Incorporating the measurement of social determinants of health (SDOH) into health care practice and US health policy reforms is a promising approach to improving population health nationwide. One way health care practitioners have started to incorporate consideration of SDOH in clinical care is by using International Classification of Diseases, Tenth Revision (ICD-10), Z-codes, a set of diagnosis codes spanning a range of social and economic circumstances. Our study summarizes Z-codes used by code type, setting, and patient demographics between Medicaid and commercial insurance to help identify strategies to optimize their use within each program and understand their differences. Overall, Z-code use was highly limited nationwide in Medicaid and commercial insurance between 2020 and 2021. Still, we found notable differences in the use of Z-codes between the programs; Medicaid beneficiaries were more likely to receive Z-codes related to financial and economic issues, while commercially insured beneficiaries were more likely to receive Z-codes indicating problems with social and familial relationships. Policy efforts focused on increasing the rate and ease of patient SDOH screening will potentially expand SDOH measurement and facilitate actions to address patient social needs.
Long-term treatment with medications for opioid use disorder (OUD), including methadone, is lifesaving. There has been little examination of how to measure methadone continuity in claims data.To develop an approach for measuring methadone continuity in claims data, and compare estimates of methadone versus buprenorphine continuity.Observational cohort study using de-identified commercial claims from OptumLabs Data Warehouse (January 1, 2017-June 30, 2021).Individuals diagnosed with OUD, ≥1 methadone or buprenorphine claim and ≥180 days continuous enrollment (N=29,633).OUD medication continuity: months with any use, days of continuous use, and proportion of days covered.5.4% (N=1607) of the study cohort had any methadone use. Ninety-seven percent of methadone claims (N=160,537) were from procedure codes specifically used in opioid treatment programs. Place of service and primary diagnosis codes indicated that several methadone procedure codes were not used in outpatient OUD care. Methadone billing patterns indicated that estimating days-supply based solely on dates of service and/or procedure codes would yield inaccurate continuity results and that an approach incorporating the time between service dates was more appropriate. Among those using methadone, mean [s.d.] months with any use, days of continuous use, and proportion of days covered were 4.8 [1.8] months, 79.7 [73.4] days, and 0.64 [0.36]. For buprenorphine, the corresponding continuity estimates were 4.6 [1.9], 80.7 [70.0], and 0.73 [0.35].Estimating methadone continuity in claims data requires a different approach than that for medications largely delivered by prescription fills, highlighting the importance of consistency and transparency in measuring methadone continuity across studies.
Objectives: Although high-deductible health plans (HDHPs) reduce health care spending, higher deductibles may lead to forgone care. Our goal was to determine the effects of HDHPs on the use of and spending on substance use disorder (SUD) services. Study Design: We used difference-in-differences models to compare service use and spending for treating SUD among enrollees who were newly offered an HDHP relative to enrollees offered only traditional plan options throughout the study period. Methods: We used deidentified commercial claims data from OptumLabs (2007-2017) to identify a sample of 28,717,236 person-years (2.2% with a diagnosed SUD). The main independent measure was an indicator for being offered an HDHP. The main dependent measures were the probability of (and spending associated with) using SUD services and specific treatment types. Results: Enrollees were 6.6% (,P, < .001) less likely to use SUD services after being offered an HDHP relative to the comparison group. Reductions were concentrated in inpatient, intermediate, and ambulatory care, as well as medication use. Being offered an HDHP was associated with a decrease of 21% (,P, < .001) on health plan spending and an increase of 14% (,P, < .01) on out-of-pocket spending. Conclusions: Offering an HDHP was associated with a reduction in SUD service use and a shift in spending from the plan to the enrollee. In the context of the US drug epidemic, these study findings highlight a concern that the movement toward HDHPs may be exacerbating undertreatment of SUD
To characterize US patients with ankylosing spondylitis (AS) who were treated with secukinumab and to assess rheumatologist-reported reasons for prescribing treatment in clinical practice. This descriptive analysis of data from a US retrospective medical chart review included patients aged ≥ 18 years diagnosed with AS who initiated secukinumab after 15 January 2016. Eligible rheumatologists used online forms to collect patient demographics, disease characteristics, co-morbidity profile, and treatment history prior to or on the index date, defined as the date of the first secukinumab prescription recorded in the medical chart. Information on physician-level characteristics and reasons for secukinumab prescription and dosing were also collected. Medical charts from 78 patients with AS who initiated secukinumab were reviewed by 25 rheumatologists between 7 July 2017 and 11 August 2017. Overall, 76.9% of patients were male, mean (SD) age was 39.8 (10.8) years, and 34.6% were biologic naïve. The most common reasons for secukinumab initiation among biologic-naïve and biologic-experienced patients, respectively, were efficacy/effectiveness (77.8%) and failure of other prior biologics (84.3%). Nearly all patients (94.9%) received a loading dose, including 150 mg every week (39.7%), 300 mg every week (53.8%), and other (1.3%). Overall, 73 patients (93.6%) received ≥ 1 maintenance secukinumab dose, of whom 56.2% and 43.8% received 150 mg and 300 mg, respectively, every 4 weeks. In this US medical chart review of patients with AS who initiated secukinumab, approximately one-third were biologic naïve, and secukinumab efficacy/effectiveness and failure of other biologics were the most common reasons for initiating secukinumab.
Studies indicate similar survival and toxicity between pazopanib and sunitinib, but few have examined real-world outcomes among elderly patients with advanced renal cell carcinoma (RCC). The purpose of this retrospective claims analysis was to assess real-world overall survival (OS), healthcare resource utilization (HRU), and healthcare costs (both all-cause and associated with RCC diagnosis) among elderly advanced RCC patients starting pazopanib or sunitinib treatment.Advanced RCC patients aged 65 years or older who started first-line treatment with pazopanib or sunitinib (index drug; the initiation date was the index date) were identified from the 100% Medicare database plus Part D linkage (January 1, 2006 to December 31, 2014). Patients were stratified by index drug and matched 1:1 with use of propensity scores based on baseline characteristics. OS was assessed from the index date to death and compared by Kaplan-Meier analyses and univariable Cox models; patients were censored at the end of eligibility/data. Monthly HRU and costs from an intent-to-treat perspective were compared by Wilcoxon signed-rank tests.Baseline characteristics were balanced after matching (both N = 522). Treatment with pazopanib was associated with significantly longer median OS compared with treatment with sunitinib (18.2 months vs 14.6 months, respectively; log-rank p = 0.015). Pazopanib was associated with significantly lower monthly all-cause costs compared with sunitinib ($8845 vs $10,416, respectively), as well as lower inpatient costs associated with RCC diagnosis ($1542 vs $2522), fewer monthly inpatient admissions (0.179 vs 0.262), and shorter length of inpatient stay (1.375 days vs 1.883 days; all p ≤ 0.004).Among elderly Medicare patients with advanced RCC, first-line pazopanib tretament was associated with significantly longer OS, as well as lower healthcare costs and HRU, compared with first-line sunitinib treatment.
Objectives Evaluate the reliability of using diagnosis codes and prescription data to identify the timing of symptomatic onset, cognitive assessment and diagnosis of Alzheimer’s disease (AD) among patients diagnosed with AD. Methods This was a retrospective cohort study using the UK Clinical Practice Research Datalink (CPRD). The study cohort consisted of a random sample of 50 patients with first AD diagnosis in 2010–2013. Additionally, patients were required to have a valid text-field code and a hospital episode or a referral in the 3 years before the first AD diagnosis. The earliest indications of cognitive impairment, cognitive assessment and AD diagnosis were identified using two approaches: (1) using an algorithm based on diagnostic codes and prescription drug information and (2) using information compiled from manual review of both text-based and coded data. The reliability of the code-based algorithm for identifying the earliest dates of the three measures described earlier was evaluated relative to the comprehensive second approach. Additionally, common cognitive assessments (with and without results) were described for both approaches. Results The two approaches identified the same first dates of cognitive symptoms in 33 (66%) of the 50 patients, first cognitive assessment in 29 (58%) patients and first AD diagnosis in 43 (86%) patients. Allowing for the dates from the two approaches to be within 30 days, the code-based algorithm’s success rates increased to 74%, 70% and 94%, respectively. Mini-Mental State Examination was the most commonly observed cognitive assessment in both approaches; however, of the 53 tests performed, only 19 results were observed in the coded data. Conclusions The code-based algorithm shows promise for identifying the first AD diagnosis. However, the reliability of using coded data to identify earliest indications of cognitive impairment and cognitive assessments is questionable. Additionally, CPRD is not a recommended data source to identify results of cognitive assessments.
Financial, material, and social assets are core drivers of access to salutary resources. However, there is a paucity of research about how non-income financial assets shape mental health. We explore the relation of financial assets with symptoms of depression and of anxiety using a nationally representative, longitudinal survey of U.S. adults fielded annually from 2020 to 2023 (n = 1,296 unique participants). We used multivariable logistic regression models to estimate the association of financial assets and financial stress separately and together with symptoms of depression (PHQ-9 > 9), anxiety (GAD-7 > 9), and their co-occurrence, controlling for demographic indicators and year fixed effects. We found, first, that adults with <$5,000 in accrued financial assets reported over two times the odds of positive screen for depression, anxiety, and co-occurring depression and anxiety, respectively, as adults with ≥$100,000 in financial assets. Second, when controlling for accrued financial assets, annual household income was not associated with symptoms of anxiety. Third, the gap in positive screen for depression between household financial assets groups stayed consistent and did not differ significantly over the study period. Annual income alone does not capture the influence of all financial assets on mental health.
To examine the relationship between insurers' commercial market power and negotiated prices in Medicaid Managed Care (MMC) plans for hospital care. MMC prices from hospital-disclosed price transparency data as of July 2023 compiled by Turquoise Health, insurance enrollment information from the 2021 Clarivate InterStudy enrollment data. Log-transformed linear regression with hospital and procedure fixed effects estimating the within-hospital MMC price variation as a function of insurers' commercial market share quartile and MMC market share for 15 common outpatient hospital services. A total of 39,049 MMC price samples measured at hospital-procedure-MMC insurer level are merged with county-insurer level market share data. Around 25% of price variation in MMC plans are driven by within-hospital factors. Compared with MMC insurers from the lowest commercial market share quartile (<0.8%), those from the highest commercial market share quartile (>17%) are associated with negotiating 4.6% (95% confidence interval: [2.8%-6.4%], p < 0.001) lower MMC prices for outpatient hospital care, including 3.6% (p < 0.05) for medical/surgical procedures, 3.6% (p < 0.01) for radiology, and 6.7% (p < 0.001) for emergency department visits. MMC insurers with substantial commercial market share negotiate lower MMC prices for multiple outpatient hospital services.
Objectives Overdose mortality has risen most rapidly among racial and ethnic minority groups while buprenorphine prescribing has increased disproportionately in predominantly non-Hispanic White urban areas. To identify whether buprenorphine availability equitably meets the needs of diverse populations, we examined the differential geographic availability of buprenorphine in areas with greater concentrations of racial and ethnic minority groups. Methods Using IQVIA longitudinal prescription data, IQVIA OneKey data, and Microsoft Bing Maps, we calculated 2 outcome measures across the continental United States: the number of buprenorphine prescribers per 1000 residents within a 30-minute drive of a ZIP code, and the number of buprenorphine prescriptions dispensed per capita at retail pharmacies among nearby buprenorphine prescribers. We then estimated differences in these outcomes by ZIP codes’ racial and ethnic minority composition and rurality with t tests. Results Buprenorphine prescribers per 1000 residents within a 30-minute drive decreased by 3.8 prescribers per 1000 residents in urban ZIP codes (95% confidence interval = −4.9 to −2.7) and 2.6 in rural ZIP codes (95% confidence interval = −3.0 to −2.2) whose populations consisted of ≥5% racial and ethnic minority groups. There were 45% to 55% fewer prescribers in urban areas and 62% to 79% fewer prescribers in rural areas as minority composition increased. Differences in dispensed buprenorphine per capita were similar but larger in magnitude. Conclusions Achieving more equitable buprenorphine access requires not only increasing the number of buprenorphine-prescribing clinicians; in urban areas with higher racial and ethnic minority group populations, it also requires efforts to promote greater buprenorphine prescribing among already prescribing clinicians.
