Assessing appropriateness of lipid management among patients with diabetes mellitus: moving from target to treatment.

BACKGROUND: Performance measures that emphasize only a treat-to-target approach may motivate overtreatment with high-dose statins, potentially leading to adverse events and unnecessary costs. We developed a clinical action performance measure for lipid management in patients with diabetes mellitus that is designed to encourage appropriate treatment with moderate-dose statins while minimizing overtreatment. METHODS AND RESULTS: We examined data from July 2010 to June 2011 for 964 818 active Veterans Affairs primary care patients ≥18 years of age with diabetes mellitus. We defined 3 conditions as successfully meeting the clinical action measure for patients 50 to 75 years old: (1) having a low-density lipoprotein (LDL) <100 mg/dL, (2) taking a moderate-dose statin regardless of LDL level or measurement, or (3) receiving appropriate clinical action (starting, switching, or intensifying statin therapy) if LDL is ≥100 mg/dL. We examined possible overtreatment for patients ≥18 years of age by examining the proportion of patients without ischemic heart disease who were on a high-dose statin. We then examined variability in measure attainment across 881 facilities using 2-level hierarchical multivariable logistic models. Of 668 209 patients with diabetes mellitus who were 50 to 75 years of age, 84.6% passed the clinical action measure: 67.2% with LDL <100 mg/dL, 13.0% with LDL ≥100 mg/dL and either on a moderate-dose statin (7.5%) or with appropriate clinical action (5.5%), and 4.4% with no index LDL on at least a moderate-dose statin. Of the entire cohort ≥18 years of age, 13.7% were potentially overtreated. Facilities with higher rates of meeting the current threshold measure (LDL <100 mg/dL) had higher rates of potential overtreatment (P<0.001). CONCLUSIONS: Use of a performance measure that credits appropriate clinical action indicates that almost 85% of diabetic veterans 50 to 75 years of age are receiving appropriate dyslipidemia management. However, many patients are potentially overtreated with high-dose statins.

Time trends in medication use and expenditures in older patients with rheumatoid arthritis.

BACKGROUND: We sought to examine how expansions in insurance coverage of nonbiologic and biologic disease-modifying antirheumatic drugs affected the access, costs, and health status of older patients with rheumatoid arthritis. METHODS: We identified a nationally representative sample of older adults with rheumatoid arthritis in the 2000-2006 Medicare Current Beneficiary Survey (unweighted n=1051). We examined changes in disease-modifying antirheumatic drug use, self-reported health status, functional status (activities of daily living), and total costs and out-of-pocket costs for medical care and prescription drugs. Tests for time trends were conducted using weighted regressions. RESULTS: Between 2000 and 2006, the proportion of older adults with rheumatoid arthritis who received biologics tripled (4.6% vs 13.2%, P=.01), whereas the proportion of people who used a nonbiologic did not change. During the same period, the proportion of older patients with rheumatoid arthritis rating their health as excellent/good significantly increased (43.0% in 2000 to 55.6% in 2006; P=.015). Significant improvements occurred in activities of daily living measures of functional status. Total prescription drug costs (in 2006 US dollars) increased from $2645 in 2000 to $4685 in 2006, P=.0001, whereas out-of-pocket prescription costs remained constant ($842 in 2000 vs $832 in 2006; P=.68). Total medical costs did not significantly increase ($16,563 in 2000 vs $19,510 in 2006; P=.07). CONCLUSION: Receipt of biologics in older adults with rheumatoid arthritis increased over a period of time when insurance coverage was expanded without increasing patients' out-of-pocket costs. During this time period, concurrent improvements in self-reported health status and functional status suggest improved arthritis care.

Improving chronic illness care for veterans within the framework of the Patient-Centered Medical Home: experiences from the Ann Arbor Patient-Aligned Care Team Laboratory.

While key components of the Patient-Centered Medical Home (PCMH) have been described, improved patient outcomes and efficiencies have yet to be conclusively demonstrated. We describe the rationale, conceptual framework, and progress to date as part of the VA Ann Arbor Patient-Aligned Care Team (PACT) Demonstration Laboratory, a clinical care-research partnership designed to implement and evaluate PCMH programs. Evidence and experience underlying this initiative is presented. Key components of this innovation are: (a) a population-based registry; (b) a navigator system that matches veterans to programs; and (c) a menu of self-management support programs designed to improve between-visit support and leverage the assistance of patient-peers and informal caregivers. This approach integrates PCMH principles with novel implementation tools allowing patients, caregivers, and clinicians to improve disease management and self-care. Making changes within a complex organization and integrating programmatic and research goals represent unique opportunities and challenges for evidence-based healthcare improvements in the VA.

Predictors of rheumatoid arthritis patient-physician communication about medication costs during visits to rheumatologists.

OBJECTIVE: To examine the frequency with which medication costs are discussed, and the predictors of these discussions, during visits between rheumatologists and their patients with rheumatoid arthritis (RA). METHODS: Audiotapes of medical visits, patient questionnaires, medical records, and physician questionnaires were collected from March 2003 to December 2005. Data were collected from 200 RA patients from 4 rheumatology clinics. Audiotapes were coded for the presence of communication about medication costs using a detailed coding instrument. The final analysis sample included 193 patients and 8 rheumatologists. Stepwise multivariable logistic regression was used to examine the role of patient, physician, medication, and relationship characteristics on discussions of medication costs. RESULTS: Despite medication changes being made in more than 50% of the visits, only 34% of those visits included discussions of medication-related costs; 48% of these discussions were initiated by patients. In multivariable logistic regression models, communication about medication costs occurred more often when patients were white (compared with nonwhite) and reported an annual income of $20,000-$59,999 (compared with those earning > or =$60,000). Discussions about medication costs also were more common when physicians were white. CONCLUSION: Although medication changes were common, medication costs were only discussed in one-third of the visits. Communication about medication costs was more common among patients who were white and in a middle income category. Disparities in communication about medication costs have the potential to negatively impact prescribing and subsequent medication use. Further research should examine potential disparities in communication about medication costs.