Anirban Basu

With the arrival of direct-acting antivirals, the implementation of universal hepatitis C virus screening, and simplified treatment protocols, the landscape for managing hepatitis C has become less complicated and more adaptable to primary care settings. In 2019, Washington State created and implemented a statewide comprehensive plan aimed at eliminating hepatitis C by 2030. This study aims to understand provider-based perceptions about screening and treating hepatitis C, and how these perceptions influence care across Washington State. This is a qualitative study using semi-structured in-depth interviews exploring screening and treatment practices of health providers across Washington State. Qualitative data collection was guided by the Updated Consolidated Framework for Implementation Research. Data was analyzed using thematic analysis to identify key factors. Fourteen providers participated in interviews. Most providers (86%) treated hepatitis C, and (71%) of those providers also treated substance use disorders. Emerging themes included organizational barriers, patient barriers, provider barriers, and stigma. Healthcare provider shortages, high turnover in rural parts of the state, lack of provider knowledge about current guidelines and access to information, patient competing priorities, and lack of updated screening and treatment care models were identified as strong barriers to treatment implementation.

Background: Subscription-based payment models (SBPMs) have been adopted to expand access to hepatitis C virus (HCV) treatment within Medicaid programs. Objective: To evaluate the impact of SBPMs on HCV screening, RNA testing, and direct-acting antiviral (DAA) uptake among Medicaid Managed Care enrollees in Louisiana and Washington, and to identify factors associated with differential policy effects. Research Design: Quasi-experimental study using the synthetic control method to compare outcomes in Louisiana and Washington—the only states implementing SBPMs in July 2019—with weighted combinations of 14 control states. Subjects: Adults aged 18–64 years or older enrolled in Medicaid Managed Care between January 2018 and December 2022. Measures: Monthly HCV screening, RNA testing, DAA initiation, and refill rates identified from payer-complete closed claims. Results: Louisiana SBPM was associated with significant increases in RNA testing (+35.2/100,000 persons/mo), DAA initiation (+7.8/1000 patients/mo), and DAA refills (+24.4/1000 patients/mo; all P =0.07). Gains were broad-based across subgroups and geographically consistent. Washington SBPM was associated with nonsignificant screening changes and significant declines in DAA initiation (−3.6/1000 patients/mo) and refills (−12.9/1000 patients/mo; P =0.07), with uniformly negative or null subgroup effects. Conclusions: SBPM yielded markedly different outcomes across states. Louisiana gains likely reflect convergence with recent Medicaid expansion and prior removal of DAA restrictions, generating a large treatment-eligible pool at implementation. Washington earlier expansion (2014) and fibrosis-restriction removal (2016) may have already addressed this demand. As the federal government invests $12.3 billion in HCV elimination with SBPM as a central mechanism, payment reform must be paired with comprehensive strategies—including provider engagement, screening infrastructure, and patient navigation—to achieve elimination goals.

Financial incentives can distort physicians' treatment decisions and amplify healthcare spending. Altruism, a core element of medical professionalism, may counteract these distortions. We link experimentally elicited altruism from a sample of U.S. physicians to administrative data on industry transfers and drug prescribing. Non-altruistic physicians receive substantially higher annual payments (USD 1,932, or 190%) relative to their altruistic peers and increase prescribing of promoted drugs after payment, whereas altruistic physicians do not. Heterogeneity by altruism is largest in drug classes with high clinical substitutability, where prescribing is more discretionary. Our findings suggest that physician altruism moderates the influence of financial incentives in industry ties, limiting the scope for agency problems in prescribing.

Background: Evidence is required on the relative effectiveness of sulphonylureas, dipeptidyl peptidase-4 inhibitors or sodium–glucose cotransporter 2 inhibitors added to metformin for people with type 2 diabetes mellitus. Objectives: To assess disparities in the initiation of second-line antidiabetic treatments prescribed among people with type 2 diabetes mellitus in England according to ethnicity and social deprivation. To compare the effectiveness of sulphonylureas, dipeptidyl peptidase-4 inhibitors and sodium–glucose cotransporter 2 inhibitors added to metformin for people with type 2 diabetes mellitus who require second-line treatment in routine clinical practice. To examine heterogeneity in the comparative short-term (12 months) effectiveness of sulphonylureas versus dipeptidyl peptidase-4 inhibitors combined with metformin on levels of glycated haemoglobin across the entire target population and subpopulations of decision-making relevance. To assess the comparative effectiveness of sulphonylureas, dipeptidyl peptidase-4 inhibitors or sodium–glucose cotransporter 2 inhibitors added to metformin according to individual risk-factor profiles of multiple long-term conditions. To calibrate the RAPIDS microsimulation model to UK data and then use the resultant RAPIDS-UK model to predict probabilities of long-term complications for people with type 2 diabetes mellitus in England after second-line treatment with sulphonylureas, dipeptidyl peptidase-4 inhibitors or sodium–glucose cotransporter 2 inhibitors added to metformin. Methods: We included adults with type 2 diabetes mellitus who initiated second-line antidiabetic treatment with sulphonylureas, dipeptidyl peptidase-4 inhibitors or sodium–glucose cotransporter 2 inhibitors added to metformin monotherapy. We used data from the Clinical Practice Research Datalink linked to Hospital Episode Statistics and the Office of National Statistics. We applied target trial emulation and instrumental variable analyses to reduce the risks of biases, including confounding. The primary outcome was change in mean glycated haemoglobin (mmol/mol) at 1-year follow-up. Secondary outcomes: change in mean body mass index, systolic blood pressure, estimated glomerular filtration rate and time to major adverse kidney event, major adverse cardiovascular event, heart failure hospitalisation, eye disease, amputation and all-cause mortality. We assessed treatment effect heterogeneity according to multiple long-term conditions. We used a microsimulation model to report the impact on long-term complications. Results: After the instrumental variable analysis, the mean 95% confidence interval differences in glycated haemoglobin change between baseline and 1 year were: −2.5 mmol/mol (−3.7 to −1.3) for sodium–glucose cotransporter 2 inhibitors versus sulphonylureas, and −3.2 mmol/mol (−4.6 to −1.8) for sodium–glucose cotransporter 2 inhibitors versus dipeptidyl peptidase-4 inhibitors. Sodium–glucose cotransporter 2 inhibitors were more effective in reducing body mass index and systolic blood pressure compared to either sulphonylureas or dipeptidyl peptidase-4 inhibitors. Sodium–glucose cotransporter 2 inhibitors were also more effective at reducing mean glycated haemoglobin at 2-year follow-up, at reducing body mass index and systolic blood pressure at 1- and 2-year follow-ups and at reducing the hazards of heart failure hospitalisation (vs. dipeptidyl peptidase-4 inhibitors) and ≥ 40% decline in estimated glomerular filtration rate (vs. sulphonylureas). We did not find evidence of treatment effect heterogeneity by baseline cardiovascular disease status or multiple long-term condition profiles. The microsimulation model found that sodium–glucose cotransporter 2 inhibitors led to lower predicted incidence of end-stage kidney disease, heart failure and eye disease. Public and patient involvement translation workshop participants provided valuable insights on how best to share our findings. Limitations: We could only partially evaluate the main instrumental variable assumptions. Conclusions: We found that sodium–glucose cotransporter 2 inhibitors were better than dipeptidyl peptidase-4 inhibitors and sulphonylureas at improving important risk factors and at reducing the risk of complications among a general population of people with type 2 diabetes mellitus. Future work: Newer antidiabetic treatments should be evaluated. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR128490.

This case-control study evaluates the delay in treating relapsed or refractory diffuse large B-cell lymphoma due to distant access to chimeric antigen receptor T-cell (CAR T) therapy.

Purpose Typically, cost-effectiveness analyses use societal utility weights for health states. These anticipated utility weights are derived from asking the general population to assess the impacts of hypothetical health states on their quality-of-life. This study evaluates how these weights align with real-world self-reported experienced health statuses. Methods We compared the self-reported health statuses of approximately 30,000 Argentine respondents from the nationally representative National Risk Factors Survey to their corresponding derived health-related quality of life (HRQoL) using social utility weights estimated by Augustovski et al. (Value Health 12:587–596, 2009) for this population. Survey weights ensured national representativeness. We modeled the relationship between these derived HRQoL and the probability of self-reported health states (ranging from poor to excellent) using a multinomial logistic regression with various nonlinear specifications, selecting models via AIC and BIC. Results The analysis revealed a distinct non-monotonic relationship between HRQOL and probabilities of self-reported “poor” and “good” health statuses. The non-monotonicity was found over the lower range of HRQOL values up to 0.16, where the likelihood of “poor” (“good”) health increased as HRQoL increased (decreased). A positive monotonic relationship was found for “very good” and “excellent.” Conclusions The findings indicate a discrepancy between societal HRQOL weights and patient-reported outcomes at lower health levels. This discrepancy may reflect that the general population underestimates the burden of severe health conditions rather than patient adaptation, as adaptation is unlikely to translate into experiencing good or better health when true health is poor. Our results suggest that the field of cost-effectiveness should consider patients’ experienced utility weights.

PURPOSE: In the past decade, advanced lung cancer and melanoma have witnessed a surge in Food and Drug Administration (FDA)–approved treatment innovations. Yet, the impact of these advancements on population-level survival and survival disparities remains unclear. We aimed to evaluate whether cancer treatment innovations were associated with survival disparities by county-level income. METHODS: This quasi-experimental study used data from the SEER registry, including 357,095 adults diagnosed with advanced cancers that experienced significant treatment advancement between 2007 and 2016 (melanoma and non–small cell lung cancer [NSCLC]) and cancers that lacked similar advancements (bladder, uterine, head and neck, and liver cancers). Using a difference-in-difference-in-differences approach, we compared changes in 2-year survival between cancers with and without treatment advancement and quantified survival disparities as the differences in these changes between high-income and low-income counties. RESULTS: Between 2007 and 2016, cancer treatment approvals resulted in an adjusted survival increase of 3.7 percentage points (95% CI, 2.7 to 4.6) for NSCLC and 16.8 percentage points (95% CI, 14.5 to 19.2) for melanoma. The approval of epidermal growth factor receptor tyrosine kinase inhibitors and anti–PD-1 immunotherapies for NSCLC was associated with increased survival disparities between high-income and low-income counties by 2.4 percentage points (95% CI, 0.07 to 4.7). The approval of PD-1 inhibitors and BRAF/MEK inhibitors for melanoma was associated with an increase in survival disparity by 6.1 percentage points (95% CI, 0.1 to 12.1). CONCLUSION: Although FDA approvals are significantly associated with improved survival in NSCLC and melanoma, they have also exacerbated survival disparities. These findings indicate a possible causal link between new therapeutic innovations and health disparities, emphasizing the need to integrate equity considerations into policies related to drug pricing, coverage, and dissemination to mitigate disparity impacts and to address systemic inequities.

Introduction: The Community Eligibility Provision (CEP) is a federal policy that allows high poverty schools to provide universally free breakfast and lunch to all children. Providing universal free meals has potential to decrease childhood obesity, but so far studies are limited and findings mixed. Methods: We used electronic health record data from a large network of community-based healthcare organizations and linked school-level data paired with extended two-way fixed effects models for staggered policy adoption to compare child body mass index z-scores (BMIz) from schools that adopted CEP to eligible, non-adopting schools. Results: The sample consisted of 149,052 distinct lower-income children who attended a balanced panel of 1,085 schools in 12 states. Mean age was 10.8 years, with 84% being publicly insured, and plurality race/ethnicity being Hispanic (43.1%). Children in CEP schools gained less in BMIz compared to children in eligible, non-adopting schools (difference-in-difference: -0.02 (95% CI: -0.04, -0.004)); estimates becoming more negative over time. However, we also find some evidence of heterogeneity by the year of adoption with increases in BMIz in some specifications. Conclusions: This study builds on the evidence suggesting that, for some low-income populations, universal free school meals are associated with relative decreases in BMI.

Despite well‐established econometric theory, less attention is paid to the type of treatment effects being estimated using alternate instrumental variable (IV) approaches and the support for IV in the health literature. We illustrate this case using a commonly used IV—differential distance (DD). We summarize the literature and find that DD was used as an IV in various forms and approaches in the literature, leading to the estimation of different identified parameters, which were not always explained. We illustrate the sources of these differences using theoretical reasoning and a case study to evaluate the causal effects of going to a for‐profit (FP) hospital versus a not‐for‐profit (NFP) hospital on the total cost of psychiatric inpatient stay. We find that estimates of treatment effects differ considerably when using two‐stage least squares with binary versus continuous DD. In contrast, two‐stage residual inclusion (2SRI) approaches using binary or continuous DD yield similar estimates of the treatment effects when we adequately model the control function. Both the 2SRI estimates are close to the average treatment effect estimate generated by local IV approaches, which can illustrate the extent of selection into FP versus NFP hospitals through marginal treatment effect heterogeneity.

Background: Recent advancements in cancer treatments have improved survival rates, but rising costs associated with these innovations raise concerns about their financial impact on patients. This study investigates the trade-off between improved survival and the financial toxicity over time in advanced non-small cell lung cancer (NSCLC). Methods: We conducted a retrospective cohort study using linked data from the Western Washington SEER cancer registry and TransUnion credit records, focusing on adults diagnosed with advanced NSCLC, bladder, uterine, head and neck, and liver cancers between 2013 and 2017. Financial toxicity was assessed through major adverse financial events (AFEs), including collections, charge offs, liens, delinquent payments, foreclosures, repossessions, and bankruptcies. Multivariable multinomial logistic regression evaluated trends in a composite outcome of survival and AFEs for NSCLC patients within 2 years post-diagnosis. A falsification test evaluated a negative control group of advanced cancers lacking new therapies. Results: Our study included 6548 patients (mean age 69; 42% female; 86% non-Hispanic White). Two-year survival for NSCLC patients increased from 15.2% to 19.2% between 2013 and 2017 (mean change 4.0%pt, 95% CI = 0.7 to 7.3). The proportion of survivors without AFEs increased by 2.2%pt (95% CI = −0.6 to 5.1), while those alive with major AFEs increased by 1.9%pt (95% CI = 0.02 to 3.6). This trend was absent in the negative control group. Conclusions: The trade-off between survival gains and increased economic hardships linked to treatment innovations underscores the need to expand our focus beyond clinical outcomes and implement protective measures that ensure healthcare advancements promote population health without inducing financial distress.