RESUMEN
Alleviating health inequality among different income groups has become a significant policy goal in China to promote common prosperity. Based on the data from the China Health and Retirement Longitudinal Study (CHARLS) covering the period from 2013 to 2018, this study empirically examines the impact of Integrated Medical Insurance System (URRBMI) on the health and health inequality of older adult rural residents. The following conclusions are drawn: First, URRBMI have elevated the level of medical security, reduced the frailty index of rural residents, and improved the health status of rural residents. Second, China exhibits "pro-rich" health inequality, and URRBMI exacerbates health inequality among rural residents with different incomes. This result remains robust when replacing the frailty index with different health modules. Third, the analysis of influencing mechanisms indicates that the URRBMI exacerbate inequality in the utilization of medical services among rural residents, resulting in a phenomenon of "subsidizing the rich by the poor" and intensifying health inequality. Fourth, in terms of heterogeneity, URRBMI have significantly widened health inequality among the older adult and in regions with a higher proportion of multiple-tiered medical insurance schemes. Finally, it is suggested that China consider establishing a medical financing and benefit assurance system that is related to income and age and separately construct a unified public medical insurance system for the older adult population.
Asunto(s)
Disparidades en el Estado de Salud , Seguro de Salud , Población Rural , Humanos , China , Población Rural/estadística & datos numéricos , Seguro de Salud/estadística & datos numéricos , Estudios Longitudinales , Anciano , Masculino , Persona de Mediana Edad , Femenino , Beneficios del Seguro/estadística & datos numéricos , Beneficios del Seguro/economía , Factores SocioeconómicosRESUMEN
This Viewpoint discusses the proliferation of Medicare Advantage plans targeting specific groups of individuals and whether these plans will improve quality of care for beneficiaries.
Asunto(s)
Beneficios del Seguro , Medicare Part C , Calidad de la Atención de Salud , Planes de Aranceles por Servicios , Medicare Part C/economía , Medicare Part C/estadística & datos numéricos , Medicare Part C/tendencias , Indicadores de Calidad de la Atención de Salud , Calidad de la Atención de Salud/economía , Calidad de la Atención de Salud/normas , Estados Unidos/epidemiología , Cobertura del Seguro/economía , Cobertura del Seguro/estadística & datos numéricos , Cobertura del Seguro/tendencias , Beneficios del Seguro/economía , Beneficios del Seguro/estadística & datos numéricos , Beneficios del Seguro/tendenciasRESUMEN
Importance: American Indian and Alaska Native persons face significant health disparities; however, data regarding the burden of cardiovascular disease in the current era is limited. Objective: To determine the incidence and prevalence of cardiovascular disease, the burden of comorbid conditions, including cardiovascular disease risk factors, and associated mortality among American Indian and Alaska Native patients with Medicare insurance. Design, Setting, and Participants: This was a population-based cohort study conducted from January 2015 to December 2019 using Medicare administrative data. Participants included American Indian and Alaska Native Medicare beneficiaries 65 years and older enrolled in both Medicare part A and B fee-for-service Medicare. Statistical analyses were performed from November 2022 to April 2023. Main Outcomes and Measures: The annual incidence, prevalence, and mortality associated with coronary artery disease (CAD), heart failure (HF), atrial fibrillation/flutter (AF), and cerebrovascular disease (stroke or transient ischemic attack [TIA]). Results: Among 220â¯598 American Indian and Alaska Native Medicare beneficiaries, the median (IQR) age was 72.5 (68.5-79.0) years, 127â¯402 were female (57.8%), 78â¯438 (38.8%) came from communities in the most economically distressed quintile in the Distressed Communities Index. In the cohort, 44.8% of patients (98â¯833) were diagnosed with diabetes, 61.3% (135â¯124) were diagnosed with hyperlipidemia, and 72.2% (159â¯365) were diagnosed with hypertension during the study period. The prevalence of CAD was 38.6% (61â¯125 patients) in 2015 and 36.7% (68â¯130 patients) in 2019 (P < .001). The incidence of acute myocardial infarction increased from 6.9 per 1000 person-years in 2015 to 7.7 per 1000 patient-years in 2019 (percentage change, 4.79%; P < .001). The prevalence of HF was 22.9% (36â¯288 patients) in 2015 and 21.4% (39â¯857 patients) in 2019 (P < .001). The incidence of HF increased from 26.1 per 1000 person-years in 2015 to 27.0 per 1000 person-years in 2019 (percentage change, 4.08%; P < .001). AF had a stable prevalence of 9% during the study period (2015: 9.4% [14â¯899 patients] vs 2019: 9.3% [25â¯175 patients]). The incidence of stroke or TIA decreased slightly throughout the study period (12.7 per 1000 person-years in 2015 and 12.1 per 1000 person-years in 2019; percentage change, 5.08; P = .004). Fifty percent of patients (110â¯244) had at least 1 severe cardiovascular condition (CAD, HF, AF, or cerebrovascular disease), and the overall mortality rate for the cohort was 19.8% (43â¯589 patients). Conclusions and Relevance: In this large cohort study of American Indian and Alaska Native patients with Medicare insurance in the US, results suggest a significant burden of cardiovascular disease and cardiometabolic risk factors. These results highlight the critical need for future efforts to prioritize the cardiovascular health of this population.
Asunto(s)
Indio Americano o Nativo de Alaska , Enfermedades Cardiovasculares , Medicare , Pobreza , Determinantes Sociales de la Salud , Anciano , Femenino , Humanos , Masculino , Indio Americano o Nativo de Alaska/estadística & datos numéricos , Aleteo Atrial , Enfermedades Cardiovasculares/economía , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/etnología , Enfermedades Cardiovasculares/mortalidad , Estudios de Cohortes , Enfermedad de la Arteria Coronaria , Insuficiencia Cardíaca , Ataque Isquémico Transitorio , Medicare/economía , Medicare/estadística & datos numéricos , Accidente Cerebrovascular , Estados Unidos/epidemiología , Beneficios del Seguro/economía , Beneficios del Seguro/estadística & datos numéricos , Costo de Enfermedad , Incidencia , Prevalencia , Comorbilidad , Factores de Riesgo , Factores de Riesgo Cardiometabólico , Determinantes Sociales de la Salud/economía , Determinantes Sociales de la Salud/etnología , Determinantes Sociales de la Salud/estadística & datos numéricos , Pobreza/economía , Pobreza/etnología , Pobreza/estadística & datos numéricosRESUMEN
BACKGROUND: Brazil has made great progress in reducing child mortality over the past decades, and a parcel of this achievement has been credited to the Bolsa Família program (BFP). We examined the association between being a BFP beneficiary and child mortality (1-4 years of age), also examining how this association differs by maternal race/skin color, gestational age at birth (term versus preterm), municipality income level, and index of quality of BFP management. METHODS AND FINDINGS: This is a cross-sectional analysis nested within the 100 Million Brazilian Cohort, a population-based cohort primarily built from Brazil's Unified Registry for Social Programs (Cadastro Único). We analyzed data from 6,309,366 children under 5 years of age whose families enrolled between 2006 and 2015. Through deterministic linkage with the BFP payroll datasets, and similarity linkage with the Brazilian Mortality Information System, 4,858,253 children were identified as beneficiaries (77%) and 1,451,113 (23%) were not. Our analysis consisted of a combination of kernel matching and weighted logistic regressions. After kernel matching, 5,308,989 (84.1%) children were included in the final weighted logistic analysis, with 4,107,920 (77.4%) of those being beneficiaries and 1,201,069 (22.6%) not, with a total of 14,897 linked deaths. Overall, BFP participation was associated with a reduction in child mortality (weighted odds ratio [OR] = 0.83; 95% CI: 0.79 to 0.88; p < 0.001). This association was stronger for preterm children (weighted OR = 0.78; 95% CI: 0.68 to 0.90; p < 0.001), children of Black mothers (weighted OR = 0.74; 95% CI: 0.57 to 0.97; p < 0.001), children living in municipalities in the lowest income quintile (first quintile of municipal income: weighted OR = 0.72; 95% CI: 0.62 to 0.82; p < 0.001), and municipalities with better index of BFP management (5th quintile of the Decentralized Management Index: weighted OR = 0.76; 95% CI: 0.66 to 0.88; p < 0.001). The main limitation of our methodology is that our propensity score approach does not account for possible unmeasured confounders. Furthermore, sensitivity analysis showed that loss of nameless death records before linkage may have resulted in overestimation of the associations between BFP participation and mortality, with loss of statistical significance in municipalities with greater losses of data and change in the direction of the association in municipalities with no losses. CONCLUSIONS: In this study, we observed a significant association between BFP participation and child mortality in children aged 1-4 years and found that this association was stronger for children living in municipalities in the lowest quintile of wealth, in municipalities with better index of program management, and also in preterm children and children of Black mothers. These findings reinforce the evidence that programs like BFP, already proven effective in poverty reduction, have a great potential to improve child health and survival. Subgroup analysis revealed heterogeneous results, useful for policy improvement and better targeting of BFP.
Asunto(s)
Mortalidad del Niño , Programas de Gobierno , Beneficios del Seguro , Evaluación de Programas y Proyectos de Salud , Brasil , Preescolar , Estudios de Cohortes , Análisis Costo-Beneficio , Estudios Transversales , Conjuntos de Datos como Asunto , Femenino , Programas de Gobierno/economía , Humanos , Lactante , Beneficios del Seguro/economía , Masculino , Evaluación de Programas y Proyectos de Salud/economía , Medición de RiesgoRESUMEN
BACKGROUND: To strengthen the impact of cash transfers, these interventions have begun to be packaged as cash-plus programmes, combining cash with additional transfers, interventions, or services. The intervention's complementary ("plus") components aim to improve cash transfer effectiveness by targeting mediating outcomes or the availability of supplies or services. This study examined whether cash-plus interventions for infants and children <5 are more effective than cash alone in improving health and well-being. METHODS AND FINDINGS: Forty-two databases, donor agencies, grey literature sources, and trial registries were systematically searched, yielding 5,097 unique articles (as of 06 April 2021). Randomised and quasi-experimental studies were eligible for inclusion if the intervention package aimed to improve outcomes for children <5 in low- and middle-income countries (LMICs) and combined a cash transfer with an intervention targeted to Sustainable Development Goal (SDG) 2 (No Hunger), SDG3 (Good Health and Well-being), SDG4 (Education), or SDG16 (Violence Prevention), had at least one group receiving cash-only, examined outcomes related to child-focused SDGs, and was published in English. Risk of bias was appraised using Cochrane Risk of Bias and ROBINS-I Tools. Random effects meta-analyses were conducted for a cash-plus intervention category when there were at least 3 trials with the same outcome. The review was preregistered with PROSPERO (CRD42018108017). Seventeen studies were included in the review and 11 meta-analysed. Most interventions operated during the first 1,000 days of the child's life and were conducted in communities facing high rates of poverty and often, food insecurity. Evidence was found for 10 LMICs, where most researchers used randomised, longitudinal study designs (n = 14). Five intervention categories were identified, combining cash with nutrition behaviour change communication (BCC, n = 7), food transfers (n = 3), primary healthcare (n = 2), psychosocial stimulation (n = 7), and child protection (n = 4) interventions. Comparing cash-plus to cash alone, meta-analysis results suggest Cash + Food Transfers are more effective in improving height-for-age (d = 0.08 SD (0.03, 0.14), p = 0.02) with significantly reduced odds of stunting (OR = 0.82 (0.74, 0.92), p = 0.01), but had no added impact in improving weight-for-height (d = -0.13 (-0.42, 0.16), p = 0.24) or weight-for-age z-scores (d = -0.06 (-0.28, 0.15), p = 0.43). There was no added impact above cash alone from Cash + Nutrition BCC on anthropometrics; Cash + Psychosocial Stimulation on cognitive development; or Cash + Child Protection on parental use of violent discipline or exclusive positive parenting. Narrative synthesis evidence suggests that compared to cash alone, Cash + Primary Healthcare may have greater impacts in reducing mortality and Cash + Food Transfers in preventing acute malnutrition in crisis contexts. The main limitations of this review are the few numbers of studies that compared cash-plus interventions against cash alone and the potentially high heterogeneity between study findings. CONCLUSIONS: In this study, we observed that few cash-plus combinations were more effective than cash transfers alone. Cash combined with food transfers and primary healthcare show the greatest signs of added effectiveness. More research is needed on when and how cash-plus combinations are more effective than cash alone, and work in this field must ensure that these interventions improve outcomes among the most vulnerable children.
Asunto(s)
Servicios de Salud del Niño/economía , Beneficios del Seguro/economía , Seguro de Salud , Preescolar , Humanos , Evaluación de Programas y Proyectos de SaludRESUMEN
Primary prevention implantable cardioverter-defibrillators (ICDs) in patients with recent myocardial infarction or coronary revascularization and those with newly diagnosed or severe heart failure (HF) are considered non-evidence-based, as defined by pivotal randomized clinical trials. Although non-evidence-based ICDs have been associated previously with greater risk of in-hospital adverse events, longitudinal outcomes are not known. We used Medicare-linked data from the National Cardiovascular Data Registry's ICD Registry to identify patients discharged alive following first-time primary prevention ICD implantations performed between 2010 and 2013. We compared longitudinal outcomes, including all-cause mortality and all-cause hospital readmission among patients receiving non-evidence-based versus evidence-based ICDs, up to 4.75 years after implantation, using multivariable time-to-event analyses. Of 71,666 ICD implantations, 9,609 (13.4%) were classified as non-evidence-based. Compared to patients receiving evidence-based ICDs, non-evidence-based ICD recipients had greater mortality risk at 90 days (HR = 1.44, CI: 1.37 - 1.52, p <0.0001) and at 1 year (HR = 1.19, CI: 1.15 - 1.24, p <0.0001), but similar mortality risk at 3 years (HR = 1.03, CI: 0.98 - 1.08, p = 0.2630). Risk of all-cause hospitalization was higher in patients with non-evidence-based ICDs at 90 days (HR = 1.17, CI: 1.14 - 1.20, p <0.0001), but the difference diminished at 1 year (HR = 1.04, CI 1.00 - 1.07, p = 0.0272) and at 3 years (HR = 0.94, CI: 0.90 - 0.99, p = 0.0105). In conclusion, among patients undergoing primary prevention ICD implantations between 2010 and 2013, those with non-evidence-based ICDs were at increased risk of mortality and readmission during longitudinal follow-up. Differences in the risk of mortality and hospitalization were highest in the first year following device implantation.
Asunto(s)
Muerte Súbita Cardíaca/prevención & control , Desfibriladores Implantables , Insuficiencia Cardíaca/terapia , Beneficios del Seguro/economía , Prevención Primaria/métodos , Sistema de Registros , Anciano , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/economía , Insuficiencia Cardíaca/mortalidad , Hospitalización , Humanos , Masculino , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Factores de Tiempo , Estados Unidos/epidemiologíaRESUMEN
Importance: More than 50 million US residents have lost work during the coronavirus disease 2019 (COVID-19) pandemic, and food insecurity has increased. Objective: To evaluate the association between receipt of unemployment insurance, including a $600/wk federal supplement between April and July, and food insecurity among people who lost their jobs during the COVID-19 pandemic. Design, Setting, and Participants: This cohort study used difference-in-differences analysis of longitudinal data from a nationally representative sample of US adults residing in low- and middle-income households (ie, <$75â¯000 annual income) who lost work during the COVID-19 pandemic. Data were from 15 waves of the Understanding Coronavirus in America study (conducted April 1 to November 11, 2020). Exposure: Receipt of unemployment insurance benefits. Main Outcomes and Measures: Food insecurity and eating less due to financial constraints, assessed every 2 weeks by self-report. Results: Of 2319 adults living in households earning less than $75â¯000 annually and employed in February 2020, 1119 (48.3%) experienced unemployment during the COVID-19 pandemic and made up our main sample (588 [53.6%] White individuals; mean [SD] age 45 [15] years; 732 [65.4%] women). Of those who lost employment, 415 (37.1%) reported food insecurity and 437 (39.1%) reported eating less due to financial constraints in 1 or more waves of the study. Among people who lost work, receipt of unemployment insurance was associated with a 4.3 (95% CI, 1.8-6.9) percentage point decrease in food insecurity (a 35.0% relative reduction) and a 5.7 (95% CI, 3.0-8.4) percentage point decrease in eating less due to financial constraints (a 47.8% relative reduction). Decreases in food insecurity were larger with the $600/wk supplement and for individuals who were receiving larger amounts of unemployment insurance. Conclusions and Relevance: In this US national cohort study, receiving unemployment insurance was associated with large reductions in food insecurity among people who lost employment during the COVID-19 pandemic. The $600/wk federal supplement and larger amounts of unemployment insurance were associated with larger reductions in food insecurity.
Asunto(s)
COVID-19/economía , COVID-19/epidemiología , Inseguridad Alimentaria , Beneficios del Seguro/economía , Pandemias/economía , Desempleo , Adulto , Femenino , Humanos , Renta/estadística & datos numéricos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , SARS-CoV-2 , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: The relationship between diet quality and health care costs is unclear. OBJECTIVE: The aim of this study was to investigate the relationship between baseline diet quality and change in diet quality over time, with 15-year cumulative health care claims/costs. DESIGN: Data from a longitudinal cohort study were analyzed. PARTICIPANTS/SETTING: Data for survey 3 (2001) (n = 7,868) and survey 7 (2013) (n = 6,349 both time points) from the 1946-1951 cohort of the Australian Longitudinal Study on Women's Health were analyzed. MAIN OUTCOME MEASURES: Diet quality was assessed using the Australian Recommended Food Score (ARFS). Fifteen-year cumulative Medicare Benefits Schedule (Australia's universal health care coverage) data were reported by baseline ARFS quintile and category of diet quality change ("diet quality worsened" [ARFS change ≤ -4 points], "remained stable" [-3 ≤ change in ARFS ≤3 points], or "improved" [ARFS change ≥4 points]). STATISTICAL ANALYSES: Linear regression analyses were conducted adjusting for area of residence, socioeconomic status, lifestyle factors, and private health insurance status. RESULTS: Consuming a greater variety of vegetables at baseline but fewer fruit and dairy products was associated with lower health care costs. For every 1-point increment in the ARFS vegetable subscale, women made 3.3 (95% CI, 1.6-5.0) fewer claims and incurred AU$227 (95% CI, AU$104-350 [US$158; 95% CI, US$72-243]) less in costs. Women whose diet quality worsened over time made more claims (median, 251 claims; quintile 1, quintile 3 [Q1; Q3], 168; 368 claims) and incurred higher costs (AU$15,519; Q1; Q3, AU$9,226; AU$24,847 [US$10,793; Q1; Q3, US$6,417; US$17,281]) compared with those whose diet quality remained stable (median, 236 claims [Q1; Q3, 158; 346 claims], AU$14,515; Q1; Q3, AU$8,539; AU$23,378 [US$10,095; Q1; Q3, US$5,939; US$16,259]). CONCLUSIONS: Greater vegetable variety was associated with fewer health care claims and costs; however, this trend was not consistent across other subscales. Worsening diet quality over 12 years was linked with higher health care claims and costs.
Asunto(s)
Dieta/economía , Dieta/normas , Dieta/tendencias , Costos de la Atención en Salud/tendencias , Beneficios del Seguro/economía , Programas Nacionales de Salud/economía , Anciano , Australia , Estudios de Cohortes , Femenino , Humanos , Estudios Longitudinales , Persona de Mediana Edad , Verduras , Salud de la MujerRESUMEN
BACKGROUND: Although recent research suggests that primary care provided by nurse practitioners costs less than primary care provided by physicians, little is known about underlying drivers of these cost differences. RESEARCH OBJECTIVE: Identify the drivers of cost differences between Medicare beneficiaries attributed to primary care nurse practitioners (PCNPs) and primary care physicians (PCMDs). STUDY DESIGN: Cross-sectional cost decomposition analysis using 2009-2010 Medicare administrative claims for beneficiaries attributed to PCNPs and PCMDs with risk stratification to control for beneficiary severity. Cost differences between PCNPs and PCMDs were decomposed into payment, service volume, and service mix within low-risk, moderate-risk and high-risk strata. RESULTS: Overall, the average PCMD cost of care is 34% higher than PCNP care in the low-risk stratum, and 28% and 21% higher in the medium-risk and high-risk stratum. In the low-risk stratum, the difference is comprised of 24% service volume, 6% payment, and 4% service mix. In the high-risk stratum, the difference is composed of 7% service volume, 9% payment, and 4% service mix. The cost difference between PCNP and PCMD attributed beneficiaries is persistent and significant, but narrows as risk increases. Across the strata, PCNPs use fewer and less expensive services than PCMDs. In the low-risk stratum, PCNPs use markedly fewer services than PCMDs. CONCLUSIONS: There are differences in the costs of primary care of Medicare beneficiaries provided by nurse practitioners and MDs. Especially in low-risk populations, the lower cost of PCNP provided care is primarily driven by lower service volume.
Asunto(s)
Costos de la Atención en Salud/estadística & datos numéricos , Beneficios del Seguro/economía , Medicare/clasificación , Enfermeras Practicantes/economía , Médicos/economía , Estudios Transversales , Costos de la Atención en Salud/clasificación , Humanos , Beneficios del Seguro/estadística & datos numéricos , Medicare/estadística & datos numéricos , Enfermeras Practicantes/estadística & datos numéricos , Médicos/estadística & datos numéricos , Atención Primaria de Salud/economía , Atención Primaria de Salud/estadística & datos numéricos , Estados UnidosRESUMEN
BACKGROUND: Neurosurgical spine specialists receive considerable amounts of industry support that may impact the cost of care. The aim of this study was to evaluate the association between industry payments received by spine surgeons and the total hospital and operating room (OR) costs of an anterior cervical discectomy and fusion (ACDF) procedure among Medicare beneficiaries. METHODS: All ACDF cases were identified among the Medicare carrier files from January 1, 2013, to December 31, 2014, and matched to the Medicare inpatient baseline file. The total hospital and OR charges were obtained for these cases. Charges were converted to cost using year-specific cost-to-charge ratios. Surgeons were identified among the Open Payments database, which is used to quantify industry support. Analyses were performed to examine the association between industry payments received and ACDF costs. RESULTS: Matching resulting in the inclusion of 2209 ACDF claims from 2013-2014. In 2013 and 2014, the mean total cost for an ACDF was $21,798 and $21,008, respectively; mean OR cost was $5878 and $6064, respectively. Mann-Whitney U test demonstrated no significant differences in the mean total or OR cost for an ACDF based on quartile of general industry payment received (P = 0.21 and P = 0.54), and linear regression found no association between industry general payments, research support, or investments on the total hospital cost (P = 0.41, P = 0.13, and P = 0.25, respectively), or OR cost for an ACDF (P = 0.35, P = 0.24, and P = 0.40, respectively). CONCLUSIONS: This study suggests that spine surgeons performing ACDF surgeries may receive industry support without impacting the cost of care.
Asunto(s)
Vértebras Cervicales/cirugía , Discectomía/economía , Costos de Hospital , Medicare/economía , Médicos/economía , Fusión Vertebral/economía , Anciano , Anciano de 80 o más Años , Discectomía/tendencias , Femenino , Costos de Hospital/tendencias , Humanos , Industrias/economía , Industrias/tendencias , Beneficios del Seguro/economía , Beneficios del Seguro/tendencias , Masculino , Medicare/tendencias , Médicos/tendencias , Fusión Vertebral/tendencias , Estados UnidosRESUMEN
OBJECTIVES: To estimate the impact on testosterone prescribing over 3 years following the 2015 tightening of Pharmaceutical Benefits Scheme (PBS) criteria. DESIGN: Analysis of testosterone prescribing data from PBS and private (non-PBS) sources between 2012 and 2018 covering 2015 change in PBS prescribing criteria. MAIN OUTCOME MEASURES: New and total PBS testosterone prescriptions estimating usage by quarter analyzed by product type, patient age-group, indication and prescriber type. Total national testosterone prescriptions (private plus PBS) was verified from an independent data supplier (IQVIA). RESULTS: PBS usage peaked in 2014 declining by 30% in 2017-8 with PBS prescribing covering a fall from 97.6% by usage in 2014 to 74% in 2017-18 of all testosterone prescribing. The tighter 2015 PBS restrictions sustained the selective reduction in GP initiation of prescriptions for middle-aged men without pathological hypogonadism whereas specialist initiations and prescription for adult hypogonadism or pediatric/prepubertal indications were largely unaffected. CONCLUSIONS: The tightening of PBS criteria from 1 April 2015 to curb off-label prescribing remained effective and selective over 3 years yet total national testosterone prescribing continued with little change, reflecting a shift to private prescriptions. The continuation of off-label testosterone prescribing for unproven indications suggests that long-term androgen dependence is created in men without pathological hypogonadism who commence testosterone. This highlights the need to avoid prescribing testosterone to men without pathological hypogonadism in the absence of sound evidence of efficacy and safety, the latter including the little unrecognized risks of long-term androgen dependency when trying to quit.
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Prescripciones de Medicamentos/estadística & datos numéricos , Beneficios del Seguro/legislación & jurisprudencia , Uso Fuera de lo Indicado/economía , Mecanismo de Reembolso/legislación & jurisprudencia , Testosterona/economía , Adulto , Factores de Edad , Australia , Niño , Prescripciones de Medicamentos/economía , Política de Salud/economía , Política de Salud/legislación & jurisprudencia , Humanos , Hipogonadismo/tratamiento farmacológico , Beneficios del Seguro/economía , Masculino , Persona de Mediana Edad , Uso Fuera de lo Indicado/legislación & jurisprudencia , Uso Fuera de lo Indicado/estadística & datos numéricos , Farmacoepidemiología/estadística & datos numéricos , Mecanismo de Reembolso/economía , Testosterona/uso terapéuticoAsunto(s)
Diabetes Mellitus/terapia , Medicare/tendencias , Educación del Paciente como Asunto/economía , Educación del Paciente como Asunto/métodos , Automanejo/educación , Academias e Institutos , Anciano , Dietética , Humanos , Beneficios del Seguro/economía , Beneficios del Seguro/tendencias , Medicare/economía , Medicare Part B , Defensa del Paciente , Mecanismo de Reembolso , Automanejo/economía , Resultado del Tratamiento , Estados UnidosRESUMEN
Objective This study assessed the effect of the frequency of general practitioner (GP) visitation in the 12 months before a 21% consumer copayment increase in the Pharmaceutical Benefits Scheme (PBS; January 2005) on the reduction or discontinuation of statin dispensing for tertiary prevention. Methods The study used routinely collected, whole-population linked PBS, Medicare, mortality and hospital data from Western Australia. From 2004 to 2005, individuals were classified as having discontinued, reduced or continued their use of statins in the first six months of 2005 following the 21% consumer copayment increase on 1 January 2005. The frequency of GP visits was calculated in 2004 from Medicare data. Multivariate logistic regression models were used to determine the association between GP visits and statin use following the copayment increase. Results In December 2004, there were 22495 stable statin users for tertiary prevention of prior coronary heart disease, prior stroke or prior coronary artery revascularisation procedure. Following the copayment increase, patients either discontinued (3%), reduced (12%) or continued (85%) their statins. Individuals who visited a GP three or more times in 2004 were 47% less likely to discontinue their statins in 2005 than people attending only once. Subgroup analysis showed the effect was apparent in men, and long-term or new statin users. The frequency of GP visits did not affect the proportion of patients reducing their statin therapy. Conclusions Patients who visited their GP at least three times per year had a lower risk of ceasing their statins in the year following the copayment increase. GPs can help patients maintain treatment following rises in medicines costs. What is known about the topic? Following the 21% increase in medication copayment in 2005, individuals discontinued or reduced their statin usage, including for tertiary prevention. What does this paper add? Patients who visited their GP at least three times per year were less likely to discontinue their statin therapy for tertiary prevention following a large copayment increase. What are the implications for practitioners? This paper identifies the important role that GPs have in maintaining the continued use of important medications following rises in medicines costs.
Asunto(s)
Utilización de Medicamentos/estadística & datos numéricos , Medicina General/estadística & datos numéricos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/economía , Beneficios del Seguro/economía , Seguro de Servicios Farmacéuticos/economía , Adulto , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/tratamiento farmacológico , Utilización de Medicamentos/economía , Femenino , Médicos Generales/estadística & datos numéricos , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Masculino , Persona de Mediana Edad , Aceptación de la Atención de Salud/estadística & datos numéricos , Estudios Retrospectivos , Australia OccidentalRESUMEN
Importance: Benzodiazepines, which are associated with safety-related harms for older adults, were not covered when the US Medicare Part D prescription drug benefit began. Coverage was extended to benzodiazepines in 2013. Objective: To examine whether the expansion of benzodiazepine coverage among Medicare Advantage (MA) beneficiaries was associated with increases in fall-related injuries or overdoses among older adults. Design, Setting, and Participants: This ecological study used interrupted time-series with comparison-series analyses of MA claims data from 4â¯635â¯312 age-eligible MA beneficiaries and 940â¯629 commercially insured individuals (comparison group) stratified by age (65-69, 70-74, 75-79, and ≥80 years) to separately compare trends in fall-related injury and overdose before (January 1, 2010, to December 31, 2012) and after (January 1, 2013, to December 31, 2015) coverage expansion for benzodiazepines. Data analysis was performed from September 1, 2018, to August 31, 2019. Exposures: Expansion of benzodiazepine coverage in Medicare Part D in 2013. Main Outcomes and Measures: Monthly rate of fall-related injury and overdose. Results: In 2012 (the year before the policy change), women constituted 57.5% of the MA group and 47.4% of the comparison group. A total of 25.8% of individuals in the MA group were aged 65 to 69 years, and 29.3% were 80 years or older (mean [SD], 75.1 [6.4] years); 56.7% of individuals in the comparison group were aged 65 to 69 years, and 15.1% were 80 years or older (mean [SD] age, 70.9 [6.5] years). In the MA group, 4â¯635â¯312 individuals contributed 156â¯754â¯749 person-months from 2010 through 2015; in the comparison group, 940â¯629 individuals contributed 25â¯104â¯534 person-months. After coverage of benzodiazepines began, the rate (ie, slope) of fall-related injury among MA beneficiaries increased from before to after coverage among all age groups. Compared with the comparison group, the increase in rate was statistically significant for those 80 years or older (rate changes for the MA vs comparison groups: 0.12 [95% CI, 0.07 to 0.17] vs -0.01 [95% CI, -0.11 to 0.10]; P = .04 for interaction). The overdose trend changed from decreasing to increasing among MA beneficiaries after coverage for all age groups, with a statistically significant increase compared with the comparison group among those aged 65 to 69 years (rate changes for the MA vs comparison groups: 0.23 [95% CI, 0.17 to 0.30] vs 0.02 [95% CI, -0.06 to 0.11]; P < .001 for interaction) and among those 80 years or older (rate changes for the MA vs comparison groups: 0.07 [95% CI, 0.00 to 0.14] vs -0.20 [95% CI, -0.35 to -0.05]; P = .002 for interaction). Results among MA beneficiaries were consistent when stratified by sex and when limited to those prescribed opioids. Conclusions and Relevance: Medicare's expansion of benzodiazepine coverage may have been associated with increases in the rates of overdose among adults ages 65 to 69 years and in the rates of overdose and fall-related injury among those 80 years or older.
Asunto(s)
Accidentes por Caídas/estadística & datos numéricos , Benzodiazepinas/efectos adversos , Beneficios del Seguro/tendencias , Cobertura del Seguro/estadística & datos numéricos , Medicare Part D/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Algoritmos , Benzodiazepinas/uso terapéutico , Estudios de Casos y Controles , Sobredosis de Droga/epidemiología , Femenino , Humanos , Beneficios del Seguro/economía , Análisis de Series de Tiempo Interrumpido , Masculino , Medicare Part C , Medicare Part D/economía , Seguridad del Paciente , Medicamentos bajo Prescripción/efectos adversos , Medicamentos bajo Prescripción/provisión & distribución , Estados Unidos/epidemiologíaRESUMEN
Background The optimal timing of treatment with vitamin D therapy for patients with chronic kidney disease (CKD), vitamin D insufficiency, and secondary hyperparathyroidism (SHPT) is a pressing question in nephrology with economic and patient outcome implications. Objective The objective of this study was to estimate the cost-effectiveness of earlier vitamin D treatment in CKD patients not on dialysis with vitamin D insufficiency and SHPT. Design A cost-effectiveness analysis based on a Markov model of CKD progression was developed from the Medicare perspective. The model follows a hypothetical cohort of 1000 Stage 3 or 4 CKD patients over a 5-year time horizon. The intervention was vitamin D therapy initiated in CKD stages 3 or 4 through CKD stage 5/end-stage renal disease (ESRD) versus initiation in CKD stage 5/ESRD only. The outcomes of interest were cardiovascular (CV) events averted, fractures averted, time in CKD stage 5/ESRD, mortality, quality-adjusted life years (QALYs), and costs associated with clinical events and CKD stage. Results Vitamin D treatment in CKD stages 3 and 4 was a dominant strategy when compared to waiting to treat until CKD stage 5/ESRD. Total cost savings associated with treatment during CKD stages 3 and 4, compared to waiting until CKD stage 5/ESRD, was estimated to be $19.9 million. The model estimated that early treatment results in 159 averted CV events, 5 averted fractures, 269 fewer patient-years in CKD stage 5, 41 fewer deaths, and 191 additional QALYs. Conclusions Initiating vitamin D therapy in CKD stages 3 or 4 appears to be cost-effective, largely driven by the annual costs of care by CKD stage, CV event costs, and risks of hypercalcemia. Further research demonstrating causal relationships between vitamin D therapy and patient outcomes is needed to inform decision making regarding vitamin D therapy timing.
Asunto(s)
Diálisis/métodos , Beneficios del Seguro/economía , Vitamina D/uso terapéutico , Análisis Costo-Beneficio/métodos , Diálisis/tendencias , Humanos , Beneficios del Seguro/métodos , Insuficiencia Renal Crónica/prevención & control , Vitamina D/economía , Vitaminas/economía , Vitaminas/uso terapéuticoRESUMEN
BACKGROUND: Medical care overuse is a significant source of patient harm and wasteful spending. Understanding the drivers of overuse is essential to the design of effective interventions. OBJECTIVE: We tested the association between structural factors of the health care delivery system and regional differences systemic overuse. RESEARCH DESIGN: We conducted a retrospective analysis of deidentified claims for 18- to 64-year-old adults from the IBM MarketScan Commercial Claims and Encounters Database. We calculated a semiannual Johns Hopkins Overuse Index for each of the 375 Metropolitan Statistical Areas in the United States, from January 2011 to June 2015. We fit an ordinary least squares regression to model the Johns Hopkins Overuse Index as a function of regional characteristics of the health care system, adjusted for confounders and time. RESULTS: The supply of regional health care resources was associated with systemic overuse in commercially insured beneficiaries. Regional characteristics associated with systemic overuse included number of physicians per 1000 residents (P=0.001) and higher Medicare malpractice geographic price cost index (P<0.001). Regions with a higher density of primary care physicians (P=0.008) and a higher proportion of hospital-based providers (P=0.016) had less systemic overuse. Differences in hospital and insurer market power were inversely associated with systemic overuse. CONCLUSIONS: Systemic overuse is associated with observable, structural characteristics of the regional health care system. These findings suggest that interventions that aim to improve care efficiency via reductions in overuse should focus on the structural drivers of this phenomenon, rather than on the eradication of individual overused procedures.