Medicare Advantage Health Plan Research Articles

588. Retrospective Analysis of Clinical Characteristics and Treatment Patterns Among HIV Patients with Commercial and Medicare Advantage Health Insurance in the United States

BackgroundWith modern antiretroviral (ARV) regimens, HIV infection has evolved into a manageable chronic condition. The ultimate goal of treatment is to maximize the virologic suppression of HIV virus while minimizing intolerability, toxicity, drug-to-drug interactions, and noncompliance. The objectives of this study were to describe clinical characteristics and treatment history of currently treated HIV-1 patients in commercial and Medicare Advantage health plans in the United States.MethodsA retrospective cohort study of adults (≥18 years) with ≥1 ARV pharmacy claim from January 1, 2012 to March 31, 2017 and ≥1 HIV-1 diagnosis code in the Optum Research Database. A claims-based algorithm was used to identify lines of therapy (LOT), including the most recent LOT (LOT0) and previous LOTs dating back to January 1, 2007. Subjects were continuously enrolled 12 months prior to the start of LOT0 (baseline) and comorbidities assessed. Treatment-naïve subjects were defined as having LOT0 only during baseline, while subjects with >1 LOT were defined as treatment-experienced. Study variables were summarized descriptively and results were stratified by treatment status, insurance type, and age groups.ResultsThere were 18,699 eligible subjects, of whom 27% were treatment naïve. Average age was 47 years (±12), 84% were male, 51% Caucasian, and 82% had commercial insurance. Common baseline comorbidities among subjects were hyperlipidemia (41%), cardiovascular disease (41%), hypertension (34%), and depression (17%). Most comorbidities increased with age except for depression and anxiety, which were mostly constant across age groups. Among all subjects, the average cumulative proportion of days covered with an ARV was 85%. Average total pills per day, ARV and non-ARV, increased with age corresponding with Medicare subjects having 9.2 and commercial subjects having 3.7 pills per day.ConclusionAs ARV regimens have improved the life expectancy for patients with HIV, management of comorbidities and overall medication burden has become increasingly complex. HIV treatment guidelines suggest streamlined ARV regimens may be considered as patient complexity evolves over time to decrease disease burden taking into account co-morbidities, drug–drug interactions and total pill burden.Disclosures J. Priest, ViiV Healthcare: Employee, Salary. T. Burton, Optum: Consultant and Employee, Salary. AstraZeneca: Research Contractor, Consulting fee. C. Blauer-Peterson, Optum: Employee, Salary. ViiV: Research Contractor, Consulting fee. K. Andrade, Optum: Employee, Salary. Viiv: Research Contractor, Consulting fee. A. Oglesby, ViiV Healthcare: Employee and Shareholder, Salary.

Coverage of Nonpharmacologic Treatments for Low Back Pain Among US Public and Private Insurers

Despite epidemic rates of addiction and death from prescription opioids in the United States, suggesting the importance of providing alternatives to opioids in the treatment of pain, little is known regarding how payers' coverage policies may facilitate or impede access to such treatments. To examine coverage policies for 5 nonpharmacologic approaches commonly used to treat acute or chronic low back pain among commercial and Medicare Advantage insurance plans, plus an additional 6 treatments among Medicaid plans. Cross-sectional study of 15 commercial, 15 Medicaid, and 15 Medicare Advantage health plans for the 2017 calendar year in 16 states representing more than half of the US population. Interviews were conducted with 43 senior medical and pharmacy health plan executives from representative plans. Medical necessity and coverage status for the treatments examined, as well as the use of utilization management tools and cost-sharing magnitude and structure. Commercial and Medicare insurers consistently regarded physical and occupational therapy as medically necessary, but policies varied for other therapies examined. Payers most commonly covered physical therapy (98% [44 of 45 plans]), occupational therapy (96% [43 of 45 plans]), and chiropractic care (89% [40 of 45 plans]), while transcutaneous electrical nerve stimulation (67% [10 of 15 plans]) and steroid injections (60% [9 of 15 plans]) were the most commonly covered among the therapies examined for Medicaid plans only. Despite evidence in the literature to support use of acupuncture and psychological interventions, these therapies were either not covered by plans examined (67% of all plans [30 of 45] did not cover acupuncture) or lacked information about coverage (80% of Medicaid plans [12 of 15] lacked information about coverage of psychological interventions). Utilization management tools, such as prior authorization, were common, but criteria varied greatly with respect to which conditions and what quantity and duration of services were covered. Interviewees represented 6 Medicaid managed care organizations, 2 Medicare Advantage or Part D plans, 9 commercial plans, and 3 trade organizations (eg, Blue Cross Blue Shield Association). Interviews with plan executives indicated a low level of integration between the coverage decision-making processes for pharmacologic and nonpharmacologic therapies for chronic pain. Wide variation in coverage of nonpharmacologic treatments for low back pain may be driven by the absence of best practices, the administrative complexities of developing and revising coverage policies, and payers' economic incentives. Such variation suggests an important opportunity to improve the accessibility of services, reduce opioid use, and ultimately improve the quality of care for individuals with chronic, noncancer pain while alleviating the burden of opioid addiction and overdose.

Racial And Ethnic Differences In The Attainment Of Behavioral Health Quality Measures In Medicare Advantage Plans.

As the Medicare population becomes more diverse and its demand for behavioral health care grows, a better understanding of racial/ethnic disparities in the quality of behavioral health care is crucial. Medicare Advantage (MA) plans are accountable through the public reporting of quality performance on measures, including the Healthcare Effectiveness Data and Information Set (HEDIS). We examined HEDIS data on eight MA behavioral health care quality measures, using mixed-effects logistic regressions to distinguish racial/ethnic differences within and between MA health plans. We found that performance differed across racial/ethnic groups by more than 10 percentage points on most quality measures. Significant within-plan disparities were found in twenty of twenty-four comparisons of racial/ethnic minority groups with whites. Within-plan disparities varied widely across plans, with performance being equivalent across racial/ethnic groups in some plans and widely divergent in others. Unlike other types of medical care, in behavioral health within-plan quality disparities are prominent in MA plans, which suggests a role for stratified reporting by racial/ethnic group.

Healthcare Cost and Utilization in Nonalcoholic Fatty Liver Disease: Real-World Data From a Large U.S. Claims Database.

The prevalence of nonalcoholic fatty liver disease (NAFLD) is increasing. The health care burden resulting from the multidisciplinary management of this complex disease is unknown. We assessed the total health care cost and resource utilization associated with a new NAFLD diagnosis, compared with controls with similar comorbidities. We used OptumLabs Data Warehouse, a large national administrative claims database with longitudinal health data of over 100 million individuals enrolled in private and Medicare Advantage health plans. We identified 152,064 adults with a first claim for NAFLD between 2010 and 2014, of which 108,420 were matched 1:1 by age, sex, metabolic comorbidities, length of follow-up, year of diagnosis, race, geographic region, and insurance type to non-NAFLD contemporary controls from the OptumLabs Data Warehouse database. Median follow-up time was 2.6 (range 1-6.5) years. The final study cohort consisted of 216,840 people with median age 55 (range 18-86) years, 53% female, 78% white. The total annual cost of care per NAFLD patient with private insurance was $7,804 (interquartile range [IQR] $3,068-$18,688) for a new diagnosis and $3,789 (IQR $1,176-$10,539) for long-term management. These costs are significantly higher than the total annual costs of $2,298 (IQR $681-$6,580) per matched control with similar metabolic comorbidities but without NAFLD. The largest increases in health care utilization that may account for the increased costs in NAFLD compared with controls are represented by liver biopsies (relative risk [RR] = 55.00, 95% confidence interval [CI] 24.48-123.59), imaging (RR = 3.95, 95% CI 3.77-4.15), and hospitalizations (RR = 1.87, 95% CI 1.73-2.02). Conclusion: The costs associated with the care for NAFLD independent of its metabolic comorbidities are very high, especially at first diagnosis. Research efforts shouldfocus on identification of underlying determinants of use, sources of excess cost, and development of cost-effective diagnostic tests.

Validation of body mass index (BMI)-related ICD-9-CM and ICD-10-CM administrative diagnosis codes recorded in US claims data.

To quantify the sensitivity and positive predictive value (PPV) of body mass index (BMI)-related ICD-9-CM and ICD-10-CM diagnosis codes in claims data. De-identified electronic health record (EHR) and claims data were obtained from the Optum Integrated Claims-Clinical Database for cross-sections of commercial and Medicare Advantage health plan members age≥20years in 2013, 2014, and 2016. In each calendar year, health plan members' BMI as coded in the insurance claims data (error-prone measure) was compared with their BMI as recorded in the EHR (gold standard) to estimate the sensitivity and PPV of BMI-related ICD-9-CM and ICD-10-CM diagnosis codes. The unit of analysis was the person-year. The study sample included 746763 distinct health plan members who contributed 1116283 eligible person-years (median age 56years; 57% female; 65% commercially insured and 35% with Medicare Advantage). BMI-related diagnoses were coded for 14.6%. The sensitivity of BMI-related diagnoses codes for the detection of underweight, normal weight, overweight, and obesity was 10.1%, 3.7%, 6.0%, and 25.2%, and the PPV was 49.0% for underweight, 89.6% for normal weight, 73.4% for overweight, and 92.4% for obesity, respectively. The sensitivity of BMI-related diagnosis codes was higher in the ICD-10-CM era relative to the ICD-9-CM era. The PPV of BMI-related diagnosis codes for normal weight, overweight, and obesity was high (>70%) but the sensitivity was low (<30%). BMI-related diagnoses were more likely to be coded in patients with class II or III obesity (BMI ≥35kg/m2 ), and in 2016 relative to 2013 or 2014.

Understanding the Relationship between Primary Care Provider (PCP) Encounter Cadence, Medication Adherence, and Diabetes Control

Introduction: Regular PCP encounters are associated with wellbeing; there is limited evidence to support the ideal PCP encounter cadence to optimize patient outcomes. The aim of this study was to measure the association between PCP encounter cadence and medication adherence and diabetes control, among those newly diagnosed with T2DM. Methods: A cohort of 7,106 persons enrolled in a Medicare Advantage health plan and newly diagnosed with T2DM between 7/1/12-6/30/13, was identified and followed for 36 months. Two methods measured PCP encounter cadence: total PCP encounters (frequency) and quarters with PCP encounter (regularity). Proportion of days covered (PDC) assessed noninsulin diabetes medication (NIDM) adherence (PDC ≥80.0%). Diabetes control was defined as A1c ≤ 8.0%. Logistic regression was used to measure the relationship between PCP encounter cadence and outcomes (NIDM adherence, diabetes control). Covariates included patient demographics, Charlson Comorbidity Index score, chronic conditions, healthcare utilization, insulin use, and prior NIDM adherence and diabetes control. Results: Overall, 5,212 and 326 people met inclusion criteria for the NIDM adherence and diabetes control analyses, respectively. Adjusted models indicated that each additional PCP encounter was associated with a 12.3% increase in the likelihood of NIDM adherence (95% CI 1.10, 1.15), and each additional quarter with a PCP encounter was associated with a 27.4% increase in the likelihood of NIDM adherence (95% CI 1.22, 1.33). PCP encounters (OR 1.06; 95% CI 1.00, 1.12) and quarters with a PCP encounter (OR 1.13; 95% CI 0.98, 1.30) were directionally associated with diabetes control. Conclusion: Our findings suggest that frequency and regularity of PCP encounters were associated with medication adherence. This study contributes to the data needed to establish evidence-based guidelines for PCP encounter cadence, for those newly diagnosed with T2DM. Disclosure S.E. Wixson: None. J. Dobbins: Employee; Self; Humana Inc. T.A. Cordier: Employee; Self; Humana Inc.. Stock/Shareholder; Self; Humana Inc.. G. Haugh: None. A. Renda: None. L.E. Happe: Employee; Self; Humana. Other Relationship; Self; Journal of Managed Care Pharmacy. A. Turchin: Research Support; Self; Sanofi-Aventis. Advisory Panel; Self; Merck Sharp &amp; Dohme Corp., Monarch Medical Technologies. Stock/Shareholder; Self; Brio Systems. Research Support; Self; Eli Lilly and Company.

Separable covariance models for health care quality measures across years and topics.

Public quality reports for Medicare Advantage health plans include 11 measures of patient experiences reported in the annual Consumer Assessment of Healthcare Providers and Systems surveys. Computing summaries at the health plan level (of multiple measures in multiple years) yields an array-structured random variable. To summarize associations among measures and years, we model the variance-covariance matrix governing the plan-level vectors of yearly quality measures as a Kronecker product of an across-measure matrix and an across-year matrix, or a sum of such Kronecker products. This approach extends separable covariance structure to Fay-Herriot models. In addition, we develop linear combinations of Kronecker products similar to principal components for array random variables. To each Kronecker-product term, we apply post hoc analyses suited to the corresponding dimension of the cross-classification: 1-way factor analysis for the across-measure factor and time-series analysis to the across-year factor. These methods draw out key patterns of variation in the quality measures over time and suggest new strategies for reporting quality information to consumers.

Burden of Illness Associated with Tenosynovial Giant Cell Tumors

PurposeLittle is known about the burden of illness in patients with tenosynovial giant cell tumors (TGCT), which are rare, typically benign, lesions of the synovial tissue including giant cell tumor of the tendon sheath (GCT-TS) and pigmented villonodular synovitis (PVNS). The objective of this study was to describe health care resource use and costs for patients with GCT-TS and PVNS, which are rare and typically benign TGCT. MethodsA retrospective cohort study design was used to analyze administrative claims for adult commercial and Medicare Advantage health plan enrollees with evidence of GCT-TS and PVNS from January 1, 2006 through March 31, 2015. Participants were continuously enrolled for 12 months before (pre-index period) and 12 months after (post-index period) the date of the first tenosynovial giant cell tumor (TGCT) claim (index date). Preindex and postindex measures were compared using the McNemar test and Wilcoxon signed-rank test. Results were stratified by TGCT type. FindingsThe study identified 4664 patients with TGCT, 284 with GCT-TS, and 4380 with PVNS. Mean age (GCT-TS group: 50 years; PVNS group: 51 years) and sex distributions (GCT-TS group: 60.2% female; PVNS group: 59.5% female) were similar for each group. Most patients with GCT-TS (78.2%) had at least one postindex surgery, compared with 38.7% of patients with PVNS. Mean total health care costs increased from $8943 in the preindex period to $14,880 in the postindex period (P < 0.001) for GCT-TS and from $13,221 in the preindex period to $17,728 in the postindex period (P < 0.001) for PVNS. Preindex to postindex ambulatory costs increased nearly 120% for patients with GCT-TS ($4340 to $9570, P < 0.001) and 50% for patients with PVNS ($6782 to $10,278, P < 0.001), and physical therapy use increased significantly during the same period (GCT-TS: 18% to 40%, P < 0.001; PVNS: 38% to 60%, P < 0.001). ImplicationsCosts increased substantially 1 year after the first TGCT claim, with more than half the costs covering ambulatory care. These results suggest a high health care burden once TGCT is identified.

Personalized Care and the Role of Insulin as a Vehicle to Optimizing Treatments in Diabetes Care.

In patients with type 2 diabetes (T2D) with poor glycemic control, there is an unmet need for treatment optimization involving the initiation and/or intensification of insulin therapy, which is often delayed because of clinical inertia. Educational initiatives that target patients and physicians might be one way to address this need. To evaluate the effectiveness of educational materials mailed to physicians and their patients in affecting initiation of insulin therapy and other health care outcomes. This study, named PIVOTs (Personalized care and the role of Insulin as a Vehicle to Optimizing Treatments), used integrated medical and pharmacy claims data from the U.S.-based HealthCore Integrated Research Database between January 1, 2006, and April 4, 2014, to identify patients who were potential candidates for insulin therapy. Eligible patients were aged 18-75 years, currently enrolled in a commercial or Medicare Advantage health plan, with T2D diagnosis codes. Patients selected for insulin treatment education had glycated hemoglobin A1c (A1c) > 10%, irrespective of the number of noninsulin antihyperglycemic drugs used, or A1c > 8.0% and ≤ 10% while receiving ≥ 2 noninsulin antihyperglycemic drugs. For each identified patient, a corresponding treating physician was identified on a hierarchical basis. Physician-level randomization was conducted to assign physicians and their linked patients to the following 4 cohorts: (1) a cross-sectional cohort in which educational materials were sent to patients and physicians on a single outreach date; (2) a longitudinal cohort in which educational materials were sent to patients and physicians on 2 occasions, 3 months apart; (3) an enhanced cohort in which patients and physicians received the same mailings as the longitudinal cohort, plus physicians were invited to attend a 1:1 video conference academic detailing session; and (4) a control cohort in which patients and physicians did not receive any educational materials. Insulin initiation rates, A1c levels, and medical and pharmacy costs were assessed from claims over 6 and 12 months follow-up within each cohort. Mean insulin initiation rates at 12 months ranged from 9.2%-10.3% (all patients) to 12.3%-14.9% (subset with baseline A1c ≥ 9.0%), with similar rates across the intervention and control cohorts. Reductions in A1c from baseline were also similar across cohorts for all patients (0.1%-0.6%), as well as for those with a baseline A1c ≥ 9.0% (0.9%-1.6%). Approximately 14%-20% of patients achieved A1c < 7.0%, with no differences across cohorts. Changes in mean total all-cause and diabetes-related health care costs were also similar across cohorts. The findings of this real-world, randomized intervention call into question the value of educational mailings as a means to overcoming clinical inertia and improving health outcomes in patients with T2D, at least in the context of insulin initiation. This study was funded by Sanofi US. Bieszk and Wei are employees of Sanofi US. Grabner, Barron, and Quimbo are employees of HealthCore, which was under contract with Sanofi US for the conduct of this study. Yan is an employee of PHAR, LLC and was employed by HealthCore at the time this study was conducted and completed. Biel is an employee of Anthem. Chu is a consultant for Sanofi US; a member of the lecture bureaus for AstraZeneca, Eli Lilly, and Sanofi US; and has received research funding from Novo Nordisk. Study concept and design were contributed by Bieszk, Grabner, Wei, Quimbo, and Barron. Yan, Barron, Quimbo, and Grabner collected the data, which were interpreted by Biel, Chu, Bieszk, and Wei, with assistance from the other authors. The manuscript was written by Bieszk, with assistance from the other authors, and revised by Bieszk, Grabner, Biel, and Chu, along with the other authors. Part of this work was presented in poster format at the 76th Scientific Sessions of the American Diabetes Association; June 10-14, 2016; New Orleans, Louisiana.

Correlates of second-line type 2 diabetes medication selection in the USA

ObjectivePast research provides insufficient evidence to inform second-line diabetes medication prescribing when metformin is no longer sufficient. We evaluated patient, prescriber, and health plan characteristics associated with selection of second-line...

A Reduction in Physician-Recorded Heart Failure Signs and Symptoms and All-Cause Hospitalizations Following Initiation of Sacubitril/Valsartan Treatment among Patients with Heart Failure and Reduced Ejection Fraction in a Real-World Setting

Introduction: In May 2016, the ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure and reduced ejection fraction (HFrEF; class II-III) included an angiotensin receptor-neprilysin inhibitor, sacubitril/valsartan, to replace angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. The study aimed to support clinical decision making by incorporating real world evidence from HFrEF patients treated with sacubitril/valsartan prior to the release of the Focused Update. Hypothesis: Patients with HFrEF will have a reduction in HF-related signs and symptoms and healthcare resource utilization (HCRU) following sacubitril/valsartan treatment. Methods: A within-subject pre/post initiation study of patients treated with sacubitril/valsartan from 8/1/2015-3/15/2016 was conducted. Patients with a Humana Medicare Advantage or commercial health plan, aged 18–89 years, and 6 months pre-treatment enrollment were included. Claims data were supplemented with chart data. The post-initiation period was 3 months in duration and began after a 4 week titration period. The dose of sacubitril/valsartan was evaluated at initiation and at the end of the post-initiation period. HF-related signs and symptoms were abstracted for the 3-month pre- and 3-month post-initiation periods. Shortness of breath and dyspnea were reported separately by providers but considered jointly as dyspnea descriptively. Two HCRU measures were evaluated: 1) inpatient stays and 2) having one or more emergency department (ED) visits. Changes in symptoms and HCRU were assessed using McNemar's test. Results: Sacubitril/valsartan initiators (n = 200) were 30.5% female, 76.5% white, 18.0% black, with a median [IQR] age of 72 [12], and 96.5% Medicare. The majority of patients, 68.5%, initiated sacubitril/valsartan at 24/26 mg, 30.5% at 49/51 mg and 1.0% at the 97/103 mg dose. The ending dose was 24/26 mg (45.0%), 49/51 mg (37.6%), and 97/103 mg (17.4%) reflecting lower than expected dosing based on the PARADIGM-HF clinical trial (NCT01035255). Fatigue was noted in 51.8% of patients pre- and 39.5% post-initiation, P = .027. Dyspnea was found in 78% of patients pre-initiation. Changes in paired tests of shortness of breath or dyspnea, as documented by the provider, yielded a significant reduction post-initiation, P = .023. Post-initiation, fewer patients had an inpatient stay (27.5% pre-; 17.0% post-initiation; P = .009) or an ED visit (37.5% pre; 30.0% post-initiation; P = .083). Conclusion: Treatment with sacubitril/valsartan was associated with improvement in HF-related symptoms and hospitalizations even at lower than target dosing. Given this, it is possible that additional benefit to some patients may be achieved as treatment aligns more closely with the 2016 guidelines.

LEVERAGING MEDICARE CLAIMS TO CHARACTERIZE DIAGNOSTIC PATHWAYS IN ALZHEIMER’S DISEASE

Real-world, administrative claims data is uniquely suited to help characterize the journey of Alzheimer's disease (AD) patients from the onset of disease symptoms through diagnosis and beyond. The primary aims of this analysis were to: (1) characterize the temporal relationship between diagnostic and treatment codes associated with AD; and (2) explore the pre-diagnostic claims record for the appearance of codes suggestive of AD-related symptoms. Medical and pharmacy claims data from a large, geographically diverse, commercial, US Medicare Advantage health plan, for the period 2009–2014, was used to identify cases of newly diagnosed AD. Beneficiaries with claims for AD-specific diagnostic codes and prescription fills for a medication indicated to treat AD were included in the analysis. Among the 4,039 beneficiaries identified for inclusion in the analysis: 31% received a treatment prior to their first Alzheimer's-specific diagnostic code, 14% received an AD diagnostic code prior to their first treatment; and 23% received their treatment and diagnostic codes within 60 days of one another. Thirty-percent of the diagnosed cohort had multiple diagnostic codes but no evidence of treatment at any time during the 48-month observation period (24 months prior to and after incident diagnosis). Notable gaps between treatment and diagnosis were observed. The median number of days between treatment and diagnosis among those receiving a treatment first was 577; the median number of days between diagnosis and treatment in those receiving a diagnosis first was 397. Sixty-three percent of the combined cohort had an average of 6.1 claims suggestive of AD-related symptoms (e.g. memory loss, mild cognitive impairment) before their incident diagnostic code. These data suggests there is considerable heterogeneity in the AD diagnostic and treatment pathways. While the first appearance of a diagnosis code is commonly used as the index date from which disease related health care use is attributed, measurable care-seeking behavior and therapy associated with AD begins much earlier. Further research is needed to better understand the factors influencing pathway variability and the risks associated with diagnostic and treatment delays.

Second or none: Many patients treated for refractory differentiated thyroid cancer with small molecular kinase inhibitors do not receive a second line of therapy.

e17589 Background: Describe the treatment patterns of patients initiated on NCCN-recommended small molecular kinase inhibitors (SMKIs) for radioiodine-refractory differentiated thyroid cancer (DTC) approved in the United States. Methods: A large national US claims database was used to identify adult patients diagnosed with thyroid cancer (≥2 non-DX medical claims, ≥ 30 days apart) from 1/1/2006 - 6/30/2016 (study period) with claims for SMKIs from 1/1/2010 - 5/31/2016. Continuous enrollment required participation in a commercial or Medicare Advantage health plan ≥3 months before and ≥1 month following index date (date of first pharmacy claim for SMKI). Line of therapy (LOT) periods were defined by receipt and timing of SMKIs. Patient follow up was earliest disenrollment, death or end of the study period. Patient characteristics and SMKI treatment patterns were described. Results: A total of 217 DTC patients were identified; 63% commercially insured and 37% Medicare Advantage. Almost half were male (48%); mean age was 61.2 years (standard deviation SD 12.5 years) and mean follow-up period was 499 days (SD 414 days). In the study period, 35% (n = 77) of patients had ≥2 LOTs and 18% (n = 39) had ≥3 LOTs. Mean treatment duration was 5.4 months (SD 6.7 mos) for LOT1, 4.9 months (SD 3.8 mos) for LOT2, and 4.2 months (SD 4.9 mo) for LOT3. During the full study period, the most used regimens were Sorafenib for both LOT1 (37%) and LOT2 (25%), pazopanib (18%) and sunitinib (18%) in LOT3. Also, in the study period, 33 patients had sorafenib in LOT1 of which 16 were treated with sorafenib again (48%) in LOT2. Post FDA approval in 2015, Lenvatinib became the predominant first-line regimen (47%, n = 29) during study period. Across all first line therapies, for those patients with ≥12 months of follow-up, 53% (n = 60) initiated LOT2. Conclusions: Sorafenib was the most common first line of therapy for DTC, with Lenvatinib adoption increasing as first-line therapy since the drug’s approval in 2015. Depending on the period evaluated, almost half to 2/3 of patients are not receiving a second line of treatment, efficacious and patient appropriate therapy is of importance in treating this rare cancer.

Effect of 2013 ACC/AHA Blood Cholesterol Guidelines on Statin Treatment Patterns and Low-Density Lipoprotein Cholesterol in Atherosclerotic Cardiovascular Disease Patients.

BackgroundPreceding release of the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol guidelines, prescribers aimed for specific low‐density lipoprotein cholesterol (LDL‐C) goals in patients with atherosclerotic cardiovascular disease (ASCVD). The 2013 guidelines changed this focus to treating patients with appropriate statin intensity given their ASCVD risk. We examined statin use and LDL‐C levels before and after the 2013 ACC/AHA guidelines in patients with clinical ASCVD as defined in the guidelines.Methods and ResultsWe conducted a retrospective cohort study of adult commercial and Medicare Advantage health plan enrollees in the Optum Research Database. Patients had ≥1 claim with a diagnosis of clinical ASCVD between November 1, 2012 and December 31, 2014 and were continuously enrolled 6 months before (baseline) and 7 months after (follow‐up) the first ASCVD visit. Patients were assigned to monthly cohorts based on ASCVD event month. Statin use and intensity were measured at baseline and first month of follow‐up. LDL‐C changes were assessed using ordinary least squares regression. For 90 287 patients, mean (SD) age was 68 (12) years; 50% were female; and 30% had commercial insurance. Statin use remained consistent before and after guidelines (32% and 31%, respectively). Of patients receiving statins, high‐intensity use increased by 4 percentage points 1 year after guidelines (P<0.001). Mean LDL‐C levels were 2.4 mmol/L (94 mg/dL) both pre‐ and postguidelines.ConclusionsStatin use and mean monthly LDL‐C before and after the guidelines remained largely unchanged; statin intensity increased modestly. More effort may be needed to increase guideline understanding and adherence to improve treatment of high‐risk patients.

2005 to 2014 CT and MRI Utilization Trends in the Context of a Nondenial Prior Authorization Program.

Purpose:Reducing unnecessary testing may benefit patients, as some computed tomography (CT) and magnetic resonance imaging (MRI) expose patients to contrast, and all CTs expose patients to radiation. This observational study with historical controls assessed shifts in CT and MRI utilization over a 9-year period after a private health insurer’s implementation of a nondenial, consultative prior authorization program.Methods/Materials:Normalized rates of exams per 1000 person-years were plotted over 2005 to 2014 for people with commercial and Medicare Advantage health plans in the San Antonio market, with 2005 utilization set as the baseline. The program was implemented at the start of 2006. Computed tomography and MRI utilization changes were compared with contemporaneous changes in low-tech plain film and ultrasound utilization.Results:Growth in high-tech imaging utilization decelerated or reversed during the period. In 2006, CT utilization dropped to between 76% and 90% of what it had been in 2005, depending on the plan. In 2014, it was between 52% and 88% of its initial level. MRI utilization declined to between 86% and 94% of its initial level in 2006, and then to between 50% and 75% in 2014. Ultrasound utilization was greater in 2014 than in 2005 for some plans. Plain film utilization declined between 2005 and 2014 for all plans.Conclusion:There was an immediate and sustained decline in CT and MRI utilization after the introduction of the program. While many factors may have impacted the long-term trends, the mixed trends in low-tech imaging suggest that a decline in low-tech imaging was not responsible for the decline in CT and MRI utilization.

Differences in Receipt of Three Preventive Health Care Services by Race/Ethnicity in Medicare Advantage Plans: Tracking the Impact of Pay for Performance, 2010 and 2013

IntroductionIn 2012, the Centers for Medicare and Medicaid Services (CMS) introduced the Quality Bonus Payment Demonstration, a pay-for-performance (P4P) program, into Medicare Advantage plans. Previous studies documented racial/ethnic disparities in receipt of care among participants in these plans. The objective of this study was to determine whether P4P incentives have affected these disparities in Medicare Advantage plans.MethodsWe studied 411 Medicare Advantage health plans that participated in the Medicare Health Outcome Survey in 2010 and 2013. Preventive health care was defined as self-reported receipt of health care provider communication or treatment to reduce risk of falling, improve bladder control, and monitor physical activity among individuals reporting these problems. Logistic regression stratified by health care plan was used to examine racial/ethnic disparities in receipt of preventive health care before and after the introduction of the P4P program in 2012.ResultsWe found similar racial/ethnic differences in receipt of preventive health care before and after the introduction of P4P. Blacks and Asians were less likely than whites to receive advice to improve bladder control and more likely to receive advice to reduce risk of falling and improve physical activity. Hispanics were more likely to report receiving advice about all 3 health issues than whites. After the introduction of P4P, the gap decreased between Hispanics and whites for improving bladder control and monitoring physical activity and increased between blacks and whites for monitoring physical activity.ConclusionRacial/ethnic differences in receipt of preventive health care are not always in the expected direction. CMS should consider developing a separate measure of equity in preventive health care services to encourage health plans to reduce gaps among racial/ethnic groups in receiving preventive care services.

Estimated Budget Impact of Increased Use of Mirabegron, A Novel Treatment for Overactive Bladder.

BACKGROUND: Oral pharmacological treatment for overactive bladder (OAB) consists of antimuscarinics and the beta-3 adrenergic agonist mirabegron. Antimuscarinic adverse events (AEs) such as dry mouth, constipation, and blurry vision can result in frequent treatment discontinuation rates, leaving part of the OAB population untreated. Antimuscarinics also contribute to a patient’s anticholinergic cognitive burden (ACB), so the Beers Criteria recommends cautious use of antimuscarinics in elderly patients who take multiple anticholinergic medications or have cognitive impairment. Since mirabegron does not affect the cholinergic pathways, it is unlikely to contribute to a patient’s ACB. OBJECTIVE: To estimate the health care costs associated with the pharmacological treatment of OAB with mirabegron and antimuscarinics from U.S. commercial payer and Medicare Advantage perspectives, using a budget impact model. METHODS: For this budget impact model, 2 analyses were performed. The primary analysis estimated the b...

Incidence and Early Outcomes of Heart Failure in Commercially Insured and Medicare Advantage Patients, 2006 to 2014.

Heart failure (HF) affects >5.7 million individuals in the United States1 with 870 000 individuals newly diagnosed each year.2 Previous epidemiological studies have demonstrated that the incidence of HF varies by race and ethnicity, with the highest incidence in blacks.3–5 However, this association is partially mediated by differences in socioeconomic factors,3 such as access to care, and whether differences extend to commercially insured populations requires examination. Furthermore, although the incidence of HF is known to increase with age,6,7 younger individuals with HF remain understudied because several large epidemiological cohorts8 and claims-based studies6 are restricted to older individuals. Our goal was to address these gaps in knowledge by leveraging a large US insurance claims database, containing information from >100 million individuals enrolled in private and Medicare Advantage health plans. The objectives of this study were to evaluate the incidence of HF by age, sex, and race/ethnicity and to examine differences in the rate of hospitalizations and office visits in the year after diagnosis. ### Data Source We conducted a retrospective analysis using the OptumLabs Data Warehouse, a large US commercial insurance database.9 The database comprises medical claims for individuals in all 50 states and of all ages and ethnic and racial groups.10 Medical claims include claims for professional (eg, physician), facility (eg, hospital), and outpatient prescription medication services. Pursuant to the Health Insurance Portability and Accountability Act, the use of de-identified data does not require Institutional Review Board approval. ### Study Population We included adult enrollees for whom a diagnosis of HF ( International Classification of Diseases, Ninth Revision, Clinical Modification codes 428.XX, 402.X1, 404.X1, or 404.X36 appeared on a single inpatient claim between January 1, 2006 and April 1, 2014. We also included individuals with an HF diagnosis on at least 3 physician or …

Screening Mammography for Free: Impact of Eliminating Cost Sharing on Cancer Screening Rates.

To study the impact of eliminating cost sharing for screening mammography on mammography rates in a large Medicare Advantage (MA) health plan which in 2010 eliminated cost sharing in anticipation of the Affordable Care Act mandate. Large MA health maintenance organization offering individual-subscriber MA insurance and employer-supplemented group MA insurance. We investigated the impact on breast cancer screening of a policy that eliminated a $20 copayment for screening mammography in 2010 among 53,188 women continuously enrolled from 2007 to 2012 in an individual-subscriber MA plan, compared with 42,473 women with employer-supplemented group MA insurance in the same health maintenance organization who had full screening coverage during this period. We used differences-in-differences analysis to study the impact of cost-sharing elimination on mammography rates. Annual screening rates declined over time for both groups, with similar trends pre-2010 and a slower decline after 2010 among women whose copayments were eliminated. Among women aged 65-74years in the individual-subscriber MA plan, 44.9 percent received screening in 2009 compared with 40.9 percent in 2012, while 49.5 percent of women in the employer-supplemented MA plan received screening in 2009 compared with 44.1 percent in 2012, that is, a difference-in-difference effect of 1.4 percentage points less decline in screening among women experiencing the cost-sharing elimination. Effects were concentrated among women without recent screening. There were no differences by neighborhood socioeconomic status or race/ethnicity. Eliminating cost sharing for screening mammography was associated with modesty lower decline in screening rates among women with previously low screening adherence.

Primary Nonadherence, Associated Clinical Outcomes, and Health Care Resource Use Among Patients with Rheumatoid Arthritis Prescribed Treatment with Injectable Biologic Disease-Modifying Antirheumatic Drugs.

Adherence to biologic disease-modifying antirheumatic drugs (bDMARDs) among patients with rheumatoid arthritis (RA) is often suboptimal in routine clinical practice. Low or nonadherence can reduce the effectiveness of bDMARD therapies. To evaluate filling of newly prescribed initial bDMARDs for the treatment of RA and evaluate potential for characterizing treatment decisions and patient outcomes. In this retrospective cohort analysis, patients aged ≥ 18 years with an RA diagnosis (ICD-9-CM code 714.xx) were selected from a de-identified database of clinical information from the Electronic Health Record (EHR; Humedica) database linked to health care claims (Optum) from commercial and Medicare Advantage health plans (2007-2013). The first biologic prescription date in EHR was the index date. Patients were categorized as filling the prescription within 30 days (early fillers), 31-180 days (late fillers), or not at all within 180 days (nonfillers) of index date. Of 373 patients meeting inclusion criteria, 170 (45.6%), 59 (15.8%), and 144 (38.6%) were categorized as early fillers, late fillers, and nonfillers, respectively. Most prescriptions were written or ordered for tumor necrosis factor inhibitors (88.7%). Compared with late and nonfillers, early fillers were younger and more likely to be female, with higher pain scores (among those reporting pain scores) and RA severity scores pre-index, and filled more prescriptions for any reason pre-index. More nonfillers (66.0%) were Medicare patients than early (17.7%) and late (35.6%) fillers. During days 0-30 post-index, conventional synthetic DMARD use was greatest for early fillers (45.9%) and lowest among nonfillers (24.3%); however, during days 31-180 post-index, the proportion was highest for late fillers (61.0%) and lowest for nonfillers (35.4%). Of early fillers, 12.9% did not fill/receive a bDMARD after 30 days. Only 23 patients had pre/post-index pain scores, and 47 patients had a rationale for stopping or not filling a bDMARD. In patients with pharmacy and medical coverage for 180 days post-index, early fillers had greater RA-related pharmacy and medical resource use and costs than late and nonfillers combined. These findings confirm a high rate of primary nonadherence to bDMARDs among patients with RA.