Distinguishing between primary and secondary racial identification in analyses of health disparities of a multiracial population in Hawaii.

OBJECTIVE: To examine the importance of distinguishing between primary and secondary racial identification in analyzing health disparities in a multiracial population. METHODS: A cross-sectional analysis of 2012 Hawaii Behavioral Risk Factor Surveillance System (H-BRFSS). As part of the survey, respondents were asked to identify all their races, and then which race they considered to be their primary race. We introduce two analytic approaches to investigate the association between multiracial status and general health: (1) including two separate dichotomous variables for each racial group (primary and secondary race; for example, 'primary Native Hawaiian' and, separately, 'secondary Native Hawaiian'), and (2) including one combined variable for anyone choosing a particular racial group, whether as primary or secondary race ('combined race'; e.g. Native Hawaiian). Linear regression then compares the multiracial health disparities identified by the two approaches, adjusted for age and gender. RESULTS: The 2012 H-BRFSS had 7582 respondents. The four most common self-identified primary racial/ethnic groups were White, Japanese, Filipino, and Native Hawaiian. Native Hawaiians were the largest multiracial group with over 80% self-identifying as multiracial. Health disparities for Native Hawaiians, Portuguese and Puerto Ricans were attenuated by 10% after accounting for multiracial status. Populations that self-identified secondarily as Japanese, Puerto Rican, Mexican, and other PI had significantly poorer self-reported health. CONCLUSION: The analysis illustrates the importance of accounting for multiracial populations in health disparities research and demonstrates the ability of two approaches to identify multiracial health disparities in data sets with limited sample sizes. The 'primary and secondary race' approach might work particularly well for a multicultural population like Hawaii.

The Daniel K. Inouye College of Pharmacy Scripts: Prescription Drug Pricing.

Prescription drugs have reduced morbidity and mortality and improved the quality of life of millions of Americans. Yet, concerns over drug price increases loom. Drug spending has risen relatively slowly over the past decade because many of the most popular brand-name medicines lost patent protection. In the near future, there will be fewer low-cost generics coming into the market to offset the rising prices of brand-name drugs. Drug expenditures are influenced by both volume and price. This article focuses on how drug prices are set in the United States and current trends. Drug prices are determined through an extremely complicated set of interactions between pharmaceutical manufacturers, wholesalers, retailers, insurers, pharmacy benefit managers (PBMs), managed care organizations, hospitals, chain stores, and consumers. The process differs depending on the type of drug and place of delivery. Rising drug prices have come under increased scrutiny due to increased cost inflation and because many price increases come as a result of mergers and acquisitions of generic drug companies or changes in ownership of brand name drug manufacturers. Other countries have reigned in drug prices by negotiating with or regulating pharmaceutical manufacturers. The best long-term solution to rising drug prices is yet to be determined but the United States will continue to debate this issue and the discussions will get more heated if drug expenditures continue to rise at a rapid rate (ie, increasing 13% in 2014 from the previous year).

Inpatient Hospitalization Costs: A Comparative Study of Micronesians, Native Hawaiians, Japanese, and Whites in Hawai'i.

Considerable interest exists in health care costs for the growing Micronesian population in the United States (US) due to their significant health care needs, poor average socioeconomic status, and unique immigration status, which impacts their access to public health care coverage. Using Hawai'i statewide impatient data from 2010 to 2012 for Micronesians, whites, Japanese, and Native Hawaiians (N = 162,152 hospitalizations), we compared inpatient hospital costs across racial/ethnic groups using multivariable models including age, gender, payer, residence location, and severity of illness (SOI). We also examined total inpatient hospital costs of Micronesians generally and for Medicaid specifically. Costs were estimated using standard cost-to-charge metrics overall and within nine major disease categories determined by All Patient Refined Diagnosis Related Groups. Micronesians had higher unadjusted hospitalization costs overall and specifically within several disease categories (including infectious and heart diseases). Higher SOI in Micronesians explained some, but not all, of these higher costs. The total cost of the 3486 Micronesian hospitalizations in the three-year study period was $58.1 million and 75% was covered by Medicaid; 23% of Native Hawaiian, 3% of Japanese, and 15% of white hospitalizations costs were covered by Medicaid. These findings may be of particular interests to hospitals, Medicaid programs, and policy makers.

Hawaii state legislator views on e-cigarettes and likelihood of legislative action.

OBJECTIVE: To examine perspectives on e-cigarette use and regulations in Hawaii through key informant interviews with state legislators. BACKGROUND: E-cigarette use is rapidly increasing, with sales in 2013 topping $1 billion in the United States, but e-cigarettes are still a largely unregulated industry. Although e-cigarettes are thought by most to be a healthier alternative to traditional cigarettes, long-term health effects are not yet known. METHODS: Semistructured key informant interviews were conducted with Hawaii state legislators (n = 15). RESULTS: We found a lack of consensus among legislators, which suggests that substantial legislative action is unlikely in the upcoming session. However, most legislators believe that some type of incremental legislation will pass, such as enactment of a small tax, limitations on advertising to protect adolescents, or regulations concerning where people can use e-cigarettes. CONCLUSION: Legislators eagerly await further research to clarify the overall benefits and harms of e-cigarettes at both the individual and population levels.

Medicare reimbursement to ophthalmologists: a comparison of Hawai'i to other states.

When Medicare publically released data on payments made to specific physicians in April of 2014, it quickly became apparent that a large portion of 2012 Medicare reimbursements went to ophthalmologists. Part of the reason for this unusually high level of reimbursement was thought to be the cost of injectable drugs such as ranibizumab (brand name Lucentis). This study was designed to compare Hawai'i ophthalmologists' Medicare reimbursements with those of other states. In 2012, Medicare payment to ophthalmologists in Hawai'i was $18.2 million. Hawai'i ranked third in the nation in terms of percentage of total reimbursement going to ophthalmologists at 11.1% and 34th (8.2%) in percentage of ophthalmologist reimbursements going to injectable biological products. Hence, the high percentage of reimbursement going to ophthalmologists in Hawai'i is unlikely due to high use of injectable medications. Further research, based on a more detailed analysis of clinical data, is needed to determine how to slow the growth of health care costs while promoting high-value, effective care, not only for ophthalmic services but in other high-cost areas as well.

Factors affecting medication adherence trajectories for patients with heart failure.

OBJECTIVES: To examine the relationship between patient characteristics and medication adherence trajectories for patients with congestive heart failure (CHF). STUDY DESIGN: Historical prospective study. METHODS: We conducted a secondary analysis of data assembled for the Practice Variation and Care Outcomes (PRAVCO) study, which examined patterns of cardiovascular care. We used group based trajectory modeling to define medication adherence trajectories, and then modeled factors associated with belonging to a trajectory group during the 6year period from 2005 to 2010 (n = 10,986). We focused on the use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) for secondary prevention of CHF. RESULTS: Four trajectory groups were optimal in characterizing adherence level patterns: 1) low adherence group, with an initial average adherence rate of 62% that dropped to between 40% and 50%; 2) increasing adherence group, with an initial average adherence rate of 55% that increased to 90%; 3) decreasing adherence group, with an initial average adherence rate above 90% that decreased to 60%; 4) high adherence group, with an average adherence rate consistently above 90%. Age, region, education, smoking, and race were all significantly associated with the likelihood of belonging to a particular trajectory. Nonwhites were less likely to be in the high adherence group, and smoking was more common in the low adherence group (22%) than in the high group (10%); increasing body mass index and Charlson Comorbidity Index (CCI) scores were also associated with being in the low adherence group. CONCLUSIONS: Population characteristics associated with sustained low adherence might be used to target interventions and improve vulnerable patients' prospects of heart health.

The excess cost of interisland transfer of intracerebral hemorrhage patients.

BACKGROUND: Currently, intracerebral hemorrhage (ICH) patients from neighbor islands are air transported to a higher-level facility on Oahu with neuroscience expertise. However, the majority of them do not receive subspecialized neurosurgical procedures (SNP) upon transfer. Hence, their transfer may potentially be considered as excess cost. METHODS: Consecutive ICH patients hospitalized at a tertiary center on Oahu between 2006 and 2013 were studied. Subspecialized neurosurgical procedure was defined as any neurosurgical procedure or conventional cerebral angiogram. Total excess cost was estimated as the cost of interisland transfer multiplied by the number of interisland transfer patients who did not receive any SNP. RESULTS: Among a total of 825 patients, 100 patients (12%) were transferred from the neighbor islands. Among the neighbor-island patients, 69 patients (69%) did not receive SNP, which translates to $1035000 of excess cost over an 8-year period (approximately $129375/y). Multivariable analyses showed age (odds ratio [OR], 0.95; 95% confidence interval [CI]: 0.94-0.96), lack of hypertension (OR, 1.62; 95% CI: 1.002-2.61), initial Glasgow Coma Scale (OR, 0.94; 95% CI: 0.89-0.98), lobar hemorrhage (OR, 2.74; 95% CI: 1.59-4.71), cerebellar hemorrhage (OR, 5.47; 95% CI: 2.78-10.76), primary intraventricular hemorrhage (OR, 4.40; 95% CI: 1.77-10.94), and any intraventricular hemorrhage (OR, 2.47l 95% CI: 1.53-3.97) to be independent predictors of receiving SNP. CONCLUSION: Approximately two-thirds of ICH patients who were air transferred did not receive SNP. Further study is needed to assess the cost-effectiveness of creating a triage algorithm to optimally select ICH patients who would benefit from air transport to a higher-level facility.

Disparities in medication therapy in patients with heart failure across the State of Hawai'i.

The purpose of this study is to evaluate if heart failure patients in Hawai'i are receiving recommended standard therapy of a select beta-blocker in combination with an ACE inhibitor (ACEI) or angiotensin receptor blocker (ARB), and to determine if a gap in quality of care exists between the different regions within the state. A retrospective claims-based analysis of all adult patients (age > 18 years of age) with CHF who were enrolled in a large health plan in Hawai'i was performed (n = 24,149). Data collected included the presence of pharmaceutical claims for ACEI, ARBs and select ß-blockers, region of residence, gender, and age. Multivariable logistic regression was used to examine whether there were regional differences in Hawai'i related to medication usage, after adjustment for age and gender. Results showed that only 28.4 % of patients were placed on the recommended therapy of an ACEI or ARB and a select ß-blocker with significant differences being found between different regions. Further research is needed to better understand factors affecting regional differences in prescribing patterns.

Significance of HbA1c and its measurement in the diagnosis of diabetes mellitus: US experience.

The 2014 American Diabetes Association guidelines denote four means of diagnosing diabetes. The first of these is a glycosylated hemoglobin (HbA1c) >6.5%. This literature review summarizes studies (n=47) in the USA examining the significance, strengths, and limitations of using HbA1c as a diagnostic tool for diabetes, relative to other available means. Due to the relatively recent adoption of HbA1c as a diabetes mellitus diagnostic tool, a hybrid systematic, truncated review of the literature was implemented. Based on these studies, we conclude that HbA1c screening for diabetes has been found to be convenient and effective in diagnosing diabetes. HbA1c screening is particularly helpful in community-based and acute care settings where tests requiring fasting are not practical. Using HbA1c to diagnose diabetes also has some limitations. For instance, HbA1c testing may underestimate the prevalence of diabetes, particularly among whites. Because this bias differs by racial group, prevalence and resulting estimates of health disparities based on HbA1c screening differ from those based on other methods of diagnosis. In addition, existing evidence suggests that HbA1c screening may not be valid in certain subgroups, such as children, women with gestational diabetes, patients with human immunodeficiency virus, and those with prediabetes. Further guidelines are needed to clarify the appropriate use of HbA1c screening in these populations.

Failure to reach target glycated a1c levels among patients with diabetes who are adherent to their antidiabetic medication.

The objectives of this study were to describe patient characteristics and types of medications taken by those with poor glycemic control (A1c>7%) despite being adherent to antidiabetic medications. This is a retrospective analysis of administrative data from adult patients with diabetes enrolled in a large health plan in Hawaii (n=21,267 observations for 11,013 individuals) and adherent to their antidiabetic medications. Multivariable logistic regressions were estimated to determine characteristics and types of medications associated with poor glycemic control. Separate models were estimated to examine category of medication (insulin only, 1 oral medication, multiple oral medications, both oral medications and insulin) and specific therapeutic class of oral antidiabetic medications. Despite being adherent to their medications, 56.1% of patients had poor glycemic control. Compared to patients taking combination sulfonylureas, patients had a higher odds of having A1c>7% for all other oral diabetic medications, with odds ratios ranging from OR=2.07 for sulfonylureas alone to OR=1.33 for combination DPP-4 inhibitors. More than half of patients in this study had poor A1c control despite being adherent to their medications. This suggests that physicians, pharmacists, and other providers may need to monitor treatment regimens more carefully, encourage healthy behaviors, and intensify pharmacological treatment as needed.

A descriptive study of Marshallese and Chuukese patients with diabetes in Hawai'i.

Diabetes is a growing epidemic in the United States with significant racial and ethnic health disparities among minorities. In Pacific Islanders, diabetes ranks as the fifth leading cause of death, higher than the national average. Despite this, little is known about diabetes in this population, and even less so in subpopulations such as Micronesians. To target these high-risk individuals, a federally qualified health center on Hawai'i Island started a multi-disciplinary diabetes care program for two Micronesian populations. This manuscript describes the characteristics of the Marshallese and Chuukese patients with diabetes enrolled in this program. Program enrollees had low socioeconomic status and poor health literacy, as well as high prevalence of co-morbidities commonly linked with diabetes. These findings support the data available on Micronesian populations and highlight the need to develop approaches that will improve health outcomes and bridge health disparities for these individuals.

Interventions to increase medication adherence in African-American and Latino populations: a literature review.

The objective of this systematic review was to investigate the effectiveness of interventions to improve medication adherence in ethnic minority populations. A literature search from January 2000 to August 2012 was conducted through PubMed/Medline, Web of Science, The Cochrane Library, and Google Scholar. Search terms used included: medication (MeSH), adherence, medication adherence (MeSH), compliance (MeSH), persistence, race, ethnicity, ethnic groups (MeSH), minority, African-American, Hispanic, Latino, Asian, Pacific Islander, and intervention. Studies which did not have ≥75% of the sample population comprised of individuals of any one ethnic background were excluded, unless the authors performed sub-group analyses by race/ethnicity. Of the 36 studies identified, 20 studies showed significant post-intervention differences. Sample population sizes ranged from 10 to 520, with a median of 126.5. The studies in this review were conducted with patients of mainly African-American and Latino descent. No studies were identified which focused on Asians, Pacific Islanders, or Native Americans. Interventions demonstrating mixed results included motivational interviewing, reminder devices, community health worker (CHW) delivered interventions, and pharmacist-delivered interventions. Directly observed therapy (DOT) was a successful intervention in two studies. Interventions which did not involve human contact with patients were ineffective. In this literature review, studies varied significantly in their methods and design as well as the populations studied. There was a lack of congruence among studies in the way adherence was measured and reported. No single intervention has been seen to be universally successful, particularly for patients from ethnic minority backgrounds.

Drug take back in Hawai'i: partnership between the University of Hawai'i Hilo College of Pharmacy and the Narcotics Enforcement Division.

Unused/unwanted medications in households and patient care facilities expose vulnerable populations, including children, elders, and pets, to potential harm through inadvertent ingestion, as well as the potential for theft and assault. Hawai'i Administrative Rules prohibit the return of any prescription medications to retail pharmacies after dispensing. The Hawai'i Narcotics Enforcement Division (NED) partnered with the University of Hawai'i at Hilo Daniel K. Inouye College of Pharmacy (CoP) in eleven Drug Take Back events throughout the state. Most participants heard of the events via newspaper and television marketing. The most common methods of medication disposal are via trash or down household drains. Over 8,000 lbs of unused/unwanted medications was collected, identified and logged from 2011 through 2012. The majority of returned drugs were non-controlled substances (90%). Commonly returned medications included prescription cardiac medications such as simvastatin and lisinopril, non-prescription analgesics such as aspirin and ibuprofen, and dietary supplements such as vitamins and iron. Commonly returned controlled substance medications included narcotics such as hydrocodone/acetaminophen combinations and oxycodone, and sedative hypnotics such as zolpidem and lorazepam.

Factors Affecting Sustained Medication Adherence and Its Impact on Health Care Utilization in Patients with Diabetes.

OBJECTIVE: To identify factors associated with years of medication adherence and to examine the relationship between years of adherence and health care utilization. METHODS: This retrospective analysis used administrative data from adult patients with diabetes enrolled in health plan in Hawaii for four years (n= 23,450 patients). Ordered logistic regression was used to examine factors related to years of medication adherence for three types of medications (anti-diabetic, antihypertensive, lipid-lowering). Multivariable logistic regression and negative binomial regression were used to examine relationship between years of adherence and health care utilization (hospitalizations and emergency department visits). KEY FINDINGS: Adherence to any of the medications for all four years was significantly associated with lower odds of a hospitalization or emergency department visit in the third year. The magnitude of reduction in utilization was greater for adherence to anti-diabetic and lipid-lowering medications, at 31% compared to 22% for antihypertensives. The 9% of patients who were adherent to all three types of medications for all four years showed a reduction of 53%. CONCLUSIONS: Improvement is needed in medication adherence across all three types of medication. Interventions may need to target younger adults, women, patients with congestive heart failure, Filipinos and Native Hawaiians.

Factors associated with poor glycemic control or wide glycemic variability among diabetes patients in Hawaii, 2006-2009.

INTRODUCTION: Although glycemic control is known to reduce complications associated with diabetes, it is an elusive goal for many patients with diabetes. The objective of this study was to identify factors associated with sustained poor glycemic control, some glycemic variability, and wide glycemic variability among diabetes patients over 3 years. METHODS: This retrospective study was conducted among 2,970 diabetes patients with poor glycemic control (hemoglobin A1c [HbA1c] >9%) who were enrolled in a health plan in Hawaii in 2006. We conducted multivariable logistic regressions to examine factors related to sustained poor control, some glycemic variability, and wide glycemic variability during the next 3 years. Independent variables evaluated as possible predictors were age, sex, type of insurance coverage, morbidity, diabetes duration, history of cardiovascular disease, and number of medications. RESULTS: Longer duration of diabetes, being under age 35, and taking 15 or more medications were significantly associated with sustained poor glycemic control. Preferred provider organization and Medicare (vs health maintenance organization) enrollees and patients with high morbidity were less likely to have sustained poor glycemic control. Wide glycemic variability was significantly related to being younger than age 50, longer duration of diabetes, having coronary artery disease, and taking 5 to 9 medications per year. CONCLUSION: Results indicate that duration of diabetes, age, number of medications, morbidity, and type of insurance coverage are risk factors for sustained poor glycemic control. Patients with these characteristics may need additional therapies and targeted interventions to improve glycemic control. Patients younger than age 50 and those with a history of coronary heart disease should be warned of the health risks of wide glycemic variability.

The relationship of hospital quality and cost per case in Hawaii.

One of the leading questions of our time is whether high-quality care leads to lower health care costs. Using data from Hawaii hospitals, this paper addresses the relationship of overall cost per case to a composite measure of the quality of inpatient care and a 30-day readmission rate. We found that low-cost hospitals tend to have the highest quality but the worst readmission performance. Change in quality and change in cost were also negatively correlated, but not statistically significant. We conclude that high-quality hospital care does not have to cost more, but that the dynamics of the readmission rate differ substantially from other quality dimensions.

Heart failure patients receiving ACEIs/ARBs were less likely to be hospitalized or to use emergency care in the following year.

Angiotensin-converting enzyme inhibitors (ACEIs) have been shown to decrease morbidity and mortality in heart failure (HF) patients in randomized-controlled trials; observational studies have confirmed this benefit among patients discharged with HF. Investigating the benefit of ACEIs or angiotensin receptor blockers (ARBs) among general HF patients has important implications for quality-of-care measurement and quality initiatives. The objective of this study is to assess the impact of receipt of ACEIs/ARBs among patients with HF on hospitalization, emergency care, and healthcare cost during the following year. Using administrative data, we identified HF patients between 2000 and 2005 in a large health plan (n=2,396 patients). We conducted multivariate analysis to assess the impact of receipt of an ACEI/ARB on likelihood of hospitalization and emergency care, and on total healthcare cost. We found that patients who received ACEIs/ARBs were less likely to be hospitalized (odds ratio [OR]=0.82, p<.05) or use emergency care (OR=0.82, p<.05) in the following year. Receipt of ACEIs/ARBs was not associated with significantly increased cost. Incentivizing the receipt of ACEIs/ARBs in a general population with HF may be a suitable target for pay-for-performance programs, disease management programs, or newer complementary frameworks, such as value-based insurance design.

Does pay for performance improve cardiovascular care in a "real-world" setting?

The objective was to investigate the impact of a pay-for-performance program (P4P) on quality care and outcomes among cardiovascular disease (CVD) patients. Claims data were used to identify CVD patients in a commercial plan in 1999-2006. Multivariate analyses were employed to examine the impact of P4P on quality care (lipid monitoring and treatment) and quality care on outcomes (new coronary events, hospitalizations, and lipid control). Patients who were treated by physicians participating in P4P were more likely to receive quality care than patients who were not. Patients who received quality care were less likely to have new coronary events (odds ratio [OR] = 0.80; 95% confidence interval [CI] = 0.69-0.92), be hospitalized (OR = 0.76; 95% CI = 0.69-0.83), or have uncontrolled lipids (OR = 0.67; 95% CI = 0.61-0.73) than patients who did not. A P4P program was associated with increased lipid monitoring and treatment. Receipt of this quality care was associated with improved lipid control and reduced likelihood of new coronary events and hospitalizations.

Disparities in health, obesity and access to care among an insured population of Asian and Pacific Islander Americans in Hawai'i.

OBJECTIVE: To examine differences in health status, obesity and access among Asian and Pacific Islander Americans in Hawai'i using data from a 2007 health plan survey, including Caucasians, Puerto Ricans, American Indian and Alaska Natives, Chinese, Filipinos, Japanese, Koreans, Native Hawai'ians, Samoans, and Other Pacific Islanders. METHODS: Data were collected through a stratified random sample of adult members of a health plan in Hawai'i (n = 119,563) who saw a physician in the past 12 months. Multivariable logistic and ordinary least squares regression analyses were used to examine racial/ethnic differences in health status, access, and obesity and the impact of obesity and access on health status, after controlling for age, gender, and education. RESULTS: The highest obesity rates were found among Samoans (50%), Puerto Ricans (37%), Native Hawai'ians (36%), and Other Pacific Islanders (35%). Puerto Ricans and Samoans reported the highestnumber of poor physical health days (5.4). Samoans reported the highest number of poor mental health days (4.4). Obesity had a stronger impact than access on self-reported health status. CONCLUSION: Samoans had the highest rate of obesity, low health ratings, and a high number of days of poor health. Targeted interventions may be needed for this group.

Impact of a pay-for-performance program on low performing physicians.

Studies have shown that the lowest performing physicians in pay-for-performance (P4P) programs improved the most; however, it is unclear whether this would occur without the P4P program or be sustained. The objective of this study is to investigate the impact of P4P in a Preferred Provider Organization (PPO) on low performing physicians over a 4-year period. We used administrative claims data from a PPO health plan in Hawaii, which implemented a P4P program, and a PPO plan in the South, which did not implement a P4P program. The difference-indifference model was used to compare the quality scores between the two physician groups in preventive measures, a heart failure measure, and an HbA1c testing measure. We found that P4P programs may be effective in incentivizing low performing physicians to improvement quality of care and sustain improvement, and the positive benefit of the P4P program may not be realized until the 3rd or 4th year of the program.