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OBJECTIVES: Equity and effectiveness of the medication therapy management (MTM) program in Medicare has been a policy focus since its inception. The objective of this study was to evaluate the cost-effectiveness of the Medicare MTM program in improving medication utilization quality across racial and ethnic groups. METHODS: This study analyzed 2017 Medicare data linked to the Area Health Recourses File. A propensity score was used to match MTM enrollees and nonenrollees, and an incremental cost-effectiveness ratio between the 2 groups was calculated. Effectiveness was measured as the proportion of appropriate medication utilization based on medication utilization measures developed by Pharmacy Quality Alliance. Net monetary benefits were compared across racial and ethnic groups at various societal willingness-to-pay (WTP) thresholds. The 95% confidence intervals were obtained by nonparametric bootstrapping. RESULTS: MTM dominated non-MTM among the total sample (N = 699 992), as MTM enrollees had lower healthcare costs ($31 135.89 vs $32 696.69) and higher proportions of appropriate medication utilization (87.47% vs 85.31%) than nonenrollees. MTM enrollees had both lower medication costs ($10 681.21 vs $11 003.08) and medical costs ($20 454.68 vs $21 693.61) compared with nonenrollees. The cost-effectiveness of MTM was higher among Black patients than White patients across the WTP thresholds. For instance, at a WTP of $3006 per percentage point increase in effectiveness, the net monetary benefit for Black patients was greater than White patients by $2334.57 (95% confidence interval $1606.53-$3028.85). CONCLUSIONS: MTM is cost-effective in improving medication utilization quality among Medicare beneficiaries and can potentially reduce disparities between Black and White patients. Expansion of the current MTM program could maximize these benefits.
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Etnicidade , Medicare , Adesão à Medicação , Conduta do Tratamento Medicamentoso , Grupos Raciais , Idoso , Humanos , Masculino , Análise de Custo-Efetividade , Etnicidade/estatística & dados numéricos , Medicare/economia , Adesão à Medicação/etnologia , Adesão à Medicação/estatística & dados numéricos , Conduta do Tratamento Medicamentoso/economia , Avaliação de Programas e Projetos de Saúde , Grupos Raciais/estatística & dados numéricos , Estados Unidos , FemininoRESUMO
BACKGROUND: Alzheimer's Disease (AD) is the mostcommon cause of dementia, a neurological disorder characterized by memory loss and judgment impairment. Hyperlipidemia, a commonly co-occurring condition, should be treated to prevent associated complications. Medication adherence may be difficult for individuals with AD due to the complexity of AD management. Comprehensive Medication Reviews (CMRs), a required component of Medicare Part D Medication Therapy Management (MTM), have been shown to improve medication adherence. However, many MTM programs do not target AD. Additionally, racial/ethnic disparities in MTM eligibility have been revealed. Thus, this study examined the effects of CMR receipt on reducing racial/ethnic disparities in the likelihood of nonadherence to hyperlipidemia medications (statins) among the AD population. METHODS: This retrospective study used 2015-2017 Medicare data linked to the Area Health Resources Files. The likelihood of nonadherence to statin medications across racial/ethnic groups was compared between propensity-score-matched CMR recipients and non-recipients in a ratio of 1 to 3. A difference-in-differences method was utilized to determine racial/ethnic disparity patterns using a logistic regression by including interaction terms between dummy variables for CMR receipt and each racial/ethnic minority group (non-Hispanic Whites, or Whites, as reference). RESULTS: The study included 623,400 Medicare beneficiaries. Blacks and Hispanics had higher statin nonadherence than Whites: Compared to Whites, Blacks' nonadherence rate was 4.53% higher among CMR recipients and 7.35% higher among non-recipients; Hispanics' nonadherence rate was 2.69% higher among CMR recipients and 7.38% higher among non-recipients. Differences in racial/ethnic disparities between CMR recipients and non-recipients were significant for each minority group (p < 0.05) except Others. The difference between Whites and Hispanics in the odds of statin nonadherence was 11% lower among CMR recipients compared to non-recipients (OR = 0.89; 95% Confidence Interval = 0.85-0.94 for the interaction term between dummy variables for CMR and Hispanics). Interaction terms between dummy variables for CMR and other racial/ethnic minorities were not significant. CONCLUSIONS: Receiving a CMR was associated with a disparity reduction in nonadherence to statin medications between Hispanics and Whites among patients with AD. Strategies need to be explored to increase the number of MTM programs that target AD and promote CMR completion.
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Doença de Alzheimer , Inibidores de Hidroximetilglutaril-CoA Redutases , Medicare Part D , Idoso , Doença de Alzheimer/tratamento farmacológico , Etnicidade , Disparidades em Assistência à Saúde , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Revisão de Medicamentos , Grupos Minoritários , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Drug-drug interactions (DDIs) cause many preventable hospitalizations and admissions. Efforts have been made to raise DDI awareness and reduce DDI occurrence; for example, Medicare Part D Star Ratings, a health plan quality assessment program, included a DDI measure. Previous research reported racial and ethnic disparities in health services utilization and that racial and ethnic minorities, compared with non-Hispanic whites (whites), may be less likely to be targeted for a similar measure, a Star Ratings adherence measure for diabetes medications. OBJECTIVE: This study aimed to investigate whether any racial and ethnic disparities are associated with the DDI measure in Part D Star Ratings among Medicare populations with diabetes, hypertension, and hyperlipidemia. METHODS: This cross-sectional study analyzed a 2017 Medicare Part D data sample, including 3,960,813 beneficiaries. Because the inclusion in the denominator of the Star Ratings DDI measure was determined by the use of a list of target medications, the likelihood of using a listed target medication was compared between racial and ethnic minorities and whites. Individuals with diabetes, hypertension, and hyperlipidemia were included in the analysis owing to the high prevalence of these conditions. Patient- and community-level characteristics were adjusted by logistic regression. RESULTS: Of the entire study sample, 26.2% used a target medication. Compared with whites, most racial and ethnic minorities were less likely to use a target medication. For example, among individuals with diabetes, blacks, Hispanics, Asians/Pacific Islanders, and others had, respectively, 14% (odds ratio 0.86 [95% CI 0.84-0.88]), 5% (0.95 [0.93-0.98]), 12% (0.88 [0.84-0.92]), and 10% (0.90 [0.87-0.93]) lower odds compared with whites. Findings were similar among hypertension and hyperlipidemia cohorts, except that Hispanics had similar odds of use as whites. CONCLUSION: Most racial and ethnic minorities may have lower likelihood of being targeted for the DDI measure compared with whites. Future studies should examine whether these disparities affect health outcomes and devise new DDI measures for racial and ethnic minorities.
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Medicare Part D , Preparações Farmacêuticas , Idoso , Estudos Transversais , Interações Medicamentosas , Minorias Étnicas e Raciais , Disparidades em Assistência à Saúde , Humanos , Conduta do Tratamento Medicamentoso , Estados UnidosRESUMO
PURPOSE: Perfluorocarbons (PFCs) can transport 50 times more oxygen than human plasma. Their properties may be advantageous in preservation of tissue viability in oxygen-deprived states, such as in acute lung injury. We hypothesized that an intravenous dose of the PFC emulsion Oxycyte® would improve tissue oxygenation and thereby mitigate the effects of acute lung injury. METHODS: Intravenous oleic acid (OA) was used to induce lung injury in anesthetized and instrumented Yorkshire swine assigned to three experimental groups: (1) PFC post-OA received Oxycyte® (5 ml/kg) 45 min after oleic acid-induced lung injury (OALI); (2) PFC pre-OA received Oxycyte® 45 min before OALI; and (3) Controls which received equivalent dose of normal saline. Animals were observed for 3 h after OALI began, and then euthanized. RESULTS: The median survival times for PFC post-OA, PFC pre-OA, and control were 240, 87.5, and 240 min, respectively (p = 0.001). Mean arterial pressure and mean pulmonary arterial pressure were both higher in the PFC post-OA (p < 0.001 for both parameters). Oxygen content was significantly different between PFC post-OA and the control (p = 0.001). Histopathological grading of lung injury indicated that edema and congestion was significantly less severe in the PFC post-OA compared to control (p = 0.001). CONCLUSION: The intravenous PFC Oxycyte® improves blood oxygen content and lung histology when used as a treatment after OALI, while Oxycyte® used prior to OALI was associated with increased mortality. Further exploration in other injury models is indicated.
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Lesão Pulmonar Aguda/tratamento farmacológico , Lesão Pulmonar Aguda/patologia , Fluorocarbonos/administração & dosagem , Oxigênio/sangue , Equilíbrio Ácido-Base , Lesão Pulmonar Aguda/induzido quimicamente , Administração Intravenosa , Animais , Pressão Arterial/efeitos dos fármacos , Gasometria , Modelos Animais de Doenças , Feminino , Fluorocarbonos/efeitos adversos , Ácido Láctico/sangue , Masculino , Ácido Oleico , Pressão Propulsora Pulmonar/efeitos dos fármacos , Síndrome do Desconforto Respiratório/tratamento farmacológico , Índice de Gravidade de Doença , Taxa de Sobrevida , SuínosRESUMO
BACKGROUND: Inappropriate medication utilization among older adults is a pressing concern in the United States, owing to its high prevalence and the consequential detrimental impact it engenders. The adverse effects stemming from the inappropriate use of medication may be unequally borne by racial/ethnic minority populations, calling for greater efforts towards promoting equity in healthcare. The study objective was to assess the cost-effectiveness of Medication Therapy Management (MTM) services among Medicare beneficiaries and across racial/ethnic groups. METHODS: Medicare administrative data from 2016 to 2017 linked to Area Health Resources Files were used to analyze Medicare fee-for-service patients aged 65 or above with continuous Parts A/B/D coverage. The intervention group included new MTM enrollees in 2017; the control group referred to patients who met the general MTM eligible criteria but did not enroll in 2016 or 2017. The 2 groups were matched using a propensity score method. Effectiveness was evaluated as the proportion of appropriate medication utilization based on performance measures developed by the Pharmacy Quality Alliance. Costs were computed as total healthcare costs from Medicare perspective. A multivariable net benefit regressions with a classic linear model and Bayesian analysis were utilized. Net benefit was calculated based on willingness-to-pay thresholds at various multiples of the gross domestic product in 2017. Three-way interaction terms among dummy variables for MTM enrollment, 2017, and racial/ethnic minority groups were incorporated in a difference-in-differences study design. RESULTS: After adjusting for patient characteristics, the findings indicate that MTM receipt was associated with incremental net benefit among each race and ethnicity. For instance, the net benefit of MTM among the non-Hispanic White patients was $2498 (95% confidence intervalâ =â $1609, $3386) at a willingness-to-pay value of $59,908. The study found no significant difference in net benefits for MTM services between minority and White patients. CONCLUSION: The study provides evidence that MTM is a cost-effective tool for managing medication utilization among the Medicare population. However, MTM may not be cost-effective in reducing racial/ethnic disparities in medication utilization in the short term. Further research is needed to understand the long-term cost-effectiveness of MTM on racial/ethnic disparities.
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Análise Custo-Benefício , Medicare , Conduta do Tratamento Medicamentoso , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Etnicidade/estatística & dados numéricos , Medicare/economia , Conduta do Tratamento Medicamentoso/economia , Conduta do Tratamento Medicamentoso/estatística & dados numéricos , Grupos Raciais/estatística & dados numéricos , Estados Unidos , BrancosRESUMO
Background: Medicare Part D plans are required to provide Medication therapy management (MTM) services to eligible beneficiaries to optimize medication utilization. Comprehensive medication review (CMR) is a core element of the MTM program. Despite the availability of advanced medical treatment for patients with chronic obstructive pulmonary disease (COPD), medication adherence to maintenance medications poses a continued challenge for patients with COPD. Objective: To examine the effects of CMR on medication adherence among patients with COPD. Methods: Medicare data for 2016-2017 linked to Area Health Resource Files were analyzed. The study population was Medicare beneficiaries with COPD. The intervention group consisted of beneficiaries who received CMR in 2017 but not in 2016. Patients who were eligible for MTM services but did not receive these services in 2016 or 2017 made up the control group. Propensity score matching was used to select an intervention and control group with balanced characteristics. The study outcome was adherence to COPD medications with the proportion of days covered at or above 80%. A difference-in-differences approach was adopted in the logistic regression analyses with an interaction term between the status of CMR receipt and the year 2017. Results: The study sample included 25,564 patients with COPD. The proportions of adherent patients were similar in the control group in both years but increased significantly from 60.08% in 2016 to 69.38% in 2017 in the intervention group (P < .001). The odds of medication adherence in the intervention group increased from 2016 to 2017 by 59% more than in the control group (adjusted odds ratio = 1.59, 95% confidence interval = 1.48-1.71). Conclusions: Receiving CMR was associated with improved adherence to COPD medications among Medicare beneficiaries. Policymakers should ensure that Medicare beneficiaries with COPD receive CMR.
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Background: Evidence is sparse on the effects of Medicare medication therapy management (MTM) on racial/ethnic disparities in medication adherence among patients with Alzheimer's disease and related dementias. Objectives: This study examined the Medicare MTM program's effects on racial/ethnic disparities in the adherence to antidementia medications among patients with Alzheimer's disease and related dementias. Methods: This is a retrospective analysis of 100% of 2010-2017 Medicare Parts A, B, and D data linked to Area Health Resources Files. The study outcome was nonadherence to antidementia medications, and intervention was defined as new MTM enrollment in 2017. Propensity score matching was conducted to create intervention and comparison groups with comparable characteristics. A difference-in-differences model was employed with logistic regression, including interaction terms of dummy variables for the intervention group and racial/ethnic minorities. Results: Unadjusted comparisons revealed that Black, Hispanic, and Asian/Pacific Islander patients were more likely to be nonadherent than non-Hispanic White (White) patients in 2016. Differences in odds of nonadherence between Black and White patients among the intervention group were lower in 2017 than in 2016 by 27% (odds ratios [OR]: 0.73, 95% confidence interval [CI]: 0.65-0.82). A similar lowering was seen between Hispanic and White patients by 26% (OR: 0.74, 95% CI: 0.63-0.87). MTM enrollment was associated with reduced disparities in nonadherence for Black-White patients of 33% (OR: 0.67, 95% CI: 0.57-0.78) and Hispanic-White patients of 19% (OR: 0.81, 95% CI: 0.67-0.99). Discussion: The Medicare MTM program was associated with lower disparities in adherence to antidementia medications between Black and White patients, and between Hispanic and White patients in the population with Alzheimer's disease and related dementias. Conclusions: Expanding the MTM program may particularly benefit racial/ethnic minorities in Alzheimer's disease and related dementia care.
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BACKGROUND: Previous studies noted that racial/ethnic minority groups were less likely than non-Hispanic White beneficiaries to be included in the assessment of medication utilization measures of Medicare Part D Star Ratings due to restrictive inclusion criteria for measure calculation. This study explored whether adding a measure with less stringent inclusion criteria to Star Ratings can reduce disparities in measure assessment among beneficiaries with Alzheimer's disease and related dementias (ADRD). METHODS: This cross-sectional study utilized 2017 Medicare databases linked to Area Health Resources Files. Multivariable logistic regression was used to compare disparities before and after adding the new measure. RESULTS: By adding the new measure, disparities in the odds for assessment inclusion between non-Hispanic White beneficiaries and Black, Hispanic, Asian, and Other beneficiaries were respectively reduced by 97% (odds ratio, or OR = 1.97, 95% Confidence Interval or CI = 1.89-2.05), 72% (OR = 1.72, 95% CI = 1.58-1.87), 115% (OR = 2.15, 95% CI = 1.87-2.46), and 44% (OR = 1.44, 95% CI = 1.28-1.62). CONCLUSIONS: To improve the selection of medication utilization measures in Star Ratings among beneficiaries with ADRD, policymakers should investigate the optimal composition of measures to better align the interests of patients, providers, and health plans.
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Doença de Alzheimer , Medicare Part D , Humanos , Idoso , Estados Unidos , Etnicidade , Doença de Alzheimer/tratamento farmacológico , Estudos Transversais , Grupos Minoritários , Disparidades em Assistência à SaúdeRESUMO
Background: Racial/ethnic minorities are less likely than non-Hispanic White (White) patients to be included in the Medicare Part D Star Ratings measure assessment due to the restrictive inclusion criteria for the measures. Objective: This paper examined the effects of racial/ethnic disparities in the measure assessment in Part D Star Ratings on disparities in healthcare costs among patients with Alzheimer's disease and related dementias (ADRD). Methods: This cross-sectional study analyzed 2017 Medicare data. Proportions of Beneficiaries with ADRD were categorized into the included and excluded groups based on the inclusion criteria for the calculation of medication adherence measures in Star Ratings. Outcomes included costs for medications, physician visits, emergency room (ER) visits, and total costs. A generalized linear model was employed to compare costs across racial/ethnic groups. To explore the differential disparities in healthcare costs between the 2 groups, interaction terms between dummy variables for being excluded from the measure calculation and racial/ethnic minorities were included in the models. Results: The patterns of racial/ethnic disparities in healthcare costs found in this study were generally consistent with expectations, with some exceptions. For example, compared with White patients, in the hyperlipidemia cohort, the physician visit cost for Black patients among the included group was 31% lower (cost ratio or CR = 0.69, 95% CI = 0.67-0.72); in the hypertension cohort, the hospitalization cost for Blacks among the excluded group was 15% higher (CR = 1.15, 95% CI = 1.12-1.19). More importantly, exclusion from measurement assessments was associated with differential cost disparities. For example, compared with individuals included in the measure assessment for hypertension, the Black-White disparities in costs for hospitalization and total healthcare were 30% higher (CR = 1.30, 95% CI = 1.26-1.34), and 10% higher (CR = 1.10; 95% CI = 1.08-1.12), respectively, among the excluded group. Conclusions: Medicare Part D Star Ratings may be associated with aggravated racial/ethnic disparities in healthcare costs in the Medicare Part D population.
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Background: Previous literature suggested that the consequences of inappropriate medication use may be borne disproportionately by racial/ethnic minorities. It is, therefore, essential to examine if quality improvement initiatives, such as Medicare Part D Star Ratings (Star Ratings), can improve these disparities. Objective: To assess the impact of Star Ratings bonus payments to Medicare Advantage prescription drug plans (MAPDs) implemented in 2012 on racial/ethnic disparities in medication utilization issues (MUIs). Methods: This study mainly used secondary data from Medicare administrative data linked to Area Health Resources Files for years before (2010-2011) and after MAPD bonus payment implementation (2016-2017). Patients in MAPDs were treated as the intervention group, and those in independent prescription drug plans (PDPs) were used as the comparison group because PDPs were ineligible for bonuses. MUIs targeted and not targeted in Star Ratings were both examined to determine spillover effects. A difference-in-differences approach was applied by including in a logistic regression a 3-way interaction term for dummy variables for racial/ethnic minorities, later period of 2016-2017, and MAPD plan. Results: Racial/ethnic minorities experienced more MUIs: e.g., the odds of MUIs targeted in Star Ratings among MAPD enrollees were 83% higher (odds ratio [OR] = 1.83; 95% confidence interval [CI] = 1.71-1.96) for Black than White patients. Black-White disparities in MUIs targeted in Star Ratings decreased 16% more (OR = 0.84; 95% = CI 0.78-0.91) over time among MAPD enrollees than those in PDPs. This pattern was not found for non-Star Ratings measures. Changes in Hispanic-White disparities were similar between MAPD and PDP enrollees for MUIs targeted and not-targeted by Star Ratings. Asian-White and Other-White disparities in MUIs did not experience a higher reduction among MAPD enrollees than PDP enrollees. Conclusions: Part D bonus payments are associated with lower Black-White disparities in MUIs targeted by Star Ratings. However, Part D bonus payments may not have reduced Hispanic-White or Asian-White disparities. Future research should explore the causes of the bonus payments' heterogeneous effects across racial/ethnic groups.
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The Medicare Parts C and D Star Ratings system was established to improve care quality in Medicare. Previous studies reported racial/ethnic disparities in the calculation of medication adherence measures of Star Ratings in patients with diabetes, hypertension, and hyperlipidemia. This study aimed to identify possible racial/ethnic disparities in the calculation of adherence measures of Medicare Part D Star Ratings among patients with Alzheimer's disease and related dementias (ADRD) and diabetes, hypertension, or hyperlipidemia. This retrospective study analyzed the 2017 Medicare data and Area Health Resources Files. Non-Hispanic White (White) patients were compared to Black, Hispanic, Asian/Pacific Islander (Asian), and other patients on their likelihood of being included in the calculation of adherence measures for diabetes, hypertension, and/or hyperlipidemia. To adjust for the individual/community characteristics, logistic regression was used when the outcome is the inclusion in the calculation of one adherence measure; multinomial regression was used when examining the inclusion in the calculation of multiple adherence measures. Analyzing the data of 1438,076 Medicare beneficiaries with ADRD, this study found that Black (adjusted odds ratio, or ORâ =â 0.79, 95% confidence interval, or 95% CIâ =â 0.73-0.84) and Hispanic (ORâ =â 0.82, 95% CIâ =â 0.75-0.89) patients were less likely than White patients to be included in the calculation of adherence measure for diabetes medications. Further, Black patients were less likely to be included in the calculation of the adherence measure for hypertension medications than White patients (ORâ =â 0.81, 95% CIâ =â 0.78-0.84). All minorities were less likely to be included in calculating the adherence measure for hyperlipidemia medications than Whites. The ORs for Black, Hispanic, and Asian patients were 0.57 (95% CIâ =â 0.55-0.58), 0.69 (95% CIâ =â 0.64-0.74), and 0.83 (95% CIâ =â 0.76-0.91), respectively. Minority patients were generally likely to be included in the measure calculation of fewer measures than White patients. Racial/ethnic disparities were observed in the calculation of Star Ratings measures among patients with ADRD and diabetes, hypertension, and/or hyperlipidemia. Future studies should explore possible causes of and solutions to these disparities.
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Doença de Alzheimer , Diabetes Mellitus , Hipertensão , Medicare Part C , Medicare Part D , Humanos , Idoso , Estados Unidos , Doença de Alzheimer/tratamento farmacológico , Estudos Retrospectivos , Diabetes Mellitus/tratamento farmacológico , Hipertensão/tratamento farmacológico , Disparidades em Assistência à Saúde , BrancosRESUMO
Background: The Medicare Part D medication therapy management (MTM) program has positive effects on medication and health service utilization. However, little is known about its utilization, much less so about the use among racial and ethnic minorities. Objective: To examine MTM service utilization among older Medicare beneficiaries and to identify any racial and ethnic disparity patterns. Methods: A retrospective cross-sectional analysis of 2017 Medicare administrative data, linked to the Area Health Resources Files. Fourteen outcomes related to MTM service nature, initiation, quantity, and delivery were examined using logistic, negative binomial, and Cox proportional hazards regression models. Results: Racial and ethnic disparities were found with varying patterns across outcomes. For example, compared with White patients, the odds of opting out of MTM were 8% higher for Black patients (odds ratio [OR] = 1.08, 95% confidence interval [CI] = 1.03-1.14), 57% higher for Hispanic patients (OR = 1.57, 95% CI = 1.42-1.72), and 57% higher for Asian patients (OR = 1.57, 95% CI = 1.33-1.85). The odds of continuing MTM from the previous years were 12% lower for Black patients (OR = 0.88, 95% CI = 0.86-0.90) and 3% lower for other patients (OR = 0.97, 95% CI = 0.95-0.99). In addition, the probability of being offered a comprehensive medication review (CMR) after MTM enrollment was 9% lower for Hispanic patients (hazard ratio [HR] = 0.91, 95% CI = 0.85-0.97), 9% lower for Asian patients (HR = 0.91, 95% CI = 0.87-0.94), and 3% lower for other patients (HR = 0.97, 95% CI = 0.95-0.99). Hispanic and Asian patients were more likely to have someone other than themselves receive a CMR. Conclusions: Racial and ethnic disparities in MTM service utilization were identified. Although the disparities in specific utilization outcomes vary across racial/ethnic groups, it is evident that these disparities exist and may result in vulnerable communities not fully benefiting from the MTM services. Causes of the disparities should be explored to inform future reform of the Medicare Part D MTM program.
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Objectives: Racial/ethnic disparities have been found in prior literature examining enrolment in Medicare medication therapy management programs. However, those studies were based on various eligibility scenarios because enrolment data were unavailable. This study tested for potential disparities in enrolment using actual MTM enrolment data. Methods: Medicare Parts A&B claims, Medication Therapy Management Data Files, and the Area Health Resources File from 2013 to 2014 and 2016 to 2017 were analysed in this retrospective analysis. An adjusted logistic regression compared odds of enrolment between racial/ethnic minorities and non-Hispanic Whites (Whites) in the total sample and subpopulations with diabetes, hypertension, or hyperlipidaemia. Trends in disparities were analysed by including interaction terms in regressions between dummy variables for race/ethnic minority groups and period 2016-2017. Key Findings: Disparities in MTM enrolment were detected between Blacks and Whites with diabetes in 2013-2014 (Odds Ratio = 0.78, 95% Confidence Interval = 0.75-0.81). This disparity improved from 2013-2014 to 2016-2017 for Blacks (Odds Ratio=1.08, 95% Confidence Interval = 1.04-1.11) but persisted in 2016-2017 (Odds Ratio = 0.84, 95% Confidence Interval = 0.81-0.87). A disparity was identified between Blacks and Whites with hypertension in 2013-2014 (Odds Ratio = 0.92, 95% Confidence Interval = 0.89-0.95) but not in 2016-2017. Enrolment for all groups, however, declined between periods. For example, in the total sample, the odds of enrolment declined from 2013-2014 to 2016-2017 by 22% (Odds Ratio=0.78, 95% Confidence Interval=0.75-0.81). Conclusions: Racial disparities in MTM enrolment were found between Blacks and Whites among Medicare beneficiaries with diabetes in both periods and among individuals with hypertension in 2013-2014. As overall enrolment fell between periods, concerns about program enrolment remain.
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OBJECTIVE: Medicare Part D Star Ratings are instrumental in shaping healthcare quality improvement efforts. However, the calculation metrics for medication performance measures for this program have been associated with racial/ethnic disparities. In this study, we aimed to explore whether an alternative program, named Star Plus by us that included all medication performance measures developed by Pharmacy Quality Alliance and applicable to our study population, would reduce such disparities among Medicare beneficiaries with diabetes, hypertension, and/or hyperlipidemia. METHOD: We conducted an analysis of a 10% random sample of Medicare A/B/D claims linked to the Area Health Resources File. Multivariate logistic regressions with minority dummy variables were used to examine racial/ethnic disparities in measure calculations of Star Ratings and Star Plus, respectively. RESULTS: Adjusted results indicated that relative to non-Hispanic Whites (Whites), racial/ethnic minorities had significantly lower odds of being included in the Star Ratings measure calculations: the odds ratios (ORs) for Blacks, Hispanics, Asians, and Others were 0.68 (95% confidence interval [CI] = 0.66-0.71), 0.73 (CI = 0.69-0.78), 0.88 (CI = 0.82-0.93), and 0.92 (CI = 0.88-0.97), respectively. In contrast, every beneficiary in the sample was included in Star Plus. Further, racial/ethnic minorities had significantly higher increase in the odds of being included in measure calculation in Star Plus than Star Ratings. The ORs for Blacks, Hispanics, Asians, and Others were 1.47 (CI = 1.41-1.52), 1.37 (CI = 1.29-1.45), 1.14 (CI = 1.07-1.22), and 1.09 (CI = 1.03-1.14), respectively. CONCLUSIONS: Our study demonstrated that racial/ethnic disparities may be eliminated by including additional medication performance measures to Star Ratings.
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Medicare Part D , Idoso , Humanos , Estados Unidos , Etnicidade , Conduta do Tratamento Medicamentoso , Definição da Elegibilidade , Disparidades em Assistência à SaúdeRESUMO
BACKGROUND: Policies such as Medicare Part D Star Ratings are designed to encourage medication adherence and facilitate positive health outcomes. Patients who have received a kidney transplant not included in assessment of Star Ratings measures may have worse outcomes. OBJECTIVE: To determine if criteria for inclusion in assessment of Star Ratings medication adherence measures among kidney transplant patients with diabetes, hypertension, and dyslipidemia lead to racial and ethnic disparities in who is included in this assessment. METHODS: This was a cross-sectional, secondary analysis of 94,822 adult kidney transplant patients receiving continuous coverage of Medicare Parts A/B/D and filling at least 1 prescription for diabetes, hypertension, or dyslipidemia in 2017. Utilizing 2017 Medicare claims, inclusion in assessment of Star Ratings measures was determined based on criteria for each measure concerning adherence to oral diabetes, hypertension, and dyslipidemia medication. Binary and multinomial logistic regression were conducted. RESULTS: Among kidney transplant patients with diabetes only, Black and Hispanic patients were less likely than White patients to be included in assessment of the Star Ratings adherence measure for oral diabetes medications (P < 0.0001). Among kidney transplant patients with hypertension only and dyslipidemia only, all racial and ethnic minority groups were less likely to be included in assessments of Star Ratings adherence measures for oral hypertension and dyslipidemia medications (P < 0.001). For example, among patients with hypertension, adjusted odds ratios for inclusion of Black, Hispanic, and Asian patients were 0.44 (95% CI = 0.40-0.49), 0.56 (95% CI = 0.49-0.63), and 0.55 (95% = CI 0.45-0.67), respectively. CONCLUSIONS: Disparities exist among patients who have received a kidney transplant qualifying for inclusion in Star Ratings measures, which may ultimately facilitate adverse health outcomes. DISCLOSURES: Marie Chisholm-Burns is a member of the American Society of Transplantation Board of Directors. Christina Spivey has no conflicts of interest to disclose. Chi Chun Tsang has no conflicts of interest to disclose. Junling Wang received funding for this project from the National Institute on Aging/National Institutes of Health; she has also received funding from AbbVie and Pharmaceutical Research and Manufacturers of America (additionally, she has received consulting fees from the latter). Research reported in this publication was supported by the National Institute on Aging of the National Institutes of Health under Award Number R01AG049696 (Principal Investigator: Junling Wang). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The sponsor of the research does not have any role in any aspect of the research, including study design and the collection, analysis, and interpretation of data; the writing of the report; and the decision to submit the manuscript for publication.
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Diabetes Mellitus , Dislipidemias , Hipertensão , Transplante de Rim , Medicare Part D , Adulto , Idoso , Estudos Transversais , Diabetes Mellitus/tratamento farmacológico , Dislipidemias/tratamento farmacológico , Dislipidemias/epidemiologia , Etnicidade , Feminino , Humanos , Hipertensão/tratamento farmacológico , Grupos Minoritários , Estados UnidosRESUMO
STUDY OBJECTIVE: To compare rates of catheter-related bloodstream infections (CR-BSI) in pediatric patients who received parenteral nutrition (PN) with either soybean oil-based intravenous fat emulsion (SO-IFE) or mixed oil-IFE (MO-IFE). We hypothesized that the use of MO-IFE would be independently associated with reduced infection rates compared with SO-IFE. DESIGN: Retrospective cohort study. SETTING: Tertiary referral children's hospital and its associated gastrointestinal rehabilitation clinic (01 January, 2015-31 July, 2019). PATIENTS: Days of IFE exposure were counted for patients aged <18 years on IFE initiated during the review period, who had a central venous catheter (CVC) placed for PN administration, received IFE at least three times weekly, and for at least 7 days. MEASUREMENTS: The primary outcome included total and categorical CR-BSI rates expressed as the average with standard error (SE) number of infections per 1000 fat emulsion days. The following categories were specified: Candida albicans, non-albicans Candida spp., coagulase-negative Staphylococcus (CoNS), Enterobacterales, methicillin-resistant S. aureus, methicillin-susceptible S. aureus, and Pseudomonadales. Average infection rate comparisons were quantified as incidence rate ratios (IRR) using generalized linear mixed modeling with a Poisson distribution. MAIN RESULTS: Seven hundred and forty-three SO-IFE and 450 MO-IFE exposures were reviewed from 1131 patients, totaling 37,599 and 19,796 days of therapy, respectively. From those found significantly different, the average rate of infections with CoNS was 3.58 (SE 0.5)/1000 days of SO-IFE and 1.39 (SE 0.45)/1000 days of MO-IFE (IRR [95% confidence interval, CI]: 0.27 [0.16-0.46]; p < 0.01). Total average rates of infection were 7.33 (SE 0.76)/1000 days of SO-IFE and 4.52 (SE 0.75)/1000 days of MO-IFE (IRR [95% CI]: 0.60 [0.44-0.81]; p < 0.01). Other factors associated with higher infection rates include female gender, neonatal age, and inpatient-only IFE exposure. CONCLUSIONS: Receipt of MO-IFE was associated with lower rates of CoNS and total CR-BSIs compared with SO-IFE in pediatric patients. These findings could have major implications on IFE selection for pediatric patients receiving PN.
Assuntos
Staphylococcus aureus Resistente à Meticilina , Sepse , Recém-Nascido , Humanos , Feminino , Criança , Emulsões Gordurosas Intravenosas/efeitos adversos , Óleo de Soja , Estudos Retrospectivos , Staphylococcus aureus , Nutrição Parenteral/efeitos adversosRESUMO
OBJECTIVE: Previous analysis of policy scenarios reported potential disparities in eligibility in the Medicare Medication Therapy Management (MTM) program. With recently released MTM data, this study aimed to determine if racial/ethnic disparities exist in MTM enrollment among Medicare beneficiaries with Alzheimer's disease and related dementias (ADRD). METHODS: Medicare claims/records (from 2013-2014 and 2016-2017) linked to the Area Health Resources File were examined. Included individuals were patients with ADRD and diabetes, hypertension or hyperlipidemia. The proportions of MTM enrollment were compared between non-Hispanic White (White) patients and racial/ethnic minority groups in descriptive analysis. Racial/ethnic disparities were then examined using a logistic regression adjusting for patient and community characteristics. Disparities across study periods were compared by estimating a logistic regression model with interaction terms between dummy variables for each racial/ethnic minority group and 2016-2017. RESULTS: In unadjusted analyses, minorities had higher enrollment proportions than Whites. In 2016-2017, for example, enrollment percentages for Whites, Blacks, Hispanics, Asian/Pacific Islanders (Asians) and Others were respectively 14.44%, 16.71%, 19.83%, 16.66%, and 17.78%. In adjusted analyses, Blacks had lower enrollment odds than Whites within all cohorts. In the entire study sample in 2016-2017, for example, Blacks with ADRD had 9% lower odds of MTM enrollment (odds ratio 0.91, 95% confidence interval [CI] = 0.86-0.97) than Whites. These disparities decreased over time among the ADRD sample and all sub-groups. The interaction term between Blacks and 2016-2017, for instance, indicated that disparities were lowered by 11% (odds ratio 1.11, 95% CI = 1.05-1.16) across study periods among those with ADRD. CONCLUSIONS: Blacks with ADRD, and diabetes, hypertension or hyperlipidemia have lower likelihood of MTM enrollment than Whites. Racial disparities were reduced over time but not eliminated.
Assuntos
Doença de Alzheimer , Hipertensão , Negro ou Afro-Americano , Idoso , Doença de Alzheimer/tratamento farmacológico , Etnicidade , Disparidades em Assistência à Saúde , Humanos , Medicare , Conduta do Tratamento Medicamentoso , Grupos Minoritários , Estados Unidos , População BrancaRESUMO
ABSTRACT: High health care and medication expenditures pose a financial burden on Americans seeking care. It is imperative to determine the role of affordability in influencing access to health care and medications.To investigate the association between financial burden and health care access by comparing the effects of absolute and relative financial burdens, measured by total health care/medication expenditure (Expenditure) and health care/medication expenditure as a share of annual family income (Expenditure Share), respectively.Delay in receiving health care services and delay in obtaining prescription medications.A cross-sectional analysis of the 2017 Medical Expenditure Panel Survey using multivariate logistic regressions with Expenditure and Expenditure Share variables standardized to facilitate comparison.While both absolute and relative financial burdens were found to be positively associated with the outcomes, the relative measure had a significantly higher association that was about twice as much as the absolute one. For the outcome of delay in getting health care, the standardized odds ratios (OR) for health care expenditure and health care expenditure as a share of family income were 1.13 (95% confidence interval [CI]â=â1.09-1.18) and 1.25 (95% CIâ=â1.20-1.32), respectively. For the outcome of delay in getting medications, the standardized OR for medication expenditure and medication expenditure as a share of family income were 1.11 (95% CIâ=â1.08-1.15) and 1.23 (95% CIâ=â1.18-1.29), respectively.The study illustrated the importance of including income in policy considerations intended to balance value, access, and affordability. Specifically, income should be included in measures assessing the value of medications.
Assuntos
Efeitos Psicossociais da Doença , Custos e Análise de Custo , Gastos em Saúde , Acessibilidade aos Serviços de Saúde , Renda/estatística & dados numéricos , Medicamentos sob Prescrição/economia , Custos de Medicamentos/normas , Custos de Medicamentos/estatística & dados numéricos , Características da Família , Feminino , Estresse Financeiro , Acessibilidade aos Serviços de Saúde/normas , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: Older patients with Alzheimer's disease (AD) are challenged with adhering to complex medication regimens. We examined effects of Comprehensive Medication Review (CMR), a required Medicare Part D Medication Therapy Management (MTM) program component, on medication adherence among AD patients. METHODS: This retrospective study analyzed 100% of 2016-2017 Medicare claims covering the entire United States, linked to Area Health Resources Files. Medicare beneficiaries aged ≥65 years were included. Propensity score matching identified comparable intervention and comparison groups with the intervention defined as receiving a CMR in 2017. A difference-in-differences analysis included in multivariate logistic regressions an interaction term between CMR receipt and year 2017. The outcome measured was nonadherence to diabetes, hypertension and hyperlipidemia medications, with nonadherence defined as proportion of days covered <80% for study medications. RESULTS: Unadjusted comparisons indicated the proportion of nonadherence for intervention group members decreased from 2016 to 2017 but increased for the comparison group. In adjusted analyses, reduction in medication nonadherence among the intervention group remained higher: odds ratios for the interaction term were 0.62 (95% confidence interval [CI] = 0.54-0.71), 0.54 (95% CI = 0.50-0.58) and 0.50 (95% CI = 0.47-0.53) respectively for diabetes, hypertension and hyperlipidemia medications. This suggests that the likelihood of nonadherence in the intervention group was respectively reduced by 38%, 46% and 50% more than the comparison group. CONCLUSIONS: CMR was found to reduce nonadherence to diabetes, hypertension and hyperlipidemia medications among older Medicare beneficiaries with AD. This provides evidence that the MTM program is effective for a population with unique medication compliance challenges.
Assuntos
Doença de Alzheimer , Medicare Part D , Idoso , Doença de Alzheimer/tratamento farmacológico , Doença de Alzheimer/epidemiologia , Humanos , Adesão à Medicação , Conduta do Tratamento Medicamentoso , Estudos Retrospectivos , Estados UnidosRESUMO
Background: There has been a lack of evidence on whether there are racial and ethnic disparities in medication nonadherence among individuals receiving comprehensive medication review (CMR), a required component of the Medicare Part D medication therapy management (MTM) services. Objectives: To explore racial/ethnic disparities in medication nonadherence among older MTM enrollees who received a CMR and to determine how much the identified disparities can be explained by observed characteristics. Methods: The retrospective study used 100% of the 2017 Medicare claims, including MTM data. Linked Area Health Resources Files provided community characteristics. Nonadherence was defined as proportion of days covered <80%, and was measured for diabetes, hypertension, and hyperlipidemia medications. Racial/ethnic disparities were examined by logistic regressions that included racial/ethnic minority dummy variables. A nonlinear Blinder-Oaxaca decomposition method was applied to decompose the identified disparities. Results: Compared with non-Hispanic Whites (Whites), Blacks were respectively 39% (odds ratio [OR] = 1.39, 95% confidence interval [CI] = 1.33-1.45), 27% (OR = 1.27, 95% CI = 1.22-1.32), and 43% (OR = 1.43, 95% CI = 1.39-1.47) more likely to be nonadherent to diabetes, hypertension, and hyperlipidemia medications; Hispanics were 20% (OR = 1.20, 95% CI = 1.14-1.27) more likely to be nonadherent to hyperlipidemia medications. The total portion of disparity explained was 13.42%, 7.66%, 14.87%, and 10.69% respectively for disparities in Black-White (B-W) diabetes, B-W hypertension, B-W hyperlipidemia, and Hispanic-White hyperlipidemia. The top three contributors were the proportion of married-couple families, census region, and male gender. Conclusions: A lower level of community affluence and social support, regional variations, and a lower proportion of males in Blacks and Hispanics may contribute to the disparities in medication nonadherence. The large unexplained portion of the disparity attests that nonadherence is a complex issue. The Medicare MTM program needs to implement measures to reduce disparities in medication adherence.