National study of prescription poisoning with psychoactive and nonpsychoactive medications in Medicare/Medicaid dual enrollees age 65 or over.

The purpose of this study is to assess prescription medication poisoning among psychoactive and nonpsychoactive medications used by elderly (65 years or older) Medicare & Medicaid dual enrollees as well as examine contextual components associated with poisoning. Our primary research goal was to compare medication poisonings among psychoactive medications to nonpsychoactive medications. Our second research goal was to identify components influencing medication poisonings and how they interrelate. The approach used a cross-sectional retrospective review of calendar year 2003 Centers for Medicare & Medicaid Service's Medicaid Pharmacy claims data for elderly dual enrollees. Poisonings were identified based on ICD-9-CM categorizations. Poisonings associated with the psychoactive medications were proportionally over twice as high as compared to nonpsychoactive medications (14.3 per 100,000 enrollees and 6.6 per 100,000 enrollees, respectively). Additionally, the two contextual components of (a) use of many drugs and (b) familiarity with the medication have a direct, but competing impact on poisoning. The reasons behind unintentional poisoning in the elderly have been somewhat a mystery. This study is among the first to attempt to distinguish between poisoning events associated with psychoactive medications versus nonpsychoactive medications as well as assess the impact of differing contextual components on medication poisoning.

Can Magnetic Resonance Imaging Predict Pathologic Findings for Endometrioid Endometrial Cancer?

This pilot study aimed to assess the feasibility of precisely measuring tumor diameter and myometrial invasion in patients with endometrioid endometrial cancer (EEC) using preoperative contrast-enhanced magnetic resonance imaging (MRI). Adult patients with confirmed diagnosis of complex hyperplasia with atypia or EEC were included. Three radiologists separately measured tumor diameter and myometrial invasion. Basic descriptive statistics were used to describe patient characteristics and to compare radiology- and pathology-measured tumor diameter and myometrial invasion. Using the pathology results for tumor diameter as the gold standard for comparison, at least 1 radiologist was able to predict largest tumor diameter within 5 mm for 41.7% of patients. Similarly, based on pathology results for myometrial invasion, at least 1 radiologist was able to predict myometrial invasion within 5% for 50% of patients. All radiologists were able to predict superficial (<50%) or deep (≥50%) myometrial invasion for 75% of patients, with greater sensitivity, specificity, and accuracy for deep myometrial invasion. Given variation among radiologic measurements, it is difficult to recommend preoperative MRI as a basis for measuring tumor diameter and myometrial invasion. Even so, the ability to predict superficial versus deep myometrial invasion may benefit patients with EEC for whom surgery is not a viable option or for those seeking fertility-sparing treatment options.

National study of medications associated with injury in elderly Medicare/Medicaid dual enrollees during 2003.

OBJECTIVES: To address the association between inappropriate prescribing for the elderly and adverse outcomes and to identify the magnitude of the cost of medication-associated injury in this population. DESIGN: Cross sectional. SETTING: United States, 2003. PATIENTS: 5,412,678 dually eligible Medicare/Medicaid enrollees aged 65 years or older. INTERVENTION: Beers and non-Beers medications with potential central nervous system adverse effects of dizziness/vertigo, drowsiness, and/or fainting were assessed. Emergency department (ED) visits with admitting diagnoses pertaining to injuries for elderly enrollees dually eligible for Medicare and Medicaid during the calendar year were linked to prescriptions filled during the 90 days preceding the visit. MAIN OUTCOME MEASURE: For each drug, the proportion of ED-related fills and the Medicare average revenue charge per injury-related ED visit were calculated. RESULTS: Several drugs not currently on the Beers list were found to be associated with high proportions of ED-related fills: methadone had the highest proportion of any of the drugs studied (12.3 per 1,000 fills), and bethanechol (7.8 per 1,000 fills) had the highest proportion among genitourinary products. Regarding narcotic analgesics, propoxyphene (7.7 per 1,000 fills) had a higher association with injury than morphine (6.6 per 1,000 fills) or tramadol (6.5 per 1,000 fills). For cardiovascular agents, clonidine (4.7 per 1,000 fills) and doxazosin (3.6 per 1,000 fills) had higher associations with injury than nifedipine (3.3 per 1,000 fills). Fentanyl, a non-Beers medication, was associated with the most expensive injury-related ED visits ($1,263 average revenue charge). CONCLUSION: Beers medications are associated with high injury-related ED visit rates for the elderly, and a number of drugs not currently on the Beers list also pose an apparent risk for injury-related visits.

Medicaid spending and utilization for central nervous system drugs.

Prior research has shown that prescription drug spending grew substantially during the decade of the 1990s. This analysis uses 1996 to 1998 State Medicaid Research File (SMRF) fee-for-service (FFS) data for 29 participating States to provide insight into the factors driving this growth. The analysis examines cost variation by census region, State, Medicaid basis of eligibility, and therapeutic use of drugs. In 1998, the highest expenditures were for central nervous system (CNS) drugs and for anti-psychotics compared to three other groups of CNS drugs (anti-anxiety agents, anti-depressants, and hypnotics). By eligibility group, expenditures were typically highest for disabled enrollees. There were major variations among SMRF States and their respective regions.

Medicaid prescription drug spending in the 1990s: a decade of change.

Medicaid spending increased dramatically during the 1990s, driven in part by spending for prescription drugs. From 1990 to 2000, Medicaid drug spending increased from $4.4 billion to over $20 billion, an average annual increase of 16.3 percent. Disabled persons experienced an even greater 20 percent average annual increase. By drug category in 1997 (for 29 States), the highest spending amount was for central nervous system (CNS) drugs, accounting for 17 percent of total Medicaid drug spending. These findings provide information on drug spending for dually eligible beneficiaries to policymakers as they seek to target cost-effective coverage and drug therapies.

Hospitalizations for Injury Among Medicaid Children: California, 1992.

Little is known about the incidence and cost of injuries for Medicaid children. This article provides data on hospital utilization and payments for injuries among Medicaid children, using the Health Care Financing Administration's (HCFA) State Medicaid Research Files. During 1992, there were nearly 17,000 injury hospitalizations for California's Medicaid children (758 per 100,000 enrollees), representing over $93 million in program payments. The most frequent injury hospitalizations were fractures and dislocations. Disabled children and 18- to 20-year-old males experienced the highest hospital utilization rates. These findings will assist Medicaid policymakers in targeting prevention efforts to reduce incidence and program payments for children's injuries.

Migration patterns for Medicaid enrollees 2005-2007.

BACKGROUND: Although Medicaid is a federal program, it is administered primarily by the states. Enrollees move from state to state, but their migration patterns have remained largely unknown. There are concerns about the possibility of enrollment gaps, lack of health insurance coverage, breaks in continuity of care, unmet need, risks to health status, and increased system-wide costs due to uncompensated care and the use of higher cost emergency room services because of enrollment gaps. There is also concern about the extent to which people enrolled in more than one state are double counted. OBJECTIVE: To examine the migration of Medicaid enrollees across states. METHODS: We use 2005-2007 Medicaid enrollment records that were unduplicated and linked across states and over the study period. We report descriptive statistics on enrollee migration across states. RESULTS: Among all enrollees, 3.7 percent moved to another state at least once and most moved only once. Overall, 72.2 percent of moves did not result in an enrollment gap, whereas 8.2 percent of moves resulted in gaps of fewer than three months, and 11.4 percent of moves resulted in gaps of more than six months. CONCLUSIONS: These initial findings provide a context for further examining the consequences of enrollee moves on their health and on program expenditures. The consequences of enrollment gaps will become increasingly important as the Medicaid population grows under the provisions of the Affordable Care Act.

Mid-ureteral rupture: a rare complication of urethral catheterization.

To our knowledge, there are only a few published cases of ureteral injuries secondary to urethral catheterization. We present a case of a ureteral rupture that occurred by placement of a standard 16-Fr urethral catheter. The ureteral injury was identified by computed tomography of the abdomen and pelvis and managed with ureteroureteral anastamosis.

Noncompliance in the use of cardiovascular medications in the Medicare Part D population.

OBJECTIVES: (1) to assess non-compliance among Medicare Part D recipients for the cardiovascular medication classes; (2) to identify the probability of noncompliance for each medication class when controlling for the potential risk factors of age, gender, race/ethnic origin, census region, disease burden, dual eligibility enrollment status, Part D plan status, relative out-of-pocket (OOP) non-class costs, and relative OOP daily class costs. DESIGN: Cross sectional retrospective review of 2007 Centers for Medicare & Medicaid Services (CMS) Part D data. All drugs within a drug class were used to conduct the assessment. FINDINGS: Non-compliance was found to be lower than previously reported. Patients who are male, age 65 to 74, Black, or residing in the South are associated with higher noncompliance for cardiovascular medications among the therapeutic classes we studied. Dual eligibility enrollment is typically associated with improved compliance; enrollment in a Medicare Advantage Prescription Drug (MAPD) plan may or may not improve compliance dependent on the therapeutic class under study. Increased disease burden is associated with lower compliance. OOP non-class costs had an opposing effect on compliance as compared to OOP daily costs; higher OOP non-class costs were associated with better compliance. CONCLUSION: Identifying patient characteristics that may contribute positively or negatively to medication compliance is an essential step to improved therapy. As a strategy to improve compliance, the proper selection of therapy that fits a particular patient is paramount.

A community-based approach to preventing youth violence: what can we learn from the playground?

BACKGROUND: Aggression, bullying, and victimization represent tremendous public health concerns among youth. These behaviors occur frequently in unstructured settings, such as the playground. Direct observations of the playground permit examination of these peer processes and are readily accomplished using community-based participatory research (CBPR). OBJECTIVES: To present alternative viewpoints regarding the use of playground observations to evaluate peer aggression, bullying, and victimization. METHODS: We used a (1) child-specific observational coding system and (2) naturalistic observation of the playground to examine playground behaviors. RESULTS: Peer-child processes have differential associations with conduct disorder (CD) and depression symptoms. Group-based observations suggested a number of strengths and some areas that would be amenable to intervention. CONCLUSION: A CBPR framework is useful for identifying youth involved in bullying and victimization; providing immediate support, interventions, and problem-solving strategies; and predicting potential negative outcomes, which can inform violence prevention and intervention efforts.

An examination of the Medicaid undercount in the current population survey: preliminary results from record linking.

OBJECTIVE: To assess reasons why survey estimates of Medicaid enrollment are 43 percent lower than raw Medicaid program enrollment counts (i.e., "Medicaid undercount"). DATA SOURCES: Linked 2000-2002 Medicaid Statistical Information System (MSIS) and the 2001-2002 Current Population Survey (CPS). DATA COLLECTION METHODS: Centers for Medicare and Medicaid Services provided the Census Bureau with its MSIS file. The Census Bureau linked the MSIS to the CPS data within its secure data analysis facilities. STUDY DESIGN: We analyzed how often Medicaid enrollees incorrectly answer the CPS health insurance item and imperfect concept alignment (e.g., inclusion in the MSIS of people who are not included in the CPS sample frame and people who were enrolled in Medicaid in more than one state during the year). PRINCIPAL FINDINGS: The extent to which the Medicaid enrollee data were adjusted for imperfect concept alignment reduces the raw Medicaid undercount considerably (by 12 percentage points). However, survey response errors play an even larger role with 43 percent of Medicaid enrollees answering the CPS as though they were not enrolled and 17 percent reported being uninsured. CONCLUSIONS: The CPS is widely used for health policy analysis but is a poor measure of Medicaid enrollment at any time during the year because many people who are enrolled in Medicaid fail to report it and may be incorrectly coded as being uninsured. This discrepancy should be considered when using the CPS for policy research.