Cross-sectional study estimating the psychosocial impact of genital warts and other anogenital diseases in South Korea.

OBJECTIVES: To estimate self-reported human papillomavirus (HPV) disease-related psychosocial impact among male and female patients in South Korea. DESIGN: In this multicentre cross-sectional study, psychosocial impacts were estimated using a one-time survey capturing HPV Impact Profile (HIP) results, CuestionarioEspecifico en Condilomas Acuminados (CECA; in Spanish)-'Specific questionnaire for Condylomata Acuminata' and the EuroQol-5 Dimension (EQ-5D) surveys. Student's t-tests or Mann-Whitney U tests were used for continuous comparisons; χ2 or Fisher's exact tests were applied for categorical comparisons. SETTING: 5098 clinics throughout Seoul, Busan, Daegu, Kwangju and Daejeon (South Korea). PARTICIPANTS: Patients with and without genital warts (GW) (males) and selected HPV diseases (females) visiting primary care physicians, obstetricians/gynaecologists, urologists and dermatologists with 2-30 years experience. RESULTS: Of 150 male and 250 female patients, HIP scores showed 85.3% of male patients with GW and 32.0% without reported moderate psychological impact (p<0.0001). In categorised total scores, 88.5% of female patients with and 66.0% without selected HPV-related diseases reported moderate or high psychological impacts (p=0.0004). In the CECA questionnaire, male patients had mean (SD) scores of 10.51 (3.79) in 'emotional health' and 15.90 (6.13) in 'sexual activity'. Female patients with GW reported lower scores in both dimensions with mean scores of 7.18 (4.17) in 'emotional health' and 10.97 (5.80) in 'sexual activity' (p<0.0001), indicating worse health-related quality of life (HRQoL). For the EQ-5D, male patients with GW reported lower mean Visual Analogue Scale (VAS) scores than those without (75.1 vs 81.13, p<0.0135). Mean VAS score and utility values were lower for females with HPV-related diseases than those without (72.18 vs 76.86 and 0.90 vs 0.94, respectively). CONCLUSION: In South Korea, GW in men and HPV-related diseases in women negatively impact patient well-being and HRQoL scores. Among women, those with GW suffered a greater psychosocial impact than those with other selected HPV-related diseases.

A cross-sectional study estimating the burden of illness related to genital warts in South Korea.

OBJECTIVES: Estimate the prevalence of genital warts (GW) and GW-related healthcare resource use and costs among male and female patients seeking treatment in South Korea. DESIGN: To estimate GW prevalence, physicians in five major South Korean regions recorded daily logs of patients (n=71 655) seeking care between July 26 and September 27, 2011. Overall prevalence estimates (and 95% CIs) were weighted by the estimated number of physicians in each specialty and the estimated proportion of total patients visiting each specialist type. Healthcare resource use was compared among different specialties. Corresponding p values were calculated using Mann-Whitney U tests. SETTING: The database covers 5098 clinics and hospitals for five major regions in South Korea: Seoul, Busan, Daegu, Gwangju and Daejeon. PARTICIPANTS: Primary care physicians (general practice/family medicine), obstetricians/gynaecologists, urologists and dermatologists with 2-30 years' experience. RESULTS: The estimated overall GW prevalence was 0.7% (95% CI 0.7% to 0.8%). Among women, GW prevalence was 0.6% (95% CI 0.6% to 0.7%); among men prevalence was 1.0% (95% CI 0.9% to 1.0%), peaking among patients aged 18-24 years. Median costs for GW diagnosis and treatment for male patients were US$58.2 (South Korean Won (KRW) ₩66 857) and US$66.3 (KRW₩76 113) for female patients. CONCLUSIONS: The estimated overall GW prevalence in South Korea was 0.7% and was higher for male patients. The overall median costs associated with a GW episode were higher for female patients than for male patients.

Costs of adult vaccination in medical settings and pharmacies: an observational study.

BACKGROUND: Community pharmacies are a convenient setting for vaccinating adults against infectious diseases in the United States. Whether the costs paid for vaccination in pharmacies differ from those in medical settings is unclear. OBJECTIVE: To examine whether the direct medical costs paid for adult vaccination differ by vaccination setting. METHODS: This was an observational retrospective study using 2010 MarketScan Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits databases. Adults receiving herpes zoster or shingles vaccine, pneumococcal vaccine 23-valent, or influenza vaccines were identified using Current Procedural Terminology codes and National Drug Code numbers from medical and pharmacy claims files, respectively, between January 1 and December 31, 2010, in 1 of the following 3 settings: physician offices; other medical settings (e.g., inpatient/outpatient hospitals, emergency rooms); and pharmacies. Patients were adults aged ≥60 years on the date of zoster vaccination and aged ≥19 years on the date of pneumococcal or influenza vaccinations. The final study samples meeting inclusion/exclusion criteria were 54,042 for zoster vaccine, 154,994 for pneumococcal vaccine, and 1,657,264 for influenza vaccine. The vaccination costs included the health plan and enrollee paid amounts for the product; vaccine administration; dispensing fee; and, where applicable, the visit. The mean (SD) vaccination costs paid per vaccine administration were estimated by vaccine and type of setting, overall, and by geographic region and type of health plan. The costs paid for the same vaccine across vaccination settings were compared using analysis of variance with post hoc tests (Tukey). RESULTS: Of those receiving zoster, pneumococcal, and influenza vaccines, 25%, 1%, and 7%, respectively, received the vaccines at a pharmacy. Compared with other U.S. regions, pharmacy-based vaccination for these 3 vaccines was generally more frequent in the West and the South. Overall, the mean (SD) costs paid per enrollee per vaccine administration at physician offices, other medical settings, and pharmacies were as follows: for zoster vaccine, $208.72 (42.10), $209.51 (50.83), and $168.50 (15.66), respectively (P <0.05); for pneumococcal vaccine, $65.69 (27.54), $72.11 (49.95), and $54.98 (9.72), respectively (P <0.05); and for influenza vaccine, $29.29 (15.29), $24.20 (13.12), and $21.57 (6.63), respectively (P <0.05). The mean amounts paid also differed by geographic region and type of health plan, with costs usually lower for the vaccinations given at pharmacies. CONCLUSIONS: The average direct costs paid per adult vaccination were lower in pharmacies compared with physician offices and other medical settings by 16%-26% and 11%-20%, respectively. These results were mostly consistent across geographic regions and types of health plans. These data may help payers and policymakers understand the economic value of adult vaccination in different settings, especially in pharmacies.

The Cost-Effectiveness Analysis of a Quadrivalent Human Papillomavirus Vaccine (6/11/16/18) for Females in Japan.

OBJECTIVE: We assessed the epidemiological and economic impact of a quadrivalent human papillomavirus (HPV) (6/11/16/18) vaccine for females in preventing cervical cancer, cervical intraepithelial neoplasia grades 2 and 3 (CIN 2/3), cervical intraepithelial neoplasia grade 1 (CIN 1), and genital warts in Japan by using a transmission dynamic model. METHODS: A published mathematical model of the transmission dynamics of HPV infection and disease was adapted for Japan. Model inputs were used from Japan or the Asia/Pacific region when available; otherwise, the default values in the original model were used. The transmission dynamic model was used to assess the epidemiological and economic impact of a quadrivalent HPV (6/11/16/18) vaccine for females in preventing cervical cancer, CIN 2/3, CIN 1, and genital warts in Japan.Maintaining current cervical cancer screening practices, we evaluated two strategies: routine vaccination of females by age 12 years (S1), and S1 combined with a temporary (5 years) female catch-up program for age 12 to 24 years (S2). The vaccine coverage rate was 80% for the routine and 50% for the catch-up vaccination programs. RESULTS: Compared with no vaccination, both vaccination strategies significantly reduced the incidence of HPV 6/11/16/18-related disease. The most effective strategy was S2. By using this strategy over 100 years in the Japanese population, the estimated cumulative percentage reduction in incident HPV 6/11/16/18-related genital warts-female, genital warts-male, cervical CIN 1, CIN 2/3, and cervical cancer cases was 90% (2,113,723 cases), 86% (2,082,637 cases), 72% (263,406 cases), 71% (1,328,366 cases), and 58% (323,145 cases), respectively. The cost-effectiveness ratios were JPY 1,244,000, and JPY 1,205,800 per quality-adjusted life-year gained for S1 and S2 compared with no vaccination, respectively, over a time horizon of 100 years. CONCLUSION: We conclude that a quadrivalent HPV vaccination program for females can reduce the incidence of cervical cancer, CIN, and genital warts in Japan at a cost-per-quality-adjusted life-year ratio within the range defined as cost-effective.

Estimated health and economic impact of quadrivalent HPV (types 6/11/16/18) vaccination in Brazil using a transmission dynamic model.

BACKGROUND: Cervical cancer is the second most common cancer among women in Brazil. We examined the health and economic impacts of quadrivalent HPV vaccination in Brazil. METHODS: We adapted a previously developed transmission dynamic model to estimate the effectiveness of HPV vaccination on cervical cancer, cervical intraepithelial neoplasia grades 2 and 3 (CIN2/3), CIN1, and genital warts. We evaluated following vaccination strategies: routine vaccination of 12-year-old girls and routine vaccination in combination with a catch-up vaccination of 12 to 26-year-old women. RESULTS: The model projected that the vaccination would reduce the incidence rates of HPV 6/11/16/18-related cervical cancer, CIN2/3, CIN1, and female genital warts by 94% to 98% at year 100. Routine vaccination in combination with a catch-up vaccination could prevent approximately 163,000 cases of cervical cancer, 48,000 deaths from cervical cancer, 2.3 million cases of CIN2/3, and 11.4 million genital warts in the next 50 years. The incremental cost-effectiveness ratios for female vaccination strategies ranged from R$350 to R$720 (US$219 to US$450) per quality-adjusted life year (QALY) gained. CONCLUSIONS: Our study demonstrates that quadrivalent HPV female vaccination can be a cost-effective public health intervention that can substantially reduce the burden of cervical diseases and genital warts in Brazil.

Health and economic burden of HPV-related diseases in Singapore.

OBJECTIVE: To assess the health and economic burden of human papillomavirus (HPV)-related diseases (cervical cancer, cervical intraepithelial neoplasia (CIN) 1/2/3, and genital warts) in Singapore over a period of 25 years beginning in 2008. METHODS: Incidence-based modeling was used to estimate the incidence cases and associated economic burden, with the assumption that age-stratified incidence rates will remain the same throughout the period of 25 years. The incidence rates in 2008 were projected based on data obtained from the National Cancer Registry for cervical cancer, and from a combination of published data and hospital registry review for CIN1/2/3 and genital warts. The population growth rate was factored into the projection of incidence cases over time. Direct cost data per cervical cancer and per CIN1/2/3 case were obtained from the financial database of large local hospitals while cost data for genital warts were obtained from the National Skin Center; these costs were multiplied by the number of incidence cases to produce an aggregate estimate of the economic burden over the 25-year period (in 2008 Singapore dollars) using a 3% discount rate. RESULTS: The total number of incidence cases of HPV-disease over 25 years beginning in 2008 was estimated to be 60,183, including 8,078 for cervical cancer, 11,685 for CIN 2/3, 8,849 for CIN1, and 31,572 for genital warts. The estimated total direct cost was 83.2 million Singapore Dollars over 25 years: 57.6 million attributable to cervical cancer, 13.0 million to CIN2/3, 6.83 million to CIN1, and 5.70 million to genital warts. CONCLUSION: HPV-related diseases are expected to impose significant health and economic burden on the Singapore healthcare resources in the next 25 years.

Incidence and costs of cervical intraepithelial neoplasia in a US commercially insured population.

OBJECTIVE: This study aimed to estimate incidence, cost per episode of care, and US population burden of cervical intraepithelial neoplasia (CIN). MATERIALS AND METHODS: For women continuously enrolled in a US health plan from January 1, 1999 to December 31, 2004, medical claims were used to identify potential CIN diagnosis. Presence and grade of CIN (CIN 1, CIN 2,3, or no CIN) were verified in medical records for a randomly selected subset (n = 254). Incidence, costs, and population burden were calculated. RESULTS: Annual incidence for CIN 1 and CIN 2,3 was 1.6 and 1.2 per 1,000 women, respectively. Incidence was highest among women aged 21 to 30 years (3.3 and 3.6 per 1,000) and women aged 31 to 40 years (2.9 and 2.7 per 1,000). Costs per episode of care were higher for CIN 2,3 ($1,634 vs $1,084). Estimated annual burden per 1,000 US women was $1,059 for CIN 1 and $1,803 for CIN 2,3. CONCLUSIONS: We estimate that 412,000 women in the United States are diagnosed with CIN annually, with an associated cost of approximately $570 million.

Incremental 1-year medical resource utilization and costs for patients with herpes zoster from a set of US health plans.

BACKGROUND: Nearly 1 million new episodes of herpes zoster (HZ) occur annually in the US, yet little is known about the medical resource utilization (RU) and costs associated with HZ and its complications. OBJECTIVES: To describe the medical RU and cost burden of HZ in the first 90 days and the first year after diagnosis from the health insurer perspective and to stratify this burden for patients diagnosed with post-herpetic neuralgia (PHN) and those who are immunocompromised. In addition, this study explores costs from the societal perspective as a result of work loss in the first year after diagnosis. METHODS: The medical RU and cost data were obtained from the MarketScan Research Database for the years 1998-2003. This database contains inpatient, outpatient and prescription drug data for approximately 14 million individuals of all ages, covered under a variety of fee-for-service and capitated provider reimbursement arrangements, including those with Medicare and private insurance. The work loss estimates were based on the MarketScan Health and Productivity Management Database. Claims for services incurred between 1 January 1998 and 31 December 2003 were screened to identify a cohort of HZ patients based on the presence of at least one International Classification of Diseases, 9th Revision (ICD-9) diagnosis code 053.xx. Each patient was assigned an index date based on the earliest observed occurrence of an HZ diagnosis. A cohort of PHN patients was identified as a subset of the HZ cohort with ICD-9 codes 053.12, 053.13, 053.19 or 729.2x in the period of 90 days to 12 months after the index date. Multivariable regression was used to compare HZ cases with matched controls after adjusting for demographic characteristics, insurance status, co-morbidities and medical expenditure in the 6 months prior to diagnosis for each of the endpoints. Separate regression models were developed, in which age and immune status were stratified. All costs were adjusted to March 2008 values using the medical care component of the Consumer Price Index. The average per patient cost of all HZ cases was $US605 in the first 90 days after diagnosis and $US1052 at 1 year. For the subset with PHN, the average per patient cost of HZ at 1 year was $US3815. For the subset with an immunocompromising condition, the average HZ cost at 1 year was $US1745. The majority of the costs were the result of outpatient visits and prescription drugs. The subset of HZ cases that had both absence hour and short-term disability (STD) records available had 26.5 absence hours and 2.9 STD days. Healthcare utilization, medical care costs and work loss all increased with age for all HZ cases. Based on the results from the present study, the direct medical cost burden of HZ in the US is high, exceeding $US1000 per HZ patient. This direct medical cost may be nearly twice as high in immunocompromised patients and four times as high in the subset of HZ cases with PHN. The direct medical cost burden of HZ may exceed $US1 billion annually in the US. The majority of medical RU and cost burden is incurred by the elderly. Although many people with HZ may no longer be in the workforce, HZ does contribute to lost work time.

Assessing incidence and economic burden of genital warts with data from a US commercially insured population.

OBJECTIVE: This study examined the incidence of and healthcare costs attributable to genital warts within a large US commercially insured, geographically dispersed population. RESEARCH DESIGN AND METHODS: Using a retrospective cohort study design, this longitudinal analysis assessed administrative claims of integrated medical and pharmacy encounters from five Blue Cross Blue Shield health plans. Genital warts cases were identified using a methodology previously described by Insinga et al. MAIN OUTCOME MEASURES: Age- and gender-specific incidence of genital warts per 1000 person-years in 2004, and duration-of-episode attributable direct medical costs (2004 US dollars) and healthcare resource utilization of cases diagnosed in 2002. Overall outcome measures were age- and gender-adjusted to the 2004 US civilian population. RESULTS: Genital warts incidence in 2004 was 1.2/1000 females and 1.1/1000 males. Incidence was highest among females aged 20-24 (4.6/1000) and males aged 25-29 (2.7/1000). Projected overall incidence was over 340,000 cases in 2004. Mean duration-of-episode per incident case in 2002 was 95.4 days (males 116.3 days; females 69.7 days). Mean ambulatory visits per episode were 1.5 for females and 1.9 for males, with <1 drug prescription/episode. Mean costs were $647/episode ($745 males; $528 females). The 2004 estimated economic burden was $760 per 1000 individuals in the general population with the total exceeding $220 million. LIMITATIONS: Only those genital warts cases that sought evaluation or for which the treating provider was covered by the health plan were captured in the study. CONCLUSIONS: Genital warts represent a significant health and cost burden in the US. Adoption of novel healthcare technologies such as vaccines along with traditional interventions such as physician education of signs and symptoms, condom use and abstinence or limiting number of sexual partners may significantly help reduce the burden of genital warts.

Healthcare resource use and costs associated with cervical, vaginal and vulvar cancers in a large U.S. health plan.

OBJECTIVES: To estimate healthcare resource utilization and costs of cervical, vulvar and vaginal cancers in a large U.S. health plan. METHODS: We estimated incremental ambulatory visits, hospitalizations, prescription fills and healthcare costs for cancer cases relative to population controls. Data for cervical (n=2788), vulvar (n=621) and vaginal cancer (n=254) cases and an identical number of controls were obtained from a large U.S. health plan. Cases were identified via diagnostic codes on a healthcare claim and matched to controls. Incremental resource use was assessed using a two-stage regression method developed by Carides, with costs analyzed using Lin's regression method. RESULTS: Through 4 years of follow-up, cervical cancer patients had incremental resource use of 12.0 ambulatory visits, 0.6 hospital admissions and 7.0 prescription fills per case. Cumulative 4-year incremental healthcare costs per case ranged from $8236 for vulvar cancers to $18,799 for cervical cancers. When adjusted to cervical, vulvar and vaginal cancer excess mortality rates observed within the U.S. Surveillance Epidemiology and End Results program, estimated incremental costs were $29,649 for cervical, $11,356 for vulvar and $21,963 for vaginal cancers. There was a significant upward trend in costs with increasing age for cervical cancer, however trends were less consistent for vulvar and vaginal cancers. CONCLUSIONS: Direct medical costs associated with cervical, vulvar and vaginal cancers were observed to be substantial. These data can help inform evaluations of the economic burden and cost-effectiveness of prevention of these cancers, particularly for vulvar and vaginal disease, where such data have not been previously reported.

Five-year routine cervical cancer screening rates and intervals in a US health plan.

OBJECTIVE: Cervical cancer screening with liquid-based cytology or concurrent HPV screening may decrease positive predictive value and specificity of screening results. Following changes to leading guidelines for cervical cancer screening, policy-makers may benefit from more detailed statistics to improve management of routine screening intervals. This paper reports annual cervical cancer screening rates, intervals between routine screenings, population cost burden of routine screening, and concurrent HPV screening rates in the medical claims database of a large US health plan between 2000 and 2004. RESEARCH DESIGN AND METHODS: Annual cervical cancer screening rates were reported for each calendar year between 2000 and 2004, plus intervals between routine screenings in a cohort enrolled for 5 years after a first routine screening. Interval estimates accounted for women not screened in the first year of the study period. Overall screening rates and intervals were adjusted to the US civilian female population, and costs were adjusted to 2004 dollars. This database research was exempt from IRB review. RESULTS: Annual routine screening rates during the 5-year period ranged from 33.7 to 37.2 tests per 100 enrollees. Among females with routine screenings, 68.8% were re-screened within 3 years, and 26.8% were not re-screened within 5 years. Concurrent HPV screening was 1.9 tests per 1000 routine screenings in 2000, and 27.9 per 1000 in 2004. The cost of routine screening per 1000 females was $31,282.00 in 2000 and $38,515.07 in 2004. CONCLUSION: More than a quarter of women with evidence of a routine cervical cancer screening were not re-screened within 5 years, while 43.4% were re-screened within a year. Triennial screening rates reported here are not comparable to traditional 3-year screening rates, and screening intervals were not reported separately by conventional and liquid-based cytology. Reducing rates of women receiving annual routine screening may offset the cost burden of newer screening technologies, but must be managed carefully to avoid decreasing 3-year screening rates. Clinicians should reinforce with their patients the need for routine screening at least triennially.

Quality of drug treatment of childhood persistent asthma in Maryland medicaid recipients in transition from managed fee for service to managed capitation.

BACKGROUND: From December 1991 to June 1997, approximately 80% of Maryland's Medicaid recipients were served through a fee-for-service (FFS) managed care delivery system in which assigned primary care providers served as gatekeepers for hospital and specialty services. The remaining 20% of recipients were voluntarily enrolled in 1 of 5 available health maintenance organizations (HMOs). Beginning in June 1997, Maryland required most Medicaid recipients to enroll in capitated managed care organizations (MCOs), also referred to as managed Medicaid plans. Although research has been conducted on the quality of asthma care among MCOs and in MCOs for Medicaid versus non-Medicaid members, the quality of asthma care has been less well studied for MCO patients than for FFS patients. OBJECTIVE: To determine whether quality of drug use among Medicaid children with persistent asthma was different after the transition from the managed care FFS system to a capitated managed Medicaid system. METHODS: This 4-year retrospective cohort study (from June 1, 1996, to December 31, 2000) followed children aged 5 to 18 years with persistent asthma (defined by the existence of at least 1 medical claim with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code of 493.x and receipt of 2 or more pharmacy claims for beta2-agonists in a 6-month period) enrolled in Maryland Medicaid as they transitioned from the managed FFS system to 1 of 4 large capitated MCOs. Children were selected from a review of Medicaid enrollment records and medical and pharmacy FFS claims filed between June 1, 1996, and December 31, 1997. Children with a diagnosis of cystic fibrosis were excluded. The asthma quality indicator was defined as the proportion of children with persistent asthma (who had 2 or more claims for any short-acting beta2-agonists [SABAs], including metered-dose inhalers, nebulizers, or oral forms, which we defined as rescue medication, within a 6-month period), who also had at least 1 claim for a controller medication (inhaled corticosteroid, mastcell stabilizer, or leukotriene-receptor modifier) in the same 6-month period. Subjects were followed from June 1, 1996 (or, if later, the first Medicaid eligibility date), through December 31, 2000 (or, if earlier, the last Medicaid eligibility date). Mean quality indicator rates were calculated for the 2 managed FFS periods (FFS1 and FFS2) and the 6 managed Medicaid 6-month periods. We used generalized estimating equations to test for significant trends over time and to compare changes in the quality indicator in the managed Medicaid plans. RESULTS: There were 3,721 children who met the inclusion and exclusion criteria for the study. The quality indicator (proportion of patients who received a controller medication among those receiving SABAs for asthma) was 62% in managed FFS1 and 57% in managed FFS2. In the first 6 months of managed Medicaid plans, the quality indicator rose from 56% to 57%, 59%, 61%, 66%, and 59% in the ensuing five 6-month observation periods. The results from the generalized estimating equations suggested slight improvement in the quality indicator in the managed Medicaid plans, but the difference was not significant (relative risk 1.01, 95% confidence interval, 0.95-1.08). There was no significant trend in the asthma quality indicator over time in the managed Medicaid plans. CONCLUSION: There was no distinct improvement or worsening in asthma care as measured by the quality indicator (proportion of patients who received a controller medication among those receiving SABAs for asthma) as children moved from managed FFS to managed Medicaid. Larger sample sizes with no data loss may have produced a different result.

Medicare cost differences between nursing home patients admitted with and without dementia.

PURPOSE: Our objective in this study was to compare Medicare costs of treating older adults with and without dementia in nursing home settings. DESIGN AND METHODS: An expert panel established the dementia status of a stratified random sample of newly admitted residents in 59 Maryland nursing homes between 1992 and 1995. Medicare expenditures per-person month (PPM) were compared for 640 residents diagnosed with dementia and 636 with no dementia for 1 year preadmission and 2 years postadmission. Multivariate analysis with generalized estimating equations was used to identify the source of Medicare cost differentials between the two groups. RESULTS: Medicare expenditures peaked in the month immediately preceding admission and dropped to preadmission levels by the third month in a nursing home. Adjusted PPM costs postadmission for the dementia group as a whole were 79% (p < .001) of the Medicare costs of treating residents without dementia. For the subgroup of residents admitted without a Medicare qualified stay (MQS), those with dementia had Medicare costs of just 63% (p < .001) of those without dementia. Overall Medicare costs PPM were insignificantly different between the two groups admitted with a MQS. IMPLICATIONS: Whether nursing home residents are admitted with a MQS is the single most important factor in assessing treatment cost differentials between residents admitted with and without dementia. Failure to consider this factor may lead researchers and policy makers to misdirect their attention from the true source of the differential-dementia patients admitted without a qualifying stay.

National estimates of exposure to prescription drugs with addiction potential in community-dwelling elders.

The use of prescription drugs with addiction potential is an overlooked and growing problem among today's elderly. This paper provides national prevalence estimates of exposure to prescription drugs with addiction potential among community-dwelling elders and explores risk factors for such exposure. Using the Medicare Current Beneficiary Survey, a nationally-representative database of Medicare eligibles, we calculated the prevalence of abusable prescription drug use, overall, by therapeutic class, and by drug. Nearly 22% (7.22 million) of all community-dwelling Medicare elders used at least one prescription medication with addiction potential. Opioid analgesics were used most frequently (14.9%; 95% CI 14.0, 15.8%); central nervous system (CNS) depressants were used by 10.4% of the nation's elders (95% CI 9.5, 10.8%). Using logistic regression analysis, we examined the association of explanatory variables with three outcome variables: any controlled substances use, any opioid analgesic use, and any CNS depressant use. We found that females, whites, those aged 65-79, and those with non-spousal others, were significantly more likely to use one or more prescription drugs with addiction potential, controlling for health status and severity-of-illness. The significance and magnitude of several explanatory variables, including age, race, ethnicity, living arrangement, and health status, varied by therapeutic category. This paper provides an important first step in acknowledging the widespread use of abusable prescription drugs in elders, and provides a foundation for future research and practical solutions to preventing subsequent problem use of prescription drugs.

How robust are health plan quality indicators to data loss? A Monte Carlo simulation study of pediatric asthma treatment.

OBJECTIVES: (1) To test the robustness of a health plan quality indicator (QI) for persistent asthma to various forms of data loss and (2) to assess the implications of the findings for other health plan quality measures. DATA SOURCES/STUDY SETTINGS: Maryland Medicaid fee-for-service (FFS) claims. Children with asthma (n = 5,804) were selected from Medicaid enrollment records and medical and pharmacy FFS claims filed between June 1996 and December 1997. STUDY DESIGN: A variant of a HEDIS measure for treatment of persistent asthma (the percent of asthma patients filling two or more rescue medications who also filled a controller medication) was selected to test the robustness of proportion-based QIs to loss of data. Data loss was simulated through a series of Monte Carlo experiments. DATA COLLECTION/EXTRACTION METHODS: Merged FFS medical and prescription claims. PRINCIPAL FINDINGS: The asthma QI measure was highly robust to systematic and random data loss. The measure declined by less than 2 percent in the presence of up to a 35 percent data loss. Redundancy in the numerator of the QI significantly increased the robustness of the measure to data loss. CONCLUSIONS: A HEDIS-related QI measure for persistent asthma is robust to data loss. The findings suggest that other proportion-based quality indicators, particularly those in which plan members have multiple opportunities to meet the numerator criterion, are likely to reflect true levels of health plan quality in the face of incomplete data capture.

Employer-sponsored health insurance and prescription drug coverage for new retirees: dramatic declines in five years.

Employer-sponsored health insurance is often described as the most reliable private source of Medicare supplementation, particularly for prescription drug benefits. This study's findings show that employer coverage is becoming an increasingly less dependable source of coverage for new retirees, and the problem is likely to get worse. We found that the proportion of Medicare beneficiaries ages 65-69 with employer coverage declined from 46 percent in 1996 to 39 percent in 2000. The proportion with drug coverage from an employer declined from 40 percent in 1996 to 35 percent in 2000. Losses among males, the group most affected, would have been even greater had it not been for a slight increase in benefits from spouses' policies.