Geisinger Health Plan Research Articles

Effects of Low-Sodium Oxybate on 24-Hour Total Sleep Time: Data From a Phase 3 Clinical Study in Adults With Idiopathic Hypersomnia (P5-13.001)

<h3>Objective:</h3> Evaluate the effects of lower-sodium oxybate (LXB; Xywav^®) on total sleep time (TST) in idiopathic hypersomnia. <h3>Background:</h3> Idiopathic hypersomnia is a debilitating central hypersomnolence disorder. Efficacy and safety of LXB for idiopathic hypersomnia in adults were established in a double-blind randomized withdrawal study (NCT03533114). <h3>Design/Methods:</h3> Participants began LXB treatment in an open-label titration and optimization period (10–14 weeks), followed by a 2-week, open-label, stable-dose period (SDP), then were randomized to placebo or continued LXB during a 2-week, double-blind, randomized withdrawal period (DBRWP). Participant-recorded daily sleep diaries from week 2 of the screening and SDP periods were analyzed. Results are reported by baseline TST in groups with &lt;8, ≥8 to &lt;9, or ≥9 hours of sleep per 24 hours and by treatment at study entry (treatment naive or taking alerting agents [AAs; stimulants or wake-promoting agents]). <h3>Results:</h3> There were 154 participants (mean±SD age, 40±14 years; 68% female). From baseline to end of SDP, estimated median reductions were observed in participants with ≥8 hours of reported baseline sleep in 24-hour TST (≥8 to &lt;9 hours=42 minutes; ≥9 hours=115 minutes), nocturnal TST (≥8 to &lt;9 hours=15 minutes; ≥9 hours=81 minutes), and nap duration (≥8 to &lt;9 hours=2.5 minutes; ≥9 hours=45.2 minutes). Minimal changes were observed in 24-hour TST, nocturnal TST, and nap duration in participants with &lt;8 hours of TST at baseline (1, 0, and 1.0 minutes, respectively). Reductions in TST were observed regardless of taking concomitant AAs in 24-hour TST (without AAs=61 minutes; with AAs=28 minutes), nocturnal TST (without AAs=32 minutes; with AAs=23 minutes), and nap duration (without AAs=11.3 minutes; with AAs=8.4 minutes). Common treatment-emergent adverse events (excluding placebo data) were nausea, headache, dizziness, anxiety, and vomiting. <h3>Conclusions:</h3> Open-label LXB treatment reduced TST and nap duration in participants with ≥8 hours of TST at baseline, and regardless of taking concomitant AAs. <b>Disclosure:</b> The institution of Dr. Morse has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Jazz Pharmaceuticals, Harmony Biosciences, Avadel Pharmaceuticals, Takeda Pharmaceuticals, Alkermes, National Institute for Health, and Geisinger Health Plan. The institution of Dr. Morse has received research support from Harmony Biosciences, Avadel Pharmaceuticals, Takeda Pharmaceuticals, Alkermes, National Institute for Health, and Geisinger Health Plan. Ms. Chen has received personal compensation for serving as an employee of Jazz Pharmaceuticals. Ms. Chen has received stock or an ownership interest from Jazz Pharmaceuticals. Teresa Steininger has received personal compensation for serving as an employee of Jazz Pharmaceuticals. Teresa Steininger has stock in Jazz Pharmaceuticals. Dr. Macfadden has received personal compensation for serving as an employee of Jazz pharma. Dr. Macfadden has stock in Jazz pharma.

The Financial Impact of Palliative Care and Aggressive Cancer Care on End-of-Life Health Care Costs.

Medicare cancer expenditures in the last month of life have increased. Aggressive cancer care at the end-of-life (ACEOL) is considered poor quality care. We used Geisinger Health Plan (GHP) last month's costs for cancer patients who died in 2018 and 2019 to determine the costs of and influence of Palliative Care (PC) on ACEOL. Patients with GHP ages 18-99 who died in 2018 and 2019 were included. Demographic, clinical characteristics, and Charlson Comorbid Index were compared across care groups defined as no ACEOL indicator, 1 or more than 1 indicator. Differences between groups were compared with Kruskal-Wallis tests and one-way ANOVA for 3 groups. Median two-sample tests and independent t-tests compared groups of 2. A P-value </= .05 indicated statistical significance. Of 608 eligible patients; 261 had no indicator, 133 had 1 and 214 > 1. There were incremental cost increases with each additional ACEOL indicator (p = < .0001). Palliative Care <90days before death was associated with increased costs while consultations >90days before death lowered cost (P < .0001) due to reduced chemotherapy in the last month. Completed ADs reduced cost by $4000. ACEOL indicators multiply costs during the last month of life. Palliative care instituted >90days before death reduces chemotherapy in the last month of life and AD reduces health care costs. Cancer health care costs increase with indicators of ACEOL. Palliative care consultations >90days before death; ADs reduce cancer health care costs.

Cost and clinical impact of a nonmedical DPP-4 inhibitor switch in patients with diabetes.

BACKGROUND: Nonmedical formulary switches (NMFS) routinely occur in managed health care plans and involve changing preferred medications for reasons outside of clinical considerations. The cost implications of NMFS are infrequently published and the clinical outcomes rarely assessed. OBJECTIVE: To assess the real-world clinical and cost implications of an NMFS involving sitagliptin and linagliptin. METHODS: An NMFS was made to the Geisinger Health Plan (GHP) commercial, health care reform, and Medicaid formularies on February 1, 2018, involving a change in preferred medication from sitagliptin to linagliptin. Claims data from GHP and clinical information from electronic health records of the Geisinger Health System were used to evaluate the cost and clinical impact of this change. Patients aged 18 years or older who were continuously enrolled in a GHP commercial, health care reform, or Medicaid plan throughout the entire study period and had at least 1 fill for sitagliptin during the preswitch phase were included in the study. We investigated the differences in various clinical and economic outcomes from pre- to postswitch among those who switched and remained adherent to the new preferred therapy throughout the 12-month postperiod ("linagliptin switch" group) and patients who did not ("other switch" group). Clinical outcomes included all-cause hospitalization, diabetes-related hospitalization, and glycosylated hemoglobin (HbA1c), while economic measures included changes in per member per month (PMPM) spending. The negative binomial regression model was used to estimate utilization counts. A generalized linear model with a log link and gamma distribution was used to analyze cost data. RESULTS: 1,203 patients met the inclusion criteria. Of these, 501 (41.6%) individuals switched to and remained at least 80% adherent to linagliptin in the postperiod, while 702 (58.4%) did not. No difference between groups was found when comparing the pre- to postswitch change in all-cause hospitalization (incidence rate ratio (IRR) = 1.46, 95% CI = 0.66-3.23, P = 0.3436) or diabetes-related hospitalization (IRR = 1.39, 95% CI = 0.62-3.10, P = 0.4203). Additionally, no difference was found between groups regarding the change in HbA1c 12-month postswitch compared with baseline (difference between groups = -0.10%, 95% CI = -0.39%-0.19%, P = 0.4962). Total PMPM spending was 43% higher in the other switch group compared with the linagliptin switch group (IRR = 1.43, 95% CI = 1.25-1.63, P < 0.0001). This trend was driven by 92% higher medical PMPM spending in the other switch group compared with the linagliptin switch group (IRR = 1.92, 95% CI = 1.58-2.33, P < 0.0001) but was offset by 12% lower pharmacy PMPM spending in the other switch group (IRR = 0.88, 95% CI = 0.82-0.95, P = 0.0009). CONCLUSIONS: An NMFS from sitagliptin to linagliptin resulted in overall health plan savings with no significant changes in health outcomes. DISCLOSURES: Funding for this study was provided by Geisinger Health System, which had no role in the study outside of a final review of the submitted manuscript. Johns and Gionfriddo are Geisinger employees. The authors report no financial conflicts of interest.

410 Sleep and Stroke: Improved OSA Time to Diagnosis for Stroke Patients Using an Inpatient Diagnostic and Treatment Strategy

Abstract Introduction Obstructive sleep apnea (OSA) is an independent risk for development of stroke. Despite this known relationship there is insufficient screening of sleep apnea in many recognized stroke centers, including Geisinger. In 2016, 68 patients were admitted to Geisinger Wyoming Valley (GWV) with ischemic stroke. Less than 10% had a Sleep Medicine Referral. When referred, average time to CPAP initiation was 9–12 months. An ongoing quality improvement (QI) study implemented inpatient home sleep apnea testing (HSAT) for stroke patients and subsequent autoPAP, if positive. Interim analysis demonstrates high rates of OSA using this screening method, suggesting a viable mechanism for improved time to OSA diagnosis. Methods All patients at GWV evaluated by neurology due to acute neurologic change were considered for enrollment (9/1/2019-10/10/2020). Only patients 18 years and older hospitalized with diagnosis of ischemic stroke were included. Patients were consented for participation. The evening of enrollment an Alice NightOne HSAT device was applied by a respiratory technician. If OSA was identified, the patient was placed on APAP the following evening. Results A total of 302 patients were screened with 82 patients meeting criteria for enrollment (27%) and 64 consenting for participation and attempting HSAT (21%). 18 of the 82 (22%) eligible patients refused participation. 12 patients (19%) had insufficient HSAT studies to determine OSA diagnosis. Of the patients who successfully completed an adequate HSAT study 85% (44/52) had OSA identified. Conclusion OSA is highly prevalent in patients with ischemic stroke and represents a modifiable risk factor for recurrent stroke. At baseline, rate of and time to diagnosis of OSA was poor with less than 10% of stroke patients receiving a sleep referral and time to initiation of CPAP was approximately 1 year. Standard universal in hospital surveillance for OSA using an HSAT in admitted stroke patients appears to allow for an increased rate of capture, but perhaps also a shorter time to diagnosis. This data may also suggest that prevalence of OSA in this stroke population is similar to slightly higher than previously reported. Further analysis of this program is required to evaluate for statistical significance and impact of APAP use. Support (if any) Geisinger Health Plan

Genome-Wide Meta-Analysis Identifies the Organic Anion-Transporting Polypeptide Gene &lt;i&gt;SLCO1B1&lt;/i&gt; and Statins as Modifiers of Glycemic Response to Sulfonylureas

Background: Sulfonylureas, the first available drugs for the management of type 2 diabetes, remain widely prescribed today. However there exists significant variability in glycaemic response to treatment. We aimed to establish heritability of sulfonylurea response and identify genetic variants and interacting treatments associated with HbA1c reduction. Methods: As an initiative of the Metformin Genetics Plus (MetGen Plus) and the DIabetes REsearCh on patient straTification (DIRECT) consortia, 5,485 white European adults with type 2 diabetes treated with sulfonylurea were recruited from 6 referral centres in Europe and North America. We first estimated heritability using generalized restricted maximum likelihood (REML) and then undertook GWAS of glycemic response to sulfonylureas measured as HbA1c reduction after 12 months of therapy in each cohort using linear regression followed by meta-analysis. These results were supported by cis-eQTLs and functional validation in cellular models. Findings: After establishing that sulfonylurea response is heritable (37±11%), we identified two independent loci near the GXYLT1 and SLCO1B1 genes associated with HbA1c reduction. The C-allele at rs1234032, near GXYLT1, was associated with 0.14% (1.5 mmol/mol), p=2.4×10−8) lower HbA1c reduction. Similarly, the C-allele was associated with higher glucose trough levels (β=1.61, p=0.005) in healthy volunteers in the SUGAR-MGH given glipizide (N = 857). The C-allele of rs10770791, near SLCO1B1, was associated with 0.11% (1.2 mmol/mol) greater HbA1c reduction (p=4.8×10 −8 ). In 1,183 human liver samples, the C-allele at rs10770791 is a cis-eQTL for reduced SLCO1B1 expression (p=1.61×10−7) which, together with functional studies in cells expressing SLCO1B1, supports a key role for hepatic SLCO1B1 (encoding OATP1B1) in regulation of sulfonylurea transport. Further, a significant interaction between statin use, sulfonylurea response and SCLO1B1 genotype was observed (p=0.001). In statin non-users (but not users), C-allele homozygotes at rs10770791 had a large absolute reduction in HbA1c (0.48±0.12% (5.2±1.26 mmol/mol)), equivalent to initiating a DPP4 inhibitor. Interpretation: We have identified clinically important genetic effects at genomewide levels of significance, and important drug-drug-gene interactions, which include commonly prescribed statins. With increasing availability of genetic data embedded in clinical records these findings will be important when prescribing glucose-lowering drugs. Funding Statement: Innovative Medicines Initiative, the National Institutes of Health, the Geisinger Health Plan Quality Pilot Fund. Declaration of Interests: ERP has received honoraria for speaking from Lilly and Sanofi. JCF has received honoraria for speaking at scientific conferences from Novo, and for consulting from Goldfinch Bio. All other authors declare no competing interest. Ethics Approval Statement: This study was approved by respective research ethics review boards and participants provided written informed consent.

A Novel Approach to ICU Survivor Care: A Population Health Quality Improvement Project.

Deliver a novel interdisciplinary care process for ICU survivor care and their primary family caregivers, and assess mortality, readmission rates, and economic impact compared with usual care. Population health quality improvement comparative study with retrospective data analysis. A single tertiary care rural hospital with medical/surgical, neuroscience, trauma, and cardiac ICUs. ICU survivors. Reorganization of existing post discharge health care delivery resources to form an ICU survivor clinic care process and compare this new process to post discharge usual care process. Demographic data, Acute Physiology and Chronic Health Evaluation IV scores, and Charlson Comorbidity Index scores were extracted from the electronic health record. Additional data was extracted from the care manager database. Economic data were extracted from the Geisinger Health Plan database and analyzed by a health economist. During 13-month period analyzed, patients in the ICU survivor care had reduced mortality compared with usual care, as determined by the Kaplan-Meier method (ICU survivor care 0.89 vs usual care 0.71; log-rank p = 0.0108) and risk-adjusted stabilized inverse probability of treatment weighting (hazard ratio, 0.157; 95% CI, 0.058-0.427). Readmission for ICU survivor care versus usual care: at 30 days (10.4% vs 26.3%; stabilized inverse probability of treatment weighting hazard ratio, 0.539; 95% CI, 0.224-1.297) and at 60 days (16.7% vs 34.7%; stabilized inverse probability of treatment weighting hazard ratio, 0.525; 95% CI, 0.240-1.145). Financial data analysis indicates estimated annual cost savings to Geisinger Health Plan ranges from $247,052 to $424,846 during the time period analyzed. Our ICU survivor care process results in decreased mortality and a net annual cost savings to the insurer compared with usual care processes. There was no statistically significant difference in readmission rates.

Mammography utilization among women with a negative circulating tumor DNA-based early cancer detection test.

1563 Background: Blood-based tests may enable minimally invasive detection of multiple cancer types. One such test, CancerSEEK, employs ctDNA and protein biomarkers for this purpose. Test performance has been evaluated in women without a history of cancer in an ongoing prospective study called DETECT-A. The introduction of such blood tests holds promise, and their future utility lies in augmenting, not displacing, standard-of-care (SOC) cancer screening. One important safety concern is that a negative test result could provide false reassurance that discourages adherence to SOC cancer screening. To investigate this possibility, we studied delivery of mammography to DETECT-A participants before and after receipt of a negative CancerSEEK result. Methods: DETECT-A screened 10,000 women aged 65-75 using CancerSEEK. Participants completed a survey about cancer screening at enrollment and at one-year post-enrollment. We analyzed only those participants who had received a negative CancerSEEK result, were insured by Geisinger Health Plan (GHP), and had completed both surveys. GHP claims data were used to identify mammograms performed within one year prior-to and post-enrollment. Overall utilization was determined by combining claims and survey data at enrollment and one-year post-enrollment. In addition to comparing SOC screening rates pre- versus post-testing, we evaluated the impact of primary care physician (PCP) type (Geisinger versus any other institution), as screening reminder mechanisms differ between institutions. Results: Of the 2,241 participants who met analysis criteria, 73.6% (n = 1,650) had a mammogram in the year before enrollment while a significantly great number (79.3%, n = 1,777) did so during the one-year follow-up (χ2(1) = 59.05, p &lt; 0.001). At enrollment, there were 591 participants who had not had a mammogram completed in the previous year, but 404 (68.4%) of them did have a mammogram during the one-year follow-up. The rate of change in mammography utilization did not differ between those who had a Geisinger versus a non-Geisinger PCP (χ2(2) = 1.83, p = 0.40). Conclusions: Participants in a study using a novel blood test for earlier cancer detection had a significantly higher rate of annual mammography after study enrollment and testing. These results indicate that introduction of a minimally invasive ctDNA and protein biomarker-based cancer screening test may engender greater, not lesser, utilization of SOC cancer screening. Further study is required to understand the root causes of increased utilization in this context.

Abstract P169: Randomized Controlled Trial Comparing a Self-guided vs. Dietitian-led Approach Using Web-based Tools to Lower Blood Pressure: Study Design and Rationale

Background: Weight loss, consumption of a Dietary Approaches to Stop Hypertension (DASH) dietary pattern, reduced sodium intake, and increased physical activity have been shown to lower systolic blood pressure (SBP). Use of website or smartphone-based tools could be potentially scalable solutions to improve lifestyle behaviors and lower SBP, but little data exists to support their use in clinical practice. Methods: In an ongoing single-center, 2-arm, randomized controlled trial, we compare the efficacy of a dietitian-guided approach vs. a self-guided approach in lowering 24-hour SBP in overweight/obese patients with 24-hour SBP 120-160 mmHg on 0-1 BP medication. As part of standard of care, participants with outpatient SBP ≥ 130 mmHg are identified using Geisinger electronic health record data and through Geisinger Health Plan’s health and wellness program and invited to complete 24-hour ambulatory BP monitoring (ABPM). Qualifying participants are then invited to a research visit to sign informed consent and for data collection, including a web-based food frequency questionnaire (Viocare®), which provides personalized recommendations to improve dietary quality. After a 2-week run-in period in which participants must regularly log data into www.bmiq.com, a comprehensive weight management program, and a smartphone app (Lose It!), participants are randomized 1:1 to a self-guided arm or a dietitian-led arm. All participants are instructed to use the website and app, and the dietitian-led arm additionally receives weekly telephone calls from registered dietitian nutritionists, trained in motivational interviewing. The primary outcome is 3-month change in 24-hour SBP. Other outcomes include changes in other ABPM measures, total healthy eating index-2015 (HEI) score, weight, waist circumference, metabolic equivalent of task-minutes per week (International Physical Activity Questionnaire short form), and study satisfaction. Results: Out of 210 patients who have thus far completed ABPM, 128 were eligible for the trial, 85 consented for the trial, and 78 were randomized after completing the run-in period. In a preplanned interim analysis of the first 34 randomized patients, 28 (82%) completed the 3-month study visit. Mean (SD) changes from baseline to 3 months were: -8.0 mmHg (9.9) for 24-hour SBP, -5.4 kg (4.5) for weight, -6.1 cm (7.4) for waist circumference, and 11.2 units (12.0) for HEI score. Conclusions: Confirmation of elevated BP using ABPM may provide an opportunity to engage patients in making lifestyle modifications, as more than 60% of eligible patients after 24-hour ABPM screening were successfully randomized into the trial. Completion of the study is expected by the end of 2020 and will determine the efficacy of a self-directed vs. dietitian-led approach to lower 24-hour SBP using web-based tools.

Impact of a multidisciplinary pain management program on patient care utilization and cost of care.

ObjectiveChronic pain is a highly prevalent and costly condition with few proven treatment options. Since 2014, Geisinger’s Department of Pain Medicine has implemented the Multidisciplinary Pain Program (MPP), which consists of a 3-day educational seminar followed by 12 months of comprehensive care. This study examines the impact of MPP on care utilization and cost between 2014 and 2016.MethodsA retrospective health insurance claims data analysis covering a 3-year period between January 2013 and December 2016. Among all patients referred to MPP during the period, a subset of those who were Geisinger Health Plan (GHP) members was identified (113 patients). Those who were GHP members and were referred to MPP after December 2016 served as the contemporaneous comparison group (69 patients). GHP’s claims data for the corresponding period were analyzed on a per-member-per-month (PMPM) basis.ResultsMPP was associated with US$754 PMPM reduction in total cost of care including prescription drug costs (P=0.014) and US$846 reduction in total medical cost excluding prescription drugs (P=0.006). These cost savings were attributable to reductions in utilization of high-end diagnostic imaging (52 per-1,000 members-per month; P=0.015) and acute inpatient admissions (20 per-1,000 members-per month; P=0.086).ConclusionPatients enrolled in MPP were less likely to use expensive diagnostic imaging and experienced fewer hospitalizations, resulting in total cost of care savings. These findings are consistent with the expectation that MPP improves health outcomes among patients suffering from chronic pain.

The readmission contradiction: toward clarifying common misconceptions about bariatric readmissions and quality improvement

BackgroundEfforts to improve quality in U.S. medicine have included reimbursement penalties for readmissions. ObjectivesThis study’s first phase measured readmissions after initial bariatric surgery and analyzed surgical outcomes secondarily. The second phase aimed to identify nonclinical factors associated with bariatric readmissions. SettingRural U.S. academic hospital. MethodsThis retrospective study analyzed a prospective database of patients undergoing initial Roux-en-Y gastric bypass or sleeve gastrectomy between May 1, 2007 and April 30, 2015. Phase I included readmission data as well as demographic and surgical outcomes data. Phase II focused on “nonclinical” data from readmitted patients including payor status (Medicare, Medicaid, Commercial, Geisinger Health Plan), distance from home to the index hospital, and utilization of a transfer center. ResultsA total of 2275 patients were studied; 5.5% were readmitted. Of remissions, 48% were preventable and were most often associated with nausea, vomiting, and dehydration (gastrointestinal). Nonpreventable readmissions were significantly associated with major complications. No significant difference was found in overall or preventable readmission rates by payor. Distance from index hospital was not significantly associated with readmissions; however, 28% of readmitted patients were transferred from other healthcare facilities. ConclusionsPayor status was not associated with increased risk for readmissions. Nearly half of all bariatric readmissions were preventable, identifying a quality improvement opportunity. However, 28% came through a transfer center, resulting in both better treatment and patient capture rates. Such quality improvement initiatives paradoxically risk increased reimbursement penalties.

Living goals: Prepare to die.

157 Background: Living Goals (LGs), a home-based program, is a collaboration between Geisinger Health Plan, Geisinger Home care and Hospice and Palliative Medicine. Program investigated an early intervention in those with serious illness and transition to hospice in a timely manner during FY 2015- 2017. Methods: LGs visits were led by a registered nurse after referral from physicians based on the surprise question (it would not be a surprise if this patient died within one year). Nurse facilitated end-of-life discussions and provided resources available for supportive care. LGs visits were free up to 10 visits to each patient. Results: 94 patients were enrolled in LGs from 128 referrals.59 (63%) patients transitioned to hospice and 41 (69%) were transitioned within first month of LGs visit averaging 1.4 visits. 59 patients enrolled in hospice. The median length of time between LG Start of care (SOC) and Hospice SOC is 9 days (IQR: 3-73).57 LGs patients discharged from hospice had a median length of stay (LOS) of 39 days (IQR: 10-85). For the subset of patients in FY 2015 (n = 13) median LOS was 26 days (IQR: 10-57)), in FY 2016 (n = 26) the median LOS was 27 days (IQR: 7-73), in FY 2017 (n = 18) the median LOS is 66 days (IQR: 28-144). In FY 2014, 513 hospice patients were discharged before initiation of LGs and the median LOS was 19 days (IQR: 6-61). As of now, there is a significantly longer stay for LG patients than FY 2014 hospice patients (p = 0.0130). Conclusions: This innovative home based program, appears to have a great potential in the future for delivering ongoing hospice and palliative needs to seriously ill patients.

Medication therapy disease management: Geisinger's approach to population health management.

Pharmacists' involvement in a population health initiative focused on chronic disease management is described. Geisinger Health System has cultivated a culture of innovation in population health management, as highlighted by its ambulatory care pharmacy program, the Medication Therapy Disease Management (MTDM) program. Initiated in 1996, the MTDM program leverages pharmacists' pharmacotherapy expertise to optimize care and improve outcomes. MTDM program pharmacists are trained and credentialed to manage over 16 conditions, including atrial fibrillation (AF) and multiple sclerosis (MS). Over a 15-year period, Geisinger Health Plan (GHP)-insured patients with AF whose warfarin therapy was managed by the MTDM program had, on average, 18% fewer emergency department (ED) visits and 18% fewer hospitalizations per year than GHP enrollees with AF who did not receive MTDM services, with 23% lower annual total care costs. Over a 2-year period, GHP-insured patients with MS whose pharmacotherapy was managed by pharmacists averaged 28% fewer annual ED visits than non-pharmacist-managed patients; however, the mean annual total care cost was 21% higher among MTDM clinic patients. The Geisinger MTDM program has evolved over 20 years from a single pharmacist-run anticoagulation clinic into a large program focused on managing the health of an ever-growing population. Initial challenges in integrating pharmacists into the Geisinger patient care framework as clinical experts were overcome by demonstrating the MTDM program's positive impact on patient outcomes.

Impact of Employee Wellness Program on Health Outcome: A Propensity Score-Matched Analysis

Background: Since 2012, Geisinger Health Plan has redesigned its employee wellness program MyHealth Rewards (MHR) by requiring biometric screenings and goal achievements for blood pressure, body mass index, glucose and cholesterol levels to be eligible for premium discount in subsequent year. This study is designed to evaluate the impact of MHR on stroke and myocardial infarction.

Impact of a Biometric Screening and Premium Incentive-Based Employee Wellness Program on Cost of Care and Utilization

Background: Since 2012, Geisinger Health System (GHS), in collaboration with Geisinger Health Plan, has redesigned its employee wellness program MyHealth Rewards by requiring biometric screenings and achievement of a set of predefined goals for blood pressure, body mass index, glucose and cholesterol levels to be eligible for premium discounts in the subsequent year. GHS employees can voluntarily choose to enroll in MyHealth Rewards in a given year, and to qualify for the premium discounts they are required to meet all the biometric goals prior to November of the same year.

Patterns of health care utilization and cost before and after opioid overdose: findings from 10-year longitudinal health plan claims data.

ObjectiveTo describe the longitudinal pattern of health care utilization and cost of care before and after opioid overdose (OD) over a 10-year period using health plan claims data.MethodsPatients who had experienced opioid ODs between April 2005 and March 2015 were identified from Geisinger Health System’s electronic health records. Among these patients, a subgroup of patients who were Geisinger Health Plan (GHP) members at any point between January 2006 and December 2015 were also identified. From the corresponding GHP claims data, their all-cause health care utilization (inpatient admissions, emergency department [ED] visits, and physician office visits) and total medical costs, excluding prescription medication cost, were obtained. Per-member-per-month estimates for each month before and after the index date of opioid OD were calculated, adjusting for age, gender, plan type, year, and comorbidity via multivariate regression models.ResultsA total of 942 opioid OD patients with an average GHP enrollment period of 41.4 months were identified. ED visit rates rose rapidly starting around 19–24 months prior to the opioid OD date. Acute inpatient admission rates and total medical cost also rose rapidly starting around 12 months prior. After the OD date, the utilization rates and cost declined but tended to remain above those of the pre-OD period.ConclusionOpioid OD is preceded by sharp increases in utilization of acute care and cost well before the actual OD. These findings therefore suggest that early signals of OD may be detected from patterns of acute care utilization, particularly the ED visits.

Impact of a value-based insurance design for physical therapy to treat back pain on care utilization and cost.

ObjectiveTo assess the impact of a value-based insurance design providing enhanced access to physical therapy (PT) for treatment of back pain on treatment patterns and cost of care.Study designA retrospective analysis of claims data obtained from Geisinger Health Plan (GHP). In April 2013, GHP began offering “PT bundle” – i.e., a bundle of up to five PT visits for a single one-time copay that can be renewed for another bundle of five PT visits – for its employer-based plan members with back pain.MethodsA cohort of GHP members who were preauthorized for the PT bundle were compared against a contemporaneous cohort of GHP members who were preauthorized for PT under the standard per-visit copay arrangement between January 2013 and October 2014.ResultsAmong the PT bundle cohort, the PT visit rate during the first 9 months since the PT preauthorization date had dramatically increased and then gradually decreased in subsequent months. The PT bundle was also associated with 29%–35% short-term reductions in emergency department visits and with 12%–20% reductions in primary care visits after 6 months. No significant impact on hospitalization or cost was observed.ConclusionImplementation of the PT bundle appears to have led to a change in the treatment pattern of back pain that is more consistent with the recommended guidelines to use more conservative management such as PT as the first-line treatment for back pain.

Impact of a Complex Care Management Model on Cost and Utilization Among Adolescents and Young Adults with Special Care and Health Needs.

Adolescents and young adults with special care and health needs in the United States-many of whom have Medicaid coverage-at the transition phase between pediatric and adult care often experience critical care gaps. To address this challenge, a new model-referred to as Comprehensive Care Clinic (CCC)-has been developed and implemented by Geisinger Health System since 2012. CCC comprises a care team, consisting of a generalist physician, advanced practitioner, pharmacist, and a nurse case manager, that develops and closely follows a coordinated care plan. This study examines the CCC impact on total cost of care and utilization by analyzing Geisinger Health Plan claims data obtained from 83 Medicaid patients enrolled in CCC. A set of multivariate regression models with patient fixed effects was estimated to obtain adjusted differences in cost and acute care utilization between the months in which the patients were enrolled and the months not enrolled in CCC. The results indicate that CCC enrollment was associated with a 28% reduction in per-member-per-month total cost ($3931 observed vs. $5451 expected; P = 0.028), driven by reductions in hospitalization and emergency department visits. This finding suggests a clinical redesign focused on adolescent and young adults with complex care needs can potentially reduce total cost and acute care utilization among such patients.

Patient characteristics and healthcare utilization patterns associated with unused medications among medicare patients.

To examine what patient characteristics and healthcare utilization patterns are associated with the likelihood of having unused medications among elderly Medicare patients. Secondary data analysis combining insurance claims and phone survey data of Medicare Advantage members. Regional health plan in Central Pennsylvania. 528 Medicare Advantage members (age 65 and older), who had Medicare Part D coverage through Geisinger Health Plan as of December 31, 2013, and completed the phone survey in May of 2014. Member survey response indicating whether or not the member had any unused medication at the time of the survey. 27% of the patients in the sample (142 out of 528) indicated having one or more unused medications. In a bivariate analysis, these patients had higher prevalence of chronic conditions, utilized more medical care (more emergency department visits and physician office visits), and incurred higher cost of care. In a multivariate analysis, patients who received medications with days' supply greater than 30 (odds ratio (OR)=1.59; p=0.03) and utilized more acute care (defined as inpatient admissions or emergency department visits) (OR=4.2; p=0.04) were more likely to have unused medications. Moreover, patients who were advised by health care professionals about proper medication disposal were less likely to have unused medications (OR=0.52; p=0.04). These findings suggest potential ways to develop effective strategies to reduce amounts of unused medications. Such strategies are likely to involve limiting quantities of medications dispensed at each fill, and patient education on proper disposal of unused medications, particularly during care transitions.

Patterns of Multiple Emergency Department Visits: A Discretionary Care-Seeking Behavior?

Background/Aims: Identifying an effective strategy to reduce emergency department (ED) visits remains challenging. This study seeks to empirically identify patient characteristics and utilization patterns that are significantly associated with multiple ED visits by patients within a 1-year period. The rationale is that a single ER visit is likely to be subject to random variation that is inherently difficult to predict. This study focuses only on Geisinger Health Plan members who had at least one ED visit in a 2-year period (2013–2014) across all plan types for which Geisinger Health Plan was “at risk” (i.e. Medicaid, Medicare, commercial, the Exchange) and identifies patient characteristics and other care utilizations (e.g. high-end diagnostic imaging, outpatient surgery, physician office visits) that are associated with multiple ED visits within a 12-month period.

Sharing Physician Notes Through an Electronic Portal is Associated With Improved Medication Adherence: Quasi-Experimental Study.

BackgroundIn surveys, interviews, and focus groups, patients taking medications and offered Web portal access to their primary care physicians’ (PCPs) notes report improved adherence to their regimens. However, objective confirmation has yet to be reported.ObjectiveTo evaluate the association between patient Internet portal access to primary care physician visit notes and medication adherence.MethodsThis study is a retrospective comparative analysis at one site of the OpenNotes quasi-experimental trial. The setting includes primary care practices at the Geisinger Health System (GHS) in Danville, Pennsylvania. Participants include patients 18 years of age or older with electronic portal access, GHS primary care physicians, and Geisinger health plan insurance, and taking at least one antihypertensive or antihyperlipidemic agent from March 2009 to June 2011. Starting in March 2010, intervention patients were invited and reminded to read their PCPs' notes. Control patients also had Web portal access throughout, but their PCPs' notes were not available. From prescription claims, adherence was assessed by using the proportion of days covered (PDC). Patients with a PDC ≥.80 were considered adherent and were compared across groups using generalized linear models.ResultsA total of 2147 patients (756 intervention participants, 35.21%; 1391 controls, 64.79%) were included in the analysis. Compared to those without access, patients invited to review notes were more adherent to antihypertensive medications—adherence rate 79.7% for intervention versus 75.3% for control group; adjusted risk ratio, 1.06 (95% CI 1.00-1.12). Adherence was similar among patient groups taking antihyperlipidemic agents—adherence rate 77.6% for intervention versus 77.3% for control group; adjusted risk ratio, 1.01 (95% CI 0.95-1.07).ConclusionsAvailability of notes following PCP visits was associated with improved adherence by patients prescribed antihypertensive, but not antihyperlipidemic, medications. As the use of fully transparent records spreads, patients invited to read their clinicians’ notes may modify their behaviors in clinically valuable ways.