Darius Lakdawalla

University of Southern California, Los Ángeles, California, United States

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Publications (136)464.55 Total impact

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    ABSTRACT: Medication adherence is increasingly being considered as a measure for performance-based reimbursement contracts in healthcare systems. However, the association between health outcomes and adherence at the plan level is unknown. Retrospective analysis of medical and pharmacy claims from a large private sector claims database from 2000 to 2009. We compared plan-level measures of medication adherence and health outcomes for patients with diabetes and congestive heart failure (CHF). Plan performance was based on average rates of disease complications. Medication adherence was calculated as the percent of patients having 80% of days covered for medications treating diabetes or CHF. Both adherence and outcomes were adjusted for patient differences using multivariate regression. Plans were stratified into low, moderate, and high adherence, based on adherence in the bottom quartile, middle 2 quartiles, and top quartile, respectively. Average adherence varied significantly across plans. Plans with low adherence to diabetes medications had adjusted rates of uncontrolled diabetes admissions of 13.2 per 1000 patients, compared with 11.2 in moderate adherence plans and 8.3 in high adherence plans (P < .001). The adjusted rate of CHF-related hospitalization was 15.3% in low adherence plans, compared with 12.4% in moderate adherence plans and 12.2% in high adherence plans (P < .001). These patterns were consistent across different types of complications for both diabetes and CHF. Private health plans vary considerably in average adherence to medications treating chronic diseases. Plans with higher average adherence had lower rates of disease complications, suggesting that medication adherence measures are potentially useful tools for improving the performance of health plans.
    The American journal of managed care 08/2015; 21(6):e379-89. · 2.26 Impact Factor
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    ABSTRACT: This study aims to analyze the impacts of a range of clinical evidence generation scenarios associated with comparative effectiveness research (CER) on pharmaceutical innovation. We used the Global Pharmaceutical Policy Model to project the effect of changes in pharmaceutical producer costs, revenues and timings on drug innovation and health for the age 55+ populations in the USA and Europe through year 2060 using three clinical scenarios. Changes in producer incentives from widespread CER evidence generation and use had varied but often large predicted impacts on simulated outcomes in 2060. Effect on the number of new drug introductions ranged from a 81.1% reduction to a 45.5% increase, and the effect on population-level life expectancy ranged from a 15.6% reduction to a 11.4% increase compared to baseline estimates. The uncertainty surrounding the consequences of increased clinical evidence generation and use on innovation calls for a carefully measured approach to CER implementation, balancing near-term benefits to spending and health with long-term implications for innovation.
    Journal of Comparative Effectiveness Research 05/2015; 4(3):1-11. DOI:10.2217/cer.15.9 · 0.72 Impact Factor
  • A Shrestha · A Eldar-Lissai · Y Wu · K Batt · S Krishnan · D Lakdawalla
    Value in Health 05/2015; 18(3):A2. DOI:10.1016/j.jval.2015.03.008 · 3.28 Impact Factor
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    ABSTRACT: Technology drives both health care spending and health improvement. Yet policy makers rarely see measures of cost growth that account for both effects. To fill this gap, we present the quality-adjusted cost of care, which illustrates cost growth net of growth in the value of health improvements, measured as survival gains multiplied by the value of survival. We applied the quality-adjusted cost of care to two cases. For colorectal cancer, drug cost per patient increased by $34,493 between 1998 and 2005 as a result of new drug launches, but value from offsetting health improvements netted a modest $1,377 increase in quality-adjusted cost of care. For multiple myeloma, new therapies increased treatment cost by $72,937 between 2004 and 2009, but offsetting health benefits lowered overall quality-adjusted cost of care by $67,863. However, patients with multiple myeloma on established first-line therapies saw costs rise without corresponding benefits. All three examples document rapid cost growth, but they provide starkly different answers to the question of whether society got what it paid for. Project HOPE—The People-to-People Health Foundation, Inc.
    Health Affairs 04/2015; 34(4):555-61. DOI:10.1377/hlthaff.2014.0639 · 4.97 Impact Factor
  • W. Stevens · Y. Sanchez · R. Brookmeyer · D. Lakdawalla · S. Marx · T. Juday
    Journal of Hepatology 04/2015; 62:S300-S301. DOI:10.1016/S0168-8278(15)30233-6 · 11.34 Impact Factor
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    ABSTRACT: Surrogate end points may be used as proxy for more robust clinical end points. One prominent example is the use of progression-free survival (PFS) as a surrogate for overall survival (OS) in trials for oncologic treatments. Decisions based on surrogate end points may expedite regulatory approval but may not accurately reflect drug efficacy. Payers and clinicians must balance the potential benefits of earlier treatment access based on surrogate end points against the risks of clinical uncertainty. To present a framework for evaluating the expected net benefit or cost of providing early access to new treatments on the basis of evidence of PFS benefits before OS results are available, using non-small-cell lung cancer (NSCLC) as an example. A probabilistic decision model was used to estimate expected incremental social value of the decision to grant access to a new treatment on the basis of PFS evidence. The model analyzed a hypothetical population of patients with NSCLC who could be treated during the period between PFS and OS evidence publication. Estimates for delay in publication of OS evidence following publication of PFS evidence, expected OS benefit given PFS benefit, incremental cost of new treatment, and other parameters were drawn from the literature on treatment of NSCLC. Incremental social value of early access for each additional patient per month (in 2014 US dollars). For "medium-value" model parameters, early reimbursement of drugs with any PFS benefit yields an incremental social cost of more than $170 000 per newly treated patient per month. In contrast, granting early access on the basis of PFS benefit between 1 and 3.5 months produces more than $73 000 in incremental social value. Across the full range of model parameter values, granting access for drugs with PFS benefit between 3 and 3.5 months is robustly beneficial, generating incremental social value ranging from $38 000 to more than $1 million per newly treated patient per month, whereas access for all drugs with any PFS benefit is usually not beneficial. The value of providing access to new treatments on the basis of surrogate end points, and PFS in particular, likely varies considerably. Payers and clinicians should carefully consider how to use PFS data in balancing potential benefits against costs in each particular disease.
    03/2015; 1(1). DOI:10.1001/jamaoncol.2015.0203
  • Jacquelyn W. Chou · Darius N. Lakdawalla · Jacqueline Vanderpuye-Orgle
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    ABSTRACT: The BRICS countries (Brazil, Russia, India, China, and South Africa) have experienced tremendous economic and health gains in recent decades. Two of the major health challenges faced by the BRICS and other low and middle income countries are decreasing inequity in health outcomes and increasing affordability of health insurance. One fiscally sustainable option for the BRICS governments is a public subsidy system for private health insurance plans. This essay lays out the potential applicability and impacts of public subsidies for private health insurance plans, as well as opportunities and challenges for implementation, in the BRICS countries. Overall, providing public subsidies rather than health insurance would enable the BRICS governments to avoid the open-ended financial liabilities that have plagued advanced economies, while still expanding access to health insurance and encouraging the develoment of a robust private health insurance market. We conclude by suggesting an array of pilot programs that could serve as the seeds for publicly subsidized health insurance schemes within the BRICS markets.
    Forum for Health Economics & Policy 03/2015; DOI:10.1515/fhep-2014-0023
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    ABSTRACT: To explore the relationship between commercial health care prices and Medicare spending/utilization across U.S. regions. Claims from large employers and Medicare Parts A/B/D over 2007-2009. We compared prices paid by commercial health plans to Medicare spending and utilization, adjusted for beneficiary health and the cost of care, across 301 hospital referral regions. A 10 percent lower commercial price (around the average level) is associated with 3.0 percent higher Medicare spending per member per year, and 4.3 percent more specialist visits (p < .01). Commercial health care prices are negatively associated with Medicare spending across regions. Providers may respond to low commercial prices by shifting service volume into Medicare. Further investigation is needed to establish causality. © Health Research and Educational Trust.
    Health Services Research 11/2014; 50(3). DOI:10.1111/1475-6773.12262 · 2.78 Impact Factor
  • Value in Health 11/2014; 17(7):A503. DOI:10.1016/j.jval.2014.08.1518 · 3.28 Impact Factor
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    ABSTRACT: Background: COPD is a leading cause of death and disability in the United States. Patients with COPD are at a high risk of nutritional deficiency, which is associated with declines in respiratory function, lean body mass and strength, and immune function. Although oral nutritional supplementation (ONS) has been associated with improvements in some of these domains, the impact of hospital ONS on readmission risk, length of stay (LOS), and cost among hospitalized patients is unknown. Methods: Using the Premier Research Database, we first identified Medicare patients aged ≥ 65 years hospitalized with a primary diagnosis of COPD. We then identified hospitalizations in which ONS was provided, and used propensity-score matching to compare LOS, hospitalization cost, and 30-day readmission rates in a one-to-one matched sample of ONS and non-ONS hospitalizations. To further address selection bias among patients prescribed ONS, we also used instrumental variables analysis to study the association of ONS with study outcomes. Model covariates included patient and provider characteristics and a time trend. Results: Out of 10,322 ONS hospitalizations and 368,097 non-ONS hospitalizations, a one-to-one matched sample was created (N = 14,326). In unadjusted comparisons in the matched sample, ONS use was associated with longer LOS (8.7 days vs 6.9 days, P < .0001), higher hospitalization cost ($14,223 vs $9,340, P < .0001), and lower readmission rates (24.8% vs 26.6%, P = .0116). However, in instrumental variables analysis, ONS use was associated with a 1.9-day (21.5%) decrease in LOS, from 8.8 to 6.9 days (P < .01); a hospitalization cost reduction of $1,570 (12.5%), from $12,523 to $10,953 (P < .01); and a 13.1% decrease in probability of 30-day readmission, from 0.34 to 0.29 (P < .01). Conclusions: ONS may be associated with reduced LOS, hospitalization cost, and readmission risk in hospitalized Medicare patients with COPD.
    Chest 10/2014; 147(6). DOI:10.1378/chest.14-1368. · 7.48 Impact Factor
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    ABSTRACT: Disease-associated malnutrition (DAM) is a well-recognized problem in many countries, but the extent of its burden on the Chinese population is unclear. This article reports the results of a burden-of-illness study on DAM in 15 diseases in China. Using data from the World Health Organization (WHO), the China Health and Nutrition Survey, and the published literature, mortality and disability-adjusted life years (DALYs) lost because of DAM were calculated; a financial value of this burden was calculated following WHO guidelines. DALYs lost annually to DAM in China varied across diseases, from a low of 2248 in malaria to a high of 1 315 276 in chronic obstructive pulmonary disease. The total burden was 6.1 million DALYs, for an economic burden of US$66 billion (Chinese ¥ 447 billion) annually. This burden is sufficiently large to warrant immediate attention from public health officials and medical providers, especially given that low-cost and effective interventions are available.
    Asia-Pacific Journal of Public Health 10/2014; 27(4). DOI:10.1177/1010539514552702 · 1.46 Impact Factor
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    ABSTRACT: Background: The burden imposed by disease-associated malnutrition (DAM) on patients and the healthcare system in food-abundant industrialized countries is often underappreciated. This study measured the economic burden of community-based DAM in the United States. Methods: The burden of DAM was quantified in terms of direct medical costs, quality-adjusted life years lost, and mortality across 8 diseases (breast cancer, chronic obstructive pulmonary disease [COPD], colorectal cancer [CRC], coronary heart disease [CHD], dementia, depression, musculoskeletal disorders, and stroke). To estimate the total economic burden, the morbidity and mortality burden was monetized using a standard value of a life year and combined with direct medical costs of treating DAM. Disease-specific prevalence and malnutrition estimates were taken from the National Health Interview Survey and the National Health and Nutrition Examination Survey. Deaths by disease were taken from the Center for Disease Control and Prevention. Estimates of costs and morbidity were taken from the literature. Results: The annual burden of DAM across the 8 diseases was $156.7 billion, or $508 per U.S. resident. Nearly 80% of this burden was derived from morbidity associated with DAM; around 16% derived from mortality and the remainder from direct medical costs of treating DAM. The total burden was highest in COPD and depression, while the burden per malnourished individual was highest in CRC and CHD. Conclusion: DAM exacts a large burden on American society. Therefore, improved diagnosis and management of community-based DAM to alleviate this burden are needed.
    Journal of Parenteral and Enteral Nutrition 09/2014; 38(2 Suppl). DOI:10.1177/0148607114550000 · 3.15 Impact Factor
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    ABSTRACT: Background: Nutrition deficiency is common among hospitalized children. Although oral nutrition supplements (ONS) may improve malnutrition in this population, the benefits and healthcare costs associated with their use have not yet been fully explored. The objective of this study was to assess the effect of ONS use on inpatient length of stay (LOS) and episode cost in hospitalized children. Materials and methods: Retrospective analysis of 557,348 hospitalizations of children aged 2-8 years in the Premier Research Database. The effect of ONS use on LOS and episode cost in a propensity score- matched sample was estimated in analyses with and without the use of instrumental variables (IVs) to reduce confounding from unobserved variables. Results: ONS were prescribed in 6066 of 557,348 inpatient episodes (1.09%). In IV analysis, using a matched sample of 11,031 episodes, hospitalizations with ONS use had 14.8% shorter LOS (6.4 vs 7.5 days; 1.1 days [95% CI, 0.2-2.4]). Hospitalizations with ONS use had 9.7% lower cost ($16,552 vs $18,320; $1768 [95% CI, $1924-$1612]). Conclusions: ONS use was associated with lower LOS and episode cost among pediatric inpatients. ONS use in hospitalized pediatric patients may provide a cost-effective, evidence-based approach to improving pediatric hospital care.
    Journal of Parenteral and Enteral Nutrition 09/2014; 38(2 Suppl). DOI:10.1177/0148607114549769 · 3.15 Impact Factor
  • European geriatric medicine 09/2014; 5:S182. DOI:10.1016/S1878-7649(14)70483-8 · 0.73 Impact Factor
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    ABSTRACT: Objective To examine the impact of Medicaid prior authorization for atypical antipsychotics on the prevalence of schizophrenia among the prison population. Study Design We collected drug-level information on prior authorization restrictions from Medicaid programs in 30 states to determine which states had prior authorization requirements before 2004. We linked the regulatory data to a survey of prison inmates conducted in 2004. Methods We used a sample of 16,844 inmates from a nationally representative survey and analyzed the data using cross-sectional regression. To capture the impact of prior authorization, we estimated 2 models: the first included an indicator variable for states requiring prior authorization, and a second model used per capita atypical usage. Results Evidence indicated that prior authorization restrictions on atypical antipsychotics are associated with an increase in the odds of a schizophrenic resident being imprisoned in a state. State-level prior authorization requirements for atypical antipsychotics are associated with a 2.7% increase in the likelihood that an imprisoned inmate displays psychotic symptoms, and a 1.25 increase in the likelihood that an inmate was previously diagnosed with schizophrenia by a physician. Higher state-level atypical prescriptions per capita are also associated with lower likelihood of psychotic symptoms and of prior schizophrenia diagnosis among prisoners. Conclusions Prior authorization requirements for atypical antipsychotics, which are designed to reduce healthcare costs, are associated with greater prevalence of mental illness within the criminal justice system.This association raises important questions about whether increased costs to the criminal justice system might mitigate or offset prescription drug savings created by prior authorization requirements.
    The American journal of managed care 07/2014; 20(7):577-586. · 2.26 Impact Factor
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    ABSTRACT: Objective To demonstrate how expanding services covered by a “bundled payment” can also expand variation in the costs of treating patients under the bundle, using the Medicare dialysis program as an example.Data Sources/Study SettingObservational claims-based study of 197,332 Medicare hemodialysis beneficiaries enrolled for at least one quarter during 2006–2008.Study DesignWe estimated how resource utilization (all health services, dialysis-related services, and medications) changes with intensity of secondary hyperparathyroidism (sHPT) treatment.Data Extraction Methods Using Medicare claims, a patient-quarter level dataset was constructed, including a measure of sHPT treatment intensity.Principal FindingsUnder the existing, narrow dialysis bundle, utilization of covered services is relatively constant across treatment intensity groups; under a broader bundle, it rises more rapidly with treatment intensity.Conclusions The broader Medicare dialysis bundle reimburses providers uniformly, even though patients treated more intensively for sHPT cost more to treat. Absent any payment adjustments or efforts to ensure quality, this flat payment schedule may encourage providers to avoid high-intensity patients or reduce their treatment intensity. The first incentive harms efficiency. The second may improve or worsen efficiency, depending on whether it reduces appropriate or inappropriate treatment.
    Health Services Research 07/2014; 49(6). DOI:10.1111/1475-6773.12202 · 2.78 Impact Factor
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    ABSTRACT: Background: Increasingly sedentary lifestyles and dietary changes associated with economic development in China, combined with progress in the treatment of infectious disease have resulted in a shift in the disease burden - the so-called epidemiological transition. Cardiovascular disease (CVD), including coronary heart disease (CHD) and other non-communicable diseases now play an increasingly important role in the disease burden faced by China. However, little is known about the future burden of CHD morbidity and mortality, as well as the cost-effectiveness of particular CHD-prevention policies in China. Objectives: To estimate the impact of aging and epidemiological transition on the burden of CHD morbidity and mortality over the next 15 years in China and to estimate the net value of effective lipid management. Methods: First, we estimate the prevalence of CHD and other risk factors based on the China Health and Nutrition Survey. Next, using prediction from the literature regarding trends in demographic and cardiovascular risk factors, such as elevated low-density lipoprotein cholesterol (LDL-C), we model how CHD risk will evolve between 2015 and 2030. We then estimate how expanded use of statins for lipid management over the next 15 years would alter the prevalence of elevated LDL-C as a risk factor, and determine how this would dampen the future growth in CHD burden. Accounting for the costs of statin use, we assess the net value of a policy that expands statin utilization for lipid management in China. Results: We find that - left unchecked - rising prevalence of CHD risk factors and the aging of the Chinese population will lead to the incidence of heart attacks rising from 4 million in 2015 to over 6 million in 2030. Similarly, the number of CHD deaths will rise from 1.3 million in 2015 to over 2 million in 2030. Treating all hyperlipidemia patients with statins would avert 10.5 million heart attacks and 3.5 million CHD deaths between 2015 and 2030. Based on current estimates of treatment costs in China and the cost of statins, we predict that such a policy would produce a net social value of $176 to $226 billion over the next 15 years. Conclusions: In light of its aging population and continued economic development, China faces near-certain increases in the incidence of CHD morbidity and mortality. Preventative measures such as effective lipid management may reduce the CVD burden substantially and also provide large social value to the society. At a time when the Chinese government is taking steps towards a more systematic approach to health care delivery, primary and secondary prevention of CVD should be high on the agenda.
    Circulation Cardiovascular Quality and Outcomes 06/2014; 7:A227-A. · 5.66 Impact Factor
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    ABSTRACT: Medical professional liability (MPL) remains a significant burden for physicians, in general, and cardiologists, in particular, as recent research has shown that average MPL defense costs are higher in cardiology than other specialties. Knowledge of the clinical characteristics and outcomes of lawsuits against cardiologists may improve quality of care and risk management. We analyzed closed MPL claims of 40,916 physicians and 781 cardiologists insured by a large nationwide insurer for ≥1 policy year between 1991 and 2005. The annual percentage of cardiologists facing an MPL claim was 8.6%, compared with 7.4% among physicians overall (P < .01). Among 530 claims, 72 (13.6%) resulted in an indemnity payment, with a median size of $164,988. Mean defense costs for claims resulting in payment were $83,593 (standard deviation (s.d.) $72,901). The time required to close MPL claims was longer for claims with indemnity payment than claims without (29.6 versus 18.9 months; P < .001). More than half of all claims involved a patient's death (304; 57.4%), were based on inpatient care (379; 71.5%), or involved a primary cardiovascular condition (416; 78.4%). Acute coronary syndrome was the most frequent condition (234; 44.2%). Medical professional liability claims involving noncardiovascular conditions were common (66; 12.5%) and included falls or mechanical injuries had while under a cardiologist's care and a failure to diagnose cancer. Rates of malpractice lawsuits are higher among cardiologists than physicians overall. A substantial portion of claims are noncardiovascular in nature.
    American heart journal 05/2014; 167(5):690-6. DOI:10.1016/j.ahj.2014.02.007 · 4.46 Impact Factor
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    Value in Health 05/2014; 17(3):A179-A180. DOI:10.1016/j.jval.2014.03.1046 · 3.28 Impact Factor
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    S Seabury · D.N. Lakdawalla · D. Walter · J. Hayes · T. Gustafson · A. Shrestha · D.P. Goldman
    Value in Health 05/2014; 17(3):A222. DOI:10.1016/j.jval.2014.03.1297 · 3.28 Impact Factor

Publication Stats

2k Citations
464.55 Total Impact Points


  • 2009–2015
    • University of Southern California
      • Schaeffer Center for Health Policy and Economics
      Los Ángeles, California, United States
  • 2010–2014
    • University of California, Los Angeles
      Los Ángeles, California, United States
  • 2013
    • Precision Health Economics
      San Francisco, California, United States
  • 2012
    • University of Chicago
      • Department of Economics
      Chicago, Illinois, United States
  • 1998–2012
    • RAND Corporation
      Santa Monica, California, United States
  • 2004–2007
    • The National Bureau of Economic Research
      Cambridge, Massachusetts, United States
    • Stanford University
      Palo Alto, California, United States
    • Federal Reserve Bank of New York
      New York City, New York, United States
  • 2003
    • Concordia University–Ann Arbor
      Ann Arbor, Michigan, United States