Early implementation of medicare part D in urban and rural nursing facilities.

OBJECTIVE: To determine if differences occurred in the early implementation of Medicare Part D (prescription drug program) between urban and rural nursing facilities. DESIGN: Nursing facility demographic data, obtained from the Nursing Facility Compare Medicare Web site, were used to create matched pairs of rural and urban facilities. On-site interviews were conducted in June and July 2006 with one designated representative from each nursing facility. Details for each prescription drug plan (PDP), identified by the facility representatives, were obtained from the PDP's Web site. SETTING: A prospective pilot field study of rural and urban nursing facilities was created from among 40 facilities in the 26-county Texas Panhandle. Five rural/urban nursing facilities of identical ownership and of similar perceived quality (number of cited deficiencies) and staffing (total nursing staff time per resident) were used for the pilot study. PARTICIPANTS: Nursing facility employees charged with overseeing Part D implementation and trained interviewers. INTERVENTION: None. MAIN OUTCOME MEASURES: Number of PDPs per nursing facility and distribution of persons providing enrollment decision support. RESULTS: Rural facilities used more PDPs (7.4 +/- 3.9) than did urban facilities (4.6 +/- 3.8, NSS). Independent samples Student's t-test determined that there was a significant difference in the average number of drugs per resident. Rural residents received fewer medications (8.2 +/- 1.9) than urban residents (11.2 +/- 2.2; P = 0.049, t = 2.32). CONCLUSIONS: These early findings suggest that rural nursing facilities interact with more PDPs than urban facilities and that Medicare Part D enrollment decisions are more likely to be aided by family members in rural facilities than in urban nursing facilities.

Aggressive hypertension management in patients of advancing and advanced age.

Many older patients are not being aggressively managed for hypertension. Healthcare providers are often hesitant to start or even aggressively titrate antihypertensive medication, especially in the aged. Multiple studies have demonstrated that morbidity and mortality can be significantly reduced by appropriate intervention in all age groups. There are some clinical situations, however, where the provider must approach cautiously, such as in patients with a wide pulse pressure or those with a propensity toward adverse reactions. The data are clear that in the United States, undertreatment, rather than overtreatment, appears to be the issue. This article reviews studies that support the aggressive treatment of hypertension. The nuances of aging, which often influence the healthcare provider's treatment decisions, are also discussed. Suggestions for reasonable approaches to these difficult cases will be considered.