean for the sample patients by 29.4% and 22.1%, respectively on Sundays and holidays. Furthermore, the weekly variations were similar for females and males, although females always had higher potential PA admissions on both weekdays and holidays than the males.ConclusionsWe found that potential PA admissions among persons with PD varied systematically by day of the week, with a significant peak on weekends and holidays.

Trends and Variation in Use of Breast Reconstruction in Patients With Breast Cancer Undergoing Mastectomy in the United States

Concerns exist regarding breast cancer patients' access to breast reconstruction, which provides important psychosocial benefits. Using the MarketScan database, a claims-based data set of US patients with employment-based insurance, we identified 20,560 women undergoing mastectomy for breast cancer from 1998 to 2007. We evaluated time trends using the Cochran-Armitage test and correlated reconstruction use with plastic-surgery workforce density and other treatments using multivariable regression. Median age of our sample was 51 years. Reconstruction use increased from 46% in 1998 to 63% in 2007 (P < .001), with increased use of implants and decreased use of autologous techniques over time (P < .001). Receipt of bilateral mastectomy also increased: from 3% in 1998 to 18% in 2007 (P < .001). Patients receiving bilateral mastectomy were more likely to receive reconstruction (odds ratio [OR], 2.3; P < .001) and patients receiving radiation were less likely to receive reconstruction (OR, 0.44; P < .001). Rates of reconstruction receipt varied dramatically by geographic region, with associations with plastic surgeon density in each state and county-level income. Autologous techniques were more often used in patients who received both reconstruction and radiation (OR, 1.8; P < .001) and less frequently used in patients with capitated insurance (OR, 0.7; P < .001), patients undergoing bilateral mastectomy (OR, 0.5; P < .001), or patients in the highest income quartile (OR, 0.7; P = .006). Delayed reconstruction was performed in 21% of patients who underwent reconstruction. Breast reconstruction has increased over time, but it has wide geographic variability. Receipt of other treatments correlates with the use of and approaches toward reconstruction. Further research and interventions are needed to ensure equitable access to this important component of multidisciplinary treatment of breast cancer.

Abstract 99: Geographic Access to Acute Stroke Care in the United States

Background: Only 5% of ischemic stroke (IS) patients receive IV tPA and less than 1% receive endovascular therapy (ET). Prior work has described access to Primary Stroke Centers (PSC). We describe access of the US population to all facilities that provide IV tPA or ET for IS. Methods: We used US demographic data and IV tPA and ET rates in the 2011 Medicare Provider and Analysis Review (MEDPAR), a claims-based dataset that contains fee-for-service Medicare-eligible inpatient hospital discharges in the US. ICD-9 codes 433.xx, 434.xx and 436 identified IS cases. ICD-9 code 99.10 defined IV tPA treatment. Among IS cases, hospitals that gave any IV tPA were considered IV capable. ET was defined by ICD-9 code 39.74. Hospitals that performed any ET in IS cases were considered endovascular capable. PSCs were defined as hospitals certified as such by the Joint Commission in 2010. We estimated ambulance response times using arc-GIS’s network analyst and helicopter transport times using validated models. Population access to care was determined by summing the population contained within travelsheds that could reach capable hospitals within 60minutes. Results: Of 370351 IS primary diagnosis discharges, 14926 (4%) received IV tPA and 1889 (0.5%) had ET. By ground, 81% percent of the US population had access to IV capable hospitals within 60minutes, 66% had access to PSCs and 56% had access to ET capable hospitals. By air, 97% percent had access to IV capable hospitals within 60minutes, 91% had access to PSCs and 85% had access to ET hospitals. The Figure shows 60 (yellow) and 120 minute (green) access to IV rt-PA capable hospitals. Conclusion: Most of the US population has geographic access to acute stroke care, but treatment rates remain extremely low. Given our definitions of capability, actual access may be less than described. To optimize US stroke care systems and increase the use of acute therapies, pre- and inhospital interventions to overcome barriers in access to acute stroke care are needed.

Propensity Score Matching and Missing Data Imputation in a Large Claims-Based Dataset

Propensity Score Matching and Missing Data Imputation in a Large Claims-Based Dataset

The Effect of Sacral Neuromodulation on Anticholinergic Use and Expenditures in a Privately Insured Population

Sacral neuromodulation is Food and Drug Administration approved for many types of voiding dysfunction. Goals of treatment often include cessation of anticholinergic therapy. With the goal of understanding the impact of sacral neuromodulation on anticholinergic use, we analyzed patterns of care using a national claims-based dataset. The Ingenix (i3) data base contains insurance claims, including utilization and cost data, for 75 large employers. De-identified patients who underwent sacral neuromodulation between 2002 and 2007 were identified by the unique current procedural terminology-4 procedure code for pulse generator implantation, code 64590. The number and costs of anticholinergic prescriptions were compared before and after treatment. There were 266 percutaneous and 794 two-staged procedures performed from 2002 to 2007 in the i3 dataset. A total of 484 pulse generator implantations were performed, representing 46% of the test procedures. During the year prior to pulse generator placement, each patient purchased an average of 2.1 prescriptions for an anticholinergic agent (SD 3.5). During the year after neuromodulation, each patient purchased an average of 1.0 prescription (SD 2.3, p < 0.0001 by t-test). Prescription charges were $241.31 per patient before and $103.52 after neuromodulation, a statistically significant cost difference (p < 0.0001 by t-test). During the year before the procedure, 50% of patients filled anticholinergic prescriptions. This decreased to 23% after the procedure (p < 0.0001 by chi-square test). Sacral neuromodulation was associated with a significant decrease in the use of anticholinergic medication. Cost-effectiveness analyses that take into account patient quality-adjusted life years are needed to determine the true cost-benefit ratio of sacral neuromodulation.