Papers by Stephen Stemkowski
Public Administration and Public Policy, 2008
Journal of managed care pharmacy : JMCP
Postoperative ileus, a transient impairment of gastrointestinal motility, is a common cause of de... more Postoperative ileus, a transient impairment of gastrointestinal motility, is a common cause of delay in return to normal bowel function after abdominal surgery. Colectomy surgery patients who develop postoperative ileus could have greater health care resource utilization, including prolonged hospitalization, compared with those who do not develop postoperative ileus. Very few studies have assessed the impact of postoperative ileus on resource utilization and costs using retrospective analysis of administrative databases. To assess health care utilization and costs in colectomy surgery patients who developed postoperative ileus versus those who did not. A retrospective cohort study design was used. Adult patients with a principal procedure code for colectomy (ICD-9-CM procedure codes 45.71-45.79), discharged between January 1, 2004, and December 31, 2004, were identified from the Premier Perspective database of inpatient records from more than 500 hospitals in the United States. The ...
Seminars in cardiothoracic and vascular anesthesia, 2009
Hemostatic agents (HAs) are efficacious in reducing blood loss during surgery, which may affect p... more Hemostatic agents (HAs) are efficacious in reducing blood loss during surgery, which may affect postoperative length of stay (LOS). The purpose of this study was to compare the expected and actual LOS by HA in cardiac procedures. Hospital claims data between 2003 and 2006 were extracted from a US service-level comparative database. Four cohorts for comparison were FLOSEAL, SURGICEL + thrombin, GELFOAM + thrombin, and other. Expected LOS was derived using 2006 Centers for Medicare and Medicaid LOS by diagnosis-related group, and 2-part regression models were created to assess outcome. A total of 36 950 discharges were included. FLOSEAL was associated with less likelihood of exceeding expected LOS compared with baseline (odds ratio = 0.791; P < .01). Among patients who did exceed expected LOS, FLOSEAL patients did so at a reduced rate (incidence rate ratio = 0.891; P < .01). Further assessment is warranted to distinguish products with favorable outcomes.
Seminars in cardiothoracic and vascular anesthesia, 2009
This article summarizes techniques used in reoperative cardiac surgery, outlines a risk-stratifie... more This article summarizes techniques used in reoperative cardiac surgery, outlines a risk-stratified approach to operative planning, and reviews the literature on outcomes after reoperative valvular and coronary surgery.
Journal of managed care pharmacy : JMCP
Breast cancer is one of the most common forms of cancer in the United States, with approximately ... more Breast cancer is one of the most common forms of cancer in the United States, with approximately 10% of newly diagnosed patients presenting with metastatic disease. Limited therapy options make the successful treatment of metastatic breast cancer (MBC) difficult. Current treatment options include drugs belonging to the classes of anthracyclines and taxanes as well as the drug capecitabine. Resistance to these classes of drugs is often acquired, thus highlighting the need for newer agents capable of managing treatment resistant disease. Ixabepilone is an antineoplastic agent from the epothilone class that was FDA-approved in October 2007 for the treatment of metastatic or locally advanced breast cancer. The FDA-approved indications for ixabepilone specify (a) use of ixabepilone in combination with capecitabine for the treatment of patients with metastatic or locally advanced breast cancer after (resistance to) treatment with an anthracycline and a taxane, or whose cancer is taxane re...
Advances in Skin & Wound Care, 2009
The cost of treating complex traumatic wounds is substantial because of trauma severity, potentia... more The cost of treating complex traumatic wounds is substantial because of trauma severity, potential for infection, and delayed closure. Negative pressure wound therapy using reticulated open cell foam (NPWT/ROCF) as delivered by Vacuum-Assisted Closure* (KCI Licensing, Inc, San Antonio, Texas) is an established, viable option for treating traumatic wounds. The authors used retrospective data to study the clinical and cost-effective benefits of using NPWT/ROCF early on day 1 or day 2 of treatment for traumatic wounds as compared with using it late (on day 3 or later). Hospital data records from trauma wound patients treated with NPWT/ROCF were retrospectively analyzed. Data were subdivided into 2 groups based on start of treatment. The group of patients treated on day 1 or 2 of their hospital stay was referred to as the early group, and that composed of patients treated on day 3 or later as the late group. Clinical and cost-effective metrics were compared between the 2 groups. For the early group, 518 patient records were included; 1000 records were reviewed for the late group. Early-group patients had fewer hospital inpatient days (10.6 vs 20.6 days; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001), fewer treatment days (5.1 vs 6.0 days; P = .0498), shorter intensive care unit (ICU) stays (5.3 vs 12.4 days; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001), and higher ICU admission rates (51.5 vs 44.5%; P = .0091) than the late group. Compared with late-group patients, early-group patients had lower total and variable costs per patient discharge ($43,956 vs $32,175; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001 and $22,891 vs $15,805; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001, respectively). Acute-care trauma wound patients receiving early NPWT/ROCF demonstrated significant reductions in length of stay, treatment days, and ICU stay, which resulted in significant reduced patient treatment costs. These results indicate that early intervention with NPWT/ROCF has potential clinical and cost-effective benefits for the treatment of traumatic wounds.
Journal of Clinical Oncology, 2016
Open Forum Infectious Diseases, 2016
Journal of the American College of Cardiology, 2016
Journal of Managed Care & Specialty Pharmacy, 2016
Several systemic therapies are now approved for first- and second-line treatment of metastatic re... more Several systemic therapies are now approved for first- and second-line treatment of metastatic renal cell carcinoma (mRCC). Although the National Comprehensive Cancer Network (NCCN) guidelines offer physicians evidence-based recommendations for therapy, there are few real-world studies to help inform the utilization of these agents in clinical practice. To (a) describe the patterns of use associated with systemic therapies for mRCC among Humana members in the United States diagnosed with mRCC, (b) assess consistency with the NCCN guidelines for treatment, and (c) to describe the initial first-line therapy regimen by prescriber specialty and site of care. This was a retrospective study using Humana&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s claims database of commercially insured patients and patients insured by the Medicare Advantage Prescription Drug plan. The study period was from January 1, 2007, to December 31, 2013. Patients with mRCC were identified by ICD-9-CM codes 189.0/189.1 and 196.xx to 199.xx; all patients were between 18 and 89 years of age, had received systemic therapy for their disease, and were followed up for 180 days. Outcome measures included choice of initial systemic therapy, starting and ending doses, first-line treatment persistence and compliance, and choice of second-line therapy. Persistence was measured using time to discontinuation of first-line therapy and proportion of days covered (PDC; the ratio of [total days of drug available minus days of supply of last prescription] to [last prescription date minus first prescription date]). Compliance was measured using the medication possession ratio (MPR; the ratio of [total days supply minus days supply of last prescription] to [last prescription date minus first prescription date]). A total of 649 patients met all inclusion criteria; 109 were insured by commercial plans and 540 were insured by Medicare. The mean ± SD age of patients was 68.6 ± 9.4 years, and 68.6% were male; Medicare patients were older than commercial patients (71.7 ± 7.4 vs. 56.6 ± 9.1 years, respectively; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). The most common comorbidities among the patient population were hypertension, hyperlipidemia, diabetes, and heart disease. The majority of patients (68.6%) received an oral tyrosine kinase inhibitor (TKI) as their first line of therapy: 43.9% received sunitinib, 14.0% received sorafenib, 10.0% received pazopanib, and 0.6% received axitinib. Mean ± SD time to discontinuation of first-line TKI treatment was 169.1 ± 29.5 days with sunitinib, 160.3 ± 41.1 days with pazopanib, and 160.1 ± 41.4 days with sorafenib. Other first-line therapies included inhibitors of mammalian target of rapamycin (mTOR) (19.7%) and the antivascular endothelial growth factor agent bevacizumab (9.4%). Among patients receiving mTOR inhibitors, 14.8% were started on temsirolimus and 4.9% were started on everolimus. The median starting and ending doses were the same for each drug except for sunitinib. Mean ± SD times to discontinuation of temsirolimus, everolimus, and bevacizumab were 171.8 ± 26.2, 137.0 ± 62.2, and 150.8 ± 56.0 days, respectively. Persistence on first-line regimen as measured by PDC was high (PDC ≥ 80%) for 89% of oral therapies and 77% of injectable therapies; first-line compliance was high (MPR ≥ 80%) for 77% of oral therapies and 68% of injectables. Among patients who received second-line therapy, the most common regimen was everolimus (29.2%), followed by bevacizumab (19.8%), temsirolimus (15.6%), and sunitinib (13.6%). Specialty codes obtained from the database provider identified internal medicine specialists and oncologists as the most common prescribers of TKIs and mTOR inhibitors. Patterns of use were similar for each of the prescribed systemic treatments for mRCC, and the majority of patients were highly persistent and compliant with first-line therapies. Time to treatment discontinuation was slightly longer with oral agents compared with injectable drugs. This study was supported by GlaxoSmithKline (GSK); pazopanib is an asset of Novartis AG as of March 1, 2015. Miller is an employee of Sanofi with stock/stock options and was an employee of GSK at the time of this study. Stemkowski, Saverno, Lane, and Tao are employees of Comprehensive Health Insights, Humana, which was contracted and paid by GSK to conduct the study. Hackshaw is an employee of Novartis and was an employee of GSK with stock/stock options at the time of this study. Loy is an employee of Humana with stock/stock options. Study concept and design were contributed by Miller, Saverno, Hackshaw, and Loy. Data collection was done by Stemkowski, Lane, and Tao, and data interpretation was performed by Miller, Stemkowski, Lane, Tao, Hackshaw, and Loy. The manuscript was written and revised by Miller, Stemkowski, Saverno, Lane, Tao, Hackshaw, and Loy.
Thrombosis and Haemostasis, May 1, 2008
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Clinical advances in hematology & oncology: H&O
Background: Cancer is associated with an increased risk of venous thromboembolism (VTE) in hospit... more Background: Cancer is associated with an increased risk of venous thromboembolism (VTE) in hospitalized patients. Despite availability of evidence-based guidelines recommending thromboprophylaxis in cancer patients, many cancer patients do not receive appropriate thromboprophylaxis. This study provides a large, realworld analysis of the rates of thromboprophylaxis use in hospitalized cancer patient discharges. Methods: Hospital discharge information from the Premier Perspective inpatient database from January 2002-September 2005 was used. Included discharges had a principal diagnosis of cancer, were aged 40 years or older, had a length of hospital stay of 6 days or more, and had no contraindications for anticoagulation. The rate of appropriate VTE prophylaxis was determined according to the 7th American College of Chest Physicians guidelines, taking into account mechanical compression and chemoprophylaxis, dosage of anticoagulant, and duration of therapy. Results: A total of 72,337 cancer discharges with an indication for thromboprophylaxis were identified (30,124 surgical, 42,213 nonsurgical). The overall rate of any level of VTE prophylaxis was 53.6%; however, the rate of appropriate thromboprophylaxis (according to the 7th ACCP guidelines) was 27.0% (27.0% surgical, 27.1% nonsurgical). The most common reason for inappropriate prophylaxis (46.0% of all discharges) was no prophylaxis received, despite having no contraindication to anticoagulation. Conclusions: This study highlights that despite the presence of evidence-based guidelines, appropriate thromboprophylaxis is severely underused in all types of at-risk cancer patients. Greater efforts are needed to improve the implementation of guidelines, and to ensure that more cancer patients receive appropriate thromboprophylaxis.
International journal of chronic obstructive pulmonary disease, 2012
Exacerbations of chronic obstructive pulmonary disease (COPD) lead to significant increases in re... more Exacerbations of chronic obstructive pulmonary disease (COPD) lead to significant increases in resource utilization and cost to the health care system. COPD patients with chronic bronchitis and a history of exacerbations pose an additional burden to the system. This study examined health care utilization and cost among these patients. For this retrospective analysis, data were extracted from a large national health plan with a predominantly Medicare population. This study involved patients who were aged 40-89 years, had been enrolled continuously for 24 months or more, had at least two separate insurance claims for COPD with chronic bronchitis (International Classification of Diseases, Ninth Revision, Clinical Modification code 491.xx), and had pharmacy claims for COPD maintenance medications between January 1, 2007, and March 31, 2009. Two years of data were examined for each patient; the index date was defined as the first occurrence of COPD. Baseline characteristics were obtained...
Thrombosis and haemostasis, 2008
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Clinical advances in hematology & oncology : H&O, 2008
Cancer is associated with an increased risk of venous thromboembolism (VTE) in hospitalized patie... more Cancer is associated with an increased risk of venous thromboembolism (VTE) in hospitalized patients. Despite availability of evidence-based guidelines recommending thromboprophylaxis in cancer patients, many cancer patients do not receive appropriate thromboprophylaxis. This study provides a large, real-world analysis of the rates of thromboprophylaxis use in hospitalized cancer patient discharges. Hospital discharge information from the Premier Perspective inpatient database from January 2002-September 2005 was used. Included discharges had a principal diagnosis of cancer, were aged 40 years or older, had a length of hospital stay of 6 days or more, and had no contraindications for anticoagulation. The rate of appropriate VTE prophylaxis was determined according to the 7th American College of Chest Physicians guidelines, taking into account mechanical compression and chemoprophylaxis, dosage of anticoagulant, and duration of therapy. A total of 72,337 cancer discharges with an ind...
American journal of medical quality : the official journal of the American College of Medical Quality, Jan 5, 2014
Novel approaches for assessing patients with chest pain and related symptoms may improve outpatie... more Novel approaches for assessing patients with chest pain and related symptoms may improve outpatient care. The REGISTRY I study measured the impact of a personalized gene expression score (GES) on subsequent cardiac referral decisions by primary care providers. Of the 342 stable, nonacute patients evaluated, the mean age was 55 years, 53% were female, and mean (SD) GES was 16 (±10) (range = 1-40). Low GES (≤15), indicating a low current likelihood of obstructive coronary artery disease (CAD), was observed in 49% of patients. After clinical covariate adjustment, each 10-point GES decrease was associated with a 14-fold decreased odds of cardiac referral (P < .0001). Low GES patients had 94% reduced odds of referral relative to elevated GES patients (P < .0001), with follow-up supporting a favorable safety profile. This genomic-based test demonstrated clinical utility by guiding decision making during assessment of symptomatic patients with suspected obstructive CAD.
Hospital practice (1995), 2010
To calculate and compare the direct medical costs of guideline-recommended prophylaxis with proph... more To calculate and compare the direct medical costs of guideline-recommended prophylaxis with prophylaxis that does not fully adhere with guideline recommendations in a large, real-world population. Discharge records were retrieved from the US Premier Perspective™ database (January 2003-December 2003) for patients aged≥40 years with a primary diagnosis of cancer, chronic heart failure, lung disease, or severe infectious disease who received some form of thromboprophylaxis. Univariate analysis and multivariate regression modeling were performed to compare direct medical costs between discharges who received appropriate prophylaxis (correct type, dose, and duration based on sixth edition American College of Chest Physicians [ACCP] recommendations) and partial prophylaxis (not in full accordance with ACCP recommendations). Market segmentation analysis was used to compare costs stratified by hospital and patient characteristics. Of the 683 005 discharges included, 148,171 (21.7%) received...
Journal of Thrombosis and Haemostasis, 2007
Background: As hospitalized medical patients may be at risk of venous thromboembolism (VTE), evid... more Background: As hospitalized medical patients may be at risk of venous thromboembolism (VTE), evidence-based guidelines are available to help physicians assess patientsÕ risk for VTE, and to recommend prophylaxis options. The rate of appropriate thromboprophylaxis use in at-risk medical inpatients was assessed in accordance with the 6th American College of Chest Physicians (ACCP) guidelines. Methods: Hospital discharge information from the Premier Perspective TM inpatient data base from January 2002 to September 2005 was used. Included patients were 40 years old or more, with a length of hospital stay of 6 days or more, and had no contraindications for anticoagulation. The appropriateness of VTE thromboprophylaxis was determined in seven groups with acute medical conditions by comparing the daily thromboprophylaxis usage, including type of thromboprophylaxis, dosage of anticoagulant and duration of thromboprophylaxis, with the ACCP recommendations. Results: A total of 196 104 discharges from 227 hospitals met the inclusion criteria. The overall VTE thromboprophylaxis rate was 61.8%, although the appropriate thromboprophylaxis rate was only 33.9%. Of the 66.1% discharged patients who did not receive appropriate thromboprophylaxis, 38.4% received no prophylaxis, 4.7% received mechanical prophylaxis only, 6.3% received an inappropriate dosage, and 16.7% received an inappropriate prophylaxis duration based on ACCP recommendations. Conclusions: This study highlights the low rates of appropriate thromboprophylaxis in US acutecare hospitals, with two-thirds of discharged patients not receiving prophylaxis in accordance with the 6th ACCP guidelines. More effort is required to improve the use of appropriate thromboprophylaxis in accordance with the ACCP recommendations.
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Papers by Stephen Stemkowski