Prevalence of Cognitive and Manual Dexterity Disorders Among Men Following Artificial Urinary Sphincter Placement.

PURPOSE: Cognitive ability and manual dexterity sufficient to operate an artificial urinary sphincter (AUS) are critical for device function and safety. We aimed to define the incidence of cognitive and/or dexterity disorders among men after AUS. We secondarily aimed to assess for association between these disorders and postimplant complications. MATERIALS AND METHODS: This is a retrospective cohort study using the SEER (Surveillance, Epidemiology, and End Results)-Medicare linked database (2000-2018). We included men ≥ 66 years diagnosed with prostate cancer between 2001 to 2015 who subsequently underwent AUS placement. We excluded patients with < 1-year continuous fee-for-service Medicare enrollment or cognitive and/or manual dexterity disorder diagnoses prior to AUS implant. Subsequent cognitive/dexterity disorders and implant-related complications were queried using appropriate ICD (International Classification of Diseases)-9/10 and/or CPT (Current Procedural Terminology) codes. Associations between cognitive/dexterity disorders and postimplant complications were assessed using extended Cox proportional hazards modeling. Secondary analysis focused on serious complications (device revision/removal, Fournier's gangrene, urethral erosion). RESULTS: We identified 1560 men who underwent AUS who met inclusion criteria. Median age was 73.0 (IQR 70-77) years. Cumulative incidence function analysis estimated 44% and 17% incidence of cognitive and manual dexterity disorder, respectively, at 15 years post-AUS. Presence of cognitive with/without manual dexterity disorder was associated with increased hazard of any, but not serious, complication during follow-up. CONCLUSIONS: A significant proportion of patients develop cognitive and/or manual dexterity disorders following AUS. These data support the need for close longitudinal monitoring after implant.

Missing information in statewide and national cancer databases: Correlation with health risk factors, geographic disparities, and outcomes.

OBJECTIVE: The objectives of this study were to analyze factors associated with outcomes and missing data in women with epithelial ovarian cancer using institutional, state and national databases. METHODS: Data were abstracted from the University of Virginia cancer registry, Virginia Department of Health (VDH) database, and Surveillance, Epidemiology, and End Results (SEER) Program and analyzed for correlations with demographics, cancer characteristics, and outcomes. Statewide spatial associations between health risk factors such as smoking, obesity, and missing grade/stage were evaluated using bivariate LiSA in Geoda. RESULTS: There were 524 institutional, 3544 VDH, and 44,464 SEER cases of epithelial ovarian cancer. Institutional cases were younger, most often of white race, had increased grade 1, and decreased unknown grade and stage (all p < 0.001). Significant predictors of unknown grade were non-white race, older age, no surgery, unknown stage/stage IV, and unknown histology/adenocarcinoma. Unknown grade correlated with a significant survival disadvantage. Missing stage and grade correlated with county-level obesity and smoking, as rural regions in Southwest and Southside Virginia had high rates of health risk factors and missing stage/grade compared to urban, affluent regions in Northern Virginia. CONCLUSIONS: Over a third of nationally reported cases have an unknown grade and 10-20% have an unknown stage which correlates with the worst survival. Predictors of unknown grade include insurance, age, race, smoking status, obesity, and rural setting. Missing data may represent geographical differences or disparities in cancer care available as significantly fewer cases had an unknown grade/stage at a tertiary academic medical center compared to VDH and SEER.

Predicting Late-stage Breast Cancer Diagnosis and Receipt of Adjuvant Therapy: Applying Current Spatial Access to Care Methods in Appalachia.

PURPOSE: The 2-step floating catchment area (2SFCA) method of measuring access to care has never been used to study cancer disparities in Appalachia. First, we evaluated the 2SFCA method in relation to traditional methods. We then examined the impact of access to mammography centers and primary care on late-stage breast cancer diagnosis and receipt of adjuvant hormonal therapy. METHODS: Cancer registries from Pennsylvania, Ohio, Kentucky, and North Carolina were linked with Medicare data to identify the stage of breast cancer diagnosis for Appalachia women diagnosed between 2006 and 2008. Women eligible for adjuvant therapy had stage I, II, or III diagnosis; mastectomy or breast-conserving surgery; and hormone receptor-positive breast cancers. Geographically weighted regression was used to explore nonstationarity in the demographic and spatial access predictor variables. RESULTS: Over 21% of 15,299 women diagnosed with breast cancer had late-stage (stages III-IV) diagnosis. Predictors included age at diagnosis [odds ratio (OR)=0.86; P<0.001], insurance status (OR=1.32; P<0.001), county primary care to population ratio (OR=0.95; P<0.001), and primary-care 2SFCA score (OR=0.96; P=0.006). Only 46.9% of eligible women received adjuvant hormonal therapy, and predictors included comorbidity status (OR=1.18; P=0.047), county economic status (OR=1.32; P=0.006), and mammography center 2SFCA scores (OR=1.12; P=0.021). CONCLUSIONS: Methodologically, the 2SFCA method offered the greatest predictive validity of the access measures examined. Substantively, rates of late-stage breast cancer diagnosis and adjuvant hormonal therapy are substandard in Appalachia.

The Breast-Imaging Operations, Practices and Systems Inventory: A framework to examine mammography facility effects on screening in rural communities.

PURPOSE: Develop and test a measurement framework of mammogram facility resources, policies, and practices in Appalachia. METHODS: Survey items describing 7 domains of imaging facility qualities were developed and tested in the Appalachian regions of Kentucky, Ohio, Pennsylvania, Virginia, and West Virginia. Medicare claims data (2016-2018) were obtained on catchment area mammogram services. Construct validity was examined from associations with facility affiliation, community characteristics, mammogram screening uptake, and market reach. Analyses were performed with t-tests and ANOVA. RESULTS: A total of 192 (of 377) sites completed the survey. Five factors were initially selected in exploratory factor analysis (FA) and refined in confirmatory FA: capacity, outreach & marketing, operational support, radiology review (NNFI = .94, GFI = 0.93), and diagnostic services (NNFI = 1.00, GFI = 0.99). Imaging capacity and diagnostic services were associated with screening uptake, with capacity strongly associated with catchment area demographic and economic characteristics. Imaging facilities in economically affluent versus poorer areas belong to larger health systems and have significantly more resources (P < .001). Facilities in economically distressed locations in Appalachia rely more heavily on outreach activities (P < .001). Higher facility capacity was significantly associated (P < .05) with larger catchment area size (median split: 48.5 vs 51.6), mammogram market share (47.4 vs 52.7), and screening uptake (47.6 vs 52.4). CONCLUSIONS: A set of 18 items assessing breast imaging services and facility characteristics was obtained, representing policies and practices related to a facility's catchment area size, market share, and mammogram screening uptake.

Risk score for predicting long-term mortality after coronary artery bypass graft surgery.

BACKGROUND: No simplified bedside risk scores have been created to predict long-term mortality after coronary artery bypass graft surgery. METHODS AND RESULTS: The New York State Cardiac Surgery Reporting System was used to identify 8597 patients who underwent isolated coronary artery bypass graft surgery in July through December 2000. The National Death Index was used to ascertain patients' vital statuses through December 31, 2007. A Cox proportional hazards model was fit to predict death after CABG surgery using preprocedural risk factors. Then, points were assigned to significant predictors of death on the basis of the values of their regression coefficients. For each possible point total, the predicted risks of death at years 1, 3, 5, and 7 were calculated. It was found that the 7-year mortality rate was 24.2 in the study population. Significant predictors of death included age, body mass index, ejection fraction, unstable hemodynamic state or shock, left main coronary artery disease, cerebrovascular disease, peripheral arterial disease, congestive heart failure, malignant ventricular arrhythmia, chronic obstructive pulmonary disease, diabetes mellitus, renal failure, and history of open heart surgery. The points assigned to these risk factors ranged from 1 to 7; possible point totals for each patient ranged from 0 to 28. The observed and predicted risks of death at years 1, 3, 5, and 7 across patient groups stratified by point totals were highly correlated. CONCLUSION: The simplified risk score accurately predicted the risk of mortality after coronary artery bypass graft surgery and can be used for informed consent and as an aid in determining treatment choice.

Development and validation of a scale measuring satisfaction with maternal and newborn health care following childbirth.

To demonstrate the validity and internal consistency of a multi-item scale measuring women's satisfaction with health care received in the weeks following childbirth for both themselves and their newborns. Data are from 1,154 women delivering healthy singletons or twins recruited for a randomized trial. Satisfaction with care items were selected from prior research, including the previously validated Primary Care Satisfaction Survey for Women (PCSSW) and studies of postpartum care. After randomly splitting the sample (1:1) for cross-validation purposes, Exploratory (EFA) and Confirmatory factor analysis (CFA) on ordinal data using the WLSMV estimator available in the MPLUS statistical modeling program were conducted. A CFA was also conducted on available data at 2 weeks and 2 months after discharge in order to examine internal consistency at follow-up. A one factor model with 11 items was selected, with the main factor explaining 83% of total 11-item variation in the overall sample. The Cronbach's alpha for the final 11-item scale at baseline and follow-up time periods was 0.96. High correlations with overall trust in provider (Spearman rho = 0.78) and quality of healthcare (0.75) supported convergent validity. The baseline mean score was 47.9 with a standard deviation of 7.13 and a possible range of 11 (low) to 55 (high satisfaction). This validated scale is a new tool for measuring satisfaction with health care received during the postpartum period for mothers and their newborns. This tool will be useful in studies assessing quality of care and the outcomes of postpartum health care interventions, and it is the first tool to focus on care for the mother-baby unit.

Preconception predictors of birth outcomes: prospective findings from the central Pennsylvania women's health study.

OBJECTIVE: To examine maternal pre-pregnancy (preconception) predictors of birthweight and fetal growth for singleton live births occurring over a 2-year period in a prospective study. METHODS: Data are from a population-based cohort study of 1,420 women who were interviewed at baseline and 2-years later; self-report data and birth records were obtained for incident live births during the followup period. The analytic sample includes 116 singleton births. Baseline preconception maternal health status and health-related behaviors were examined as predictors of birthweight and fetal growth, controlling for prenatal and sociodemographic variables, using multiple regression analysis. RESULTS: Preconception BMI (overweight or obese) and vegetable consumption (at least one serving per day) had statistically significant independent and positive effects on birthweight and fetal growth. Maternal weight gain during pregnancy, a prenatal variable, was an additional independent predictor of birthweight and fetal growth. Sociodemographic variables were not significant predictors after controlling for preconception and prenatal maternal characteristics. CONCLUSIONS: Findings confirm that preconception maternal health status and health-related behaviors can affect birthweight and fetal growth independent of prenatal and socioeconomic variables. Implications for preconception care are discussed.

Associations between initiating antihypertensive regimens on stage I-III colorectal cancer outcomes: A Medicare SEER cohort analysis.

PURPOSE: Colorectal cancer (CRC) diagnosis is associated with high mortality in the United States and thus warrants the study of novel treatment approaches. Vascular changes are well observed in cancers and evidence indicates that antihypertensive (AH) medications may interfere with both tumor vasculature and in recruiting immune cells to the tumor microenvironment based on preclinical models. Extant literature also shows that AH medications are correlated with improved survival in some forms of cancer. Thus, this study sought to explore the impact of AH therapies on CRC outcomes. PATIENTS AND METHODS: This study was a non-interventional, retrospective analysis of patients aged 65 years and older with CRC diagnosed from January 1, 2007 to December 31st, 2012 in the Surveillance, Epidemiology, and End-Results (SEER)-Medicare database. The association between AH drug utilization on AJCC stage I-III CRC mortality rates in patients who underwent treatment for cancer was examined using Cox proportional hazards models. RESULTS: The study cohort consisted of 13,982 patients diagnosed with CRC. Adjusted Cox proportional hazards regression showed that among these patients, the use of AH drug was associated with decreased cancer-specific mortality (HR: 0.79, 95% CI: 0.75-0.83). Specifically, ACE inhibitors (hazard ratio [HR]: 0.84, 95% CI: 0.80-0.87), beta-blockers (HR: 0.87, 95% CI: 0.84-0.91), and thiazide diuretics (HR: 0.83, 95% CI: 0.80-0.87) were found to be associated with decreased mortality. An association was also found between adherence to AH therapy and decreased cancer-specific mortality (HR: 0.94, 95% CI: 0.90-0.98). CONCLUSION: Further research needs to be performed, but AH medications may present a promising, low-cost pathway to supporting CRC treatment for stage I-III cancers.

Good adherence and early efficacy using desonide hydrogel for atopic dermatitis: results from a program addressing patient compliance.

BACKGROUND: Patients with atopic dermatitis (AD) may have poor adherence for several reasons, including fear of side effects or dislike of messy topical therapies. PURPOSE: To assess adherence to and efficacy of a multifaceted program for atopic dermatitis using a lightweight, easy-to-apply medication and more frequent return visits. METHODS: Forty-one subjects with mild-to-moderate atopic dermatitis were instructed to use desonide hydrogel 0.05% twice daily. Disease severity was measured at baseline and weeks 1, 2 and 4. Subjects also received a follow-up phone call on day 3. Adherence was assessed using electronic monitors. At the end of the study, subjects sampled and rated the vehicle attributes of six different topical corticosteroid formulations. RESULTS: Mean adherence to twice-daily application slowly declined over time, from 81% on day 1 to 50% by day 27. An improvement in pruritus was observed as early as day 3, and by week 4, mean pruritus and EASI scores improved from baseline by 60% and 61%, respectively. Mean SGA scores also improved to marked improvement/almost clear by week 4. In vehicle attribute surveys, the hydrogel was consistently rated higher than the other vehicles in all categories. CONCLUSION: Subjects responded very well to treatment, and adherence to desonide hydrogel 0.05% was much better than previously reported with ointments. The early efficacy, favorable attributes of the hydrogel vehicle and judicious follow up likely increased adherence to topical therapy. The use of ointments or more potent topical steroids as a first choice may be counterproductive in the treatment of atopic dermatitis.

Pregnancy intention and health behaviors: results from the Central Pennsylvania Women's Health Study cohort.

OBJECTIVE: Our objective was to determine whether intention for future pregnancy affects selected preconception health behaviors that may impact pregnancy outcomes. METHODS: Analyses are based on data from a population-based cohort study of women ages 18-45 residing in Central Pennsylvania. A subsample of 847 non-pregnant women with reproductive capacity comprise the analytic sample. We determined the associations between intention for future pregnancy and the pattern in the following health behaviors over a 2-year period: nutrition (fruit and vegetable consumption), folic acid supplementation, physical activity, binge drinking, smoking, and vaginal douching. Multivariable analyses controlled for pregnancy-related variables, health status, health care utilization, and sociodemographic variables. RESULTS: At baseline, 9% of women were considering pregnancy in the next year, 37% of women were considering pregnancy some other time in the future, and 53% of women were not considering future pregnancy. In multivariable analyses, there were no associations between intention for future pregnancy and maintaining healthy behavior or improving behavior for any of the seven longitudinal health behaviors studied. CONCLUSIONS: The importance of nutrition, folic acid supplementation, physical activity, avoiding binge drinking, not smoking, and avoiding vaginal douching in the preconception period needs to be emphasized by health care providers and policy makers.

Predicting pregnancy from pregnancy intentions: prospective findings from the Central Pennsylvania Womens's Heath Study (CePAWHS).

OBJECTIVE: We examined whether adult women's intention for future pregnancy predicted actual pregnancies occurring in a 2-year follow-up study. METHODS: Data are from the Central Pennsylvania Women's Health Study population-based longitudinal survey of women ages 18-45 (n = 1,420). The analytic sample consists of 889 nonpregnant women who had reproductive capacity. Intention for future pregnancy was ascertained at baseline, and women were re-interviewed 2 years later to document interval pregnancies. The impact of pregnancy intention on subsequent pregnancy was analyzed using multiple logistic regression adjusting for relevant covariates. RESULTS: At baseline, 46% of women were considering a future pregnancy. One hundred thirty-seven women became pregnant during the 2-year study; of these pregnancies, 83% were intended (occurring in women considering a future pregnancy at baseline) and 17% were unintended (occurring in women not considering a future pregnancy at baseline). Pregnancies occurred in 28% of women who at baseline were considering future pregnancy and 5% of women not considering pregnancy. In adjusted analysis, baseline pregnancy intention was predictive of with pregnancy occurrence in women ages 25-34 (adjusted odds ratio [OR], 4.19; 95% confidence interval [CI], 2.20-7.97) and ages 35-45 (adjusted OR, 26.89; 95% CI, 9.05-79.93), but not in women ages 18-24. CONCLUSIONS: In this prospective study, pregnancy intention was strongly associated with pregnancy incidence over a 2-year follow-up period among women ages 25 and older, suggesting that pregnancy intentions could be used to identify women at greater risk of pregnancy. Future investigation is needed to confirm these findings and to explore the reasons why pregnancy intentions were not predictive for women ages 18-24.

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.

Cost impact of oral capecitabine compared to intravenous taxane-based chemotherapy in first-line metastatic breast cancer.

OBJECTIVE: Few studies have examined the costs associated with differing first-line chemotherapy regimens in patients with metastatic breast cancer (MBC). This study compares the relative cost impact of women starting first-line chemotherapy with capecitabine versus taxanes. METHODS: Women receiving first-line chemotherapy for MBC from 1998 to 2002 were identified from a hybrid North Carolina Medicaid-claims-tumour registry linked database and Medicare records, and were followed through to 2005 with claims data. Statistical t- and chi-square tests were used to compare baseline characteristics between patients who received first-line chemotherapy with capecitabine versus taxanes. Projected mean costs for 12 months continuous eligibility were estimated using an ordinary least squares linear regression. Overall cost impact of capecitabine after start of therapy was then examined using a multivariate log-linear regression model. RESULTS: While patients starting taxanes had significantly lower total costs in the pre-index year than patients starting capecitabine (mean: $20,042 vs. $35,538, p<0.001), in the post-index year, the patients on taxanes experienced significantly higher healthcare utilisation and associated costs compared to patients on capecitabine (mean: $43,353 vs. $35,842, p=0.0089). The differences were primarily attributable to lower expenses in chemotherapy related claims and fewer visit days to outpatient settings for patients on capecitabine. After adjustment with propensity scores and other confounders, the capecitabine group was associated with 32% lower healthcare costs compared to the taxane group (p=0.0001). CONCLUSIONS: In this population-based study, women who received capecitabine as first-line treatment for MBC had significantly lower costs compared to women starting taxane therapy.

Adherence to acitretin and home narrowband ultraviolet B phototherapy in patients with psoriasis.

BACKGROUND: In the treatment of psoriasis, patient adherence to oral medications is poor and even worse for topical therapy. However, few data exist about adherence rates to home phototherapy, adding to concerns about the appropriateness of home phototherapy as a psoriasis treatment option. OBJECTIVE: We sought to assess adherence to both oral acitretin and home ultraviolet B phototherapy for the treatment of psoriasis. METHODS: In all, 27 patients with moderate to severe psoriasis were treated with 10 to 25 mg of acitretin daily, combined with narrowband ultraviolet B, 3 times weekly at home, for 12 weeks. Adherence to acitretin was monitored by an electronic monitoring medication bottle cap, and to phototherapy by a light-sensing data logger. RESULTS: Adherence data were collected on 22 patients for acitretin and 16 patients for adherence to ultraviolet B. Mean adherence to acitretin decreased steadily during the 12-week trial (slope -0.24), whereas mean adherence to home phototherapy remained steady at 2 to 3 d/wk. Adherence was similar between patients who reported side effects and those who did not. LIMITATIONS: Small sample size and lack of follow-up on some patients were limitations of this study. CONCLUSIONS: Adherence rates to home phototherapy were very good and higher than adherence rates for the oral medication. Side effects of treatment were well tolerated in this small group and did not affect use of the treatment. Home phototherapy with acitretin may be an appropriate option for some patients with extensive psoriasis.

Prescription refills and healthcare costs associated with topical metronidazole in Medicaid enrolled patients with rosacea.

BACKGROUND: Refill adherence to medications and healthcare costs are important factors to consider while making informed decisions regarding the treatment of rosacea patients. OBJECTIVE: The objective of this study was to examine predictors of number of refills related to topical metronidazole and total healthcare costs in rosacea patients. METHODS: This study utilized a longitudinal cohort design and followed rosacea patients enrolled in North Carolina Medicaid and who were prescribed at least one study medication (topical metronidazole, adapalene, azelaic acid, permethrin, and sulfacetamide). Patients' demographic characteristics, number of metronidazole refills, and different components of healthcare costs were examined. RESULTS: Out of the total 2587 rosacea patients, the majority (approximately 69%, n=1771) had one or more prescriptions for topical metronidazole. Most of the patients in this study were white (73%). After controlling for other variables, increasing age was associated with a higher number of metronidazole refills and healthcare costs (both p<0.001). Compared with white patients, African American patients had a significantly lower number of metronidazole refills (p<0.001). Compared with white patients, African American patients and 'other' races were associated with an 8.6% and 10.3% decrease in total healthcare costs respectively (both p<0.001). An increase in the number of metronidazole refills was not associated with an increase in healthcare costs. CONCLUSION: Patients' race is significantly associated with the number of topical metronidazole refills. Patients' healthcare costs increased with increasing age and charges paid for prescriptions. Topical metronidazole seems to be an economically feasible treatment option for Medicaid-enrolled patients with rosacea.

Use of a silklike bedding fabric in patients with atopic dermatitis.

Symptoms of atopic dermatitis are often affected by environmental irritants. Modulation of potential irritants may benefit such symptoms. The purpose of this study was to evaluate the impact of a novel silklike bedding fabric for persons with mild to moderate atopic dermatitis. Participants with mild to moderate atopic dermatitis were provided a bedsheet set. Eczema Area and Severity Index and Investigator Global Assessment were the primary outcome measures. Visual Analog Scale for itch and a quality of life were also evaluated. The Wilcoxon signed rank test indicated a significant decrease in severity, with the Investigator Global Assessment score decreasing from 2.05 to 1.74 at week 8 (p = 0.03), the Eczema Area and Severity Index decreasing from 2.63 at baseline to 2.19 (p = 0.014), and the itching score decreasing from 3.97 to 3.00 (p = 0.010). An increase in the study-specific quality of life index was also observed, changing from -0.08 (no change in quality of life) to 1.23 (some improvement) (p < 0.0001). Atopic dermatitis is commonly recalcitrant to therapy and synthetic silklike bed linens may have value as another option for the treatment of this disease. This pilot study demonstrated promising results that warrant confirmation in controlled clinical studies.

The influence of co-morbidities on prescribing pharmacotherapy for insomnia: evidence from US national outpatient data 1995-2004.

OBJECTIVE: Patients with insomnia are likely to have other co-morbidities that could affect pharmacotherapeutic choices. This study examined the prevalence and impact of co-morbidities on the pharmacological treatment of insomnia. STUDY DESIGN: A retrospective data analysis of the National Ambulatory Medical Care Survey from 1995 to 2004, comprising patients with a diagnosis of insomnia, was conducted. Multivariate logistic regression models were used to predict the impact of co-morbidities on pharmacotherapy for insomnia. RESULTS: A total of 5,487 unweighted patient visits with insomnia were identified, representing 161.4 million patients in the US. Approximately 38% of these patients had at least one co-morbid condition. Patients with mental co-morbidities, especially anxiety, had decreased likelihood of receiving pharmacotherapy for insomnia. CONCLUSIONS: Mental co-morbidities such as episodic mood disorder, anxiety and depression are prevalent in patients with insomnia. However, many co-morbid patients do not receive pharmacological therapy specific for insomnia.

Comparisons of rosiglitazone versus pioglitazone monotherapy introduction and associated health care utilization in medicaid-enrolled patients with type 2 diabetes mellitus.

BACKGROUND: Outcomes in patients with type 2 diabetes mellitus (DM) can differ based on the antidiabetic medication that is used. Thiazolidinediones (TZDs) are a newer class of agents used for the treatment of type 2 DM. No previous study has compared health care utilization associated with the 2 TZDs on the market. OBJECTIVE: The objective of this study was to compare health care utilization and costs associated with initiation of treatment with either rosiglitazone or pioglitazone by Medicaid-enrolled patients with type 2 DM. METHODS: This was a retrospective data analysis comparing cohorts of patients with type 2 DM starting a new antidiabetic medication in terms of hospitalizations, emergency department visits, outpatient physician visits, and health care costs reimbursed by the North Carolina Medicaid program. The perspective adopted in this analysis was that of the third-party payer (ie, the North Carolina Medicaid program). Patients starting rosiglitazone between July 1, 2001, and June 30, 2002, were compared with patients starting pioglitazone during the same period. The patients were followed up for 30 months to examine the difference in health care utilization over time. Multivariate regression techniques were employed for comparisons between the 2 different antidiabetic therapies. RESULTS: A total of 1705 patients with type 2 DM were identified and included in the final cohort. There were 660 patients (mean [SD] age, 49.0 [10.2] years) in the rosiglitazone arm and 1045 patients (mean [SD] age, 49.1 [10.5] years) in the pioglitazone arm. Multivariate analysis showed that the rosiglitazone monotherapy group was associated with a 12.2% decrease in the mean number of hospitalizations, a 10.4% decrease in the mean number of emergency department visits, and a 7.3% decrease in total health care costs compared with the pioglitazone monotherapy group (all, P < 0.05). This study only looked at patients who used the same drug for the entire follow-up period. It did not account for drug switching or addition of a new drug to an existing therapy. CONCLUSIONS: Introduction of rosiglitazone was associated with a decreased number of hospitalizations, emergency department visits, and total health care costs compared with pioglitazone. The utilization of oral antidiabetic agents, with documented clinical and economic benefits, should continue to be advocated to reduce avoidable medical care utilization and to improve patient outcomes in this population.

Health care costs and medication adherence associated with initiation of insulin pen therapy in medicaid-enrolled patients with type 2 diabetes: a retrospective database analysis.

BACKGROUND: Clinical, health, and economic outcomes in patients with type 2 diabetes may be influenced by self-management behaviors and type of pharmacotherapy. OBJECTIVE: This study examined differences in medication adherence and total health care costs among patients with type 2 diabetes who initiated or converted to insulin administration with a pen device in comparison with a vial/syringe as add-on therapy to oral antidiabetic drugs. METHODS: This study evaluated patients with type 2 diabetes who were enrolled in the North Carolina Medicaid program from September 24, 2001, to July 18, 2006. Patients receiving insulin with a vial/syringe who converted to pen therapy were compared with those who remained on vial/syringe in both unmatched comparisons (n = 560 and n = 9988, respectively) and after pair-matching (both cohorts, n = 560) with the use of propensity scores. In a second analysis, patients who initiated insulin with vial/syringe (n = 1162) were compared with a cohort that initiated insulin pen therapy (n = 168) after controlling for covariates in a multivariate regression model. All included patients had complete enrollment for at least 24 months of followup. Multiple linear regression models were used to predict the comparative impact on total health care costs and medication adherence for each cohort. Adjusted means were calculated to determine the group differences for each outcome. RESULTS: Diabetes-related and overall medication adherence was comparable for patients initiating insulin with a pen versus a syringe (53% vs 50% and 94% vs 94%, respectively). However, total annualized health care costs were significantly lower for patients using pen therapy than for those using a syringe ($14,857.42 vs $31,764.78, respectively; P < 0.05). Cost reductions with pen therapy were reflected in hospital costs ($1195.93 vs $4965.31, respectively; P < 0.05), diabetes-related costs ($7324.37 vs $13,762.21, respectively; P < 0.05), and outpatient costs ($7795.98 vs $13,103.51, respectively; P < 0.05). However, prescription costs of syringe were significantly lower ($535.70 vs $670.52; P < 0.05) and costs of pen were higher ($840.33 vs $0; P < 0.05) in patients who were switched from syringe to pen versus those who remained on syringe therapy. CONCLUSIONS: In a state Medicaid setting among patients with type 2 diabetes, initiating insulin therapy with a pen device was associated with comparable medication adherence and significant reductions in health care resource utilization and associated costs compared with vial/syringe insulin. Health care professionals and policy makers should consider the potential economic benefits of pen therapy when initiating insulin among Medicaid beneficiaries who fail to respond to oral antidiabetic drugs.

Adherence to topical therapy increases around the time of office visits.

BACKGROUND: The efficacy of topical medications is limited by non-adherence. Interventions to improve adherence to topical treatments are not well characterized. OBJECTIVE: To assess the impact of office visits on patients' adherence to topical treatment. METHODS: Twenty-nine subjects enrolled in a clinical trial for psoriasis and were followed for up to 8 weeks. Subjects were told to apply 6% salicylic acid gel twice daily. Electronic monitors were used to assess adherence. Results were compared to adherence in clinical trials of hand dermatitis and atopic dermatitis. RESULTS: Adherence rates were significantly higher around the time of office visits (P < .05). LIMITATIONS: This is a small study in a limited patient population. The study was observational and not a randomized trial of the effect of increased office visits. CONCLUSION: Frequent follow-up visits in clinical trials increase patients' adherence to medications. The use of a follow-up visit shortly after initiating treatment may be an effective way to boost patients' use of their medication and achieve better treatment outcomes.