Person: Wharam, James
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Wharam
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James
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Wharam, James
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Publication Intensity of End-of-Life Care in a Cohort of Commercially Insured Women With Metastatic Breast Cancer in the United States(American Society of Clinical Oncology (ASCO), 2021-02) Ferrario, Alessandra; Xu, Xin; Zhang, Fang; Ross-Degnan, Dennis; Wharam, James; Wagner, AnitaPURPOSE:There is limited evidence on the intensity of end-of-life (EOL) care for women < 65 years old, who account for about 40% of breast cancer deaths in the United States. Using established indicators, we estimated the intensity of EOL care among these women. METHODS: We used 2000-2014 claims data from a large US insurer to identify women with metastatic breast cancer who, in the last month of their lives, had more than one hospital admission, emergency department visit, or an intensive care unit (ICU) admission and/or used antineoplastic therapy in the last 14 days of life. Using multivariate logistic regression, we assessed whether intensity of EOL care differed by demographic characteristics, socioeconomic factors, or regions. RESULTS: Adjusted estimates show an increase in EOL ICU admissions between 2000-2003 and 2010-2014 from 14% (95% CI, 10% to 17%) to 23% (95% CI, 20% to 26%) and a small increase in emergency department visits from 10% (95% CI, 7% to 13%) to 12% (95% CI, 9% to 15%), both statistically significant. There was no statistically significant change in the proportions of women experiencing more than one EOL hospitalization (14% in 2010-2014; 95% CI, 11% to 17%) and of those receiving EOL antineoplastic treatment (24% in 2010-2014; 95% CI, 21% to 27%). Living in predominantly mixed, Hispanic, Black, or Asian neighborhoods correlated with more intense care (odds ratio, 1.39; 95% CI, 1.10 to 1.77 for ICU). CONCLUSION: Consistent with findings in the Medicare population, our results suggest an overall increase in the number of ICU admissions at the EOL over time. They also suggest that patients from non-White neighborhoods receive more intense acute care.Publication Emergency Department Use and Subsequent Hospitalizations Among Members of a High-Deductible Health Plan(American Medical Association (AMA), 2007) Wharam, James; Landon, Bruce; Galbraith, Alison; Kleinman, Kenneth Paul; Soumerai, Stephen; Ross-Degnan, DennisContext Patients evaluated at emergency departments often present with nonemergency conditions that can be treated in other clinical settings. High-deductible health plans have been promoted as a means of reducing overutilization but could also be related to worse outcomes if patients defer necessary care. Objectives To determine the relationship between transition to a high-deductible health plan and emergency department use for low- and high-severity conditions and to examine changes in subsequent hospitalizations. Design, Setting, and Participants Analysis of emergency department visits and subsequent hospitalizations among 8724 individuals for 1 year before and after their employers mandated a switch from a traditional health maintenance organization plan to a high-deductible health plan, compared with 59 557 contemporaneous controls who remained in the traditional plan. All persons were aged 1 to 64 years and insured by a Massachusetts health plan between March 1, 2001, and June 30, 2005. Main Outcome Measures Rates of first and repeat emergency department visits classified as low, indeterminate, or high severity during the baseline and follow-up periods, as well as rates of inpatient admission after emergency department visits. Results Between the baseline and follow-up periods, emergency department visits among members who switched to high-deductible coverage decreased from 197.5 to 178.1 per 1000 members, while visits among controls remained at approximately 220 per 1000 (−10.0% adjusted difference in difference; 95% confidence interval [CI], −16.6% to −2.8%; P = .007). The high-deductible plan was not associated with a change in the rate of first visits occurring during the study period (−4.1% adjusted difference in difference; 95% CI, −11.8% to 4.3%). Repeat visits in the high-deductible group decreased from 334.6 to 255.3 visits per 1000 members and increased from 321.1 to 334.4 per 1000 members in controls (−24.9% difference in difference; 95% CI, −37.5% to −9.7%; P = .002). Low-severity repeat emergency department visits decreased in the high-deductible group from 142.5 to 92.1 per 1000 members and increased in controls from 128.0 to 132.5 visits per 1000 members (−36.4% adjusted difference in difference; 95% CI, −51.1% to −17.2%; P<.001), whereas a small decrease in high-severity visits in the high-deductible group could not be excluded. The percentage of patients admitted from the emergency department in the high-deductible group decreased from 11.8 % to 10.9% and increased from 11.9% to 13.6% among controls (−24.7% adjusted difference in difference; 95% CI, −41.0% to −3.9%; P = .02). Conclusions Traditional health plan members who switched to high-deductible coverage visited the emergency department less frequently than controls, with reductions occurring primarily in repeat visits for conditions that were not classified as high severity, and had decreases in the rate of hospitalizations from the emergency department. Further research is needed to determine long-term health care utilization patterns under high-deductible coverage and to assess risks and benefits related to clinical outcomes.Publication Mammography Rates 3 Years After the 2009 US Preventive Services Task Force Guidelines Changes(American Society of Clinical Oncology (ASCO), 2015) Wharam, James; Landon, Bruce; Zhang, Fang; Xu, Xin; Soumerai, Stephen; Ross-Degnan, DennisPurpose In November 2009, the US Preventive Services Task Force (USPSTF) changed its mammography recommendations from every 1 to 2 years among women age ≥ 40 years to personalized screening decisions for women age 40 to 49 years and screening every 2 years for women age 50 to 74 years. Methods We studied mammography trends among 5.5 million women age 40 to 64 years enrolled in a large national health insurer. We used 2005 to 2009 mammography trends to predict 2012 rates. Our primary measure was the estimated difference between observed and predicted 2012 annual and biennial mammography rates. We stratified results by age group and race/ethnicity. Results Among women age 40 to 49 years, 2012 mammography rates declined by 9.9% (95% CI, −10.4% to −9.3%) relative to the predicted 2012 rate. Decreases were lowest among black women (−2.3%; 95% CI, −6.3% to 1.8%) and highest among Asian women (−17.4; 95% CI, −20.0 to −14.8). Annual mammography rates among women age 50 to 64 years declined by 6.1% (95% CI, −6.5% to −5.7%) by 2012. Regarding biennial mammography rates, women age 40 to 49 years experienced a 9.0% relative reduction (95% CI, −9.6% to −8.4%). White, Hispanic, and Asian women age 40 to 49 years demonstrated similar relative reductions of approximately 9% to 11%, whereas black women had no detectable changes (0.1%; 95% CI, −4.0% to 4.3%). Women age 50 to 64 years had a 6.2% relative reduction (95% CI, −6.6% to −5.7%) in biennial mammography that was similar among white, Hispanic, and Asian women. Black women age 50 to 64 years did not have changes in biennial mammography (0.4%; 95% CI, −2.6% to 3.5%). Conclusion Three years after publication of the 2009 USPSTF guidelines, mammography rates declined by 6% to 17% among white, Hispanic, and Asian women but not among black women. Small reductions in biennial mammography might be an unintended consequence of the updated guidelines.Publication Impact of Emerging Health Insurance Arrangements on Diabetes Outcomes and Disparities: Rationale and Study Design(Centers for Disease Control and Prevention, 2013) Wharam, James; Soumerai, Steve; Trinacty, Connie; Eggleston, Emma; Zhang, Fang; LeCates, Robert; Canning, Claire; Ross-Degnan, DennisConsumer-directed health plans combine lower premiums with high annual deductibles, Internet-based quality-of-care information, and health savings mechanisms. These plans may encourage members to seek better value for health expenditures but may also decrease essential care. The expansion of high-deductible health plans (HDHPs) represents a natural experiment of tremendous proportion. We designed a pre–post, longitudinal, quasi-experimental study to determine the effect of HDHPs on diabetes quality of care, outcomes, and disparities. We will use a 13-year rolling sample (2001–2013) of members of an HDHP and members of a control group. To reduce selection bias, we will limit participants to those whose employers mandate a single health insurance type. The study will measure rates of monthly hemoglobin A1c, lipid, and albuminuria testing; availability of blood glucose test strips; and rates of retinal examinations, high-severity emergency department visits, and preventable hospitalizations. Results could be used to design health plan features that promote high-quality care and better outcomes among people who have diabetes.Publication High Quality Care and Ethical Pay-for-performance: A Society of General Internal Medicine Policy Analysis(Springer-Verlag, 2009) Wharam, James; Paasche-Orlow, Michael K.; Farber, Neil J.; Sinsky, Christine; Rucker, Lisa; Rask, Kimberly J.; Figaro, M. Kathleen; Braddock, Clarence; Barry, Michael; Sulmasy, Daniel P.BACKGROUND: Pay-for-performance is proliferating, yet its impact on key stakeholders remains uncertain. OBJECTIVE: The Society of General Internal Medicine systematically evaluated ethical issues raised by performance-based physician compensation. RESULTS: We conclude that current arrangements are based on fundamentally acceptable ethical principles, but are guided by an incomplete understanding of health-care quality. Furthermore, their implementation without evidence of safety and efficacy is ethically precarious because of potential risks to stakeholders, especially vulnerable patients. CONCLUSION: We propose four major strategies to transition from risky pay-for-performance systems to ethical performance-based physician compensation and high quality care. These include implementing safeguards within current pay-for-performance systems, reaching consensus regarding the obligations of key stakeholders in improving health-care quality, developing valid and comprehensive measures of health-care quality, and utilizing a cautious evaluative approach in creating the next generation of compensation systems that reward genuine quality.Publication High-Deductible Health Plans Paired With Health Savings Accounts Increased Medication Cost Burden Among Individuals With Bipolar Disorder(Physicians Postgraduate Press, Inc, 2022-03-09) Lu, Christine Y.; Zhang, Fang; Wallace, Jamie; LeCates, Robert; Busch, Alisa; Madden, Jeanne; Callahan, Matthew; Foxworth, Phyllis; Soumerai, Stephen; Ross-Degnan, Dennis; Wharam, JamesObjective: High-deductible health plans (HDHPs) paired with health savings accounts (HSAs) require substantial out-of-pocket spending for most services, including medications. We examined effects of HSA-eligible HDHPs on medication out-of-pocket spending and use among those with bipolar disorder. Methods: This was a quasi-experimental study using claims data (01/2003-12/2014). We studied a national sample of 348 members with bipolar disorder, aged 12 to 64 years, who were continuously enrolled for 1-year in a low-deductible plan (≤USD500) then 1-year in an HSA-eligible HDHP (≥USD1000) after an employer-mandated switch. HSA-HDHP members were matched to 4,087 contemporaneous controls who remained in low-deductible plans. Outcome measures included out-of-pocket spending and use of bipolar disorder medications, non-bipolar psychotropics, and all other medications. Results: Pre-to-post out-of-pocket spending per person for bipolar disorder medications increased 150.0% among HSA-HDHP members, relative to controls (95%CI: 109.9%, 189.5%). Specifically, out-of-pocket spending increased for antipsychotics (220.9% [95%CI: 150.0%, 291.8%]) and anticonvulsants (109.6% [95%CI: 67.3%, 152.0%]); the increase for lithium did not reach statistical significance (25% [95%CI: -5.5%, 55.4%]). We did not detect statistically significant changes in use of bipolar disorder medications, non-bipolar psychotropics, or all other medications. Conclusions: We did not detect changes in medication use among HSA-HDHP members. However, HSA-HDHP members experienced substantial and concerning increases in out-of-pocket burdens for medications essential for their functioning and well-being, which could be a financial strain for some people.