Economic Burden of Asthma-Chronic Obstructive Pulmonary Disease Overlap among Older Adults in the United States.

The objective of this study is to estimate the excess economic burden of Asthma-COPD Overlap (ACO) among older adults in the United States. We used a cross-sectional study design with data from a nationally representative survey of Medicare beneficiaries (Medicare Current Beneficiary Survey) linked to Medicare fee-for-service claims. Older adults with ACO had higher average total healthcare expenditures ($45,532 vs. $12,743) and higher out-of-pocket spending burden (19% vs. 8.5%) compared to those with no-asthma no-COPD (NANC). Individuals with ACO also had almost two, and 1.5 times higher expenditures compared to individuals with asthma only and COPD only, respectively. Multivariable regression models indicated that the adjusted associations of ACO to economic burden remained positive and statistically significant. In comparison with NANC, nearly three-quarters of the excess total healthcare expenditures and 83% of the out-of-pocket spending burden of older adults with ACO were explained by differences in predisposing, enabling, need, personal healthcare practices, and external factors among the two groups. The higher number of unique medications and the increased incidence of fragmented care were the leading contributors to the excess economic burden among older adults with ACO comparing to NANC individuals. Interventions that reduce the number of medications and fragmented care have the potential to reduce the excess economic burden among older adults with ACO.

Association of the severity of diabetes-related complications with stage of breast cancer at diagnosis among elderly women with pre-existing diabetes.

PURPOSE: This study assessed the association between the severity of diabetes complications using diabetes complications severity index (DCSI) and stage of breast cancer (BC) at diagnosis among elderly women with pre-existing diabetes and incident BC. METHODS: Using Surveillance, Epidemiology and End Results-Medicare data, we identified women with incident BC during 2004-2011 and pre-existing diabetes (N = 7729). Chi-square tests were used to test for group differences in stage of BC at diagnosis. Multinomial logistic regression was used to examine the associations between the severity of diabetes complications and stage of BC at diagnosis. RESULTS: Overall, women with a DCSI = 2 and a DCSI ≥ 3 were more likely to be diagnosed at advanced stages as compared to those with no diabetes complications. In full adjusted association (after adding BC screening to the analysis model), the severity of diabetes complications was no longer an independent predictor of advanced stages at diagnosis. However, women with a DCSI = 2 were 26% more likely to be diagnosed at stage I (versus stage 0) of BC at diagnosis as compared to those without diabetes complications (OR 1.26, 95% CI 1.03-1.53). CONCLUSION: The increased likelihood of having advanced-stage BC at diagnosis associated with severity of diabetes-related complications appears to be mediated by lower rates of breast cancer screening among elderly women with pre-existing diabetes complications. Therefore, reducing disparity in receiving breast cancer screening among elderly women with diabetes may reduce the risk of advanced-stage breast cancer diagnosis.

Receipt of Guideline-Concordant Care Among Older Women With Stage I-III Breast Cancer: A Population-Based Study.

Background: This study examined receipt of guideline-concordant care (GCC) according to evidence-based treatment guidelines and quality measures and specific types of treatment among older women with breast cancer. Patients and Methods: A total of 142,433 patients aged ≥66 years diagnosed with stage I-III breast cancer between 2007 and 2011 were identified in the SEER-Medicare linked database. Algorithms considering cancer characteristics and the appropriate course of care as per guidelines versus actual care received determined receipt of GCC. Multivariable logistic regression estimated the likelihood of GCC and specific types of treatment for women aged ≥75 versus 66 to 74 years. Results: Overall, 39.7% of patients received GCC. Patients diagnosed at stage II or III, with certain preexisting conditions, and of nonwhite race were less likely to receive GCC. Patients with hormone-negative tumors, higher grade tumors, and greater access to oncology care resources were more likely to receive GCC. Patients aged ≥75 years were approximately 40% less likely to receive GCC or adjuvant endocrine therapy, 78% less likely to have any surgery, 61% less likely to have chemotherapy, and about half as likely to have radiation therapy than those aged 66 to 74 years. Conclusions: Fewer than half of older women with breast cancer received GCC, with the lowest rates observed among the oldest age groups, racial/ethnic minorities, and women with later-stage cancers. However, patients with more aggressive tumor characteristics and greater access to oncology resources were more likely to receive GCC. Considering that older women have the highest incidence of breast cancer and that many are diagnosed at stages requiring more aggressive treatment, efforts to increase rates of earlier stage diagnosis and the development of less toxic treatments could help improve GCC and survival while preserving quality of life.

Differences in Medicare Expenditures Between Appalachian and Nationally Representative Cohorts of Elderly Women With Breast Cancer: An Application of Decomposition Technique.

Background: Differences in Medicare expenditures during the initial phase of cancer care among rural and medically underserved elderly women with breast cancer (BC) and those from a nationally representative cohort have not been reported. The objective of this study was to determine Medicare expenditures during the initial phase of care among women in West Virginia (WV) who were Medicare beneficiaries with BC and compare them with national estimates. The magnitude of differences in these expenditures was also determined by using a linear decomposition technique. Methods: A retrospective observational study was conducted using the WV Cancer Registry-Medicare database and the SEER-Medicare database. Our study cohorts consisted of elderly women aged ≥66 years diagnosed with incident BC in 2003 to 2006. Medicare expenditures during the initial year after BC diagnosis were derived from all of the Medicare files. Generalized linear regressions were performed to model expenditures, after controlling for predisposing factors, enabling resources, need, healthcare use, and external healthcare environmental factors. Blinder-Oaxaca decomposition was conducted to examine the proportion of the differences in the average expenditures explained by independent variables included in the model. Results: Average Medicare expenditures for the WV Medicare cohort during the initial phase of BC care were $25,626 compared with $29,502 for the SEER-Medicare cohort; a difference of $3,876. In the multivariate regression, this difference decreased to $708 and remained significant. Only 16% of the differences in the average expenditures between the cohorts were explained by the independent variables included in the model. Enabling resources (6.86%), healthcare use (7.55%), and external healthcare environmental factors (3.33%) constituted most of the explained portion of the differences in the average expenditures. Conclusions: The difference in average Medicare expenditures between the elderly beneficiaries with BC from a rural state (WV) and their national counterparts narrowed but remained significantly lower after multivariate adjustment. The explained portion of this difference was mainly driven by enabling and healthcare use factors, whereas 84% of this difference remained unexplained.

Healthcare Utilization and Costs During the Initial Phase of Care Among Elderly Women With Breast Cancer.

Background: Understanding the patterns of healthcare utilization and costs during the initial phase of care (12 months after breast cancer [BC] diagnosis) in older women (aged ≥65 years) is crucial in the allocation of Medicare resources. The objective of this study was to determine healthcare utilization and costs during the initial phase of care in older, female, Medicare fee-for-service beneficiaries diagnosed with BC, and to determine the factors associated with higher costs. Methods: A retrospective observational study using the SEER-Medicare linked database was conducted in 69,307 women aged ≥66 years diagnosed with primary incident BC in 2003-2009 to determine healthcare utilization, average costs, and costs for specific services during the initial phase of care. Generalized linear model regression was conducted to identify the factors associated with higher costs in a multivariate framework. Results: A total of 96% of women were treated with surgery during the initial phase of BC care, whereas 21% and 54% underwent chemotherapy and radiotherapy, respectively. Costs during the initial phase of care totalled $28,075 in 2012 USD, comprising $13,344 for physician services and $7,456 for outpatient services. Factors associated with higher costs during the initial phase of care were younger age (66-69 years), African American race, higher household income, advanced stages of BC, initial BC treatment, higher number of primary care physician visits, and presence of comorbidities and/or a mental condition. Conclusions: The economic burden of BC is substantial during the initial phase of care. Physician and outpatient services accounted for the highest proportion of costs. Predisposing factors, need-related factors, healthcare use, and external environmental healthcare factors significantly predicted costs during the initial phase of care.

Caregiver Burdens and Preventive Dental Care for Children with Autism Spectrum Disorder, Developmental Disability and/or Mental Health Conditions: National Survey of CSHCN, 2009-2010.

Objective The purpose of this study is to examine the burdens of caregivers on perception of the need and receipt of preventive dental care for a subset of children with special health care needs-children with Autism Spectrum disorder, developmental disability and/or mental health conditions (CASD/DD/MHC). Methods The authors used the 2009-2010 National Survey of CSHCN. The survey included questions addressing preventive dental care and caregivers' financial, employment, and time-related burdens. The associations of these burdens on perceptions and receipt of preventive dental care use were analyzed with bivariate Chi square analyses and multinomial logistic regressions for CASD/DD/MHC (N = 16,323). Results Overall, 16.3 % of CASD/DD/MHC had an unmet preventive dental care need. There were 40.0 % of caregivers who reported financial burden, 20.3 % who reported employment burden, and 10.8 % who reported time burden. A higher percentage of caregivers with financial burden, employment burden, and time-related burden reported that their CASD/DD/MHC did not receive needed preventive dental care (14.1, 16.5, 17.7 % respectively) compared to caregivers without financial, employment, or time burdens (9.0, 9.6 %, 11.0 % respectively). Caregivers with financial burden (adjusted multinomial odds ratio, 1.38 [95 % CI 1.02, 1.86] and employment burden (adjusted multinomial odds ratio, 1.45 [95 % CI 1.02, 2.06] were more likely to report that their child did not receive preventive dental care despite perceived need compared to caregivers without financial or employment burdens. Conclusions for practice Unmet needs for preventive dental care were associated with employment and financial burdens of the caregivers of CASD/DD/MHC.

Tobacco-use Cessation Counseling Service Usage.

Objectives: Tobacco-use is common among elderly lung cancer patients and continued tobacco-use can impact prognosis. This study evaluates patterns of receipt of Tobacco-use Cessation Counseling (TCC) services among these patients. Methods: Using West Virginia Cancer Registry-Medicare linked database (2004-2007), we identified elderly patients with lung cancer (n = 922) and categorized them by receipt of TCC services. Hierarchical generalized logistic model was constructed and survival outcomes were analyzed by Kaplan-Meier analysis, Log-Rank test, and Cox proportional hazards modeling. Results: Majority of patients (76.7%) received TCC services. Unadjusted analysis showed favorable survival outcomes in patients who received TCC services. However, adjusted lung cancer mortality risk was no different between the groups (HR (95% CI) = 1.78 (0.87-3.64)). Conclusion: This study highlights the critical need to address disparities in receipt of TCC services among elderly. Although lung cancer preventive services are covered under the Medicare program, underutilization of these services is a concern.

A Discrete Choice Experiment to Elicit Patient Willingness to Pay for Attributes of Treatment-Induced Symptom Relief in Comorbid. Insomnia.

PURPOSE: Insomnia is a burdensome, commonly comorbid condition. How patients value various aspects of the safety and efficacy of available drugs has not been studied. The aim of the present study was to quantify patient-rated utility by studying willingness to pay (WTP) for attributes of symptom relief via a discrete choice experiment (DCE). METHODOLOGY: Adult primary care patients (West Virginia University Hospital) with comorbid insomnia were enrolled. The attributes and levels examined were sleep onset latency (SOL; 10, 20,30 minutes), awakenings (1, 2, 3), wake time after sleep onset (WASO; 15,45, 60 minutes), total sleep time (TST; 6, 7, 8 hours), hangover (none, mild, moderate), FDA-approved duration of use (short term, not restricted to short term, no restrictions), and out-of-pocket cost per month ($20, $35, $50). Willingness to pay (WTP) data were analyzed using a random effects binary logistic regression model. RESULTS: A total of 82 patients completed the DCE (74 analyzed). SOL, WASO, TST, and cost were all found to predict treatment choice. Higher values of SOL, WASO, and cost resulted in decreased preference for a particular treatment, while higher TST predicted increased preference. Modeling revealed an estimated marginal WTP of $66.69 for an example product that improved SOL by 10 minutes, reduced WASO by 15 minutes, and improved TST by 1 hour. CONCLUSION: Patient WTP for symptomatic relief in insomnia can help clinicians fine-tune interventions based on patient preferences, provide evidence for drug formulary and reimbursement decisions, and potentially guide the development of novel drugs.

Association of Entrepreneurial Traits With Interest in Becoming a Pharmacist Provider Among Student Pharmacists.

BACKGROUND: With the emerging opportunities for pharmacists to gain provider status, the need for understanding interest to become a pharmacist provider has never been greater. OBJECTIVE: To determine which entrepreneurial traits (locus of control, innovativeness, autonomy, risk-taking propensity, proactiveness, achievement motivation, people liking, problem-solving, and leadership) are associated with interest in becoming a pharmacist provider. METHODS: A cross-sectional survey was conducted among second- and third-year student pharmacists. Exploratory factor analysis (principal components with varimax rotation) was used to determine any underlying dimensions. Significant differences in interest in becoming a pharmacist provider by demographic and other characteristics were determined using t tests and analysis of variance (ANOVA; P ≤ .05). Multiple linear regression was used to determine the factors associated with interest in becoming a pharmacist provider. RESULTS: A total of 137 completed questionnaires were received. Gender (P = .003) and preference of workplace (P < .001) were significantly associated with interest in becoming a pharmacist provider. All factor loadings were more than 0.50 and Cronbach alpha values were more than .68. In the multiple linear regression analysis model, proactiveness (P = .036) and achievement motivation (P = .018) were positive predictors of interest in becoming a pharmacist provider. Females (P = .006) and individuals who preferred to work in a hospital (P < .001) or in specialty care (P = .007) had a significantly greater interest in becoming a pharmacist provider. CONCLUSIONS: Proactiveness and achievement motivation can be predictors of interest in becoming a pharmacist provider.

Initial maintenance therapy adherence among older adults with asthma-COPD overlap.

OBJECTIVES: To examine the impact of initial maintenance therapy (IMT) type (inhaled corticosteroid [ICS] vs fixed-dose combination of ICS and long-acting ß agonist [ICS/LABA]) on trajectories of adherence among older adults (≥ 65 years) with coexisting asthma and chronic obstructive pulmonary disease (COPD), known as asthma-COPD overlap (ACO). STUDY DESIGN: We used a longitudinal, retrospective cohort design. METHODS: This study used a cohort of older adults with ACO using longitudinal data from a 10% sample of Optum's Deidentified Clinformatics Data Mart. We adopted group-based trajectory modeling to identify medication adherence trajectories over 12 months. Multinomial logistic regressions were used to evaluate the unadjusted and adjusted associations of IMT medication and adherence trajectory categories. All analyses accounted for treatment option selection bias with inverse probability treatment weighting. RESULTS: Of 1555 individuals, 73% of the sample used ICS/LABA for IMT. Four medication adherence trajectories were observed regardless of regimen: (1) persistent high adherence (12.0%), (2) progression to high adherence (20.8%), (3) progression to low adherence (10.5%), and (4) persistent low adherence (56.7%). Those who were initiated on ICS/LABA were less likely to have persistent low adherence (unadjusted odds ratio [OR], 0.44; 95% CI, 0.29-0.67) compared with those initiated on ICS monotherapy when "persistent high adherence" was used as the reference group. The relationship remained significant in adjusted regressions (adjusted OR, 0.38; 95% CI, 0.24-0.59). CONCLUSIONS: Real-world evidence suggests that using ICS/LABA for IMT may decrease the likelihood of persistent low adherence over time among older adults with ACO compared with ICS monotherapy.

Determining the Entrepreneurial and Intrapreneurial Intentions of Student Pharmacists in Iran.

Objective. To identify factors and entrepreneurial characteristics associated with entrepreneurial and intrapreneurial intentions among Doctor of Pharmacy (PharmD) students in Iran.Methods. First, the Entrepreneurial-Intrapreneurial Pharmacist Questionnaire (EIPQ), which was developed in the United States, was translated from English to Persian. The paper-based Persian-EIPQ questionnaire was then tested in a convenience sample of student pharmacists enrolled in pharmacy schools in Iran. The entrepreneurial characteristics questionnaire was evaluated using exploratory factor analysis with varimax rotation. Internal consistency was examined using Cronbach alpha. The association of demographics and educational variables and entrepreneurial characteristics with entrepreneurial and intrapreneurial intentions was determined using a multiple linear regression model.Results. A total of 504 surveys, 98.6% of the completed questionnaires received, were analyzed. A majority of the participants were female (75.8%) and from 18 to 25 years old (92.2%). Entrepreneurial intention had a positive and significant association with risk-taking propensity, leadership self-efficacy, autonomy, achievement motivation, and having an entrepreneur in the family. Intrapreneurial intention had a positive and significant association with risk-taking propensity, leadership self-efficacy, achievement motivation, people liking, attending a private school, and having an entrepreneur in the family.Conclusion. Based on the findings, student pharmacists with higher levels of risk-taking propensity, achievement motivation, leadership self-efficacy, autonomy, and people liking may be more likely to have greater levels of entrepreneurial and/or intrapreneurial intention.

Perceived barriers to provision of medication therapy management services (MTMS) and the likelihood of a pharmacist to work in a pharmacy that provides MTMS.

BACKGROUND: Recently, medication therapy management services (MTMS) has gained significant attention as an important type of pharmaceutical care designed to improve patient outcomes with more appropriate medication usage and monitoring. Although the provision of MTMS is increasing in pharmacies across the nation, and pharmacists are well equipped to administer MTMS, many community pharmacists are not currently providing these services. OBJECTIVE: To determine barriers to provision of MTMS perceived by pharmacists and factors associated with the likelihood of working in a pharmacy that provides MTMS. METHODS: Surveys were mailed to 906 community pharmacists licensed in West Virginia using a stratified random sample. The instrument was constructed and finalized following a review by experts and pilot tested in a convenience sample of pharmacists. Principal components analysis was performed to determine the factors that describe perceived barriers to provision of MTMS. Discriminant analysis using factor scores and other demographic and practice variables was performed to predict respondents' likelihood to work in a pharmacy that provides MTMS. RESULTS: A 3-factor model was extracted from the responses, which explained 53.3% of the total variance. The factors included perceived ability to respond to patient interest, pharmacy-related factors, and enabling factors. The discriminant function correctly classified 76.2% of cases and included comfort level with provision of services, perceived value of services to patients, perceived ability to respond to patient interest, and whether they currently offer MTMS. These variables were all positively correlated with pharmacists' likelihood of working in a pharmacy that provides MTMS. CONCLUSIONS: Comfort level and ability are important factors that influence pharmacists' likelihood of working in a pharmacy that provides MTMS. These findings highlight the importance of advanced practice experiences, certificate programs, and residencies to build pharmacists' confidence, and the role of targeted recruitment to attract pharmacists to community pharmacies that provide MTMS.

Initial Validation of an Instrument for Measuring Entrepreneurial and Intrapreneurial Intentions in Student Pharmacists.

Objective. To develop a questionnaire for measuring entrepreneurial and intrapreneurial intentions among student pharmacists and to identify characteristics and personality traits that are associated with these intentions. Methods. A 105-item survey instrument was developed and administered to all Doctor of Pharmacy (PharmD) students (incoming to third year) at a large public university. It consisted of nine scales pertaining to entrepreneurism including previously validated and some newly developed scales adapted for use among student pharmacists. Data analysis consisted of factor analysis to determine scale constructs, reliability assessment, and systematic item-reduction analysis. Multiple linear regression and structural equation modeling was used to determine and confirm the association of personality traits and demographic characteristics with entrepreneurial and intrapreneurial intentions. Results. Of 289 students surveyed, 286 useable survey instruments were included in the analysis. Factor analysis was conducted for each scale, and items that did not load on their theorized factor or had cross-loadings above the permissible limits were removed, reducing the survey to 69 items. Findings demonstrated that gender, joint degree program, and autonomy were significant predictors of entrepreneurial intentions, and achievement motivation, leadership self-efficacy, and problem-solving were significant predictors of intrapreneurial intentions. Conclusion. A multi-dimensional questionnaire to measure entrepreneurial and intrapreneurial intentions of student pharmacists was developed and a few key predictors of such intentions were identified. When fully validated, the questionnaire may be used in pharmacy schools for several purposes, including in the PharmD admission process to gain additional insights into a student's potential to become a future innovative entrepreneurial or intrapreneurial practitioner.

Cluster analysis of state Medicaid prescription drug benefit programs based on potential determinants of per capita drug expenditure.

BACKGROUND: Drug cost-containment strategies result in varied outcomes in different state Medicaid programs perhaps, because they differ in ways beyond the usual considerations of similarity among the states and their Medicaid populations. OBJECTIVE: To classify state Medicaid programs into homogenous groups based on potential determinants of their prescription drug expenditures. METHODS: Cluster analysis techniques were used to identify clusters of state Medicaid programs, and their characteristics, using variables identified as potential determinants of Medicaid prescription drug expenditures. RESULTS: Five distinct clusters were identified with memberships ranging from 1 to 24 states. Sociodemographic factors like race/ethnicity and elderly persons in Medicaid, severity of diseases, state population covered by Medicaid, population below poverty level, and high-school graduates; access factors like access to hospitals, pharmacies, physicians, and prenatal care; and policy factors like support for publicly funded health care were identified as key characteristics that distinguished among these clusters. Per capita prescription drug expenditure was also found to be significantly different among these clusters. CONCLUSION: Knowledge of clusters among state Medicaid programs and their characteristics could potentially increase the chances of success for Medicaid administrative policies and interventions at lower costs of targeted implementation.

Medication therapy management services in West Virginia: pharmacists' perceptions of educational and training needs.

BACKGROUND: The Medicare Modernization Act of 2003 recognizes the challenges associated with drug therapy in elderly patients with multiple chronic diseases, and requires the development of medication therapy management services (MTMS) for such beneficiaries. OBJECTIVE: To assess pharmacists' perception of educational and training needs necessary to implement MTMS in community pharmacies in West Virginia, USA. METHODS: Self-administered mail surveys with an explanatory cover letter were mailed to the designated pharmacist-in-charge (PIC) of each licensed community pharmacy (506) in West Virginia. Main outcome measures included pharmacists' comfort level, perceptions of value to patients, barriers to provision of services, and pharmacists' interest in receiving education and training related to MTMS. RESULTS: Of the 503 surveys that were deliverable, 203 (40.4%) usable responses were received. Fifty-five (27.1%) PICs reported that MTMS are currently being provided in their pharmacy. Respondents were likely to use services that aid in the development of MTMS and disease-state management, felt relatively comfortable in providing MTMS, and had a favorable view of the value of services to patients, but reported that lack of time tended to be a barrier. CONCLUSION: PICs in West Virginia are interested in and open to their pharmacists receiving education and training for implementation of MTMS.

Breast cancer screening, incidence, and mortality in West Virginia.

Situated entirely in the Appalachian region, West Virginia (WV) as a state is characterized by a diverse population, with a major portion of the population residing in rural areas. Breast cancer is the most commonly diagnosed cancer among women residents of the state. Using different data sources, we have reported the most recent screening, incidence, and mortality information associated with breast cancer in WV. In 2006, roughly one-fourth of women > or =40 years of age had not had a mammogram in the past two years. Sociodemographic factors were found to be associated with lack of mammography screening among these women. The leveling off of the increase in the in-situ breast cancer incidence rates in WV since 1999 is closely associated with the bottoming out of the proportion of women without mammography that has been seen since early this decade. Counties in southern and northern part of the state generally have higher invasive breast cancer incidence rates than those in the central part. Breast cancer-related mortality is higher among southern counties in comparison to counties in northern and central part of the state, with mortality rates higher than the national average in McDowell, Mingo, Wayne, and Mason Counties. There is a compelling need to increase access to mammography screening among women residents in the state.

Smoking and breast cancer screening in West Virginia: opportunities for intervention.

Smoking has been increasingly identified as a risk factor for breast cancer among women. West Virginia has high rates of smoking, which can be further examined in relation to breast cancer screening and smoking related variables. This study used 2006 Behavioral Risk Factor Surveillance System (BRFSS) data to examine the relationship between smoking related variables and breast cancer screening behaviors among women in West Virginia age 40 and older. Findings showed that approximately 21.6% of women in the sample were current smokers, with a majority of these women smoking every day (82.5%). Half of the women in the study sample had made at least one past year quit attempt. Current smokers were less likely to have had breast cancer screening in the past one or two years, and among these women who smoke, every day smokers were less likely to obtain breast cancer screening. Smokers who did not make a quit attempt during the past year were also significantly less likely to have had mammography screening. Study results highlight an unmet need and opportunity for intervention related to breast cancer screening among women who smoke, and especially those with higher smoking intensity. Smoking status and smoking intensity should be recognized as predictors of women who are less likely to obtain breast cancer screening. These women can be identified and targeted as an important high risk population with unmet need for smoking cessation and breast cancer screening interventions.

Making a case for employing a societal perspective in the evaluation of Medicaid prescription drug interventions.

The choice of a perspective is among the most critical influences of the potential outcome of an economic evaluation, since it determines whose interest is relevant in any given analysis. For publicly funded programmes such as Medicaid, and now Medicare, it is important that economic evaluations are undertaken from a societal perspective because such evaluations inform decisions about allocation of healthcare resources. It has been argued that approaches other than the societal perspective selectively include specific costs, while ignoring other costs that are very much more 'real', and hence lack theoretical foundation in welfare economics. In view of the importance of perspectives in economic evaluations, this paper reviews 25 existing reports of economic evaluations of interventions involving prescription drugs in the Medicaid programme to examine the perspectives employed in such evaluations, based on the specific cost and benefit measurements. No explicit statement of the perspective employed was included in any of the articles selected for this review. Based on an analysis of the cost measures, none of the studies were found to have adopted a societal perspective in their evaluation. Most studies were from the perspective of Medicaid as the payer and as such did not include costs and benefits from outside the Medicaid system. Ten of the identified evaluations of interventions focused just on costs related to prescription drugs. Six studies included an evaluation of the impact of the intervention on overall programme costs along with the costs of prescription drugs. The nine remaining evaluations employed a broader approach to include related effects of the drug-benefit intervention on costs and utilization of other healthcare services such as physician, outpatient and inpatient services. This review emphasizes the importance of a societal approach in evaluating the effects of interventions in Medicaid and other publicly funded drug benefit programmes. Existing evaluations fall short of employing such a broad perspective. This, along with the limitations in design and data, make findings from these studies less reliable than should be used to make major decisions regarding allocation of tax dollars. While methodological challenges to such an approach are valid and understandable, there is an increasing need to attempt evaluations of cost-containment strategies from a broad-based societal perspective to ensure continuity and sustainability of publicly funded drug benefit programmes such as Medicaid and Medicare.

Comparing adherence to and persistence with antipsychotic therapy among patients with bipolar disorder.

BACKGROUND: Medication nonadherence is a significant problem among patients with bipolar disorder. OBJECTIVE: To compare adherence and persistence among patients with bipolar disorder initiated on antipsychotics in a state Medicaid system over a 12 month follow-up period. METHODS: Claims data for patients with bipolar disorder from a de-identified Medicaid database were examined. Patients were classified into 4 monotherapy treatment groups (risperidone, olanzapine, quetiapine, or typical antipsychotic) based on the first prescription filled between January 1, 1999, and December 31, 2001. Adherence and persistence were analyzed over a 12 month follow-up period. Adherence was measured using the Medication Possession Ratio (MPR). Persistence was defined as the total number of days from the initiation of treatment to therapy modification (ie, discontinuation, switching, or combination with another antipsychotic). Adjustment for confounding variables was undertaken using ordinary least-squares and Cox proportional hazard regression modeling. RESULTS: The mean MPRs were 0.68 for risperidone (n = 231), 0.68 for olanzapine (n = 283), 0.71 for quetiapine (n = 106), and 0.46 for typical antipsychotics (n = 205). Patients initiated on typical antipsychotics were 23.6% less adherent than patients initiated on risperidone (p < 0.001). Mean persistence (days) was 194.8 for risperidone, 200.9 for olanzapine, 219.8 for quetiapine, and 179.2 for typical antipsychotics. Extended Cox regression modeling indicated no significant differences between antipsychotics in hazards of therapy modification within 250 days of initiation. However, patients initiated on typical antipsychotics were 5.2 times more likely to modify therapy compared with those initiated on risperidone after 250 days of antipsychotic therapy (p < 0.001). CONCLUSIONS: Adherence and persistence were similar between atypical antipsychotic groups. The typical antipsychotic group, however, demonstrated lower adherence and a greater likelihood of patients modifying therapy compared with the risperidone cohort.

Treatment and Survival of Medicare Beneficiaries with Colorectal Cancer: A Comparative Analysis Between a Rural State Cancer Registry and National Data.

The aim was to examine and compare with "national" estimates, receipt of colorectal cancer (CRC) treatment in the initial phase of care and survival following a CRC diagnosis in rural Medicare beneficiaries. A retrospective study was conducted on fee-for-service Medicare beneficiaries diagnosed with CRC in 2003-2006, identified from West Virginia Cancer Registry (WVCR)-Medicare linked database (N = 2119). A comparative cohort was identified from Surveillance, Epidemiology, and End Results (SEER)-Medicare (N = 38,168). CRC treatment received was ascertained from beneficiaries' Medicare claims in the 12 months post CRC diagnosis or until death, whichever happened first. Receipt of minimally appropriate CRC treatment (MACT) was defined using recommended CRC treatment guidelines. All-cause and CRC-specific mortality in the 36-month period post CRC diagnosis were examined. Differences in usage of CRC surgery, chemotherapy, and radiation were observed between the 2 populations, with those from WVCR-Medicare being less likely to receive any type of CRC surgery (adjusted odds ratio [AOR] = 0.82; 95% confidence interval [CI] = [0.73-0.93]). Overall, those from WVCR-Medicare had a lower likelihood of receiving MACT, (AOR = 0.85; 95% CI = [0.76-0.96]) compared to their national counterparts. Higher hazard of CRC mortality was observed in the WVCR-Medicare cohort (adjusted hazard ratio = 1.26; 95% CI = [1.20-1.32]) compared to the SEER-Medicare cohort. Although more beneficiaries from WVCR-Medicare were diagnosed in early-stage CRC compared to their SEER-Medicare counterparts, they had a lower likelihood of receiving MACT and a higher hazard of CRC mortality. This study highlights the need for an increased focus on improving access to care at every phase of the CRC care continuum, especially for those from rural settings.