UNC Medical Center (UNCMC) is a 905-bed non-profit, nationally ranked, public, research and academic medical center located in Chapel Hill, North Carolina, providing tertiary care for the Research Triangle, surrounding areas and North Carolina. The medical center is the flagship campus of the UNC Health Care Health System and is made up of four hospitals that include the North Carolina Memorial Hospital, North Carolina Children's Hospital, North Carolina Neurosciences Hospital, North Carolina Women's Hospital, and the North Carolina Cancer Hospital. UNCMC is affiliated with the University of North Carolina School of Medicine. UNCMC features an ACS designated adult and pediatric Level 1 Trauma Center and has a helipad to handle medevac patients.
Introduction Medication costs are a concern for patients with heart failure with reduced ejection fraction (HFrEF). As of January 1, 2025, there are substantial changes for Medicare patients, with a transition away from the coverage gap, and maximum annual out-of-pocket costs capped at $2000. Other associated costs with guideline directed medical therapy (GDMT) initiation are not well described. We aim to provide a comprehensive cost assessment for HFrEF patients from a multidisciplinary Medication Titration Clinic (MTC). Hypothesis Out-of-pocket GDMT costs are highly variable and highly dependent on insurance coverage. Methods The UNC Rex Heart Failure MTC employs Clinical Pharmacist Practitioners (CPPs) to rapidly initiate GDMT, billing for their services. As part of ongoing quality initiatives, CPPs have collected limited MTC data, such as dates in program, insurance type, number of visits, estimated costs, and participation in assistance programs. Published Average Wholesale Prices for medications have been utilized. Simple descriptive statistics are included. Results Between April 2022 and October 2024, 200 patients completed MTC. The median number of visits per patient was 4 (range 1-9). Figure 1 includes primary insurance and cost per visit. About 14% of patients received approval for one or more assistance programs. Figure 2 includes estimated annual costs prior to and after 1/1/2025, considering changes in the Medicare system and medication prices. Non-medication and medication costs are highly variable, with three distinct patient groupings evident: Medicaid/Medicare, Medicare Advantage/Commercial, and self-pay. In 2025, costs have only substantially increased for self-pay patients, with Medicare patients approaching the $2000 cap with GDMT alone. Conclusions Rapid initiation of GDMT has been shown to improve outcomes in HFrEF patients, with significant attention on costs of medications. Non-medication costs, complexities of insurance coverage, and screening for medication assistance programs should be included when counseling patients.
This cross-sectional study examines trends in the use, modality, and reimbursement of outpatient psychotherapy among commercially insured children in the US from 2016 to 2023.
Introduction Cytomegalovirus (CMV) infection is common and clinically significant following allogeneic stem cell transplant (allo-HCT). Letermovir is FDA-approved for CMV prophylaxis in CMV-seropositive allo-HCT recipients (R+) and is considered the standard of care. This study represents the longest survival analysis of 5 years in a real-world patient population using letermovir. Objectives The primary objective of this single-center, retrospective cohort study was to evaluate the effects of letermovir on overall survival (OS) and time to clinically significant CMV in a real-world cohort of R+ allo-HCT recipients. Methods UNC IRB 23-1408 study eligibility included adult subjects who received their first allo-HCT at UNC Medical Center between May 2015 and April 2025 with available CMV serostatus data. Subjects with any donor serostatus (D+ or D-) and negative recipient serostatus (R-) were included as defined additional control groups. The primary outcome was 5-year OS between R+ subjects treated with letermovir versus those with no letermovir. Secondary outcomes included 6-month and 1-year OS between R+ subjects treated with letermovir versus those with no letermovir, incidence of clinically significant CMV infection (defined as CMV disease/viremia requiring preemptive treatment) at 6 months and 1 year after allo-HCT, time to clinically significant CMV infection, and 5-year OS between R+ subjects treated with letermovir and D-/R- (i.e., subjects with lowest risk of clinically significant CMV). Results A total of 552 subjects were included in the study, with 291 R+ subjects (n=150 treated with letermovir, n=141 with no letermovir). The letermovir-treated group included 47 subjects (31%) with low-level positive CMV detected by polymerase chain reaction at the time of initiation. The median start time in the letermovir treated group was day +15. The study met its primary endpoint demonstrating letermovir significantly improved 5-year OS (HR 0.53, 95% CI 0.37-0.75, P=0.0004) (Fig. 1A). Among R+ subjects, letermovir was associated with improved OS at 6 months (HR 0.40, 95% CI 0.23-0.72, P=0.003) and 1 year (HR 0.40, 95% CI 0.25-0.62, P<0.0001). Letermovir was also associated with longer time to clinically significant CMV infection among R+ subjects (median not reached vs. 56 days; HR 0.36, 95% CI 0.25-0.51, P<0.0001) (Fig. 1B). The D-/R+ and D+/R+ serotype subjects treated with letermovir had a significantly lower incidence of clinically significant CMV when compared to those with no letermovir (Fig. 1C). Lastly, 5-year OS was not significantly different between R+ subjects treated with letermovir and D-/R- subjects (P=0.25) (Fig. 1D). Conclusion These data suggest letermovir is associated with improved long-term overall survival and significantly decreases the risk of clinically significant CMV infection compared to no letermovir use among R+ allo-HCT recipients.
