Srikanth Kadiyala

Off-label prescribing — when medications are used for indications not approved by the FDA — is widespread in the U.S. healthcare system. This study uses trazodone, a drug approved in 1981 for depression, as a case study to examine broader issues surrounding off-label utilization and spending.

Findings: Although only approved to treat depression, trazodone is frequently prescribed off-label for indications of uncertain clinical value (insomnia, anxiety). Using nationally representative data from the Medical Expenditure Panel Survey, authors estimate that approximately 24 million trazodone prescriptions were filled in 2019, with healthcare spending of $294 million. At least 85% of prescriptions (∼20 million) and 84% of spending ($247 million) were for off-label indications, primarily insomnia. Health plan reimbursement per prescription was nearly identical for on-label and off-label use, despite the significant evidence gap.

These findings illustrate the scale and inefficiency of off-label prescribing and highlight challenges facing clinicians, patients, and payers. Authors propose a set of policy solutions — including public and private investment in evidence generation, pricing drugs to account for off-label use, and value-based reimbursement — to advance a more efficient system of off-label use. Trazodone presents a revealing case of the broader systemic problem of off-label prescribing for indications of uncertain clinical value.

Authors randomized 48 primary care pediatric practices to online communication training vs. usual care. Online communication training reduced missed opportunities (MOs) for initial human papillomavirus (HPV) vaccination at well-child care (WCC) visits by 6.8 percentage points among children aged 11–17 years. The current study estimated implementation costs of the communication training intervention at WCC visits.

Authors analyzed monthly surveys completed by intervention practice lead clinicians to track clinician plus office staff personnel hours devoted to implementing the intervention. They converted personnel time into 2019 U.S. dollars using national median hourly wages for physicians and other health care workers; they tracked nonpersonnel costs. Authors calculated costs per practice (overall and by practice size) and estimated costs per averted MO for HPV vaccine initiation using an effectiveness estimate determined by grouped logistic regression at the practice level.

Findings: Practices varied from 1 to 24 clinicians and from 241 to 8,866 visits during the 6-month intervention. Total intervention costs varied substantially across the 24 intervention practices from $370 to $6,653, with a mean of $2,003 and median of $1,305. The incremental cost per averted MO for HPV vaccine initiation at WCC visits averaged $110 ($212 in practices with 1 or 2 physicians and $94 in practices with 3 or more physicians).

The implementation cost per averted MO for HPV vaccine initiation at WCC visits of this online communication training intervention was modest, particularly among larger pediatric practices.

The Inflation Reduction Act of 2022 (IRA) included additional federal subsidies to make health insurance more affordable in the individual market, but these expire at the end of 2025. If Congress does not extend the expanded subsidies and levels revert to those in the original Affordable Care Act, all 2.37 million Californians in the individual market — including those not receiving subsidies — would face higher health insurance premiums and be forced to choose between more expensive coverage, less generous coverage, or forgoing coverage altogether and going uninsured. Under this scenario, authors project that in 2026:

• 1,558,000 Californians would pay an average of $967 more per year but maintain coverage despite having their subsidies reduced or eliminated;
• 740,000 Californians enrolled in unsubsidized coverage would pay an average of $253 more per year due to the worse risk-mix of the individual market if the IRA subsidies were eliminated;
• 69,000 additional Californians would become uninsured.

Authors conclude that maintaining IRA-level subsidies in the individual market would protect 2.37 million Californians from insurance premium increases and keep 69,000 Californians covered. For these subsidies to continue, Congress must act in 2024 or 2025. In early 2025, insurers will develop their rates for the 2026 coverage year, and rates will be finalized by the middle of 2025. Congressional action before then could help avoid premium increases.

Summary: This policy brief examines geographic disparities in rates of potentially preventable hospitalizations and emergency department (ED) visits among adults ages 18 and older by Service Planning Areas (SPA) in Los Angeles County from 2016 to 2021. Authors look at three combinations of conditions that are typically preventable, given appropriate disease management: all conditions, chronic conditions, and diabetes-related conditions.

Findings: South Los Angeles (SPA 6) and the Antelope Valley (SPA 1) have the highest rates of potentially preventable hospitalizations and emergency department visits among Los Angeles’ 8 SPAs. South Los Angeles has a rate of preventable hospitalizations for all conditions that is 1.7 times that of West Los Angeles (SPA 5), which has the lowest rate. Also, SPA 6 has the highest proportion covered by Medi-Cal (35.2%), followed by SPA 1 (27.9%), while SPA 5 has the lowest percentage insured with Medi-Cal (10.7%). Authors recommend that state and local policymakers and payers should consider improving access to primary and specialty care and increasing payments for Medi-Cal providers to help prevent costly ED visits and hospitalizations.

Read the Publication:

• Policy Brief: Geographic Disparities in Preventable Hospitalizations and Emergency Department Visits in Los Angeles County
• Infographic