Adherence to and persistence with adjuvant hormone therapy, healthcare utilization, and healthcare costs among older women with breast cancer: A population-based longitudinal cohort study.

INTRODUCTION: To assess associations between adherence to and persistence with adjuvant hormone therapy, healthcare utilization, and healthcare costs among older women with breast cancer. MATERIALS AND METHODS: This study was a population-based longitudinal cohort study using the Surveillance, Epidemiology, and End Results (SEER) registry linked with Medicare claims. This study included older women diagnosed with stage I-III hormone receptor-positive breast cancer from 2009 through 2017. Participants were considered adherent with a proportion of days covered (PDC) of 0.80 or more and persistent if they had no hormone therapy discontinuation, i.e., a break of at least 180 continuous days. Length of persistence was calculated as time from therapy initiation to discontinuation. All participants were followed for up to five years after hormone therapy initiation. Generalized linear mixed models with repeated measures or hurdle generalized linear mixed models in the event of excess zeroes were used to assess associations between adherence to and persistence with annual healthcare utilization and costs. RESULTS: This study included 25,796 women. Being adherent was associated with lower annual healthcare utilization, i.e., hospitalizations, hospital days, emergency room visits, and hospital outpatient visits. Persistence was associated with fewer annual hospitalizations, hospital days, emergency room visits, and hospital outpatient visits. Adherent participants had lower annual inpatient costs, outpatient costs, medical costs, and total healthcare costs despite higher prescription drug costs. Both being persistent and longer persistence were associated with lower inpatient costs, outpatient costs, medical costs, and total healthcare costs despite higher prescription drug costs. DISCUSSION: This study underscores the economic benefits associated with adherence to and persistence with adjuvant hormone therapy based on comprehensive measures for healthcare utilization and costs. To our best knowledge, this was the first study that reported total healthcare cost savings associated with adherence to and persistence with adjuvant hormone therapy.

Social determinants of health and disparate disability accumulation in a cohort of Black, Hispanic, and White patients with multiple sclerosis.

BACKGROUND: Black and Hispanic patients with multiple sclerosis (MS) have been shown to accumulate greater multiple sclerosis-associated disability (MSAD) than White patients. Disparities in social determinants of health (SDOH) among these groups have also been reported. OBJECTIVE: To determine the extent to which associations of race and ethnicity with MSAD may be attributable to differences in SDOH. METHODS: Retrospective chart analysis of patients at an academic MS center grouped by self-identified Black (n = 95), Hispanic (n = 93), and White (n = 98) race/ethnicity. Individual patient addresses were geocoded and matched with neighborhood-level area deprivation index (ADI) and social vulnerability index (SVI). RESULTS: Average Expanded Disability Status Scale (EDSS) scores at last-recorded evaluations of White patients (1.7 ± 2.0) were significantly lower than Black (2.8 ± 2.4, p = 0.001) and Hispanic (2.6 ± 2.6, p = 0.020) patients. Neither Black race nor Hispanic ethnicity was significantly associated with EDSS in multivariable linear regression models that included individual-level SDOH indicators and either ADI or SVI. CONCLUSION: Black race and Hispanic ethnicity are not significantly associated with EDSS in models that include individual and neighborhood-level SDOH indicators. Further research should elucidate mechanisms by which structural inequities affect MS disease course.

Survival benefits associated with being adherent and having longer persistence to adjuvant hormone therapy across up to five years among U.S. Medicare population with breast cancer.

PURPOSE: To assess associations between adherence to and persistence with adjuvant hormone therapy and mortality among older women with breast cancer. METHODS: The surveillance, epidemiology, and end results data linked with U.S. Medicare claims was used. This study included older women diagnosed with stage I-III hormone receptor-positive breast cancer from 2009 through 2017. Adherence was defined as having proportion of days covered (PDC) ≥ 0.80. Persistence was defined as having no discontinuation, i.e., no break of ≥ 180 continuous days. Length of persistence was calculated as time from therapy initiation to discontinuation. Cox models with time-dependent covariates were used to assess associations between adherence and persistence with mortality. RESULTS: This study included 25,796 women. Adherence rates were 78.1 percent, 75.2 percent, 72.4 percent, 70.0 percent, and 61.5 percent from year 1 to year 5 after hormone therapy initiation. Persistence rates were 87.5 percent, 81.7 percent, 77.1 percent, 72.9 percent, and 68.9 percent through cumulative intervals of 1 year up to 5 years. Adherence was associated with all-cause mortality but not associated with breast cancer-specific mortality. Persistent women had lower risk of all-cause mortality and breast cancer-specific mortality. Each additional year of persistence had additional contributions to survival benefits (11% decreased risk of all-cause mortality and 37% decreased risk of breast cancer-specific mortality). CONCLUSION: This study confirms the detrimental effect of nonadherence to adjuvant hormone therapy across up to 5 years on all-cause survival in older U.S. women. It also reveals the survival benefits associated with having longer persistence across up to 5 years.

Inequitable use of health services for Indigenous mothers who experience stillbirth in Australia.

OBJECTIVES: The purpose of this study was to identify differences in health service expenditure on Indigenous and non-Indigenous women who experience a stillbirth, women's out-of-pocket costs, and health service use. METHODS: The project used a whole-of-population linked data set called "Maternity1000," which includes all women who gave birth in Queensland, Australia, between July 1, 2012, and June 30, 2018 (n = 396 158). Multivariable analysis was undertaken to assess differences in mean health service expenditure; and number of health care services accessed between Indigenous and non-Indigenous women who had a stillbirth from birth to twelve months postpartum. Costs are presented in 2019/20 Australian dollars. RESULTS: There was a total of 1864 babies stillborn to women in Queensland between July 1, 2012, and June 30, 2018, with 135 being born to Indigenous women and 1729 born to non-Indigenous women. There was significantly lower total expenditure per woman for Indigenous women compared with non-Indigenous women ($16 083 and $18 811, respectively). This was consistent across public hospital inpatient ($12 564 compared with $14 075), outpatient ($1127 compared with $1470), community-based services ($198 compared with $313), pharmaceuticals ($8 compared with $22), private hospital ($434 compared with $1265), and for individual out-of-pocket fees ($21 compared with $86). Mean expenditure on emergency department services per woman was higher for Indigenous women compared with non-Indigenous women ($947 compared with $643). Indigenous women who experienced a stillbirth accessed fewer general practitioners, allied health, specialist, obstetrics, and outpatient services, and fewer pathology and diagnostic test than their non-Indigenous counterparts. CONCLUSIONS: Inequities in access to health services exist between Indigenous and non-Indigenous women who experience a stillbirth.

Contemporary economic burden in a real-world heart failure population with Commercial and Medicare supplemental plans.

BACKGROUND: Limited real-world data exist on healthcare resource utilization (HCRU) and associated costs of patients with heart failure (HF) with reduced ejection fraction (HFrEF) and preserved EF (HFpEF), including urgent HF visits, which are assumed to be less burdensome than HF hospitalizations (hHFs) HYPOTHESIS: This study aimed to quantify the economic burden of HFrEF and HFpEF, via a retrospective, longitudinal cohort study, using IBM® linked claims/electronic health records (Commercial and Medicare Supplemental data only). METHODS: Adult patients, indexed on HF diagnosis (ICD-10-CM: I50.x) from July 2012 through June 2018, with 6-month minimum baseline period and varying follow-up, were classified as HFrEF (I50.2x) or HFpEF (I50.3x) according to last-observed EF-specific diagnosis. HCRU/costs were assessed during follow-up. RESULTS: About 109 721 HF patients (22% HFrEF, 31% HFpEF, 47% unclassified EF; median 18 months' follow-up) were identified. There were 3.2 all-cause outpatient visits per patient-month (HFrEF, 3.3; HFpEF, 3.6); 69% of patients required inpatient stays (HFrEF, 80%; HFpEF, 78%). Overall, 11% of patients experienced hHFs (HFrEF, 23%; HFpEF, 16%), 9% experienced urgent HF visits (HFrEF, 15%; HFpEF, 12%); 26% were hospitalized less than 30 days after first urgent HF visit versus 11% after first hHF. Mean monthly total direct healthcare cost per patient was $9290 (HFrEF, $11 053; HFpEF, $7482). CONCLUSIONS: HF-related HCRU is substantial among contemporary real-world HF patients in US Commercial or Medicare supplemental health plans. Patients managed in urgent HF settings were over twice as likely to be hospitalized within 30 days versus those initially hospitalized, suggesting urgent HF visits are important clinical events and quality improvement targets.

Patient Perception of Physicians and Medication Adherence Among Older Adults With Hypertension.

Objective: To assess association between patient perception of physicians and adherence to antihypertensive medication among Medicare beneficiaries. Method: Logistic regression was used to assess association between the Patient Perception of Physicians Scale score and adherence to antihypertensive medication. The 2007 Medicare Current Beneficiary Survey data were used to create a 12-item patient perception of physician scale and 2008 Medicare Part D claims to assess adherence. Results: There were 2,510 beneficiaries included in the sample. The mean age was 76.4 years (SD = ±6.88 years). Sixty-five percent of the sample was adherent in filling their antihypertensive medication. Beneficiaries with more favorable perceptions of their physician (scores 37 or higher) were more likely to be adherent to antihypertensive medications than beneficiaries with scores less than 37 (odds ratio [OR] = 1.341, 95% confidence interval [CI] = [1.101, 1.632], p = .0035). Discussion: These findings provide some evidence that patient perceptions of their physician are associated with adherence, and that the physician-patient relationship is an important factor.

What are the costs of stillbirth? Capturing the direct health care and macroeconomic costs in Australia.

BACKGROUND: Reducing stillbirth rates is an international priority; however, little is known about the cost of stillbirth. This analysis sought to quantify the costs of stillbirth in Australia. METHODS: Mothers and costs were identified by linking a state-based registry of all births between 2012 and 2015 to other administrative data sets. Costs from time of birth to 2 years postbirth were included. Propensity score matching was used to account for differences between women who had a stillbirth and those that did not. Macroeconomic costs were estimated using value of lost output analysis and value of lost welfare analysis. RESULTS: Cost to government was on average $3774 more per mother who had a stillbirth compared with mothers who had a live birth. After accounting for gestation at birth, the cost of a stillbirth was 42% more than a live birth (P < .001). Costs for inpatient services, emergency department services, services covered under Medicare (such as primary and specialist care, diagnostic tests and imaging), and prescription pharmaceuticals were all significantly higher for mothers who had a stillbirth. Mothers who had a stillbirth paid on average $1479 out of pocket, which was 52% more than mothers who had a live birth after accounting for gestation at birth (P < .001). The value of lost output was estimated to be $73.8 million (95% CI: 44.0 million-103.9 million). The estimated value of lost social welfare was estimated to be $18 billion. DISCUSSION: Stillbirth has a sustained economic impact on society and families, which demonstrates the potential resource savings that could be generated from stillbirth prevention.

Incremental health care resource utilization and expenditures associated with autosomal-dominant polycystic kidney disease.

PURPOSE: Incremental health care resource utilization and expenditures associated with autosomal dominant polycystic kidney disease (ADPKD) were estimated. METHODS: Study data were from a large administrative claims database. Individuals aged 18 years or older enrolled in tracked health plans for 12 months from April 1, 2011 through March 31, 2012, and with an International Classification of Disease, Ninth Revision, Clinical Modification diagnosis code for "polycystic kidney, autosomal dominant" (753.13) or for "polycystic kidney, unspecified type" (753.12) were identified as having ADPKD, and linked one-to-one with individuals without ADPKD based on age and gender. Zero-inflated negative binomial models estimated incremental health care resource utilization and expenditures, adjusting for risk factors. RESULTS: A total of 3,844 individuals with ADPKD who satisfied selection criteria were linked one-to-one with 3,844 individuals without ADPKD. Multivariate, regression models adjusting for risk factors revealed incremental mean (standard error) resource use associated with ADPKD of 0.68 (0.090) hospital days, equal to 68 additional hospital days per 100 ADPKD patients, and 6.9 (0.28) outpatient visits, equal to 690 additional visits per 100 ADPKD patients. Mean (standard error) incremental total expenditures associated with ADPKD were US$8,639 ($470). Mean incremental expenditures were largest for outpatient expenditures at US$4,918 ($198), followed by mean incremental hospital expenditures of US$2,603 ($263), and mean incremental medication expenditures of US$1,589 ($77). Based on sub-group analysis, mean incremental total expenditures were US$2,944 ($417) among ADPKD patients without end-stage renal disease and US$38,962 ($6,181) for those with end-stage renal disease. CONCLUSION: ADPKD was associated with considerable incremental health care resource utilization and expenditures. Significant illness burden was found even before patients reached end-stage renal disease.

Survey of collaborative drug therapy management in U.S. hospitals.

PURPOSE: Results of a survey assessing the extent and scope of collaborative drug therapy management (CDTM) in U.S. hospitals are presented. METHODS: A survey questionnaire was mailed to a national random sample of hospital pharmacies. Pharmacy directors provided data on CDTM activities; their views on support for CDTM, the financial and strategic impact of CDTM, and the effect of state regulations on CDTM practice were assessed using summative Likert-type scales. Logistic regression was performed to assess associations of respondent demographics and hospital characteristics with CDTM use. RESULTS: The usable response rate was 30.2%. Pharmacists were reported to be engaged in CDTM in 66% of respondents' hospitals, a significantly (p < 0.0001) greater proportion than reported in a comparable 2003 survey. The most prevalent CDTM activities were ordering laboratory and related tests (58.7% of hospitals), adjusting drug strength (57.9%), and changing the frequency of administration (53.8%). The most commonly reported diseases or treatment areas for CDTM use were anticoagulation (52.4% of hospitals), infectious diseases (44.8%), and parenteral nutrition (32.6%). CONCLUSION: From 2003 to 2013, the prevalence of CDTM use in surveyed U.S. hospitals increased significantly, from about 50% to 66%. The 3 most common specific CDTM activities in 2003-ordering test results, adjusting drug strength, and changing frequency of administration-were still the most common in 2013 but were allowed at higher percentages of hospitals.

Sex Differences in Survival From Out-of-Hospital Cardiac Arrest in the Era of Regionalized Systems and Advanced Post-Resuscitation Care.

BACKGROUND: The purpose of this study was to evaluate sex differences in out-of-hospital cardiac arrest (OHCA) characteristics, interventions, and outcomes. METHODS AND RESULTS: This is a retrospective analysis from a regionalized cardiac arrest system. Data on patients treated for OHCA are reported to a single registry, from which all adult patients were identified from 2011 through 2014. Characteristics, treatment, and outcomes were evaluated with stratification by sex. The adjusted odds ratio (OR) for survival with good neurological outcome (cerebral performance category 1 or 2) was calculated for women compared to men. There were 5174 out-of-hospital cardiac arrests (OHCAs; 3080 males and 2094 females). Women were older, median 71 (interquartile range [IQR], 59-82) versus 66 years (IQR, 55-78). Despite similar frequency of witnessed arrest, women were less likely to present with a shockable rhythm (22% vs 35%; risk difference [RD], 13%; 95% CI, 11-15), have ST-segment elevation myocardial infarction (23% vs 32%; RD, 13%; 95% CI, 7-11), or receive coronary angiography (11% vs 25%; RD, 14%; 95% CI, 12-16), percutaneous coronary intervention (5% vs 14%; RD, 9%; 95% CI, 7-11), or targeted temperature management (33% vs 40%; RD, 7%; 95% CI, 4-10). Women had decreased survival to discharge (33% vs 40%; RD, 7%; 95% CI, 4-10) and a lower proportion of good neurological outcome (16% vs 24%; RD, 8%; 95% CI, 6-10). In multivariable modeling, female sex was not associated with decreased survival with good neurological outcome (OR, 0.9; 95% CI, 0.8-1.1). CONCLUSIONS: Sex-related differences in OHCA characteristics and treatment are predictors of survival outcome disparities. With adjustment for these factors, sex was not associated with survival or neurological outcome after OHCA.

Ensuring innovation in diagnostics for bacterial infection: implications for policy

The inappropriate use of antibiotics is a primary cause of the ongoing increase in drug resistance amongst pathogenic bacteria. The resulting decrease in the efficacy of antibiotics threatens the ability to combat infectious diseases. Rapid, point-of-care tests to identify pathogens and better target the appropriate treatment could greatly improve the use of antibiotics, yet few such tests are available or being developed, despite the rapid pace of medical innovation. Clearly, something is inhibiting the much-needed development of new and more convenient diagnostic tools. This study delineates priorities for developing diagnostics to improve antibiotic prescription and use, in order to manage and curb the expansion of drug resistance. It calls for new approaches, particularly in the provision of diagnostic devices, and, in doing so, outlines some of the inadequacies in health, science and policy initiatives that have led to the dearth of such devices. The authors make the case that innovation is clearly and urgently needed, not only in the technology of diagnosis but also in public policy and medical practice to support the availability and use of better diagnostic tools. This book explores the complexities of the diagnostics market from the perspective of both supply and demand, unearthing interesting bottlenecks: some obvious, some more subtle. It calls for a broad, multifaceted policy response, and an overhaul of current practice, so that the growth of bacterial resistance can be stemmed.

Clinical and economic effectiveness of percutaneous ventricular assist devices for high-risk patients undergoing percutaneous coronary intervention.

BACKGROUND: Comparative effectiveness research (CER) is taking a more prominent role in formalizing hospital treatment protocols and health-care coverage policies by having health-care providers consider the impact of new devices on costs and outcomes. CER balances the need for innovation with fiscal responsibility and evidence-based care. This study compared the clinical and economic impact of percutaneous ventricular assist devices (pVAD) with intraaortic balloon pumps for high-risk patients undergoing percutaneous coronary intervention (PCI). METHODS: This study conducted a review of all comparative randomized control trials of the pVADS (Impella and TandemHeart) vs IABP for patients undergoing high-risk percutaneous coronary intervention (PCI). A retrospective analysis of the 2010 and 2011 Medicare MEDPAR data files was also performed to compare procedural costs and hospital length of stay (LOS). Readmission rates between the devices were also studied. RESULTS: Based on available trials, there is no significant clinical benefit with pVAD compared to IABP. Use of pVADs is associated with increased length of Intensive Care Unit stay and a total longer LOS. The incremental budget impact for pVADs was $33,957,839 for the United States hospital system (2010-2011). CONCLUSIONS: pVADs are not associated with improved clinical outcomes, reduced hospital length of stay, or reduced readmission rates. Management of high-risk PCI and cardiogenic shock patients with IABP is more cost effective than a routine use of pVADS. Use of IABP as initial therapy in high-risk PCI and cardiogenic shock patients may result in savings of up to $2.5 billion annually of incremental costs to the hospital system.

Survival and neurologic outcome after out-of-hospital cardiac arrest: results one year after regionalization of post-cardiac arrest care in a large metropolitan area.

BACKGROUND: Post-resuscitation care of cardiac arrest patients at specialized centers may improve outcome after out-of-hospital cardiac arrest (OOHCA). This study describes experience with regionalized care of resuscitated patients. METHODS: Los Angeles (LA) County established regionalized cardiac care in 2006. Since 2010, protocols mandate transport of nontraumatic OOHCA patients with field return of spontaneous circulation (ROSC) to a STEMI Receiving Center (SRC) with a hypothermia protocol. All SRC report outcomes to a registry maintained by the LA County Emergency Medical Services (EMS) Agency. We report the first year's data. The primary outcome was survival with good neurologic outcome, defined by a Cerebral Performance Category (CPC) score of 1 or 2. RESULTS: The SRC treated 927 patients from April 2011 through March 2012 with median age 67; 38% were female. There were 342 patients (37%) who survived to hospital discharge. CPC scores were unknown in 47 patients. Of the 880 patients with known CPC scores, 197 (22%) survived to hospital discharge with a CPC score of 1 or 2. The initial rhythm was VF/VT in 311 (34%) patients, of whom 275 (88%) were witnessed. For patients with an initial shockable rhythm, 183 (59%) survived to hospital discharge and 120 (41%) had survival with good neurologic outcome. Excluding patients who were alert or died in the ED, 165 (71%) patients with shockable rhythms received therapeutic hypothermia (TH), of whom 67 (42%) had survival with good neurologic outcome. Overall, 387 patients (42%) received TH. In the TH group, the adjusted OR for CPC 1 or 2 was 2.0 (95%CI 1.2-3.5, p = 0.01), compared with no TH. In contrast, the proportion of survival with good neurologic outcome in the City of LA in 2001 for all witnessed arrests (irrespective of field ROSC) with a shockable rhythm was 6%. CONCLUSION: We found higher rates of neurologically intact survival from OOHCA in our system after regionalization of post-resuscitation care as compared to historical data.

Hospital readmission among older adults who return home with unmet need for ADL disability.

PURPOSE: This study determined whether returning to the community from a recent hospitalization with unmet activities of daily living (ADL) need was associated with probability of readmission. METHODS: A total of 584 respondents to the 1994, 1999, and/or 2004 National Long-Term Care Surveys (NLTCS) who were hospitalized within 90 days prior to the interview and reported ADL disability at the time of the interview were considered for analysis. Medicare claims linked to the NLTCS provided information about hospital episodes, so those enrolled in Health Maintenance Organizations or Veterans Affairs Medical Centers were not included (n = 62), resulting in a total sample size of 522. ADL disability was defined as needing human help or equipment to complete the task. Unmet ADL need was defined as receiving inadequate or no help for one or more ADL disabilities. Disability that began within 90 days of the interview was considered new disability. RESULTS: After adjusting for demographic, health, and functioning characteristics, unmet ADL need was associated with increased risk for hospital readmission (HR: 1.37, 95% CI: 1.03-1.82). Risk of readmission was greater for those with unmet need for new disabilities than those with unmet need for disabilities that were present before the index hospitalization (HR: 1.66, 95% CI: 1.01-2.73). IMPLICATIONS: Many older patients are discharged from the hospital with ADL disability. Those who report unmet need for new ADL disabilities after they return home from the hospital are particularly vulnerable to readmission. Patients' functional needs after discharge should be carefully evaluated and addressed.

Wellness coaching and health-related quality of life: a case-control difference-in-differences analysis.

OBJECTIVES: Association between wellness coaching and changes in health-related quality of life over 1 year and 2 years was assessed. METHODS: Difference-in-differences analysis of covariance assessed association between coaching and change in 8-item short-form health survey (SF-8) summary scores. Ordered logistic models assessed coaching and change in SF-8 individual domain scores. This was a case-control study. RESULTS: Participants in at least one coaching program were more likely to have increases in social functioning after 1 year and less likely to have increases in role physical after 2 years. Participants in nutrition coaching had more positive change in mental component summary scores after 1 year. Participants in stress management had more negative change in mental component summary scores after 1 year and after 2 years and had more negative change in physical component summary scores after 2 years. CONCLUSIONS: Findings were mixed regarding association between coaching and change in health-related quality of life.

Incremental dementia-related expenditures in a medicaid population.

OBJECTIVES: With the growing number of older adults, understanding expenditures associated with treating medical conditions that are more prevalent among older adults is increasingly important. The objectives of this research were to estimate incremental medical encounters and incremental Medicaid expenditures associated with dementia among Indiana Medicaid recipients 40 years or older in 2004. METHODS: A retrospective cohort design analyzing Indiana Medicaid administrative claims files was used. Individuals at least 40 years of age with Indiana Medicaid eligibility during 2004 were included. Patients with dementia were identified via diagnosis codes in claims files between July 2001 and December 2004. Adjusted annual incremental medical encounters and expenditures associated with dementia in 2004 were estimated using negative binomial regression and zero-inflated negative binomial regression models. RESULTS: A total of 18,950 individuals (13%) with dementia were identified from 145,684 who were 40 years or older. The unadjusted mean total annualized Medicaid expenditures for the cohort with dementia ($28,758) were significantly higher than the mean expenditures for the cohort without dementia ($14,609). After adjusting for covariates, Indiana Medicaid incurred annualized incremental expenditures of $9,829 per recipient with dementia. Much of the annual incremental expenditure associated with dementia was driven by the higher number of days in nursing homes and resulting nursing-home expenditures. Drug expenditures accounted for the second largest component of the incremental expenditures. On the basis of disease prevalence and per recipient annualized incremental expenditures, projected incremental annualized Indiana Medicaid spending associated with dementia for persons 40 or more years of age was $186 million. CONCLUSIONS: Dementia is associated with significant expenditures among Medicaid recipients. Disease management initiatives designed to reduce nursing-home use among recipients with dementia may have much potential to decrease Medicaid expenditures associated with dementia.

Volume of home- and community-based services and time to nursing-home placement.

OBJECTIVE: The purpose of this study was to determine whether the volume of Home- and Community-Based Services (HCBS) that target Activities of Daily Living disabilities, such as attendant care, homemaking services, and home-delivered meals, increases recipients' risk of transitioning from long-term care provided through HCBS to long-term care provided in a nursing home. DATA SOURCES: Data are from the Indiana Medicaid enrollment, claims, and Insite databases. Insite is the software system that was developed for collecting and reporting data for In-Home Service Programs. STUDY DESIGN: Enrollees in Indiana Medicaid's Aged and Disabled Waiver program were followed forward from time of enrollment to assess the association between the volume of attendant care, homemaking services, home-delivered meals, and related covariates, and the risk for nursing-home placement. An extension of the Cox proportional hazard model was computed to determine the cumulative hazard of nursing-home placement in the presence of death as a competing risk. PRINCIPAL FINDINGS: Of the 1354 Medicaid HCBS recipients followed in this study, 17% did not receive any attendant care, homemaking services, or home-delivered meals. Among recipients who survived through 24 months after enrollment, one in five transitioned from HCBS to a nursing-home. Risk for nursing-home placement was significantly lower for each five-hour increment in personal care (HR=0.95, 95% CI=0.92-0.98) and homemaking services (HR=0.87, 95% CI=0.77-0.99). CONCLUSIONS: Future policies and practices that are focused on optimizing long-term care outcomes should consider that a greater volume of HCBS for an individual is associated with reduced risk of nursing-home placement.

Modeling correlated healthcare costs.

Accurate estimation and prediction of healthcare costs play crucial roles in decisions made by healthcare agencies on policy and resource allocation. Development of a cost model allows these decision-makers the opportunity to investigate the impact of different policies and/or allocations of resources. With increased subject-specific information, longitudinal studies and the breakdown of total costs into categories comes the need for healthcare cost models to account for correlation. In this article, we review the statistical models used to fit joint costs, emphasizing the use of copulas as a flexible and relatively straightforward approach to move from marginal to joint modeling.

Incident use and outcomes associated with potentially inappropriate medication use in older adults.

BACKGROUND: Most studies of potentially inappropriate medication (PIM) use among older adults have focused on prevalence rather than incidence. OBJECTIVES: The goals of this study were to determine the 1-year incidence of PIM use among elderly Indiana Medicaid residents of nursing homes and to examine associations between incident PIM use and hospitalization and mortality. METHODS: A retrospective analysis was conducted using Indiana Medicaid enrollment and administrative claims files. Individuals were included if they were Medicaid eligible and aged ≥65 years as of January 2003 and received nursing home services in each month of 2003 or until death in 2003. Individuals also had to receive nursing home services from October 2002 through December 2002 for inclusion in the sample. To focus analysis on incident PIM use, individuals who received any PIM prescription medication from October 2002 through December 2002 were excluded from the sample, as were those not prescribed any new medication in 2003. PIMs were identified using the 2003 Beers criteria. Associations between incident PIM use and hospitalization and mortality were assessed using logistic regression models after controlling for other risk factors. Potential selection bias was examined using bivariate probit models. RESULTS: The study sample consisted of 7594 individuals (mean age, 83.07 years). A majority of the sample was female (76.5%), white (89.7%), and widowed (58.8%). Most individuals received care in nursing homes located in urban areas (5306 [69.9%]) and in the central region of Indiana (2838 [37.4%]). One-year incidence of PIM use was 42.1%. Incident PIM users were more likely to be hospitalized (odds ratio [OR] = 1.27; 95% CI, 1.10-C1.46) and more likely to die (OR = 1.46; 95% CI, 1.31-C1.62) in the 12 months after first receiving a PIM than nonusers, even after adjusting for demographic and clinical risk factors. CONCLUSIONS: Incident PIM use was high among these elderly Indiana Medicaid residents of nursing homes. Individuals who began use of a PIM were at a higher risk of hospitalization and of dying.

Volume of home- and community-based Medicaid waiver services and risk of hospital admissions.

OBJECTIVES: To evaluate whether type and volume of Medicaid Home- and Community-Based Services (HCBS) waiver program are associated with risk of hospitalization and whether this association changes over time. DESIGN: Prospective. SETTING: Indiana Medicaid claims data from June 2001 to December 2004. PARTICIPANTS: Medicaid recipients (N=1,354) who enrolled in the Aged and Disabled waiver program between January 2002 and June 2004. MEASUREMENTS: Time to hospital admission since enrollment in the HCBS waiver program, adjusted for demographics, comorbidities, prior use of health services, and volume of HCBS received, including attendant care, homemaking, and home-delivered meals. RESULTS: A greater volume of attendant care, homemaking services, and home-delivered meals was associated with a lower risk of hospitalization. This effect diminished over time for attendant care and homemaking. The risk of hospitalization for subjects receiving 5 hours of attendant care per month was 54% (hazard ratio (HR)=0.46, 95% confidence interval (CI)=0.38-0.57) lower during the first month of enrollment and 20% lower by Month 10 (HR=0.80, 95% CI=0.73-0.88) than for those receiving no attendant care. CONCLUSION: Greater volume of HCBS services was associated with lower risk of hospitalization. The findings highlight the potential importance of assessing and monitoring the volume of HCBS patients receive.