Cost Effectiveness of Treatment Sequences in Advanced Renal Cell Carcinoma.

BACKGROUND: The treatment landscape for metastatic renal cell carcinoma (mRCC) has significantly evolved in recent years. Without direct comparator trials, factors such as cost effectiveness (CE) are important to guide decision-making. OBJECTIVE: To assess the CE of guideline-recommended approved first- and second-line treatment regimens. DESIGN, SETTING, AND PARTICIPANTS: A comprehensive Markov model was developed to analyze the CE of the five current National Comprehensive Cancer Network-recommended first-line therapies with appropriate second-line therapy for patient cohorts with International Metastatic RCC Database Consortium favorable and intermediate/poor risk. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Life years, quality-adjusted life years (QALYs), and total accumulated costs were estimated using a willingness-to-pay threshold of $150 000 per QALY. One-way and probabilistic sensitivity analyses were performed. RESULTS AND LIMITATIONS: In patients with favorable risk, pembrolizumab + lenvatinib followed by cabozantinib added $32 935 in costs and yielded 0.28 QALYs, resulting in an incremental CE ratio (ICER) of $117 625 per QALY in comparison to pembrolizumab + axitinib followed by cabozantinib. In patients with intermediate/poor risk, nivolumab + ipilimumab followed by cabozantinib added $2252 in costs and yielded 0.60 QALYs compared to cabozantinib followed by nivolumab, yielding an ICER of $4184. Limitations include differences in median follow-up duration between treatments. CONCLUSIONS: Pembrolizumab + lenvatinib followed by cabozantinib, and pembrolizumab + axitinib followed by cabozantinib were cost-effective treatment sequences for patients with favorable-risk mRCC. Nivolumab +ipilimumab followed by cabozantinib was the most cost-effective treatment sequence for patients with intermediate-/poor-risk mRCC, dominating all preferred treatments. PATIENT SUMMARY: Because new treatments for kidney cancer have not been compared head to head, comparison of their cost and efficacy can help in making decisions about the best treatments to use first. Our model showed that patients with a favorable risk profile are most likely to benefit from pembrolizumab and lenvatinib or axitinib followed by cabozantinib, while patients with an intermediate or poor risk profile will probably benefit most from nivolumab and ipilimumab followed by cabozantinib.

Self-help smoking cessation intervention for Spanish-speaking Hispanics/Latinxs in the United States: A randomized controlled trial.

BACKGROUND: Hispanic/Latinx smokers living in the United States face unique challenges in quitting smoking. This study evaluated the efficacy of a culturally relevant, Spanish-language, extended self-help smoking cessation intervention among Hispanic smokers. METHODS: A 2-arm parallel randomized controlled trial was conducted with Hispanic/Latinx smokers living in the United States who preferred health information in Spanish and smoked 5 or more cigarettes per week. Participants were randomly allocated to receive Libre del Cigarrillo (LDC), which consisted of 11 booklets and 9 pamphlets mailed monthly over 18 months, or the usual care (UC), which was a single Spanish-language self-help booklet from the National Cancer Institute. The primary outcome was self-reported 7-day point prevalence smoking abstinence assessed 6, 12, 18, and 24 months after the baseline. Eight prespecified moderators of the intervention were evaluated. Cost-effectiveness was also evaluated. All statistical tests were 2-sided. RESULTS: Data from all participants randomized to LDC (n = 714) or UC (n = 703) were used for analyses after multiple imputation to manage missing data. Generalized estimating equation analyses indicated that LDC abstinence rates were higher (P < .001) across all assessments. Logistic regression analyses revealed that at 24 months, the abstinence rate was greater for LDC (33.1%) than UC (24.3%; odds ratio, 1.54; 95% confidence interval, 1.18-2.02; P = .002). Men exhibited a strong intervention effect at all assessments (P values < .001), whereas the intervention effect for women was observed only at 6 and 12 months (P values < .018). In comparison with UC, the incremental cost per quitter in the LDC arm was $648.43 at 18 months and $683.93 at 24 months. CONCLUSIONS: A culturally relevant, Spanish-language intervention was efficacious and cost-effective for smoking cessation. LAY SUMMARY: Research is needed to develop interventions for ethnic minority smokers. The aim of the current study was to test a Spanish-language adaptation of a validated and easily implemented self-help smoking cessation intervention in a nationwide randomized controlled trial. The findings demonstrated that the intervention produced greater smoking abstinence in comparison with a standard self-help booklet. Participants also were more satisfied with the intervention, and it was cost-effective. Efforts aimed at promoting tobacco abstinence in this underserved population could have significant public health implications, including potential reductions in cancer health disparities associated with tobacco smoking.

Targeted smoking cessation for dual users of combustible and electronic cigarettes: a randomised controlled trial.

BACKGROUND: Although many smokers use electronic cigarettes (e-cigarettes) to quit smoking, most continue to smoke while vaping. This dual use might delay cessation and increase toxicant exposure. We aimed to test the efficacy of a self-help intervention designed to help dual users to quit smoking. METHODS: In this three-arm randomised controlled trial we recruited individuals in the USA using Facebook and multimedia advertisements. Included participants were 18 years or older, smoked at least weekly in the preceding year, and vaped at least weekly in the preceding month. We used computer generated randomisation with balanced-permuted blocks (block size 10, with 2-4-4 ratio) to allocate participants to assessment only (ASSESS group), generic smoking cessation self-help booklets (GENERIC group), or booklets targeting dual users (eTARGET group). Individuals in the generic or targeted intervention groups received monthly cessation materials for 18 months, with assessments every 3 months for 24 months. The main outcome was self-reported 7-day point-prevalence smoking abstinence at each assessment point. All randomly allocated participants were included in primary analyses using generalised estimating equations for each of 20 datasets created by multiple imputation. Analysis of the χ2s produced an F test. The trial is registered with ClinicalTrials.gov, NCT02416011, and is now closed. FINDINGS: Between July 12, 2016, and June 30, 2017, we randomly assigned 2896 dual users (575 to assessment, 1154 to generic intervention, and 1167 to targeted self-help). 7-day point-prevalence smoking abstinence increased from 14% at 3 months to 42% at 24 months (F7,541·7=67·1, p<0·0001) in the overall sample. Targeted self-help resulted in higher smoking abstinence than did assessment alone throughout the treatment period (F1,973·8=10·20, p=0·0014 [α=0·017]). The generic intervention group had abstinence rates between those of the assessment and targeted groups, but did not significantly differ from either when adjusted for multiple comparisons (GENERIC vs eTARGET F1,1102·5=1·79, p=0·18 [α=0·05]; GENERIC vs ASSESS F1,676·7=4·29, p=0·039 [α=0·025]). Differences between study groups attenuated after the interventions ended. INTERPRETATION: A targeted self-help intervention with high potential for dissemination could be efficacious in promoting smoking cessation among dual users of combustible cigarettes and e-cigarettes. FUNDING: National Institute on Drug Abuse, National Cancer Institute.

Neighbourhood greenness and depression among older adults.

BACKGROUND: Neighbourhood greenness or vegetative presence has been associated with indicators of health and well-being, but its relationship to depression in older adults has been less studied. Understanding the role of environmental factors in depression may inform and complement traditional depression interventions, including both prevention and treatment.AimsThis study examines the relationship between neighbourhood greenness and depression diagnoses among older adults in Miami-Dade County, Florida, USA. METHOD: Analyses examined 249 405 beneficiaries enrolled in Medicare, a USA federal health insurance programme for older adults. Participants were 65 years and older, living in the same Miami location across 2 years (2010-2011). Multilevel analyses assessed the relationship between neighbourhood greenness, assessed by average block-level normalised difference vegetative index via satellite imagery, and depression diagnosis using USA Medicare claims data. Covariates were individual age, gender, race/ethnicity, number of comorbid health conditions and neighbourhood median household income. RESULTS: Over 9% of beneficiaries had a depression diagnosis. Higher levels of greenness were associated with lower odds of depression, even after adjusting for demographics and health comorbidities. When compared with individuals residing in the lowest tertile of greenness, individuals from the middle tertile (medium greenness) had 8% lower odds of depression (odds ratio 0.92; 95% CI 0.88, 0.96; P = 0.0004) and those from the high tertile (high greenness) had 16% lower odds of depression (odds ratio 0.84; 95% CI 0.79, 0.88; P < 0.0001). CONCLUSIONS: Higher levels of greenness may reduce depression odds among older adults. Increasing greenery - even to moderate levels - may enhance individual-level approaches to promoting wellness.Declaration of interestNone.

Relationship of Neighborhood Greenness to Heart Disease in 249 405 US Medicare Beneficiaries.

Background Nature exposures may be associated with reduced risk of heart disease. The present study examines the relationship between objective measures of neighborhood greenness (vegetative presence) and 4 heart disease diagnoses (acute myocardial infarction, ischemic heart disease, heart failure, and atrial fibrillation) in a population-based sample of Medicare beneficiaries. Methods and Results The sample included 249 405 Medicare beneficiaries aged 65 years and older whose location ( ZIP +4) in Miami-Dade County, Florida, did not change from 2010 to 2011. Analyses examined relationships between greenness, measured by mean block-level normalized difference vegetation index from satellite imagery, and 4 heart disease diagnoses. Hierarchical regression analyses, in a multilevel framework, assessed the relationship of greenness to each heart disease diagnosis, adjusting successively for individual sociodemographics, neighborhood income, and biological risk factors (diabetes mellitus, hypertension, and hyperlipidemia). Higher greenness was associated with reduced heart disease risk, adjusting for individual sociodemographics and neighborhood income. Compared with the lowest tertile of greenness, the highest tertile of greenness was associated with reduced odds of acute myocardial infarction by 25% (odds ratio, 0.75; 95% CI , 0.63-0.90), ischemic heart disease by 20% (odds ratio, 0.80; 95% CI , 0.77-0.83), heart failure by 16% (odds ratio, 0.84; 95% CI , 0.80-0.88), and atrial fibrillation by 6% (odds ratio, 0.94; 95% CI , 0.87-1.00). Associations were attenuated after adjusting for biological risk factors, suggesting that cardiometabolic risk factors may partly mediate the greenness to heart disease relationships. Conclusions Neighborhood greenness may be associated with reduced heart disease risk. Strategies to increase area greenness may be a future means of reducing heart disease at the population level.

Neighborhood Greenness and Chronic Health Conditions in Medicare Beneficiaries.

INTRODUCTION: Prior studies suggest that exposure to the natural environment may impact health. The present study examines the association between objective measures of block-level greenness (vegetative presence) and chronic medical conditions, including cardiometabolic conditions, in a large population-based sample of Medicare beneficiaries in Miami-Dade County, Florida. METHODS: The sample included 249,405 Medicare beneficiaries aged ≥65 years whose location (ZIP+4) within Miami-Dade County, Florida, did not change, from 2010 to 2011. Data were obtained in 2013 and multilevel analyses conducted in 2014 to examine relationships between greenness, measured by mean Normalized Difference Vegetation Index from satellite imagery at the Census block level, and chronic health conditions in 2011, adjusting for neighborhood median household income, individual age, gender, race, and ethnicity. RESULTS: Higher greenness was significantly associated with better health, adjusting for covariates: An increase in mean block-level Normalized Difference Vegetation Index from 1 SD less to 1 SD more than the mean was associated with 49 fewer chronic conditions per 1,000 individuals, which is approximately similar to a reduction in age of the overall study population by 3 years. This same level of increase in mean Normalized Difference Vegetation Index was associated with a reduced risk of diabetes by 14%, hypertension by 13%, and hyperlipidemia by 10%. Planned post-hoc analyses revealed stronger and more consistently positive relationships between greenness and health in lower- than higher-income neighborhoods. CONCLUSIONS: Greenness or vegetative presence may be effective in promoting health in older populations, particularly in poor neighborhoods, possibly due to increased time outdoors, physical activity, or stress mitigation.

Factors associated with contralateral preventive mastectomy.

INTRODUCTION: Contralateral prophylactic mastectomy (CPM) is an option for women who wish to reduce their risk of breast cancer or its local recurrence. There is limited data on demographic differences among patients who choose to undergo this procedure. METHODS: The population-based Florida cancer registry, Florida's Agency for Health Care Administration data, and US census data were linked and queried for patients diagnosed with invasive breast cancer from 1996 to 2009. The main outcome variable was the rate of CPM. Primary predictors were race, ethnicity, socioeconomic status (SES), marital status and insurance status. RESULTS: Our population was 91.1% White and 7.5% Black; 89.1% non-Hispanic and 10.9% Hispanic. Out of 21,608 patients with a single unilateral invasive breast cancer lesion, 837 (3.9%) underwent CPM. Significantly more White than Black (3.9% vs 2.8%; P<0.001) and more Hispanic than non-Hispanic (4.5% vs 3.8%; P=0.0909) underwent CPM. Those in the highest SES category had higher rates of CPM compared to the lowest SES category (5.3% vs 2.9%; P<0.001). In multivariate analyses, Blacks compared to Whites (OR =0.59, 95% CI =0.42-0.83, P=0.002) and uninsured patients compared to privately insured (OR =0.60, 95% CI =0.36-0.98, P=0.043) had significantly less CPM. CONCLUSION: CPM rates were significantly different among patients of different race, socio-economic class, and insurance coverage. This observation is not accounted for by population distribution, incidence or disease stage. More in-depth study of the causes of these disparities in health care choice and delivery is critically needed.

Native American race, use of the Indian Health Service, and breast and lung cancer survival in Florida, 1996-2007.

We evaluated associations of race, primary payer at diagnosis, and survival among patients diagnosed in Florida with lung cancer (n = 148,140) and breast cancer (n = 111,795), from 1996 through 2007. In multivariate models adjusted for comorbidities, tumor characteristics, and treatment factors, breast cancer survival was worse for Native American women than for white women (hazard ratio [HR], 1.52; 95% confidence interval [CI], 1.05-2.20) and for women using the Indian Health Service than for women using private insurance (HR, 1.71; 95% CI, 1.33-2.19). No survival association was found for Native American compared with white lung cancer patients or those using the Indian Health Service versus private insurance in fully adjusted models. Additional resources are needed to improve surveillance strategies and to reduce cancer burden in these populations.

Disparities in survival after female breast cancer diagnosis: a population-based study.

BACKGROUND: Despite advances in treatment and increased screening, female breast cancer survival is affected by race, ethnicity, and socioeconomic status (SES). The purpose of this study was to substantiate disparities in breast cancer mortality in a large and unique dataset containing 7 distinct racial groups, 31 comorbidities, demographic and clinical/pathological patient characteristics, and neighborhood poverty information. METHODS: Florida Cancer Data System registry (1996-2007) linked with the Agency for Health Care Administration and U.S. Census tract (n = 127,754) explored median survival and 1-, 3-, and 5-year survival rates by the Kaplan-Meier method. Log-rank tests compared survival curves by race/ethnicity/SES. Cox proportional hazards regression models were used to obtain unadjusted and adjusted hazard ratios (HR) and 95% confidence intervals. RESULTS: Native Americans had the lowest median survival (7.4 years) and Asians had the highest (12.6 years). For the univariate analysis, worse survival was seen for blacks (HR = 1.44; p < 0.001) and better survival for Asians (HR = 0.71; p < 0.001), Asian Indians or Pakistanis (HR = 0.65; p = 0.013), and Hispanics (HR = 0.92; p < 0.001). Multivariate analysis demonstrated sustained survival detriment for blacks (HR = 1.28; p < 0.001) and improved survival for Hispanics (HR = 0.90; p = 0.001). For SES, there was an incremental improvement in survival for each higher SES category in all analyses (p < 0.001). CONCLUSIONS: Utilizing a large enriched state cancer registry controlling for multiple demographic, clinical, and comorbidities, we fully explored survival disparities in female breast cancer and found certain aspects of race, ethnicity, and SES to remain significantly associated with breast cancer survival. More research is needed to uncover the source of these ongoing disparities.

Developing an urban community-campus partnership: lessons learned in infrastructure development and communication.

BACKGROUND: A low-income, African American neighborhood in Miami, Florida, experiences health disparities including an excess burden of cancer. Many residents are disenfranchised from the healthcare system, and may not participate in cancer prevention and screening services. OBJECTIVE: We sought to describe the development of a partnership between a university and this community and lessons learned in using a community-based participatory research (CBPR) model. METHODS: To better understand the community's health behaviors and status, a randomized door-to-door survey was conducted in collaboration with a community partner. LESSONS LEARNED: This collaboration helped foster a mutual understanding of the benefits of CBPR. We also describe challenges of adhering to study protocols, quality control, and sharing fiscal responsibility with organizations that do not have an established infrastructure. CONCLUSIONS: Understanding the organizational dynamics of a community is necessary for developing a CBPR model that will be effective in that community. Once established, it can help to inform future collaborations.

Development and preliminary results of the Financial Incentive Coercion Assessment questionnaire.

Financial incentives are often used in research, yet no measure exists to determine whether they lead to perceptions of coercion in subjects. We present a preliminary evaluation of a recently developed Financial Incentive Coercion Assessment (FICA) questionnaire. FICA measures perceived coercion specifically related to payment for participation in a research study. Two hundred sixty-six subjects were recruited from a large randomized controlled trial; 152 returned for a 6-month follow-up and completed the FICA. Approximately 30% of participants reported the major reason for participating was "for the money," but less than 5% felt that the financial incentives were coercive. FICA results are consistent with levels of perceived coercion using an alternative measure. Initial assessment of responses on the FICA suggests that it may provide a novel approach to measuring perceived coercion from financial incentives in research. Future work will refine the FICA and analyze its psychometric properties.

Effects of poverty and race on outcomes in acute myeloid leukemia.

OBJECTIVES: To determine how patient race, ethnicity, and degree of poverty affect treatment and survival for acute myeloid leukemia (AML). METHODS: A linked database of the Florida cancer registry and State inpatient and outpatient hospital data for 1998-2002 was queried. Effects of demographic and treatment characteristics on survival were explored using univariate and multivariate analyses methods. RESULTS: A total of 4659 patients with AML were identified. Over 50% of patients with AML were 70 years of age or older. African American (AA) patients were diagnosed at significantly younger ages than were whites (P < 0.001). In multivariate analysis, independent predictors of worse survival in AML were aged over 50 (hazard ratios [HRs]: 1.60, 2.15, 3.04, and 3.62 over the decade-cohorts, all P < 0.001), AA race (HR: 1.27, P < 0.001), being a former or current user of tobacco (HR: 1.13, P = 0.004 and HR: 1.28, P < 0.001, respectively), residing in an area with the highest poverty level (HR: 1.15, P = 0.007), and being covered only by Medicaid (HR: 1.23, P = 0.014). No differences in outcomes were observed related to gender or ethnicity. Receipt of chemotherapy was strongly associated with improved survival (HR: 0.59, P < 0.001). When only those patients who received and appeared to respond to treatment are included, AAs continued to demonstrate a worse outcome than Whites. CONCLUSIONS: AML disproportionately affects the elderly. AA patients and patients from poorer communities with AML have significantly worse survival. Interventions to provide earlier diagnosis in these patients as well as to improve overall outcomes are needed to address these disparities.

Relationship between clinical conditions and use of Veterans Affairs health care among Medicare-enrolled veterans.

OBJECTIVE: To determine how reliance on Veterans Affairs (VA) for medical care among veterans enrolled in Medicare is affected by medical conditions, access, and patient characteristics. DATA SOURCES/STUDY SETTING: Department of Veterans Affairs. STUDY DESIGN: We examined reliance on the VA for inpatient, outpatient, and overall medical care among all VA users in fiscal years 2003 and 2004 who were also enrolled in Medicare. We calculated the marginal effects of patient factors on VA reliance using fractional logistic regression; we also analyzed overall VA reliance separately for under-65 and age-65+ groups. The primary focus of this analysis was the relationship between aggregated condition categories (ACCs), which represent medical conditions, and reliance on the VA. PRINCIPAL FINDINGS: Mean VA reliance was significantly higher in the under-65 population than in the age-65+ group (0.800 versus 0.531). Lower differential distance to the VA, and higher VA-determined priority for health care, predicted higher VA reliance. Most individual ACCs were negatively associated with VA reliance, though substance abuse and mental health disorders were significantly associated with increased reliance on VA care. Conditions of the eyes and ears/nose/throat had positive marginal effect on VA reliance for the under 65, while diabetes was positive for age 65+. Among inpatients, veterans with ACCs for mental health conditions, eye conditions, amputations, or infectious and parasitic conditions had higher likelihood of a VA hospitalization than inpatients without these conditions. CONCLUSIONS: Many dually enrolled Veterans use both Medicare and VA health care. Age, accessibility, and priority level for VA services have a clear relationship with VA reliance. Because dual use is common, coordination of care among health care settings for such patients should be a policy priority.

What is the institutional financial impact of an MD-PhD program without extramural funding?

BACKGROUND: Training in the form of MD-PhD programs is an important part of the academic mission of medical schools, yet the costs incurred in providing these programs may be considerable. This research explores the financial impacts on a university of supporting an MD-PhD program. SUMMARY: We estimate the net financial impact of an MD-PhD program under a variety of assumptions about the financial gain that the school obtains through MD-PhD students' contributions to externally funded research. Under certain assumptions, the net financial impact of the MD-PhD program is positive, and under the most unfavorable assumptions the cost per student year is less than $30, 000. CONCLUSIONS: The apparent costs of an MD-PhD program are ameliorated or even turned into gains when one considers the resources generated by MD-PhD students. Thus, such programs can serve as a means of increasing external awards and improving the overall quality in graduate schools.

Do racial or socioeconomic disparities exist in lung cancer treatment?

BACKGROUND: Determine the effects of race, socioeconomic status, and treatment on outcomes for patients diagnosed with lung cancer. METHODS: The Florida cancer registry and inpatient and ambulatory data were queried for patients diagnosed from 1998-2002. RESULTS: A total 76,086 of lung cancer patients were identified. Overall, 55.6% were male and 44.4% were female. The demographic distribution of patients was 92.7% Caucasian, 6.7% African American, and 5.7% Hispanic. The mean age of diagnosis was 70 years old. African American patients presented at a younger age, with more advanced disease, and were less likely to undergo surgical therapy than their Caucasian counterparts. Median survival time (MST) for the entire cohort was 8.7 months, while MST for African American patients was 7.5 months. Patients who received surgery, chemotherapy, or radiation therapy demonstrated significantly improved outcomes. Stepwise multivariate analysis revealed that African American race was no longer a statistically significant predictor of worse outcomes once corrections were made for demographics and comorbid conditions, suggesting that the originally reported disparities in lung cancer outcomes and race may be in part because of poor pretreatment performance status. In contrast, patients of the lowest socioeconomic status continue to have a slightly worse overall prognosis than their affluent counterparts (hazard ratio = 1.05, P = .001). CONCLUSIONS: Lung cancer continues to carry a poor prognosis for all patients. Once comorbidities are corrected for, African American patients carry equivalently poor outcomes. Nonetheless, emphasis must be placed on improving pretreatment performance status among African American patients and efforts for earlier diagnosis among the impoverished patients must be made.

Are patients of low socioeconomic status receiving suboptimal management for pancreatic adenocarcinoma?

BACKGROUND: The objective of this study was to define the effects of socioeconomic status (SES) and other demographic variables on outcomes for patients with pancreatic adenocarcinoma. METHODS: Florida cancer registry and inpatient hospital data were queried for pancreatic adenocarcinoma diagnosed from 1998 to 2002. RESULTS: In total, 16,104 patients were identified. Low SES (LSES) patients were younger at diagnosis (P < .001) but presented with similar disease stage and tumor grade. LSES patients were less likely to receive surgical extirpation (16.5% vs 19.8%; P < .001), chemotherapy (30.7% vs 36.4%; P < .001), or radiotherapy (14.3% vs 16.9%; P = .003). Among surgical patients, 30-day mortality was significantly higher (5.1% vs 3.7%; P < .001) and overall median survival was significantly worse (5.0 months vs 6.2 months; P < .001) in the LSES cohorts. Although surgical patients who were treated at teaching facilities (TF) did significantly better; an increased 30-day surgical mortality (2.2% vs 1.3%; P < .001) and decreased median survival (5 months for poverty level >15% vs 6.2 months for poverty level <5%; P < .001) also were observed for patients of LSES. In a multivariate analysis that corrected for patient comorbidities, significant independent predictors of a poorer prognosis included LSES (hazard ratio [HR], 1.09); treatment at a non-TF (HR, 1.09); and failure to receive surgical extirpation (HR, 1.92), chemotherapy (HR 1.41), or radiation (HR 1.25). CONCLUSIONS: Patients of LSES were less likely to receive surgical extirpation, chemotherapy, or radiation and had significantly higher perioperative and long-term mortality rates. A greater understanding of the barriers to providing optimal care and identifying means for improving successful delivery of therapies to the poor with pancreatic cancer are needed.

The association of Medicare drug coverage with use of evidence-based medications in the Veterans Health Administration.

BACKGROUND: Veterans with Medicare managed-care plans have access to pharmacy benefits outside the Veterans Health Administration (VA), but how this coverage affects use of medications for specific disease conditions within the VA is unclear. OBJECTIVE: To examine patterns of pharmacotherapy among patients with diabetes mellitus, ischemic heart disease, and chronic heart failure enrolled in fee-for-service (FFS) or managed-care (HMO) plans and to test whether pharmacy benefit coverage within Medicare is associated with the receipt of evidence-based medications in the VA. METHODS: A retrospective analysis of veterans dually enrolled in the VA and Medicare healthcare systems was conducted. We used VA and Medicare administrative data from 2002 in multivariable logistic regression analysis to determine the unique association of enrollment in Medicare FFS or managedcare plans on the use of medications, after adjusting for sociodemographic, geographic, and patient clinical factors. RESULTS: A total of 369,697 enrollees met inclusion criteria for diabetes, ischemic heart disease, or chronic heart failure. Among patients with diabetes, adjusted odds ratios (ORs) of receiving angiotensin-converting enzyme (ACE) inhibitors and oral hypoglycemics in the FFS group were, respectively, 0.86 and 0.80 (p < 0.001). Among patients with ischemic heart disease, FFS patients were generally less likely to receive beta-blockers, antianginals, and statins. Among patients with chronic heart failure, adjusted ORs of receiving ACE inhibitors, angiotensin-receptor blockers, and statins in the FFS group were, respectively, 0.90, 0.78, and 0.79 (all p < 0.05). There were few systematic differences within HMO coverage levels. CONCLUSIONS: FFS-enrolled veterans were generally less likely to be receiving condition-related medications from the VA, compared with HMO-enrolled veterans with lower levels of prescription drug coverage. Pharmacy prescription coverage within Medicare affects the use of evidence-based medications for specific disease conditions in the VA.

VHA pharmacy use in veterans with Medicare drug coverage.

OBJECTIVE: To determine how Medicare benefits affect veterans' use of Veterans Health Administration (VHA) pharmacy services. STUDY DESIGN: Retrospective analysis of veterans dually enrolled in the Veterans Health Administration and Medicare healthcare systems. METHODS: We used VHA and Medicare administrative data for calendar year 2002 to examine the effect of Medicare HMO pharmacy benefit levels on VHA pharmacy use. RESULTS: In 2002, 64% of the VHA and Medicare dually enrolled veterans in our study sample received medications from the VHA. Use of VHA pharmacy services varied monotonically by the level of pharmacy benefits among Medicare HMO enrollees, with veterans enrolled in plans with both low and high pharmacy benefit levels significantly less likely to use VHA pharmacy services than veterans in plans with no pharmacy benefits (odds ratios = .83 and .53, respectively, versus plans with no benefits). Among VHA pharmacy users, enrollment in plans with high levels of benefits was associated with significantly lower annual pharmacy costs than enrollment in plans with no benefits or enrollment in traditional Medicare. CONCLUSIONS: Our findings indicate that non-VHA pharmacy benefits affect both the likelihood and magnitude of VHA pharmacy use. This suggests that Medicare pharmacy coverage (Part D) may significantly reduce the demand for VHA pharmacy services, particularly in geographic regions previously underserved by Medicare managed care plans.

Method to develop health care peer groups for quality and financial comparisons across hospitals.

OBJECTIVE: To develop and explore the characteristics of a novel "nearest neighbor" methodology for creating peer groups for health care facilities. DATA SOURCES: Data were obtained from the Department of Veterans Affairs (VA) databases. STATISTICAL METHODS AND FINDINGS: Peer groups are developed by first calculating the multidimensional Euclidean distance between each of 133 VA medical centers based on 16 facility characteristics. Each medical center then serves as the center for its own peer group, and the nearest neighbor facilities in terms of Euclidean distance comprise the peer facilities. We explore the attributes and characteristics of the nearest neighbor peer groupings. In addition, we construct standard cluster analysis-derived peer groups and compare the characteristics of groupings from the two methodologies. CONCLUSIONS: The novel peer group methodology presented here results in groups where each medical center is at the center of its own peer group. Possible advantages over other peer group methodologies are that facilities are never on the "edge" of a group and group size-and thus group dispersion-is determined by the researcher. Peer groups with these characteristics may be more appealing to some researchers and administrators than standard cluster analysis and may thus strengthen organizational buy-in for financial and quality comparisons.