Algorithm for Identifying Nursing Home Days Using Medicare Claims and Minimum Data Set Assessment Data.

BACKGROUND: No consensus exists about methods of measuring nursing home (NH) length-of-stay for Medicare beneficiaries to identify long-stay and short-stay NH residents. OBJECTIVES: To develop an algorithm measuring NH days of stay to differentiate between residents with long and short stay (≥101 and <101 consecutive days, respectively) and to compare the algorithm with Minimum Data Set (MDS) alone and Medicare claims data. RESEARCH DESIGN: We linked 2006-2009 MDS assessments to Medicare Part A skilled nursing facility (SNF) data. This algorithm determined the daily NH stay evidence by MDS and SNF dates. NH length-of-stay and characteristics were reported in the total, long-stay, and short-stay residents. Long-stay residents identified by the algorithm were compared with the NH evidence from MDS-alone and Medicare parts A and B data. RESULTS: Of 276,844 residents identified by our algorithm, 40.8% were long stay. Long-stay versus short-stay residents tended to be older, male, white, unmarried, low-income subsidy recipients, have multiple comorbidities, and have higher mortality but have fewer hospitalizations and SNF services. Higher proportions of long-stay and short-stay residents identified by the MDS/SNF algorithm were classified in the same group using MDS-only (98.9% and 100%, respectively), compared with the parts A and B data (95.0% and 67.1%, respectively). NH length-of-stay was similar between MDS/SNF and MDS-only long-stay residents (mean±SD: 717±422 vs. 720±441 d), but the lengths were longer compared with the parts A and B data (approximately 474±393 d). CONCLUSIONS: Our MDS/SNF algorithm allows the differentiation of long-stay and short-stay residents, resulting in an NH group more precise than using Medicare claims data only.

Depression among older adults after traumatic brain injury: a national analysis.

OBJECTIVE: Sequelae of traumatic brain injury (TBI) include depression, which could exacerbate the poorer cognitive and functional recovery experienced by older adults. The objective of this study was to estimate incidence rates of depression after hospital discharge for TBI among Medicare beneficiaries aged at least 65 years, quantify the increase in risk of depression after TBI, and evaluate risk factors for incident depression post-TBI. METHODS: Using a retrospective analysis, the authors studied Medicare beneficiaries at least 65 years old hospitalized for TBI during 2006 to 2010 who survived to hospital discharge and had no documented diagnosis of depression before the study period (N = 67,347). RESULTS: The annualized incidence rate of depression per 1,000 beneficiaries was 62.8 (95% confidence interval [CI]: 61.6, 64.1) pre-TBI and 123.9 (95% CI: 121.6, 126.2) post-TBI. Annualized incidence rates were highest immediately after hospital discharge and declined over the 12 months post-TBI. TBI increased the risk of incident depression in men (hazard ratio: 1.95; 95% CI: 1.84, 2.06; Wald χ(2) = 511.4, df = 1, p <0.001) and in women (hazard ratio: 1.69; 95% CI: 1.62, 1.77; Wald χ(2) = 589.3, df = 1, p <0.001). The strongest predictor of depression post-TBI for both men and women was discharge to a skilled nursing facility (men: odds ratio, 1.91; 95% CI, 1.77, 2.06; Wald χ(2) = 277.1, df = 1, p <0.001; women: odds ratio, 1.72; 95% CI, 1.63, 1.83; Wald χ(2) = 324.2, df = 1, p <0.001). CONCLUSION: TBI significantly increased the risk of depression among older adults, especially among men and those discharged to a skilled nursing facility. Results from this study will help increase awareness of the risk of depression post-TBI among older adults.

Stroke incidence following traumatic brain injury in older adults.

OBJECTIVE: Following traumatic brain injury (TBI), older adults are at an increased risk of hemorrhagic and thromboembolic events, but it is unclear whether the increased risk continues after hospital discharge. We estimated incidence rates of hemorrhagic and ischemic stroke following hospital discharge for TBI among adults 65 years or older and compared them with pre-TBI rates. PARTICIPANTS: A total of 16 936 Medicare beneficiaries 65 years or older with a diagnosis of TBI in any position on an inpatient claim between June 1, 2006, and December 31, 2009, who survived to hospital discharge. DESIGN: Retrospective analysis of a random 5% sample of Medicare claims data. MAIN MEASURES: Hemorrhagic stroke was defined as ICD-9 (International Classification of Diseases, Ninth Revision) codes 430.xx-432.xx. Ischemic stroke was defined as ICD-9 codes 433.xx-435.xx, 437.0x, and 437.1x. RESULTS: There was a 6-fold increase in the rate of hemorrhagic stroke following TBI compared with the pre-TBI period (adjusted rate ratio, 6.5; 95% confidence interval, 5.3-7.8), controlling for age and sex. A smaller increase in the rate of ischemic stroke was observed (adjusted rate ratio, 1.3; 95% CI, 1.2-1.4). CONCLUSION: Future studies should investigate causes of increased stroke risk post-TBI as well as effective treatment options to reduce stroke risk and improve outcomes post-TBI among older adults.

A Systematic Review of the Benefits and Risks of Anticoagulation Following Traumatic Brain Injury.

OBJECTIVE: To synthesize the existing literature on benefits and risks of anticoagulant use after traumatic brain injury (TBI). DESIGN: Systematic review. A literature search was performed in MEDLINE, International Pharmaceutical Abstracts, Health Star, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) on October 11, 2012, and updated on September 2, 2013, using terms related to TBI and anticoagulants. MAIN MEASURES: Human studies evaluating the effects of post-TBI anticoagulation on venous thromboembolism, hemorrhage, mortality, or coagulation parameters with original analyses were eligible for the review. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline was followed throughout the conduct of the review. RESULTS: Thirty-nine eligible studies were identified from the literature, of which 23 studies with complete information on post-TBI anticoagulant use and patient outcomes were summarized in this review. Meta-analysis was unwarranted because of varying methodological design and quality of the studies. Twenty-one studies focused on the effects of pharmacological thromboprophylaxis (PTP) post-TBI on venous thromboembolism and/or progression of intracranial hemorrhage, whereas 2 randomized controlled trials analyzed coagulation parameters as the result of anticoagulation. CONCLUSION: Pharmacological thromboprophylaxis appears to be safe among TBI patients with stabilized hemorrhagic patterns. More evidence is needed regarding effectiveness of PTP in preventing venous thromboembolism as well as preferred agent, dose, and timing for PTP.

Physician specialty cost differences of treating nonmelanoma skin cancer.

Specialty-related cost differences for the treatment of nonmelanoma skin cancer (NMSC) have been previously reported but without taking into account confounding factors. Using a previously validated model for NMSC episode of care, episodes were identified in the Medicare Current Beneficiary Survey claims 2005 to 2007. A γ regression with log link model estimated the effect of physician exposure on total episode costs controlling for sociodemographics, health status and comorbidities, treatment and repair procedures, as well as tumor size and location. Treatment-related NMSC episodes (1285) were identified. In the unadjusted model, episodes managed by generalists were associated with 36% lower costs, those by otolaryngologists/plastic surgeons with 82% higher costs, and those by multiple specialists with 111% higher costs, compared to dermatologists. Cost differences were substantially reduced in the adjusted regression analysis; compared to dermatologists, episodes managed by generalists were associated with 20% lower costs (P < 0.0001), whereas otolaryngologists/plastic surgeons and multiple specialists were associated with 20% (P < 0.01) and 11% (P = 0.02) higher costs, respectively. Overall, comparison between unadjusted and adjusted estimates suggests that controlling for severity and treatment modalities explains most of the specialty cost differences. Our estimates could be subject to residual confounding due to selection bias and the limitations to using claims data to characterize an NMSC episode of care. Adjusting for the severity of the disease and other confounders, our study found much smaller specialty-related cost differences for the management of NMSC than previously reported unadjusted estimates.

Dementia severity and the longitudinal costs of informal care in the Cache County population.

BACKGROUND: Dementia costs are critical for influencing healthcare policy, but limited longitudinal information exists. We examined longitudinal informal care costs of dementia in a population-based sample. METHODS: Data from the Cache County Study included dementia onset, duration, and severity assessed by the Mini-Mental State Examination (MMSE), Clinical Dementia Rating Scale (CDR), and Neuropsychiatric Inventory (NPI). Informal costs of daily care (COC) was estimated based on median Utah wages. Mixed models estimated the relationship between severity and longitudinal COC in separate models for MMSE and CDR. RESULTS: Two hundred and eighty-seven subjects (53% female, mean (standard deviation) age was 82.3 (5.9) years) participated. Overall COC increased by 18% per year. COC was 6% lower per MMSE-point increase and compared with very mild dementia, COC increased over twofold for mild, fivefold for moderate, and sixfold for severe dementia on the CDR. CONCLUSIONS: Greater dementia severity predicted higher costs. Disease management strategies addressing dementia progression may curb costs.

Validation of disability status, a claims-based measure of functional status for cancer treatment and outcomes studies.

BACKGROUND: In prior research, we developed a claims-based prediction model for poor patient disability status (DS), a proxy measure for performance status, commonly used by oncologists to summarize patient functional status and assess ability of a patient to tolerate aggressive treatment. In this study, we implemented and validated the DS measure in 4 cohorts of cancer patients: early and advanced non-small cell lung cancers (NSCLC), stage IV estrogen receptor-negative (ER-) breast cancer, and myelodysplastic syndromes (MDS). DATA AND METHODS: SEER-Medicare data (1999-2007) for the 4 cohorts of cancer patients. Bivariate and multivariate logistic regression tested the association of the DS measure with designated cancer-directed treatments: early NSCLC (surgery), advanced NSCLC (chemotherapy), stage IV ER- breast cancer (chemotherapy), and MDS (erythropoiesis-stimulating agents). Treatment model fit was compared across model iterations. RESULTS: In both unadjusted and adjusted results, predicted poor DS was strongly associated with a lower likelihood of cancer treatment receipt in all 4 cohorts [early NSCLC (N=20,280), advanced NSCLC (N=31,341), stage IV ER- breast cancer (N=1519), and MDS (N=6058)] independent of other patient, contextual, and disease characteristics, as well as the Charlson Comorbidity Index. Inclusion of the DS measure into models already controlling for other variables did not significantly improve model fit across the cohorts. CONCLUSIONS: The DS measure is a significant independent predictor of cancer-directed treatment. Small changes in model fit associated with both DS and the Charlson Comorbidity Index suggest that unobserved factors continue to play a role in determining cancer treatments.

The effect of supplemental medical and prescription drug coverage on health care spending for Medicare beneficiaries with cancer.

OBJECTIVES: To examine whether patients with newly diagnosed cancer respond differently to supplemental coverage than the general Medicare population. METHODS: A cohort of newly diagnosed cancer patients (n = 1,799) from the 1997-2007 Medicare Current Beneficiary Survey and a noncancer cohort (n = 9,726) were identified and matched by panel year. Two-year total medical care spending was estimated by using generalized linear models with gamma distribution and log link-including endogeneity-corrected models. Interactions between cancer and type of insurance allowed testing for differential effects of a cancer diagnosis. RESULTS: The cancer cohort spent an adjusted $15,605 more over 2 years than did the noncancer comparison group. Relative to those without supplemental coverage, beneficiaries with employer-sponsored insurance, other private with prescription drug coverage, and public coverage had significantly higher total spending ($3,510, $2,823, and $4,065, respectively, for main models). For beneficiaries with cancer, supplemental insurance effects were similar in magnitude yet negative, suggesting little net effect of supplemental insurance for cancer patients. The endogeneity-corrected models produced implausibly large main effects of supplemental insurance, but the Cancer × Insurance interactions were similar in both models. CONCLUSIONS: Medicare beneficiaries with cancer are less responsive to the presence and type of supplemental insurance than are beneficiaries without cancer. Proposed restrictions on the availability of supplemental insurance intended to reduce Medicare spending would be unlikely to limit expenditures by beneficiaries with cancer, but would shift the financial burden to those beneficiaries. Policymakers should consider welfare effects associated with coverage restrictions.

Association between depression and maintenance medication adherence among Medicare beneficiaries with chronic obstructive pulmonary disease.

OBJECTIVE: Depression is a significant comorbidity in patients with chronic obstructive pulmonary disease (COPD). Although comorbid depression is associated with low use and poor adherence to medications treating other chronic conditions, evidence of the relationship between depression and COPD management is limited. This study estimated the association between depression and COPD maintenance medication (MM) adherence among patients with COPD. METHODS: This cross-sectional study used a 5% random sample of 2006-2007 Chronic Condition Warehouse data. Medicare beneficiaries enrolled in Parts A, B, and D plans with diagnosed COPD who survived through 2006 were included (n = 74,863). COPD MM adherence was measured as medication discontinuation and proportion of days covered (PDC). Depression was identified through the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Multivariable models with modified generalized estimating equations were used to estimate adjusted association between depression diagnosis and medication adherence, controlling for sociodemographics, comorbidities, and disease severity. RESULTS: Among the sample, about one third (33.6%) had diagnosed depression. More than half (61.8%) of beneficiaries with COPD filled at least one COPD MM prescription. Depressed beneficiaries had a higher likelihood of using COPD MM than non-depressed beneficiaries (adjusted prevalence ratios [PR] = 1.02; 95% confidence intervals [CI] = 1.01, 1.03). Among COPD MM users, depressed beneficiaries were more likely to discontinue medications (PR = 1.09; 95% CI = 1.04, 1.14) and less likely to exhibit PDC ≥ 0.80 (PR = 0.89; 95% CI = 0.86, 0.92) than non-depressed beneficiaries. CONCLUSIONS: Depression is prevalent in Medicare beneficiaries with COPD and independently associated with lower COPD MM adherence. Interventions to improve medication adherence for COPD patients may consider management of comorbidities such as depression.

Use of and spending on supportive care medications among Medicare beneficiaries with cancer.

PURPOSE: The study objective was to provide population-based estimates of supportive care medication (SCM) use among Medicare beneficiaries with cancer and determine factors related to SCM receipt. METHODS: This retrospective cohort study of community-based Medicare beneficiaries used the Medicare Current Beneficiary Survey (1997­2007). Dependent variables comprised use and spending on SCMs for three medication classes: opioids, antidepressants/sedative/hypnotics (ASH), and antiemetics. Independent variables of interest were supplemental insurance coverage, cancer site, and treatment. Multivariate models determined factors affecting receipt of, and spending on, SCMs. We also compared SCM use and spending among beneficiaries with and without cancer in order to understand what portion of SCM use and spending could be attributed to cancer as opposed to other comorbid conditions. RESULTS: A total of 1,836 Medicare beneficiaries with cancer and 9,898 beneficiaries without cancer were eligible for the study. Beneficiaries with cancer were more likely to receive opioids, ASH, and antiemetics compared to non-cancer beneficiaries. Adjusted annual payments for antiemetics were on average $637 higher in with cancer versus without cancer (p<0.01), while ASH payments were $184 lower (p<0.01). Opioid spending was similar among cancer and non-cancer users. Relative to colon cancer, beneficiaries with prostate cancer were least likely to receive any of the three SCM classes. Receipt of antineoplastic treatment increased the probability of use of all three classes of SCMs. Insurance coverage did not influence the use of or spending on opioids or antiemetics, but was associated with both outcomes for ASH. The use of all three SCM classes was significantly lower during years before Part D implementation of the new Medicare Part D prescription drug benefit and was higher after implementation of Part D. CONCLUSION: This study provides population-based information on SCM use among Medicare beneficiaries with cancer. Cancer site and treatment modality were important predictors of SCM use.

Out-of-pocket health care expenditure burden for Medicare beneficiaries with cancer.

BACKGROUND: There is increasing concern regarding the financial burden of care on cancer patients and their families. Medicare beneficiaries often have extensive comorbidities and limited financial resources, and may face substantial cost sharing even with supplemental coverage. In the current study, the authors examined out-of-pocket (OOP) spending and burden relative to income for Medicare beneficiaries with cancer. METHODS: This retrospective, observational study pooled data for 1997 through 2007 from the Medicare Current Beneficiary Survey linked to Medicare claims. Medicare beneficiaries with newly diagnosed cancer were selected using claims-based diagnoses. Generalized linear models were used to estimate OOP spending. Logistic regression models identified factors associated with a high OOP burden, defined as spending > 20% of one's income during the cancer diagnosis and subsequent year. RESULTS: The cohort included 1868 beneficiaries with and 10,047 without cancer. Compared with the noncancer cohort, cancer patients were older, had more comorbidities, and were more likely to lack supplemental coverage. The mean OOP spending for cancer patients was $4727. Cancer patients faced an adjusted $976 (P < .01) incremental OOP spending. Greater than one-quarter (28%) of beneficiaries with cancer experienced a high OOP burden compared with 16% of beneficiaries without cancer (P < .001). Supplemental insurance and higher income were found to be protective against a high OOP burden, whereas assets, comorbidity, and receipt of cancer-directed radiation and antineoplastic therapy were associated with a higher OOP burden. CONCLUSIONS: Medicare beneficiaries with cancer face a higher OOP burden than their counterparts without cancer; some of the higher burden was explained by the higher comorbidity burden and lack of supplemental insurance noted among these patients. Financial pressures may discourage some elderly patients from pursuing treatment.

Single-dose etomidate is not associated with increased mortality in ICU patients with sepsis: analysis of a large electronic ICU database.

OBJECTIVE: Retrospective analyses of several trials suggest etomidate may be unsafe for intubation in patients with sepsis. We evaluated the association of etomidate and mortality in a large cohort of septic patients to determine if single-dose etomidate was associated with increased in-hospital mortality. DESIGN AND SETTING: Retrospective cohort study at the Philips eICU Research Institute ICU clinical database. INTERVENTIONS: None. PATIENTS: Among 741,036 patients monitored from 2008 through 2010, we identified 2,014 adults intubated in the ICU 4-96 hrs after admission, having clinical criteria consistent with sepsis, severe sepsis, or septic shock. In all, 1,102 patients received etomidate and 912 received other induction agents for intubation. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was in-hospital mortality, but we also evaluated demographic and clinical factors, severity of illness, ICU mortality, ICU length of stay, hospital length of stay, ventilator days, and vasopressor days. Competing risk Cox proportional hazard regression models were used for primary outcomes. Demographics and illness severity were similar between the groups. Hospital mortality was similar between the groups (37.2% vs. 37.8%, p = 0.77), as were ICU mortality (30.1% vs. 30.2%, p = 0.99), ICU length of stay (8.7 days vs. 8.9 days, p = 0.66), and hospital length of stay (15.2 vs. 14.6 days, p = 0.31). More patients in the etomidate group received steroids before and after intubation (52.9% vs. 44.5%, p < 0.001), but vasopressor use and duration of mechanical ventilation were similar. No regression model showed an independent association of etomidate with mortality, shock, duration of mechanical ventilation, ICU or hospital length of stay, or vasopressor use. A hospital mortality model limited to only patients with septic shock (n = 650) also showed no association of etomidate and hospital mortality. CONCLUSION: In a mixed-diagnosis group of critically ill patients with sepsis, severe sepsis, and septic shock, single-dose etomidate administration for intubation in the ICU was not associated with higher mortality or other adverse clinical outcomes.

Use and spending on antineoplastic therapy for Medicare beneficiaries with cancer.

BACKGROUND: Oral antineoplastic drugs, not generally covered by Medicare Part B, have assumed an increasingly important role in cancer treatment. OBJECTIVE: We examined use and spending on infused/injected (Part B covered) and non-Part B antineoplastic agents in a Medicare beneficiary population with cancer, and the effect of supplemental insurance. RESEARCH DESIGN: This retrospective, observational study used pooled 1997-2007 data from the Medicare Current Beneficiary Survey, linked to Medicare claims. Logistic regression models identified factors associated with antineoplastic use. Generalized linear models were used to estimate spending among antineoplastic users. POPULATION STUDIED: A total of 1836 Medicare beneficiaries with newly diagnosed cancer were selected based on the presence of claims-based diagnoses after a 12-month washout period. RESULTS: Five hundred fifty-nine (31.0%) Medicare beneficiaries received antineoplastic therapy; 395 (21.3%) used Part B, 253 (14.6%) used non-Part B antineoplastics. Spending per user was $7841 (any), $10,364 (Part B), and $1535 for non-Part B antineoplastics. Supplemental insurance was associated with antineoplastic use. Primary cancer site and age were key predictors of spending among users. Spending on non-Part B antineoplastics increased during 2006-2007 relative to 2004-2005 but time trends were not significant in multivariate analysis. CONCLUSIONS: Antineoplastic therapy use by Medicare beneficiaries is sensitive to the presence but not type of supplemental insurance. Non-Part B therapy was used by a relatively large proportion of beneficiaries with cancer receiving therapy, although spending was less than for Part B therapy. Monitoring the role of supplemental insurance, and particularly the role of Medicare Part D is a critical area for ongoing research.

Association between intensive care unit-acquired dysglycemia and in-hospital mortality.

OBJECTIVE: Our objective was to quantify the association between intensive care unit-acquired dysglycemia (hyperglycemia, hypoglycemia, and high variability) and in-hospital mortality. DESIGN: Retrospective, observational study. SETTING: eICU Research Institute participating hospitals with an active tele-ICU program between January 1, 2008, and September 30, 2010, representing 784,392 adult intensive care unit patients. PATIENTS: A total of 194,772 patients met inclusion criteria with an intensive care unit length of stay >48 hrs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Acute Physiology and Chronic Health Evaluation IV standardized mortality ratios were calculated for dysglycemia present at admission and acquired in the intensive care unit. Intensive care unit-acquired dysglycemia was modeled using multivariable modified Poisson regression to account for confounding not incorporated in Acute Physiology and Chronic Health Evaluation. Dysglycemia severity was assessed by the relative risk of in-hospital mortality associated with the maximum, time-weighted average daily glucose; lowest glucose value throughout the intensive care unit stay; and quintiles of variability (coefficient of variation). The association of duration beyond thresholds of dysglycemia on mortality was also modeled. The adjusted relative risk (95% confidence interval) of mortality for the maximum intensive care unit average daily glucose was 1.13 (1.04-1.58), 1.43 (1.30-1.58), 1.63 (1.47-1.81), 1.76 (1.55-1.99), and 1.89 (1.62-2.19) for 110-150 mg/dL, 151-180 mg/dL, 180-240 mg/dL, 240-300 mg/dL, and >300 mg/dL, respectively, compared to patients whose highest average daily glucose was 80-110 mg/dL. The relative risk of mortality for the lowest glucose value was 1.67 (1.37-2.03), 1.53 (1.37-1.70), 1.12 (1.04-1.21), and 1.06 (1.01-1.11) for <20 mg/dL, 20-40 mg/dL, 40-60 mg/dL, and 60-80 mg/dL, respectively, compared to patients whose lowest value was 80-110 mg/dL. The relative risk of mortality increased with greater duration of hyperglycemia and with increased variability. The relative risk for the highest compared to lowest quintile of variability was 1.61 (1.47-1.78). The association of duration of hyperglycemia on mortality was more pronounced with more severe hyperglycemia. CONCLUSIONS: The risk of mortality progressively increased with severity and duration of deviation from euglycemia and with increased variability. These data suggest that severe intensive care unit-acquired hyperglycemia, hypoglycemia, and variability are associated with similar risks of mortality.

Eligibility and take-up of the Medicare Part D low-income subsidy.

There is concern about poor take-up of the Medicare Part D Low-Income Subsidy (LIS), but uncertainty in published estimates. The Medicare Current Beneficiary Survey (MCBS), which contains Medicare LIS enrollment records and extensive survey data on individual beneficiary characteristics, would appear an ideal resource for evaluating LIS take-up. However, use of the MCBS to identify eligible beneficiaries is limited due to underreporting of income and lack of asset information in the published MCBS releases. We evaluate LIS eligibility and participation by enhancing the reliability of MCBS financial information using unpublished survey data on income and assets together with an income imputation procedure.

Medication use and adherence among elderly Medicare beneficiaries with diabetes enrolled in Part D and retiree health plans.

BACKGROUND: Employer-based retiree drug benefits have long been viewed as the gold standard of drug coverage for elderly Medicare beneficiaries. The question for policy makers is whether beneficiaries enrolled in Part D plans exhibit drug utilization patterns comparable with those seen in retiree plans. OBJECTIVE: To compare utilization patterns for antidiabetic agents, renin-angiotensin-aldosterone system inhibitors, and antihyperlipidemics by elderly Medicare beneficiaries with diabetes enrolled in Medicare prescription drug plans (PDPs) and retiree health plans (RHPs). METHODS: A random 5% sample (N=45,613) of elderly diabetic patients with continuous 2006 PDP enrollment was selected from Medicare files and compared with a similar sample of elderly RHP enrollees from MarketScan (N=211,919) on any use, duration of therapy, and medication possession ratio for each drug class. Adjusted comparisons were made on samples (N=16,859 each) using propensity score matching. RESULTS: Drug utilization and adherence rates were high in both groups. In propensity score adjusted comparisons, prevalence rates for PDP enrollees were within 2.2% of the level of RHP enrollees for antidiabetic agents and renin-angiotensin-aldosterone system inhibitors, but differed sharply for antihyperlipidemics (61% vs. 69%; P<0.0001). There were no clinically meaningful differences between PDP and RHP enrollees in duration of therapy or medication possession ratio for any drug class. CONCLUSION: When otherwise similar Medicare beneficiaries with diabetes have drug coverage, the source of benefits has little effect on use and adherence with most (but not all) drugs recommended in diabetes guidelines.

Impact of the 2004 Food and Drug Administration pediatric suicidality warning on antidepressant and psychotherapy treatment for new-onset depression.

OBJECTIVE: To assess the national impact of the March 2004 Food and Drug Administration (FDA) antidepressant suicidality warning on the outpatient treatment of new-onset depression in youth. METHOD: A repeated measures, longitudinal design in a cohort of youth diagnosed with new-onset depression was used to assess pre- and post-FDA warning effects. US commercial insurance enrollees in the i3 INNOVUS database from January 2003 through December 2006 were examined. The study population included youth 2- to 17-years old with a new-onset depression diagnosis from July 2003 through June 2006 (N = 40,309). The main independent variables were the warning period (post- vs. pre-FDA warning) and age group (children vs. adolescents). The main outcome measures were youth with antidepressant dispensings and psychotherapy visits measured in 30-day intervals across 36 months following a new-onset diagnosis of any depressive disorder (N = 40,309) and specifically major depressive disorder (MDD) (N = 11,532). RESULTS: Compared to youth with a new-onset diagnosis of depression in the pre-FDA warning period, youth with new-onset diagnosis of depression during the postwarning period had (1) A significantly lower likelihood of antidepressant use: (odds ratio [OR] = 0.85 [0.81-0.89]); When youth with the diagnosis of depression were separated into those with MDD and those with less severe depression diagnoses, only the latter had a significant postwarning antidepressant decline. (2) A significant increase in the odds of a psychotherapy visit (children, OR = 1.31 [1.23-1.40]; adolescents OR = 1.19 [1.15-1.24]). CONCLUSIONS: The FDA suicidality warning was associated with an overall decrease in antidepressant treatment for youth with a clinician-reported diagnosis of depression, but not for those with MDD. Also, following the warning, psychotherapy without medication increased.

Trends in disparities in receipt of adjuvant therapy for elderly stage III colon cancer patients: the role of the medical oncologist evaluation.

BACKGROUND: Race disparities in adjuvant chemotherapy for stage III colon cancer patients have been documented, and medical oncologist evaluation is a critical step in the treatment process. Recent healthcare system and environmental changes may have reduced treatment gaps. OBJECTIVES: To examine differential rates of oncologist evaluation and conditional treatment, by race, and to determine whether changing evaluation and treatment patterns reduced disparities. RESEARCH DESIGN: Retrospective analysis of Surveillance Epidemiology and End Results-Medicare registry, enrollment, and claims data. SUBJECTS: Patients age >65, white or African American race, diagnosed with American Joint Committee on Cancer stage III colon cancer between 1997 and 2002. N = 7176. KEY MEASURES: Oncology specialty evaluation and management visit or chemotherapy claim; receipt of 5-fluorouracil based chemotherapy. Time periods are grouped into early (1997-1998), middle (1999-2000), and late (2001-2002). RESULTS: Initial adjusted oncologist evaluation rates were higher for whites compared with African American patients (58.7% vs. 42.9%), but changes over time reduced the race gap substantially. We did not find significant race-time trends in treatment rates conditional on oncologist evaluation. CONCLUSIONS: Race disparities in medical oncologist evaluations diminished over time, possibly in response to increased provider supply or changing patient and provider attitudes, but there was no parallel reduction in disparities in conditional treatment rates. Projected decreases in oncologist supply suggest the need for further research on this relationship. Research on the role of supplemental medical insurance on disparities in treatment is needed, particularly as the cost of recommended adjuvant therapy increases.

Association of antipsychotic use with hospital events and mortality among medicare beneficiaries residing in long-term care facilities.

OBJECTIVE: Antipsychotic (AP) utilization has grown significantly in long-term care (LTC) settings. Although a growing literature associates AP use with higher mortality in elderly with dementia, the association of APs with hospital events is unclear. The authors examine prevalence and trends in AP use by Medicare beneficiaries residing in LTC and the association of APs and other drug use variables with hospital events and mortality. DESIGN: Retrospective analysis using sequential multivariate Cox proportional hazards models. SETTING: Medicare Current Beneficiary Survey linked to Institutional Drug Administration and Minimum Data Set files. PARTICIPANTS: A total of 2,363 LTC Medicare beneficiaries, 1999-2002. MEASUREMENTS: Trends in LTC AP use overall and by type and duplicative use; association of AP utilization and two outcomes: hospital events and all-cause mortality. RESULTS: AP use rose markedly from 1999 to 2002 (26.4%-35.9%), predominantly due to increased use of atypical agents. After controlling for sociodemographic and clinical factors, AP use is not related to hospital events (hazard ratio [HR] = 0.98, 95% confidence interval [CI] = 0.82-1.63 p = 0.7951). AP use is associated with reduced mortality in unadjusted and intermediate models, but loss of significance in the final model (HR = 0.83, 95% CI = 0.69-1.00, p = 0.0537) suggests that disease and drug burden factors may confound the AP-mortality relationship. CONCLUSION: This study provides no evidence of increased hospital events or mortality in LTC residents who use AP medications. Findings contribute to a growing body of evidence that APs, particularly atypical agents, may be associated with reduced mortality in LTC residents.

Administrators' perceptions of medication management in assisted living facilities: results from focus groups.

OBJECTIVE: Assisted living (AL) residents are vulnerable to adverse events as a result of using numerous medications and frequently need assistance in administering medications. Very little is known, however, about the ways in which medications are managed within this level of care. DESIGN: AL administrators from the metropolitan Baltimore, Maryland area were invited to participate in focus groups to explore issues involved in medication management. SETTING AND PARTICIPANTS: Four administrators from smaller (15 beds or fewer) and six larger (more than 15 beds) certified AL facilities serving primarily older residents participated. Administrators must have served in their position at least six months. RESULTS: Administrators described interactions with residents, physicians, and pharmacists as well as the issues of state regulations and their enforcement. We uncovered themes concerning the challenges faced in negotiating competing needs of residents, providers, and regulatory bodies. CONCLUSIONS: Administrators often feel torn between competing requirements of their position, and they experience some degree of conflict in allowing residents to retain autonomy in the face of demands of family, providers, and regulators. Small-facility administrators especially report being in a position to allow them to monitor residents' medication reactions and needs. Large-facility administrators sometimes find their actions hampered by decisions made at higher (ownership) levels. Administrators want AL facilities to remain at an intermediate level of care, with less stringent regulations than for those for nursing facilities, but would also like more consistency in enforcement of regulations. Qualitative assessment of medication-related issues in AL can help to guide policy in this area.