Differences in managed care drug formularies: what can consumers learn?

Pharmaceutical coverage has become an especially important issue in health plan design. This article develops an objective measure of drug coverage generosity in managed care drug formularies. Formulary generosity is important because patients respond differently to drugs within a therapeutic class, and so there is benefit in offering a wide variety of products to prescribing physicians. The measure of coverage generosity considers not only the number of products offered to patients through a formulary, but whether plans systematically exclude more expensive products. The correlation between formulary generosity and health plan member satisfaction is analyzed to see if formulary generosity is perceived by subscribes to be related to perceived health plan quality. The findings are that plans vary widely in offering access to pharmaceuticals but that generosity is not highly correlated with health plan satisfaction.

Effectiveness of a prospective physician self-audit transfusion-monitoring system.

BACKGROUND: The purpose of this study was to search for a more effective transfusion-monitoring system than the existing system of retrospective peer review. STUDY DESIGN AND METHODS: This research used a study-control, preintervention and postintervention design, to evaluate the effectiveness of a prospective physician self-audit transfusion-monitoring system that functioned without the direct involvement of transfusion service physicians. This research also evaluated the effectiveness of issuing to physicians a memo with transfusion guidelines. Three process indicators were used to assess physician behavior at various stages of the blood-ordering process: 1) the number of crossmatches ordered per admission, 2) the transfusion-to-crossmatch ratio, and 3) the number of blood units returned to the laboratory after physician self-auditing. The study used two outcome indicators to reflect overall blood utilization: 1) the percentage of patients who received red cell transfusions and 2) the number of blood units transfused per recipient each month. RESULTS: The prospective physician self-audit system implemented at the study hospital did not reverse physician transfusion decisions, and the process of issuing to physicians a memo with transfusion guidelines at the control hospital failed to reduce blood usage. However, a transient reduction in blood utilization was observed at the study hospital. CONCLUSION: The reduction was hypothesized to be due to a Hawthorne effect, in which observed behavior is affected by the subject's awareness of the research study.

Sexual activity and satisfaction among very old adults: results from a community-dwelling Medicare population survey.

This article explores the relationship between sociopsychological factors, sexual activity, and sexual satisfaction in a sample of 1,216 elderly people (mean age = 77.3). Almost 30% had participated in sexual activity in the past month and 67% were satisfied with current level of sexual activity. Men are more likely to be sexually active, but less apt than women to be satisfied with their level of sexual activity. Regarding predictors of sexual activity, for men the strongest predictors were being younger and having more education. For women, the strongest predictor by far was being married. For both men and women the strongest predictors for satisfaction were being sexually active and having positive mental health scores. In summary, the main variables predicting sexual activity were being married, having more education, being younger, being male, and having good social networks. The main predictors for satisfaction with sexual activity were, in addition to being sexually active, being female, having good mental health, and better functional status.

Are retrospective peer-review transfusion monitoring systems effective in reducing red blood cell utilization?

OBJECTIVE: This research used a study-control group design and examined data collected from five hospitals to evaluate the effectiveness of retrospective peer-review systems on reducing utilization of red blood cells (RBCs). DESIGN: The effects of retrospective peer-review systems were studied in three parts: (1) trends of RBC utilization were compared by the slopes of linear regression lines that assessed the effect of time on RBC utilization among four study hospitals and one control hospital, (2) diagnosis-specific RBC utilization was compared between the control hospital and one matched study hospital, and (3) the effect of the retrospective review system of one study hospital was assessed by linear regression using data accumulated 1 year before and 2 years after implementation of the program. RESULTS: Three study hospitals showed no significant changes in RBC utilization during the 10-month study period. One study hospital and the control hospital demonstrated trends of reduced RBC use with negative slopes of regression lines; however, there was no difference in the degree of the two slopes, and the diagnosis-specific RBC utilization was not lower at the study hospital than at the control hospital. Furthermore, implementation of the retrospective peer-review system at one study hospital demonstrated no effect on RBC utilization. CONCLUSIONS: We conclude that the retrospective peer-review systems implemented at these four hospitals had no effect on reducing red blood cell utilization.

Mammography use in older women with regular physicians: what are the predictors?

Results of a longitudinal study of 1,050 women 65 years of age and older under the care of faculty internists demonstrate that individual and sociodemographic factors predict mammography use. The majority of the sample (79%) had received a mammogram within the past two years. Multiple logistic regression analyses of findings from a telephone survey showed that mammographic screening was significantly higher among women who had recently received a Pap smear, whose annual household incomes exceeded $30,000, and whose personal health care habits were preventively oriented; they used more preventive services such as routine dental care and engaged in more preventive behaviors such as seat-belt use and routine exercise. Mammography use was significantly higher among those 75 or younger. These findings suggest that enhancing patient preventive orientations should be part of interventions designed to increase screening. Medical Subject Headings (MeSH): appropriateness review, preventive health services, utilization, aged, Medicare.

Screening for depression among a well elderly population.

This article describes a geriatric wellness program in which social work practitioners played a major role. The focus of this article is twofold: to examine the use of a telephone screening test for depression among a well elderly population and to compare the results of that screening with the clinical judgment of social workers. Overall findings indicated that a telephone screening instrument incorporating the Rand Mental Health Inventory and the Center for Epidemiological Studies Depression Scale was an efficient tool for assessing a population with a higher rate of major depression. Furthermore, the social workers identified many previously undetected cases of major depression, and a majority of people referred for treatment completed those referrals.

Factors affecting self-ratings of oral health.

OBJECTIVES: The purpose of this study is to determine the relationship of self-rated oral health to a comprehensive battery of clinical, sociodemographic, physical health, and mental health measures in a well-elderly urban population. METHODS: Results are based on telephone interviews and clinical assessments of 550 subjects over 65 years of age participating in a Los Angeles-based Medicare project during 1990. Subjects were mostly female, white (89%), with above-average income. RESULTS: Findings show that: (1) the DMF measure is not as strongly related to self-rated oral health as was a single measure of missing teeth; (2) the major predictors of self-rated oral health were "worry about teeth" and "appearance of teeth" followed by total missing teeth, race, education, and depression scores; and (3) self-rated general health is related to self-rated oral health. CONCLUSION: Self-rated oral health may be, for older adults, a better measure of "health" than of "morbidity".

Health promotion and disease prevention for older adults: opportunity for change or preaching to the converted?

Health promotion and disease prevention for the elderly offer the potential for improving the quality of life for the growing population of older adults, while reducing the economic burden on the health system. Whether this potential can be realized depends, in part, on whether those older adults whose health behaviors put them at risk actually use preventive services when offered the opportunity. In 1988 the Health Care Financing Administration began a series of health promotion demonstrations to address health issues related to older adults. This article reports on program participation at one of the five demonstration sites. Over 1,900 community-dwelling Medicare beneficiaries who receive their health care through fee-for-service providers were enrolled in the demonstration. These enrollees were randomly assigned to control and experimental groups, with the latter offered health screening and promotion services. Nine hundred-seventy-three of the experimental subjects and 938 of the control subjects completed a lengthy telephone interview, which determined each person's use of preventive services and practices. Although all 973 experimental subjects were invited by letter and follow-up telephone calls to attend these free-of-charge, Medicare-provided sessions, not everyone attended. We analyzed 17 health behaviors of those who attended the first session and those who did not. Those engaging in these preventive behaviors were neither more nor less likely to attend the screening services. Thus, we found neither "favorable" nor "unfavorable" selection bias in the use of these preventive services.

Manpower issues affecting public health policy.

This paper addresses the efficiency of health care delivery in several countries. Confusions arising from comparing the share of gross domestic product going to health care in various countries are discussed, along with the varying levels of coverage enjoyed by the populace. Factors contributing to the rising cost of health care are analyzed and suggestions for improvement are offered.

Benzodiazepine use in older, community-dwelling southern Californians: prevalence and clinical correlates.

OBJECTIVE: To determine the use of benzodiazepines (BZDs) in an older, community-dwelling sample and to examine the sociodemographic and clinical correlates of BZD use. DESIGN: A cross-sectional study of 1752 elderly people (aged > or = 65 y) who completed a mailed medication survey and a telephone health status survey. PARTICIPANTS: Participants were invited to participate in a large Medicare demonstration project on prevention by their private physicians, who were also enrolled in the larger study. Participants had to be English-speaking, could not have dementia or a terminal illness, and had to give informed consent to participate in the study. MAIN OUTCOME MEASURES: Sociodemographic and health status variables that predicted BZD use were examined. Sociodemographic variables included age, gender, ethnicity, education, and income. Health status variables included functional status, with measures of mental, social, and physical health. Influenza immunization status was used as an indicator for preventive health services use and self-reported chronic illness was used as a measure of comorbidity. RESULTS: Twenty percent of the participants used BZDs at least twice in the past year. We found that those who used BZDs were more than twice as likely to take ten or more drugs, two-and-a-half times more likely to have difficulty falling asleep, and over twice as likely to be depressed. BZD users were also more likely to be white, to have a college education, and to have received a recent influenza shot, but were not more likely to be women when controlled for health status. CONCLUSIONS: Further clinical research should explore the relationship between BZD use among older patients and the BZD-associated adverse clinical factors we observed, as well as the association between multiple drug use and potential adverse outcomes in older BZD users.

Comparisons between dentist ratings and self-ratings of dental appearance in an elderly population.

Little is known about dental appearance in terms of the elderly population. The purpose of this paper is to compare self-reported dental appearance with dentist-rated appearance for individuals over 65. The subjects (N = 550) were participants in the Los Angeles based Medicare Screening and Health Promotion Trial. Most were female (57.3%), white (89.0%), and married (62.0%), with a mean age of 74.5 years. About one-third had incomes greater than $25,000. Results are based on a 45 minute telephone interview and onsite dental screening. Findings show that 40% of the self-ratings on a five point scale were higher than the dentist ratings, and 22% were lower. Bivariate analyses showed that both sets of ratings were related to dental status variables, self-reported health, and education. High self-ratings were also associated with being white and having a positive mental health status, while high dentist ratings were associated with patients who were younger, married, and who had higher income and social network scores. Comparison of results from two multiple regressions showed unique predictors for the self-ratings (marital status and GOHAI scores) and for the dentist ratings (sex and income). These discrepancies can raise barriers to effective treatment planning in the elderly, which could affect utilization and satisfaction.

The relationship between dental utilization and preventive participation among a well-elderly sample.

Previous studies have shown that dental utilization by older people is lower than for the general population. This study hypothesizes that an elder's tendency toward participating in preventive health activities may be an important factor in explaining the likelihood of accessing the dentist. Subjects included 1,911 older individuals who enrolled in the UCLA Medicare Screening and Health Promotion Trial. All were interviewed about their utilization of preventive health services and participation in preventive behaviors. A recent dental visit was positively associated with all sociodemographic variables examined except age and sex. It was also related to health status questions and utilization of the preventive health services and health behaviors studied. Logistic regression analysis showed that both summary preventive health behavior and preventive service utilization variables were important factors in explaining a recent dental visit (model chi-square = 221.4, P = .001) along with income, not having a removable prosthesis, and perceiving the need for dental care. This study showed that dental utilization is related to older people's participation in other preventive activities. When in contact with older people, health care professionals should consider current oral and general preventive health status and encourage appropriate referral for preventive activities.

Comparison of oral health ratings by dentists and dentate elders.

Previous studies suggest a discrepancy between the way dentists and patients measure oral health. The purpose of this study was to determine the relationship between a dentist's rating of an older dentate person's oral health and the patient self-rating using a single-item indicator, and to compare the clinical (i.e., number of teeth, caries, etc.) and subjective (problems with function, pain, etc.) factors that influence the rating. The study sample consisted of 776 older dentate people. Results showed that dentists judged subjects' oral health significantly more positively than the self-ratings. Approximately 30 percent of the elders rated their oral health identically to the dentist and half rated their oral health lower than the dentist. Bivariate comparisons showed that similar clinical and subjective variables were associated with the dentist and patient ratings. Multiple regression findings, however, highlighted differences in the factors that influenced the ratings. In addition, the proportion of variance accounted for by the clinical factors as opposed to the subjective factors was greater for the dentist rating (R2 = .28 of .33) than the subject self-rating (R2 = .18 of .43).

The costs of a pediatric hospice program.

The recent literature on economic issues of hospice care leaves several questions unanswered. The most important issue concerns how this type of care can be made financially attractive to patients and families for whom it is a medical option. A major study of a home-based pediatric hospice program permitted a more careful analysis than was previously feasible of the charges for hospice care and how those charges are paid. Data on provider utilization and duration in the program were obtained retrospectively on 177 patients. Costs of incidental expenditures and indirect costs were obtained prospectively from the families of 27 patients. A cost model was developed which is general enough to be used by other hospitals that might contemplate establishing a similar hospice program. Our findings are that insurance coverage, especially for publicly funded patients, is likely to be a major impediment for families deciding whether or not to use a hospice program at home.

Patient-related predictors of rehabilitation use for community-dwelling older Americans.

OBJECTIVE: To determine patient factors that predict use of physical or occupational therapy (PT/OT) services by elderly people. DESIGN: Time-series study of the relationship of PT/OT use to a variety of characteristics present at baseline. PARTICIPANTS: Eight-hundred nine community-dwelling men and women aged 65 and older. SETTING: The Medicare Screening and Health Promotion Trial at UCLA. MAIN OUTCOME MEASURES: Use of PT/OT services, as reported in a telephone survey 1 year after initial information was obtained on the same subjects by the baseline telephonic survey. RESULTS: Fifteen percent of the sample used PT/OT within 12 months of baseline. In multiple logistic regression analysis, PT/OT use was significantly less frequent among racial minorities, less well educated groups, and the oldest age group. PT/OT use was higher among those who had both functional disability and the presence of arthritis, heart or lung disease, or a prior history of stroke. However, neither functional disability alone nor the presence of arthritis, cardiovascular or lung disease, in the absence of limited functioning, was associated with PT/OT use. Patients who had obtained a pneumococcal vaccination or used transportation services were also more likely to receive PT/OT. CONCLUSIONS: Our findings suggest that there may be important sociodemographic inequalities in the use of rehabilitation services and raise the possibility of inappropriate underuse in certain subgroups. Additional studies are needed to determine whether similar inequalities of PT/OT use are found in other populations and whether rehabilitation is effective in various subgroups.

The effect of Medicaid formularies on the availability of new drugs.

This study expands our previous work on the availability of new drug introductions to poor patients in states in the USA with restrictive Medicaid formularies. In particular, it focuses on the experience of 9 states over the period 1979 to 1985. In these states, a typical new drug took 20 months after FDA approval to gain acceptance onto the Medicaid formulary. New drug introductions were available to Medicaid patients less than 40% of the time during their first 4 years of market life. Restrictions on availability also extended to drugs ranked high in terms of both therapeutic and commercial importance. There was substantial variation observed across states and therapeutic categories. While formularies are prohibited under legislation recently enacted by the US Congress, state governments may attempt to continue to restrict access to expensive new medicines through prior approval systems. This is an issue that warrants future attention and study.

Quality and cost of AIDS nursing care as a function of inpatient delivery systems.

Decisions to hospitalize persons with AIDS (PWAs) and the subsequent nursing process and outcomes associated with this hospitalization are of major concern to nurse administrators. Although decisions to hospitalize may be out of their control, events occurring during hospitalization that affect the quality of nursing care received are clearly the nurse administrator's responsibility. This report addresses a major issue concerning the care of PWAs: the decision to establish a dedicated AIDS unit. The effect upon both quality care and nursing care costs is discussed.

Chemoprophylaxis of prosthetic joint patients during dental treatment: a decision-utility analysis.

A decision-analytic model and a cost effectiveness analysis was performed on 1 million hypothetic prosthetic joint patients undergoing dental treatment, to determine the most cost-effective strategy to prevent late prosthetic joint infections. The cost per quality-adjusted life-year saved (QALY) was determined for three preventive strategies: no prophylaxis, oral penicillin, and oral cephalexin. The UCLA Pain-Walking-Function-Activity Scale was used to obtain quality-of-life adjustments (utility assessment) for the study population. Costs were derived from 70 patients hospitalized between July 1, 1982, and June 30, 1986, at the UCLA Center for Health Sciences. The most cost-effective preventive strategy was the no prophylaxis alternative ($196,500/QALY). However, by recommending a 1-day strategy of oral cephalexin only to those dental patients at high risk for late prosthetic joint infections rather than a 3-day regimen to all patients, the cost effectiveness improved from $1.1 million/QALY to $446,100/QALY while maintaining a low risk of death (0.38 deaths per 10(6) dental visits).