Association between race, depression, and antiretroviral therapy adherence in a low-income population with HIV infection.

BACKGROUND: Racial disparities exist in many aspects of HIV/AIDS. Comorbid depression adds to the complexity of disease management. However, prior research does not clearly show an association between race and antiretroviral therapy (ART) adherence, or depression and adherence. It is also not known whether the co-existence of depression modifies any racial differences that may exist. OBJECTIVE: To examine racial differences in ART adherence and whether the presence of comorbid depression moderates these differences among Medicaid-enrolled HIV-infected patients. DESIGN: Retrospective cohort study. SETTING: Multi-state Medicaid database (Thomson Reuters MarketScan®). PARTICIPANTS: Data for 7,034 HIV-infected patients with at least two months of antiretroviral drug claims between 2003 and 2007 were assessed. MAIN MEASURES: Antiretroviral therapy adherence (90 % days covered) were measured for a 12-month period. The main independent variables of interest were race and depression. Other covariates included patient variables, clinical variables (comorbidity and disease severity), and therapy-related variables. KEY RESULTS: In this study sample, over 66 % of patients were of black race, and almost 50 % experienced depression during the study period. A significantly higher portion of non-black patients were able to achieve optimal adherence (≥90 %) compared to black patients (38.6 % vs. 28.7 %, p < 0.001). In fact, black patients had nearly 30 % decreased odds of being optimally adherent to antiretroviral drugs compared to non-black patients (OR = 0.70, 95 % CI: 0.63-0.78), and was unchanged regard less of whether the patient had depression. Antidepressant treatment nearly doubled the odds of optimal ART adherence among patients with depression (OR = 1.92, 95 % CI: 1.12-3.29). CONCLUSIONS: Black race was significantly associated with worse ART adherence, which was not modified by the presence of depression. Under-diagnosis and under-treatment of depression may hinder ART adherence among HIV-infected patients of all races.

Expenditures associated with dose titration at initiation of therapy in patients with major depressive disorder: a retrospective analysis of a large managed care claims database.

OBJECTIVE.: Although selective serotonin reuptake inhibitors (SSRIs) are considered cost-effective medications for patients with major depressive disorder (MDD), significant dosage adjustments are often necessary when treatment is initiated. Our study was conducted to examine whether dose titration for SSRIs at initiation of therapy was associated with a greater use of health care resources and higher costs. STUDY DESIGN.: A retrospective database analysis was conducted. METHODS.: A nationally representative cohort of individuals with MDD was identified in a large managed care claims database between January 1, 2004, and December 31, 2006. A study-specific titration algorithm was used to identify patients who underwent dose titration, compared with those who did not, within the first eight weeks of initiating SSRI therapy. We calculated propensity scores and identified a 1:1 matched cohort of titration versus non-titration patients. We used univariate and multivariate statistical tests to compare the mean number of therapeutic days, health care service utilization, and expenditures between the two groups during the first eight weeks (56 days) of treatment and six months (180 days) after treatment began. RESULTS.: Over the first eight weeks, the titration cohort had a 32% decrease in the adjusted mean number of therapeutic days (38 vs. 56, respectively; P < 0.001), a 50% increase in depression-related outpatient visits (1.8 vs. 1.2; P < 0.001), a 38% increase in depression-related outpatient costs ($137 vs. $81; P ≤ 0.001), an increase in antidepressant pharmacy costs ($139 vs. $61; P < 0.001), and a 64% increase in psychiatric visits (0.69 vs. 0.42; P = 0.001), compared with the matched non-titration cohort. These differences were consistent among individual SSRI groups as well as during the six-month period. CONCLUSION.: Patients undergoing dose titration of SSRIs at the beginning of therapy consumed more medical resources and spent more days receiving a subtherapeutic dose than a comparable control group without dose titration. Differences in the utilization of resources were consistent with increased patient monitoring in the titration group; however, the added benefit of titration could not be assessed with this database.

Validation and reliability of 2 specialty care satisfaction scales.

DrScore.com an online patient satisfaction survey, uses 2 patient satisfaction scales, namely, satisfaction with physician care and satisfaction with office policy and procedures, including accessibility to care, convenience of office and practice location, and staff friendliness. This study assesses the validity and reliability of the scales. The sample includes 11,212 specialty care visits, comprised of 64% women, 82% established patients, and 24% routine visits. A confirmatory factor analysis is used to test factor structure. Convergent validity also is examined. The goodness-of-fit index is 0.99, and standardized factor loadings are uniformly high, exceeding 0.90 for all but 2 items. Cronbach alpha is 0.99 for the physician scale and 0.94 for the office scale. Both scales discriminate other satisfaction indicators. Correlation between scales is high at 0.90. Both scales possess excellent psychometric properties but are not clearly differentiated. Results agree with the unidimensional view of patient satisfaction and confirm that online surveys can be reliable and valid.

Correlates of patient satisfaction with physician visit: differences between elderly and non-elderly survey respondents.

BACKGROUND: Few studies document differences in patient satisfaction with physicians in the elderly (> or = 65 years) and compare it to non-elderly (<65 years) patients. METHODS: A cross-sectional survey study on a convenience sample of 20,901 patients rated their recent visit to a physician through a web-based survey. Survey included validated questions based on aspects of physician care practice such as "friendliness", wait times and time spent with doctor. These scales were then used to measure patient satisfaction with physician. Statistical analysis involved pair-matching of non-elderly patients with elderly patients (both cohorts, n = 507 each) using propensity scores. RESULTS: Even though elderly and non-elderly patients had similar waiting times, elderly patients gave higher physician satisfaction scores than non-elderly patients (all p < 0.05). When predictors of physician satisfaction ratings were examined, shorter waiting time was more significantly associated with better treatment satisfaction in non-elderly patients (partial rho = -0.25 in the non-elderly compared to partial rho = -0.11 in elderly, p < 0.05). Increased time spent with the physician was more significantly correlated with higher physician satisfaction ratings in the non-elderly patients (partial rho = 0.38 in the non-elderly compared to partial rho = 0.18, p < 0.001). CONCLUSION: Increased patient satisfaction ratings of the non-elderly were associated more strongly with shorter waiting times than in the elderly. However overall, elderly patients reported similar waiting times and better physician satisfaction scores. Similarly, higher physician satisfaction in non-elderly patients were more strongly associated with increased time spent with physician than in the elderly patients.

Impact of nighttime awakenings on worker productivity and performance.

OBJECTIVE: To describe the relationship between nighttime awakenings and work performance. METHODS: Employees (N = 4188) at four US companies described their sleep patterns and completed the Work Limitations Questionnaire. Participants were categorized by number of nighttime awakenings: 0 (n = 464; 11%), 1 to 2 (n = 2373; 58%), 3 to 4 (n = 984; 24%), or > or =5 (n = 289; 7%). Work Limitations Questionnaire performance and productivity measures were compared among the groups using a one-way analysis of variance model. RESULTS: Thirty-one percent of the sample averaged > or =3 nighttime awakenings. Compared with respondents with fewer nighttime awakenings, these respondents had the greatest work performance and productivity impairments across a wide range of dimensions. CONCLUSIONS: Workers who experienced > or =3 nighttime awakenings have poorer work productivity and performance than do workers who experience fewer awakenings.