Effect of Dual Use of Veterans Affairs and Medicare Part D Drug Benefits on Antihypertensive Medication Supply in a National Cohort of Veterans with Dementia.

OBJECTIVE: To evaluate the effect of dual use of VA/Medicare Part D drug benefits on antihypertensive medication supply in older Veterans with dementia. DATA SOURCES/STUDY SETTING: National, linked 2007-2010 Veterans Affairs (VA) and Medicare utilization and prescription records for 50,763 dementia patients with hypertension. STUDY DESIGN: We used inverse probability of treatment (IPT)-weighted multinomial logistic regression to examine the association of dual prescription use with undersupply and oversupply of antihypertensives. DATA COLLECTION/EXTRACTION METHODS: Veterans Affairs and Part D prescription records were used to classify patients as VA-only, Part D-only, or dual VA/Part D users of antihypertensives and summarize their antihypertensive medication supply in 2010: (1) appropriate supply of all prescribed antihypertensive classes, (2) undersupply of ≥1 class with no oversupply of another class, (3) oversupply of ≥1 class with no undersupply, or (4) both undersupply and oversupply. PRINCIPAL FINDINGS: Dual prescription users were more likely than VA-only users to have undersupply only (aOR = 1.28; 95 percent CI = 1.18-1.39), oversupply only (aOR = 2.38; 95 percent CI = 2.15-2.64), and concurrent under- and oversupply (aOR = 2.89; 95 percent CI = 2.53-3.29), versus appropriate supply of all classes. CONCLUSIONS: Obtaining antihypertensives through both VA and Part D was associated with increased antihypertensive under- and oversupply. Efforts to understand how best to coordinate dual-system prescription use are critically needed.

Caregiver psychological distress as a barrier to influenza vaccination among community-dwelling elderly with dementia.

OBJECTIVE: This study examined whether informal caregiver psychologic distress decreases the likelihood of influenza vaccination for community-dwelling elderly with dementia. A secondary aim was to determine whether psychologic distress mediates the relationship between other predisposing, enabling, and medical need variables and vaccination. METHODS: Data were drawn from the 1998 National Longitudinal Caregiver Survey. The final sample consisted of 1406 community-dwelling male veterans with dementia and their coresiding female informal caregivers. Presence of caregiver psychologic distress was measured using the Boston Short Form of the Center for Epidemiologic Studies Depression Scale. Vaccination was identified by examining Veteran Administration Outpatient Data Files for visits indicating influenza vaccine administration during the 1998 influenza vaccine season (September 1 to December 31). Multivariate path analysis with observed variables was used to estimate direct and indirect probit path coefficients between independent variables, caregiver psychologic distress, and veteran vaccination. RESULTS: As hypothesized, caregiver distress was significantly associated with a decreased likelihood of care-recipient vaccination (unstandardized coefficient [b] = -0.023, P < 0.01). Adjusted for other variables, the predicted probability of vaccination was 37.7% for care-recipients with nondistressed caregivers compared with 29.4% for care-recipients with distressed caregivers. Furthermore, a number of factors significantly influenced vaccination via their influence on psychologic distress. CONCLUSION: We conclude that caregiver psychologic distress may interfere with access to influenza vaccination in persons with dementia. Access to vaccination may be improved directly by detecting and treating emotional health problems in caregivers and indirectly by addressing precursors to caregiver distress.