Katalin Bognar

Undertreatment of osteoporosis and the role of gastrointestinal events among elderly osteoporotic women with Medicare Part D drug coverage

Objectives To examine the rate of osteoporosis (OP) undertreatment and the association between gastrointestinal (GI) events and OP treatment initiation among elderly osteoporotic women with Medicare Part D drug coverage. Methods This retrospective cohort study utilized a 20% random sample of Medicare beneficiaries. Included were women ≥66 years old with Medicare Part D drug coverage, newly diagnosed with OP in 2007–2008 (first diagnosis date as the index date), and with no prior OP treatment. GI event was defined as a diagnosis or procedure for a GI condition between OP diagnosis and treatment initiation or at the end of a 12-month follow-up, whichever occurred first. OP treatment initiation was defined as the use of any bisphosphonate (BIS) or non-BIS within 1 year postindex. Logistic regression, adjusted for patient characteristics, was used to model the association between 1) GI events and OP treatment initiation (treated versus nontreated); and 2) GI events and type of initial therapy (BIS versus non-BIS) among treated patients only. Results A total of 126,188 women met the inclusion criteria: 72.1% did not receive OP medication within 1 year of diagnosis and 27.9% had GI events. Patients with a GI event were 75.7% less likely to start OP treatment (odds ratio [OR]=0.243; P<0.001); among treated patients, patients with a GI event had 11.3% lower odds of starting with BIS versus non-BIS (OR=0.887; P<0.001). Conclusion Among elderly women newly diagnosed with OP, only 28% initiated OP treatment. GI events were associated with a higher likelihood of not being treated and, among treated patients, a lower likelihood of being treated with BIS versus non-BIS.

Regional disparities in the quality of stroke care

Background and purpose: There is widespread geographic variation in healthcare quality, but we often lack clear strategies for improving quality in underserved areas. This study characterized geographic disparities in stroke care quality to assess whether improved access to neurological services has the potential to bridge the care quality gap, particularly in terms of alteplase (rt‐PA) administration. Methods: This was a retrospective study using quality performance data from the 2015 Hospital Compare database linked to information on certification status from the Joint Commission and information on local access to neurological services from the Area Health Resources File. We used these data to compare stroke care quality according to geographic area, certification, and neurologist access. Results: Non‐metropolitan hospitals performed worse than metropolitan hospitals on all assessed stroke care quality measures. The most prevalent disparity occurred in the use of rt‐PA for eligible patients (52.2% versus 82.7%, respectively). Certified stroke centers in every geographic designation provided higher quality of care, whereas large variation was observed among non‐certified hospitals. Regression analyses suggested that improvements in hospital certification or access to neurologists were associated with absolute improvements of 44.9% and 21.3%, respectively, in the percentage of patients receiving rt‐PA. Conclusions: The large quality gap in stroke care between metropolitan and non‐metropolitan areas could be at least partly addressed through improved procedural efforts by stroke center certification increasing the supply of neurological services, (i.e. through training and hiring new neurologists) or by adopting decision support systems such as telemedicine.

Identifying Patients at Risk for High Medical Costs and Good Candidates for Obesity Intervention

Purpose. To develop a risk-scoring tool to identify in a base year patients likely to have high medical spending in the subsequent year and to understand the role obesity and obesity reduction may play in mitigating this risk. Design. Cross-sectional analysis, using commercial claims and health risk assessment data. Setting. United States, 2004–2009. Subjects. Panel of 192,750 person-year observations from 116,868 unique working-age employees of large companies. Measures. Probability of high medical expenses (80th percentile or above) in the following year; adjusted body mass index (BMI). Analysis. Generate risk scores by modeling the likelihood of high next-year expenses as a function of base-year age, sex, medical utilization, comorbidities, and BMI. Estimate the effect of simulated bariatric intervention on patient risk scores. Results. Individuals with higher BMI were more likely to be categorized in the very high risk group, in which the average annual medical expense was

Estimated prevalence of undiagnosed atrial fibrillation in the United States

8621. A weight-loss intervention transitioning a patient to the next lower obesity class was predicted to reduce this risk by 1.5% to 27.4%—comparable to hypothetically curing a patient of depression or type 2 diabetes. Conclusion. A logistic model was used to capture the effect of BMI on the risk of high future medical spending. Weight-loss interventions for obese patients may generate significant savings by reducing this risk.

The potential value of rapid, cloud-enabled onsite testing for the diagnosis of rheumatoid arthritis in the United States

Introduction As atrial fibrillation (AF) is often asymptomatic, it may remain undiagnosed until or even after development of complications, such as stroke. Consequently the observed prevalence of AF may underestimate total disease burden. Methods To estimate the prevalence of undiagnosed AF in the United States, we performed a retrospective cohort modeling study in working age (18–64) and elderly (≥65) people using commercial and Medicare administrative claims databases. We identified patients in years 2004–2010 with incident AF following an ischemic stroke. Using a back-calculation methodology, we estimated the prevalence of undiagnosed AF as the ratio of the number of post-stroke AF patients and the CHADS2-specific stroke probability for each patient, adjusting for age and gender composition based on United States census data. Results The estimated prevalence of AF (diagnosed and undiagnosed) was 3,873,900 (95%CI: 3,675,200–4,702,600) elderly and 1,457,100 (95%CI: 1,218,500–1,695,800) working age adults, representing 10.0% and 0.92% of the respective populations. Of these, 698,900 were undiagnosed: 535,400 (95%CI: 331,900–804,400) elderly and 163,500 (95%CI: 17,700–400,000) working age adults, representing 1.3% and 0.09% of the respective populations. Among all undiagnosed cases, 77% had a CHADS2 score ≥1, and 56% had CHADS2 score ≥2. Conclusions Using a back-calculation approach, we estimate that the total AF prevalence in 2009 was 5.3 million of which 0.7 million (13.1% of AF cases) were undiagnosed. Over half of the modeled population with undiagnosed AF was at moderate to high risk of stroke.

Does knowledge of patient non-compliance change prescribing behavior in the real world? A claims-based analysis of patients with serious mental illness

Abstract Aims: Improvements in information technology have granted the recent development of rapid, cloud-enabled, onsite laboratory testing for rheumatoid arthritis (RA). This study aims to quantify the value to payers of such technologies. Materials and methods: To calculate the value of rapid, cloud-enabled, onsite laboratory testing to diagnose RA relative to traditional, centralized laboratory testing, an Excel-based decision tree model was created that simulated potential cost-savings to payers who cover routine evaluations of RA patients in the US. First, a conceptual framework was created to identify the value components of rapid, cloud-enabled onsite testing. Second, value associated with patient time savings, savings on visit fees, change in treatment costs, and QALY improvements was measured, leveraging existing literature and information from an observational study. Lastly, these value components were combined to estimate the total incremental value accruing to payers per patient-year relative to centralized laboratory testing. Results: Rapid, cloud-enabled, onsite testing is estimated to save one office and 1.81 laboratory visits during the evaluation period for the average patient. Results from an observational study found that rapid, cloud-enabled testing increased the likelihood of completing diagnostic orders from 84.5% to 97%, resulting in an increased probability of early treatment (3.5 percentage points) with disease-modifying anti-rheumatic drugs among patients eligible for treatment. The combined total value was

ECONOMIC BURDEN OF UNDIAGNOSED NONVALVULAR ATRIAL FIBRILLATION IN THE UNITED STATES

5,648 per evaluated patient-year. This value is primarily attributed to health benefits of early treatment (

Economic Burden of Undiagnosed Nonvalvular Atrial Fibrillation in the United States.

5,048), fewer visit payments (

An optimal voting procedure when voting is costly

459), and patient time savings due to fewer office (

An optimal Voting System when Voting is costly

216) and laboratory visits (