Carly J. Paoli

Red blood cell (RBC) transfusion rates among US chronic dialysis patients during changes to Medicare end-stage renal disease (ESRD) reimbursement systems and erythropoiesis stimulating agent (ESA) labels

BackgroundSeveral major ESRD-related regulatory and reimbursement changes were introduced in the United States in 2011. In several large, national datasets, these changes have been associated with decreases in erythropoiesis stimulating agent (ESA) utilization and hemoglobin concentrations in the ESRD population, as well as an increase in the use of red blood cell (RBC) transfusions in this population. Our objective was to examine the use of RBC transfusion before and after the regulatory and reimbursement changes implemented in 2011 in a prevalent population of chronic dialysis patients in a large national claims database.MethodsPatients in the Truven Health MarketScan Commercial and Medicare Databases with evidence of chronic dialysis were selected for the study. The proportion of chronic dialysis patients who received any RBC transfusion and RBC transfusion event rates per 100 patient-months were calculated in each month from January 1, 2007 to March 31, 2012. The results were analyzed overall and stratified by primary health insurance payer (commercial payer or Medicare).ResultsOverall, the percent of chronic dialysis patients with RBC transfusion and RBC transfusion event rates per 100 patient-months increased between January 2007 and March 2012. When stratified by primary health insurance payer, it appears that the increase was driven by the primary Medicare insurance population. While the percent of patients with RBC transfusion and RBC transfusion event rates did not increase in the commercially insured population between 2007 and 2012 they did increase in the primary Medicare insurance population; the majority of the increase occurred in 2011 during the same time frame as the ESRD-related regulatory and reimbursement changes.ConclusionsThe regulatory and reimbursement changes implemented in 2011 may have contributed to an increase in the use of RBC transfusions in chronic dialysis patients in the MarketScan dataset who were covered by Medicare plus Medicare supplemental insurance.

Productivity losses associated with cardiovascular disease: a systematic review

ABSTRACT Introduction: People with cardiovascular disease (CVD) often require time off work to recover from illness or surgery; for example, following a myocardial infarction (MI) or stroke. These individuals incur income losses, work-related productivity is reduced for employers, and output is reduced for the wider economy. Productivity impacts to the economy also arise due to CVD-related mortality. Areas covered: A systematic literature review was conducted to identify and collate studies that report the magnitude of work-related productivity losses associated with CVD generally or specific cardiovascular (CV) events or conditions (coronary heart disease, MI, stroke, transient ischemic attack, angina, heart failure, peripheral artery disease, coronary revascularization). The search was conducted using Medline, Embase, the Cochrane Library, and Google to find studies published from January 2004 to January 2015. In total, 60 studies were identified, including 20 studies conducted in the USA, 25 studies conducted in Europe, and 18 studies conducted in other countries (three studies were conducted in multiple regions). The studies differed by the scope of losses assessed (absenteeism, presenteeism, early retirement, premature mortality) and CVD conditions/events included. Studies reported either average patient or population losses, and generally used a human capital rather than friction cost method. Outcomes were standardized and adjusted to 2015 US dollars where possible. Expert commentary: The review demonstrates that CVD imposes substantial morbidity- and mortality-related productivity costs. The studies identified in the review may be used to inform and populate societal economic evaluations in CVD, with the most appropriate source study being that most closely matching the context of the evaluation.

Osteoporosis Diagnosis and Management in Long-Term Care Facility

Background:Contemporary estimates of the prevalence of diagnosed osteoporosis among long-term care facility residents are limited. Methods:This chart review collected data between April 1, 2012 and August 31, 2013 for adult (age ≥ 30 years) residents of 11 long-term care facilities affiliated with the Louisiana State University Health Sciences Center in the New Orleans metropolitan area. Data (demographics; comorbidities; osteoporosis diagnosis, risk factors, diagnostic assessments, treatments; fracture history; fall risk; activities of daily living) were summarized. Data for residents with and without diagnosed osteoporosis were compared using &khgr;2 tests and t tests. Results:The study included 746 residents (69% women, mean [SD] age: 76.3 [13.9] years, median length of stay approximately 18.5 months). An osteoporosis diagnosis was recorded for 132 residents (18%), 30% of whom received a pharmacologic osteoporosis therapy. Fewer than 2% of residents had bone mineral density assessments; 10% had previous fracture. Calcium and vitamin D use was more prevalent in residents with diagnosed osteoporosis compared with other residents (calcium: 49% versus 12%, vitamin D: 52% versus 28%; both P < 0.001). Over half (304/545) of assessed residents had a high fall risk. Activities of daily living were similarly limited regardless of osteoporosis status. Conclusions:The prevalence of diagnosed osteoporosis was higher than previously reported for long-term care residents, but lower than epidemiologic estimates of osteoporosis prevalence for the noninstitutional U.S. population. In our sample, osteoporosis diagnostic testing was rare and treatment rates were low. Our results suggest that osteoporosis may be underdiagnosed and undertreated in long-term care settings.

Lipid-lowering treatment modifications among patients with hyperlipidemia and a prior cardiovascular event: a US retrospective cohort study

Abstract Background: Numerous studies demonstrate that, even with use of statins, many patients are unable to meet their LDL-C goals. This study examined modifications to statin and/or ezetimibe therapy among patients with hyperlipidemia and prior history of cardiovascular (CV) events in a US commercially insured population. Methods: Adults (age ≥18 years) initiating statins and/or ezetimibe between 1 January 2007 and 31 December 2008 were identified from HealthCore Integrated Research Database. The index date was the initiation date of statins and/or ezetimibe. All patients had ≥1 medical claims related to myocardial infarction, unstable angina, ischemic stroke, transient ischemic attack, coronary artery bypass graft, or percutaneous coronary intervention within 12 months prior to the index date. Treatment modifications to statins and/or ezetimibe initiated on the index date (index therapy) included permanent discontinuation of any lipid lowering therapy (LLT), rechallenge, switching, subtraction, augmentation, and dose changes. Results: Among 17,902 patients, around 90% initiated with statin monotherapy, followed by statin and ezetimibe combination (3.0%: 18–64 years; 3.8%: ≥65 years). Ten percent or less initiated on high intensity statins. Most common treatment modifications were rechallenging index therapy (25.2%: 18–64 years, 27.0%: ≥65 years), switching (27.5%: 18–64 years, 24.6%: ≥65 years), and permanent discontinuation of any LLT (18.6%: 18–64 years, 21.0%: ≥65 years). Only 10% of patients in both groups underwent dose escalation. Conclusions: Real-world evidence indicates that few high-risk patients initiate therapy with high-intensity statins. More than 50% of patients underwent a rechallenge or switching. Despite high CVD risk profile, approximately 20% of patients permanently discontinued any LLT. Key limitations: Pharmacy claims do not provide information on whether patients who had a pharmacy fill actually took the medication as prescribed. It is unknown whether rechallenge was a simple delay in filling a prescription or an actual rechallenge of their index therapy. Reasons for treatment discontinuations or modifications were unavailable in claims data.

TRENDS IN REAL-WORLD TREATMENT MODIFICATIONS AMONG HIGH-CARDIOVASCULAR DISEASE RISK PATIENTS WITH HYPERLIPIDEMIA

This study evaluated the patterns in lipid treatment modifications among patients with high cardiovascular disease (CVD) risk and newly treated with lipid lowering therapy (LLT). HealthCore Integrated Research DatabaseSM was used to identify patients (age 18-64) initiating statins and /or ezetimibe

Systematic Litertaure Review Of Direct Health Care Costs For Cardiovascular Events Among European Patients With Dyslipidemia Or High Cardiovascular Risk

economic burden of stroke was estimated from a societal perspective with an incidence approach.Data were collected from clinical registries and 100 patients were included. In the cost calculations, both direct and indirect costs were estimated. Results: Men (78%) consumed more acute care in hospitals, than the women (22%). Younger patients (59%) brought a significantly higher burden on society compared with the older patients due to the loss of productivity and the increased use of resources in health care.41% of patients who have hypertension and 45% of patients with alcohol and smoking habits have more prone to stroke rather than the patients with other habits and comorbidities.56% of patients have the hospital stay of 5-10 days and 52% are using 4-7 medicines per day. From the study results ,average direct medical costs and direct nonmedical costs and Indirect costs were found to be 2819 ,705 and 754 rupees. In essence, majority of the costs for stroke care fall on the hospital,than the long-time care and informal care costs and productivity loss. ConClusions: The result of this study can be used for further development of the methods for economic analyses as well as for analysis of improvements and investments in health care. This aspect highlights the enormous importance, for our healthcare service, to invest more in prevention. This cost analysis highlights the importance of clinical pharmacist to set up significant prevention programs on selected,high-risk population to reduce the economic burden of stroke, which is mostly attributable to hospital and inpatient rehabilitation costs immediately after the acute episode.

Hemoglobin Stability and Patient Compliance With Darbepoetin Alfa in Peritoneal Dialysis Patients After the Implementation of the Prospective Payment System

PURPOSE Since the Centers for Medicare & Medicaid Services implemented the End-Stage Renal Disease Prospective Payment System, dialysis providers have increasingly focused on balancing resource utilization and quality outcomes for the treatment of anemia in patients undergoing peritoneal dialysis. Limited data exist regarding anemia management outcomes for these patients in US-based dialysis centers after the implementation of the new payment system. METHODS This was a retrospective, observational, cohort study of stable PD patients with end-stage renal disease who received darbepoetin alfa for anemia management over a 15-month period (April 1, 2011-June 29, 2012). The medication was administered by staff in the home-training unit instead of being self-administered at home. The primary end point was mean quarterly hemoglobin (Hb) levels. Variability in Hb levels was assessed over the 5 quarters by using repeated measures ANOVA to test for differences in the observed mean SDs. FINDINGS In the 139 adult patients on stable peritoneal dialysis and meeting the eligibility criteria, mean (SD) Hb level by quarter was 10.8 (1.2) g/dL in quarters 2 and 3 of 2011, 10.5 (1.1) g/dL in quarter 4 of 2011, and 10.4 (1.1) g/dL in quarters 1 and 2 of 2012. Hb levels were stable (mean SDs, 0.58-0.72) over the 5 quarters of the study. Patient compliance with attendance for all scheduled home training unit visits was 84%. IMPLICATIONS PD patients who underwent darbepoetin alfa administration and twice-monthly laboratory testing in the home-training unit had stable Hb levels. Despite more frequent center visits compared with a home-administered approach, patient compliance was high.