Why higher copayments for opioids did not reduce use among Medicare beneficiaries

To examine whether higher cost-sharing deterred prescription opioid use. Medicare Part D claims from 2007 to 2016 for a 20% random sample of Medicare enrollees. We obtain estimates of the effect of cost-sharing on prescription opioid use using ordinary least squares and instrumental variables methods. In both, we exploit the variation (change) in cost-sharing within plans over time for a sample of beneficiaries who remain in the same plan. Focusing on changes in cost-sharing within a plan for a constant sample of beneficiaries mitigates potential bias from plan selection and using a constant set of weights derived from use in year (t) eliminates changes in the cost-sharing indexes due to (endogenous) consumer choice in year (t+1). Part D plans adopted benefit changes designed to reduce opioid use, including moving opioids to higher cost-sharing tiers. Increasing plan copayments for hydrocodone or oxycodone was associated with reductions in plan-paid claims and offsetting increases in cash claims. Widespread availability of low-cost generics combined with the anti-clawback provision in Part D mediated the effect of higher cost sharing to curb opioid use. As plans moved generic opioids to higher cost-sharing tiers, beneficiaries simply paid cash prices and aggregate use remained largely unchanged. The anti-clawback provision in Part D, intended to protect beneficiaries from price gouging, limited plans' ability to constrain opioid use through typical demand-side measures such as increased cost-sharing.

Medicare Part D Plans Greatly Increased Utilization Restrictions On Prescription Drugs, 2011-20

Drug utilization management tools can be employed to ensure that medicines are prescribed cost-effectively, but they can also be implemented in ways that reduce adherence and harm patient health. We examined trends in the prevalence of utilization restrictions on non-protected-class compounds in Medicare Part D plans during the period 2011-20, including prior authorization and step therapy requirements as well as formulary exclusions. Part D plans became significantly more restrictive over time, rising from an average of 31.9 percent of compounds restricted in 2011 to 44.4 percent restricted in 2020. The prevalence of formulary exclusions grew particularly fast: By 2020, plan formularies excluded an average of 44.7 percent of brand-name-only compounds. Formulary restrictions were more common among brand-name-only compared with generic-available compounds, among more expensive compounds, and in stand-alone compared with Medicare Advantage prescription drug plans.

Estimates of diagnosed dementia prevalence and incidence among diverse beneficiaries in traditional Medicare and Medicare Advantage

Approximately half of Medicare beneficiaries are enrolled in Medicare Advantage (MA), a private plan alternative to traditional Medicare (TM). Yet little is known about diagnosed dementia rates among MA enrollees, limiting population estimates. All (100%) claims of Medicare beneficiaries using encounter data for MA and claims for TM for the years 2015 to 2018 were used to quantify diagnosed dementia prevalence and incidence rates in MA, compare rates to TM, and provide estimates for the entire Medicare population and for different racial/ethnic populations. In 2017, dementia incidence and prevalence among MA beneficiaries were 2.54% (95% confidence interval [CI]: 2.53 to 2.55) and 7.04% (95% CI: 7.03 to 7.06). Comparison to TM adjusted for sociodemographic and health differences among beneficiaries in MA and TM; the prevalence of diagnosed dementia among beneficiaries in MA was lower (7.1%; 95% CI: 7.12 to 7.13) than in TM (8.7%; 95% CI: 8.71 to 8.72). The diagnosed dementia incidence rate was also lower in MA (2.50%; 95% CI: 2.50 to 2.50) compared to TM (2.99%; 95% CI: 2.99 to 2.99). There were lower rates in MA compared to TM for men and women and White, Black, Hispanic, Asian, American Indian/Alaska Native persons. Diagnosed dementia prevalence and incidence for the entire Medicare population was 7.9% (95% CI: 7.91 to 7.93) and 2.8% (95% CI: 2.77 to 2.78). Lower diagnosed dementia rates in MA compared to TM may exacerbate racial/ethnic disparities in diagnosed dementia. Rates tracked over time will provide understanding of the impact on dementia diagnosis of 2020 MA risk adjustment for dementia.

Potentially Inappropriate Medication Use in Community-Dwelling Older Adults Living with Dementia

Background: The Beers Criteria identifies potentially inappropriate medications (PIMs) that should be avoided in older adults living with dementia. Objective: The aim of this study was to provide estimates of the prevalence and persistence of PIM use among community-dwelling older adults living with dementia in 2011-2017. Methods: Medicare claims data were used to create an analytic dataset spanning from 2011 to 2017. The analysis included community-dwelling Medicare fee-for-service beneficiaries aged 65 and older who were enrolled in Medicare Part D plans, had diagnosis for dementia, and were alive for at least one calendar year. Dementia status was determined using Medicare Chronic Conditions Date Warehouse (CCW) Chronic Condition categories and Charlson Comorbidity Index. PIM use was defined as 2 or more prescription fills with at least 90 days of total days-supply in a calendar year. Descriptive statistics were used to report the prevalence and persistence of PIM use. Results: Of 1.6 million person-year observations included in the sample, 32.7% used one or more PIMs during a calendar year in 2011-2017. Breakdown by drug classes showed that 14.9% of the sample used anticholinergics, 14.0% used benzodiazepines, and 11.0% used antipsychotics. Conditional on any use, mean annual days-supply for all PIMs was 270.6 days (SD = 102.7). The mean annual days-supply for antipsychotic use was 302.7 days (SD = 131.2). Conclusion: Significant proportion of community-dwelling older adults with dementia used one or more PIMs, often for extended periods of time. The antipsychotic use in the community-dwelling older adults with dementia remains as a significant problem.

Part D beneficiaries' incentives and responses under preferred pharmacy networks

OBJECTIVES

The share of Medicare stand-alone prescription drug plans with a preferred pharmacy network has grown from less than 9% in 2011 to 98% in 2021. This article assesses the financial incentives that such networks created for unsubsidized and subsidized beneficiaries and their pharmacy switching.

STUDY DESIGN

We analyzed prescription drug claims data for a nationally representative 20% sample of Medicare beneficiaries from 2010 through 2016.

METHODS

We evaluated the financial incentives for using preferred pharmacies by simulating unsubsidized and subsidized beneficiaries' annual out-of-pocket spending differentials between using nonpreferred and preferred pharmacies for all their prescriptions. We then compared beneficiaries' use of pharmacies before and after their plans adopted preferred networks. We also examined the amount of money that beneficiaries left on the table under such networks, based on their pharmacy use.

RESULTS

Unsubsidized beneficiaries faced substantial incentives-on average, $147 annually in out-of-pocket spending-and moderately switched toward preferred pharmacies, whereas subsidized beneficiaries were insulated from the incentives and demonstrated little switching. Among those who continued to mainly use nonpreferred pharmacies (half of the unsubsidized and about two-thirds of the subsidized), on average, the unsubsidized paid more out of pocket ($94) relative to if they had used preferred pharmacies, whereas Medicare bore the extra spending ($170) for the subsidized through cost-sharing subsidies.

CONCLUSIONS

Preferred networks have important implications for beneficiaries' out-of-pocket spending and the low-income subsidy program. Further research is needed about the impact on the quality of beneficiaries' decision-making and cost savings to fully evaluate preferred networks.

Reforming the Medicare Part D Benefit Design: Financial Implications for Beneficiaries, Private Plans, Drug Manufacturers, and the Federal Government

CONTEXT

Reforming the Medicare Part D program-which provides prescription drug coverage to 49 million beneficiaries-has emerged as a key policy priority.

METHODS

The authors evaluate prescription drug claims from a 100% sample of Medicare Part D beneficiaries to evaluate the current spending distribution across different payers for different types of beneficiaries across different benefit phases. They then model how these estimates would change under a proposal to redesign the Medicare Part D standard benefit.

FINDINGS

Spending patterns differ for beneficiaries who do and do not qualify for low-income subsidies. Part D plans face limited liability for total spending under the current standard benefit design, amounting to 36% of total spending for beneficiaries who do not receive low-income subsidies and 28% of total spending for those who do. Proposed reforms would increase plan liability and significantly change the distribution of liability across plans, drug manufacturers, and the federal government.

CONCLUSIONS

Though the original goal of the Part D program was to create a market of competing private plans that provide prescription drug coverage to Medicare beneficiaries, the standard benefit design that was included in the original legislation reflected significant political compromises. Reforming the standard benefit design to give plans more skin in the game could significantly affect competition in the market, with differential impact across drug classes and types of beneficiaries.

Formulary restrictions and stroke risk in patients with atrial fibrillation

OBJECTIVES

To determine the use of formulary restrictions (prior authorization and step therapy) on the use of non-vitamin K antagonist oral anticoagulants (NOACs) and their effect on health outcomes.

STUDY DESIGN

Longitudinal cohort study. We identified a sample of Medicare beneficiaries with an incident diagnosis of atrial fibrillation (AF) in 2011 to 2015 and followed them until the end of 2016 or death. We compared anticoagulant use and health outcomes associated with Medicare Part D plan coverage of NOACs.

METHODS

The primary outcomes were composite rates of death, stroke, transient ischemic attack, and systemic embolism. We used Cox proportional hazards models to estimate the association between formulary restrictions and adverse health outcomes.

RESULTS

Beneficiaries enrolled in Part D plans that restricted access to NOACs had a lower probability of NOAC use (30.2% vs 32.2%), worse adherence conditional on NOAC use (32.1% vs 34.3% adherent), and longer delays in filling an initial prescription (46% vs 55% filled within 30 days of AF diagnosis). Beneficiaries in restricted plans had higher aggregate risk of mortality/stroke/transient ischemic attack (adjusted HR, 1.098; 95% CI, 1.079-1.118).

CONCLUSIONS

Limiting access to NOACs may exacerbate current underuse of anticoagulants and increase the risk of stroke among patients with newly diagnosed AF. Pharmacy benefit managers and Part D plans need to continuously review the appropriateness of formulary policies to ensure patient access to effective medications.

Pharmacy switching in response to preferred pharmacy networks in Medicare Part D

OBJECTIVE

To evaluate the effects of preferred pharmacy networks-a tool that Medicare Part D plans have recently adopted to steer patients to lower cost pharmacies-on the use of preferred pharmacies and factors underlying beneficiaries' decisions on whether to switch to preferred pharmacies.

DATA SOURCES

Medicare claims data were collected for a nationally representative 20% sample of beneficiaries during 2010-2016 and merged with annual Part D pharmacy network files.

STUDY DESIGN

We examined preferred networks' impact on pharmacy choice by estimating a difference-in-differences model comparing preferred pharmacies' claim share before and after implementation among unsubsidized and subsidized beneficiaries. Additionally, we evaluated the factors affecting whether a beneficiary switched from mainly using nonpreferred to preferred pharmacies.

DATA COLLECTION/EXTRACTION METHODS

We examined stand-alone drug plans that adopted a preferred network during 2011-2016. Our main sample included beneficiaries 65 years and older who stayed in their plan in both the first year of implementation and the year before and whose cost-sharing subsidy status and ZIP code remained unchanged during the 2-year period.

PRINCIPAL FINDINGS

Unsubsidized Part D beneficiaries faced an average difference of $129 per year in out-of-pocket spending between using nonpreferred and preferred pharmacies, while subsidized beneficiaries were insulated from these cost differences. The implementation of preferred networks resulted in a 3.7-percentage point (95% CI: 3.3, 4.2) increase in preferred pharmacies' claim share in the first year among the unsubsidized. Existing relationships with preferred pharmacies, the size of financial incentives, proximity to preferred pharmacies, and urban residence were positively associated with beneficiaries' decisions to switch to these pharmacies.

CONCLUSIONS

Preferred pharmacy networks caused a moderate shift on average towards preferred pharmacies among unsubsidized beneficiaries, although stronger financial incentives correlated with more switching. Researchers and policymakers should better understand plans' cost-sharing strategies and assess whether communities have equitable access to preferred pharmacies.

Benzodiazepine use and the risk of dementia

Introduction

Benzodiazepines (BZDs) are commonly prescribed for anxiety and agitations, which are early symptoms of Alzheimer's disease and related dementias (ADRD). It is unclear whether BZDs causally affect ADRD risk or are prescribed in response to early symptoms of dementia.

Methods

We replicate prior case-control studies using longitudinal Medicare claims. To mitigate bias from prodromal use, we compare rates of ADRD diagnosis for beneficiaries exposed and unexposed to BZDs for cervical/lumbar pain, stenosis, and sciatica, none of which are associated with dementia.

Results

Approximately 8% of Medicare beneficiaries used a BZD in 2007, increasing to nearly 13% by 2013. Estimates from case-control designs are sensitive to duration of look-back period, health histories, medication use, and exclusion of decedents. Incident BZD use is not associated with an increased risk of dementia in an "uncontaminated" sample of beneficiaries prescribed a BZD for pain (odds ratios (ORs) of 1.007 [95% confidence interval [CI] = 0.885, 1.146] and 0.986 [95% CI = 0.877, 1.108], respectively, in the 2013 and 2013 to 2015 pooled samples). Higher levels of BZD exposure (>365 days over a 2-year period) are associated with increased odds of a dementia diagnosis, but the results are not statistically significant at the 5% or 10% levels (1.190 [95% CI = 0.925, 1.531] and 1.167 [95% CI = 0.919, 1.483]).

Discussion

We find little evidence of a causal relation between BZD use and dementia risk. Nonetheless, providers should limit the extended use in elderly populations.

Acute Bacterial Infections and Longitudinal Risk of Readmissions and Mortality in Patients Hospitalized with Heart Failure

Aims: Infections are associated with worse short-term outcomes in patients with heart failure (HF). However, acute infections may have lasting pathophysiologic effects that adversely influence HF outcomes after discharge. Our objective was to describe the impact of acute bacterial infections on longitudinal outcomes of patients hospitalized with a primary diagnosis of HF. Methods and Results: This paper is based on a retrospective cohort study of patients hospitalized with a primary diagnosis of HF with or without a secondary diagnosis of acute bacterial infection in Optum Clinformatics DataMart from 2010–2015. Primary outcomes were 30 and 180-day hospital readmissions and mortality, intensive care unit admission, length of hospital stay, and total hospital charge, compared between those with or without an acute infection. Cohorts were compared after inverse probability of treatment weighting. Multivariable logistic regression was used to examine relationship to outcomes. Of 121,783 patients hospitalized with a primary diagnosis of HF, 27,947 (23%) had a diagnosis of acute infection. After weighting, 30-day hospital readmissions [17.1% vs. 15.7%, OR 1.11 (1.07–1.15), p < 0.001] and 180-day hospital readmissions [39.6% vs. 38.7%, OR 1.04 (1.01–1.07), p = 0.006] were modestly greater in those with an acute infection versus those without. Thirty-day [5.5% vs. 4.3%, OR 1.29 (1.21–1.38), p < 0.001] and 180-day mortality [10.7% vs. 9.4%, OR 1.16 (1.11–1.22), p < 0.001], length of stay (7.1 ± 7.0 days vs. 5.7 ± 5.8 days, p < 0.001), and total hospital charges (USD 62,200 ± 770 vs. USD 51,100 ± 436, p < 0.001) were higher in patients with an infection. Conclusions: The development of an acute bacterial infection in patients hospitalized for HF was associated with an increase in morbidity and mortality after discharge.

The Importance of the Pharmacist’s Role and the Quality of Pharmacy Services in Nursing Home Care

The Centers for Medicare & Medicaid Services requires nursing homes (NHs) to provide pharmacy services to ensure the safety of medication use, such as minimizing off-label medication use for residents with dementia. This study examined NH’s response to this requirement and its relationship to medication-related outcomes. The contemporaneous relationship between the quality of pharmacy services and outcome measures were modeled using facility-level longitudinal data from 2011-2017 and facility fixed-effects. The results revealed that deficiency in pharmacy services increased medication-related issues by: 11% in inappropriate medication regimen, 5% in medication error rate &gt;5%, and 3% in any serious medication errors. Additionally, deficiency in pharmacy services was associated with small but statistically significant increases in antipsychotic use, residents with daily pain, number of hospitalizations and rehospitalization rate. The results suggest that pharmacy services have a direct and immediate impact on medication outcomes. The results underscore the importance of pharmacy services in NHs.

Diagnosis of Behavioral Symptoms of Dementia and CNS-Active Drug Use Among Diverse Persons Living With Dementia

Approximately 90% of persons living with dementia (PLWD) experience behavioral and psychological symptoms of dementia (BPSD). Studies demonstrated high use of central nervous system (CNS) active drugs in nursing homes; one recent study documented high use among community-dwelling PLWD. Racial/ethnic disparities in BPSD diagnosis and CNS-active drug use, however, are unknown. We quantified disparities in BPSD diagnoses and CNS-active drug use using 100% Medicare Part A and B claims, 2017-2019, and Part D, 2018-2019. Beneficiaries were ages 65 and older in 2017, community-dwelling, and had a dementia diagnosis (n=801,597). We estimated models of CNS-active drug use to quantify racial/ethnic differences adjusting for confounders. Among PLWD, 66% had a BPSD diagnosis and 65% were taking a CNS-acting drug. Asians/Pacific Islanders were less likely to have a BPSD diagnosis (55%) than other groups, particularly affective diagnoses (40%). Whites were most likely to have any diagnosis (67%). Blacks were most likely to have hyperactivity diagnoses (7%). Antidepressants were most commonly used drug class (44%). Thirteen percent used an antipsychotic. Models adjusted for age, sex, comorbid conditions, dual-eligibility and BPSD diagnoses, showed non-Whites were less likely to use any CNS-active drug than Whites, but Blacks and Hispanics were slightly more likely to use antipsychotics. We found racial/ethnic differences in BPSD diagnoses and CNS-active drug use. Whether these disparities are due to differences in BPSD symptoms, health-care access or care-seeking remains an important question. Further study of disparity in outcomes associated with use will inform risk and benefit of CNS-active drugs use among PLWD.

Comparison of Spending on Common Generic Drugs by Medicare vs Costco Members

This cross-sectional study uses 2017 and 2018 Medicare Part D clams to compare the amount Medicare pays for common generic prescriptions in Part D with prices available to patients without insurance at Costco.

Pharmaceutical Treatment for Alzheimer's Disease and Related Dementias: Utilization and Disparities

BACKGROUND

Four prescription drugs (donepezil, galantamine, memantine, and rivastigmine) are approved by the US FDA to treat symptoms of Alzheimer's disease (AD). Even modest effectiveness could potentially reduce the population-level burden of AD and related dementias (ADRD), especially for women and racial/ethnic minorities who have higher incidence of ADRD.

OBJECTIVE

Describe the prevalence of antidementia drug use and timing of initiation relative to ADRD diagnosis among a nationally representative group of older Americans, and if there are disparities in prevalence and timing by sex and race/ethnicity.

METHODS

Descriptive analyses and logistic regressions of Medicare claims (2008-2016) for beneficiaries who had an ADRD or dementia-related symptom diagnosis, or use of an FDA approved drug for AD. We investigate prevalence of use and timing of treatment initiation relative to ADRD diagnosis across time and beneficiary characteristics (age, sex, race/ethnicity, socioeconomic status, comorbidities).

RESULTS

Among persons diagnosed with ADRD or related symptoms, 33.3% used an approved drug over the study period. Odds of use was higher among Whites than non-Whites. Among ADRD drug users, 40% initiated use within 6 months of the initial ADRD or related symptoms diagnosis, and 16% initiated prior to a diagnosis. We observed disparities by race/ethnicity: 28% of Asians, 24% of Hispanics, 16% of Blacks, and 15% of Whites initiated prior to diagnosis.

CONCLUSIONS

The use of antidementia drugs is relatively low and varies widely by race/ethnicity. Heterogeneity in timing of initiation and use may affect health and cost outcomes, but these effects merit further study.

Association of Out-of-Pocket Spending With Insulin Adherence in Medicare Part D

This cross-sectional study examines whether efforts to limit out-of-pocket spending for enrollees in nonsubsidized Medicare Part D plans are associated with insulin adherence rates among these patients.

Drug therapies for chronic conditions and risk of Alzheimer's disease and related dementias: A scoping review

INTRODUCTION

Most older Americans use drug therapies for chronic conditions. Several are associated with risk of Alzheimer's disease and related dementias (ADRD).

METHODS

A scoping review was used to identify drug classes associated with increasing or decreasing ADRD risk. We analyzed size, type, and findings of the evidence.

RESULTS

We identified 29 drug classes across 11 therapeutic areas, and 404 human studies. Most common were studies on drugs for hypertension (93) or hyperlipidemia (81). Fewer than five studies were identified for several anti-diabetic and anti-inflammatory drugs. Evidence was observational only for beta blockers, proton pump inhibitors, benzodiazepines, and disease-modifying anti-rheumatic drugs. For 13 drug classes, 50% or more of the studies reported consistent direction of effect on risk of ADRD.

DISCUSSION

Future research targeting drug classes with limited/non-robust evidence, examining sex, racial heterogeneity, and separating classes by molecule, will facilitate understanding of associated risk, and inform clinical and policy efforts to alleviate the growing impact of ADRD.

Variation in generic dispensing rates in Medicare Part D

OBJECTIVES

The use of generics in Medicare Part D generates cost savings for plan sponsors, beneficiaries, and the federal government. However, there is considerable variation in generic use across plans, even within a therapeutic class. Our objective is to understand the extent of variation in generic use in Part D and to understand factors associated with generic use.

STUDY DESIGN

We used an observational study design using Medicare Part D claims from 2006 to 2016.

METHODS

We used descriptive statistics and regression analysis to examine the variation in generic and brand use across plans and the extent to which patient, plan, and area characteristics are associated with the choice of medication within a therapeutic class.

RESULTS

Although generic use has increased markedly over time in Part D, substantial variation across plans persists in a number of common therapeutic classes. Beneficiary characteristics such as gender and health status are associated with higher/lower generic use, as are plan characteristics such as plan type (stand-alone prescription drug plan or Medicare Advantage), premium, and parent company.

CONCLUSIONS

Because we cannot study the impact of brand-name drug rebates on generic use, we can study the variation in generic use across Part D plans as an indirect way to assess pharmacy benefit manager and plan incentives. We find circumstantial evidence that, in certain classes, rebates may play a role in influencing brand over generic use, although the exact relationship is unknowable given the proprietary nature of rebates.

Association of combination statin and antihypertensive therapy with reduced Alzheimer's disease and related dementia risk

BACKGROUND

Hyperlipidemia and hypertension are modifiable risk factors for Alzheimer's disease and related dementias (ADRD). Approximately 25% of adults over age 65 use both antihypertensives (AHTs) and statins for these conditions. While a growing body of evidence found statins and AHTs are independently associated with lower ADRD risk, no evidence exists on simultaneous use for different drug class combinations and ADRD risk. Our primary objective was to compare ADRD risk associated with concurrent use of different combinations of statins and antihypertensives.

METHODS

In a retrospective cohort study (2007-2014), we analyzed 694,672 Medicare beneficiaries in the United States (2,017,786 person-years) who concurrently used both statins and AHTs. Using logistic regression adjusting for age, socioeconomic status and comorbidities, we quantified incident ADRD diagnosis associated with concurrent use of different statin molecules (atorvastatin, pravastatin, rosuvastatin, and simvastatin) and AHT drug classes (two renin-angiotensin system (RAS)-acting AHTs, angiotensin converting enzyme inhibitors (ACEIs) or angiotensin-II receptor blockers (ARBs), vs non-RAS-acting AHTs).

FINDINGS

Pravastatin or rosuvastatin combined with RAS-acting AHTs reduce risk of ADRD relative to any statin combined with non-RAS-acting AHTs: ACEI+pravastatin odds ratio (OR) = 0.942 (CI: 0.899-0.986, p = 0.011), ACEI+rosuvastatin OR = 0.841 (CI: 0.794-0.892, p<0.001), ARB+pravastatin OR = 0.794 (CI: 0.748-0.843, p<0.001), ARB+rosuvastatin OR = 0.818 (CI: 0.765-0.874, p<0.001). ARBs combined with atorvastatin and simvastatin are associated with smaller reductions in risk, and ACEI with no risk reduction, compared to when combined with pravastatin or rosuvastatin. Among Hispanics, no combination of statins and RAS-acting AHTs reduces risk relative to combinations of statins and non-RAS-acting AHTs. Among blacks using ACEI+rosuvastatin, ADRD odds were 33% lower compared to blacks using other statins combined with non-RAS-acting AHTs (OR = 0.672 (CI: 0.548-0.825, p<0.001)).

CONCLUSION

Among older Americans, use of pravastatin and rosuvastatin to treat hyperlipidemia is less common than use of simvastatin and atorvastatin, however, in combination with RAS-acting AHTs, particularly ARBs, they may be more effective at reducing risk of ADRD. The number of Americans with ADRD may be reduced with drug treatments for vascular health that also confer effects on ADRD.

Longitudinal analysis of dementia diagnosis and specialty care among racially diverse Medicare beneficiaries

INTRODUCTION

There is insufficient understanding of diagnosis of etiologic dementia subtypes and contact with specialized dementia care among older Americans.

METHODS

We quantified dementia diagnoses and subsequent health care over five years by etiologic subtype and physician specialty among Medicare beneficiaries with incident dementia diagnosis in 2008/09 (226,604 persons/714,015 person-years).

RESULTS

Eighty-five percent of people were diagnosed by a nondementia specialist physician. Use of dementia specialists within one year (22%) and five years (36%) of diagnosis was low. "Unspecified" dementia diagnosis was common, higher among those diagnosed by nondementia specialists (33.2%) than dementia specialists (21.6%). Half of diagnoses were Alzheimer's disease.

DISCUSSION

Ascertainment of etiologic dementia subtype may inform hereditary risk and facilitate financial and care planning. Use of dementia specialty care was low, particularly for Hispanics and Asians, and associated with more detection of etiological subtype. Dementia-related professional development for nonspecialists is urgent given their central role in dementia diagnosis and care.

Incorporating Prescription Drug Utilization Information Into the Marketplace Risk Adjustment Model Improves Payment Accuracy and Reduces Adverse Selection Incentives

Beginning with the 2018 benefit year, the Centers for Medicare and Medicaid Services started incorporating select prescription drug utilization information into the Marketplace risk adjustment model. There has been little evidence about the impact of this change on payment accuracy and the mechanisms through which it may occur. Using commercial claims in 2017 from a large national health insurer, we find that the policy change improves payment accuracy in our sample and would help mitigate insurers' selection incentives for some enrollees through two channels: imputing missing diagnoses and varying risk scores to better capture the heterogeneity in expenditures among patients with certain health conditions. However, while improving payment accuracy overall, there are potential perverse incentives that could distort treatment choice for marginal patients. Additionally, overcompensation and undercompensation persists for certain patient subgroups, suggesting an opportunity to further refine and improve the model.

Growing Number Of Unsubsidized Part D Beneficiaries With Catastrophic Spending Suggests Need For An Out-Of-Pocket Cap

Medicare Part D has no cap on beneficiaries' out-of-pocket spending for outpatient prescription drugs, and, unlike Medicare Parts A and B, beneficiaries are prohibited from purchasing supplemental insurance that could provide such a cap. Historically, most beneficiaries whose annual Part D spending reached the catastrophic level were protected from unlimited personal liability by the Low-Income Subsidy (LIS). However, we found that the proportion of beneficiaries whose spending reached that level but did not qualify for the subsidy-and therefore remained liable for coinsurance-increased rapidly, from 18 percent in 2007 to 28 percent in 2015. Moreover, average total per person per year spending grew much more rapidly for those who did not qualify for the LIS than for those who did, primarily because of differences in price and utilization trends for the drugs that represented disproportionately large shares of their spending. We estimated that a cap for all Part D enrollees in 2015 would have raised monthly premiums by only $0.40-$1.31 per member.

Generic Drug Price Hikes And Out-Of-Pocket Spending For Medicare Beneficiaries

Recent increases in prices of longtime generic drugs have focused attention on competition in generic markets. We used Medicare Part D data for the period 2006-15 to examine sudden large price increases in generic drugs in the context of their base prices, duration, and accompanying changes in patients' out-of-pocket spending. The fraction of drugs that at least doubled in price increased from 1.00 percent of generic products in 2007 to 4.39 percent in 2013. Almost all were initially low- or medium-price medications and not among the most widely used generics. Changes in out-of-pocket spending for these drugs were modest. However, the elevated prices persisted for two to five years. Data for 2011-15 showed similar trends. Potential steps to ensure that generic markets remain strong include fast-tracking new generic drug applications when competition is limited, allowing temporary importation of off-patent drugs, and implementing greater oversight of drug company mergers and takeovers.

Racial and ethnic disparities in medication adherence among privately insured patients in the United States

OBJECTIVE

To examine the association between socioeconomic status (SES) and racial and ethnic disparities in medication adherence for three widely prescribed therapeutic classes.

METHODS

We linked longitudinal claims data from a large US-based insurance provider (2011-2013) to detailed SES information to identify patients treated with oral antidiabetic (N = 56,720), antihypertensive (N = 156,468) or antihyperlipidemic (N = 144,673) medications. We measured adherence and discontinuation by therapeutic class, and conducted regression analysis to quantify the contributions of different factors in the association between race/ethnicity and medication adherence.

RESULTS

During an average follow-up period of 2.5 years, average adherence rates of Blacks and Hispanics were at least 7.5 percentage points lower than those of Whites. Controlling for demographics, health status, out-of-pocket costs, convenience of refilling prescriptions and SES attenuated the association by 30 to 50 percent, nonetheless substantial racial disparities persisted (4.1-5.8 percentage points), particularly for asymptomatic conditions. Separating adherence among existing users from those that discontinued therapies indicates that racial/ethnic disparities in adherence reflect inconsistent pill-taking rather than differential rates of discontinuation.

CONCLUSIONS

Racial/ethnic disparities in adherence are mitigated, but persist after controlling for detailed socioeconomic measures. Interventions should focus more on improving medication adherence of existing users, particularly in treating asymptomatic conditions.

The association of multiple anti-hypertensive medication classes with Alzheimer's disease incidence across sex, race, and ethnicity

BACKGROUND

Antihypertensive treatments have been shown to reduce the risk of Alzheimer's disease (AD). The renin-angiotensin system (RAS) has been implicated in AD, and thus RAS-acting AHTs (angiotensin converting enzyme inhibitors (ACEIs), and angiotensin-II receptor blockers (ARBs)) may offer differential and additional protective benefits against AD compared with other AHTs, in addition to hypertension management.

METHODS

In a retrospective cohort design, we examined the medical and pharmacy claims of a 20% sample of Medicare beneficiaries from 2007 to 2013, and compared rates of AD diagnosis for 1,343,334 users of six different AHT drug treatments, 65 years of age or older (4,215,338 person-years). We compared AD risk between RAS and non-RAS AHT drug users, and between ACEI users and ARB users, by sex and race/ethnicity. Models adjusted for age, socioeconomic status, underlying health, and comorbidities.

FINDINGS

RAS-acting AHTs were slightly more protective against onset of AD than non-RAS-acting AHTs for males, (male OR = 0.931 (CI: 0.895-0.969)), but not so for females (female OR = 0.985 (CI: 0.963-1.007)). Relative to other AHTs, ARBs were superior to ACEIs for both men (male ARB OR = 0.834 (CI: 0.788-0.884); male ACEI OR = 0.978 (CI: 0.939-1.019)) and women (female ARB OR = 0.941 (CI: 0.913-0.969); female ACEI OR = 1.022 (CI: 0.997-1.048)), but only in white men and white and black women. No association was shown for Hispanic men and women.

CONCLUSION

Hypertension management treatments that include RAS-acting ARBs may, in addition to lowering blood pressure, reduce AD risk, particularly for white and black women and white men. Additional studies and clinical trials that include men and women from different racial and ethnic groups are needed to confirm these findings. Understanding the potentially beneficial effects of certain RAS-acting AHTs in high-risk populations is of great importance.

Frequency and Magnitude of Co-payments Exceeding Prescription Drug Costs

This study uses Centers for Medicare & Medicaid Services data to assess the proportion of pharmacy claims with patient co-pay overpayment and the mean dollar amount of overpayment in 2013.

Medicare Beneficiaries Face Growing Out-Of-Pocket Burden For Specialty Drugs While In Catastrophic Coverage Phase

The Affordable Care Act (ACA) includes provisions to reduce Medicare beneficiaries' out-of-pocket spending for prescription drugs by gradually closing the coverage gap between the initial coverage limit and the catastrophic coverage threshold (known as the doughnut hole) beginning in 2011. However, Medicare beneficiaries who take specialty pharmaceuticals could still face a large out-of-pocket burden because of uncapped cost sharing in the catastrophic coverage phase. Using 2008-12 pharmacy claims data from a 20 percent sample of Medicare beneficiaries, we analyzed trends in total and out-of-pocket spending among Medicare beneficiaries who take at least one high-cost specialty drug from the top eight specialty drug classes in terms of spending. Annual total drug spending per specialty drug user studied increased considerably during the study period, from $18,335 to $33,301, and the proportion of expenditures incurred while in the catastrophic coverage phase increased from 70 percent to 80 percent. We observed a 26 percent decrease in mean annual out-of-pocket expenditures incurred below the catastrophic coverage threshold, likely attributable to the ACA's doughnut hole cost-sharing reductions, but increases in mean annual out-of-pocket expenditures incurred while in the catastrophic coverage phase offset these reductions almost entirely. Policy makers should consider implementing limits on patients' out-of-pocket burden.

Physician Reimbursement in Medicare Advantage Compared With Traditional Medicare and Commercial Health Insurance

Importance

Nearly one-third of Medicare beneficiaries are enrolled in a Medicare Advantage (MA) plan, yet little is known about the prices that MA plans pay for physician services. Medicare Advantage insurers typically also sell commercial plans, and the extent to which MA physician reimbursement reflects traditional Medicare (TM) rates vs negotiated commercial prices is unclear.

Objective

To compare prices paid for physician and other health care services in MA, traditional Medicare, and commercial plans.

Design, Setting, and Participants

Retrospective analysis of claims data evaluating MA prices paid to physicians and for laboratory services and durable medical equipment between 2007 and 2012 in 348 US core-based statistical areas. The study population included all MA and commercial enrollees with a large national health insurer operating in both markets, as well as a 20% sample of TM beneficiaries.

Exposures

Enrollment in an MA plan.

Main Outcomes and Measures

Mean reimbursement paid to physicians, laboratories, and durable medical equipment suppliers for MA and commercial enrollees relative to TM rates for 11 Healthcare Common Procedure Coding Systems (HCPCS) codes spanning 7 sites of care.

Results

The sample consisted of 144 million claims. Physician reimbursement in MA was more strongly tied to TM rates than commercial prices, although MA plans tended to pay physicians less than TM. For a mid-level office visit with an established patient (Current Procedural Terminology [CPT] code 99213), the mean MA price was 96.9% (95% CI, 96.7%-97.2%) of TM. Across the common physician services we evaluated, mean MA reimbursement ranged from 91.3% of TM for cataract removal in an ambulatory surgery center (CPT 66984; 95% CI, 90.7%-91.9%) to 102.3% of TM for complex evaluation and management of a patient in the emergency department (CPT 99285; 95% CI, 102.1%-102.6%). However, for laboratory services and durable medical equipment, where commercial prices are lower than TM rates, MA plans take advantage of these lower commercial prices, ranging from 67.4% for a walker (HCPCS code E0143; 95% CI, 66.3%-68.5%) to 75.8% for a complete blood cell count (CPT 85025; 95% CI, 75.0%-76.6%).

Conclusions and Relevance

Traditional Medicare's administratively set rates act as a strong anchor for physician reimbursement in the MA market, although MA plans succeed in negotiating lower prices for other health care services for which TM overpays. Reforms that transition the Medicare program toward some premium support models could substantially affect how physicians and other clinicians are paid.

The price may not be right: the value of comparison shopping for prescription drugs

OBJECTIVES

To measure variations in drug prices across and within zip codes that may reveal simple strategies to improve patients' access to prescribed medications.

STUDY DESIGN

We compared drug prices at different types of pharmacies across and within local markets. In-store prices were compared with a Web-based service providing discount coupons for prescription medications. Prices were collected for 2 generic antibiotics because most patients have limited experience with them and are less likely to know the price ranges for them.

METHODS

Drug prices were obtained via telephone from 528 pharmacies in Los Angeles (LA) County, California, from July to August 2014. Online prices were collected from GoodRx, a popular Web-based service that aggregates available discounts and directly negotiates with retail outlets.

RESULTS

Drug prices found at independent pharmacies and by using discount coupons available online were lower on average than at grocery, big-box, or chain drug stores for 2 widely prescribed antibiotics. The lowest-price prescription was offered at a grocery, big-box, or chain drug store in 6% of zip codes within the LA County area. Drug prices varied dramatically within a zip code, however, and were less expensive in lower-income areas. The average price difference within a zip code was $52 for levofloxacin and $17 for azithromycin.

CONCLUSIONS

Price shopping for medications within a small geographic area can yield considerable cost savings for the uninsured and consumers in high-deductible health plans with high negotiated prices. Clinicians and patient advocates have an incentive to convey this information to patients to improve adherence to prescribed medicines and lower the financial burden of purchasing prescription drugs.

Sex and Race Differences in the Association Between Statin Use and the Incidence of Alzheimer Disease

Importance

To our knowledge, no effective treatments exist for Alzheimer disease, and new molecules are years away. However, several drugs prescribed for other conditions have been associated with reducing its risk.

Objective

To analyze the association between statin exposure and Alzheimer disease incidence among Medicare beneficiaries.

Design, Setting, and Participants

We examined the medical and pharmacy claims of a 20% sample of Medicare beneficiaries from 2006 to 2013 and compared rates of Alzheimer disease diagnosis for 399 979 statin users 65 years of age or older with high or low exposure to statins and with drug molecules for black, Hispanic, and non-Hispanic white people, and men and women of Asian, Native American, or unkown race/ethnicity who are referred to as "other."

Main Outcomes and Measures

The main outcome was incident diagnosis of Alzheimer disease based on the International Classification of Diseases, Ninth Revision, Clinical Modification. We used Cox proportional hazard models to analyze the association between statin exposure and Alzheimer disease diagnosis for different sexes, races and ethnicities, and statin molecules.

Results

The 399 979 study participants included 7794 (1.95%) black men, 24 484 (6.12%) black women, 11 200 (2.80%) Hispanic men, 21 458 (5.36%) Hispanic women, 115 059 (28.77%) white men, and 195 181 (48.80%) white women. High exposure to statins was associated with a lower risk of Alzheimer disease diagnosis for women (hazard ratio [HR], 0.85; 95% CI, 0.82-0.89; P<.001) and men (HR, 0.88; 95% CI, 0.83-0.93; P<.001). Simvastatin was associated with lower Alzheimer disease risk for white women (HR, 0.86; 95% CI, 0.81-0.92; P<.001), white men (HR, 0.90; 95% CI, 0.82-0.99; P=.02), Hispanic women (HR, 0.82; 95% CI, 0.68-0.99; P=.04), Hispanic men (HR, 0.67; 95% CI, 0.50-0.91; P=.01), and black women (HR, 0.78; 95% CI, 0.66-0.93; P=.005). Atorvastatin was associated with a reduced risk of incident Alzheimer disease diagnosis for white women (HR, 0.84, 95% CI, 0.78-0.89), black women (HR, 0.81, 95% CI, 0.67-0.98), and Hispanic men (HR, 0.61, 95% CI, 0.42-0.89) and women (HR, 0.76, 95% CI, 0.60-0.97). Pravastatin and rosuvastatin were associated with reduced Alzheimer disease risk for white women only (HR, 0.82, 95% CI, 0.70-0.95 and HR, 0.81, 95% CI, 0.67-0.98, respectively). High statin exposure was not associated with a statistically significant lower Alzheimer disease risk among black men.

Conclusions and Relevance

The reduction in Alzheimer disease risk varied across statin molecules, sex, and race/ethnicity. Clinical trials that include racial and ethnic groups need to confirm these findings. Because statins may affect Alzheimer disease risk, physicians should consider which statin is prescribed to each patient.

Specialty drug spending trends among Medicare and Medicare Advantage enrollees, 2007-11

Specialty pharmaceuticals include most injectable and biologic agents used to treat complex conditions such as rheumatoid arthritis, multiple sclerosis, and cancer. We analyzed trends in specialty drug spending among Medicare beneficiaries ages sixty-five and older using 2007-11 pharmacy claims data from a 20 percent sample of Medicare beneficiaries. Annual specialty drug spending per beneficiary who used specialty drugs increased considerably during the study period, from $2,641 to $8,976. However, specialty drugs accounted for only 6.7 percent of total drug spending per beneficiary in 2007 and 9.1 percent in 2011. Moreover, in 2011 cost-sharing reductions under the Affordable Care Act significantly reduced specialty drug users' out-of-pocket burden, which decreased 26 percent from 2010. Oral cancer agents accounted for a significant proportion of the increase in specialty drug spending among the study population. This suggests that the migration of specialty drug coverage from Medicare's Part B medical benefit to the Part D pharmacy benefit because of new treatment options may play an important role in specialty pharmacy trends. This shift is likely to continue as pharmaceutical innovations enable more specialty therapeutics to be self-administered and to be covered under the pharmacy instead of the medical benefit.

American surgery and the Affordable Care Act

The Affordable Care Act (ACA) attempts to change the way we finance and deliver health care by coordinating the delivery of primary, specialty, and hospital services in accountable care organizations. The ways in which accountable care organizations will develop and evolve is unclear; however, the effects on surgeons and their patients will be substantial. High-value care in the ACA emphasizes quality, safety, resource use and appropriateness, and the patient's experience of care. Payment will be linked to these principles. Department chairs overseeing a clinical enterprise in academic medical centers now must add financial and quality measures to the traditional missions of education, research, and clinical service. At a time when surgical training is in dramatic evolution, with work hour limitations for residents and an emphasis on quality, productivity, and increasing oversight of trainees for faculty, residency programs will need to meet the increasing demands of an aging population and newly insured patients under the ACA. The American College of Surgeons, with its century-long commitment to quality improvement, research-based standards, and performance measurement and verification, has begun its Inspiring Quality Campaign, is developing new educational tools, and is preparing proposals for payment reform based on surgeons' participation in quality programs.

Medicaid cost control measures aimed at second-generation antipsychotics led to less use of all antipsychotics

"Atypical" or second-generation antipsychotics are a class of drug introduced in the 1990 s for the treatment of schizophrenia. Given their growing use and rising cost, these and other psychotherapeutic drugs are increasingly subject to prior authorization and other restrictions in state Medicaid programs. To evaluate the effects of these policies, we collected drug-level information on their use and on utilization management strategies--for example, requirements for prior authorization, quantity limits, and so-called step therapy--in thirty state Medicaid programs between 1999 and 2008. In the eleven states that instituted prior authorization during that period, use of atypicals per enrollee rose by 14 percent, versus 19 percent in the other nineteen states. Prior authorization also had spillover effects, in that reduced use of drugs subject to this requirement was not fully offset by the substitution of other atypicals or of typical antipsychotics. To understand the impact on patients and the resulting use of health services, studies should be undertaken of a large, national sample of Medicaid enrollees being treated with atypical antipsychotics. Comparative effectiveness research should guide physicians and health plans on appropriate first treatments, while prior authorization policies should focus on moving patients to appropriate second-line therapies when necessary.

Complex plasmas in external fields: the role of non-hamiltonian interactions

Dedicated experiments with strongly coupled complex plasmas in external electric fields were carried out under microgravity conditions using the PK-4 dc discharge setup. The focus was put on the comparative analysis of the formation of stringlike anisotropic structures due to reciprocal (hamiltonian) and nonreciprocal (non-hamiltonian) interactions between microparticles (induced by ac and dc fields, respectively). The experiments complemented by numerical simulations demonstrate that the responses of complex plasmas in these two regimes are drastically different. It is suggested that the observed difference is a manifestation of intrinsic thermodynamic openness of driven strongly coupled systems.

Association between the birth of twins and parental divorce

OBJECTIVE

Mothers of multiple births face higher rates of postpartum depression, yet evidence on the marital consequences of multiple births is limited. We examined the association between twin births and parental divorce.

METHODS

We used the 1980 U.S. Census to identify a large sample of mothers with and without twin births. The goal was to estimate multivariate logistic models of the association between birth of twins and divorce adjusting for race, age at marriage and first birth, and college education. We examined whether the association was affected by maternal education, age and sex composition of twins, and family size.

RESULTS

Twins at first birth were associated with greater parental divorce compared with singletons (odds ratio, 1.08; 95% confidence interval, 1.01-1.16; absolute risk 13.7% with twins compared with 12.7%; P=.02). The association was statistically greater among mothers not attending college (14.9% with twins compared with 13.3%; P=.01) compared with those with some college (10.4% with twins compared with 10.5%; P=.34); those with children older than 8 years (15.6% with twins compared with 13.5%; P<.01) compared with younger children (10.6% with twins compared with 10.8%; P=.42); and those with at least one twin girl (13.8% with twins compared with 12.6%; P=.03) compared with twin boys (12.1% with twins compared with 12.5%, P=.38). Mothers with four or more children had a larger association between birth of twins and divorce (15.4% for mothers with twins at fourth birth compared with 11.3% for all other mothers with four or more children; P<.01) compared with mothers with twins at first birth (13.7% for twins at first birth compared with 12.7%; P=.02).

CONCLUSION

Health consequences of twin births for children and mothers are well known. Twin births may be associated with longer-term parental divorce. Specific groups, namely mothers not completing college and mothers who already have more children, may be at higher risk.

LEVEL OF EVIDENCE

II.

First observation of electrorheological plasmas

We report the experimental discovery of "electrorheological (ER) complex plasmas," where the control of the interparticle interaction by an externally applied electric field is due to distortion of the Debye spheres that surround microparticles (dust) in a plasma. We show that interactions in ER plasmas under weak ac fields are mathematically equivalent to those in conventional ER fluids. Microgravity experiments, as well as molecular dynamics simulations, show a phase transition from an isotropic to an anisotropic (string) plasma state as the electric field is increased.

Economic evaluation of treatment strategies for benign prostatic hyperplasia--is medical therapy more costly in the long run?

PURPOSE

Although medical therapy for newly diagnosed benign prostatic hyperplasia is initially less expensive than surgery, to our knowledge the long-term costs of these treatments are unknown. We defined longer term costs of these treatment strategies.

MATERIALS AND METHODS

We examined spending on benign prostatic hyperplasia related services by examining health care claims for a 5-year period subsequent to a new benign prostatic hyperplasia diagnosis. Expenditures for subjects treated initially with surgery were compared to expenditures for those with initial medical treatment. Expenditures were projected during longer periods and the net current value of these expenditures was calculated.

RESULTS

Of the 970 subjects identified who received benign prostatic hyperplasia treatment 913 (94.1%) relied on medical therapy as initial treatment. Of those subjects 832 (91.1%) were on alpha-blockers. The secondary treatment rates for surgery far exceeded those for medical therapy (37% vs 8%). Average total expenditures were higher for subjects who initially received surgery ($12,699, 95% CI 9,865-15,533) than for those initially treated with medication ($2,193, 95% CI 1,959-2,428). If future streams of spending were discounted at standard rates (3%), the costs of initial medical therapy as a treatment strategy would always be lower than those of initial surgical therapy even at 40 years.

CONCLUSIONS

In a cohort of privately insured men with newly diagnosed benign prostatic hyperplasia monotherapy with alpha-blockers was the most common initial treatment. Surgical therapy was associated with higher treatment failure rates and higher costs during 5 years. Increased expenditures related to initial surgical therapy were consistent when projected over long time frames.

Increasing costs of urinary incontinence among female Medicare beneficiaries

PURPOSE

We measured the financial burden of urinary incontinence in the United States from 1992 to 1998 among women 65 years old or older.

MATERIALS AND METHODS

We analyzed Medicare claims for 1992, 1995 and 1998 and estimated spending on the treatment of urinary incontinence. Total costs were stratified by type of service (inpatient, outpatient and emergency department).

RESULTS

Costs of urinary incontinence among older women nearly doubled between 1992 and 1998 in nominal dollars, from $128 million to $234 million, primarily due to increases in physician office visits and ambulatory surgery. The cost of inpatient services increased only slightly during the period. The increase in total spending was due almost exclusively to the increase in the number of women treated for incontinence. After adjusting for inflation, per capita treatment costs decreased about 15% during the study.

CONCLUSIONS

This shift from inpatient to outpatient care likely reflects the general shift of surgical procedures to the outpatient setting, as well as the advent of new minimally invasive incontinence procedures. In addition, increased awareness of incontinence and the marketing of new drugs for its treatment, specifically anticholinergic medication for overactive bladder symptoms, may have increased the number of office visits. While claims based Medicare expenditures are substantial, they do not include the costs of pads or medications and, therefore, underestimate the true financial burden of incontinence on the aging community.

An HIV Collaborative in the VHA: Do Advanced HIT and One-Day Sessions Change the Collaborative Experience?

BACKGROUND

Many organizations participate in quality collaboratives, yet the return on investment of the associated time and costs is unclear.

METHOD

Semistructured interviews, surveys, and direct observation were used to assess experiences, improvement activities, and costs associated with participation in a year-long modified Institute for Healthcare Improvement-style collaborative designed to improve HIV care within the Veterans Health Administration. All nine sites had access to automated patient registries and semi-automated clinical measure reports; five sites also received computerized clinical reminders. Three one-day learning sessions were conducted.

RESULTS

Participants reported that burden was small and value high, although many suggested that more time for peer-to peer learning would have been helpful. Teams averaged five quality improvement activities per site and most reported improvements in HIV care processes. The average annual cost per site was dollars 28,000 but costs varied considerably by site.

DISCUSSION

Shortened learning sessions and the incorporation of health information technology can reduce some of the costs and burdens associated with collaboratives, yet peer-to-peer interaction and local organizational factors remain important to ensuring perceived effectiveness of collaboratives.

Implementation and maintenance of quality improvement for treating depression in primary care

OBJECTIVE

Little is known about the long-term success of quality improvement efforts for the treatment of depression in primary care. This study assessed factors associated with the successful implementation, maintenance, and spread of such efforts.

METHODS

The authors conducted an independent process evaluation of data from monthly progress reports and 18-month telephone interviews from multidisciplinary quality improvement teams in 17 diverse primary care organizations that participated in the Institute for Healthcare Improvement's Breakthrough Series for Depression from February 2000 through March 2001.

RESULTS

All sites made changes toward improving care in three of six categories: delivery system redesign, self-management strategies, and information systems. The changes that were most commonly viewed as major successes were delivery system changes (ten sites, or 59 percent) and information system changes (nine sites, or 53 percent); these types of changes were also the most often sustained over time (ten sites, or 59 percent, and 16 sites, or 94 percent, respectively). Fifteen sites made changes in decision support, community linkages, and health system support but were less likely to view these changes as major successes or to sustain them. Organizational structure and leadership support were the most common facilitators. Staff resistance, time constraints, and information technology were the most common barriers. Implementation strategies varied with sets of barriers.

CONCLUSIONS

Despite substantial challenges, there was evidence of broad success at implementation and maintenance of quality improvement for depression treatment in primary care.

Direct and indirect costs of nephrolithiasis in an employed population: opportunity for disease management?

BACKGROUND

More than 5% of the United States population has been diagnosed with nephrolithiasis and about one half of (first-time) stone formers will have a recurrence within 5 years. The prevalence of nephrolithiasis is concentrated among working age adults, yet little prior work has examined the economic burden of the disease on employers and their employees. We sought to estimate the direct and indirect costs of nephrolithiasis for working age adults (18-64) with employer-provided insurance.

METHODS

This was an observational study using retrospective claims data. Detailed medical and pharmacy claims from 25 large employers and absentee data from a subset of firms were used to estimate the direct and indirect costs associated with nephrolithiasis in a privately insured, non-elderly population. Multivariate regression models were used to predict health care expenditures for persons with and without the condition, controlling for differences in patient (health status) and plan characteristics.

RESULTS

More than 1% of working-age adults were treated for nephrolithiasis in 2000. Prevalence was considerably higher among men and employees age 55 to 64. About one third of employees treated for nephrolithiasis in 2000 missed work due to the condition, with an average work loss for the entire treated population of 19 hours per person. Conditional on receiving treatment, the incremental costs of nephrolithiasis were 3,494 US dollars per person in 2000.

CONCLUSION

The direct and indirect costs of nephrolithiaisis are substantial among working-age adults. Interventions that prevent recurrence among known stone formers may be a cost-effective component of disease management programs.

Differences in Education, Knowledge, Self-Management Activities, and Health Outcomes for Patients With Heart Failure Cared for Under the Chronic Disease Model: The Improving Chronic Illness Care Evaluation

BACKGROUND

The objective of this study was to determine whether participation in a quality improvement (QI) collaborative for heart failure (HF) was associated with better interpersonal aspects of care and health outcomes.

METHODS AND RESULTS

We conducted a cross-sectional telephone survey of patients in 6 organizations who participated in a QI collaborative for HF (participants, n = 387) and 6 comparable control organizations (controls, n = 414) and measured provider-patient communication, education received, knowledge of HF, self-management behaviors, satisfaction, and quality of life. The participant group patients were more likely to report their doctor and nurse discussed treatment options and reviewed self-management (P < .01 for both). A total of 88% of participants were told to weigh themselves daily and record their weight compared with 34% of controls (P < .01). Participants were more likely to know how often to check their weight (P < .01), recognize symptoms of worsening HF (P < or = .01 for all), have a scale (P = .002), and monitor their weight daily (P < .001). Participants had similar quality of life but fewer emergency department visits and hospitalizations.

CONCLUSION

Participation in a QI collaborative for HF was associated with better communication, education, and knowledge, and lower health care use. Collaboratives may be a useful method for disseminating quality improvement strategies.

Economic costs of benign prostatic hyperplasia in the private sector

PURPOSE

Several studies document the impact of benign prostatic hyperplasia (BPH) in working, aged men. Direct medical costs related to BPH treatment are largely borne by employees through higher premiums. However, indirect costs related to lost work are primarily borne by the employer. In this study we used claims data and absentee records from large employers to estimate the costs associated with BPH in working age males.

MATERIALS AND METHODS

We used 2 data sources to examine direct and indirect costs associated with BPH in a privately insured, nonelderly population. Multivariate regression models were used to predict spending for persons with and without a medical claim for BPH, controlling for relevant covariates. Data on work loss were linked to medical claims to estimate work loss related to treatment for BPH.

RESULTS

Mean annual expenditures were 4,193 dollars for men without a medical claim for BPH. In contrast, annual spending was 5,729 dollars for men with a claim for BPH. Thus, the incremental cost associated with a diagnosis of BPH was 1,536 dollars yearly. Overall the average employee with the condition missed 7.3 hours of work yearly related to BPH with approximately 10% reporting some work loss related to a health care encounter for BPH.

CONCLUSIONS

Treatment of men with BPH places a significant burden on employees and their employers through direct medical costs as well as through lost work time. Direct and indirect costs to the private sector related to BPH treatment are estimated to be 3.9 billion dollars.

Quasineutral plasma models

The quasineutral plasma model proposed by Langmuir more than 75 years ago is still widely used today and is based on two approximations: charge neutrality and the Boltzmann relationship for electrons. However, the Boltzmann relationship is unnecessary and is not always justified. Moreover, because the Boltzmann relationship is fluid based, it compromises kinetic treatments and gives rise to troublesome singularities in the Bohm condition. To overcome these limitations, more general quasineutral models are developed. Two of the models are fluid based while the third is fully kinetic. The kinetic model and one of the fluid models lead directly to the Bohm condition, but without the singularities seen earlier. Fluid simulations are presented to test and compare the various approaches.

Force on a charged test particle in a collisional flowing plasma

The force on a charged test particle embedded in a flowing (electron-ion) plasma is calculated using the linear dielectric response formalism. This approach allows us to take into account ion-neutral collisions self-consistently. The effect of collisions on the ion drag force is analyzed. It is shown that collisions can play a major role and can enhance the force substantially.