Publications

OBJECTIVE: To evaluate Medicare Part D's impact on use of antihypertensive medications among seniors with hypertension.

DATA SOURCES: Medicare-Advantage plan pharmacy data from January 1, 2004 to December 12, 2007 from three groups who before enrolling in Part D had no or limited drug benefits, and a comparison group with stable employer-based coverage.

STUDY DESIGN: Pre-post intervention with a comparison group design was used to study likelihood of use, daily counts, and substitutions between angiotensin-converting enzyme inhibitors and angiotensin-II receptor blockers (ARBs).

PRINCIPAL FINDINGS: Antihypertensive use increased most among those without prior drug coverage: likelihood of use increased (odds ratio = 1.40, 95 percent confidence interval [CI] 1.25-1.56), and daily counts increased 0.29 (95 percent CI 0.24-0.33). Proportion using ARBs increased from 40 to 46 percent.

CONCLUSIONS: Part D was associated with increased antihypertensive use and use of ARBs over less expensive alternatives.

BACKGROUND: Mirizzi syndrome (MS) is characterized by extrinsic compression of the common hepatic duct by stones impacted in the cystic duct or gallbladder neck. Open cholecystectomy (OC) has been the standard treatment; however, laparoscopy has challenged this approach.

STUDY DESIGN: The objective of this study was to review our clinical experience with MS since the introduction of laparoscopic cholecystectomy (LC) and determine the impact of alternative approaches. We conducted a retrospective review of patients with MS from January 1987 to December 2009.

RESULTS: There were 36 patients with MS among 21,450 cholecystectomies (frequency 0.18%). Seventeen were women. The most common presenting symptoms were abdominal pain (n = 23) and jaundice (n = 19). Preoperative diagnostic studies included ultrasonography (n = 27), CT (n = 24), and endoscopic retrograde cholangiopancreatography (n = 32). Cholecystectomy was performed in 35 patients; LC was initiated in 15 and OC in 21. Conversion rate from LC to OC was 67%. Five patients who had successful LC had type I MS. Of the patients who underwent LC with conversion or OC, 14 had type I and 16 had type II MS. The cystic duct for type I and the bile duct for type II MS were managed diversely according to surgeon's preference. There was no operative mortality. Morbidity was 31% with Clavien class I in 2, IIIa in 4, IIIb in 1, and IV in 3 patients. Mean hospitalization was 9 days (range 2 to 40 days). Mean follow-up was 37 months (range 1 to 187 months).

CONCLUSIONS: Low incidence and nonspecific presentation of MS precludes referral and substantive individual experience. Although LC may be applicable in selected patients with type I MS, OC remains the standard of care.

CONTEXT: Collaborative depression care management (DCM), by addressing barriers disproportionately affecting patients of racial/ethnic minority and low education, may reduce disparities in depression treatment and outcomes.

OBJECTIVE: To examine the effects of DCM on treatment disparities by education and race/ethnicity in older depressed primary care patients.

DESIGN: Analysis of data from the randomized controlled trial Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT).

SETTING: Twenty primary care practices.

PARTICIPANTS: A total of 396 individuals 60 years or older with major depression. We conducted model-based analysis to estimate potentially differential intervention effects by education, independent of those by race/ethnicity (and vice versa).

INTERVENTION: Algorithm-based recommendations to physicians and care management by care managers.

MAIN OUTCOME MEASURES: Antidepressant use, depressive symptoms, and intensity of DCM over 2 years.

RESULTS: The PROSPECT intervention had a larger and more lasting effect in less-educated patients. At month 12, the intervention increased the rate of adequate antidepressant use by 14.2 percentage points (pps) (95% confidence interval [CI], 1.7 to 26.4 pps) in the no-college group compared with a null effect in the college-educated group (-9.2 pps [95% CI, -25.0 to 2.7 pps]); at month 24, the intervention reduced depressive symptoms by 2.6 pps on the Hamilton Depression Rating Scale (95% CI, -4.6 to -0.4 pps) in no-college patients, 3.8 pps (95% CI, -6.8 to -0.4) more than in the college group. The intervention benefitted non-Hispanic white patients more than minority patients. Intensity of DCM received by minorities was 60% to 70% of that received by white patients after the initial phase but did not differ by education.

CONCLUSIONS: The PROSPECT intervention substantially reduced disparities by patient education but did not mitigate racial/ethnic disparities in depression treatment and outcomes. Incorporation of culturally tailored strategies in DCM models may be needed to extend their benefits to minorities.

TRIAL REGISTRATION: clinicaltrials.gov Identifier for

PROSPECT: NCT00279682.

OBJECTIVE: Little is known about the effect recent health care reform legislation will have on coverage of individuals with severe mental disorders. The authors examined current and predicted sources of insurance coverage and use of mental health services among adults with and without severe mental disorders and modeled postreform changes.

METHOD: The authors obtained sociodemographic, health status, mental health care use, and insurance coverage data from the 2004-2006 Medical Expenditure Panel Surveys to estimate changes that will occur after reform is fully implemented in 2019.

RESULTS: Adults with severe mental disorders, identified as self-reported severe depression or other psychological distress, were more likely than those without such disorders to be uninsured (21.0% compared with 16.5%). Only one-fifth of individuals with severe mental disorders who lacked full-year insurance coverage had any mental health service use in the 2004-2006 period, compared with approximately half of those who had coverage. The authors estimate that the expansion of insurance coverage under reform will lead to 1.15 million new users of mental health services, which represents a 4.5% increase. The authors estimate an increase of 2.3 million users of mental health services in Medicaid and nearly 2 million in private insurance.

CONCLUSIONS: Public insurance programs that currently play a major role in financing mental health services will play an even greater role after reform is implemented. Significant increases can be expected both in the overall number of users of mental health services and in their resources to pay for care.

Although studies have suggested that a patient's perceived cost-benefit of a medical intervention could affect his or her utilization of the intervention, the economic value of influenza vaccine from the patient's perspective remains unclear. Therefore, we developed a stochastic decision analytic computer model representing an adult's decision of whether to get vaccinated. Different scenarios explored the impact of the patient being insured versus uninsured, influenza attack rate, vaccine administration costs and vaccination time costs. Results indicated that the cost of avoiding influenza was fairly low (with one driver being required vaccination time). To encourage vaccination, decision makers may want to focus on ways to reduce this time, such as vaccinating at work, churches, or other normally frequented locations.

OBJECTIVES: Depression in older adults is often undertreated due, in part, to medication costs. We examined the impact of improved prescription drug coverage under Medicare Part D on use of antidepressants, medication choice, and adherence.

DESIGN, SETTING AND PARTICIPANTS: Observational claims-based study of older adults with depression (ICD-9: 296.2, 296.3, 311, 300.4) continuously enrolled in a Medicare managed care plan between 2004 and 2007. Three groups with limited ($150 or $350 quarterly caps) or no drug coverage in 2004-2005 obtained Part D benefits in 2006. A comparison group had stable employer-sponsored coverage throughout.

MEASUREMENTS: Any antidepressant prescription fill, antidepressant choice (tricyclics or monoamine oxidase inhibitors versus newer antidepressants), and adherence (80% of days covered) in the first 6 months of treatment.

RESULTS: : Part D was associated with increased odds of any antidepressant use among those who previously lacked coverage (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.41-1.85) but odds of use did not change among those with limited prior coverage. Use of older antidepressant agents did not change with Part D. All three groups whose coverage improved with Part D had significantly higher odds of 80% of days covered with an antidepressant (OR = 1.86 [95% CI: 1.44-2.39] for no coverage, 1.74 [95% CI: 1.25%3.42] for $150 cap; and 1.19 [95% CI: 1.06-1.34] for the $350 cap groups).

CONCLUSIONS: Medicare Part D was associated with improvements in antidepressant use and adherence in depressed older adults who previously had no or limited drug coverage but not with changes in use of older agents. use and adherence in depressed older adults who previously had no or limited drug coverage but not with changes in use of older agents.

BACKGROUND: Cost-related underuse of medications is common among older adults, who seldom discuss medication costs with their physicians. Some older adults may use free drug samples or industry-sponsored patient assistance programs (PAP) in hopes of lowering out-of-pocket costs, although the long-term effect of these programs on drug spending is unclear.

OBJECTIVE: To examine older adults' use of industry-sponsored strategies to reduce out-of-pocket drug costs and the association between doctor-patient communication and use of these programs.

DESIGN: Cross-sectional analysis of a 2006 nationally representative survey of Medicare beneficiaries.

PARTICIPANTS: 14,322 community-dwelling Medicare beneficiaries age ≥65.

MAIN MEASURES: We conducted bivariate and multivariate analyses of the association between receipt of free samples and participation in PAPs with sociodemographic characteristics, health status, access to care, drug coverage, medication cost burden, and doctor-patient communication.

KEY RESULTS: 51.4% of seniors reported receiving at least one free sample over the last 12 months and 29.2% reported receiving free samples more than once. In contrast, only 1.3% of seniors reported participating in an industry-sponsored PAP. Higher income respondents were more likely to report free sample receipt than low-income respondents (50.8% vs. 43.8%, p < 0.001) and less likely to report participating in a PAP (0.42% vs. 2.2%, p < 0.001). In multivariate analyses, those who reported talking to their doctor about the cost of their medications had more than twice the odds of receiving samples as those who did not (OR 2.17, 95% CI 1.95-2.42).

CONCLUSIONS: In 2006, over half of seniors in Medicare received free samples, but only 1.3% reported receiving any medications from a patient assistance program. Doctor-patient communication is strongly associated with use of these programs, which has important implications for clinical care regardless of whether these programs are viewed as drivers of prescription costs or a remedy for them.

OBJECTIVE: To examine the prevalence and correlates of non-opioid and opioid analgesic use and descriptively evaluate potential undertreatment in a sample of community-dwelling elders with symptomatic knee and/or hip osteoarthritis (OA).

DESIGN: Cross-sectional.

SETTING: Health, Aging, and Body Composition Study.

PATIENTS: Six hundred and fifty-two participants attending the year 6 visit (2002-03) with symptomatic knee and/or hip OA.

OUTCOME MEASURES: Analgesic use was defined as taking ≥1 non-opioid and/or ≥1 opioid receptor agonist. Non-opioid and opioid doses were standardized across all agents by dividing the daily dose used by the minimum effective analgesic daily dose. Inadequate pain control was defined as severe/extreme OA pain in the past 30 days from a modified Western Ontario and McMaster Universities Osteoarthritis Index.

RESULTS: Just over half (51.4%) reported taking at least one non-opioid analgesic and approximately 10% was taking an opioid, most (88.5%) of whom also took a non-opioid. One in five participants (19.3%) had inadequate pain control, 39% of whom were using <1 standardized daily dose of either a non-opioid or opioid analgesic. In adjusted analyses, severe/extreme OA pain was significantly associated with both non-opioid (adjusted odds ratio [AOR] = 2.44; 95% confidence interval [95% CI] = 1.49-3.99) and opioid (AOR = 2.64; 95% CI = 1.26-5.53) use.

CONCLUSIONS: Although older adults with severe/extreme knee and/or hip OA pain are more likely to take analgesics than those with less severe pain, a sizable proportion takes less than therapeutic doses and thus may be undertreated. Further research is needed to examine barriers to optimal analgesic use.

OBJECTIVES: To evaluate the literature regarding the effect of Medicare Part D on the under- and overuse of specific medications and corresponding health outcomes.

DESIGN: Systematic review.

SETTING: Medline search of the peer-reviewed literature from January 1, 2006, to October 8, 2010.

PARTICIPANTS: Medicare beneficiaries who obtained drug insurance from the Part D program.

MEASUREMENTS: The review evaluated changes in the use of specific drugs or drug classes after implementation of Part D, as described in original, peer-reviewed articles.

RESULTS: Nineteen articles met inclusion criteria. Part D's implementation was associated with greater use of essential medications such as clopidogrel and statins, especially in beneficiaries who had been previously uninsured, but increases in inappropriate antibiotic use for the treatment of acute respiratory tract infections and increases in claims for the often overused proton pump inhibitor drug class were also observed. In the Part D transition period, dually eligible beneficiaries' drug use remained largely unchanged. When beneficiary cost sharing increased in the coverage gap, use of essential and overused medications declined.

CONCLUSION: Increasing drug coverage led to greater use of underused essential medications and inappropriate, or overused, medications under Medicare Part D. Despite efforts to have it do so, the Part D benefit did not sufficiently discriminate between essential and nonessential medication use.