Payer Claims Research Articles

Anti-Osteoporotic Treatment Reduces Risk of Revision Following Total Shoulder Arthroplasty in Patients with Osteoporosis

Osteoporosis, a prevalent bone density disorder, introduces a complex dynamic in the context of total shoulder arthroplasty (TSA). However, despite the well-established association between osteoporosis and an elevated risk of revision, the existing literature lacks comprehensive insights into the impact of anti-osteoporotic therapy on surgical outcomes in the setting of TSA. Thus, the purpose of this study was to investigate whether anti-osteoporotic therapy correlates with improved revision outcomes following TSA. A retrospective cohort analysis was performed using a national all payer's claims database. Patients who underwent TSA were identified using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) procedure codes. Patients with a preoperative diagnosis of osteoporosis were included, then stratified into two groups: (1) patients with osteoporosis who underwent anti-osteoporotic therapy within 6 months prior to surgery (Anti-OP cohort) and (2) patients with osteoporosis who never received anti-osteoporotic treatment (No Anti-OP cohort). Primary outcomes included the incidence of 2-year all-cause revision, periprosthetic fracture (PPF), periprosthetic joint infection (PJI), and mechanical loosening. Univariate and multivariable regression analysis was conducted to compare outcomes between the two cohorts. In total, 40,532 osteoporotic patients were included in this study, with 11,577 (28.5%) having undergone anti-osteoporotic treatment. Patients who did not receive anti-osteoporotic treatment had significantly higher odds of 2-year all-cause revision (Odds Ratio [OR]: 1.31; P < 0.001) and mechanical loosening (OR: 1.25; P < 0.001) following TSA when compared to those treated for osteoporosis. This study demonstrates a significant association between anti-osteoporotic therapy and reduced rates of 2-year revision following TSA. Orthopedic surgeons should recognize the heightened risk of early implant failure in the absence of osteoporosis therapy. This underscores the imperative for increased screening initiatives given the high prevalence of undiagnosed or untreated osteoporosis in the TSA population. These results also emphasize the importance of integrating osteoporosis management strategies into the broader context of surgical decision-making, thereby contributing to enhanced patient outcomes and quality of care in shoulder surgery.

Safe, Social, and Engaged: Clinician perspectives on good institution‐free days for people with dementia

AbstractBackgroundComposite measures of survival and residence, such as institution‐free days (IFDs), encompass many patient and family priorities and are readily measured using payer claims or electronic health record data. However, knowledge gaps limit their application to studies of people with dementia (PWD). First, PWD, family care partners, and clinician perspectives on survival‐residence composite outcomes are unknown. Second, approaches to measuring IFDs consider all institution days equally poor and all home days equally well, which may be inconsistent with stakeholder assessments.MethodWe conducted a qualitative study to explore stakeholders’ perspectives on what makes a “good day” for a PWD. This included semi‐structured interviews with clinicians who provide care to PWD. Clinicians were also asked for their opinions regarding the use of survival‐residence composite outcomes in dementia research. Interviews were audio‐recorded and professionally transcribed. De‐identified transcripts were reviewed by the research team independently and during weekly consensus meetings to identify relevant themes.ResultThematic saturation was reached after 24 interviews. Nearly half of clinicians also had personal experience as a care partner of a PWD. Participant characteristics are summarized in Table 1. Salient themes were identified and grouped into 2 major categories: (1) attributes of quality of days for PWD, and (2) impressions of survival‐residence composite outcomes (Table 2). Key attributes of quality of days were safety, socialization and engagement, and neuropsychiatric distress. These qualities were more important in defining “home” than type of residence (Figure). Clinicians appreciated that a survival‐residence composite outcome, such as IFDs, could capture the important aspects of “aging in place” and avoiding burdensome hospitalizations. They also noted a desire for such a measure to capture the quality of those days. Concerns were raised over how differential access to home‐based services due to socioeconomic factors would influence patient accrual of IFDs and whether such a measure might also increase existing stigma around institutions.ConclusionFuture work will integrate these findings with the perspectives of PWD and their family care partners as well as further explore the relative values of these attributes of a survival‐residence composite outcome for studies of patients with ADRD.

EPH62 Annual Burden of Non-COVID-19 Respiratory Tract Infections in the Pre- to Post- Pandemic Eras: Analysis from the Anlitiks’ All Payor Claims Database

The current study aims to shed light on the overall burden of patients with RTIs in the pre- to post-COVID pandemic eras in the US. A retrospective, administrative claims database, cross-sectional analysis is underway using the open-source Anlitiks’ All Payer Claims (AAPC) database. Total burden of RTIs [ICD-9/10= 465.8x, 465.9x, J06.9 (LRTI); and J22 (URTI)], including annual incidence and prevalence rates, will be ascertained among adults aged ≥18 years with inpatient or outpatient claims for non-COVID RTIs, including all upper and respiratory infections from 01/11/2016 to 12/31/2021. The denominator population will consist of all eligible patients within each respective year of study. Annual impact of health resource utilization will also be investigated. All analyses will be conducted using our RapidAnalyzer ecosystem, based on SQL and R analytic platforms. Preliminary results demonstrate the following number of patients with infections in 2016, 2017, 2018, 2019, 2020, 2021 and 2022 (through September, 2022): 11,929,725, 13,650,181, 13,635,828, 13,295,812, 9,032,305, 10,188,512 and 6,001,566, respectively. Prevalence and incidence of rates of RTIs will be addressed using proportions and person-years. Though overall rates of non-COVID RTIs may have decreased, it is unclear if lower rates of testing for non-COVID RTIs, and consequently under-diagnosis of other RTIs may have occurred in the post-pandemic era. Results from this analysis will contribute to the growing body of understanding the prevalence of RTIs over time, utilizing the APCD and RapidAnalyzer platform.

PC27. Understanding Factors Associated with Paid Malpractice Claims in Plastic Surgery

PURPOSE: Few studies have investigated malpractice broadly in the field of plastic surgery. The purpose of this analysis was to characterize plastic surgery malpractice cases and examine factors influencing malpractice case outcomes, thereby identifying areas of patient safety concern. METHODS: The Candello database, which catalogs approximately 30% of all paid and unpaid malpractice claims in the United States, was utilized to obtain cases involving plastic surgery closed between 2009 and 2018. A total of 2674 cases were identified. A multivariable regression model was developed to analyze factors associated with a malpractice case closing with indemnity payment. RESULTS: A total of 716 (26.8%) of claims resulted in an indemnity payment. The clinical severity was determined to be high in 229 cases (8.6%). Emotional trauma (n=558, 20.9%) was the most frequently cited injury category. Major differences between procedure groups were not observed, with consistent severity of injury across categories. Poor surgical technique, problems with communication among providers, inadequate informed consent, and deficient documentation were significant factors predictive of malpractice cases closing with payment. Issues with technical performance resulting in a known complication and patient factors were protective against paid claims. CONCLUSION: Overall, both the financial and clinical severity of malpractice claims in plastic surgery were relatively low. Multiple factors were found to be associated with a case closing with an indemnity payment. Taken together, these data highlight the importance of the informed consent process and managing expectations in the clinical care of surgical patients.

Artificial Neural Network for Classifying Financial Performance in Jordanian Insurance Sector

Over the past few decades, financial performance has attracted researchers’ attention, especially in the insurance sector. Insurance is a tool for the growth and sustainability of both rising and developing economies. It promotes economic stability for people, organizations, and governments by taking on risk and spreading it across the market. We intend to classify insurance companies’ financial performance in Jordan’s Amman Stock Exchange (ASE). The sample size is 15 out of 22 selected insurance firms from 2008 to 2020. We apply the Multi-Layer Perceptron (MLP) model for the detection of (high/low) total asset turnover (TAT) as output, while we select the subrogation (SB), claims paid (CP), market capitalization (MC), and total shareholders’ equity (SE) as input to the MLP model. The performance of the MLP model is evaluated using different criteria, namely the false positive rate (FP rate), false negative rate (FN rate), F-measure, precision, and accuracy (ACC). The results show that MLP is efficient and performs well in multiple criterion tests through iteration growth. Based on our knowledge, the paper assesses the financial performance of Jordanian insurance firms, which has not been investigated previously. Furthermore, this study gives valuable information to regulators and policymakers to improve asset management efficiency in the insurance sector.

Diagnoses, treatment, and utilization changes in oncology patients before and during COVID-19.

e18779 Background: COVID-19 has had an unprecedented impact on the healthcare system. During the pandemic, cancer patients experienced delayed diagnoses, interruptions in care and suboptimal care. This study aimed to understand the impact of COVID-19 on breast, lung, colon and prostate cancer patients’ diagnoses, treatment and utilization during the pandemic. Methods: This is a retrospective cohort study of breast, lung, colon and prostate cancer patients insured by a large Commercial and Medicare health plan in the United States. To assess the impact of COVID-19 on newly diagnosed treatment and utilization rates, we compareda pre-COVID period (March 1 to December 31, 2019) to a COVID period (March 1 to December 31, 2020) to assess how COVID-19 impacted diagnoses and treatment. We defined a new cancer diagnosis as a patient with medical insurance but no paid claim for cancer for at least six months before the initial claim with a cancer diagnosis. We utilized both medical and pharmacy claims to identify utilization patterns. The newly diagnosed rate and cancer diagnosis claims were normalized by total membership in the given year by line of business. Results: This study included 113,795 patients in 2019 and 112,837 patients in 2020. The newly diagnosed rate decreased by 4% (2.2 to 2.1 per 1000 patients) (p = 0.0014) for Commercial and 3% (16.2 to 15.8 per 1000 patients) (p &lt; 0.001) for Medicare patients. Patients with infused chemotherapy treatments, among patients with cancer diagnoses, increased by 4% (9.6% to 10%) (p = 0.02) for Medicare patients but not for Commercial patients. Among patients with infused treatments, there were no significant changes in average number of infusions per patient for Commercial and Medicare patients (all p &gt; 0.05). In 2020, there was a 2% decrease in infused treatments in the hospital setting (52% to 50%; p &lt; 0.01) for Medicare patients; it remained stable for Commercial patients. There was also a switch from infused drugs to oral drugs for Commercial (2.4%, p &lt; 0.001) and Medicare patients (2.0%, p &lt; 0.001). From March to May 2020, there was a 31-35% decrease (p &lt; 0.001) in new cancer diagnoses for Commercial and Medicare patients with a rebound in the last six months of 2020. There was an 18-21% decrease (p &lt; 0.001) in the percentage of existing cancer patients with cancer claims during this time, reflecting a decrease in utilization. Conclusions: During the COVID-19 pandemic, we observed significant decreases in cancer diagnoses and utilization rates among new and existing Commercial and Medicare patients; however, chemotherapy treatments increased for Medicare patients during this time. We observed site of care changes in patients undergoing infused treatments. While new cancer diagnoses and utilization rates declined during the pandemic’s height, both rates quickly rebounded in the last months of 2020. As the COVID-19 pandemic continues to evolve, care for patients with cancer will need to evolve as well.

The Transforming Outcomes for Patients Through Medical Home Evaluation and reDesign (TOPMED) Cluster Randomized Controlled Trial: Cost and Utilization Results.

Primary Care Medical Home (PCMH) redesign efforts are intended to enhance primary care's ability to improve population health and well-being. PCMH transformation that is focused on "high-value elements" (HVEs) for cost and utilization may improve effectiveness. The objective of this study was to determine if a focus on achieving HVEs extracted from successful primary care transformation models would reduce cost and utilization as compared with a focus on achieving PCMH quality improvement goals. A stratified, cluster randomized controlled trial with 2 arms. All practices received equal financial incentives, health information technology support, and in-person practice facilitation. Analyses consisted of multivariable modeling, adjusting for the cluster, with difference-in-difference results. Eight primary care clinics that were engaged in PCMH reform. We examined: (1) total claims payments; (2) emergency department (ED) visits; and (3) hospitalizations among patients during baseline and intervention years. In total, 16,099 patients met the inclusion criteria. Intervention clinics had significantly lower baseline ED visits (P=0.02) and claims paid (P=0.01). Difference-in-difference showed a decrease in ED visits greater in control than intervention (ED per 1000 patients: +56; 95% confidence interval: +96, +15) with a trend towards decreased hospitalizations in intervention (-15; 95% confidence interval: -52, +21). Costs were not different. In modeling monthly outcome means, the generalized linear mixed model showed significant differences for hospitalizations during the intervention year (P=0.03). The trial had a trend of decreasing hospitalizations, increased ED visits, and no change in costs in the HVE versus quality improvement arms.

Length of Stay in Pediatric Neurology Hospital Admissions.

To describe inpatient length of stay patterns, identify key drivers related to prolonged length of stay, and evaluate the relationship between length of stay and readmission in pediatric neurology. This was a retrospective review of patients <19 years old admitted with a principal neurologic diagnosis to our hospital between January 2017 and July 2019. Scheduled admissions and hospital admissions lasting >30 days were excluded from analysis. Length of stay was obtained in addition to demographic characteristics, principal discharge diagnosis, multispecialty care, use of multiple antiseizure medications, inpatient hospital costs (ie, claims paid), and pediatric intensive care unit (ICU) admission for unplanned admissions and 7- and 30-day readmissions. There were a total of 1579 unplanned admissions. The most common reasons for admission were seizure (n = 942), headache (n = 161), other neurologic diagnosis (n = 121), and psychiatric disorders/functional neurologic disorder (n = 60). Children admitted to the hospital for a neurologic condition have an average length of stay of 2.8±5.0 days for unplanned admissions, 4.5±7.4 days for 7-day readmissions, and 5.2±7.5 days for 30-day readmissions. Average inpatient hospital costs were $44 075±56 976 for unplanned admissions, $60 361±71 427 for 7-day readmissions, and $55 434±56 442 for 30-day readmissions. Prolonged length of stay and increased hospital costs were associated with pediatric ICU admission, multispecialty care, 7- and 30-day readmission, multiple antiseizure medications, and psychiatric disorders / functional neurologic disorders. Pediatric ICU admission, multispecialty care, readmission, multiple antiseizure medications, and psychiatric disorder / functional neurologic disorder prolong length of stay and increase hospital costs.

Are Your Services Profitable?

Physicians are up against complex payer policies and claims edits, health plans shifting financial burden to patients, and increasing costs of providing health care services. To keep their practices profitable, physicians need to be aware of areas where the profitability of providing services may be diminished.

Site of service trend and chemotherapy costs of commercial insured patients in 2020 compared to 2014.

e18858 Background: Over the past decade, chemotherapy site of service has shifted from the physician’s office setting to the hospital outpatient setting. This trend has led to a concern that cancer care costs increase when patients are administered chemotherapy in the hospital outpatient setting (H) compared to a physician’s outpatient office setting (O). In 2014, we published data on the impact of site of service and chemotherapy costs. The purpose of this study is to evaluate the site of service trend and cost differential in a Commercial Insured (CI) population over time. Methods: We examined (CI) claims paid for chemotherapy by a large national payor from February 2019 through January 2020 for breast, colon, and lung cancer (BCL) patients. We then compared these changes to our July 2013 through June 2014 chemotherapy paid claims for BCL patients. Results: From February 2019 through January 2020, paid chemotherapy claims for approximately 23,000 unique patients with BCL had an increase of 23% from 2014. For all patients receiving chemotherapy with BCL, 56% received chemotherapy in the H setting and 44% received chemotherapy in the O setting. This was a significant shift from 2014 where 24% received chemotherapy in H and 76% in O settings. In 2020, the chemotherapy allowable reimbursement share was 67% for H and 33% in the O, a change from 2014 where the chemotherapy allowable reimbursement share was 34% in H and 66% in O. The overall cost per patient increased 57% from 2014 to 2020. When examining costs per patient by site of service, there was a statistically significant increase in H costs from $35,460 to $45,273 (p &lt; 0.0001) per patient and a statistically significant increase in O costs from $21,577 to $28,270 (p &lt; 0.0001) per patient treated in 2014 compared to 2020. Conclusions: In this study, the majority of BCL patients received chemotherapy in the H; this trend has led to substantially higher costs of care for patients treated with chemotherapy in the H compared to the O. Future studies are needed to determine the impact of clinical characteristics, genetic factors and treatment choice on these differences.

Crop insurance in India: Status of PMFBY against different crop insurance schemes

Crop insurance has been implemented in the country since 1972, yet it has been beset with several problems such as delayed payment of claims, high premium, lack of transparency and delay in conducting crop cutting experiments etc. From these schemes none of them has been able to make a significant impact on farming system; as just 23.50 per cent of farmers were insured in kharif 2016. The existing relief and compensation criteria for farmers against crop loss was adhoc, messy and politicized and was ineffective to bring well-timed and satisfactory relief to affected farmers. This research article examines the cumulative performance of different crop insurance schemes implemented time to time. The claim premium ratio in First Individual Approach Scheme was 8.34, indicating that for every one rupee of premium collected; the scheme paid Rs 8.34 in claims. It shows high out go in the scheme. The benefits of CCIS were highly twisted towards few states and many more failures found in these schemes. Under PMFBY from kharif 2016 to kharif 2017, there has been a significant increase in the number of gross premiums (21 %), claims paid (64 %) and farmers benefitted (29%), respectively. The difference between gross premium and claim paid in the Kharif season has abridged and indicated a divergence in the data on the payout of claims and the profits made by private insurance companies. The new scheme revealed that overall area insured and farmers covered were decreased over the years from Kharif 2016 to Kharif 2018. On the other hand, there has been a significant increase in the number of gross premiums as 45 per cent. The PMFBY has therefore failed to achieve the targets, i.e. increasing the area and the number of farmers insured. The exclusion under the scheme are-risks and losses arising out of war and nuclear risks, malicious damage, theft, grazed and destroyed by domestic and wild animals.

Primary care for new vs established Medicaid enrollees.

To understand changes in primary care (PC) utilization in Medicaid and the Children's Health Insurance Program (CHIP) 3 years after the Affordable Care Act (ACA). Secondary data analysis using Medicaid/CHIP paid claims and managed care encounters. Pre-/post-ACA trends in total enrollment and PC visits among newly enrolled and established patients were analyzed in half-year increments from the first half of 2012 to the second half of 2016. After ACA expansion, there was a temporary surge in new Medicaid/CHIP enrollment (which included surges in pre-ACA eligibility categories) and slow, steady growth in total enrollment. The percentage of new enrollees completing a PC visit within 90, 180, and 365 days of enrollment fell markedly in the first half of 2014 and then rebounded to pre-ACA levels thereafter. Conversely, the percentage of new enrollees remaining enrolled at 90, 180, and 365 days spiked upward in the first half of 2014 and gradually fell thereafter. Among established enrollees, PC visits per person exhibited a downward trend throughout the post-ACA period, driven mostly by a decline in the percentage of individuals with any PC visits. The first 6 months of ACA implementation in New Jersey were marked by a surge in Medicaid/CHIP enrollment that extended beyond the ACA target population, greater enrollment retention, and apparent bottlenecks in PC delivery. After the initial surge, new enrollees used PC at rates at least as high as in the pre-ACA period, whereas established enrollees used PC at a declining rate throughout the post-ACA period. PC delivery for new enrollees may have limited the availability of services for some established enrollees.

Financial performance of Slovak insurance companies. Covid-19 consequences

Research background: Globalization trends are manifested at many levels as key phenomena of current business in the international environment. The development of international cooperation, interconnection of economies and emergence of multinational companies enable companies to increase their efficiency and performance, strengthen their position in the global market, which makes them resilient to global risks and increases investors’ return on investment. Currently, the COVID-19 pandemic with its related side effects present significant global risks that have affected strong financial companies, insurance companies included. Risk-insuring insurers face several challenges in this regard in terms of fulfillment of contractual obligations towards clients on the one hand, and the need to ensure the required financial performance and return on invested resources for the owners on the other. Purpose of the article: The aim of the paper is to identify and quantify the impact of the COVID-19 pandemic and related measures and consequences on the financial situation of insurance companies with the seat in Slovakia. Methods: The financial performance of insurance companies will be quantified for the years 2016-2020 through selected indicators of financial analysis that are used by Standard &amp; Poor’s. Significance of differences will be detected through the Wilcoxon Two-Related-Samples Test. The sample of entities includes all insurance companies seated in Slovakia. Findings &amp; Value added: The basic characteristics of the Slovak insurance market within the period 2019-2020 indicate a decrease in value of gross written premiums (-2.47%), insurance claims and benefits (-12.3%) and an increase of the reinsurer’s share of written premiums (2.17%) and of claims paid (22.54%).

Small-Area Variation in the Care of Low-Risk Neonates in Massachusetts and Texas

The success of neonatal intensive care in improving outcomes for critically ill neonates led to rapid growth of NICU use in the United States, despite a relatively stable birth cohort. Less is known about NICU use among late-preterm and term infants, although recent studies have observed wide variation in their care patterns. In this study, we measure special care days (SCDs) (intermediate or intensive), length of stay, and readmission rates among low-risk neonates across regions within 2 states. In this retrospective cohort study, we analyzed data from Massachusetts (all payer claims) and Texas (BlueCross BlueShield) from 2009 to 2012. A low-risk cohort was defined by identifying newborns with diagnostic codes indicating a gestational age ≥35 weeks and birth weight ≥1500 g and excluding infants with diagnoses and procedures generally necessitating nonroutine care. Outcomes were measured across neonatal intensive care regions by diagnosis and payer type. We identified 255 311 low-risk newborns. SCD use varied nearly sixfold across neonatal intensive care regions. Use was highest among commercially insured Texas infants (8.42 per 100), followed by Medicaid-insured Massachusetts infants (6.67 per 100) and commercially insured Massachusetts infants (5.15 per 100). Coefficients of variation indicated high variation within each payer-specific cohort and moderate to high variation across each condition. No consistent relationship between regional SCD use and 30-day readmissions was identified. Use of NICU services varied widely across regions in this cohort of low-risk infants. Further investigation is needed to delineate outcomes associated with patterns of care received by this population.

Medical Malpractice and Physician Discipline: The Good, The Bad and The Ugly

We study the overlap between the medical malpractice (“med mal”) and medical disciplinary systems, using the records of Illinois physicians who held an active license at any point from 1990-2012. We quantify the specialty-specific risk of having a paid med mal claim or a disciplinary action; how many physicians have both; and the extent to which physicians with 2+ paid claims or 2+ disciplinary actions account for a disproportionate share of the activity of both systems. We also examine which factors are associated with paid claims and disciplinary actions, and whether physicians with multiple paid claims or disciplinary actions are concentrated at particular hospitals. Physicians with 2+ paid claims account for 2.6% of all licensed physicians, 54% of paid claims and 52% of payouts. Physicians with 2+ disciplinary actions account for 0.5% of physicians and 38% of all disciplinary actions. The risk of paid claims and disciplinary actions varies greatly by specialty. Physicians who attended non-U.S. medical schools are more likely to have paid claims but (except for high-disciplinary risk specialties) are not more likely to be subject to disciplinary action. Physicians with prior paid claims are more likely to be the target of disciplinary action – but not vice versa. A small number of Illinois hospitals are staffed by physicians with unusually high numbers of paid med mal claims, disciplinary actions, or both.

Real-World Assessment of Health Care Costs for Patients with Metastatic Pancreatic Cancer Following Initiation of First-Line Chemotherapy.

Management of metastatic pancreatic ductal adenocarcinoma (mPDA) places a significant financial burden on the U.S. health care system because of such factors as treatment with multidrug chemotherapy regimens, management of chemotherapy-related adverse events, and disease- or treatment-related hospitalizations. Depending on functional status, first-line chemotherapy regimens that are guideline recommended include nab-paclitaxel with gemcitabine (AG) and FOLFIRINOX (FFX), the combination of fluorouracil, leucovorin, irinotecan, and oxaliplatin. However, few previous studies have examined overall health care costs associated with mPDA management. To describe health care costs following initiation of first-line treatment with AG or FFX among patients with mPDA. Retrospective cohorts of first-line AG and FFX initiators were constructed from the MarketScan database (2014-2017). The index date was the date of first-line AG or FFX initiation. Included patients had insurance enrollment for 6 months before the index date. Total cumulative health care costs and costs from outpatient services, inpatient admissions, emergency department visits, chemotherapy administrations, and pharmacy dispensing were assessed within 12 months after the index date (i.e., 0-1, 0-2, …, 0-12 months). Patient-level cost data began accruing from the first paid claim and continued accruing until the censoring date. A total of 2,199 patients with mPDA initiated first-line AG (n = 1,352) or FFX (n = 847). Compared with AG initiators, FFX patients were younger (mean age 59 vs. 63 years) and had better baseline health status, with fewer having diabetes (43% vs. 57%) or coronary artery disease (12% vs. 22%). Median follow-up was 5.4 and 7.2 months for AG and FFX, respectively. Median first-line treatment duration was 2.1 months with AG and 2.3 months with FFX. Six months following first-line treatment initiation, total cumulative health care costs (median) were $85,714 (95% CI = $79,683-$91,788) and $114,116 (95% CI = $105,816-$119,591) for AG and FFX initiators, respectively. Outpatient services contributed the largest fractional cost for both groups. Total health care costs for patients with mPDA who initiated FFX or AG are driven mostly by outpatient rather than inpatient costs. Further research, using comparative methodology, is warranted to fully understand cost drivers and whether higher costs for FFX patients relate primarily to use of FFX or higher underlying use of outpatient care among FFX patients. This study was funded by Halozyme Therapeutics. Oestreicher and Yeganegi were employees of Halozyme Therapeutics at the time of the study and were involved in study design, data interpretation, and the decision to submit the data for publication. Bullock reports advisory board fees from Eisai, Exelixis, Bayer, and Taiho and consulting fees from Halozyme Therapeutics, outside the submitted work. Rowan reports consulting fees from Halozyme Therapeutics, during the conduct of the study. Chiorean reports grants and consulting fees from Celgene and Halozyme Therapeutics; grants from Lilly, Stemline, Ignyta, Roche, Merck, Boehringer-Ingelheim, Bristol Meyer Squibb, Incyte, Macrogenics, Rafael, and AADi; and consulting fees from Astra Zeneca, Array, Eisai, Ipsen, Five Prime Therapeutics, Seattle Genetics, Vicus, and Legend, outside the submitted work.

Real-World Evidence for Chronic Lymphocytic Leukemia in the Era of Targeted Therapies.

The landscape of chronic lymphocytic leukemia has transformed in the era of small molecule inhibitor targeted therapies. While randomized controlled trials remain the criterion standard in evaluating new therapies, they are often unable to keep pace with the clinical questions that arise during the use of novel agents. Real-world evidence is generated through analysis of data such as electronic medical records, payer claims, and patient registry databases and can provide invaluable information to supplement randomized controlled trials, such as outcomes in patient populations excluded from clinical trials, rates of discontinuation or dose reductions in clinical practice, survival outcomes, and optimal sequencing of novel agents. This review aims to discuss major findings from recent, relevant, real-world evidence publications that have greatly informed our understanding of chronic lymphocytic leukemia as it is treated in clinical practice.

Participation in an innovative patient support program reduces prescription abandonment for adalimumab-treated patients in a commercial population.

PurposeNonadherence to indicated therapy reduces treatment effectiveness and may increase cost of care. HUMIRA Complete, a Patient Support Program (PSP), aims to reduce nonadherence in patients prescribed adalimumab (ADA). The objective of this study was to assess the relationship between participation in the PSP and prescription abandonment rates among ADA-treated patients.Patients and methodsThis longitudinal study using patient-level data from AbbVie’s PSP linked with medical and pharmacy claims data included patients ≥18 years with an ADA-approved indication, ≥1 pharmacy claim for ADA, and available data ≥3 months before and ≥6 months after the index date (defined as the initial ADA claim [01/2015 to 02/2017]). Abandonment was defined as reversal of initial ADA prescription with no paid claim during 3-month follow-up. Abandonment rates were compared between PSP and non-PSP cohorts using multivariable logistic regression controlling for potentially confounding baseline characteristics.ResultsIn 17,371 patients (9,851 PSP; 7,520 non-PSP), the overall abandonment rate was 10.8–16.8% across indications. The odds of ADA abandonment were 70% less for PSP vs non-PSP patients (5.6% vs 20.4%, odds ratio [OR]=0.30, [95% confidence interval (CI)=0.27–0.33] P<0.001), 38% less for patients using specialty vs retail pharmacy (OR=0.62, 95% CI=0.56–0.69, P<0.001), 20% less for those with income of $50–99K vs $0–49K (OR=0.80, 95% CI=0.69–0.92, P<0.01), and 78% greater for those with copayment of $26–100 vs $0–25 (OR=1.78, 95% CI=1.55–2.05, P<0.001).ConclusionParticipation in the PSP, higher income, and using a specialty pharmacy were associated with lower odds of abandoning ADA therapy, whereas increased copayments were associated with greater abandonment. PSPs should be considered to improve initiation of ADA therapy.

Changes in Practice among Physicians with Malpractice Claims

BackgroundPhysicians with poor malpractice liability records may pose a risk to patient safety. There are long-standing concerns that such physicians tend to relocate for a fresh start, but little is known about whether, how, and where they continue to practice.MethodsWe linked an extract of the National Practitioner Data Bank to the Medicare Data on Provider Practice and Specialty data set to create a national cohort of physicians 35 to 65 years of age who practiced during the period from 2008 through 2015. We analyzed associations between the number of paid malpractice claims that physicians accrued and exits from medical practice, changes in clinical volume, geographic relocation, and change in practice-group size.ResultsThe cohort consisted of 480,894 physicians who had 68,956 paid claims from 2003 through 2015. A total of 89.0% of the physicians had no claims, 8.8% had 1 claim, and the remaining 2.3% had 2 or more claims and accounted for 38.9% of all claims. The number of claims was positively associated with the odds of leaving the practice of medicine (odds ratio for 1 claim vs. no claims, 1.09; 95% confidence interval [CI], 1.06 to 1.11; odds ratio for ≥5 claims, 1.45; 95% CI, 1.20 to 1.74). The number of claims was not associated with geographic relocation but was positively associated with shifts into smaller practice settings. For example, physicians with 5 or more claims had more than twice the odds of moving into solo practice than physicians with no claims (odds ratio, 2.39; 95% CI, 1.79 to 3.20).ConclusionsPhysicians with multiple malpractice claims were no more likely to relocate geographically than those with no claims, but they were more likely to stop practicing medicine or switch to smaller practice settings. (Funded by SUMIT Insurance and the Australian Research Council.)

Follow-up Care Vital to Keeping Survivors of Opioid Overdose Alive

Back to table of contents Previous article Next article Professional NewsFull AccessFollow-up Care Vital to Keeping Survivors of Opioid Overdose AliveJoAnn BlakeJoAnn BlakeSearch for more papers by this authorPublished Online:8 Dec 2017https://doi.org/10.1176/appi.pn.2017.12a8Patients who survive opioid overdose are at high risk of death and should be offered counseling, buprenorphine, and follow-up care prior to discharge, said an emergency department physician at the annual meeting of the American College of Emergency Physicians (ACEP). The results of an online survey of 1,261 emergency department (ED) physicians conducted this fall and presented at the meeting showed that 57 percent of ED doctors believe that detox and treatment facilities “are rare or not accessible” in their areas.In fact, one of the greatest problems fueling the opioid crisis is the shortage of opioid treatment programs, said Paul Kivela, M.D., president of ACEP and managing partner of Napa Valley Emergency Medical Group. “These patients are by no means ‘out of the woods.’ The opioid-overdose patient who sobers in the hallway [and] is offered a detox list and then discharged, has a 1 in 10 chance of being dead within one year,” Scott Weiner, M.D., director of the Comprehensive Opioid Response and Education Program at Brigham and Women’s Hospital in Boston, told conference attendees. Weiner’s statement was based on an observational study he and colleagues in Boston conducted to determine one-year mortality of patients who received naloxone by emergency medical services (EMS) and initially survived. The researchers relied on data from three statewide datasets in Massachusetts: EMS, all payer claims, and death records.Patients were included who received at least one naloxone administration by EMS between July 1, 2013, and December 31, 2015, and did not receive naloxone between January 1, 2013, and June 30, 2013.Between July 1, 2013, and December 31, 2015, there were 12,192 EMS naloxone administrations in Massachusetts, or 406.4 per month. Death records showed that 6.5 percent of patients (787) died the same day they received naloxone, 9.3 percent (1,132) died within one year, and 84.3 percent (10,273) were alive at one year. Opioid overdose was the listed cause of death for nearly 50 percent of those who died the same day and for 35 percent of those who died within one year. ■ ISSUES NewArchived