Ezekiel J Emanuel’s research while affiliated with University of Pennsylvania and other places

Importance Adherence to glucagon-like peptide-1 receptor agonists (GLP-1 RAs) is important for their effectiveness. Discontinuation and reinitiation patterns are not well understood. Objective To describe rates of and factors associated with discontinuation and subsequent reinitiation of GLP-1 RAs among adults with overweight or obesity. Design, Setting, and Participants In this retrospective cohort study, 125 474 adults with overweight or obesity newly initiated treatment with a dual-labeled GLP-1 RA (liraglutide, semaglutide, or tirzepatide) between January 1, 2018, and December 31, 2023, with a baseline body mass index of 27 or more, an available weight measurement within 60 days before initiation, and regular care in the year before initiation were identified using electronic health record data from a collective of US health care systems. Patients were followed up for up to 2 years to assess discontinuation and for 2 additional years to assess reinitiation. Exposure Patients were stratified by presence of type 2 diabetes at baseline. Main Outcomes and Measures Proportions of patients discontinuing and reinitiating GLP-1 RA were estimated from Kaplan-Meier models. Associations of sociodemographic characteristics, health factors, weight changes, and gastrointestinal adverse events with discontinuation and reinitiation outcomes were modeled using time-varying Cox proportional hazards regression models. All analyses were conducted separately for patients with and patients without type 2 diabetes. Results In this cohort study of 125 474 adults (mean [SD] age, 54.4 [13.1] years; 82 063 women [65.4%]), 76 524 (61.0%) had type 2 diabetes. One-year discontinuation was significantly higher for patients without type 2 diabetes (64.8% [95% CI, 64.4%-65.2%]) compared with those with type 2 diabetes (46.5% [95% CI, 46.2%-46.9%]). Higher weight loss (1% reduction in weight from baseline was associated with a 3.1% [95% CI, 2.9%-3.2%] lower hazard of discontinuation for patients with type 2 diabetes and a 3.3% [95% CI, 3.2%-3.5%] lower hazard of discontinuation for patients without type 2 diabetes) and higher income (type 2 diabetes only; >$80 000: hazard ratio [HR], 0.72 [95% CI, 0.69-0.76]) were significantly associated with lower rates of discontinuation, while moderate or severe incident gastrointestinal adverse events were associated with a higher hazard of discontinuation (with type 2 diabetes: HR, 1.38 [95% CI, 1.31-1.45]; without type 2 diabetes: HR, 1.19 [95% CI, 1.12-1.27]). Of 41 792 patients who discontinued and had a discontinuation weight measurement available, 1-year reinitiation was lower for those without type 2 diabetes (36.3% [95% CI, 35.6%-37.0%]) compared with those with type 2 diabetes (47.3% [95% CI, 46.6%-48.0%]). Weight regain of 1% from discontinuation was significantly associated with increased hazards of reinitiation of 2.3% (95% CI, 1.9%-2.8%) for patients with type 2 diabetes and 2.8% (95% CI, 2.4%-3.2%) for patients without type 2 diabetes. Conclusions and Relevance In this cohort study, most patients with overweight or obesity discontinued GLP-1 RA therapy within 1 year, but those without type 2 diabetes had higher discontinuation rates and lower reinitiation rates. Inequities in access and adherence to effective treatments have the potential to exacerbate disparities in obesity.

The World Bank’s report, Open and inclusive: fair processes for financing universal health coverage, represents an important effort to specify the benefits and criteria of fair processes in health financing decisions. Here we argue that the report’s justification for increasing public engagement in health financing decisions, one of its most novel contributions, rests on a widely shared but flawed assumption that public engagement will produce more equitable outcomes. Examining evidence from national-level public engagement initiatives cited in the report, we argue that there is no reason to assume that engaged publics will prioritize equity over other relevant values such as the maximization of population health. We conclude that instead of seeing public engagement as a tool for advancing particular values, policy-makers should view it as a neutral way of assessing what the public values and gathering insights that can inform the design of health benefits packages. If policy-makers wish to prioritize equity, they should do so directly through substantive policy choices regarding the design and financing of coverage schemes.

Importance Adherence to GLP-1 RA is important for efficacy. Discontinuation and reinitiation patterns for patients with and without type 2 diabetes (T2D) are not well-understood. Objective To describe rates and factors associated with discontinuation and reinitiation of GLP-1 RA, for patients with and without T2D. Design In this retrospective cohort study, adults with overweight or obesity initiated on GLP-1 RA between January 2018 and December 2023 were identified using electronic health record (EHR) data from a collective of 30 US healthcare systems. Patients were followed for up to 2 years to assess discontinuation and for 2 additional years to assess reinitiation. Setting Clinical and prescribing data from EHRs linked to dispensing information Participants Adults newly initiated on GLP-1 RA between 2018 and 2023, with a baseline BMI ≥27 and an available weight measurement within 60 days before initiation, and regular care in the year before initiation. Exposure/Covariates Patients were stratified by presence of T2D at baseline. Associations with socio-demographics, health factors, weight changes, and gastrointestinal (GI) adverse events (AE) were modeled. Main Outcomes and Measures Proportion of patients discontinuing and reinitiating GLP-1 RA were estimated from Kaplan-Meier models. Associations between covariates and discontinuation and reinitiation outcomes were modeled using time-varying Cox proportional hazards models. All analyses were conducted for patients with and without T2D. Results Among 96,544 adults initiating GLP-1 RA, the mean (SD) age was 55.1 (13.3) years, 65.2% were female, 73.7% were white, and 61.3% had T2D. Individual income exceeded $50,000 for 49.7% of patients with and 57.2% of patients without T2D. One-year discontinuation was significantly higher for patients without T2D (65.1%), compared to those with T2D (45.8%). Higher weight loss, absence of GI AE, and higher income (T2D only) were significantly associated with higher discontinuation. Of 28,142 who discontinued and had a discontinuation weight available, one-year reinitiation was lower for those without T2D (34.7%), compared to those with T2D (51.0%). Weight re-gain was significantly associated with increased reinitiation. Conclusions and Relevance Most patients with overweight or obesity discontinue GLP-1 RA within 1 year, but those without T2D discontinue at higher rates and reinitiate at lower rates. Inequities in access and adherence to effective treatments have the potential exacerbate disparities in obesity. Key points Question How frequently do adults with overweight or obesity discontinue and subsequently reinitiate GLP-1 RA? What factors are associated with these outcomes? Findings In this study of 96,544 patients initiating GLP-1 RA, 46% of patients with and 65% without type 2 diabetes (T2D) discontinued within 1 year. Weight loss, income, gastrointestinal adverse events, and comorbidities were significantly associated with discontinuation. Following discontinuation, 51% of patients with and 35% without T2D reinitiated within a year. Weight re-gain since discontinuation was significantly associated with reinitiation. Meaning While most patients discontinue GLP-1 RA within a year, discontinuation is significantly higher and reinitiation is significantly lower for patients without T2D. Weight changes, tolerability, and proxies of access to care are significantly associated with sustained treatment.

Background: Among patients with serious illness, palliative care before hospice enrollment is associated with improved quality of life, reduced symptom burden, and earlier transitions to hospice. However, fewer than half of eligible patients receive specialty palliative care referrals. As most hospice clinicians and administrators have experience in specialty palliative care, several emerging programs propose engaging hospice clinicians to provide early palliative care. Objective: We sought to identify barriers and facilitators to upstream palliative care. Design: We conducted a key informant qualitative study among hospice administrators and clinicians. Setting/Subjects: We conducted semi-structured interviews with 23 hospice administrators and clinicians in eight states from March to August 2022. We identified participants using snowball and purposive sampling using states that participate in Medicare Advantage's value-based insurance design Model. Results: Respondents indicated that barriers to early palliative care included inadequate staffing and reimbursement. Hospice clinicians providing community-based palliative care can address access barriers and improve transitions to hospice. Respondents expressed desire for payer guidance in identifying eligible patients but were cautious about payers acting as direct palliative care providers. However, payers could facilitate uptake by broadening and specifying coverage of services to include goals of care conversations and symptom management. Routine referrals initiated by objective measures could potentially increase access. Conclusions: Utilizing hospice providers to provide upstream palliative care can increase access, improve outcomes, and ease the transition to hospice.

US health care use declined during the initial phase of the COVID-19 pandemic in 2020. Although utilization is known to have recovered in 2021 and 2022, it is unknown how revenue in 2020-22 varied by physician specialty and practice setting. This study linked medical claims from a large national federation of commercial health plans to physician and practice data to estimate pandemic-associated impacts on physician revenue (defined as payments to eligible physicians) by specialty and practice characteristics. Surgical specialties, emergency medicine, and medical subspecialties each experienced a greater than 9 percent adjusted gross revenue decline in 2020 relative to prepandemic baselines. By 2022, pathology and psychiatry revenue experienced robust recovery, whereas surgical and oncology revenue remained at or below baseline. Revenue recovery in 2022 was greater for physicians practicing in hospital-owned practices and in practices participating in accountable care organizations. Pandemic-associated revenue recovery in 2021 and 2022 varied by specialty and practice type. Given that physician financial instability is associated with health care consolidation and leaving practice, policy makers should closely monitor revenue trends among physicians in specialties or practice settings with sustained gross revenue reductions during the pandemic.