Automated Assessment of Thoracic-Abdominal Asynchrony in Patients with Morquio Syndrome.

Morquio syndrome is a rare disease caused by a disorder in the storage of mucopolysaccharides that affects multiple organs, including musculoskeletal, respiratory, cardiovascular, and digestive systems. Respiratory failure is one of the leading causes of mortality in Morquio patients; thus, respiratory function testing is vital to the management of the disease. An automated respiratory assessment methodology using the pneuRIP device and a machine-learning algorithm was developed. pneuRIP is a noninvasive approach that uses differences between thoracic and abdominal movements (thoracic-abdominal asynchrony) during respiration to assess respiratory status. The technique was evaluated on 17 patients with Morquio (9 females and 8 males) between the ages of 2 and 57 years. The results of the automated technique agreed with the clinical assessment in 16 out of the 17 patients. It was found that the inverse cumulative percentage representation of the time delay between the thorax and abdomen was the most critical variable for accurate evaluation. It was demonstrated that the technique could be successfully used on patients with Morquio who have difficulty breathing with 100% compliance. This technique is highly accurate, portable, noninvasive, and easy to administer, making it suitable for a variety of settings, such as outpatient clinics, at home, and emergency rooms.

Tracking Cardiac Rehabilitation Participation and Completion Among Medicare Beneficiaries to Inform the Efforts of a National Initiative.

BACKGROUND: Despite cardiac rehabilitation (CR) being shown to improve health outcomes among patients with heart disease, its use has been suboptimal. In response, the Million Hearts Cardiac Rehabilitation Collaborative developed a road map to improve CR use, including increasing participation rates to ≥70% by 2022. This observational study provides current estimates to measure progress and identifies the populations and regions most at risk for CR service underutilization. METHODS AND RESULTS: We identified Medicare fee-for-service beneficiaries who were CR eligible in 2016, and assessed CR participation (≥1 CR session attended), timely initiation (participation within 21 days of event), and completion (≥36 sessions attended) through 2017. Measures were assessed overall, by beneficiary characteristics and geography, and by primary CR-qualifying event type (acute myocardial infarction hospitalization; coronary artery bypass surgery; heart valve repair/replacement; percutaneous coronary intervention; or heart/heart-lung transplant). Among 366 103 CR-eligible beneficiaries, 89 327 (24.4%) participated in CR, of whom 24.3% initiated within 21 days and 26.9% completed CR. Eligibility was highest in the East South Central Census Division (14.8 per 1000). Participation decreased with increasing age, was lower among women (18.9%) compared with men (28.6%; adjusted prevalence ratio: 0.91 [95% CI, 0.90-0.93]) was lower among Hispanics (13.2%) and non-Hispanic blacks (13.6%) compared with non-Hispanic whites (25.8%; adjusted prevalence ratio: 0.63 [0.61-0.66] and 0.70 [0.67-0.72], respectively), and varied by hospital referral region and Census Division (range: 18.6% [East South Central] to 39.1% [West North Central]) and by qualifying event type (range: 7.1% [acute myocardial infarction without procedure] to 55.3% [coronary artery bypass surgery only]). Timely initiation varied by geography and qualifying event type; completion varied by geography. CONCLUSIONS: Only 1 in 4 CR-eligible Medicare beneficiaries participated in CR and marked disparities were observed. Reinforcement of current effective strategies and development of new strategies will be critical to address the noted disparities and achieve the 70% participation goal.

An Investigation of Interrater Reliability for the Rorschach Performance Assessment System (R-PAS) in a Nonpatient U.S. Sample.

The Rorschach Performance Assessment System (R-PAS) aims to provide an evidence-based approach to administration, coding, and interpretation of the Rorschach Inkblot Method (RIM). R-PAS analyzes individualized communications given by respondents to each card to code a wide pool of possible variables. Due to the large number of possible codes that can be assigned to these responses, it is important to consider the concordance rates among different assessors. This study investigated interrater reliability for R-PAS protocols. Data were analyzed from a nonpatient convenience sample of 50 participants who were recruited through networking, local marketing, and advertising efforts from January 2013 through October 2014. Blind recoding was used and discrepancies between the initial and blind coders' ratings were analyzed for each variable with SPSS yielding percent agreement and intraclass correlation values. Data for Location, Space, Contents, Synthesis, Vague, Pairs, Form Quality, Populars, Determinants, and Cognitive and Thematic codes are presented. Rates of agreement for 1,168 responses were higher for more simplistic coding (e.g., Location), whereas agreement was lower for more complex codes (e.g., Cognitive and Thematic codes). Overall, concordance rates achieved good to excellent agreement. Results suggest R-PAS is an effective method with high interrater reliability supporting its empirical basis.

Use of and spending on supportive care medications among Medicare beneficiaries with cancer.

PURPOSE: The study objective was to provide population-based estimates of supportive care medication (SCM) use among Medicare beneficiaries with cancer and determine factors related to SCM receipt. METHODS: This retrospective cohort study of community-based Medicare beneficiaries used the Medicare Current Beneficiary Survey (1997­2007). Dependent variables comprised use and spending on SCMs for three medication classes: opioids, antidepressants/sedative/hypnotics (ASH), and antiemetics. Independent variables of interest were supplemental insurance coverage, cancer site, and treatment. Multivariate models determined factors affecting receipt of, and spending on, SCMs. We also compared SCM use and spending among beneficiaries with and without cancer in order to understand what portion of SCM use and spending could be attributed to cancer as opposed to other comorbid conditions. RESULTS: A total of 1,836 Medicare beneficiaries with cancer and 9,898 beneficiaries without cancer were eligible for the study. Beneficiaries with cancer were more likely to receive opioids, ASH, and antiemetics compared to non-cancer beneficiaries. Adjusted annual payments for antiemetics were on average $637 higher in with cancer versus without cancer (p<0.01), while ASH payments were $184 lower (p<0.01). Opioid spending was similar among cancer and non-cancer users. Relative to colon cancer, beneficiaries with prostate cancer were least likely to receive any of the three SCM classes. Receipt of antineoplastic treatment increased the probability of use of all three classes of SCMs. Insurance coverage did not influence the use of or spending on opioids or antiemetics, but was associated with both outcomes for ASH. The use of all three SCM classes was significantly lower during years before Part D implementation of the new Medicare Part D prescription drug benefit and was higher after implementation of Part D. CONCLUSION: This study provides population-based information on SCM use among Medicare beneficiaries with cancer. Cancer site and treatment modality were important predictors of SCM use.

The effect of supplemental medical and prescription drug coverage on health care spending for Medicare beneficiaries with cancer.

OBJECTIVES: To examine whether patients with newly diagnosed cancer respond differently to supplemental coverage than the general Medicare population. METHODS: A cohort of newly diagnosed cancer patients (n = 1,799) from the 1997-2007 Medicare Current Beneficiary Survey and a noncancer cohort (n = 9,726) were identified and matched by panel year. Two-year total medical care spending was estimated by using generalized linear models with gamma distribution and log link-including endogeneity-corrected models. Interactions between cancer and type of insurance allowed testing for differential effects of a cancer diagnosis. RESULTS: The cancer cohort spent an adjusted $15,605 more over 2 years than did the noncancer comparison group. Relative to those without supplemental coverage, beneficiaries with employer-sponsored insurance, other private with prescription drug coverage, and public coverage had significantly higher total spending ($3,510, $2,823, and $4,065, respectively, for main models). For beneficiaries with cancer, supplemental insurance effects were similar in magnitude yet negative, suggesting little net effect of supplemental insurance for cancer patients. The endogeneity-corrected models produced implausibly large main effects of supplemental insurance, but the Cancer × Insurance interactions were similar in both models. CONCLUSIONS: Medicare beneficiaries with cancer are less responsive to the presence and type of supplemental insurance than are beneficiaries without cancer. Proposed restrictions on the availability of supplemental insurance intended to reduce Medicare spending would be unlikely to limit expenditures by beneficiaries with cancer, but would shift the financial burden to those beneficiaries. Policymakers should consider welfare effects associated with coverage restrictions.

How Medicare Part D benefit phases affect adherence with evidence-based medications following acute myocardial infarction.

OBJECTIVE: Assess impact of Medicare Part D benefit phases on adherence with evidence-based medications after hospitalization for an acute myocardial infarction. DATA SOURCE: Random 5 percent sample of Medicare beneficiaries. STUDY DESIGN: Difference-in-difference analysis of drug adherence by AMI patients stratified by low-income subsidy (LIS) status and benefit phase. DATA COLLECTION/EXTRACTION METHODS: Subjects were identified with an AMI diagnosis in Medicare Part A files between April 2006 and December 2007 and followed until December 2008 or death (N = 8,900). Adherence was measured as percent of days covered (PDC) per month with four drug classes used in AMI treatment: angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs), beta-blockers, statins, and clopidogrel. Monthly exposure to Part D benefit phases was calculated from flags on each Part D claim. PRINCIPAL FINDINGS: For non-LIS enrollees, transitioning from the initial coverage phase into the Part D coverage gap was associated with statistically significant reductions in mean PDC for all four drug classes: statins (-7.8 percent), clopidogrel (-7.0 percent), beta-blockers (-5.9 percent), and ACE inhibitor/ARBs (-5.1 percent). There were no significant changes in adherence associated with transitioning from the gap to the catastrophic coverage phase. CONCLUSIONS: As the Part D doughnut hole is gradually filled in by 2020, Medicare Part D enrollees with critical diseases such as AMI who rely heavily on brand name drugs are likely to exhibit modest increases in adherence. Those reliant on generic drugs are less likely to be affected.

Out-of-pocket health care expenditure burden for Medicare beneficiaries with cancer.

BACKGROUND: There is increasing concern regarding the financial burden of care on cancer patients and their families. Medicare beneficiaries often have extensive comorbidities and limited financial resources, and may face substantial cost sharing even with supplemental coverage. In the current study, the authors examined out-of-pocket (OOP) spending and burden relative to income for Medicare beneficiaries with cancer. METHODS: This retrospective, observational study pooled data for 1997 through 2007 from the Medicare Current Beneficiary Survey linked to Medicare claims. Medicare beneficiaries with newly diagnosed cancer were selected using claims-based diagnoses. Generalized linear models were used to estimate OOP spending. Logistic regression models identified factors associated with a high OOP burden, defined as spending > 20% of one's income during the cancer diagnosis and subsequent year. RESULTS: The cohort included 1868 beneficiaries with and 10,047 without cancer. Compared with the noncancer cohort, cancer patients were older, had more comorbidities, and were more likely to lack supplemental coverage. The mean OOP spending for cancer patients was $4727. Cancer patients faced an adjusted $976 (P < .01) incremental OOP spending. Greater than one-quarter (28%) of beneficiaries with cancer experienced a high OOP burden compared with 16% of beneficiaries without cancer (P < .001). Supplemental insurance and higher income were found to be protective against a high OOP burden, whereas assets, comorbidity, and receipt of cancer-directed radiation and antineoplastic therapy were associated with a higher OOP burden. CONCLUSIONS: Medicare beneficiaries with cancer face a higher OOP burden than their counterparts without cancer; some of the higher burden was explained by the higher comorbidity burden and lack of supplemental insurance noted among these patients. Financial pressures may discourage some elderly patients from pursuing treatment.

Use and spending on antineoplastic therapy for Medicare beneficiaries with cancer.

BACKGROUND: Oral antineoplastic drugs, not generally covered by Medicare Part B, have assumed an increasingly important role in cancer treatment. OBJECTIVE: We examined use and spending on infused/injected (Part B covered) and non-Part B antineoplastic agents in a Medicare beneficiary population with cancer, and the effect of supplemental insurance. RESEARCH DESIGN: This retrospective, observational study used pooled 1997-2007 data from the Medicare Current Beneficiary Survey, linked to Medicare claims. Logistic regression models identified factors associated with antineoplastic use. Generalized linear models were used to estimate spending among antineoplastic users. POPULATION STUDIED: A total of 1836 Medicare beneficiaries with newly diagnosed cancer were selected based on the presence of claims-based diagnoses after a 12-month washout period. RESULTS: Five hundred fifty-nine (31.0%) Medicare beneficiaries received antineoplastic therapy; 395 (21.3%) used Part B, 253 (14.6%) used non-Part B antineoplastics. Spending per user was $7841 (any), $10,364 (Part B), and $1535 for non-Part B antineoplastics. Supplemental insurance was associated with antineoplastic use. Primary cancer site and age were key predictors of spending among users. Spending on non-Part B antineoplastics increased during 2006-2007 relative to 2004-2005 but time trends were not significant in multivariate analysis. CONCLUSIONS: Antineoplastic therapy use by Medicare beneficiaries is sensitive to the presence but not type of supplemental insurance. Non-Part B therapy was used by a relatively large proportion of beneficiaries with cancer receiving therapy, although spending was less than for Part B therapy. Monitoring the role of supplemental insurance, and particularly the role of Medicare Part D is a critical area for ongoing research.

Medication adherence and Medicare expenditure among beneficiaries with heart failure.

OBJECTIVES: To (1) measure utilization of and adherence to heart failure medications and (2) assess whether better adherence is associated with lower Medicare spending. STUDY DESIGN: Pooled cross-sectional design using six 3-year cohorts of Medicare beneficiaries with congestive heart failure (CHF) from 1997 through 2005 (N = 2204). METHODS: Adherence to treatment was measured using average daily pill counts. Bivariate and multivariate methods were used to examine the relationship between medication adherence and Medicare spending. Multivariate analyses included extensive variables to control for confounding, including healthy adherer bias. RESULTS: Approximately 58% of the cohort were taking an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), 72% a diuretic, 37% a beta-blocker, and 34% a cardiac glycoside. Unadjusted results showed that a 10% increase in average daily pill count for ACE inhibitors or ARBs, beta-blockers, diuretics, or cardiac glycosides was associated with reductions in Medicare spending of $508 (not significant [NS]), $608 (NS), $250 (NS), and $1244 (P <.05), respectively. Estimated adjusted marginal effects of a 10% increase in daily pill counts for beta-blockers and cardiac glycosides were reductions in cumulative 3-year Medicare spending of $510 to $561 and $750 to $923, respectively (P <.05). CONCLUSIONS: Higher levels of medication adherence among Medicare beneficiaries with CHF were associated with lower cumulative Medicare spending over 3 years, with savings generally exceeding the costs of the drugs in question.

Simulated value-based insurance design applied to statin use by Medicare beneficiaries with diabetes.

OBJECTIVE: To examine cost responsiveness and total costs associated with a simulated "value-based" insurance design for statin therapy in a Medicare population with diabetes. METHODS: Four-year panels were constructed from the 1997-2005 Medicare Current Beneficiary Survey selected by self-report or claims-based diagnoses of diabetes in year 1 and use of statins in year 2 (N = 899). We computed the number of 30-day statin prescription fills, out-of-pocket and third-party drug costs, and Medicare Part A and Part B spending. Multivariate ordinary least squares regression models predicted statin fills as a function of out-of-pocket costs, and a generalized linear model with log link predicted Medicare spending as a function of number of fills, controlling for baseline characteristics. Estimated coefficients were used to simulate changes in fills associated with co-payment caps from $25 to $1 and to compute changes in third-party payments and Medicare cost offsets associated with incremental fills. Analyses were stratified by patient cardiovascular event risk. RESULTS: A simulated out-of-pocket price of $25 [$1] increased plan drug spending by $340 [$794] and generated Medicare Part A/B savings of $262 [$531]; savings for high-risk patients were $558 [$1193], generating a net saving of $249 [$415]. CONCLUSIONS: Reducing statin co-payments for Medicare beneficiaries with diabetes resulted in modestly increased use and reduced medical spending. The value-based insurance design simulation strategy met financial feasibility criteria but only for higher-risk patients.

Association of chronic obstructive pulmonary disease maintenance medication adherence with all-cause hospitalization and spending in a Medicare population.

BACKGROUND: Although maintenance medications are a cornerstone of chronic obstructive pulmonary disease (COPD) management, adherence remains suboptimal. Poor medication adherence is implicated in poor outcomes with other chronic conditions; however, little is understood regarding links between adherence and outcomes in COPD patients. OBJECTIVE: This study investigates the association of COPD maintenance medication adherence with hospitalization and health care spending. METHODS: Using the 2006 to 2007 Chronic Condition Warehouse administrative data, this retrospective cross-sectional study included 33,816 Medicare beneficiaries diagnosed with COPD who received at least 2 prescriptions for ≥1 COPD maintenance medications. After a 6-month baseline period (January 1, 2006 to June 30, 2006), beneficiaries were followed through to December 31, 2007 or death. Two medication adherence measures were assessed: medication continuity and proportion of days covered (PDC). PDC values ranged from 0 to 1 and were calculated as the number of days with any COPD maintenance medication divided by duration of therapy with these agents. The association of adherence with all-cause hospital events and Medicare spending were estimated using negative binomial and γ generalized linear models, respectively, adjusting for sociodemographics, Social Security disability insurance status, low-income subsidy status, comorbidities, and proxy measures of disease severity. RESULTS: Improved adherence using both measures was significantly associated with reduced rate of all-cause hospitalization and lower Medicare spending. Patients who continued with their medications had lower hospitalization rates (relative rate [RR] = 0.88) and lower Medicare spending (-$3764), compared with patients who discontinued medications. Similarly, patients with PDC ≥0.80 exhibited lower hospitalization rates (RR = 0.90) and decreased spending (-$2185), compared with patients with PDC <0.80. CONCLUSIONS: COPD patients with higher adherence to prescribed regimens experienced fewer hospitalizations and lower Medicare costs than those who exhibited lower adherence behaviors. Findings suggested the clinical and economic importance of medication adherence in the management of COPD patients in the Medicare population.

Does medication adherence lower Medicare spending among beneficiaries with diabetes?

OBJECTIVE: To measure 3-year medication possession ratios (MPRs) for renin-angiotensin-aldosterone system (RAAS) inhibitors and statins for Medicare beneficiaries with diabetes, and to assess whether better adherence is associated with lower spending on traditional Medicare services controlling for biases common to previous adherence studies. DATA SOURCE: Medicare Current Beneficiary Survey data from 1997 to 2005. STUDY DESIGN: Longitudinal study of RAAS-inhibitor and statin utilization over 3 years. DATA COLLECTION: The relationship between MPR and Medicare costs was tested in multivariate models with extensive behavioral variables to control for indication bias and healthy adherer bias. PRINCIPAL FINDINGS: Over 3 years, median MPR values were 0.88 for RAAS-I users and 0.77 for statin users. Higher adherence was strongly associated with lower Medicare spending in the multivariate analysis. A 10 percentage point increase in statin MPR was associated with U.S.$832 lower Medicare spending (SE=219; p<.01). A 10 percentage point increase in MPR for RAAS-Is was associated with U.S.$285 lower Medicare costs (SE=114; p<.05). CONCLUSIONS: Higher adherence with RAAS-Is and statins by Medicare beneficiaries with diabetes results in lower cumulative Medicare spending over 3 years. At the margin, Medicare savings exceed the cost of the drugs.

Residential and health care transition patterns among older medicare beneficiaries over time.

PURPOSE: To describe annual care transition patterns across residential and health care settings and assess consistency in care transition patterns across years. DESIGN AND METHODS: This retrospective cohort study used the Medicare Current Beneficiary Survey (2000-2005). The sample comprised beneficiaries aged 65 years and older (N = 57,684 person-years of observation). We defined annual care transition patterns by combining 4 types of settings: C (community), F (facility), S (skilled nursing facility-SNF), and H (hospital). We compared weighted frequencies of transition patterns across years. We counted repeated/multiple transitions that involved movement into hospital and SNF settings and compared them by demographic characteristics. RESULTS: Care transition patterns remained consistent from year to year. Approximately 22% of the study population experienced a transition annually. The most frequent transition pattern was transition to the hospital and back. Care transition patterns were enormously heterogeneous with more than 230 unique patterns; approximately 1 in 4 community-dwelling (∼23%) and most facility-dwelling (∼60%) beneficiaries with at least one transition had a unique transition pattern. Beneficiaries residing in a facility were more likely to undergo multiple transitions to hospitals and SNFs compared with community-dwelling beneficiaries. IMPLICATIONS: The study provides a description of annual care transition patterns across six years. Knowledge of the consistency of care transition patterns may serve as a baseline from which to compare future patterns and aid in designing interventions targeted at specific transitions.

Changing patterns in medication use with increasing probability of death for older Medicare beneficiaries.

OBJECTIVES: To determine whether use of symptom relief drugs (e.g., antidepressants, anxiolytics, opioid analgesics, sleep aids) rises and use of two commonly prescribed classes of chronic medications (statins and osteoporosis drugs) falls with greater probability of death for older Medicare beneficiaries. DESIGN: Pooled cross-sectional study. SETTING: Noninstitutionalized older Medicare population in 2000 to 2005. PARTICIPANTS: Community-dwelling Medicare beneficiaries aged 65 and older (N=20,233). MEASUREMENTS: Use of medications measured according to dichotomous flags; intensity of use by annual medication fills. Annual probability of death modeled using logistic regression and stratified into seven groups with predicted probabilities of death that range from less than 5% to greater than 50%. Prevalence of use and intensity (mean prescription fills per month) were computed for each class of medication. RESULTS: For symptom relief medications, there is relatively constant use with increasing probability of death, along with greater intensity of use. For the two chronic medications, there was a monotonic decrease in use but at a relatively constant intensity. Decline in statin use ranged from 34.4% in the lowest mortality stratum to 17.6% for those in the highest (P<.001). Use of osteoporosis drugs fell from 10.4% to 6.6% over the same range (P<.001). CONCLUSION: Greater intensity of use of symptom relief medications with increasing probability of death is consistent with hypothesized use. The different profile for chronic medications suggests that the time to benefit is being considered regarding therapy initiation, which results in lower use.

Does influenza vaccination of older adult Medicare beneficiaries lower treatment costs for acute and chronic respiratory disease?

BACKGROUND: Influenza accounts for a large proportion of hospitalizations and deaths among older adults, resulting in substantial health care expenses. Influenza vaccinations are effective in reducing respiratory infections in younger populations, but it is less certain whether they reduce costs associated with respiratory infections among older adults. OBJECTIVE: The purpose of this study was to determine whether influenza vaccination of older adult Medicare beneficiaries reduced costs associated with acute and chronic respiratory conditions during 3 recent influenza seasons. METHODS: This study analyzed the relationship between influenza vaccination and costs for respiratory conditions among Medicare beneficiaries >or=55 years of age in influenza seasons (October-May) between 2002 and 2005 using data from the Medicare Current Beneficiary Survey. Two-part multiple regressions of vaccination status were estimated on the probability and cost of treating respiratory conditions in each influenza season controlling for influenza risk factors and other covariates. Various sensitivity tests were conducted by type of service, subgroup analysis for specific population risk segments, propensity score-matched comparisons, and difference equations. RESULTS: The study sample included 13,402 Medicare beneficiaries for the 3 influenza seasons examined. Vaccination rates varied between 67.3% and 74.9% over the 3 influenza seasons. In unadjusted comparisons, no significant difference in the cost of treating respiratory conditions was found between vaccinated and unvaccinated beneficiaries in 2002/2003 (-$104), but vaccinated beneficiaries had significantly higher mean cost differentials in the more recent influenza seasons ($258 in 2003/2004, P = 0.012; $254 in 2004/2005, P = 0.003). Based on 2-part multiple regressions of vaccine status over the 3 seasons combined, costs of respiratory conditions were $142 dollars higher on average for vaccinated beneficiaries (P = 0.014). The base regression models showed no significant cost savings from vaccination in any year. Results of 2 of the 54 sensitivity tests that were conducted indicated significant savings from vaccination (inpatient costs for 2002/2003 and difference in total costs for persons unvaccinated in 2002/2003 but vaccinated in 2003/2004). CONCLUSION: In this study of older adults, no significant cost savings were found with influenza vaccines in the 3 influenza seasons examined (2002-2005) when the outcome was measured in terms of differential spending for acute and chronic respiratory conditions.

Lessons learned: who didn't enroll in Medicare drug coverage in 2006, and why?

The law that created Medicare's prescription drug benefit, Medicare Part D, also established extra help for low-income seniors in the form of a subsidy. This study, the first in-depth analysis of Part D enrollment among Medicare beneficiaries without prior drug coverage, finds that 63 percent of all eligible seniors and 69 percent of low-income beneficiaries were enrolled in Part D in 2006. However, only 29 percent of low-income beneficiaries were enrolled in the subsidy program, leaving millions without coverage. Many reported that premiums were too costly, enrollment too difficult, and information too hard to obtain for enrollment. Additionally, provisions of the recently enacted Patient Protection and Affordable Care Act may have the perverse impact of reducing enrollment in Part D for certain beneficiaries. Our findings emphasize the need to expand eligibility and improve policies to foster enrollment.

Impact of maintenance therapy on hospitalization and expenditures for Medicare beneficiaries with chronic obstructive pulmonary disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is associated with high levels of hospitalization and health care expenditures among the aged. Adherence to appropriate maintenance drug regimens has been reported to reduce hospitalization and health care spending in clinical trials. However, little research has been conducted to compare use versus nonuse of these medications in terms of health-related outcomes in routine practice. OBJECTIVE: The purpose of this study was to compare differences between users and nonusers of maintenance medications in terms of selected outcomes for a nationally representative sample of Medicare beneficiaries with COPD. METHODS: The study sample was selected from Medicare Current Beneficiary Surveys conducted between 1997 and 2005. Beneficiaries with COPD who used ≥1 maintenance medication annually were compared with nonusers on 3 claims-based outcomes: any hospitalization, any rehospitalization within 31 days, and total annual Medicare expenditures. RESULTS: The study sample consisted of 6322 Medicare beneficiaries who contributed a total of 9161 person-year observations for analysis. Over the 9-year study period, 39.9% (3659/9161) of the person-year observations were recorded for maintenance medication users, and 60.1% (5502/9161) were recorded for nonusers. Most of the observations for medication users involved beneficiaries who were female (50.1% [1833/3659]), non-Hispanic white (85.4% [3124/3659]), and ≥65 years of age (88.2% [3228/3659]); most of the observations for nonusers involved beneficiaries who were male (51.9% [2855/5502]), non-Hispanic white (82.7% [4550/5502]), and ≥65 years of age (88.1% [4848/5502]). Annually, 40% of the sample filled prescriptions for COPD maintenance medications. In multivariate models, maintenance drug users were less likely than nonusers to be hospitalized (odds ratio [OR] = 0.70; 95% CI, 0.61 to 0.79) or rehospitalized (OR= 0.74; 95% CI, 0.63 to 0.87), and had significantly lower annual Medicare expenditures (-$3916; 95% CI, -$4977 to -$2854). CONCLUSIONS: In this comparison of users and nonusers of maintenance medication for COPD, use of maintenance therapy was associated with significantly lower risks of hospitalization and rehospitalization and reduced Medicare expenditures.

Association of antipsychotic use with hospital events and mortality among medicare beneficiaries residing in long-term care facilities.

OBJECTIVE: Antipsychotic (AP) utilization has grown significantly in long-term care (LTC) settings. Although a growing literature associates AP use with higher mortality in elderly with dementia, the association of APs with hospital events is unclear. The authors examine prevalence and trends in AP use by Medicare beneficiaries residing in LTC and the association of APs and other drug use variables with hospital events and mortality. DESIGN: Retrospective analysis using sequential multivariate Cox proportional hazards models. SETTING: Medicare Current Beneficiary Survey linked to Institutional Drug Administration and Minimum Data Set files. PARTICIPANTS: A total of 2,363 LTC Medicare beneficiaries, 1999-2002. MEASUREMENTS: Trends in LTC AP use overall and by type and duplicative use; association of AP utilization and two outcomes: hospital events and all-cause mortality. RESULTS: AP use rose markedly from 1999 to 2002 (26.4%-35.9%), predominantly due to increased use of atypical agents. After controlling for sociodemographic and clinical factors, AP use is not related to hospital events (hazard ratio [HR] = 0.98, 95% confidence interval [CI] = 0.82-1.63 p = 0.7951). AP use is associated with reduced mortality in unadjusted and intermediate models, but loss of significance in the final model (HR = 0.83, 95% CI = 0.69-1.00, p = 0.0537) suggests that disease and drug burden factors may confound the AP-mortality relationship. CONCLUSION: This study provides no evidence of increased hospital events or mortality in LTC residents who use AP medications. Findings contribute to a growing body of evidence that APs, particularly atypical agents, may be associated with reduced mortality in LTC residents.