The impact of persistence with therapy on inpatient admissions and emergency room visits in the US among patients with multiple sclerosis

Objective:

Disease-modifying therapy (DMT) for multiple sclerosis (MS) can reduce relapses and delay progression; however, poor adherence and persistence with DMT can result in sub-optimal outcomes. The associations between DMT adherence and persistence and inpatient admissions and emergency room (ER) visits were investigated.

Methods:

Patients with MS who initiated a DMT in a US administrative claims database were followed for 1 year. Persistence to initiated DMT was measured as the time from DMT initiation to discontinuation (a gap of >60 days without drug ‘on hand’) or end of 1-year follow-up. Adherence to initiated DMT was measured during the persistent period and was operationalized as the medication possession ratio (MPR). Patients with an MPR <0.80 were considered non-adherent. Claims during the 1-year follow-up period were evaluated for the presence of an all-cause inpatient admission or an ER visit. Adjusted odds ratios (AORs) for inpatient admission or ER visit comparing persistent vs non-persistent and adherent vs non-adherent patients were estimated using logistic regression models adjusted for patient characteristics.

Results:

The final sample included 16,218 patients. During the 1-year follow-up period, 35.3% of patients discontinued their initiated DMT and 13.9% were not adherent while on therapy. During that same period, 10.0% of patients had an inpatient admission and 24.9% had an ER visit. The likelihoods of inpatient admission and ER visit were significantly decreased in persistent patients (AOR [95% CI]?=?0.50 [0.45, 0.56] and 0.65 [0.60, 0.69], respectively) and in adherent patients (AOR [95% CI]?=?0.83 [0.71, 0.97] and 0.86 [0.77, 0.95], respectively).

Conclusions:

Persistence and adherence with initiated DMT are associated with decreased likelihoods of inpatient admission or ER visit, which may translate to improved clinical outcomes.     

Persistence,adherence, and all-cause healthcare costs in atazanavir- and darunavir-treated patients with human immunodeficiency virus in a real-world setting

Objectives:

Atazanavir (ATV) and darunavir (DRV) are protease inhibitors approved for HIV treatment in combination with ritonavir (/r). The objectives of this study were to compare persistence (time to treatment discontinuation/modification), adherence, and healthcare costs among patients with human immunodeficiency virus (HIV) initiating ATV/r or DRV/r.

Methods:

This retrospective cohort study used commercial and Medicaid administrative insurance claims data. Patients initiating ATV/r or DRV/r from 2006–2013 with continuous enrollment for ≥6 months before and ≥3 months after initiation were included. Patients were followed from initiation until discontinuation/modification (≥30 day gap in ATV or DRV or initiation of a new antiretroviral medication), during which time adherence (proportion of days covered [PDC], with PDC ≥80% or 95% considered adherent) and per-patient per-month (PPPM) total healthcare costs were measured. DRV/r patients were propensity score matched to ATV/r patients at a 1:1 ratio to achieve balance on potentially confounding demographic and clinical factors. Commercial and Medicaid samples were analyzed separately, as were antiretroviral (ART)-naïve and experienced patients.

Results:

The final samples comprised 2988 commercially-insured and 1158 Medicaid-insured patients. There were no significant differences in hazards of discontinuation/modification between the ATV/r or DRV/r cohorts. With respect to odds of being adherent, the only marginally significant result was comparing odds of achieving PDC ≥80% among ART-naïve Medicaid patients, which favored ATV/r. All other adherence comparisons were not significant. Although ATV/r cohorts tended to have lower PPPM costs, the majority of these differences were not statistically significant.

Conclusions:

Patients with HIV treated with either ATV/r or DRV/r had similar time to treatment discontinuation/modification, adherence, and monthly healthcare costs. Results were similar across the pre-specified sub-groups. These findings are useful not only as an insight into clinical practice, but also as a resource for healthcare providers and payers evaluating treatment options for HIV+ individuals.     

IMAGINING A DECOLONIZED CITY IN AND FROM AOTEAROA NEW ZEALAND

Imagining decolonized cities creates space to explore how urban places could strip away colonial dominance and restore the ability of Indigenous people to live, know and be. In this essay, we describe one attempt to create such space. While working in Porirua in Aotearoa New Zealand, we ran an urban design competition, hosted workshops with young people and held a symposium. Through all three phases we drew on utopian thinking to imagine beyond the current constraints of urban form in Aotearoa New Zealand to consider how cities might reflect the diverse realities of Māori. While this approach is an attempt at generating hopeful geographies, it also sat in tension with (post)colonial realities, such as racist attempts by white people to claim Indigeneity, and the ongoing need for land to be returned to Indigenous people. We argue that envisioning how cities might be decolonized is useful and needs to be rooted in the particular politics of place, but this imagining needs to be paired with action to confront persistent colonialism.     

How to examine external validity within an experiment

A fundamental concern for researchers who analyze and design experiments is that the estimate obtained from the experiment might not be externally valid for other policies of interest. Researchers often attempt to assess external validity by comparing data from an experiment to external data. In this paper, I discuss approaches from the treatment effects literature that researchers can use to begin the examination of external validity internally, within the data from a single experiment. I focus on presenting the approaches simply using stylized examples.     

Fraud Firms' Non-Implicated CFOs: An Investigation of Reputational Contagion and Subsequent Employment Outcomes*

We investigate labor market consequences for CFOs employed by fraud firms, focusing on reputational contagion for those who are not implicated. These individuals provide an opportunity to understand reputational contagion and the nuanced meaning of “guilt” because the labor market may suspect complicity or infer negligence regardless of whether that is truly the case. We compare these CFOs to a matched sample of non-fraud CFOs and track both turnover and subsequent employment positions. Non-implicated CFOs are more likely to experience turnover compared to non-fraud CFOs, driven in particular by the public revelation of fraud to the labor market. We further find that non-implicated CFOs are more likely to obtain comparable subsequent employment than non-fraud CFOs before the fraud is publicly revealed, but not after. In supplementary analyses, we find that turnover rates are highest for non-implicated CFOs who started their employment with the firm before the fraud began as compared to non-implicated CFOs who started their employment after the fraud began. These results highlight the labor market significance of the public revelation of fraud and imply that the labor market does not fully distinguish between fraud firm association and general firm performance when making executive hiring decisions.