Optum

Introduction: Post-acute care (PAC) disposition decisions influence costs and outcomes. Skilled nursing facilities (SNFs) provide intensive oversight, home health agencies (HHA) deliver care in familiar settings, often at lower cost. Comparative effectiveness for clinically similar Medicare Advantage members remains unclear. The purpose of this article is to compare clinical and cost outcomes for Medicare Advantage members discharged to HHA versus SNF after acute hospitalizations using a retrospective, quasi-experimental framework. Methods: Using deidentified medical claims from care organizations across 7 states, we identified members discharged to HHA or SNF following acute hospitalizations. Propensity score matching balanced demographics, clinical characteristics, prior utilization, and social determinants of health. Outcomes included readmissions, mortality, costs, emergency room visits, and primary care utilization. Results: No significant difference in 30-day readmissions (5.9% vs 6.4%, OR 0.91, 95% CI 0.67-1.25) or 90-day mortality (8.2% vs 9.9%, OR 0.81, 95% CI 0.64-1.02). HHA had lower costs at 30 days (-$7510, P < .001). Conclusions: Among Medicare Advantage members with comparable clinical profiles, discharge to home with HHA yields similar clinical outcomes at substantially lower cost than SNF. These savings present opportunities to reinvest in transitional care programs and address social determinants of health within the home setting. Findings support consideration of home-based care as a cost-effective alternative for appropriate members.

Pre-exposure prophylaxis (PrEP) is a highly effective biomedical prevention tool for HIV yet remains underutilized among key populations, particularly among young sexual and gender minorities (SGM). Recognizing the popularity of specific dating and social media apps among SGM young adults, we leveraged user data from these platforms to build a machine learning (ML) model that could inform targeted, data-driven interventions aimed at improving PrEP uptake and adherence. We adapted eWellness, an Android mobile app, to passively collect data from research participants capturing mobile app usage, keystroke patterns and logs, and GPS location data between 2021 and 2024. These data were used to train a ML model to predict self-reported PrEP use. Model accuracy was evaluated through F1 scores across different data types and feature combinations. Study protocols were developed in collaboration with community partners and adhered to strict ethical and privacy standards. A total of 82 SGM young adults participated, with 46 (56%) reporting PrEP use at baseline. Our machine learning model demonstrated good predictive accuracy for predicting PrEP use and non-use, achieving an F1 score of 0.84 (PrEP use) and 0.82 (non-use) outcomes when incorporating data from all mobile apps, including messaging, dating, and social media mobile apps. By contrast, predictions based solely on social media mobile app usage, language associated with sexual behavior and substance use risk, or location monitoring demonstrated worse accuracy (F1 scores of 0.79/0.75, 0.70/0.57, and 0.70/0.52, respectively). Additional feature extraction methods, as well as various combinations of these features, were also tested. However, none achieved predictive accuracy as well as the model incorporating all mobile app usage data combined. This study demonstrates the potential of machine learning to accurately predict PrEP use status among SGM young adults. The findings offer a foundation for developing more personalized PrEP promotion strategies, particularly among SGM young adults who use social media and dating apps. Future research should assess the model's adaptability across diverse SGM subgroups to further inform intervention development. Registry: ClinicalTrials.gov, ID: NCT04710901, November 9, 2020.

Objectives Thrombotic microangiopathy (TMA) is a serious and potentially life-threatening complication of hematopoietic stem cell transplantation (HSCT), and as previously presented, associated with increased healthcare resource utilization. This analysis examined differences in cumulative incidence of early and late clinical complications between HSCT recipients with and without TMA. Methods The ENDURE study was a retrospective analysis of Komodo’s Healthcare Map, a large multi-payer US claims database. Pediatric and adult HSCT recipients were identified by Current Procedural Terminology, Healthcare Common Procedure Coding System, and ICD-10 procedure codes. HSCT recipients without a TMA code (controls) within 12 months following HSCT were matched 10:1 to patients with HSCT-TMA (cases). The index date was defined as the first claim for a TMA diagnosis (cases) or a date based on comparable post-HSCT time (controls), with follow-up until disenrollment or death. Results Between January 2016 and March 2024, 1,732 adults and 325 children who underwent HSCT and subsequently diagnosed with HSCT-TMA were matched to 18,691 and 2,335 controls, respectively. Over a mean follow-up of 18–29 months across different cohorts, both children and adults with HSCT-TMA experienced significantly higher complication rates compared to HSCT patients without HSCT-TMA including acute kidney injury, chronic kidney disease (CKD), hypertension, graft versus host disease (GVHD), sinusoidal obstructive syndrome, gastrointestinal (GI) bleeding, and blood stream infections (BSI; all p<0.05; Fig. 1).Absolute risk differences (RD) between cases and controls increased rapidly in the first 6 months post-index, then continued to rise for up to 3 years. Among children with HSCT-TMA, 3-year RDs for hypertension, CKD, and GI bleeding reached 33%, 13%, and 12%, respectively. Risk of BSI was 30% higher among HSCT-TMA patients vs. HSCT patients without HSCT-TMA at 6-month post-index and consistently elevated up to 3 years post-index. (Fig. 2).Adults with HSCT-TMA exhibited similarly elevated risks of clinical complications compared to HSCT patients without HSCT-TMA. Three-year RDs for hypertension, CKD, heart failure, ascites, and thrombosis were 20%, 15%, 12%, 10%, and 10%, respectively. Six-month RD for BSI reached 40% and remained stable up to 3-years post-index. (Fig. 3). Conclusions HSCT-TMA is associated with significant organ dysfunction and complications for up to 3 years post-diagnosis in survivors. Beyond the known increased rate of CKD, new findings show increased rates of heart failure, liver failure, BSI, and thrombosis in this untreated population that may not have been considered severe. These results suggest that HSCT-TMA may have lasting effects underscoring its substantial clinical burden and the importance of interventions to reduce its impact.

Background and Aims Low-density lipoprotein cholesterol (LDL-C)-lowering therapies are proven effective in atherosclerotic cardiovascular disease (ASCVD), but real-world evidence for proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) monoclonal antibodies (mAb) remains limited. This study evaluated their impact in patients with ASCVD without prior ischaemic events. Methods Patients initiating PCSK9i mAb from January 2016 to December 2022 were identified in the Optum Research Database. A 1:2 propensity score-matched comparator cohort of PCSK9i non-initiators was developed. The primary endpoint was a composite of non-fatal myocardial infarction, non-fatal ischaemic stroke, or all-cause mortality. Key outcomes from the parametric G-formula were 5-year event rates, relative risk reduction (RRR) and absolute risk reduction (ARR), with intention-to-treat (ITT) analysis. Additional outcomes for PCSK9i mAb initiators included absolute and percent LDL-C reduction from baseline. Results Overall, 19 670 patients met selection criteria (6545 PCSK9i mAb initiators; 13 125 non-initiators). Baseline characteristics were well-balanced. Under ITT, estimated 5-year event rates were 17.5% [95% confidence interval (CI) 15.5%, 19.5%] with PCSK9i mAb vs 25.4% (95% CI 23.6%, 27.1%) without PCSK9i, yielding a RRR of 30.9% and ARR of 7.8%. Individual endpoints showed RRRs of 28.3% for myocardial infarction (P < .0001), 26.4% for ischaemic stroke (P = .02), and 28.5% for all-cause mortality (P < .0001). Among initiators, mean baseline and follow-up LDL-C were 117.8 and 54.7 mg/dL (on-treatment analysis), respectively, representing an absolute reduction of 63.1 mg/dL and percent reduction of 53.6%. Conclusions In ASCVD patients without prior events in clinical practice, PCSK9i mAb treatment was associated with lower ischaemic event and mortality rates.