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Bo Ding,1 Rebecca Zaha,2 Naoyuki Makita,3 Sophie Graham,4,5 Dimitra Lambrelli,4 Samuel Huse,6 Hana Müllerová,7 Clementine Nordon,7 Shigeo Muro8 1BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden; 2Formerly of Data Analytics, Evidera, Bethesda, MD, USA; 3Medical Department, AstraZeneca K.K, Kita-ku, Osaka, Japan; 4Data Analytics, Evidera, London, UK; 5Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK; 6Data Analytics, Evidera, Bethesda, MD, USA; 7BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK; 8Department of Respiratory Medicine, Nara Medical University, Nara, JapanCorrespondence: Clementine Nordon, AstraZeneca, 136 Hills Road, Cambridge, CB2 8PA, UK, Tel +44 7425 617 995, Email Clementine.nordon@astrazeneca.comBackground: Little is known about the association between respiratory events prior to diagnosis of chronic obstructive pulmonary disease (COPD) and future clinical outcomes in Japan. We investigated the association between pre-COPD diagnosis respiratory events and the incidence of exacerbations in a cohort of newly diagnosed COPD patients in Japan.Patients and Methods: Data were retrieved from the JMDC claims database. Patients ≥ 40 years old with a first COPD diagnosis (≥ 1 hospitalization or ≥ 2 outpatient claims for COPD) between 2010 and 2016 were included. The incidence rate (IR) of exacerbations in patients with or without any respiratory event (including lower respiratory tract infection and respiratory failure) in the year preceding diagnosis was compared. A negative binomial model explored the association between pre-diagnosis respiratory event and IR ratio (IRR) of exacerbations.Results: A total of 20,212 patients newly diagnosed with COPD were identified: 61% male, mean age 55 years (SD 9); of these, 955 (4.7%) had experienced ≥ 1 respiratory event in the year preceding diagnosis. Median duration of follow-up was 3.3 years during which the IR of exacerbations was 0.31 per patient-year (95% confidence interval [CI] 0.29– 0.33) in patients with respiratory event, and 0.11 (95% CI 0.10– 0.13) in patients without. The IR for severe exacerbation was nearly 10 times greater in patients with respiratory event versus without. Experiencing respiratory event pre-diagnosis was independently associated with an increased IRR of future moderate-to-severe exacerbation (adjusted IRR, 2.7; 95% CI 2.3– 3.1).Conclusion: Patients experiencing respiratory events in the year preceding COPD diagnosis should be considered at-risk of worse clinical COPD outcomes.Keywords: COPD diagnosis, lower respiratory tract infection, exacerbation, outcome

PURPOSE: The 2018 American Heart Association/American College of Cardiology (AHA/ACC) cholesterol guideline defines very high atherosclerotic cardiovascular disease (ASCVD) risk as a history of ≥2 major ASCVD events or 1 major ASCVD event and multiple high-risk conditions. We tested if a simplified approach, having a history of a major ASCVD event, would identify a high proportion of patients that meet the 2018 AHA/ACC cholesterol guideline criteria for very high risk. METHODS: We analyzed data from US adults with health insurance in the MarketScan database who had experienced an acute coronary syndrome in the past year (recent ACS, n=3,626), a myocardial infarction (MI) other than a recent ACS (n=7,572), an ischemic stroke (n=3,551) or symptomatic peripheral artery disease (PAD, n=5,919). Patients were followed from January 1, 2016 through December 31, 2017 for recurrent ASCVD events. RESULTS: Among 16,344 patients with a history of a major ASCVD event, 94.0% met the 2018 AHA/ACC cholesterol guideline definition for very high risk including 92.9%, 96.5%, 93.1%, and 96.2% with a recent ACS, history of MI, history of stroke and symptomatic PAD, respectively. The incidence of ASCVD events per 1,000 person-years was 50.4 (95% CI: 47.6-53.3) among all patients with a history of a major ASCVD event versus 53.1 (95% CI: 50.1-56.1) among patients who met the 2018 AHA/ACC cholesterol guideline definition of very high risk. CONCLUSION: The vast majority of patients with a recent ACS, history of MI, ischemic stroke or symptomatic PAD meet the 2018 AHA/ACC cholesterol guideline definition of very high risk.

Objective: To assess variations in hospitalizations, emergency department/observational (ED/OB) stays not resulting in hospitalization, reasons for hospitalization, and hospitalization discharge destinations after chemotherapy, information not provided as part of Oncology Care Model (OCM) baseline data. Methods: OCM methodology was applied to the Medicare 20% sample data to identify 6-month patient episodes triggered by chemotherapy in 2012-2015. Proportions of episodes with hospitalization or ED/OB stays, reasons for hospitalization, and discharge destinations were summarized. Results: Of 485,186 6-month episodes for 255,229 patients in 13,823 practices, 25% of episodes led to ≥1 hospitalization (from 14% in breast cancer to 56% in acute leukemia), and 23% to ED/OB stays (from 18% in breast cancer to 36% in liver cancer). In 2,995 practices with ≥20 total episodes, practice-level proportions of episodes with hospitalization ranged from 14% to 31% (20th-80th percentile) and with ED/OB stays from 17% to 29%. For all cancers combined, the most frequent reasons for hospitalization were infection (13%), anemia (7%), dehydration (5%), and congestive heart failure (3%); the most common discharge destinations were home (71%) followed by a skilled nursing facility (13%), death (6%), and hospice (5%). Reasons for hospitalization and discharge destinations varied by cancer type; acute leukemia episodes led to the highest rates of infection and anemia, and central nervous system tumor episodes to the highest proportions of death or hospice discharge. Conclusion: The variations in frequency of and reasons for hospitalization, ED/OB stays, and hospitalization discharge destinations across cancer types should be considered when evaluating OCM practice performance.

Background The 2018 American Heart Association/American College of Cardiology (AHA/ACC) cholesterol guideline includes recommendations for intensive lipid-lowering therapy in patients at very high risk for atherosclerotic cardiovascular disease (ASCVD) events. Objectives This study sought to estimate event rates among adults with a history of ASCVD who met and did not meet the definition of very high risk in the 2018 AHA/ACC cholesterol guideline. Methods Data from U.S. adults with health insurance in the MarketScan database who had a history of ASCVD on January 1, 2016 (n = 27,775) were analyzed. Very high risk for ASCVD events was defined as a history of ≥2 major ASCVD events or 1 event and ≥2 high-risk conditions. Patients were followed through December 31, 2017, for ASCVD events, including myocardial infarction, ischemic stroke, and major adverse limb events. Results Overall, 15,366 patients (55.3%) with ASCVD met the definition of very high risk. Among patients with and without very high risk, the ASCVD event rate per 1,000 person-years was 53.1 (95% confidence interval [CI]: 50.1 to 56.1) and 17.0 (95% CI: 15.2 to 18.9), respectively. Among patients with ≥2 major ASCVD events and with 1 event and ≥2 high-risk conditions, the ASCVD event rate per 1,000 person-years was 89.8 (95% CI: 82.2 to 98.0) and 41.3 (95% CI: 38.3 to 44.4), respectively. The age- and sex-adjusted hazard ratios for ASCVD events among patients with very high risk, overall, with ≥2 major ASCVD events and with 1 event and ≥2 high-risk conditions versus those without very high risk were 2.98 (95% CI: 2.63 to 3.37), 4.89 (95% CI: 4.22 to 5.66), and 2.33 (95% CI: 2.04 to 2.66), respectively. Conclusions The 2018 AHA/ACC cholesterol guideline directs intensive lipid-lowering therapy to adults with a very high ASCVD event rate.

Background Guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) is recommended before primary prevention implantable cardioverter-defibrillator (ICD) placement. Adherence to this recommendation and associated outcomes are unknown. Objectives This study examined the use of GDMT (≥1 prescription filled for both a renin-angiotensin inhibitor [RAI] and a heart failure–approved beta-blocker [HFBB]) within 90 days before primary prevention ICD placement in patients with HFrEF. Methods Data from the National Cardiovascular Data Registry ICD Registry were merged with a 40% random sample of Medicare administrative data. Prescription fills for recipients of primary prevention ICD between 2007 and 2011 were examined, analyzing GDMT overall and for each U.S. hospital referral region. We identified characteristics associated with GDMT and the association with 1-year mortality. Results Among 19,733 patients with HFrEF and primary prevention ICD, 61.1% filled any GDMT before implantation. Across hospital referral regions, GDMT was applied in 51% to 71%. The strongest predictors of any GDMT included absence of chronic renal disease or nonsustained ventricular tachycardia, low-income prescription benefits subsidy, and less recent left ventricular ejection fraction evaluation. Patients receiving GDMT versus those without had a lower 1-year mortality rate after ICD implantation (11.1% vs. 16.2%), even after adjustment for comorbidities, left ventricular ejection fraction, and functional heart failure class. Conclusions Rates of GDMT for HFrEF before primary prevention ICD implantation were low, and failure to achieve GDMT was associated with significantly decreased 1-year survival.

Objective Patients with type II diabetes have an increased risk of bladder cancer and are commonly treated with thiazolidinediones and angiotensin receptor blockers (ARBs), which have been linked to cancer risk. We explored the relationship between use of one or both of these medication types and incident bladder cancer among diabetic patients (diabetics) enrolled in Medicare. Research Design and Methods We constructed both a prevalent and incident retrospective cohort of pharmacologically treated prevalent diabetics enrolled in a Medicare fee-for-service plan using inpatient, outpatient (2003–2011) and prescription (2006–2011) administrative data. The association of incident bladder cancer with exposure to pioglitazone, rosiglitazone and ARBs was studied using muitivariable Cox’s hazard models with time-dependent covariates in each of the two cohorts. Results We identified 1,161,443 prevalent and 320,090 incident pharmacologically treated diabetics, among whom 4433 and 1159, respectively, developed incident bladder cancers. In the prevalent cohort mean age was 75.1 years, mean follow-up time was 38.0 months, 20.2% filled a prescription for pioglitazone during follow-up, 10.4% received rosiglitazone, 31.6% received an ARB and 8.0% received combined therapy with pioglitazone + ARB. We found a positive association between bladder cancer and duration of pioglitazone use in the prevalent cohort (P for trend = 0.008), with ≥24 months of pioglitazone exposure corresponding to a 16% (95% confidence interval 0–35%) increase in the incidence of bladder cancer compared to no use. There was a positive association between bladder cancer and rosiglitazone use for

Insurance coverage for young adults has increased since 2010, when the Affordable Care Act (ACA) required insurers to permit children to remain on parental policies until age 26 as dependents. This study estimated the association between the dependent coverage provision and changes in young adults' use of hospital-based services for substance use disorders and non-substance use psychiatric disorders.The authors conducted a quasi-experimental comparison of a national sample of non-childbirth-related inpatient admissions to general hospitals (a total of 2,670,463 admissions, 430,583 of which had primary psychiatric diagnoses) and California emergency department visits with psychiatric diagnoses (N=11,139,689), using data spanning 2005 to 2011. Analyses compared young adults who were targeted by the ACA dependent coverage provision (19- to 25-year-olds) and those who were not (26- to 29-year-olds), estimating changes in utilization before and after implementation of the dependent coverage provision. Primary outcome measures included quarterly inpatient admissions for primary diagnoses of any psychiatric disorder per 1,000 population; emergency department visits with any psychiatric diagnosis per 1,000 population; and payer source.Dependent coverage expansion was associated with 0.14 more inpatient admissions for psychiatric diagnoses per 1,000 for 19- to 25-year-olds (targeted by the ACA) than for 26- to 29-year-olds (not targeted by the ACA). The coverage expansion was associated with 0.45 fewer psychiatric emergency department visits per 1,000 in California. The probability that inpatient admissions nationally and emergency department visits in California were uninsured decreased significantly.ACA dependent coverage provisions produced modest increases in general hospital psychiatric inpatient admissions and higher rates of insurance coverage for young adults nationally. Lower rates of emergency department visits were observed in California.

We evaluated the prevalence and geographic variation of short-interval (repeated in under 2 years) dual-energy X-ray absorptiometry tests (DXAs) among Medicare beneficiaries. Short-interval DXA use varied across regions (coefficient of variation = 0.64), and unlike other DXAs, rates decreased with payment cuts. The American College of Rheumatology, through the Choosing Wisely initiative, identified measuring bone density more often than every 2 years as care “physicians and patients should question.” We measured the prevalence and described the geographic variation of short-interval (repeated in under 2 years) DXAs among Medicare beneficiaries and estimated the cost of this testing and its responsiveness to payment change. Using 100 % Medicare claims data, 2006–2011, we identified DXAs and short-interval DXAs for female Medicare beneficiaries over age 66. We determined the population rate of DXAs and short-interval DXAs, as well as Medicare spending on short-interval DXAs, nationally and by hospital referral region (HRR). DXA use was stable 2008–2011 (12.4 to 11.5 DXAs per 100 women). DXA use varied across HRRs: in 2011, overall DXA use ranged from 6.3 to 23.0 per 100 women (coefficient of variation = 0.18), and short-interval DXAs ranged from 0.3 to 8.0 per 100 women (coefficient of variation = 0.64). Short-interval DXA use fluctuated substantially with payment changes; other DXAs did not. Short-interval DXAs, which represented 10.1 % of all DXAs, cost Medicare approximately US$16 million in 2011. One out of ten DXAs was administered in a time frame shorter than recommended and at a substantial cost to Medicare. DXA use varied across regions. Short-interval DXA use was responsive to reimbursement changes, suggesting carefully designed policy and payment reform may reduce this care identified by rheumatologists as low value.

Objectives: To assess uptake of postfracture care guidelines in community-dwelling Medicare recipients with fractures. Design: Retrospective observational cohort study. Setting: Claims-based study using U.S. Medicare administrative inpatient, outpatient (2003�2010), and prescription (2006�2010) data. Participants: Individuals aged 68 and older who survived at least 12 months after a fracture of the hip, radius, or humerus. Measurements: Poisson regression modeled factors, including participant characteristics, comorbidities and hospital referral region (HRR), associated with bone density testing or osteoporosis pharmacotherapy in the 6 months after fracture. Models were repeated for participants with no osteoporosis care observed before fracture (attention naive). Results: In 61,832 individuals with fractures, mean age was 80.6, 87.0% were female, 88.5% were white, 2.6% were black, and 62.1% were attention naive at the time of fracture; 21.8% received testing, pharmacotherapy, or both in the 6 months after fracture. In adjusted models, factors associated with significantly lower likelihood of receiving this care were black race, male sex, and an upper extremity fracture (vs hip). In models restricted to attention-naive participants, the same factors were associated with lower relative risk of receiving care. Adjusted HRR-level care rates ranged from 14.7% to 22.9% (10th to 90th percentile). The proportion receiving care increased from 2006 to 2009. Conclusion: Postfracture osteoporosis care was uncommon, particularly in black and male participants. Care increased over time, but for most, a fracture was insufficient to trigger effective secondary prevention, especially for participants who were not receiving prefracture osteoporosis attention. Clinicians and policy-makers must consider effective remedies to this persistent care gap.

113 Background: The Medicare OCM gives financial incentives for efficient, high-quality care. Hospitalizations of cancer patients receiving chemotherapy substantially increases costs. We assessed reasons for hospitalization and hospitalization discharge destinations after chemotherapy in cancer patients. Methods: We applied OCM methodology in a Medicare fee-for-service 20% sample data to estimate 6-month patient episodes triggered by chemotherapy from 2012 to 2015. We summarized the most frequent reasons for hospitalization (using ICD-9-CM codes in the first 5 positions of hospital claims) and the discharge destinations among all episodes and by cancer type. Results: Of 485,186 6-month episodes in 255,229 patients, 121,886 (25%) episodes had ≥1 hospitalization. The most frequent reasons for hospitalization were infection (13%), anemia (7%), dehydration (5%), and congestive heart failure (CHF; 3%; Table). Most hospitalized patients were discharged to home (71%) or a skilled nursing facility (SNF; 13%); some died in the hospital (6%) or went to hospice (5%). Reasons for hospitalization and discharge destination varied by cancer type. Patients with lung cancer had the highest rates of infection and anemia and higher proportions of death and hospice discharge compared with other cancers. Conclusions: Among Medicare beneficiaries receiving chemotherapy, hospitalizations most often occurred as a result of infection or anemia. Patients were most often discharged to home or SNF. Variations across cancer types in the reasons for hospitalization, as well as discharge destinations, should be considered when evaluating OCM practice performance. [Table: see text]

112 Background: The Medicare OCM started in 2016 to improve oncology care and reduce costs. Two metrics for care evaluation are hospitalizations and ED/OB stays. Baseline data (2012−2015) on variations in all-cause hospitalization and ED/OB stays not resulting in hospitalization in the 21 reconciliation-eligible cancer types are not well characterized. Methods: We applied OCM methodology in Medicare fee-for-service 20% sample data to estimate 6-month patient (pt) episodes triggered by chemotherapy, as well as associated cancer type and practice, from 2012 to 2015. Proportions of episodes with hospitalization and ED/OBs stay were summarized overall and by cancer for all episodes and by practice in those with ≥20 pt-episodes. Results: In total, 485,186 pt-episodes at 13,823 practices were identified (mean episodes/practice, 35.1; median, 2; IQR, 1–15). The mean number of episodes/pt was 1.90 overall (from 1.17 in anal cancer to 2.32 in multiple myeloma [MM]). The proportion of episodes with hospitalization was 25% overall (from 14% in breast cancer [BC] to 56% in acute leukemia) and with ED/OB stays was 23% overall (from 18% in BC to 36% in liver cancer). In 2,995 practices with ≥20 total episodes, at practice-level, the proportion of episodes with hospitalization ranged (20th–80th percentile) from 14% to 31% and with ED/OB stays from 17% to 29%. For select cancers, the range of proportion of episodes with hospitalization and ED/OB stays were highest for lung cancer (LC) and lowest for BC (Table). Conclusions: The proportion of 6-month OCM episodes of care with hospitalization and ED/OB stays after chemotherapy varied by cancer and was higher for certain solid and hematological malignancies. Variations between practices and cancers are important factors when evaluating OCM performance. [Table: see text]

Objective: Guideline-directed medical therapy (GDMT) is recommended prior to implantation of a primary prevention cardioverter-defibrillator (ICD). We examined GDMT use prior to primary prevention ICD implantation among Medicare beneficiaries. Methods: Using the National Cardiovascular Data Registry ICD Registry from 2007-2011, we identified recipients of a primary prevention ICD for the indication of heart failure with an ejection fraction Results: Among 433,882 patients in the ICD registry who were enrolled in Medicare, we identified 25,473 that met Medicare prescription benefit enrollment criteria. Just 60% of these patients filled one or more prescription for both GDMTs (HFBB 76%, RAI 73%). Of those with some GDMT fills, just 38% received sufficient supplies to cover 80% of days. The HRR-level proportion of patients filling any GDMT ranged from 44%-78%. Patients were significantly less likely to receive GDMT if they were male, did not receive a low-income prescription benefit subsidy, had NYHA class 4 symptoms, renal failure, a history of ventricular tachycardia, or their most recent ejection fraction assessment within 1 month prior to implant. Ejection fraction was not associated with receipt of GDMT. Those filling GDMT were significantly less likely to die within 1 year (odds ratio 0.69 adjusted for age (95% CI 0.64, 0.75)). Conclusion: Prior to primary prevention ICD implantation, GDMT use appears inadequate overall and varies widely by region. Greater GDMT use should improve heart failure outcomes and may decrease the number of patients meeting an indication for ICD implantation. Understanding drivers of high and low use would inform policies aimed at optimizing this care.

Background: Non-adherence to tuberculosis (TB) treatment jeopardizes patient health and promotes disease transmission. In July 2011, Ecuador's National Tuberculosis Program (NTP) enacted a monetary incentive program giving adherent drug-resistant TB (DR-TB) patients a US240 bonus each month. Objective: To describe patients' experiences with the program qualitatively, and to assess its effects on treatment adherence. Methods: We interviewed 92 current and five default patients about their treatment experience. NTP data on DR-TB patients receiving treatment were used to compare 12-month default rates among the incentive program group and non-program controls. Results: Our interviews found that patients are financially challenged and use the bonus for a variety of expenses, most commonly food. The most common complaint was that bonus payments were frequently delayed. The 1-year default rate among program patients (9.5%) was significantly lower than the rate among pre-program patients (26.7%). Conclusion: Ecuador's monetary incentive program alleviates the economic burden placed by treatment on patients. The bonus does not, however, directly address other treatment barriers, including psychological distress and side effects. The program could benefit from timely delivery of payments. Further research is necessary to assess the program's effect on default rates.

Objective: This study explored the relationship between adolescent substance use and intimate partner violence (IPV). Method: A secondary data analysis was conducted using the statewide Hawai‘i Youth Risk Behavior Survey data for the years 2005, 2007, and 2009. Public school students (n = 4,364) attending medium to large school districts in Hawai‘i participated. Prevalence estimates and regression models of covariates were calculated. Results: Results indicated that IPV victimization and substance use are prevalent among Hawai‘i youth. Odds ratio calculations indicated that substance use (specifically multiple drug use) is associated with an increased likelihood of reporting IPV victimization. Conclusions: Curricula and programming to prevent drug use among Hawai‘i youth must incorporate IPV prevention, and vice versa.

Background: Patients with type two diabetes mellitus (T2DM) have an increased risk of bladder cancer; they are also commonly treated with pioglitizone and angiotensin receptor blockers (ARBs), medications associated with an increased cancer risk in some studies. This study aimed to further explore the relationship between these medications and bladder cancer in an older population with higher baseline risk of this cancer and common exposure to these drugs. We examine the risk associated with exposure to the individual drug/drug class, and risk associated with exposure to both to assess for a potential cancer promoting interaction. Methods: Using a 40% Medicare random sample denominator and corresponding inpatient, outpatient (2004-2012) and prescription (2006-2012) claims, we studied fee-for-service beneficiaries age 67 and older. We identified pharmacotherapeutically treated diabetics (2006 to 2011) defined as patients filling one or more prescription for an oral hypoglycemic drug. Individual-level, time varying exposure to all oral and injectable hyopglycemics as well as ARBs and ACE-Is was calculated as count of drug-specific daily doses; daily doses were derived empirically as the median daily dose (MDDs) for this population. Cox proportional hazards models, adjusted for patient characteristics, comorbidities and diabetes complications, were used to examine the risk of incident bladder cancer associated with cumulative observed exposure to pioglitazone and ARBs. To address possible indication bias for the exposures of interest, we also estimated risk associated ACE-I exposure and non-pioglitazone TZD exposure, substitutes for the exposures of interest not suspected of increasing cancer risk. Interaction terms estimated the effect of exposure to ARBs with pioglitazone and ARBs with non-pioglitazone TZD. Secondary models repeated main models stratified on gender due to the higher baseline risk of bladder cancer in men. Results: Overall, we identified 1,161,443 diabetics, 62.5% female, 10.7% black, 9.8% Hispanic. Mean age at the beginning of follow-up was 75.1 years (SD 7.5); 18.9% had evidence of current or past tobacco use. Mean follow time was 42.2 months (SD 26.4). Overall, 20.2% of the cohort used some pioglitazone (mean exposure 642 MDDs); 31.7% used some ARB (Mean exposure 745 MDDs); 10.4% used some non-pioglitazone TZD (mean exposure 503 MDDs); 59.1% used some ACE-I (mean exposure 855 MDDs). 8.0% used both pioglitazone and ARBs; 13.2% used both pioglitazone and ACE-I; 4.1% used non-pioglitazone TZD and ARB; and 6.8% used non-pioglitazone TZD and ACE-I. In total, 5,874 bladder cancers were identified, 69% amongst men, an incidence of 0.28/1000 PY in men and 0.07/1000 PY in women. Compared to no observed exposure, the risk of bladder cancer associated with each additional year of exposure at median daily dose was: 0.97 (95% CI 0.89, 1.06) for pioglitazone, 1.04 (95% CI 0.97, 1.12) for ARBs; 0.99 (95% CI 0.95, 1.03) for ACE-Is and 0.98 (95% CI 0.86, 1.12) for non- pioglitizone TZDs. The risk of bladder cancer associated with each additional year of exposure to both pioglitizone and ARB was 0.97 (95% CI 0.91, 1.04); for pioglitazone and ACE-I, 1.01 (95% CI 0.98, 1.03); for non-pioglitazone TZD and ARB, 0.99 (95% CI 0.91, 1.08); and for non-pioglitazone TZD and ACE-I, 0.99 (95% CI 0.93, 1.04). Results did not differ when stratified by sex. Conclusions: We found no increased risk of bladder cancer associated with pioglitizone use, ARB use or exposure to both over an average observation time of 3.5 years. While the findings of this observational study should be confirmed in a prospective trial of longer duration, overall the results should reassure diabetics and their clinicians using these products to minimize the substantial health risks associated with diabetes. Citation Format: Jeremy Smith, Rebecca Zaha, Todd A. Mackenzie, Margaret R. Karagas, Nancy E. Morden. Association between diabetes pharmacotherapies and bladder cancer: A Medicare epidemiologic study. [abstract]. In: Proceedings of the Thirteenth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2014 Sep 27-Oct 1; New Orleans, LA. Philadelphia (PA): AACR; Can Prev Res 2015;8(10 Suppl): Abstract nr A27.

The coverage and financing of health care services for individuals with mental illness and substance use disorders are changing rapidly in the U.S. The 2008 Federal parity legislation requires that insurance benefit design and management for mental health and substance abuse treatment match those for medical and surgical services. The 2010 Patient Protection and Affordable Care Act (PPACA), with coverage provisions mirroring Massachusetts’ 2006 health reform,1 expands health insurance coverage to populations with high behavioral health needs through Medicaid expansions,2,3 establishes health insurance exchanges to ease purchase of individual and small group health insurance, and requires that insurers permit dependent children to remain on parental insurance policies to age 26. Furthermore, PPACA requires health plans offered through new insurance exchanges to cover mental health and substance abuse treatment, and other PPACA reforms integrate care across settings for behavioral health treatment.4 Most behavioral health disorders, 75%, emerge by age 24,5 and the odds of having a 12-month DSM IV disorder are higher for individuals age 18 to 29 than any other adult age group.6 Despite the long-term mortality, disability, and labor market consequences of these disorders,7,8 young adults lack health insurance coverage more often than other age groups.9 The lack of coverage is particularly important for young adults in foster care, child Supplemental Security Income recipients, and Medicaid recipients, for whom the 18th birthday coincides with a loss of benefits.10,11 In outpatient settings, demand for behavioral health treatment is more responsive to insurance coverage and patient cost sharing than other health care services, suggesting that hospital-based services may rise in response to increased insurance coverage.12,13 Alternatively, hospital-based services may fall with increased insurance coverage either because outpatient care use substitutes for inpatient care, or due to utilization management of managed behavioral health organizations responsible for new enrollees.14 Little is known about behavioral health service use when young adults acquire coverage. In this paper, we study the experience of the Massachusetts health reform to examine inpatient hospital admissions and emergency department visits for young adults aged 19 to 25 diagnosed with behavioral health disorders. To understand how utilization of hospital-based care, and insurance coverage for such care changed following health insurance coverage expansion, we compared inpatient admissions before and after 2006 in Massachusetts to the rest of the US. We further compared these differences among the 19 to 25 year olds to differences among adolescents aged 12 to 18 in Massachusetts, for whom insurance coverage changed less after health reform.15 To examine changes in emergency department (ED) visits, we use a similar approach, focusing on the universe of ED visits in Massachusetts and Maryland. We estimated the net effect of opposing influences of insurance coverage on hospital-based behavioral health services against a null hypothesis that service use would not change after coverage expanded.