To assess off-label use of the topical calcineurin inhibitors (TCIs), tacrolimus and pimecrolimus, in children during periods before and after regulatory action by the US Food and Drug Administration (FDA) in 2005.We identified new pediatric (age <20 years) users of topical tacrolimus or pimecrolimus in US Medicaid from 2001 to 2009, and examined the annual rate of drug use (pre- and postregulatory action) by age. We assessed medical claims for diagnoses consistent with an indication for a TCI, and assessed prescriptions for evidence of first-line atopic dermatitis therapy use before TCI initiation.There were 57,664 eligible pediatric tacrolimus users and 425,242 eligible pediatric pimecrolimus users at baseline. The rate of TCI use decreased substantially after FDA regulatory action. The proportion of new users younger than 2 years of age significantly decreased for both tacrolimus (36.7% to 22.5%, P < .001) and pimecrolimus (47.0% to 33.7%, P < .001) after regulatory actions. Previous use of topical corticosteroids increased by ≈ 7% for both TCIs from the pre- to postregulatory period. However, after regulatory actions, there was only a small increase in the proportion of tacrolimus or pimecrolimus users with an atopic dermatitis or eczema diagnosis before drug initiation, and high strength use of tacrolimus was unchanged.The rate of TCI use in children younger than 2 years of age fell substantially after FDA regulatory action in 2005. Off-label use of TCI as first-line therapy changed little.
It is well known that disability rates among the American elderly have declined over the past decades.The cause of this decline is less well established.In this paper, we test one important possible explanation--that the decline in disability occurred because of chronic disease prevention efforts among the elderly.For this purpose we analyze data from the National Long Term Care Survey and from the National Health and Interview Survey.Our findings suggest that primary prevention, as reflected in decreased disease prevalence, was not responsible for advances made in elderly functioning between 1980 and 2000.We found a broad decline in less severe forms of disability that is unlikely to have resulted from improved disease management.Instead, these measured improvements in functioning may reflect environmental, technological, and/or socioeconomic changes.Improvements in the more severe forms of disability were modest and were restricted to those suffering from particular illnesses, which make improved and/or more aggressive management a plausible explanation and one that might increase costs should the trend persist.
Introduction 2 How have tax and welfare policies changed?2.1 US tax and welfare programs 2.2 UK tax and welfare programs 3 Recent empirical trends 3.1 Data sources 3.2 Participation 3.3 Hours of work 3.4 Real wages 4 A framework for understanding labor supply 4.1 The static labor supply model 4.2 Multiperiod models of labor supply under certainty 4.3 Multiperiod models of labor supply under uncertainty 4.4 Basic empirical speci®cations 4.5 Which elasticities for policy evaluation?5 Policy reforms and the natural experiment approach 5.1 The natural-experiment approach and the difference-in-differences estimator 5.2 Does the difference-in differences estimator measure behavioral responses?5.3 A review of some empirical applications 6 Estimation with non-participation and non-linear budget constraints 6.1 Basic economic model with taxes
Previous studies have found that the risk of severe hypoglycemia does not differ between long-acting insulin analogs and neutral protamine Hagedorn (NPH) insulin in patients with type 2 diabetes. However, these studies did not focus on patients 65 years or older, who are at an increased risk for hypoglycemia, or did not include patients with concomitant prandial insulin use.
Objective
To examine the risk of emergency department (ED) visits or hospitalizations for hypoglycemia among older community-residing patients with type 2 diabetes who initiated long-acting insulin or NPH insulin in real-world settings.
Design, Setting, and Participants
This retrospective, new-user cohort study assessed Medicare beneficiaries 65 years or older who initiated insulin glargine (n = 407 018), insulin detemir (n = 141 588), or NPH insulin (n = 26 402) from January 1, 2007, to July 31, 2019.
Exposures
Insulin glargine, insulin detemir, and NPH insulin.
Main Outcomes and Measures
The primary outcome was time to first ED visit or hospitalization for hypoglycemia, defined using a modified validated algorithm. Propensity score–weighted Cox proportional hazards regression was used to estimate hazard ratios (HRs) and 95% CIs. The risk of recurring hypoglycemia events was estimated using the Andersen-Gill model. Post hoc analyses were conducted investigating possible effect modification by age.
Results
Of the 575 008 patients initiating use of insulin (mean [SD] age 74.9 [6.7] years; 53% female), 407 018 used glargine, 141 588 used detemir, and 26 402 used NPH insulin. The study included 7347 ED visits or hospitalizations for hypoglycemia (5194 for glargine, 1693 for detemir, and 460 for NPH insulin, with a median follow-up across the 3 cohorts of 0.37 years (interquartile range, 0.20-0.76 years). Initiation of glargine and detemir use was associated with a reduced risk of hypoglycemia compared with NPH insulin use (HR for glargine vs NPH insulin, 0.71; 95% CI, 0.63-0.80; HR, detemir vs NPH insulin, 0.72; 95% CI, 0.63-0.82). The HRs were similar for the recurrent event analysis. The protective association of long-acting insulin analogs varied by age and was not seen with concomitant prandial insulin use.
Conclusions and Relevance
In this cohort study, initiation of long-acting analogs was associated with a lower risk of ED visits or hospitalizations for hypoglycemia compared with NPH insulin in older patients with type 2 diabetes in Medicare. However, this association was not seen with concomitant prandial insulin use.
PAPER BY Philip K. Robins and Charles Michalopoulos COMMENTARIES BY Christopher Jencks Thomas MaCurdy USING FINANCIAL INCENTIVES TO ENCOURAGE WELFARE RECIPIENTS TO BECOME ECONOMICALLY SELF-SUFFICIENT Philip K. Robins and Charles Michalopoulos I. INTRODUCTION On August 22, 1996, President Clinton signed the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), which radically altered the structure of the welfare system in the United States. Among other things, the act replaced the Aid to Families with Dependent Children (AFDC) program, a federal entitlement, with the Temporary Assistance for Needy Families (TANF) program, a system of block grants to states. One of the primary goals of TANF is to move welfare recipients into work and economic self-sufficiency. Although states were given much flexibility in how to achieve this goal, the federal government imposed some guidelines in the form of requirements that welfare recipients be participating in a work-related (work participation requirements) and time limits on length of welfare receipt. The focus of this paper is on alternative financial incentive schemes that are being used or could be used to help states meet the work participation requirements specified by the federal legislation. In particular, the paper considers whether an earnings supplement conditioned on full-time work would encourage more people to work than the enhanced earnings disregards currently being used or tested by many states. The remainder of the paper is organized as follows. Section II provides a background of the PRWORA legislation and describes methods that states have been using to encourage employment and economic self-sufficiency among the welfare population. The discussion focuses on various financial incentive schemes adopted by the states. Section III describes a financial incentive scheme currently not being used in the United States (but being used on an experimental basis in Canada) that conditions benefits on full-time employment. Section IV discusses how such a scheme might be implemented in the United States. Section V presents estimated effects of such a scheme based on results from a microsimulation model. Finally, Section VI summarizes the results and offers some concluding observations. II. BACKGROUND The federal PRWORA legislation stipulated that 25 percent of the caseload in a particular state had to be participating in work activities by fiscal year 1997.(1) The minimum work participation requirement has been and will be increasing by 5 percent each year until fiscal year 2002, when it will reach 50 percent. States failing to meet the work participation requirements might not receive the full value of the federal TANF block grant. Since 1997, continued economic prosperity and substantial declines in welfare caseloads have left states with substantial TANF surpluses, and no state thus far has failed to meet the work participation requirements (U.S. Department of Health and Human Services 2000, pp. 41-3).(2) The federal legislation defines an allowable work activity as unsubsidized employment, subsidized private sector or public sector employment, on-the-job training, job-search assistance for up to six weeks, community service programs, vocational education training for up to one year, and education for persons who have not yet completed high school. The legislation emphasizes work activities and places caps on the number of people who can be placed in educational activities. Reducing the caseload can also count toward the participation requirement. States have considerable latitude in penalizing household heads who fail to comply with the work requirements. Benefits can be reduced or terminated, at state discretion. States can exempt certain people from the requirements, such as single parents of young children, but they must meet federal requirements for the percentage of their caseload participating in work activities. …
