Early investments in state capacity promote persistently higher levels of social capital.

Social capital has been shown to positively influence a multitude of economic, political, and social outcomes. Yet the factors that affect long-run social capital formation remain poorly understood. Recent evidence suggests that early state formation, especially investments in state capacity, are positively associated with higher levels of contemporary social capital and other prosocial attitudes. The channels by which early state capacity leads to greater social capital over time are even less understood. We contribute to both questions using the spatial and temporal expansion of the US postal network during the 19th century. We first show that county-level variation in post office density is highly correlated with a bevy of historical and contemporary indicators of social capital (e.g., associational memberships, civic participation, health, and crime). This finding holds even when controlling for historical measures of development and contemporary measures of income, inequality, poverty, education, and race. Second, we provide evidence of an informational mechanism by which this early investment in infrastructural capacity affected long-run social capital formation. Namely, we demonstrate that the expansion of the postal network in the 19th century strongly predicts the historical and contemporary location of local newspapers, which were the primary mode of impersonal information transmission during this period. Our evidence sheds light on the role of the state in both the origins of social capital and the channels by which it persists. Our findings also suggest that the consequences of the ongoing decline in local newspapers will negatively affect social capital.

Sample Transport Optimization: Mali Pilot Study.

In Mali, qualified laboratories for testing of dangerous pathogens are centralized in Bamako. Creating a specimen transport system respecting timeline, specimen quality, biosafety, and biosecurity standards is a challenge. The current ad hoc system that relies on untrained public transport companies carries risks of spoilage, accidental release of pathogens, and delays, which compromise specimen quality. This pilot study aimed to evaluate the effectiveness (ie, timeline, quality of specimen, and cost) of using the trained postal service for sample transportation from district to central level, compared with the current system. The postal service intervention ran from mid-2016 to mid-2017 and covered 3 districts. Data were collected in the same districts during the same period of the preceding year for comparison. In all, 41 specimens were shipped using public transportation and 51 were shipped using the postal service. These included suspected meningitis, measles, yellow fever, and polio samples. Only 46% of samples sent by public transportation were received in Bamako within 72 hours of collection, compared to 71% of samples shipped via the postal service (p < .05). Further, 93% of samples shipped by public transportation arrived in good condition at the receiving laboratory, compared to 98% by postal service. Although cost comparisons were difficult (flat fee vs per-specimen fare), the average cost per specimen was 8 times higher with the postal service. Shipment of specimens from districts to central level using the postal service was feasible and appeared to be faster than public transportation, thus allowing specimen quality to be preserved. Further analysis regarding the most efficient costing mechanism is needed.

Implementation of a billable transitional care model for stroke patients: the COMPASS study.

BACKGROUND: The COMprehensive Post-Acute Stroke Services (COMPASS) pragmatic trial compared the effectiveness of comprehensive transitional care (COMPASS-TC) versus usual care among stroke and transient ischemic attack (TIA) patients discharged home from North Carolina hospitals. We evaluated implementation of COMPASS-TC in 20 hospitals randomized to the intervention using the RE-AIM framework. METHODS: We evaluated hospital-level Adoption of COMPASS-TC; patient Reach (meeting transitional care management requirements of timely telephone and face-to-face follow-up); Implementation using hospital quality measures (concurrent enrollment, two-day telephone follow-up, 14-day clinic visit scheduling); and hospital-level sustainability (Maintenance). Effectiveness compared 90-day physical function (Stroke Impact Scale-16), between patients receiving COMPASS-TC versus not. Associations between hospital and patient characteristics with Implementation and Reach measures were estimated with mixed logistic regression models. RESULTS: Adoption: Of 95 eligible hospitals, 41 (43%) participated in the trial. Of the 20 hospitals randomized to the intervention, 19 (95%) initiated COMPASS-TC. Reach: A total of 24% (656/2751) of patients enrolled received a billable TC intervention, ranging from 6 to 66% across hospitals. IMPLEMENTATION: Of eligible patients enrolled, 75.9% received two-day calls (or two attempts) and 77.5% were scheduled/offered clinic visits. Most completed visits (78% of 975) occurred within 14 days. Effectiveness: Physical function was better among patients who attended a 14-day visit versus those who did not (adjusted mean difference: 3.84, 95% CI 1.42-6.27, p = 0.002). Maintenance: Of the 19 adopting hospitals, 14 (74%) sustained COMPASS-TC. CONCLUSIONS: COMPASS-TC implementation varied widely. The greatest challenge was reaching patients because of system difficulties maintaining consistent delivery of follow-up visits and patient preferences to pursue alternate post-acute care. Receiving COMPASS-TC was associated with better functional status. TRIAL REGISTRATION: ClinicalTrials.gov number: NCT02588664. Registered 28 October 2015.

Economic Impact of Financial Incentives and Mailing Nicotine Patches to Help Medicaid Smokers Quit Smoking: A Cost-Benefit Analysis.

An RCT designed to increase Medicaid smokers' quitting success was conducted in California during 2012-2013. In the trial, alternative cessation treatment strategies were embedded in the state's ongoing quitline services. It found that modest financial incentives of up to $60 per participant and sending nicotine patches induced significantly higher cessation rates compared with usual care alone and usual care plus nicotine patches. Building upon that study, this study assessed potential population-level costs and benefits of integrating financial incentives and nicotine patches in a quitline setting for Medicaid smokers. A cost-benefit analysis was undertaken from the Medicaid program's perspective. The Cardiovascular Disease Policy Model was used to simulate future healthcare expenditures over a 10-year horizon for each treatment strategy for a study cohort of California Medicaid enrollees who were aged 35-64 years in 2014 (n=2,452,000). To simulate potential population-level benefits under each treatment strategy, each treatment was applied to all active smokers in the study cohort (n=478,300). Sensitivity analyses were conducted by varying key parameters, such as cessation costs, discount rate, relapse rates, and time horizon. Adding both financial incentives and nicotine patches to usual quitline care would result in $15 million net savings over 10 years, with a benefit-cost ratio of 1.30 compared with the usual care plus nicotine patches strategy. It would yield $44 million net savings, with a benefit-cost ratio of 1.90 compared with usual care alone. The strategy of providing financial incentives and mailing nicotine patches directly to Medicaid smokers who call the quitline is cost saving. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Receipt of Tobacco Direct Mail Coupons and Changes in Smoking Status in a Nationally Representative Sample of US Adults.

Introduction: Direct-to-consumer tobacco marketing, including direct mail and email coupons, is a potentially influential marketing strategy. We examined the associations between receipt of tobacco direct mail/email coupons and trajectories of smoking behavior among US adults. Methods: Data were from the US Population Assessment on Tobacco and Health (PATH) Study adult sample (n = 32160) collected during 2013-2014. Participants self-reported their smoking status (every day, some days, not at all) 12 months prior to the survey (T0) and at the time of the survey (T1). Three smoking trajectories were identified: nonsmokers progressing to current smokers, current smokers continuing to smoke, and among current smokers at T0, progressing to or continuing with daily smoking. Participants also reported receipt of direct mail/email tobacco coupons in the 6 months preceding T1 (yes/no). Weighted multiple logistic regression models were used to test the associations between receiving direct mail/email tobacco coupons and different smoking trajectories adjusted for demographic characteristics. Results: One in eight (12.4%) US adult nonsmokers and 36.2% adult smokers at T0 reported receiving tobacco coupons. Receipt of tobacco coupons was negatively associated with poverty status. Receipt of tobacco coupons was associated with increased odds of progression to current smoking (AOR = 1.76, 95% CI = 1.45 to 2.12), continuation of smoking (AOR = 1.34, 95% CI = 1.09 to 1.65), and current smokers' progression to or continuation with daily smoking (AOR = 1.70, 95% CI = 1.50 to 1.91). Conclusions: Direct-to-consumer tobacco coupons may promote progression of smoking among nonsmokers, and continuation of smoking and progression to daily smoking among smokers in US adults. Implications: Distributing direct mail coupons is a strategy employed by tobacco companies to promote their products. We found, in a US national study, that many adults received tobacco coupons, and receiving these coupons was associated with subsequent progression of smoking among nonsmokers, and continuation of smoking and daily smoking among smokers. Scrutiny over the use of direct mail coupons and its effects on population health is warranted. Future research is needed to evaluate the effect of different interventions to reduce the impact of these coupons on smoking behaviors.

Remote biochemical verification of tobacco use: Reducing costs and improving methodological rigor with mailed oral cotinine swabs.

INTRODUCTION: Multi-site tobacco cessation trials could benefit from remote biochemical verification for tobacco use without invasive, time-consuming, or expensive collection processes. To the authors' knowledge, there have been no previous studies examining the predictive validity of oral fluid swabs for the detection of cotinine levels with samples collected off-site and mailed for on-site interpretation. METHODS: Tobacco users were recruited through an online survey and participants who met the initial eligibility criteria were invited to take part. Those who elected to enroll provided two positive iScreen Oral Fluid Device (OFD) cotinine test samples during an in-office visit. One sample was used as a control and stored in a temperature-regulated location, while the other was mailed from one of ten surrounding counties. Mailing method and time from collection to mailing were varied, and results were assessed against control samples. RESULTS: Twenty tobacco users enrolled in the study. Participants ranged in age from 18 to 31 (M = 16.45, SD = 1.54). Several types of tobacco use were reported, with electronic cigarettes the most commonly reported product. None of the mailed sample interpretations changed from pre- to post-mailing, with up to twenty-one days from sample collection to results confirmation. CONCLUSIONS: Results indicate that the use of mailed oral swabs may be an easy to use, reliable, and low-cost option for the detection of cotinine in tobacco users when in-person collection is not feasible. Test result interpretations were found to be unchanged after mailing, and after extended post-collection time gaps.

A pedometer-based walking intervention in 45- to 75-year-olds, with and without practice nurse support: the PACE-UP three-arm cluster RCT.

BACKGROUND: Guidelines recommend walking to increase moderate to vigorous physical activity (MVPA) for health benefits. OBJECTIVES: To assess the effectiveness, cost-effectiveness and acceptability of a pedometer-based walking intervention in inactive adults, delivered postally or through dedicated practice nurse physical activity (PA) consultations. DESIGN: Parallel three-arm trial, cluster randomised by household. SETTING: Seven London-based general practices. PARTICIPANTS: A total of 11,015 people without PA contraindications, aged 45-75 years, randomly selected from practices, were invited. A total of 6399 people were non-responders, and 548 people self-reporting achieving PA guidelines were excluded. A total of 1023 people from 922 households were randomised to usual care (n = 338), postal intervention (n = 339) or nurse support (n = 346). The recruitment rate was 10% (1023/10,467). A total of 956 participants (93%) provided outcome data. INTERVENTIONS: Intervention groups received pedometers, 12-week walking programmes advising participants to gradually add '3000 steps in 30 minutes' most days weekly and PA diaries. The nurse group was offered three dedicated PA consultations. MAIN OUTCOME MEASURES: The primary and main secondary outcomes were changes from baseline to 12 months in average daily step counts and time in MVPA (in ≥ 10-minute bouts), respectively, from 7-day accelerometry. Individual resource-use data informed the within-trial economic evaluation and the Markov model for simulating long-term cost-effectiveness. Qualitative evaluations assessed nurse and participant views. A 3-year follow-up was conducted. RESULTS: Baseline average daily step count was 7479 [standard deviation (SD) 2671], average minutes per week in MVPA bouts was 94 minutes (SD 102 minutes) for those randomised. PA increased significantly at 12 months in both intervention groups compared with the control group, with no difference between interventions; additional steps per day were 642 steps [95% confidence interval (CI) 329 to 955 steps] for the postal group and 677 steps (95% CI 365 to 989 steps) for nurse support, and additional MVPA in bouts (minutes per week) was 33 minutes per week (95% CI 17 to 49 minutes per week) for the postal group and 35 minutes per week (95% CI 19 to 51 minutes per week) for nurse support. Intervention groups showed no increase in adverse events. Incremental cost per step was 19p and £3.61 per minute in a ≥ 10-minute MVPA bout for nurse support, whereas the postal group took more steps and cost less than the control group. The postal group had a 50% chance of being cost-effective at a £20,000 per quality-adjusted life-year (QALY) threshold within 1 year and had both lower costs [-£11M (95% CI -£12M to -£10M) per 100,000 population] and more QALYs [759 QALYs gained (95% CI 400 to 1247 QALYs)] than the nurse support and control groups in the long term. Participants and nurses found the interventions acceptable and enjoyable. Three-year follow-up data showed persistent intervention effects (nurse support plus postal vs. control) on steps per day [648 steps (95% CI 272 to 1024 steps)] and MVPA bouts [26 minutes per week (95% CI 8 to 44 minutes per week)]. LIMITATIONS: The 10% recruitment level, with lower levels in Asian and socioeconomically deprived participants, limits the generalisability of the findings. Assessors were unmasked to the group. CONCLUSIONS: A primary care pedometer-based walking intervention in 45- to 75-year-olds increased 12-month step counts by around one-tenth, and time in MVPA bouts by around one-third, with similar effects for the nurse support and postal groups, and persistent 3-year effects. The postal intervention provides cost-effective, long-term quality-of-life benefits. A primary care pedometer intervention delivered by post could help address the public health physical inactivity challenge. FUTURE WORK: Exploring different recruitment strategies to increase uptake. Integrating the Pedometer And Consultation Evaluation-UP (PACE-UP) trial with evolving PA monitoring technologies. TRIAL REGISTRATION: Current Controlled Trials ISRCTN98538934. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 37. See the NIHR Journals Library website for further project information.

A randomized trial found online questionnaires supplemented by postal reminders generated a cost-effective and generalizable sample but don't forget the reminders.

OBJECTIVES: The objective of this study was to compare the response rates, data completeness, and representativeness of survey data produced by online and postal surveys. STUDY DESIGN AND SETTING: A randomized trial nested within a cohort study in Yorkshire, United Kingdom. Participants were randomized to receive either an electronic (online) survey questionnaire with paper reminder (N = 2,982) or paper questionnaire with electronic reminder (N = 2,855). RESULTS: Response rates were similar for electronic contact and postal contacts (50.9% vs. 49.7%, difference = 1.2%, 95% confidence interval: -1.3% to 3.8%). The characteristics of those responding to the two groups were similar. Participants nevertheless demonstrated an overwhelming preference for postal questionnaires, with the majority responding by post in both groups. CONCLUSION: Online survey questionnaire systems need to be supplemented with a postal reminder to achieve acceptable uptake, but doing so provides a similar response rate and case mix when compared to postal questionnaires alone. For large surveys, online survey systems may be cost saving.

Cost-effective recruitment methods for a large randomised trial in people with diabetes: A Study of Cardiovascular Events iN Diabetes (ASCEND).

BACKGROUND: Clinical trials require cost-effective methods for identifying, randomising, and following large numbers of people in order to generate reliable evidence. ASCEND (A Study of Cardiovascular Events iN Diabetes) is a randomised '2 × 2 factorial design' study of aspirin and omega-3 fatty acid supplements for the primary prevention of cardiovascular events in people with diabetes; this study used central disease registers and a mail-based approach to identify, randomise, and follow 15,000 people. In collaboration with UK consultants and general practitioners (GPs), researchers identified potentially eligible people with diabetes from centrally held registers (e.g. for retinopathy screening) and GP-held disease registers. Permission was obtained under section 251 of the National Health Service Act 2006 (previously section 60 of the NHS act 2001) to allow invitation letters to be generated centrally in the name of the holder of the register. In addition, with the collaboration of the National Institutes for Health Research (NIHR) Diabetes and Primary Care Research Networks (DRN and PCRN), general practices sent pre-assembled invitation packs to people with a diagnosis of diabetes. Invitation packs included a cover letter, screening questionnaire (with consent form), information leaflet, and a Freepost envelope. Eligible patients entered a 2-month, pre-randomisation, run-in phase on placebo tablets and were only randomised if they completed a randomisation form and remained willing and eligible at the end of the run-in. Follow-up is ongoing, using mail-based approaches that are being supplemented by central registry data. RESULTS: Information on approximately 600,000 people listed on 58 centrally held diabetes registers was obtained, and 300,188 potentially eligible patients were invited to join the study. In addition, 785 GP practices mailed invitations to 120,875 patients. A further 2,340 potential study participants were identified via other routes. In total, 423,403 people with diabetes were invited to take part; 26,462 entered the 2-month, pre-randomisation, run-in phase; and 15,480 were randomised. CONCLUSION: If sufficient numbers of potentially eligible patients can be identified centrally and the trial treatments do not require participants to attend clinics, the recruitment and follow-up of patients by mail is feasible and cost-effective. Wider use of these methods could allow more, large, randomised trials to be undertaken successfully and cost-effectively. TRIAL REGISTRATION: Current Controlled Trials, ISRCTN60635500 , registered on 14 July 2005.

Challenges for Managed Care from 340B Contract Pharmacies.

The federal 340B Drug Pricing Program has expanded rapidly, with important yet still unmeasured impact on both managed care practice and policies. Notably, providers increasingly rely on external, contract pharmacies to extend 340B pricing to a broad set of patients. In 2014, 1 in 4 U.S. retail, mail, and specialty pharmacy locations acted as contract pharmacies for 340B-covered entities. This commentary discusses crucial ways in which 340B growth is affecting managed care pharmacy through formulary rebates, profits from managed care paid prescriptions, disruption of retail pharmacy networks, and reduced generic dispensing rates. Managed care should become more engaged in the discussion on how the 340B program should evolve and offer policy proposals to mitigate the challenges being encountered. There is also an urgent need for objective, transparent research on the 340B program's costs, benefits, and implications for managed care pharmacy and practice.

Recruiting Community-Based Dementia Patients and Caregivers in a Nonpharmacologic Randomized Trial: What Works and How Much Does It Cost?

OBJECTIVES: The aim of this study was to evaluate the yield and cost of three recruitment strategies-direct mail, newspaper advertisements, and community outreach-for identifying and enrolling dementia caregivers into a randomized trial testing a nonpharmacologic approach to enhancing quality of life of patients and caregivers (dyads). METHOD: Enrollment occurred between 2006 and 2008. The number of recruitment inquiries, number and race of enrollees, and costs for each recruitment strategy were recorded. RESULTS: Of 284 inquiries, 237 (83%) dyads enrolled. Total cost for recruitment across methodologies was US$154 per dyad. Direct mailings resulted in the most enrollees (n = 135, 57%) and was the least costly method (US$63 per dyad) compared with newspaper ads (US$224 per dyad) and community outreach (US$350 per dyad). Although enrollees were predominately White, mailings yielded the highest number of non-Whites (n = 37). DISCUSSION: Direct mailings was the most effective and least costly method for enrolling dyads in a nonpharmacologic dementia trial.

Participant recruitment into a randomised controlled trial of exercise therapy for people with multiple sclerosis.

BACKGROUND: The success of a clinical trial is often dependant on whether recruitment targets can be met in the required time frame. Despite an increase in research into the benefits of exercise in people with multiple sclerosis (PwMS), no trial has reported detailed data on effective recruitment strategies for large-scale randomised controlled trials. The main purpose of this report is to provide a detailed outline of recruitment strategies, rates and estimated costs in the Exercise Intervention for Multiple Sclerosis (ExIMS) trial to identify best practices for future trials involving multiple sclerosis (MS) patient recruitment. METHODS: The ExIMS researchers recruited 120 PwMS to participate in a 12-week exercise intervention. Participants were randomly allocated to either exercise or usual-care control groups. Participants were sedentary, aged 18-65 years and had Expanded Disability Status Scale scores of 1.0-6.5. Recruitment strategies included attendance at MS outpatient clinics, consultant mail-out and trial awareness-raising activities. RESULTS: A total of 120 participants were recruited over the course of 34 months. To achieve this target, 369 potentially eligible and interested participants were identified. A total of 60 % of participants were recruited via MS clinics, 29.2 % from consultant mail-outs and 10.8 % through trial awareness. The randomisation yields were 33.2 %, 31.0 % and 68.4 % for MS clinic, consultant mail-outs and trial awareness strategies, respectively. The main reason for ineligibility was being too active (69.2 %), whilst for eligible participants the most common reason for non-participation was the need to travel to the study site (15.8 %). Recruitment via consultant mail-out was the most cost-effective strategy, with MS clinics being the most time-consuming and most costly. CONCLUSIONS: To reach recruitment targets in a timely fashion, a variety of methods were employed. Although consultant mail-outs were the most cost-effective recruitment strategy, use of this method alone would not have allowed us to obtain the predetermined number of participants in the required time period, thus leading to costly extensions of the project or failure to reach the number of participants required for sufficient statistical power. Thus, a multifaceted approach to recruitment is recommended for future trials. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Registry number: ISRCTN41541516 ; date registered: 5 February 2009.

Patterns of use and expenses associated with mail-service pharmacy in adults with diabetes.

OBJECTIVES: To identify socioeconomic factors associated with mail-service pharmacy use and compare the differences in disease-specific prescription medication and medical utilization expenses in a nationally representative sample of adults with diabetes. DESIGN: A retrospective, longitudinal, cross-sectional study. SETTING: United States in 2006-11. PARTICIPANTS: Medical Expenditure Panel Survey household component (MEPS-HC) participants aged 18 years or older diagnosed with diabetes and prescribed antidiabetic medications. MAIN OUTCOME MEASURES: Likelihood of mail-service pharmacy use, diabetes-related medical utilization, and medication expenses. RESULTS: Among 4,430 eligible participants identified in the 2006-11 surveys, representing more than 83 million U.S. individuals, nearly 13% of the participants obtained two-thirds or more of their antidiabetic medications via mail service predominantly. Mail-service pharmacy users were older, had high school or college degrees, had higher incomes, and were more likely to be covered by private insurance. There were no significant differences in diabetes-related medical utilization and drug expenses between the two groups. CONCLUSION: Besides pharmacy benefit design, sociodemographic and economic factors influenced drug dispensing channel use (mail service versus community pharmacy). No significant differences in diabetes-related drug and medical expenses between mail-service and community pharmacy users were observed.

A comparison of costs of Medicare Part D prescriptions dispensed at retail and mail order pharmacies.

BACKGROUND: Plan sponsors encourage the use of mail order pharmacies because they believe mail order dispensing will lower their prescription drug costs. Health plans and pharmacy benefit management companies (PBMs) usually offer patients substantially lower copayments to incentivize them to use mail order pharmacies. A number of health plans and PBMs now require patients to use these pharmacies for maintenance prescriptions. OBJECTIVES: To (a) compare costs for prescriptions dispensed through mail order and retail pharmacies in Medicare Part D plans and (b) examine whether mail order or retail pharmacies provided lower all third-party costs for each of the top 300 products; the relationship between whether a product was available generically and whether mail order or retail pharmacies provided lower prices; and the generic substitution rates at mail order and retail pharmacies. METHODS: The sample for this study consisted of 2010 Medicare Part D prescription drug data for the 300 products with the highest sales at mail order pharmacies. The prescriptions included in the study were dispensed in the initial coverage limit phase of Part D by retail or mail order pharmacies to patients who were insured by Part D for 12 months in 2010, who received no Part D subsidies, and who were alive for the full year in 2010. Mean-per-unit costs were calculated for both mail order and retail prescriptions for each of the top 300 products. Products were defined by Medi-Span Generic Product Indentifier. Summary statistics for the overall costs of mail order and retail prescriptions were calculated as the weighted mean-per-unit costs of the top 300 products. The weighting factor for both mail order and retail prescriptions included both the mail order quantity dispensed per prescription and the number of prescriptions dispensed. Weighting both mail and retail prescriptions by mail order quantities dispensed and numbers of prescriptions ensured that the results reflected actual cost differences rather than differences in the mix or quantities of prescriptions dispensed. These calculations were made for total costs, costs covered by the Medicare Standard Benefit (MSB), costs paid by all third-party payers (including Medicare), and patient costs. RESULTS: The top 300 products accounted for 84.8% of mail order costs. Among all prescriptions in the sample--both mail order and retail--mail order prescriptions accounted for 7.8% of prescriptions dispensed and 14.1% of total spending. Comparison of 90-day or greater supplies indicated that costs per unit of medication for retail pharmacies were lower for total costs ($0.94 for retail pharmacies vs. $0.96 for mail order pharmacies), MSB costs ($0.59 for retail pharmacies vs. $0.63 for mail order pharmacies), and all third-party payer costs ($0.64 for retail pharmacies vs. $0.72 for mail order pharmacies), but higher for patient costs ($0.31 for retail pharmacies vs. $0.24 for mail order pharmacies). Retail pharmacies had lower all third-party payer costs for 244 products, while mail pharmacies had lower costs for 56 products. Retail pharmacies were more likely to have lower costs for products that included generic alternatives, while mail order pharmacies were more likely to have lower costs for products that included only branded drugs. Generic substitution rates were 91.4% for retail pharmacies versus 88.8% for mail order pharmacies. Results from secondary analyses that compared all prescriptions which met the inclusion criteria, regardless of days supply, and that compared exactly 90-day supplies, yielded similar results. CONCLUSIONS: Third-party payers, including Medicare, paid more for prescriptions dispensed at mail order pharmacies than for those dispensed at retail pharmacies in the Medicare Part D program. The higher payments appeared to result, for the most part, because of higher patient cost sharing at retail pharmacies. Further, total costs--including both third-party payer and patient payments--for 90-day and 90-day or greater supplies were lower at retail pharmacies than at mail pharmacies. These results suggest that, all other things being equal, Medicare Part D plan sponsors do not realize savings when patients use mail order pharmacies.

Short-term morbidity following No-Scalpel Vasectomy: an assessment of clients' perceptions by novel postcard system.

OBJECTIVE: Data on short-term (within a week) morbidity of No-Scalpel Vasectomy (NSV) is lacking. We studied clients' perceptions of early post-vasectomy morbidity by self innovated postcard pictorial questionnaire. METHODS: Between March 2011 and April 2012, 821 men underwent NSV and provided pre-printed revalidated pictorial postcards depicting various grades of severity of local pain, swelling, and bleeding. Clients were asked to tick mark their problems and post them on the third day after NSV. Data were compiled and statistically analyzed. RESULTS: Completed postcards were returned by 702 clients (85.5%). 25 postcards were excluded due to illegitimate filling of card. About 80.8% of clients complained of pain and minimal, moderate and severe pain was experienced by 77.69%, 18.09% and 4.20%, respectively. 16.24% of clients observed local swelling, which was minimal in 90.9%, moderate and severe in 7.27% and 1.81% of cases. 2.95% of clients noted mild bloody discharge. Most of clients managed their problems by following the instructions given in postcards; level 1 and 2 morbidity did not affect their daily activity. CONCLUSION: Early morbidity after NSV is usually mild in severity and easily manageable. The postcard system is a feasible, effective, and economical way of collecting data and managing short-term post NSV problems.

Feasibility and acceptability of alternate methods of postnatal data collection.

This study was done in preparation for the launch of the National Children's Study (NCS) main study. The goal of this study was to examine the feasibility (completion rates and completeness of data), acceptability, staff time and cost-effectiveness of three methods of data collection for the postnatal 3- and 9-month questionnaires completed as part of NCS protocol. Eligible NCS participants who were scheduled to complete a postnatal questionnaire at three and nine months were randomly assigned to receive either: (a) telephone data collection (b) web-based data collection, or (c) self-administered (mailed) questionnaires. Event completion rates and satisfaction across the three data collection methods were compared and the influence of socio-demographic factors on completion rates and satisfaction rates was examined. Cost data were compared to data for completion and satisfaction for each of the delivery methods. Completion rates and satisfaction did not differ significantly by method, but completeness of data did, with odds of data completeness higher among web than phone (p < 0.001) or mail (p < 0.001). Costs were highest for the phone, followed by mail and web methods (p < 0.001). No significant differences in participant time (i.e. burden) across the three data collection methods were seen. Mail and phone data collection were the least complete of the three methods and were the most expensive. Mailed data collection was neither complete nor exceptionally economical. Web-based data collection was the least costly and provided the most complete data. Participants without web access could complete the questionnaire over the phone.

Survey methods and response rates among rural community dwelling older adults.

BACKGROUND: Rural older adults are not often targeted for surveys, and little is known about survey response rates in this population. Because overall numbers of rural older adults are small, it is important to consider techniques to improve their survey response rates. OBJECTIVES: The purpose of this study was to work with community partners to determine whether rural older adults participating in a rural county home-delivered meals program were more likely to respond to an injury risk survey hand-delivered via the postal service or hand-delivered by the home-delivered meals drivers. METHODS: All home-delivered meals clients older than 65 years old were randomized to one of two groups. One group (n = 70) received the following via the postal service: a prenotice letter, a survey packet containing a description of the survey, the survey, a stamped and addressed return envelope, and a reminder/thank-you card. Older adults in the other group (n = 69) were personally handed the survey packet by the home-delivered meals driver. RESULTS: The overall survey response rate was 43.9%. Older adults who were handed the survey packets by the home-delivered meals drivers were older and significantly more likely to return the survey (57%) compared with those who received survey materials in the mail (31%). Only 27% of respondents agreed to be contacted regarding participation in future face-to-face interviews. When taking into account response rates, postage costs alone were over five times higher for the postal-delivered surveys compared with the hand-delivered surveys. DISCUSSION: By working with community partners, we were able to determine that older adults in a rural community were more likely to respond to surveys personally handed to them by someone they knew.

Telephone follow-up was more expensive but more efficient than postal in a national stroke registry.

OBJECTIVE: To compare the efficiency and differential costs of telephone- vs. mail-based assessments of outcome in patients registered in a national clinical quality of care registry, the Australian Stroke Clinical Registry (AuSCR). STUDY DESIGN AND SETTING: The participants admitted to hospital with stroke or transient ischemic attack were randomly assigned to complete a health questionnaire by mail or telephone interview at 3-6 months postevent. Response rate, researcher burden, and costs of each method were compared. RESULTS: Compared with the participants in the mail questionnaire arm (n=277; 50% female; mean age: 70 years), those in the telephone arm (n=282; 45% female; mean age: 68 years) required a shorter time to complete the follow-up (mean difference: 24.2 days; 95% confidence interval [CI]: 15.0, 33.5 days). However, the average cost of completing a telephone follow-up was greater (US$20.87 vs. US$13.86) and had a similar overall response to the mail method (absolute difference: 0.57%; 95% CI: -4.8%, 6%). CONCLUSION: Posthospital stroke outcome data were slower to collect by mail, but the method achieved a similar completion rate and was significantly cheaper to conduct than follow-up telephone interview. Findings are informative for planning outcome data collection in large numbers of patients with acute stroke.