Background While vaccination is the most important way to combat the SARS-CoV-2 pandemic, there may still be a need for early outpatient treatment that is safe, inexpensive, and currently widely available in parts of the world that do not have access to the vaccine. There are in-silico, in-vitro, and in-tissue data suggesting that metformin inhibits the viral life cycle, as well as observational data suggesting that metformin use before infection with SARS-CoV2 is associated with less severe COVID-19. Previous observational analyses from single-center cohorts have been limited by size. Methods Conducted a retrospective cohort analysis in adults with type 2 diabetes (T2DM) for associations between metformin use and COVID-19 outcomes with an active comparator design of prevalent users of therapeutically equivalent diabetes monotherapy: metformin versus dipeptidyl-peptidase-4-inhibitors (DPP4i) and sulfonylureas (SU). This took place in the National COVID Cohort Collaborative (N3C) longitudinal U.S. cohort of adults with +SARS-CoV-2 result between January 1 2020 to June 1 2021. Findings included hospitalization or ventilation or mortality from COVID-19. Back pain was assessed as a negative control outcome. Results 6,626 adults with T2DM and +SARS-CoV-2 from 36 sites. Mean age was 60.7 +/- 12.0 years; 48.7% male; 56.7% White, 21.9% Black, 3.5% Asian, and 16.7% Latinx. Mean BMI was 34.1 +/- 7.8kg/m 2 . Overall 14.5% of the sample was hospitalized; 1.5% received mechanical ventilation; and 1.8% died. In adjusted outcomes, compared to DPP4i, metformin had non-significant associations with reduced need for ventilation (RR 0.68, 0.32–1.44), and mortality (RR 0.82, 0.41–1.64). Compared to SU, metformin was associated with a lower risk of ventilation (RR 0.5, 95% CI 0.28–0.98, p = 0.044) and mortality (RR 0.56, 95%CI 0.33–0.97, p = 0.037). There was no difference in unadjusted or adjusted results of the negative control. Conclusions There were clinically significant associations between metformin use and less severe COVID-19 compared to SU, but not compared to DPP4i. New-user studies and randomized trials are needed to assess early outpatient treatment and post-exposure prophylaxis with therapeutics that are safe in adults, children, pregnancy and available worldwide.
372 Background: Studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days. This study aimed to compare the one-year costs of trimodal therapy versus radical cystectomy, accounting for survival and intensity effects on total costs. Methods: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data, we included a total of 2,963 patients aged ≥66 years diagnosed with clinical stage T2-4a bladder cancer between 2002 and 2011. We compared total Medicare costs within one year of diagnosis among patients following radical cystectomy or trimodal therapy using inverse probability of treatment weighted (IPTW) propensity score models, which included a two-part estimator to account for intrinsic selection bias. Results: Median total costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83,754 vs. $68,692; median difference $11,805, 95% CI $7,745 to $15,864), 180 days ($187,162 vs. $109,078; median difference $62,370, 95% CI $55,581 to $69,160), and 365 days ($289,142 vs. $148,757; median difference $109,027, 95% CI $98,692 to $119,363), respectively. Outpatient, radiology, pharmacy and pathology/laboratory costs contributed largely to the significantly higher costs associated with trimodal therapy. On IPTW-adjusted analyses, patients undergoing trimodal therapy had $142,337 (95% CI $117,423-$175,300) higher costs compared with radical cystectomy one year after treatment (Table). Conclusions: Compared to radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. Extrapolating cost figures to the total US population resulted in excess spending of $853 million for trimodal therapy compared with radical cystectomy for patients diagnosed in 2018. [Table: see text]
Abstract Rationale, aims and objectives Individual comparisons of the performance of risk‐adjustment indices have been widely conducted. Few reviews have been conducted to summarize the performance of different risk‐adjustment indices. A 30‐day mortality rate is widely used to evaluate the quality of care in hospitals by federal agencies like the C enters for M edicare and M edicaid S ervices. This study examined relative performance of risk‐adjustment indices that predict 30‐day mortality. Methods Databases including M edline, PubMed and PsycINFO were searched for studies that compared risk‐adjustment indices. The search protocol included comparative studies in which the performance of risk‐adjustment indices were compared across any defined cohort to compare 30‐day mortality, including mortality within 30 days and intensive care unit mortality, which lasts less than 30 days. Data were extracted using a structured form and abstract data included author and publication year, population studied (including location, sample size, study time period), comparison indices, outcome studied, results and conclusions from the results. A meta‐analytical approach was used to summarize all the studies. Scaled ranking score was used to estimate the relative superiority of any given risk‐adjustment indices. A hypergeometric test was carried out to evaluate the performance of risk‐adjustment measures. Results Out of 2805 studies identified, 23 studies met the eligibility criteria. Main risk‐adjustment indices used for comparison included Ac ute P hysiology and C hronic H ealth E valuation, S equential O rgan F ailure A ssessment score, C harlson co‐morbidity index, M odel for E nd‐ S tage L iver D isease score and S implified A cute P hysiology S core ( SAPS ). Based on scaled ranking score, SAPS performed best (score 0.510) among all the risk‐adjustment indices. However, based on hypergeometric test, the five measures performed equally well. Conclusions Although all the selected risk‐adjustment indices perform equally well, SAPS seems better than other indices for short‐term mortality based on scaled ranking score.
e16021 Background: Earlier studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days. The objective of this study is to compare the one-year costs associated with trimodal therapy versus radical cystectomy, accounting for survival and intensity effects on total costs. Methods: This cohort study used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Data analysis was performed from March 5, 2018 through December 4, 2018. A total of 2,963 patients aged 66-85 years diagnosed with clinical stage T2-4a muscle-invasive bladder cancer from January 1, 2002 through December 31, 2011. Total Medicare costs within one year of diagnosis following radical cystectomy versus trimodal therapy were compared using inverse probability of treatment-weighted (IPTW) propensity score models, which included a two-part estimator to account for intrinsic selection bias. Results: Median costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83,754 vs. $68,692; median difference $11,805, 95% CI $7,745 to $15,864), 180 days ($187,162 vs. $109,078; median difference $62,370, 95% CI $55,581 to $69,160), and 365 days ($289,142 vs. $148,757; median difference $109,027, 95% CI $98,692 to $119,363), respectively. Outpatient care, radiology, medication expenses and pathology/laboratory costs contributed largely to the higher costs associated with trimodal therapy. On IPTW-adjusted analyses, patients undergoing trimodal therapy had $129,854 (95% CI $115,793-$145,299) higher costs compared with radical cystectomy one year after diagnosis. Conclusions: Compared to radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. Extrapolating cost figures resulted in nationwide excess spending of $444 million for trimodal therapy compared with radical cystectomy for patients diagnosed in 2017.
Importance Understanding whether there are racial and ethnic and residential disparities in prenatal telehealth uptake is necessary for ensuring equitable access and guiding implementation of future hybrid (ie, both telehealth and in-person) prenatal care. Objective To assess temporal changes in individuals using hybrid prenatal care before and during the COVID-19 public health emergency (PHE) by race and ethnicity and residence location in the US. Design, Setting, and Participants This retrospective cohort study analyzed electronic health record data of prenatal care visits from the National COVID Cohort Collaborative Data Enclave, comprising data from 75 health systems and freestanding institutes in all 50 US states. Data were analyzed on 349 682 nationwide pregnancies among 349 524 people who gave birth from June 1, 2018, through May 31, 2022. Multivariable generalized estimating equations were used to examine variations in receiving hybrid vs only in-person prenatal care. Data phenotyping and analysis occurred from June 13, 2023, to September 27, 2024. Exposures Prenatal period overlap (never, partially, or fully overlapping) with the COVID-19 PHE, maternal race and ethnicity, and urban or rural residence. Main Outcomes and Measures Hybrid vs in-person–only prenatal care. Results Of 349 682 pregnancies (mean [SD] age, 29.4 [5.9] years), 59 837 (17.1%) were in Hispanic or Latino individuals, 14 803 (4.2%) in non-Hispanic Asian individuals, 65 571 (18.8%) in non-Hispanic Black individuals, 162 677 (46.5%) in non-Hispanic White individuals, and 46 794 (13.4%) in non-Hispanic individuals from other racial and ethnic groups. A total of 31 011 participants (8.9%) resided in rural communities. Hybrid prenatal care increased from nearly none before March 2020 to a peak of 8.1% telehealth visits in November 2020, decreasing slightly to 6.2% by March 2022. Among the fully overlapping group, urban residents had nearly 2-fold odds of hybrid prenatal care compared with rural people (adjusted odds ratio [AOR], 1.98; 95% CI, 1.84-2.12). Hispanic or Latino people (AOR, 1.48; 95% CI, 1.41-1.56), non-Hispanic Asian people (AOR, 1.47; 95% CI, 1.35-1.59), and non-Hispanic Black people (AOR, 1.18; 95% CI, 1.12-1.24) were more likely to receive hybrid prenatal care than non-Hispanic White people. Conclusions and Relevance In this cohort study, hybrid prenatal care increased substantially during the COVID-19 PHE, but pregnant people living in rural areas had lower levels of hybrid care than urban people, and individuals who belonged to racial and ethnic minority groups were more likely to have hybrid care than White individuals. These findings suggest that strategies that improve equitable access to telehealth for people who live in rural areas and people in some minority racial and ethnic groups may be useful.
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