Potentially inappropriate medication use at ambulatory care visits by elderly patients covered by National Health Insurance in Korea.

OBJECTIVES: Potentially inappropriate medication (PIM) use is an important and preventable safety concern in the care of elderly patients and has been associated with adverse drug reactions, hospitalization, and mortality. Although PIM use for the elderly is a common and serious public health issue worldwide, there are few studies examining PIM use in the ambulatory care setting in Korea. METHODS: To examine the prevalence and risk factors of PIM use from ambulatory care visits by elderly patients covered by National Health Insurance (NHI) in Korea, the nationwide prescription claims data of elderly patients' ambulatory care visits in 2006 were analyzed. RESULTS: Potentially inappropriate prescriptions were identified using extensive criteria that included Beers', Zhan's, and Canadian criteria. In 2006, 3,770,978 elderly patients received 40,995,267 prescriptions. 36.7% of the total prescriptions for elderly patients who visited ambulatory care clinics were identified as PIM use. Findings in this study indicated that the strongest risk factors for PIM prescriptions were the number of drugs prescribed and visit characteristics. CONCLUSION: Therefore, it is necessary to develop the explicit criteria of PIM prescription in Korea that can be included in the Drug Utilization Review (DUR) system, which is expected to lead to more appropriate and judicious prescribing.

The effects of employment conditions on smoking status and smoking intensity: the analysis of Korean labor & income panel 8(th)-10(th) wave.

BACKGROUND: The neoliberal policies and its socioeconomic consequences in Korea have made employment conditions insecure and affected employees' health as well. METHODS AND FINDINGS: To examine the association between employment condition and smoking status, we selected male respondents aged 20-59 that participated in all of the 8(th)-10(th) wave of Korean Labor and Income Panel Study(KLIPS) which is a nationally representative data. Precarious working was significantly associated with smoking compared to standard working even after adjusting for socioeconomic indicators and self rated health status. After controlling for overall life satisfaction, the odds ratio of smoking among precarious workers decreased, but it was still marginally significant (OR = 1.43, 95% CI = 0.99 to 2.07). A relation between precarious working and heavy smoking was also significant. Precarious working was associated with a decreased likelihood of quitting smoking, while it was not significant any more after adjusting for overall satisfaction on life. Precarious work was also related to a higher likelihood of relapse among former smokers, but was not significant after adjusting for other confounders. CONCLUSIONS: Precarious workers were more likely to be smokers and heavy smokers than standard workers. Unemployment is also a significant risk factor for decreased quitting and smoking relapse. However, insecure employment was an even more consistent determinant of current smoking behavior than unemployment.

Prescription drug coverage and effects on drug expenditures among elderly Medicare beneficiaries.

OBJECTIVE: To identify determinants of drug coverage among elderly Medicare beneficiaries and to investigate the impact of drug coverage on drug expenditures with and without taking selection bias into account. DATA SOURCES/STUDY SETTING: The primary data were from the 2000 Medicare Current Beneficiary Survey (MCBS) Cost and Use file, linked to other data sources at the county or state-level that provided instrumental variables. Community-dwelling elderly Medicare beneficiaries who completed the survey were included in the study (N=7,525). A probit regression to predict the probability of having drug coverage and the effects of drug coverage on drug expenditures was estimated by a two-part model, assuming no correlation across equations. In addition, the discrete factor model estimated choice of drug coverage and expenditures for prescription drugs simultaneously to control for self-selection into drug coverage, allowing for correlation of error terms across equations. PRINCIPAL FINDINGS: Findings indicated that unobservable characteristics leading elderly Medicare beneficiaries to purchase drug coverage also lead them to have higher drug expenditures on conditional use (i.e., adverse selection), while the same unobservable factors do not influence their decisions whether to use any drugs. After controlling for potential selection bias, the probability of any drug use among persons with drug coverage use was 4.5 percent higher than among those without, and drug coverage led to an increase in drug expenditures of $308 among those who used prescription drugs. CONCLUSIONS: Given significant adverse selection into drug coverage before the implementation of the Medicare Prescription Drug Improvement and Modernization Act, it is essential that selection effects be monitored as beneficiaries choose whether or not to enroll in this voluntary program.

The association between clinical care strategies and the attenuation of racial/ethnic disparities in diabetes care: the Translating Research Into Action for Diabetes (TRIAD) Study.

OBJECTIVE: We sought to determine whether greater implementation of clinical care strategies in managed care is associated with attenuation of known racial/ethnic disparities in diabetes care. RESEARCH DESIGN AND METHODS: Using cross-sectional data, we examined the quality of diabetes care as measured by frequencies of process delivery as well as medication management of intermediate outcomes, for 7426 black, Latinos, Asian/Pacific Islanders, and white participants enrolled in 10 managed care plans within 63 provider groups. We stratified models by intensity of 3 clinical care strategies at the provider group level: physician reminders, physician feedback, or use of a diabetes registry. RESULTS: Exposure to clinical care strategy implementation at the provider group level varied by race and ethnicity, with <10% of black participants enrolled in provider groups in the highest-intensity quintile for physician feedback and <10% of both black and Asian/Pacific Islander participants enrolled in groups in the highest-intensity quintile for diabetes registry use. Although disparities in care were confirmed, particularly for black relative to white subjects, we did not find a consistent pattern of disparity attenuation with increasing implementation intensity for either processes of care or medication management of intermediate outcomes. CONCLUSIONS: For the most part, high-intensity implementation of a diabetes registry, physician feedback, or physician reminders, 3 clinical care strategies similar to those used in many health care settings, are not associated with attenuation of known disparities of diabetes care in managed care.

Do HMO market level factors lead to racial/ethnic disparities in colorectal cancer screening? A comparison between high-risk Asian and Pacific Islander Americans and high-risk whites.

BACKGROUND: Few studies have explored health care market structure and colorectal cancer (CRC) screening test use, and little is known whether market factors contribute to racial/ethnic screening disparities. OBJECTIVE: We investigated whether HMO market level factors, controlling for individual covariates, differentially impact Asian American and Pacific Islander (AAPI) subjects' access to CRC screening compared with white subjects. RESEARCH DESIGN AND METHODS: We used random intercept hierarchical models to predict CRC test use. Individual-level survey data was linked to market data by metropolitan statistical areas from InterStudy. SUBJECTS: Insured first-degree relatives, ages 40-80, of a random sample of colorectal cancer cases identified from the California Cancer Registry: 515 white subjects and 396 AAPI subjects residing in 36 metropolitan statistical areas (MSAs). MEASURES: Dependent variables were receipt of (1) annual fecal occult blood test only; (2) sigmoidoscopy in the past 5 years; (3) colonoscopy in the past 10 years; and (4) any of these tests over the recommended time interval. Market characteristics were HMO penetration, HMO competition, and proportion of staff/group/network HMOs. FINDINGS: Market characteristics were as important as individual-level characteristics for AAPI but not for white subjects. Among AAPI subjects, a 10% increase in the percent of group/staff/network model HMO was associated with a reduction in colonoscopy use (28.9% to 20.5%) and in receipt of any of the CRC tests (53.2% to 45.4%). CONCLUSIONS: The prevailing organizational structure of a health care market confers a penalty on access to CRC test use among high-risk AAPI subjects but not among high-risk white subjects. Identifying the differential effect of market structure on race/ethnicity can potentially reduce the cancer burden among disadvantaged racial groups.