Young First-Time Mothers' Parenting of Infants: The Role of Depression and Social Support.

OBJECTIVES: This study examines the contributions of social support and depressive symptoms on sensitive parenting behaviors, parenting attitudes and parenting stress among first-time young mothers. Additionally, the study tests the moderating role of depression in associations between various types and sources of social support and parenting outcomes. METHODS: Young (M = 17.4 years), low-income, African American mothers (n = 192) were interviewed and video-recorded interacting with their 4-month-old infants. RESULTS: Regression analyses showed that depressive symptoms (CES-D) were associated with less sensitivity observed during mother-infant interactions, less sensitive attitudes (AAPI) and greater parenting stress (PSI), but the role of social support was more nuanced. Direct infant care support from the mother's parent figure (typically her own mother) was related to more sensitive parenting behaviors and attitudes, while general support and direct infant care support from the father of the baby were related to reduced parenting stress. Depressive symptoms moderated the relationship between general support from the parent figure and parenting outcomes. Specifically, higher levels of general support contributed to more sensitive maternal behaviors and attitudes only when depressive symptoms were low. CONCLUSIONS FOR PRACTICE: For young mothers, their parent figure and the father of the baby can be important sources of support in promoting positive parenting and reducing parenting stress. Young mothers with depression, however, are at risk for problematic parenting and may have difficulty taking advantage of the support offered by their parent figure.

Construct validity of the First-Year Inventory (FYI Version 2.0) in 12-month-olds at high-risk for Autism Spectrum Disorder.

LAY ABSTRACT: The First-Year Inventory 2.0 is a parent-report screening instrument designed to identify 12-month-old infants at risk for an eventual diagnosis of Autism Spectrum Disorder. This instrument focuses on Social-Communication and Sensory-Regulatory areas of infant behavior. Although the First-Year Inventory 2.0 screening performance has been previously studied, its validity has not been examined. Establishing validity of an instrument is important because it supports the effectiveness and the reliability of the instrument. In this study, we examined relationship between the First-Year Inventory 2.0 (Social-Communication and Sensory-Regulatory areas) and other instruments that measure similar areas of infant behavior in a sample of high-risk infant siblings of children with Autism Spectrum Disorder. These other instruments share some common aims and theoretical areas with the First-Year Inventory 2.0: the Autism Observation Scale for Infants, the Mullen Scales of Early Learning, the Vineland Adaptive Behavior Scales-II, and the Infant Behavior Questionnaire. Findings generally supported the validity of the First-Year Inventory 2.0 with other instruments. In particular, the Social-Communication area of the First-Year Inventory 2.0 showed greater commonality with other instruments than in the Sensory-Regulatory area. The Sensory-Regulatory area seemed to be a unique feature of the First-Year Inventory 2.0 instrument. Considering different aims and strengths of assessments, researchers and clinicians are encouraged to utilize a variety of instruments in a comprehensive evaluation of a child.

Ethnicity Moderates the Association between Autonomic Functioning and Temperament in Preschool Children.

Respiratory sinus arrhythmia (RSA) has been extensively investigated as a marker of adaptive emotional functioning in both children and adults, with studies linking RSA to temperamental dimensions such as positive affect and extraversion. However, few studies have examined the extent to which relations between RSA and temperament characteristics vary across ethnicity in childhood. We examined relations between respiratory sinus arrhythmia (RSA) and temperament dimensions (Activity Level, Task Orientation, and Affect-Extraversion) and the moderating role of ethnicity among preschoolers. Chinese- American (n = 28, Mage = 54.30 months) and European American (n = 32, Mage = 50.41 months) preschoolers were assessed for their temperament and RSA. Findings indicated higher levels of Affect-Extraversion among European American children. Ethnicity moderated the association between the baseline RSA and the Affect-Extraversion dimension of temperament, with a significant positive association found only for European American children. More research is needed to examine the effects of social-cultural experiences on the relation between children's affective regulation and autonomic functioning development.

Medicare Part D-a roundtable discussion of current issues and trends.

BACKGROUND: Medicare Part D was introduced with a goal of providing access to prescription drug coverage for all Medicare beneficiaries. Regulatory mandates and the changing landscape of health care require continued evaluation of the state of the Part D benefit. OBJECTIVE: To review the current state of plan offerings and highlight key issues regarding the administration of the Part D benefit. SUMMARY: The Part D drug benefit continues to evolve. The benefit value appears to be diluted compared to the benefit value of large employer plans. Regulatory restrictions mandated by the Centers for Medicare and Medicaid Services (CMS) are reported to inhibit the ability of plans to create an effective, competitive drug benefit for Medicare beneficiaries. Management in this restrictive environment impedes competitive price negotiations and formulary coverage issues continue to create confusion especially for patients with chronic diseases. The doughnut hole coverage gap represents a significant cost-shifting issue for beneficiaries that may impact medication adherence and persistence. To address these and other challenges, CMS is working to improve the quality of care for Part D beneficiaries by designing and supporting demonstration projects. Although these projects are in different stages, all stakeholders are hopeful that they will lead to the development of best practices by plans to help manage their beneficiaries more efficiently. CONCLUSIONS: A significant number of Medicare beneficiaries are currently receiving prescription drug benefits through Part D. The true value of this benefit has been called into question as a result of plan design parameters that lead to cost-shifting, an increasing burden for enrollees. Concerns regarding the ability to provide a competitive plan given the stringent rules and regulations have been voiced by plan administrators. In an effort to drive toward evidence-based solutions, CMS is working to improve the overall quality of care through numerous demonstration projects.

The future of Medicare Part D drug plans--results from a roundtable discussion.

BACKGROUND: The Medicare Prescription Drug, Improvement, and Modernization Act, signed into law in 2003, provided access to prescription drugs for elderly Americans. The Part D benefit continues to evolve. Changes in plan designs, the impact of the doughnut hole on beneficiaries, and increased cost shifting have the potential to hamper the future of the Part D benefit. OBJECTIVE: To discuss factors that will likely have the most impact on the future of Medicare Part D from a patient and payer perspective. SUMMARY: The continued growth of the elderly population is expected to place an increasing burden on the services provided through Medicare. Given the current financial situation, it has been predicted that Medicare's Hospital Insurance Trust Fund will be depleted by 2019. To provide quality benefits and remain competitive, health plans are continually evaluating and redesigning their Part D benefits. However, the current regulatory environment is preventing plans from offering innovative products and designs that could lower costs to beneficiaries. The growing number of beneficiaries hitting the doughnut hole is also becoming a concern for both beneficiaries and health plans. More beneficiaries are reaching the doughnut hole, and this has resulted in changes in beneficiary behaviors, including stopping medications, switching to alternative drug classes, and reducing medication use. Because of the increasing concerns about Medicare's sustainability, it is anticipated that the government may become more involved. CONCLUSION: As the health care landscape continues to change, payers will be challenged to offer benefit designs that are affordable to elderly beneficiaries. For its part, the government must allow plans to design benefits that will improve the overall quality of care. Additionally, closer attention must be given to the growing number of beneficiaries hitting the doughnut hole and its potential adverse clinical and economic consequences.

Health information technology--results from a roundtable discussion.

BACKGROUND: Health information technology (HIT), notably e-prescribing and electronic health records (EHR), have the potential to improve the quality of care, reduce medication errors and adverse events, and decrease overall health care utilization and costs. However, the United States continues to lag behind other countries in the adoption and use of HIT. OBJECTIVE: To review the various issues surrounding the implementation of HIT in the United States and potential drivers that will influence the use of e-prescribing and EHR. SUMMARY: The United States has been slow to embrace HIT. However, various factors, including increasing government involvement, are speeding the implementation and use of HIT. E-prescribing and EHR are both electronic means to provide better coordination of care by enabling various health care professionals to access patient medical records. Widespread adoption of HIT can be especially helpful for the elderly, since this population tends to have more chronic conditions requiring polypharmacy. Adoption of e-prescribing can reduce medication errors due to poor handwriting, while EHR can promote better clinical outcomes, improve medication adherence and refill rates, improve member satisfaction, and lower overall health care expenditures. Unfortunately, barriers to the adoption of e-prescribing and EHR still exist, including resistance to learning new technology, initial start-up costs, delay in seeing a return on investment, lack of a standardized platform, increased administrative burden, and misaligned incentives. In an effort to promote greater adoption of e-prescribing and EHR, the Centers for Medicare & Medicaid has designed several initiatives, and other private organizations are now becoming more involved to close the HIT gap. CONCLUSION: Although the United States has been slow to implement HIT, there is reason to be hopeful. Increasing involvement by the government and other organizations will facilitate the greater adoption and use of e-prescribing and EHR in the near future. Ongoing data are needed, however, to demonstrate improvements in overall patient care and reductions in health care utilization and costs. These data are necessary to remove existing barriers that may prevent widespread implementation.

The Performance of the First Year Inventory (FYI) Screening on a Sample of High-Risk 12-Month-Olds Diagnosed with Autism Spectrum Disorder (ASD) at 36 Months.

This study examined the performance of the First Year Inventory (FYI; version 2.0), a community-normed parent-reported screening instrument, in a high-risk (HR) sample of 12-month-olds with older siblings diagnosed with autism spectrum disorder (ASD). The FYI 2.0 was completed by parents of 86 HR infants and 35 low-risk control infants at age 12 months, followed by clinical diagnosis at 36 months. HR infants later diagnosed with ASD had significantly higher FYI 2.0 risk scores in both the social-communication and sensory-regulatory domains than typically developing infants. New FYI 2.0 cutoff scores for HR sample were explored by evaluating various cutoff options after considering tradeoffs between sensitivity and specificity and sample characteristics.

Use of secondary prevention drug therapy in patients with acute coronary syndrome after hospital discharge.

BACKGROUND: Acute coronary syndrome includes life-threatening clinical conditions ranging from unstable angina to non-Q-wave myocardial infarction and Q-wave myocardial infarction that are a major cause of emergency medical care and hospitalization in the United States. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the management of patients with unstable angina and non-ST-segment elevation myocardial infarction (2002-2004) recommend (1) angiotensinconverting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) for ACE inhibitor intolerance, (2) beta-blockers, and (3) statins for long-term treatment of patients after an acute coronary event. OBJECTIVE: To examine rates of use of 3 key evidence-based drug therapies (ACE inhibitors/ARBs, beta-blockers, and statins) after hospital discharge for patients with acute coronary syndromes (ACS). METHODS: The study cohort was identified using medical claims from commercial health plans within a managed care organization located in the Mid-Atlantic states, with approximately 3.4 million members with medical benefits of whom 1.2 million members (35.3%) had pharmacy benefits. Members were included if they were (1) aged >or= 18 years, (2) continuously enrolled with the same commercial plan from January 1, 2003, through December 31, 2005, (3) had any medical claims for hospitalization for ACS defined by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 410.xx (acute myocardial infarction) or 411.1 (intermediate coronary syndrome) during the sample identification period from July 1, 2003 through June 30, 2004, and (4) had no medical claims for ACS hospitalizations from January 1, 2003, through June 30, 2003, in any of 10 diagnosis fields on an inpatient hospital claim. Pharmacy claims for ACE inhibitors, ARBs, beta-blockers, and statins were obtained for 18 months following each index date, defined as the earliest ACS diagnosis date during the identification period. Utilization was defined as the member having at least 1 pharmacy claim within each class from index date to 3 months post-index date. Five time periods were examined to assess therapy: - 180 to 0 days (6 months prior), 0 to 90 days (3 months), 0 to 180 days (6 months), 0 to 365 days (12 months), and 0 to 548 days (18 months) following the index date. ACE inhibitors and ARBs were considered together (i.e., a patient had to have at least 1 pharmacy claim for an ACE inhibitor or an ARB). Logistic regression analyses were used to predict use of the 3 drug classes for patients with different clinical (diagnosis and prior use) and demographic (sex and age) characteristics. RESULTS: The study cohort included 1,135 patients (0.27% of 424,526 continuously enrolled members) with ACS as defined by ICD-9-CM codes in medical claims from July 1, 2003, to June 30, 2004. Nearly 65% of the sample patients were men (n = 734 men and n = 401 women), with a mean (standard deviation [SD]) age of 63.8 (SD 13.1) years. Of the 1,135 members with ACS, 588 (51.8%) had at least 1 pharmacy claim for an ACE inhibitor or ARB, 725 (63.9%) for a beta-blocker, and 710 (62.6%) for a statin during the 3-month follow-up period; receipt of at least 1 prescription in all 3 classes was found in 339 (29.9%) of patients. Patients who were aged < 45 years, 65-79 years, and e 80 years were significantly less likely than patients aged 45-64 years to receive statins (P < 0.05). In addition, patients who were aged e 80 years were significantly less likely to receive ACE inhibitors/ARBs (P = 0.003), beta-blockers (P < 0.001), or all 3 classes (P = 0.002). Women were less likely than men to receive statins (P = 0.004) and all 3 drug classes (P = 0.012). Patients with intermediate coronary syndrome were significantly less likely than those with acute myocardial infarction to receive any of the study drugs (P < 0.001). Those patients who had used ACE inhibitors/ARBs, beta-blockers, statins, and all 3 drug classes during the 6 months prior to the index diagnosis of ACS were more likely than those without prior use (odds ratios of 12.2, 9.4, 8.3, and 4.9, respectively, P < 0.001) to have these medications continued after ACS diagnosis. CONCLUSION: At 3 months following the index ACS hospitalization, the majority of the patients were not receiving the 3 guideline medication therapies. ACS patients with intermediate coronary syndrome and those aged 80 years or older were less likely to be receiving any of the 3 therapies, and women were less likely than men to receive statin therapy.

Responses of Azorhizobium caulinodans to cadmium stress.

The symbiosis of Azorhizobium caulinodans and an annul legume Sesbania rostrata was recently found to be tolerant to cadmium pollution by an unknown mechanism. In this study, A. caulinodans ORS571 and ZY-20 showed much stronger tolerance to cadmium than a mutant ORS571-X15 and a common Rhizobium sp., with minimum inhibitory concentration values as high as 4 and 5 mM (versus 1 and 0.1 mM) on yeast extract mannitol agar medium, respectively. Although Cd uptake by all three strains of A. caulinodans were mostly from absorption rather than binding (both loosely or tightly) on cell surface, in resistant strains a higher portion of extractable Cd was bound on the cell surface vs. absorbed (about 1:2.5 ratio) compared to the sensitive mutant (about 1:35.1 ratio). These results suggest that certain level of metal exclusion by a permeability barrier was involved in the mechanism of resistance to Cd by A. caulinodans ORS571 and ZY-20. Over the 12-h period of cultivation in yeast extract mannitol agar medium with Cd addition, the Cd concentrations in the outer membrane and periplasm and spheroplast were the highest at the first 3 h, and declined steadily over time. The fact that Cd concentrations in spheroplast of all three strains were many folds higher than those in outer membrane and periplasm, suggests that extracellular sequestration was not the only mechanism of Cd tolerance in A. caulinodans. The decline of Cd concentrations was significantly faster and started earlier in strains ORS571 and ZY-20 than in ORS571-X15. This suggests a second, probably more substantial, mechanism involves active transport of the metal from the cell, e.g., some efflux system for maintaining homeostasis under cadmium stress.

Prenatal depression and young low-income mothers' perception of their children from pregnancy through early childhood.

This study investigates the role of prenatal depression on young mothers' perception of difficulty in child behavior and parent-child interaction from pregnancy through the first two years of child development. 248 low-income, African American women aged between 13 and 21 years reported on their perceptions of child behavior, parent-child interaction, and on depressive symptoms at the third trimester of pregnancy and at 4-, 12- and 24-months postpartum. During pregnancy, a high percentage (47%) of the young mothers scored above the clinical level of prenatal depressive symptoms. These mothers anticipated and perceived significantly more child difficulty and parent-child interaction difficulty than did non-depressed mothers during pregnancy and over the first two years of the child's development. Moreover, prenatal depression uniquely predicted negative maternal perception throughout the early years of child development even after adjusting for postpartum depression history. The enduring association between prenatal depression and a mother's perception of her child is discussed with respect to the importance of pregnancy in mothers' developing mental schema about their children and the emerging parent-child relationship.

Adherence to antiretroviral therapy in managed care members in the United States: a retrospective claims analysis.

BACKGROUND: Antiretroviral therapy (ART) extends life for patients with human immunodeficiency virus (HIV) infection. However, HIV treatment is lifelong, and adherence presents a special challenge. Suboptimal adherence to ART may lead to disease progression and virologic failure. Earlier studies with combination ART demonstrated that as much as 90%-95% adherence was needed to prevent disease progression. OBJECTIVE: To measure adherence to ART regimens in commercially insured patients with HIV infection and analyze the clinical and demographic factors associated with ≥ 90% adherence. METHODS: This study used retrospective claims data from a Mid-Atlantic states MCO. Members 18 years and older with an HIV diagnosis identified by medical claims were included in the cohort, and pharmacy claims were retrieved for these members. An ART regimen was established for each patient within a 120-day period after the last physician's visit occurring between January 1, 2010, and August 31, 2010. For patients who received an ART regimen recommended by the U.S. Department of Health and Human Services (HHS) 2011 Antiretroviral Guidelines, adherence, as measured by medication possession ratio (MPR), was calculated based on pharmacy claims for 12 months after the end of the 120-day period. Logistic regression was used to examine the association between MPR ≥ 90% and age, sex, type of health plan, use of single-tablet regimens (STR), inpatient and outpatient utilization, and direct health care costs. RESULTS: Of the 4,547 adults with HIV diagnosis, 3,528 (77.6%) had received at least 1 antiretroviral. An HHS-recommended ART regimen was identified in 2,377 patients with 1,136 (47.8%) receiving STR. Mean MPR for patients on an HHS-recommended ART regimen was 91.5% ± 14.0 with 73.1% of patients having achieved MPR ≥ 90%. In univariate analyses, sex, number of outpatient visits, cost of inpatient care, and use of STR were significantly associated with MPR ≥ 90%. In multivariate analysis, only male sex (P = 0.027) and the use of STR (P = 0.009) were positively associated with MPR ≥ 90%. Patients on STR were 1.3 times more likely to achieve at least 90% adherence. CONCLUSIONS: Adherence is a challenge for patients with HIV, and more than a quarter of patients who were on an HHS-recommended ART regimen failed to achieve an accepted adherence MPR threshold of ≥ 90%. Use of STR was associated with an increased likelihood of achieving adherence of at least 90%. Interventions to improve ART adherence are needed, and STR may be an effective strategy as it decreases pill burden.

Failure to fill electronically prescribed antidepressant medications: a retrospective study.

OBJECTIVE: Nonadherence to antidepressants has been reported to range widely from 10% to 60%. Most adherence studies focus on persistence of use and do not include prescriptions that are not picked up by the patient. The objectives of this study were to determine the rate of unfilled antidepressant prescriptions as well as to identify factors associated with failure to fill these prescriptions. METHOD: This retrospective study used administrative and pharmacy data from a mid-Atlantic managed care organization serving 3.3 million medical members and 1.2 million pharmacy members. Electronic prescriptions for citalopram, duloxetine, sertraline, and venlafaxine sent to pharmacies from July 1, 2007, to June 30, 2009, were matched to pharmacy claims to determine the rate of unfilled antidepressant prescriptions. Patients were ≥18 years of age and had continuous pharmacy coverage from July 1, 2006, to July 31, 2009. Logistic regression was used to assess whether clinical and demographic factors were associated with unfilled electronic prescriptions. RESULTS: There were 557 electronically prescribed antidepressants for 267 patients. The rate of unfilled electronic prescriptions was 13.1%, which affected 19.9% of patients. Electronic prescriptions for new users of the antidepressant were 5 times more likely to be unfilled (odds ratio [OR]=5.13; 95% CI, 2.66-9.91; P<.001) than those for previous users. Antidepressant prescriptions for patients aged 18-34 years were most likely to be unfilled (OR=3.72; 95% CI, 1.81-7.67; P<.001). CONCLUSIONS: Nonadherence to antidepressants is a significant problem with one-fifth of patients never receiving their electronically prescribed antidepressant. Prescriptions for patients without a previous antidepressant claim and aged 18-34 years were least likely to be filled. Interventions targeting patients who fail to fill their antidepressant prescription are needed.

You wrote the prescription, but will it get filled?

PURPOSE: Despite numerous studies on adherence, there is little research on the first-fill rate of antihypertensive prescriptions. Our study took advantage of the recent increase in electronic prescribing (e-prescribing) and used data from e-prescribing physicians to determine the first-fill failure rate of antihypertensive prescriptions and to assess which factors predict first-fill failure. METHODS: This retrospective study reviewed claims from a Mid-Atlantic managed care organization (MCO). We included adult members with continuous medical and pharmacy coverage who were prescribed an antihypertensive in 2008 by an e-prescribing physician. First-fill failure occurred when the patient did not obtain the antihypertensive medication due to either a denial by the MCO or reversal by the dispensing pharmacist. (Pharmacists reverse claims when a patient fails to pick up a medication.) Multivariate regression analysis determined the clinical and demographic factors associated with failure to fill. RESULTS: The cohort consisted of 14,693 antihypertensive prescriptions, prescribed by 164 e-prescribing physicians for 7061 unique members. There were 2289 out of 14,693 prescriptions (15.6%) that went unfilled, affecting 24.3% of patients. Of the prescriptions not obtained, 1466 (64%) were denied by the MCO and 823 (36%) were reversed. Significant factors associated with first-fill failure were new diagnosis of hypertension, new antihypertensive agent, higher co-payment, and enrollment in a health maintenance organization or preferred provider organization. CONCLUSIONS: Patients newly diagnosed with hypertension and those prescribed a new antihypertensive were at particularly high risk for not obtaining their medication. Because nearly a quarter of patients did not obtain their initial fill of an antihypertensive prescription, future research should determine efficient and cost-effective systems to address first-fill failure in primary care.

Aspirin use in elderly women receiving medication therapy management services.

INTRODUCTION: Cardiovascular disease is the largest single cause of death among women in the US. The American Heart Association guidelines recommend aspirin use in women > or = 65 years of age if blood pressure is controlled and the benefits of cardiovascular risk reduction likely outweigh the risk of bleeding. The objective of this study is to determine the prevalence of aspirin use in elderly women and factors associated with use. METHODS: This retrospective study evaluated aspirin use in women aged > or = 65 years based on cardiovascular and gastrointestinal bleeding risk using a medication therapy management database within a large mid-Atlantic managed care organization. Logistic regression was used to analyze patient-related variables associated with aspirin use. Variables included clinical coronary heart disease (CHD), number of CHD risk factors, diabetes diagnosis, number of chronic medications and presence of contraindications to aspirin. RESULTS: Aspirin use was reported in 50% of patients: 68.0% in the secondary prevention group and 46.3% in the primary prevention group. The percentage of patients using aspirin or with relative aspirin contraindications increased to 84% for the secondary prevention group and 65.9% for the primary prevention group. Patients with clinical CHD and those with diabetes and without clinical CHD were 5.88 (P=0.008) and 7.54 (P=0.012) times more likely to utilize aspirin, respectively, than patients with only one CHD risk factor of age. Patients with relative contraindications to aspirin were less likely to use aspirin (P<0.001). CONCLUSION: The high use of aspirin in patients at higher CHD risk supports national recommendations. Clinical practitioners need to carefully assess the value of aspirin in patients at low CHD risk and those 80 years of age and beyond where evidence of benefit should be weighed against risk.

Persistence with injectable antidiabetic agents in members with type 2 diabetes in a commercial managed care organization.

OBJECTIVE: While many patients with type 2 diabetes require insulin to achieve glycemic goals, little is known about patients' persistence with insulin or other injectable antidiabetic therapies. The objective of this study was to evaluate persistence with injectable antidiabetic agents in patients with type 2 diabetes who were naïve to these treatments. METHODS: The study cohort was obtained using administrative and pharmacy claims data from a commercial managed care organization of approximately 1.2 million members with pharmacy benefits. The inclusion criteria were members with type 2 diabetes who had at least one pharmacy claim for insulin glargine, insulin detemir, exenatide, or isophane insulin human (NPH insulin) from January 1, 2006 through June 30, 2006. The first claim for any of these injectable therapies was considered the index prescription. Members were excluded if they filled a prescription (a) for any injectable antidiabetic medication from July 2005 through December 2005; or (b) for short/rapid-acting or mixed insulins during 2006, either prior to the index date or within 30 days following the index date. The primary outcome was persistence with the index drug, defined as number of months between the initiation of therapy (i.e., index date) and either the end of therapy (date of last fill plus days supply) or study period of 12 months. The secondary outcome was the percentage of patients with claims for new antidiabetic agents added after index date. Multivariate regression with life data (survival analysis) was performed with number of months of persistence as the dependent variable. RESULTS: The cohort consisted of 1769 members with a mean (SD) age of 53.2 (12.5) years and 47.4% were men. Mean (SD) months of persistence for members on insulin glargine, insulin detemir and exenatide were similar at 7.8 (4.1), 7.8 (4.4), and 7.6 (4.4), respectively. Members taking NPH insulin had statistically lower persistence at 5.6 (4.5) months (P < 0.001). Overall persistence was 28.7% for injectable antidiabetics at 1 year among treatment-naïve patients. In a multivariate regression model, patients who were younger (P = 0.025) and who initially received NPH insulin (P < 0.001) were less likely to persist. There was no association between persistence and sex, initial copayment, or number of oral antidiabetic medications at time of index prescription. Members in the exenatide and NPH insulin groups were less likely to receive new antidiabetic agents compared with the insulin glargine group (P < 0.001). Limitations include the use of pharmacy claims to proxy the type of diabetes and patients with gestational diabetes may have been included. Missing or inaccurate claims data, the use of samples and hospitalizations may have occurred and would result in an underestimation of persistence. CONCLUSIONS: Persistence was low for injectable antidiabetics at 1 year among treatment-naïve patients. Patients who received insulin glargine, insulin detemir, or exenatide were more likely to persist than patients receiving NPH insulin. Older patients were more likely to persist, but sex, copayment and number of oral antidiabetic medications at initiation of the injectable antidiabetic were not associated with persistence.

Effect of medication burden on persistent use of lipid-lowering drugs among patients with hypertension.

OBJECTIVE: To determine the effect of medication burden on persistent use of newly added lipid-lowering (LL) drugs among patients with hypertension. STUDY DESIGN: This retrospective database study used medical and pharmacy claims from a mid-Atlantic managed care organization. The cohort was obtained from continuous member enrollment in pharmacy and medical benefits from January 1, 2003, to December 31, 2005. METHODS: Prescription claims were obtained for 18 months following the date of the first filled LL prescription (ie, index date). Patients were stratified into patients who changed LL drug or strength (group 1) and patients who did not change LL drug or strength (group 2). The primary outcome measure was persistence to newly added LL therapy. Persistence was defined by the length of time a member remained on therapy following the index date. The secondary outcome measure was the medication possession ratio (MPR). The MPR was calculated as the ratio of the sum of the days' supply of prescription filled divided by the number of days filled, plus the days' supply for the final prescription fill. Associations between the daily medication burden, defined as the number of unique drug products, and the outcome measures were analyzed. RESULTS: In the cohort of 3058 patients, the mean medication burden was 2.9 medications. Medication burden was positively associated with persistence and MPR through 18 months. Patients who had greater medication burden had longer persistence (P <.001). Likewise, patients who had greater medication burden had higher MPRs and were more likely to be considered adherent (MPR, >80%) (P < .001 for both). CONCLUSIONS: Patients with higher medication burden had greater adherence to newly added LL therapy. Medication burden should not deter clinicians from adding LL therapy. Among patients with added LL therapy, more attention should focus on patients who have changes to their LL regimen compared with patients who continue on the same LL prescription.