BACKGROUND:The impacts of disease and treatment on a patient's family members and informal caregivers are known as "family spillover effects." Although many formal value frameworks call for the consideration of these effects, they are often not included in health technology assessments (HTAs) and cost-effectiveness analyses (CEAs). A formal evaluation of stakeholder perspectives may help address the disconnect for inclusion of family spillover effects observed in practice. OBJECTIVE:To develop stakeholder-driven recommendations for the measurement and use of family spillover effects in the United States and to identify research opportunities. METHODS:We first conducted a targeted literature review of US-based CEAs and HTA reports from the past 10 years to assess the current use of family spillover effects. We then used a purposeful sampling technique to conduct 25 qualitative interviews with outcomes researchers, patient advocates, health economists, and health policy and payer experts to gather perspectives on when and how family spillover effects should be considered in HTA processes. We conducted a thematic analysis of the interview transcripts to identify key themes and develop preliminary recommendations. Finally, we conducted an online workshop with 8 stakeholders to discuss, rate, and refine preliminary recommendations to develop final recommendations. RESULTS:A key theme identified in the stakeholder interviews was the role that data availability, analyst preferences, and prior precedence play in limiting the inclusion of spillover effects in HTAs. Additional themes included support for the inclusion of both qualitative and quantitative spillover effects and the need to capture broad and diverse impacts across populations. We developed 15 recommendations from the consensus building workshop addressing measurement, CEA modeling, and HTA processes. Key recommendations included (1) a transparent process for deciding when family spillover effects should be included, (2) measurement of direct and indirect costs with priority based on the magnitude of impact, (3) the use of validated measures, (4) the use of proxy information and expert elicitation when quality data are unavailable, and (5) the use of a modified impact inventory table for transparency of included effects. Research opportunities included patient involvement in family spillover effect research and HTAs, mapping algorithms and non-preference-based caregiver measures to generate utilities, and consensus best practices for modeling. CONCLUSIONS:The inconsistent inclusion of family spillover effects in HTAs and CEAs remains a persistent challenge. The stakeholder-driven recommendations and research opportunities identified in this study may help improve the transparency, measurement, and use of family spillover effects in assessing the clinical and economic value of novel medical technologies.

Introduction. An Alzheimer’s disease (AD) dementia diagnosis is often preceded by an extended period of cognitive decline. Few studies have examined healthcare resource use (HRU) during an extended period before AD dementia diagnosis. Methods. In a historical claims-based cohort study, propensity score-matched cohorts of patients with and without AD dementia were observed for a 5-year prediagnosis period and a 1-year postdiagnosis period. Demographics, clinical characteristics, and HRU were compared between groups. Results. Individuals in the AD dementia group displayed a greater level of medical complexity in the year before diagnosis of AD dementia relative to those in the matched cohort. Both all-cause and AD dementia complication-related HRU increased gradually, with a marked spike at the time of initial AD dementia diagnosis. Discussion. Further research into the natural history of patients with AD dementia is necessary to improve identification of early AD and to better understand its broader impact.

Background Respiratory complications often accompany influenza in patients with chronic obstructive pulmonary disease (COPD). In this retrospective study, we quantified the impact of antiviral therapy on exacerbations, healthcare resource utilization (HRU), and costs in patients with COPD across 5 influenza seasons.Methods Using claims data from US MarketScan (R) databases, we identified patients with COPD who had an influenza diagnosis during the 2012-2016 influenza seasons. Patients who received a neuraminidase inhibitor within 48 h of diagnosis (N = 4134) were identified and propensity score-matched 1:1 to a comparator cohort of untreated patients. We determined COPD- and pneumonia-related HRU and costs during month 1, each subsequent quarter, and months 2-13.Results Antiviral-treated patients had a significantly lower frequency of COPD-related outcomes than untreated patients during all periods (exacerbations: 10.4% vs 18.2% [month 1] and 17.7% vs 24.2% [months 2-13]; inpatient visit: 2.5% vs 7.9% [month 1] and 3.8% vs 6.7% [months 2-13]; P < 0.0001, all comparisons). Treated patients also had significantly lower outpatient and emergency department (ED) visits beyond month 1. Pneumonia-related inpatient, ED, and outpatient visits were significantly lower in antiviral-treated patients than in untreated patients over all periods (P < 0.0001, all comparisons). In all HRU categories, COPD- and pneumonia-related costs were significantly lower in treated patients over all periods (month-1 ED visit costs were higher).Conclusions Antiviral treatment in patients with COPD and influenza is associated with significantly lower HRU and costs in the postinfection month and for an entire year following infection compared with untreated patients.

OBJECTIVES:To evaluate the long-term effects of antiviral treatment on influenza-related health care resource utilization (HCRU) and costs in patients with type 2 diabetes (T2D) and a diagnosis of influenza.STUDY DESIGN:Retrospective cohort study.METHODS:Claims data from the IBM MarketScan Commercial Claims Database were used to identify patients with T2D and a diagnosis of influenza between October 1, 2016, and April 30, 2017. Patients who received antiviral treatment within 2 days of influenza diagnosis were identified and propensity score-matched 1:1 with a comparator cohort of untreated patients. HCRU (number of outpatient visits, emergency department visits, hospitalizations, and duration of hospitalization) and costs were assessed over 1 full year and over each quarter after influenza diagnosis.RESULTS:Treated and untreated matched cohorts consisted of 2459 patients each. In the treated cohort vs the untreated cohort, emergency department visits were reduced 24.6% over 1 year after influenza diagnosis (mean [SD], 0.94 [1.76] vs 1.24 [2.47] visits; P < .0001) and were also reduced significantly during each quarter; the duration of hospitalization decreased 35.6% in the treated cohort vs the untreated cohort over 1 full year (mean [SD], 0.71 [3.36] vs 1.11 [5.60] days; P < .0023). Mean (SD) total health care costs were 17.68% lower in the treated cohort ($20,212 [$58,627]) than in the untreated cohort ($24,552 [$71,830]) over a whole year following the index influenza visit (P = .0203).CONCLUSIONS:Antiviral treatment in patients with T2D and influenza was associated with significantly lower HCRU and costs over at least 1 year after infection.

Population-level gap and disparities are documented for the dementia diagnosis. Little is known, however, the extent to which clinician’s characteristics, including the characteristics of the patient population they serve, are associated with their likelihood of adequately diagnosing dementia, after accounting for patient characteristics. We used the 100% Medicare fee-for-service and Advantage Plan data from 2017 to 2019. Patients were attributed to primary care clinicians based on plurality of office visits. We determined each clinician’s observed number of patients with a diagnosis of dementia of any etiology and estimated the expected number of cases with a predictive model using patient characteristics (age, sex, race/ethnicity, whether dually eligible for Medicare and Medicaid). The ratio between the clinician’s observed and expected diagnosis rates (O/E ratio) serves as performance measure for diagnostic accuracy. We calculated 95% confidence intervals (CI) around those O/E ratios and categorized those whose 95% CI included 1 as diagnosing dementia at an adequate rate and those whose 95% CI did not reach 1 as underdiagnosing dementia. We then used logistic regression to predict a clinician’s likelihood of having adequate diagnosing compared to under-diagnosing using clinician characteristics: their attributed patient panel’s composition on race/ethnicity, dually eligible, and having had annual wellness visit, urban-rural location of the practice, the clinician’s specialty, and state fixed effects. Among 194,699 included clinicians, those serving more White (Odds Ratio [OR] = 1.50 for 10 percentage points [pp] increase, p<0.001), fewer Black (OR = 0.94 for 10 pp increase, p<0.001) or Hispanic patients (OR = 0.98 for 10 pp increase, p = 0.003), and fewer duals (OR = 0.82 for 10 pp increase, p<.001) were more likely to have an adequate diagnosis rate than under-diagnosing. Clinicians who practiced outside of metropolitan areas were less likely to have an adequate diagnosis rate (compared to metropolitan, OR = 0.91, p = 0.025 for micropolitan; OR = 0.75, p<0.001 for small town; OR = 0.63, p<0.001 for rural areas). No association is seen with percent of patients having annual wellness visit (OR = 1.00 for 10 pp increase, p = 0.913). Primary care clinicians who serve racial/ethnic minority or dually eligible patients and practice outside of big cities may under-detect dementia cases.

Abstract Background The estimated increase in Alzheimer’s Disease (AD) caseload may present a logistical challenge to the US healthcare system. While nurse practitioners (NPs) and physician assistants (PAs) are increasingly delivering primary care to patients with chronic diseases, the nature of their prescribing of AD medications is largely unknown. The primary objective of this study was to compare the prescribing of AD medications across provider types (physician, NP, and PA) and geographic regions. Methods We conducted a retrospective cohort study using IBM MarketScan® commercial and Medicare supplemental claims to examine unique AD prescriptions prescribed between January 1, 2016, and December 31, 2019. Parallel analysis of prescriptions for another geriatric condition, osteoporosis (OP), was also conducted for comparison. Results A total of 103,067 AD prescriptions and 131,773 OP prescriptions were included in analyses. Physicians prescribed most AD prescriptions (95.65%), followed by NPs (3.37%) and PAs (0.98%). Small differences were identified among individual AD medications prescribed by physicians compared to NP/PAs. NPs/PAs prescribed a significantly higher proportion of AD prescriptions in rural as compared to urban areas (z = 0.023, 95%CI [0.018, 0.028]). Conclusion Minimal variation exists in AD prescribing among physicians, NPs, and PAs, but NPs/PAs prescribe more AD prescriptions in rural areas. NPs/PAs, especially in rural areas, may play critical roles in alleviating projected workforce constraints. Further research assessing AD care, health outcomes, and costs by provider type and region is necessary to better guide healthcare workforce planning for AD care.

PURPOSE:To assess the burden of influenza transmission and care-seeking patterns over 3 influenza seasons among commercially insured households with a primary influenza infection.PATIENTS AND METHODS:This retrospective cohort study used commercial claims data from the US MarketScan® Commercial and Medicare Supplemental databases for the 2014, 2015, and 2016 influenza seasons. Patients with a billed diagnosis of influenza and with coverage for at least 1 household member under the same health plan policy were included. A secondary diagnosed case was defined as a diagnosis of influenza in a second household member occurring within 14 days of the index case in a household.RESULTS:Among 1,224,808 households with ≥2 members and a primary case of influenza, a secondary case of influenza was reported in 119,883 households (9.8%). A secondary diagnosed case of influenza occurred within 4 days of the primary diagnosis in 93,883 (78.3%) of those households. Both primary and secondary diagnosed influenza cases occurred most often among children (~60%). Household size was positively correlated to both the risk of a second case (6.4% of households with 2 or 3 members versus 12.6% of households with ≥4 members, P < 0.001) and the time to diagnosis of a second case (Spearman rank correlation coefficient = 0.09; P < 0.001).CONCLUSION:Claims data for 3 influenza seasons (2014, 2015, 2016) showed that intrahousehold transmission of influenza occurs in approximately 10% of households with a primary case and poses a higher burden on larger households. Intrahousehold transmission of influenza represents a large healthcare resource use burden, with an unmet need for interventions that limit transmission.

AbstractBackgroundCentral nervous system (CNS) metastasis is common in advanced melanoma patients. New treatment options have improved overall prognosis, but information is lacking for patients with CNS metastases. We investigated treatment patterns and survival outcomes in older melanoma patients with and without CNS metastases.MethodsA retrospective analysis of SEER‐Medicare, a population‐based linked database, was undertaken in patients aged > 65 years with advanced melanoma diagnosed from 2004 to 2011 and followed until 2013.ResultsA total of 2522 patients were included. CNS metastases were present in 24.8% of patients at initial metastatic diagnosis; 16.5% developed CNS metastases during follow‐up. Chemotherapy was the most common treatment regardless of CNS metastases. Overall survival (OS) was better for patients without CNS metastases (median, 9.5 months; 95% confidence interval [CI], 8.8‐10.2) vs patients with CNS metastases (3.63 months; 95% CI, 3.4‐3.9). Among patients with CNS metastases, median OS for targeted therapy, immunotherapy, and chemotherapy was 6 (95% CI, 2.5‐9.6), 5.5 (95% CI, 3.8‐7.5), and 4.5 (95% CI, 3.8‐5.4) months, respectively, vs 2.4 (95% CI, 2.1‐2.7) and 2.1 (95% CI, 1.8‐2.7) months for local radiotherapy and no treatment, respectively. Stereotactic radiosurgery demonstrated higher OS vs whole‐brain radiation therapy (median, 4.98 [95% CI, 3.5‐7.5] vs 2.4 [95% CI, 2.1‐2.7] months).ConclusionPatients with CNS metastases from melanoma remain a population with high unmet medical need despite recent advances in treatment. Systemic treatments (eg, BRAF‐targeted therapy and immunotherapy) and stereotactic radiosurgery demonstrated meaningful but modest improvements in OS. Further explorations of combinations of radiotherapy, BRAF‐targeted therapies, and immunotherapies are needed.

Seasonal influenza is known to be a significant burden to patients and the healthcare system. Understanding how this highly contagious infection is spread, particularly among family members, is important for quantifying the burden of flu and potential impact of upcoming therapeutic agents that limit transmission. This study used real-world US claims data to understand families’ medical care seeking behavior for flu infection and the relationship between family size and days families are burdened with flu within their household. This was a retrospective analysis of US commercial claims data from the 2014–2016 flu seasons. Patients with enrolled family members and a diagnosis code for flu were identified and required to have continuous coverage during each influenza episode (defined as 14 days from the first flu case in a family). We identified 1,224,808 primary cases of flu among families of 2 or more members. The median family size was 4 members (25th, 75th percentiles = 3, 4). Of these families with at least one case of flu, 119,883 (9.8%) had additional member(s) who sought care for flu within the same flu episode. 70.8% (84,903) of these cases occurred within 3 days after the first member’s claim for influenza (Figure 1). Increased family size was associated with a higher percentage of families where flu spread to other members of the family beyond the first member diagnosed (6.4% of families of size 2 or 3 vs. 12.6% of families of size 4 or greater, P < 0.001). Family size was also positively correlated with the number of days between the first and last flu-related office visit within a family (Spearman coefficient = 0.09, P < 0.001). The majority of family members who sought care for flu were children (n = 810,867; 59.5%), followed by employees (n = 323,277; 23.7%) and their spouses (n = 228,775; 16.8%). In data for the last 3 available flu seasons, we identified a significant number of secondary cases of flu among families with a primary case. Larger families had higher likelihood for subsequent flu infections and more number of days for dealing with flu. Transmission of flu between family members represents a large burden on the healthcare system and reveals an unmet need for treatment options that limit transmission. All Authors: Roche: Employee, Salary.

The CDC has reported that seasonal influenza in 2017–2018 has been one of the worst on record, with hospitalization rates among the highest recorded, especially among younger age groups (age 50–65, hospitalization rate of 63.1 per 100,000 people compared with 35.1 in last severe season, 2015–2016). Understanding how antiviral use affects rates and severity of complications is important to inform treatment decisions. This study used real-world US claims data for 3 flu seasons (2014–2016) to understand the frequency of flu complications and how intervention with antivirals may affect their occurrence. This was a retrospective cohort study using US commercial claims data from the 2014–2016 flu seasons. Patients with a diagnosis code for flu were identified and required to have continuous coverage for at least 365 days before and 91 days after diagnosis. Patients who were prescribed antivirals within 48 hours of the first flu-related encounter during the flu season were identified and propensity score matched to a comparative cohort without antiviral use within 48 hours but comparable baseline health resource utilization (HRU) and comorbidities. All-cause and respiratory-related HRU and costs in the 30 and 91 days after flu diagnosis were analyzed and compared. A total of 989,530 cases of influenza were identified over 3 flu seasons, with 60.2 percent receiving antiviral therapy (Table 1). In the matched sample, greater HRU and costs was identified in the cohort that did not receive antiviral therapy, with 15% vs. 10.4% (P < 0.001) visiting the ER, and 2.8% vs. 0.9% (P < 0.001) being admitted for inpatient care within the first month (Table 2). Similarly, greater HRU was also seen in respiratory-related HRU and costs in the cohorts that did not receive antiviral therapy. Findings were similar in unmatched cohorts. In data for the last 3 available flu seasons, flu patients treated with antivirals had less complications, healthcare resource utilization and overall costs than those who did not receive antiviral treatment. Limitations with this kind of study restrict the conclusions that can be made from this analysis, however suggest that treating flu can improve outcomes and resource utilization beyond symptom resolution. C. Wallick, Roche: Employee, Salary. N. Wu, Roche: Collaborator and Consultant, Salary. T. M. Tu, Roche: Employee, Salary. D. Keebler, Roche: Employee, Salary. D. Moawad, Roche: Employee, Salary.