Person: Brennan, Troyen
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Brennan
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Troyen
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Brennan, Troyen
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Publication Measuring the Scope of Prior Authorization Policies: Applying Private Insurer Rules to Medicare Part B(American Medical Association (AMA), 2021-05-28) Schwartz, Aaron; Brennan, Troyen; Verbrugge, Dorothea; Newhouse, JosephImportance: Health insurers use prior authorization to evaluate the medical necessity of planned medical services. Data challenges have precluded measuring the frequency with which medical services can require prior authorization, the spending on these services, the types of services and provider specialties affected, and differences in the scope of prior authorization policies between government-administered and privately administered insurance. Objective: To measure the extent of prior authorization requirements for medical services and to describe the services and provider specialties affected by them using novel data on private insurer coverage policies. Design, Setting, and Participants: We analyzed fee-for-service Medicare claims from 2017 for beneficiaries enrolled in Medicare Part B, which lacks prior authorization. We measured the use of services that would have been subject to prior authorization according to the coverage rules of a large Medicare Advantage insurer and calculated the associated spending. We report rates of these services for 14 clinical categories and 27 provider specialties. Main Outcomes and Measures: Annual count per beneficiary and associated spending for 1,151 services requiring prior authorization by the Medicare Advantage insurer; likelihood of providing one or more such service per year, by provider specialty. Results: Among 6,497,534 fee-for-service Part B beneficiaries (mean age 72.1), 41% received at least one service per year that would have been subject to prior authorization under Medicare Advantage prior authorization requirements. There were 2.2 such services per beneficiary per year (SD, 8.9; 95% CI, 2.17‒2.18), corresponding to $1,661 in spending per beneficiary per year (SD, $8,900; 95% CI, 1,654‒1,668), or 25% of total annual Part B spending. Part B drugs constituted 58% of the associated spending, mostly accounted for by hematology/oncology drugs. Radiology was the largest source of non-drug spending (16%), followed by musculoskeletal services (9%). Physician specialties varied widely in rates of services that required prior authorization, with the highest rates among radiation oncologists (97%), cardiologists (93%), and radiologists (91%), and the lowest among pathologists (2%) and psychiatrists (4%). Conclusion and Relevance: In this cross-sectional study, a large portion of fee-for-service Medicare Part B spending would have been subject to prior authorization under private insurance coverage policies. Prior authorization requirements for Part B drugs have been an important source of difference in coverage policy between government-administered and privately administered Medicare.Publication Time series analyses of the effect of FDA communications on use of prescription weight loss medications(Wiley-Blackwell, 2014) Block, Jason; Choudhry, Niteesh; Carpenter, Daniel; Fischer, Michael; Brennan, Troyen; Tong, A. Y.; Matlin, O. S.; Shrank, WilliamOBJECTIVE: To determine the impact of FDA safety communications regarding the weight loss medications sibutramine and orlistat. METHODS: The 2008 to 2011 pharmacy claims data from CVS Caremark were used to determine the effect of the relevant FDA warnings on (1) use of sibutramine and orlistat, (2) their rates of discontinuation, and (3) substitution to an alternate weight loss medication in the 3-month period following discontinuation. RESULTS: The use of sibutramine, orlistat, or phentermine declined from 45 users per 100,000 Caremark enrollees in May 2008 to 24 users per 100,000 enrollees in December 2010. In the time series analyses of overall use of medications, a very small decline in the trend of use of sibutramine after the FDA communication (0.000002% per month decline after the communication; P < 0.001) was found. However, rates of discontinuation of sibutramine and orlistat were similar before and after relevant FDA communications (all P values >0.1 for both level and trend changes post-warning). Patients discontinuing sibutramine post-communication increased use of phentermine at a rate of 0.004% per month after discontinuation (P = 0.01). CONCLUSION: From 2008 to 2010, use of prescription weight loss medications was low and declined over time. FDA communications regarding the safety of these medications had limited effect on use.Publication Five Features Of Value-Based Insurance Design Plans Were Associated With Higher Rates Of Medication Adherence(Health Affairs (Project Hope), 2014) Choudhry, Niteesh; Fischer, Michael; Smith, B. F.; Brill, G.; Girdish, C.; Matlin, O. S.; Brennan, Troyen; Avorn, Jerome; Shrank, WValue-based insurance design (VBID) plans selectively lower cost sharing to increase medication adherence. Existing plans have been structured in a variety of ways, and these variations could influence the effectiveness of VBID plans. We evaluated seventy-six plans introduced by a large pharmacy benefit manager during 2007-10. We found that after we adjusted for the other features and baseline trends, VBID plans that were more generous, targeted high-risk patients, offered wellness programs, did not offer disease management programs, and made the benefit available only for medication ordered by mail had a significantly greater impact on adherence than plans without these features. The effects were as large as 4-5 percentage points. These findings can provide guidance for the structure of future VBID plans.Publication Comparative Effectiveness of Generic and Brand-Name Statins on Patient Outcomes(American College of Physicians, 2014) Gagne, Joshua; Choudhry, Niteesh; Kesselheim, Aaron; Polinski, Jennifer Milan; Hutchins, David; Matlin, Olga S.; Brennan, Troyen; Avorn, Jerome; Shrank, WilliamBackground: Statins are effective in preventing cardiovascular events, but patients do not fully adhere to them. Objective: To determine whether patients are more adherent to generic statins versus brand-name statins (lovastatin, pravastatin, or simvastatin) and whether greater adherence improves health outcomes. Design: Observational, propensity score–matched, new-user cohort study. Setting: Linked electronic data from medical and pharmacy claims. Participants: Medicare beneficiaries aged 65 years or older with prescription drug coverage between 2006 and 2008. Intervention: Initiation of a generic or brand-name statin. Measurements: Adherence to statin therapy (measured as the proportion of days covered [PDC] up to 1 year) and a composite outcome comprising hospitalization for an acute coronary syndrome or stroke and all-cause mortality. Hazard ratios (HRs) and absolute rate differences were estimated. Results: A total of 90 111 patients who initiated a statin during the study was identified; 83 731 (93%) initiated a generic drug, and 6380 (7%) initiated a brand-name drug. The mean age of patients was 75.6 years, and most (61%) were female. The average PDC was 77% for patients in the generic group and 71% for those in the brand-name group (P < 0.001). An 8% reduction in the rate of the clinical outcome was observed among patients in the generic group versus those in the brand-name group (HR, 0.92 [95% CI, 0.86 to 0.99]). The absolute difference was −1.53 events per 100 person-years (CI, −2.69 to −0.19 events per 100 person-years). Limitation: Results may not be generalizable to other populations with different incomes or drug benefit structures. Conclusion: Compared with those initiating brand-name statins, patients initiating generic statins were more likely to adhere and had a lower rate of a composite clinical outcome. Primary Funding Source: Teva Pharmaceuticals.Publication Patterns of Initiation of Oral Anticoagulants in Patients with Atrial Fibrillation— Quality and Cost Implications(Elsevier BV, 2014) Desai, Nihar R.; Krumme, Alexis A.; Schneeweiss, Sebastian; Shrank, William; Brill, Gregory; Pezalla, Edmund J.; Spettell, Claire M.; Brennan, Troyen; Matlin, Olga S.; Avorn, Jerome; Choudhry, NiteeshBackground. Dabigatran, rivaroxaban, and apixaban have been approved for use in patients with atrial fibrillation based upon randomized trials demonstrating their comparable or superior efficacy and safety relative to warfarin. Little is known about their adoption into clinical practice, whether utilization is consistent with the controlled-trials on which their approval was based, and how their use has affected health spending for patients and insurers. Study design. We used medical and prescription claims data from a large insurer to identify patients with non-valvular atrial fibrillation who were prescribed an oral anticoagulant in 2010-2013. We plotted trends in medication initiation over time, assessed corresponding insurer and patient out-of-pocket spending, and evaluated the cumulative number and cost of anticoagulants. We identified predictors of novel anticoagulant initiation using multivariable logistic models. Finally, we estimated the difference in total drug expenditures over 6 months for patients initiating warfarin vs. a novel anticoagulant. Results. 6,893 patients with atrial fibrillation initiated an oral anticoagulant during the study period. By the end of the study period, novel anticoagulants accounted for 62% of new prescriptions and 98% of anticoagulant-related drug costs. Female sex, lower household income and higher \(CHADS_2\), \(CHA_2DS_2-VASC\), and HAS-BLED scores were significantly associated with lower odds of receiving a novel anticoagulant (p<0.001 for each). Average combined patient and insurer anticoagulant spending in the first 6 months after initiation was more than $900 greater for patients initiating a novel anticoagulant. Conclusions. This study demonstrates rapid adoption of novel anticoagulants into clinical practice, particularly among patients with lower \(CHADS_2\) and HAS-BLED scores, and high health care cost consequences. These findings provide important directions for future comparative and cost-effectiveness research.Publication Equity in the Receipt of Oseltamivir in the United States During the H1N1 Pandemic(American Public Health Association, 2014) Franklin, Jessica; Choudhry, Niteesh; Uscher-Pines, Lori; Brill, Gregory; Matlin, Olga S.; Fischer, Michael; Schneeweiss, Sebastian; Avorn, Jerome; Brennan, Troyen; Shrank, WilliamObjectives. We assessed the relationship between individual characteristics and receipt of oseltamivir (Tamiflu) in the United States during the H1N1 pandemic and other flu seasons. Methods. In a cohort of individuals enrolled in pharmacy benefit plans, we used a multivariate logistic regression model to measure associations between subscriber characteristics and filling a prescription for oseltamivir during 3 flu seasons (October 2006–May 2007, October 2007–May 2008, and October 2008–May 2010). In 19 states with county-level influenza rates reported, we controlled for disease burden. Results. Approximately 56 million subscribers throughout the United States were included in 1 or more study periods. During pandemic flu, beneficiaries in the highest income category had 97% greater odds of receiving oseltamivir than those in the lowest category (P < .001). After we controlled for disease burden, subscribers in the 2 highest income categories had 2.18 and 1.72 times the odds of receiving oseltamivir compared with those in the lowest category (P < .001 for both). Conclusions. Income was a stronger predictor of oseltamivir receipt than prevalence of influenza. These findings corroborate concerns about equity of treatment in pandemics, and they call for improved approaches to distributing potentially life-saving treatments.Publication Can the United States Afford a "No-Fault" System of Compensation for Medical Injury?(Duke University School of Law, 1997) Studdert, David Michael; Thomas, Eric J.; Zbar, Brett I.W.; Newhouse, Joesph P.; Weiler, Paul; Bayuk, Jonathon; Brennan, TroyenOne of the key issues separating US critics of a no-fault alternative to the tort system for compensating victims of medical injury from supporters is its anticipated cost. Results from a study are presented that estimate the costs of a no-fault system, one that is similar to the system now in operation in Sweden, within the context of the US health care system.Publication Association Between Trajectories of Statin Adherence and Subsequent Cardiovascular Events(Wiley-Blackwell, 2015) Franklin, Jessica; Krumme, Alexis; Tong, Angela Y.; Shrank, William; Matlin, Olga S.; Brennan, Troyen; Choudhry, NiteeshPURPOSE: Trajectory models have been shown to (1) identify groups of patients with similar patterns of medication filling behavior and (2) summarize the trajectory, the average adherence in each group over time. However, the association between adherence trajectories and clinical outcomes remains unclear. This study investigated the association between 12-month statin trajectories and subsequent cardiovascular events. METHODS: We identified patients with insurance coverage from a large national insurer who initiated a statin during January 1, 2007 to December 31, 2010. We assessed medication adherence during the 360 days following initiation and grouped patients based on the proportion of days covered (PDC) and trajectory models. We then measured cardiovascular events during the year after adherence assessment. Cox proportional hazards models were used to evaluate the association between adherence measures and cardiovascular outcomes; strength of association was quantified by the hazard ratio, the increase in model C-statistic, and the net reclassification index (NRI). RESULTS: Among 519 842 statin initiators, 8777 (1.7%) had a cardiovascular event during follow-up. More consistent medication use was associated with a lower likelihood of clinical events, whether adherence was measured through trajectory groups or PDC. When evaluating the prediction of future cardiovascular events by including a measure of adherence in the model, the best model reclassification was observed when adherence was measured using three or four trajectory groups (NRI = 0.189; 95% confidence interval: [0.171, 0.210]). CONCLUSIONS: Statin adherence trajectory predicted future cardiovascular events better than measures categorizing PDC. Thus, adherence trajectories may be useful for targeting adherence interventions. Copyright (c) 2015 John Wiley & Sons, Ltd.Publication Comparative effectiveness of generic versus brand-name antiepileptic medications(Elsevier BV, 2015) Gagne, Joshua; Kesselheim, Aaron; Choudhry, Niteesh; Polinski, Jennifer Milan; Hutchins, David; Matlin, Olga S.; Brennan, Troyen; Avorn, Jerome; Shrank, WilliamOBJECTIVE: The objective of this study was to compare treatment persistence and rates of seizure-related events in patients who initiate antiepileptic drug (AED) therapy with a generic versus a brand-name product. METHODS: We used linked electronic medical and pharmacy claims data to identify Medicare beneficiaries who initiated one of five AEDs (clonazepam, gabapentin, oxcarbazepine, phenytoin, zonisamide). We matched initiators of generic versus brand-name versions of these drugs using a propensity score that accounted for demographic, clinical, and health service utilization variables. We used a Cox proportional hazards model to compare rates of seizure-related emergency room (ER) visit or hospitalization (primary outcome) and ER visit for bone fracture or head injury (secondary outcome) between the matched generic and brand-name initiators. We also compared treatment persistence, measured as time to first 14-day treatment gap, between generic and brand-name initiators. RESULTS: We identified 19,760 AED initiators who met study eligibility criteria; 18,306 (93%) initiated a generic AED. In the matched cohort, we observed 47 seizure-related hospitalizations and ER visits among brand-name initiators and 31 events among generic initiators, corresponding to a hazard ratio of 0.53 (95% confidence interval, 0.30 to 0.96). Similar results were observed for the secondary clinical endpoint and across sensitivity analyses. Mean time to first treatment gap was 124.2days (standard deviation [sd], 125.8) for brand-name initiators and 137.9 (sd, 148.6) for generic initiators. SIGNIFICANCE: Patients who initiated generic AEDs had fewer adverse seizure-related clinical outcomes and longer continuous treatment periods before experiencing a gap than those who initiated brand-name versions.Publication Incidence of Adverse Events and Negligence in Hospitalized Patients — Results of the Harvard Medical Practice Study I(Massachusetts Medical Society, 1991-02-07) Brennan, Troyen; Leape, Lucian; Laird, Nan; Hebert, Liesi; Localio, A. Russell; Lawthers, Ann G.; Newhouse, Joseph; Weiler, Paul; Hiatt, HowardMETHODS We reviewed 30,121 randomly selected records from 51 randomly selected acute care, nonpsychiatric hospitals in New York State in 1984. We then developed population estimates of injuries and computed rates according to the age and sex of the patients as well as the specialties of the physicians. RESULTS Adverse events occurred in 3.7 percent of the hospitalizations (95 percent confidence interval, 3.2 to 4.2), and 27.6 percent of the adverse events were due to negligence (95 percent confidence interval, 22.5 to 32.6). Although 70.5 percent of the adverse events gave rise to disability lasting less than six months, 2.6 percent caused permanently disabling injuries and 13.6 percent led to death. The percentage of adverse events attributable to negligence increased in the categories of more severe injuries (Wald test χ2 = 21.04, P<0.0001). Using weighted totals, we estimated that among the 2,671,863 patients discharged from New York hospitals in 1984 there were 98,609 adverse events and 27,179 adverse events involving negligence. Rates of adverse events rose with age (P<0.0001). The percentage of adverse events due to negligence was markedly higher among the elderly (P<0.01). There were significant differences in rates of adverse events among categories of clinical specialties (P<0.0001), but no differences in the percentage due to negligence. CONCLUSIONS There is a substantial amount of injury to patients from medical management, and many injuries are the result of substandard care.