Dr. Adams is the inaugural Stanford Medicine Innovation Professor and Professor of Epidemiology and Population Health and of Medicine (Primary Care and Outcomes Research), as well as Associate Director for Health Equity and Community Engagement in the Stanford Cancer Institute. Focusing on racial and socioeconomic disparities in chronic disease treatment outcomes, Dr. Adams' interdisciplinary research seeks to evaluate the impact of changes in drug coverage policy on access to essential medications, understand the drivers of disparities in treatment adherence among insured populations, and test strategies for maximizing the benefits of treatment outcomes while minimizing harms through informed decision-making. Prior to joining Stanford School of Medicine, Dr. Adams was Associate Director for Health Care Delivery and Policy and a Research Scientist at the Kaiser Permanente Division of Research, as well as a Professor at the Bernard J. Tyson Kaiser Permanente School of Medicine. From 2000 to 2008, she was an Assistant Professor in the Department of Population Medicine (formerly Ambulatory Care and Prevention) at Harvard Medical School and Harvard Pilgrim Health care. She received her PhD in Health Policy and an MPP in Social Policy from Harvard University. She is Vice Chair of the Board of Directors for AcademyHealth and a former recipient of the John M. Eisenberg Excellence in Mentoring Award from Agency for Healthcare Research and Quality and an invited lecturer on racial disparities in health care in the 2014/2015 National Institute of Mental Health Director’s Innovation Speaker Series.
Associate Director, Stanford Cancer Institute (2021 - Present)
Boards, Advisory Committees, Professional Organizations
Member, Healthcare Delivery Research Program Advisory Board, National Cancer Institute (2016 - Present)
Member, Examining Diversity in Diversity, Recruitment, and Retention in Aging Research Advisory Board, University of Maryland School of Pharmacy--The Patients Program (2019 - Present)
Member, Stillman College Undergraduate Biomedical Academy Advisory Board (2019 - Present)
Member/Vice Chair, AcademyHealth (2020 - Present)
BA, University of Texas at Austin, Government (1992)
MPP, John F. Kennedy School of Government, Harvard University, Social Policy (1994)
PhD, Harvard University, Health Policy (1999)
Factors associated with persistent high health care utilization in managed Medicaid.
The American journal of managed care
2021; 27 (8): 340-344
OBJECTIVES: Prior studies have had difficulty predicting which patients will have persistent high utilization past 1year within the Medicaid population. The objective of this study was to examine the medical diagnoses at the time of enrollment of patients with persistent high health care utilization over 24 months following enrollment in Medicaid managed care in a large integrated care setting.STUDY DESIGN: Retrospective cohort study in a large integrated managed health care system.METHODS: We identified a cohort of high utilizers (top 5% of health care costs in 2014) and extracted their electronic health record data (2014-2016). Differences in baseline characteristics of high utilizers and the general Medicaid population were determined using bivariate analysis. We used multivariable regression to determine the independent association between medical comorbidities and demographics with persistent high health care utilization over the 2 years following enrollment.RESULTS: Compared with the general Medicaid managed care enrollee population, schizophrenia was the only mental health diagnosis at the time of enrollment associated with persistent high health care utilization (risk ratio [RR], 1.50; 95% CI, 1.20-1.86). Additional characteristics associated with persistent high utilization included age between 31and 50 years (RR, 1.20; 95% CI, 1.02-1.41), dual enrollment in Medicaid and Medicare (RR, 1.26; 95% CI, 1.09-1.45), chronic pain diagnoses (RR, 1.26; 95% CI, 1.04-1.53), and multimorbidity (RR, 1.43; 95% CI, 1.25-1.63).CONCLUSIONS: Among adults newly enrolled in Medicaid managed care, certain diagnoses noted at the time of enrollment into the plan are associated with persistent high health care utilization over the first 2 years, suggesting that targeting early supportive case management to these individuals could optimize care and reduce health care costs.
View details for DOI 10.37765/ajmc.2021.88725
View details for PubMedID 34460176
- Coronavirus Disease 2019 and Clinical Research in U.S. Nursing Homes. Journal of the American Geriatrics Society 2021
Racial Disparities in COVID-19 Testing and Outcomes : Retrospective Cohort Study in an Integrated Health System.
Annals of internal medicine
Racial disparities exist in outcomes after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.To evaluate the contribution of race/ethnicity in SARS-CoV-2 testing, infection, and outcomes.Retrospective cohort study (1 February 2020 to 31 May 2020).Integrated health care delivery system in Northern California.Adult health plan members.Age, sex, neighborhood deprivation index, comorbid conditions, acute physiology indices, and race/ethnicity; SARS-CoV-2 testing and incidence of positive test results; and hospitalization, illness severity, and mortality.Among 3 481 716 eligible members, 42.0% were White, 6.4% African American, 19.9% Hispanic, and 18.6% Asian; 13.0% were of other or unknown race. Of eligible members, 91 212 (2.6%) were tested for SARS-CoV-2 infection and 3686 had positive results (overall incidence, 105.9 per 100 000 persons; by racial group, White, 55.1; African American, 123.1; Hispanic, 219.6; Asian, 111.7; other/unknown, 79.3). African American persons had the highest unadjusted testing and mortality rates, White persons had the lowest testing rates, and those with other or unknown race had the lowest mortality rates. Compared with White persons, adjusted testing rates among non-White persons were marginally higher, but infection rates were significantly higher; adjusted odds ratios [aORs] for African American persons, Hispanic persons, Asian persons, and persons of other/unknown race were 2.01 (95% CI, 1.75 to 2.31), 3.93 (CI, 3.59 to 4.30), 2.19 (CI, 1.98 to 2.42), and 1.57 (CI, 1.38 to 1.78), respectively. Geographic analyses showed that infections clustered in areas with higher proportions of non-White persons. Compared with White persons, adjusted hospitalization rates for African American persons, Hispanic persons, Asian persons, and persons of other/unknown race were 1.47 (CI, 1.03 to 2.09), 1.42 (CI, 1.11 to 1.82), 1.47 (CI, 1.13 to 1.92), and 1.03 (CI, 0.72 to 1.46), respectively. Adjusted analyses showed no racial differences in inpatient mortality or total mortality during the study period. For testing, comorbid conditions made the greatest relative contribution to model explanatory power (77.9%); race only accounted for 8.1%. Likelihood of infection was largely due to race (80.3%). For other outcomes, age was most important; race only contributed 4.5% for hospitalization, 12.8% for admission illness severity, 2.3% for in-hospital death, and 0.4% for any death.The study involved an insured population in a highly integrated health system.Race was the most important predictor of SARS-CoV-2 infection. After infection, race was associated with increased hospitalization risk but not mortality.The Permanente Medical Group, Inc.
View details for DOI 10.7326/M20-6979
View details for PubMedID 33556278
Individual and Neighborhood Factors Associated With Failure to Vaccinate Against Influenza During Pregnancy
AMERICAN JOURNAL OF EPIDEMIOLOGY
2020; 189 (11): 1379–88
Uptake of influenza vaccine among pregnant women remains low. We investigated whether unvaccinated pregnant women were clustered geographically and determined factors associated with failure to vaccinate using spatial and multivariate logistic regression analyses. Pregnant women who were members of Kaiser Permanente Northern California in 2015 or 2016 were included in the study. More than half (53%) of the 77,607 included pregnant women were unvaccinated. Spatial analysis identified 5 clusters with a high prevalence of unvaccinated pregnant women. The proportion of unvaccinated women ranged from 57% to 75% within clusters as compared with 51% outside clusters. In covariate-adjusted analyses, residence in a cluster was associated with a 41% increase in the odds of being unvaccinated (odds ratio (OR) = 1.41, 95% confidence interval (CI): 1.36, 1.46). The odds of being unvaccinated were greater for Black women (OR = 1.58, 95% CI: 1.49, 1.69), Hispanic women (OR = 1.15, 95% CI: 1.05, 1.25), women with subsidized health insurance (OR = 1.18, 95% CI: 1.11, 1.24), women with fewer than 5 prenatal-care visits (OR = 1.85, 95% CI: 1.60, 2.16), and neighborhoods with a high deprivation index (fourth quartile vs. first: OR = 1.14, 95% CI: 1.07, 1.21). In conclusion, unvaccinated pregnant women were clustered geographically and by key sociodemographic factors. These findings suggest that interventions to increase influenza vaccine coverage among pregnant women are needed, particularly in vulnerable populations.
View details for DOI 10.1093/aje/kwaa165
View details for Web of Science ID 000592576800022
View details for PubMedID 32735018
View details for PubMedCentralID PMC7604527
Individual and neighborhood factors associated with failure to vaccinate against influenza during pregnancy
WILEY. 2020: 628-629
View details for Web of Science ID 000577640502122
Study protocol: Using peer support to aid in prevention and treatment in prediabetes (UPSTART)
CONTEMPORARY CLINICAL TRIALS
2020; 95: 106048
There is an urgent need to develop and evaluate effective and scalable interventions to prevent or delay the onset of type 2 diabetes mellitus (T2DM).In this randomized controlled pragmatic trial, 296 adults with prediabetes will be randomized to either a peer support arm or enhanced usual care. Participants in the peer support arm meet face-to-face initially with a trained peer coach who also is a patient at the same health center to receive information on locally available wellness and diabetes prevention programs, discuss behavioral goals related to diabetes prevention, and develop an action plan for the next week to meet their goals. Over six months, peer coaches call their assigned participants weekly to provide support for weekly action steps. In the final 6 months, coaches call participants at least once monthly. Participants in the enhanced usual care arm receive information on local resources and periodic updates on available diabetes prevention programs and resources. Changes in A1c, weight, waist circumference and other patient-centered outcomes and mediators and moderators of intervention effects will be assessed.At least 296 participants and approximately 75 peer supporters will be enrolled.Despite evidence that healthy lifestyle interventions can improve health behaviors and reduce risk for T2DM, engagement in recommended behavior change is low. This is especially true among racial and ethnic minority and low-income adults. Regular outreach and ongoing support from a peer coach may help participants to initiate and sustain healthy behavior changes to reduce their risk of diabetes.The ClinicalTrials.gov registration number is NCT03689530.
View details for DOI 10.1016/j.cct.2020.106048
View details for Web of Science ID 000564615600014
View details for PubMedID 32497783
Exploiting nonsystematic covariate monitoring to broaden the scope of evidence about the causal effects of adaptive treatment strategies
In studies based on electronic health records (EHR), the frequency of covariate monitoring can vary by covariate type, across patients, and over time, which can limit the generalizability of inferences about the effects of adaptive treatment strategies. In addition, monitoring is a health intervention in itself with costs and benefits, and stakeholders may be interested in the effect of monitoring when adopting adaptive treatment strategies. This paper demonstrates how to exploit nonsystematic covariate monitoring in EHR-based studies to both improve the generalizability of causal inferences and to evaluate the health impact of monitoring when evaluating adaptive treatment strategies. Using a real world, EHR-based, comparative effectiveness research (CER) study of patients with type II diabetes mellitus, we illustrate how the evaluation of joint dynamic treatment and static monitoring interventions can improve CER evidence and describe two alternate estimation approaches based on inverse probability weighting (IPW). First, we demonstrate the poor performance of the standard estimator of the effects of joint treatment-monitoring interventions, due to a large decrease in data support and concerns over finite-sample bias from near-violations of the positivity assumption (PA) for the monitoring process. Second, we detail an alternate IPW estimator using a no direct effect assumption. We demonstrate that this estimator can improve efficiency but at the potential cost of increase in bias from violations of the PA for the treatment process.
View details for DOI 10.1111/biom.13271
View details for Web of Science ID 000528769100001
View details for PubMedID 32297311
- Preventing Diabetes in High-Risk Patients: Time for a System-Level Approach to Disease Prevention JOURNAL OF GENERAL INTERNAL MEDICINE 2019; 34 (8): 1367–68
Targeted learning with daily EHR data
STATISTICS IN MEDICINE
2019; 38 (16): 3073–90
Electronic health records (EHR) data provide a cost- and time-effective opportunity to conduct cohort studies of the effects of multiple time-point interventions in the diverse patient population found in real-world clinical settings. Because the computational cost of analyzing EHR data at daily (or more granular) scale can be quite high, a pragmatic approach has been to partition the follow-up into coarser intervals of pre-specified length (eg, quarterly or monthly intervals). The feasibility and practical impact of analyzing EHR data at a granular scale has not been previously evaluated. We start filling these gaps by leveraging large-scale EHR data from a diabetes study to develop a scalable targeted learning approach that allows analyses with small intervals. We then study the practical effects of selecting different coarsening intervals on inferences by reanalyzing data from the same large-scale pool of patients. Specifically, we map daily EHR data into four analytic datasets using 90-, 30-, 15-, and 5-day intervals. We apply a semiparametric and doubly robust estimation approach, the longitudinal Targeted Minimum Loss-Based Estimation (TMLE), to estimate the causal effects of four dynamic treatment rules with each dataset, and compare the resulting inferences. To overcome the computational challenges presented by the size of these data, we propose a novel TMLE implementation, the "long-format TMLE," and rely on the latest advances in scalable data-adaptive machine-learning software, xgboost and h2o, for estimation of the TMLE nuisance parameters.
View details for DOI 10.1002/sim.8164
View details for Web of Science ID 000473655400011
View details for PubMedID 31025411
Depression in type 1 diabetes and risk of dementia
AGING & MENTAL HEALTH
2019; 23 (7): 880–86
Depression afflicts 14% of individuals with type 1 diabetes (T1D). Depression is a robust risk factor for dementia but it is unknown if this holds true for individuals with T1D, who recently started living to an age conferring dementia risk. We examined if depression is a dementia risk factor among elderly individuals with T1D.3,742 individuals with T1D age ≥50 were followed for dementia from 1/1/96-9/30/2015. Depression, dementia, and comorbidities were abstracted from electronic medical records. Cox proportional hazard models estimated the association between depression and dementia adjusting for demographics, glycosylated hemoglobin, severe dysglycemic epidsodes, stroke, heart disease, nephropathy, and end stage renal disease. The cumulative incidence of dementia by depression was estimated conditional on survival dementia-free to age 55.Five percent (N = 182) were diagnosed with dementia and 20% had baseline depression. Depression was associated with a 72% increase in dementia (fully adjusted HR = 1.72; 95% CI:1.12-2.65). The 25-year cumulative incidence of dementia was more than double for those with versus without depression (27% vs. 12%).For people with T1D, depression significantly increases dementia risk. Given the pervasiveness of depression in T1D, this has major implications for successful aging in this population recently living to old age.
View details for DOI 10.1080/13607863.2018.1455167
View details for Web of Science ID 000467950000011
View details for PubMedID 29634288
View details for PubMedCentralID PMC6179940
Prompting Patients with Poorly Controlled Diabetes to Identify Visit Priorities Before Primary Care Visits: a Pragmatic Cluster Randomized Trial
JOURNAL OF GENERAL INTERNAL MEDICINE
2019; 34 (6): 831–38
Most patients with diabetes do not meet all evidence-based goals of care, and many patients report poor communication and lack of involvement in decision-making during primary care visits.To test the hypothesis that a "Pre-Visit Prioritization" secure email message could improve visit communication and glycemic control among patients with type 2 diabetes.We conducted a pragmatic, provider-randomized, multi-site clinical trial from March 2015 to October 2016 across 30 primary care practices within Kaiser Permanente Northern California (KPNC), a large integrated care delivery system.Eligible patients had at least 1 year of KPNC membership, type 2 diabetes with most recently measured hemoglobin A1c (HbA1c) > = 8.0%, and were registered users of the KPNC online patient portal.Patients in the intervention arm, upon booking an appointment, received a secure email through the KPNC online portal with a link to the EHR allowing them to submit their top one or two priorities prior to the visit. Control patients received usual care.Glycemic control; change in HbA1c 6 and 12 months after the initial visit; patient-reported outcomes related to patient-provider communication and patient care experiences.During the study period, 1276 patients had at least one eligible visit. In post-visit surveys (n = 457), more intervention arm patients reported preparing questions for their visit (72% vs 63%, p = 0.048) and being given treatment choices to consider (81% vs 73%, p = 0.041). Patients in both arms had similar reductions in HbA1c over the 12-month study period (0.56% ± 1.45%), with no significant differences between arms.A "light touch" email-based pre-visit intervention resulted in improved measures of visit interaction but did not significantly improve glycemic control relative to usual care. Improving diabetes clinical outcomes through more effective primary care visits may require more intensive approaches to patient visit preparation.NCT02375932.
View details for DOI 10.1007/s11606-018-4756-4
View details for Web of Science ID 000469884700021
View details for PubMedID 30746642
View details for PubMedCentralID PMC6544732
UNMET SOCIAL AND ECONOMIC NEEDS AMONG PATIENTS ENROLLED IN HEALTH INSURANCE PLANS WITH COST-SHARING REQUIREMENTS
OXFORD UNIV PRESS INC. 2019: S177
View details for Web of Science ID 000473349400377
Automated symptom and treatment side effect monitoring for improved quality of life among adults with diabetic peripheral neuropathy in primary care: a pragmatic, cluster, randomized, controlled trial
2019; 36 (1): 52–61
To evaluate the effectiveness of automated symptom and side effect monitoring on quality of life among individuals with symptomatic diabetic peripheral neuropathy.We conducted a pragmatic, cluster randomized controlled trial (July 2014 to July 2016) within a large healthcare system. We randomized 1834 primary care physicians and prospectively recruited from their lists 1270 individuals with neuropathy who were newly prescribed medications for their symptoms. Intervention participants received automated telephone-based symptom and side effect monitoring with physician feedback over 6 months. The control group received usual care plus three non-interactive diabetes educational calls. Our primary outcomes were quality of life (EQ-5D) and select symptoms (e.g. pain) measured 4-8 weeks after starting medication and again 8 months after baseline. Process outcomes included receiving a clinically effective dose and communication between individuals with neuropathy and their primary care provider over 12 months. Interviewers collecting outcome data were blinded to intervention assignment.Some 1252 participants completed the baseline measures [mean age (sd): 67 (11.7), 53% female, 57% white, 8% Asian, 13% black, 20% Hispanic]. In total, 1179 participants (93%) completed follow-up (619 control, 560 intervention). Quality of life scores (intervention: 0.658 ± 0.094; control: 0.653 ± 0.092) and symptom severity were similar at baseline. The intervention had no effect on primary [EQ-5D: -0.002 (95% CI -0.01, 0.01), P = 0.623; pain: 0.295 (-0.75, 1.34), P = 0.579; sleep disruption: 0.342 (-0.18, 0.86), P = 0.196; lower extremity functioning: -0.079 (-1.27, 1.11), P = 0.896; depression: -0.462 (-1.24, 0.32); P = 0.247] or process outcomes.Automated telephone monitoring and feedback alone were not effective at improving quality of life or symptoms for people with symptomatic diabetic peripheral neuropathy.ClinicalTrials.gov (NCT02056431).
View details for DOI 10.1111/dme.13840
View details for Web of Science ID 000454409900006
View details for PubMedID 30343489
View details for PubMedCentralID PMC7236318
Disparities in knowledge and use of tobacco treatment among smokers in California following healthcare reform.
Preventive medicine reports
2019; 14: 100847
The Affordable Care Act (ACA) promised to narrow smoking disparities by expanding access to healthcare and mandating comprehensive coverage for tobacco treatment starting in 2014. We examined whether two years after ACA implementation disparities in receiving clinician advice to quit and smokers' knowledge and use of treatment resources remained. We conducted telephone interviews in 2016 with a stratified random sample of self-reported smokers newly enrolled in the Kaiser Permanente Northern California's (KPNC) integrated healthcare delivery system in 2014 (N = 491; 50% female; 53% non-white; 6% Spanish language). We used Poisson regression with robust standard errors to test whether sociodemographics, insurance type, comorbidities, smoking status in 2016 (former, light/nondaily [<5 cigarettes per day], daily), and preferred language (English or Spanish) were associated with receiving clinician advice to quit and knowledge and use of tobacco treatment. We included an interaction between smoking status and language to test whether the relation between smoking status and key outcomes varied with preferred language. Overall, 80% of respondents received clinician advice to quit, 84% knew that KPNC offers cessation counseling, 54% knew that cessation pharmacotherapy is free, 54% used pharmacotherapy, and 6% used counseling. In multivariate models, Spanish-speaking light/nondaily smokers had significantly lower rates of all outcomes, while there was no association with other demographic and clinical characteristics. Following ACA implementation, most smokers newly enrolled in KPNC received clinician advice to quit and over half used pharmacotherapy, yet counseling utilization was low. Spanish-language outreach efforts and treatment services are recommended, particularly for adults who are light/nondaily smokers.
View details for PubMedID 31024786
Clinical Response to Real-Time Patient-Reported Diabetic Peripheral Neuropathy Symptoms.
The Permanente journal
To assess clinician response to real-time patient-reported data about diabetic peripheral neuropathy (DPN) symptoms, we analyzed DPN diagnosis and treatment patterns after administration of a 4-question symptom questionnaire in a large vertically integrated health care system.Retrospective cohort study to analyze data from 160,852 patients screened for DPN symptoms from April 2012 to March 2014. Electronic medical record data were used to study changes in DPN diagnosis, treatment initiation, and treatment intensification. We used logistic regression to study the association of patient characteristics with the odds of clinical response.Of patients queried, 50,684 (31.5%) reported symptoms. Patients reporting DPN symptoms experienced a greater increase in new DPN diagnoses (16 percentage points; p < 0.0001) and medication use (4 percentage points; p < 0.0001) compared with those denying symptoms. Among patients reporting symptoms, women and nonwhite patients were less likely to receive a DPN diagnosis, whereas older patients were more likely to receive a DPN diagnosis. Overall, patients who were older, were Asian (hazard ratio = 0.67, 95% confidence interval = 0.63-0.77), and had lower socioeconomic status (hazard ratio = 0.89, 95% confidence interval = 0.80-0.99) were less likely to be treated. However, these racial and socioeconomic differences were not statistically significant for patients with preexisting DPN diagnoses.Patients' real-time reports of DPN symptoms were associated with increased clinical activity. Patient- and clinician-level factors associated with the likelihood of receiving a DPN diagnosis need further study because a formal diagnosis may be associated with more equitable treatment.
View details for DOI 10.7812/TPP/18-180
View details for PubMedID 31050645
View details for PubMedCentralID PMC6499113
Patterns of medication adherence in a multi-ethnic cohort of prevalent statin users diagnosed with breast, prostate, or colorectal cancer
JOURNAL OF CANCER SURVIVORSHIP
2018; 12 (6): 794–802
To investigate the implications of a cancer diagnosis on medication adherence for pre-existing comorbid conditions, we explored statin adherence patterns prior to and following a new diagnosis of breast, colorectal, or prostate cancer among a multi-ethnic cohort.We identified adults enrolled at Kaiser Permanente Northern California who were prevalent statin medication users, newly diagnosed with breast, colorectal, or prostate cancer between 2000 and 2012. Statin adherence was measured using the proportion of days covered (PDC) during the 2-year pre-cancer diagnosis and the 2-year post-cancer diagnosis. Adherence patterns were assessed using generalized estimating equations, for all cancers combined and stratified by cancer type and race/ethnicity, adjusted for demographic, clinical, and tumor characteristics.Among 10,177 cancer patients, statin adherence decreased from pre- to post-cancer diagnosis (adjusted odds ratio (ORadj):0.91, 95% confidence interval (95% CI):0.88-0.94). Statin adherence decreased from pre- to post-cancer diagnosis among breast (ORadj:0.94, 95% CI:0.90-0.99) and colorectal (ORadj:0.79, 95% CI:0.74-0.85) cancer patients. No difference in adherence was observed among prostate cancer patients (ORadj:1.01, 95% CI:0.97-1.05). Prior to cancer diagnosis, adherence to statins was generally higher among non-Hispanic whites and multi-race patients than other groups. However, statin adherence after diagnosis decreased only among these two populations (ORadj:0.85, 95% CI:0.85-0.92 and ORadj:0.86, 95% CI:0.76-0.97), respectively.We found substantial variation in statin medication adherence following diagnosis by cancer type and race/ethnicity among a large cohort of prevalent statin users in an integrated health care setting.Improving our understanding of comorbidity management and polypharmacy across diverse cancer patient populations is warranted to develop tailored interventions that improve medication adherence and reduce disparities in health outcomes.
View details for DOI 10.1007/s11764-018-0716-6
View details for Web of Science ID 000449874500008
View details for PubMedID 30338462
View details for PubMedCentralID PMC6238633
Examining the role of access to care: Racial/ethnic differences in receipt of resection for early-stage non-small cell lung cancer among integrated system members and non-members
2018; 125: 51–56
To examine the role of uniform access to care in reducing racial/ethnic disparities in receipt of resection for early stage non-small cell lung cancer (NSCLC) by comparing integrated health system member patients to demographically similar non-member patients.Using data from the California Cancer Registry, we conducted a retrospective cohort study of patients from four racial/ethnic groups (White, Black, Hispanic, Asian/Pacific Islander), aged 21-80, with a first primary diagnosis of stage I or II NSCLC between 2004 and 2011, in counties served by Kaiser Permanente Northern California (KPNC) at diagnosis. Our cohort included 1565 KPNC member and 4221 non-member patients. To examine the relationship between race/ethnicity and receipt of surgery stratified by KPNC membership, we used modified Poisson regression to calculate risk ratios (RR) adjusted for patient demographic and tumor characteristics.Black patients were least likely to receive surgery regardless of access to integrated care (64-65% in both groups). The magnitude of the black-white difference in the likelihood of surgery receipt was similar for members (RR: 0.82, 95% CI: 0.73-0.93) and non-members (RR: 0.86, 95% CI: 0.80-0.94). Among members, roughly equal proportions of Hispanic and White patients received surgery; however, among non-members, Hispanic patients were less likely to receive surgery (non-members, RR: 0.93, 95% CI: 0.86-1.00; members, RR: 0.98, 95% CI: 0.89-1.08).Disparities in surgical treatment for NSCLC were not reduced through integrated health system membership, suggesting that factors other than access to care (e.g., patient-provider communication) may underlie disparities. Future research should focus on identifying such modifiable factors.
View details for DOI 10.1016/j.lungcan.2018.09.006
View details for Web of Science ID 000450378500008
View details for PubMedID 30429038
View details for PubMedCentralID PMC6242353
Evaluating the Impact of Eliminating Copayments for Tobacco Cessation Pharmacotherapy
2018; 56 (11): 912–18
We examined the impact of the Affordable Care Act-mandated elimination of tobacco cessation pharmacotherapy (TCP) copayments on patient use of TCP, overall and by income.Electronic health record data captured any and combination (eg, nicotine gum plus patch) TCP use among adult smokers newly enrolled in Kaiser Permanente Northern California (KPNC). KPNC eliminated TCP copayments in 2015. We included current smokers newly enrolled in the first 6 months of 2014 (before copayment elimination, N=16,199) or 2015 (after elimination, N=16,469). Multivariable models estimated 1-year changes in rates of any TCP fill, and of combination TCP fill, and tested for differences by income (<$50k, $50≥75k, ≥$75k). Through telephone surveys in 2016 with a subset of smokers newly enrolled in 2014 (n=306), we assessed barriers to TCP use, with results stratified by income.Smokers enrolled in KPNC in 2015 versus 2014 were more likely to have a TCP fill (9.1% vs. 8.2%; relative risk, 1.19; 95% confidence interval, 1.11-1.27), and combination TCP fill, among those with any fill (42.3% vs. 37.9%; relative risk, 1.12; 95% confidence interval, 1.02-1.23); findings were stronger for low-income smokers. Low-income patients (<$50k) were less likely to report that clinicians discussed smoking treatments with them (58%) compared with higher income smokers ($50≥75k, 67%; ≥$75k, 83%), and were less aware that TCP was free (40% vs. 53% and 69%, respectively, P-values<0.05).The Affordable Care Act's copayment elimination was associated with a modest increase in TCP use and a greater effect among low-income smokers. Uptake may have been enhanced if promoted to patients directly and via providers.
View details for PubMedID 30234768
Effect of Out-of-Pocket Cost on Medication Initiation, Adherence, and Persistence among Patients with Type 2 Diabetes: The Diabetes Study of Northern California (DISTANCE)
HEALTH SERVICES RESEARCH
2018; 53 (2): 1227–47
To estimate the effect of out-of-pocket (OOP) cost on nonadherence to classes of cardiometabolic medications among patients with diabetes.Electronic health records from a large, health care delivery system for 223,730 patients with diabetes prescribed 842,899 new cardiometabolic medications during 2006-2012.Observational, new prescription cohort study of the effect of OOP cost on medication initiation and adherence.Adherence and OOP costs were based on pharmacy dispensing records and benefits.Primary nonadherence (never dispensed) increased monotonically with OOP cost after adjusting for demographics, neighborhood socioeconomic status, Medicare, medical financial assistance, OOP maximum, deductibles, mail order pharmacy incentive and use, drug type, generic or brand, day's supply, and comorbidity index; 7 percent were never dispensed the new medication when OOP cost ≥$11, 5 percent with OOP cost of $1-$10, and 3 percent when the medication was free of charge (p < .0001). Higher OOP cost was also strongly associated with inadequate secondary adherence (≥20 percent of time without adequate medication). There was no clinically significant or consistent relationship between OOP costs and early nonpersistence (dispensed once, never refilled) or later stage nonpersistence (discontinued within 24 months).Cost-sharing may deter clinically vulnerable patients from initiating essential medications, undermining adherence and risk factor control.
View details for DOI 10.1111/1475-6773.12700
View details for Web of Science ID 000428403100032
View details for PubMedID 28474736
View details for PubMedCentralID PMC5867086
Disparities in Prostate, Lung, Breast, and Colorectal Cancer Survival and Comorbidity Status among Urban American Indians and Alaskan Natives
2017; 77 (23): 6770–76
Cancer is the second leading cause of death among American Indians and Alaskan Natives (AIAN), although cancer survival information in this population is limited, particularly among urban AIAN. In this retrospective cohort study, we compared all-cause and prostate, breast, lung, and colorectal cancer-specific mortality among AIAN (n = 582) and non-Hispanic white (NHW; n = 82,696) enrollees of Kaiser Permanente Northern California (KPNC) diagnosed with primary invasive breast, prostate, lung, or colorectal cancer from 1997 to 2015. Tumor registry and other electronic health records provided information on sociodemographic, comorbidity, tumor, clinical, and treatment characteristics. Cox regression models were used to estimate adjusted survival curves and hazard ratios (HR) with 95% confidence intervals (CI). AIAN had a significantly higher comorbidity burden compared with NHW (P < 0.05). When adjusting for patient, disease characteristics, and Charlson comorbidity scores, all-cause mortality and cancer-specific mortality were significantly higher for AIAN than NHW patients with breast cancer (HR, 1.47; 95% CI, 1.13-1.92) or with prostate cancer (HR, 1.87; 95% CI, 1.14-3.06) but not for AIAN patients with lung and colorectal cancer. Despite approximately equal access to preventive services and cancer care in this setting, we found higher mortality for AIAN than NHW with some cancers, and a greater proportion of AIAN cancer patients with multiple comorbid conditions. This study provides severely needed information on the cancer experience of the 71% of AIANs who live in urban areas and access cancer care outside of the Indian Health Services, from which the vast majority of AIAN cancer information comes. Cancer Res; 77(23); 6770-6. ©2017 AACR.
View details for DOI 10.1158/0008-5472.CAN-17-0429
View details for Web of Science ID 000416854100025
View details for PubMedID 29187399
View details for PubMedCentralID PMC5728425
Effects of Transitioning to Medicare Part D on Access to Drugs for Medical Conditions among Dual Enrollees with Cancer
VALUE IN HEALTH
2017; 20 (10): 1345–54
To evaluate the impact of transitioning from Medicaid to Medicare Part D drug coverage on the use of noncancer treatments among dual enrollees with cancer.We leveraged a representative 5% national sample of all fee-for-service dual enrollees in the United States (2004-2007) to evaluate the impact of the removal of caps on the number of reimbursable prescriptions per month (drug caps) under Part D on 1) prevalence and 2) average days' supply dispensed for antidepressants, antihypertensives, and lipid-lowering agents overall and by race (white and black).The removal of drug caps was associated with increased use of lipid-lowering medications (days' supply 3.63; 95% confidence interval [CI] 1.57-5.70). Among blacks in capped states, we observed increased use of lipid-lowering therapy (any use 0.08 percentage points; 95% CI 0.05-0.10; and days' supply 4.01; 95% CI 2.92-5.09) and antidepressants (days' supply 2.20; 95% CI 0.61-3.78) and increasing trends in antihypertensive use (any use 0.01 percentage points; 95% CI 0.004-0.01; and days' supply 1.83; 95% CI 1.25-2.41). The white-black gap in the use of lipid-lowering medications was immediately reduced (-0.09 percentage points; 95% CI -0.15 to -0.04). We also observed a reversal in trends toward widening white-black differences in antihypertensive use (level -0.08 percentage points; 95% CI -0.12 to -0.05; and trend -0.01 percentage points; 95% CI -0.02 to -0.01) and antidepressant use (-0.004 percentage points; 95% CI -0.01 to -0.0004).Our findings suggest that the removal of drug caps under Part D had a modest impact on the treatment of hypercholesterolemia overall and may have reduced white-black gaps in the use of lipid-lowering and antidepressant therapies.
View details for DOI 10.1016/j.jval.2017.05.023
View details for Web of Science ID 000419245600014
View details for PubMedID 29241894
View details for PubMedCentralID PMC5734096
Overcoming barriers to diabetic polyneuropathy management in primary care
HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION
2017; 5 (4): 171–73
Diabetic polyneuropathy is a highly prevalent and costly complication of diabetes that is frequently underdiagnosed and undertreated in primary care settings. In this article, we discuss challenges in the management of diabetic polyneuropathy symptoms, including diagnostic complexity, the limited efficacy and high side effect rates associated with available treatments and the time constrained primary care visit. We call for the development of novel patient-centric, system-level strategies that engage patients between physician visits in order to facilitate timely communication of symptoms and treatment response and to promote patient-centered care.
View details for DOI 10.1016/j.hjdsi.2016.10.003
View details for Web of Science ID 000416940300004
View details for PubMedID 27939169
View details for PubMedCentralID PMC7265436
The Delivery Science Rapid Analysis Program: a research and operational partnership at Kaiser Permanente Northern California
LEARNING HEALTH SYSTEMS
2017; 1 (4)
Health care researchers and delivery system leaders share a common mission to improve health care quality and outcomes. However, differing timelines, incentives, and priorities are often a barrier to research and operational partnerships. In addition, few funding mechanisms exist to generate and solicit analytic questions that are of interest to both research and to operations within health care settings, and provide rapid results that can be used to improve practice and outcomes.The Delivery Science Rapid Analysis Program (RAP) was formed in 2013 within the Kaiser Permanente Northern California Division of Research, sponsored by The Permanente Medical Group. A Steering Committee consisting of both researchers and clinical leaders solicits and reviews proposals for rapid analytic projects that will use existing data and are feasible within 6 months and with up to $30,000 (approximately 25-50% full-time equivalent) of programmer/analyst effort. Review criteria include the importance of the analytic question for both research and operations, and the potential for the project to have a significant impact on care delivery within 12 months of completion.The RAP funded 5 research and operational analytic projects between 2013 and 2017. These projects spanned a wide range of clinical areas, including lupus, pediatric obesity, diabetes, e-cigarette use, and hypertension. The hypertension RAP project, which focused on optimizing thiazide prescribing in Black/African-American patients with hypertension, led to new insights that inform an equitable care quality metric designed to reduce blood pressure control disparities throughout the KPNC region.Programs that actively encourage research and operational analytic partnerships have significant potential to improve care, enhance research collaborations, and contribute to the building and sustaining of learning health care systems.
View details for DOI 10.1002/lrh2.10035
View details for Web of Science ID 000457886500005
View details for PubMedID 29152588
View details for PubMedCentralID PMC5687292
Association of the Affordable Care Act With Smoking and Tobacco Treatment Utilization Among Adults Newly Enrolled in Health Care
2017; 55 (5): 535–41
To examine rates of smoking and tobacco treatment utilization by insurance coverage status (Medicaid, commercial, exchange) among newly enrolled patients in the post Affordable Care Act (ACA) era.We examined new members who enrolled in Kaiser Permanente Northern California through Medicaid, the California exchange, or nonexchange commercial plans (N=122,298) in the first 6 months of 2014 following ACA implementation. We compared these groups on smoking prevalence and tested whether smokers in each group differed on sociodemographic characteristics and in their utilization of tobacco treatment (pharmacotherapy and counseling) in 2014.Smoking prevalence was higher among Medicaid (22%) than exchange (13%) or commercial (12%) patients (P<0.0001). Controlling for key sociodemographic and clinical characteristics, Medicaid (odds ratio, 1.49; 95% confidence interval, 1.29-1.73) smokers had greater odds of tobacco treatment use than commercial smokers. Other groups at risk for underuse included men, younger patients, Asians, and Latinos.In this cohort of newly enrolled patients after ACA implementation, Medicaid patients were more likely to be smokers compared with exchange and commercial patients, but they were also more likely to use tobacco treatment. Low tobacco treatment use among exchange and commercial plan smokers, as well as younger men, Asians and Latinos poses a significant obstacle to improving public health and additional targeted outreach strategies may be needed to engage these patients with available health services.
View details for DOI 10.1097/MLR.0000000000000712
View details for Web of Science ID 000401330800014
View details for PubMedID 28288073
View details for PubMedCentralID PMC5407463
Population Health Management for Diabetes: Health Care System-Level Approaches for Improving Quality and Addressing Disparities
CURRENT DIABETES REPORTS
2017; 17 (5): 31
Population care approaches for diabetes have the potential to improve the quality of care and decrease diabetes-related mortality and morbidity. Population care strategies are particularly relevant as accountable care organizations (ACOs), patient-centered medical homes (PCMH), and integrated delivery systems are increasingly focused on managing chronic disease care at the health system level. This review outlines the key elements of population care approaches for diabetes in the current health care environment.Population care approaches proactively identify diabetes patients through disease registries and electronic health record data and utilize multidisciplinary care teams, personalized provider feedback, and decision support tools to target and care for patients at risk for poor outcomes. Existing evidence suggests that these strategies can improve care outcomes and potentially ameliorate existing race/ethnic disparities in health care. However, such strategies may be less effective for patients who are disengaged from the health care system. As population care for diabetes continues to evolve, future initiatives should consider ways to tailor population care to meet individual patient needs, while leveraging improvements in clinical information systems and care integration to optimally manage and prevent diabetes in the future.
View details for DOI 10.1007/s11892-017-0858-3
View details for Web of Science ID 000399652900003
View details for PubMedID 28364355
View details for PubMedCentralID PMC5536329
Primary care visit preparation and communication for patients with poorly controlled diabetes: A qualitative study of patients and physicians
PRIMARY CARE DIABETES
2017; 11 (2): 148–53
The purpose of this study was to examine how patients with diabetes and their primary care physicians identify and discuss visit priorities prior to and during visits.We conducted a qualitative study involving patients with diabetes (4 focus groups, n=29) and primary care physicians (6 provider practice meeting discussions, n=67).Four key themes related to prioritization were identified: 1) the value of identifying visit priorities before the visit; 2) challenges to negotiating priorities during the time-limited visit; 3) the importance of "non-medical" priorities; and 4) the need for strategies to help patients prepare for visits. Both patients and physicians felt that identifying a concise list of key priorities in advance of the visit could help establish collaborative visit agendas and treatment plans.Identifying and communicating mutually agreed upon priorities for discussion is a key challenge for time-limited primary care visits.Communication between primary care physicians and their patients with diabetes could be improved by strategies that help patients identify their top visit priorities before the visit.
View details for DOI 10.1016/j.pcd.2016.11.003
View details for Web of Science ID 000396955300007
View details for PubMedID 27916628
View details for PubMedCentralID PMC5340584
Identification of the Joint Effect of a Dynamic Treatment Intervention and a Stochastic Monitoring Intervention Under the No Direct Effect Assumption
JOURNAL OF CAUSAL INFERENCE
2017; 5 (1)
The management of chronic conditions is characterized by frequent re-assessment of therapy decisions in response to the patient's changing condition over the course of the illness. Evidence most suitable to inform care thus often concerns the contrast of adaptive treatment strategies that repeatedly personalize treatment decisions over time using the latest accumulated data available from the patient's previous clinic visits such as laboratory exams (e.g., hemoglobin A1c measurements in diabetes care). The frequency at which such information is monitored implicitly defines the causal estimand that is typically evaluated in an observational or randomized study of such adaptive treatment strategies. Analytic control of monitoring with standard estimation approaches for time-varying interventions can therefore not only improve study generalizibility but also inform the optimal timing of clinical surveillance. Valid inference with these estimators requires the upholding of a positivity assumption that can hinder their applicability. To potentially weaken this requirement for monitoring control, we introduce identifiability results that will facilitate the derivation of alternate estimators of effects defined by general joint treatment and monitoring interventions in the context of time-to-event outcomes. These results are developed based on the nonparametric structural equation modeling framework using a no direct effect assumption originally introduced in a prior paper that inspired this work. The relevance and scope of the results presented here are illustrated with examples in diabetes comparative effectiveness research.
View details for DOI 10.1515/jci-2016-0015
View details for Web of Science ID 000405994900005
View details for PubMedID 29238650
View details for PubMedCentralID PMC5724814
Depressive symptoms and adherence to cardiometabolic therapies across phases of treatment among adults with diabetes: the Diabetes Study of Northern California (DISTANCE)
PATIENT PREFERENCE AND ADHERENCE
2017; 11: 643-+
Among adults with diabetes, depression is associated with poorer adherence to cardiometabolic medications in ongoing users; however, it is unknown whether this extends to early adherence among patients newly prescribed these medications. This study examined whether depressive symptoms among adults with diabetes newly prescribed cardiometabolic medications are associated with early and long-term nonadherence.An observational follow-up of 4,018 adults with type 2 diabetes who completed a survey in 2006 and were newly prescribed oral antihyperglycemic, antihypertensive, or lipid-lowering agents within the following year at Kaiser Permanente Northern California was conducted. Depressive symptoms were examined based on Patient Health Questionnaire-8 scores. Pharmacy utilization data were used to identify nonadherence by using validated methods: early nonadherence (medication never dispensed or dispensed once and never refilled) and long-term nonadherence (new prescription medication gap [NPMG]: percentage of time without medication supply). These analyses were conducted in 2016.Patients with moderate-to-severe depressive symptoms had poorer adherence than nondepressed patients (8.3% more patients with early nonadherence, P=0.01; 4.9% patients with longer NPMG, P=0.002; 7.8% more patients with overall nonadherence [medication gap >20%], P=0.03). After adjustment for confounders, the models remained statistically significant for new NPMG (3.7% difference, P=0.02). There was a graded association between greater depression severity and nonadherence for all the models (test of trend, P<0.05).Depressive symptoms were associated with modest differences in early and long-term adherence to newly prescribed cardiometabolic medications in diabetes patients. Interventions targeting adherence among adults with diabetes and depression need to address both initiation and maintenance of medication use.
View details for DOI 10.2147/PPA.S124181
View details for Web of Science ID 000397589000002
View details for PubMedID 28392679
View details for PubMedCentralID PMC5373834
A Learning Behavioral Health Care System: Opportunities to Enhance Research
2016; 67 (9): 1019–22
Sweeping changes in health care financing combined with the increased use of technology across health care systems are making it possible to address long-standing challenges to the behavioral health services delivery system. This Open Forum outlines opportunities and challenges facing health services researchers in this rapidly changing landscape. Inspired by a 2012 report by the Institute of Medicine, the authors discuss innovative research endeavors, promising study designs, and challenges involved in integrating high-impact behavioral health services research within a learning behavioral health care framework. The Open Forum concludes with a discussion of the critical next steps in this process: building consensus around common metrics for high-quality care, relevant outcomes, and contextual factors; connecting researchers to community and clinical settings; creating a data commons to pool information across sites; and designing and evaluating evidence-based decision support tools to drive improved care and outcomes.
View details for DOI 10.1176/appi.ps.201500180
View details for Web of Science ID 000388267600014
View details for PubMedID 27133723
The Diabetes Telephone Study: Design and challenges of a pragmatic cluster randomized trial to improve diabetic peripheral neuropathy treatment
2016; 13 (3): 286–93
Challenges to effective pharmacologic management of symptomatic diabetic peripheral neuropathy include the limited effectiveness of available medicines, frequent side effects, and the need for ongoing symptom assessment and treatment titration for maximal effectiveness. We present here the rationale and implementation challenges of the Diabetes Telephone Study, a randomized trial designed to improve medication treatment, titration, and quality of life among patients with symptomatic diabetic peripheral neuropathy.We implemented a pragmatic cluster randomized controlled trial to test the effectiveness of an automated interactive voice response tool designed to provide physicians with real-time patient-reported data about responses to newly prescribed diabetic peripheral neuropathy medicines. A total of 1834 primary care physicians treating patients in the diabetes registry at Kaiser Permanente Northern California were randomized into the intervention or control arm. In September 2014, we began identification and recruitment of patients assigned to physicians in the intervention group who receive three brief interactive calls every 2 months after a medication is prescribed to alleviate diabetic peripheral neuropathy symptoms. These calls provide patients with the opportunity to report on symptoms, side effects, self-titration of medication dose and overall satisfaction with treatment. We plan to compare changes in self-reported quality of life between the intervention group and patients in the control group who receive three non-interactive automated educational phone calls.Successful implementation of this clinical trial required robust stakeholder engagement to help tailor the intervention and to address pragmatic concerns such as provider time constraints. As of 27 October 2015, we had screened 2078 patients, 1447 of whom were eligible for participation. We consented and enrolled 1206 or 83% of those eligible. Among those enrolled, 53% are women and the mean age is 67 (standard deviation = 12) years. The racial ethnic make-up is 56% White, 8% Asian, 13% Black or African American, and 19% Hispanic or Latino.Innovative strategies are needed to guide improvements in healthcare delivery for patients with symptomatic diabetic peripheral neuropathy. This trial aims to assess whether real-time collection and clinical feedback of patient treatment experiences can reduce patient symptom burden. Implementation of a clinical trial closely involving clinical care required researchers to partner with clinicians. If successful, this intervention provides a critical information feedback loop that would optimize diabetic peripheral neuropathy medication titration through widely available interactive voice response technology.
View details for DOI 10.1177/1740774516631530
View details for Web of Science ID 000375689500006
View details for PubMedID 27034455
View details for PubMedCentralID PMC7261503
Improved Perinatal Depression Screening, Treatment, and Outcomes With a Universal Obstetric Program
OBSTETRICS AND GYNECOLOGY
2016; 127 (5): 917–25
To evaluate whether universal prenatal and early postnatal screening for depression leads to increased detection, subsequent intervention, and improved depressive symptom outcomes.We conducted a population-based retrospective cohort study of 97,678 pregnant Kaiser Permanente Northern California members during three phases of the Universal Perinatal Depression Screening Program (preimplementation, rollout, fully implemented) from 2007 through 2014. Depression screening scores (Patient Health Questionnaire-9), depression diagnoses, individual counseling visits, demographic characteristics, and medication dispensings were extracted from electronic health records and pharmacy databases. The percentage of women screened, new depression diagnoses, and women receiving treatment were compared among the three phases (tests of trend). Changes in depressive symptom scores up to 6 months postpartum were assessed (rollout and fully implemented phases).A significant increase emerged in the percentage of women screened over the three phases ranging from less than 1% (n=122) (preimplementation) to 98% (n=41,124) (fully implemented) (P<.001). Identification of a new depression diagnosis increased from 8.2% (n=1,341) (preimplementation) to 11.5% (n=4,943) (fully implemented) (P<.001). Although the observed percentage of women receiving treatment decreased (60.9% [preimplementation] to 47.1% [fully implemented]), significant increases in the expected percentage of women receiving treatment emerged (42.6% [preimplementation] to 47.1% [fully implemented]; P<.05). Similar trends were noted for women with Patient Health Questionnaire-9 scores of 15 or greater (greater severity), highlighting an increase in expected percentage of women receiving treatment (5.9% [preimplementation] to 81.9% [fully implemented]; P<.05). In the fully implemented phase, improvements in depressive symptoms up to 6 months postpartum were noted.These data provide evidence of benefit for universal perinatal depression screening programs regarding depression identification and treatment receipt and suggest improvement in symptom outcomes for women in screening programs, especially among integrated health care systems.
View details for DOI 10.1097/AOG.0000000000001403
View details for Web of Science ID 000376941000018
View details for PubMedID 27054938
View details for PubMedCentralID PMC4972038
Pre-Visit Prioritization for complex patients with diabetes: Randomized trial design and implementation within an integrated health care system
CONTEMPORARY CLINICAL TRIALS
2016; 47: 196–201
Despite robust evidence to guide clinical care, most patients with diabetes do not meet all goals of risk factor control. Improved patient-provider communication during time-limited primary care visits may represent one strategy for improving diabetes care.We designed a controlled, cluster-randomized, multi-site intervention (Pre-Visit Prioritization for Complex Patients with Diabetes) that enables patients with poorly controlled type 2 diabetes to identify their top priorities prior to a scheduled visit and sends these priorities to the primary care physician progress note in the electronic medical record. In this paper, we describe strategies to address challenges to implementing our health IT-based intervention study within a large health care system.This study is being conducted in 30 primary care practices within a large integrated care delivery system in Northern California. Over a 12-week period (3/1/2015-6/6/2015), 146 primary care physicians consented to enroll in the study (90.1%) and approved contact with 2496 of their patients (97.6%). Implementation challenges included: (1) navigating research vs. quality improvement requirements; (2) addressing informed consent considerations; and (3) introducing a new clinical tool into a highly time-constrained workflow. Strategies for successfully initiating this study included engagement with institutional leaders, Institutional Review Board members, and clinical stakeholders at multiple stages both before and after notice of Federal funding; flexibility by the research team in study design; and strong support from institutional leadership for "self-learning health system" research.By paying careful attention to identifying and collaborating with a wide range of key clinical stakeholders, we have shown that researchers embedded within a learning care system can successfully apply rigorous clinical trial methods to test new care innovations.
View details for DOI 10.1016/j.cct.2016.01.012
View details for Web of Science ID 000374606900026
View details for PubMedID 26820612
View details for PubMedCentralID PMC4818191
Communication Barriers and the Clinical Recognition of Diabetic Peripheral Neuropathy in a Diverse Cohort of Adults: The DISTANCE Study
JOURNAL OF HEALTH COMMUNICATION
2016; 21 (5): 544–53
The purpose of this study was to explore communication barriers as independent predictors and potential mediators of variation in clinical recognition of diabetic peripheral neuropathy (DPN). In this cross-sectional analysis, we estimated the likelihood of having a DPN diagnosis among 4,436 patients with DPN symptoms. We controlled for symptom frequency, demographic and clinical characteristics, and visit frequency using a modified Poisson regression model. We then evaluated 4 communication barriers as independent predictors of clinical documentation and as possible mediators of racial/ethnic differences: difficulty speaking English, not talking to one's doctor about pain, limited health literacy, and reports of suboptimal patient-provider communication. Difficulty speaking English and not talking with one's doctor about pain were independently associated with not having a diagnosis, though limited health literacy and suboptimal patient-provider communication were not. Limited English proficiency partially attenuated, but did not fully explain, racial/ethnic differences in clinical documentation among Chinese, Latino, and Filipino patients. Providers should be encouraged to talk with their patients about DPN symptoms, and health systems should consider enhancing strategies to improve timely clinical recognition of DPN among patients who have difficult speaking English. More work is needed to understand persistent racial/ethnic differences in diagnosis.
View details for DOI 10.1080/10810730.2015.1103335
View details for Web of Science ID 000377997600008
View details for PubMedID 27116591
View details for PubMedCentralID PMC4920056
Patient reported outcomes for diabetic peripheral neuropathy
JOURNAL OF DIABETES AND ITS COMPLICATIONS
2015; 29 (8): 1112–18
Multiple patient-reported outcomes (PROs) have been used to assess symptoms among patients with Diabetic Peripheral Neuropathy (DPN). However, there is little consistent application of measures in clinical or research settings. Our goal was to identify and compare patient reported outcome measures (PROs) specifically evaluated in neuropathy populations.Literature search, summary, and qualitative comparison of PROs validated in neuropathy populations.We identified 12 studies of PROs evaluated in neuropathy populations that included DPN patients. Two assessed sleep quality, 5 assessed painful symptoms, and 5 assessed quality of life. The number of items per measure ranged from one to 97, and the number of domains ranged from one to 18. All had adequate internal consistency (Chronbach's Alpha>0.70). There was mild to moderate standardization of domains across measures and only a few instruments used common comparators. The spectrum of DPN symptoms addressed included: sensory symptoms, autonomic symptoms, and function, beliefs, role participation, sleep quality, and perceptions of illness.There remains a need for a gold standard for DPN symptom assessment. Few existing instruments are adequately validated and the domains assessed are inconsistent. Current instrument selection should depend on the clinical and social context of the assessment.
View details for DOI 10.1016/j.jdiacomp.2015.08.015
View details for Web of Science ID 000366884900024
View details for PubMedID 26385309
An algorithm to identify medication nonpersistence using electronic pharmacy databases
JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION
2015; 22 (5): 957–61
Identifying patients who are medication nonpersistent (fail to refill in a timely manner) is important for healthcare operations and research. However, consistent methods to detect nonpersistence using electronic pharmacy records are presently lacking. We developed and validated a nonpersistence algorithm for chronically used medications.Refill patterns of adult diabetes patients (n = 14,349) prescribed cardiometabolic therapies were studied. We evaluated various grace periods (30-300 days) to identify medication nonpersistence, which is defined as a gap between refills that exceeds a threshold equal to the last days' supply dispensed plus a grace period plus days of stockpiled medication. Since data on medication stockpiles are typically unavailable for ongoing users, we compared nonpersistence to rates calculated using algorithms that ignored stockpiles.When using grace periods equal to or greater than the number of days' supply dispensed (i.e., at least 100 days), this novel algorithm for medication nonpersistence gave consistent results whether or not it accounted for days of stockpiled medication. The agreement (Kappa coefficients) between nonpersistence rates using algorithms with versus without stockpiling improved with longer grace periods and ranged from 0.63 (for 30 days) to 0.98 (for a 300-day grace period).Our method has utility for health care operations and research in prevalent (ongoing) and new user cohorts. The algorithm detects a subset of patients with inadequate medication-taking behavior not identified as primary nonadherent or secondary nonadherent. Healthcare systems can most comprehensively identify patients with short- or long-term medication underutilization by identifying primary nonadherence, secondary nonadherence, and nonpersistence.
View details for DOI 10.1093/jamia/ocv054
View details for Web of Science ID 000361282600004
View details for PubMedID 26078413
View details for PubMedCentralID PMC5009927
Ethnic Differences in Geriatric Conditions and Diabetes Complications Among Older, Insured Adults With Diabetes: The Diabetes and Aging Study
JOURNAL OF AGING AND HEALTH
2015; 27 (5): 894–918
The aim of this study was to evaluate ethnic differences in burden of prevalent geriatric conditions and diabetic complications among older, insured adults with diabetes.An observational study was conducted among 115,538 diabetes patients, aged ≥60, in an integrated health care system with uniform access to care.Compared with Whites, Asians and Filipinos were more likely to be underweight but had substantively lower prevalence of falls, urinary incontinence, polypharmacy, depression, and chronic pain, and were least likely of all groups to have at least one geriatric condition. African Americans had significantly lower prevalence of incontinence and falls, but higher prevalence of dementia; Latinos had a lower prevalence of falls. Except for end-stage renal disease (ESRD), Whites tended to have the highest rates of prevalent diabetic complications.Among these insured older adults, ethnic health patterns varied substantially; differences were frequently small and rates were often better among select minority groups, suggesting progress toward the Healthy People 2020 objective to reduce health disparities.
View details for DOI 10.1177/0898264315569455
View details for Web of Science ID 000357749100007
View details for PubMedID 25659747
View details for PubMedCentralID PMC4498983
Impact of a Pharmacy Benefit Change on New Use of Mail Order Pharmacy among Diabetes Patients: The Diabetes Study of Northern California (DISTANCE)
HEALTH SERVICES RESEARCH
2015; 50 (2): 537–59
To assess the impact of a pharmacy benefit change on mail order pharmacy (MOP) uptake.Race-stratified, random sample of diabetes patients in an integrated health care delivery system.In this natural experiment, we studied the impact of a pharmacy benefit change that conditionally discounted medications if patients used MOP and prepaid two copayments. We compared MOP uptake among those exposed to the benefit change (n = 2,442) and the reference group with no benefit change (n = 8,148), and estimated differential MOP uptake across social strata using a difference-in-differences framework.Ascertained MOP uptake (initiation among previous nonusers).Thirty percent of patients started using MOP after receiving the benefit change versus 9 percent uptake among the reference group (p < .0001). After adjustment, there was a 26 percentage point greater MOP uptake (benefit change effect). This benefit change effect was significantly smaller among patients with inadequate health literacy (15 percent less), limited English proficiency (14 percent less), and among Latinos and Asians (24 and 16 percent less compared to Caucasians).Conditionally discounting medications delivered by MOP effectively stimulated MOP uptake overall, but it unintentionally widened previously existing social gaps in MOP use because it stimulated less MOP uptake in vulnerable populations.
View details for DOI 10.1111/1475-6773.12223
View details for Web of Science ID 000351167600011
View details for PubMedID 25131156
View details for PubMedCentralID PMC4329275
Effects of Eliminating Drug Caps on Racial Differences in Antidepressant Use Among Dual Enrollees With Diabetes and Depression
2015; 37 (3): 597–609
Black patients with diabetes are at greater risk of underuse of antidepressants even when they have equal access to health insurance. This study aimed to evaluate the impact of removing a significant financial barrier to prescription medications (drug caps) on existing black-white disparities in antidepressant treatment rates among patients with diabetes and comorbid depression.We used an interrupted time series with comparison series design and a 5% representative sample of all fee-for-service Medicare and Medicaid dual enrollees to evaluate the removal of drug caps on monthly antidepressant treatment rates. We evaluated the impact of drug cap removal on racial gaps in treatment by modeling the month-to-month white-black difference in use within age strata (younger than 65 years of age or 65 years of age or older). We compared adult dual enrollees with diabetes and comorbid depression living in states with strict drug caps (n = 221) and those without drug caps (n = 1133) before the policy change. Our primary outcome measures were the proportion of patients with any antidepressant use per month and the mean standardized monthly doses (SMDs) of antidepressants per month.The removal of drug caps in strict drug cap states was associated with a sudden increase in the proportion of patients treated for depression (4 percentage points; 95% CI, 0.03-0.05, P < 0.0001) and in the intensity of antidepressant use (SMD: 0.05; 95% CI, 0.03-0.07, P < 0.001). Although antidepressant treatment rates increased for both white and black patients, the white-black treatment gap increased immediately after Part D (0.04 percentage points; 95% CI, 0.01-0.08) and grew over time (0.04 percentage points per month; 95% CI, 0.002-0.01; P < 0.001).Policies that remove financial barriers to medications may increase depression treatment rates among patients with diabetes overall while exacerbating treatment disparities. Tailored outreach may be needed to address nonfinancial barriers to mental health services use among black patients with diabetes.
View details for DOI 10.1016/j.clinthera.2014.12.011
View details for Web of Science ID 000353252300014
View details for PubMedID 25620439
View details for PubMedCentralID PMC4390474
Changes in Drug Coverage Generosity and Untreated Serious Mental Illness Transitioning From Medicaid to Medicare Part D
2015; 72 (2): 179–88
More than 1 in 5 disabled people with dual Medicare-Medicaid enrollment have schizophrenia or a bipolar disorder (ie, a serious mental illness). The effect of their transition from Medicaid drug coverage, which varies in generosity across states, to the Medicare Part D drug benefit is unknown. Many thousands make this transition annually.To determine the effect of transitioning from Medicaid drug benefits to Medicare Part D on medication use by patients with a serious mental illness and to determine the influence of Medicaid drug caps.In time-series analysis of continuously enrolled patient cohorts (2004-2007), we estimated changes in medication use before and after transitioning to Part D, comparing states that capped monthly prescription fills with states with no prescription limits. We used Medicaid and Medicare claims from a 5% national sample of community-dwelling, nonelderly disabled dual enrollees with schizophrenia (n = 5554) or bipolar disorder (n = 3675).Psychotropic treatments included antipsychotics for schizophrenia and antipsychotics, anticonvulsants, and lithium for bipolar disorder. We measured monthly rates of untreated illness, intensity of treatment, and overall prescription medication use.Prior to Part D, the prevalence of untreated illness among patients with a bipolar disorder was 30.0% in strict-cap states and 23.8% in no-cap states. In strict-cap states, the proportion of untreated patients decreased by 17.2% (relatively) 1 year after Part D, whereas there was no change in the proportion of untreated patients in no-cap states. For patients with schizophrenia, the untreated rate (20.6%) did not change in strict-cap states, yet it increased by 23.3% (from 11.6%) in no-cap states. Overall medication use increased substantially after Part D in strict-cap states: prescription fills were 35.5% higher among patients with a bipolar disorder and 17.7% higher than predicted among schizophrenic patients; overall use in no-cap states was unchanged in both cohorts.The effects of transitioning from Medicaid to Medicare Part D on essential treatment of serious mental illness vary by state. Transition to Part D in states with strict drug benefit limits may reduce rates of untreated illness among patients with bipolar disorders, who have high levels of overall medication use. Access to antipsychotic treatment may decrease after Part D for patients with a serious mental illness living in states with relatively generous uncapped Medicaid coverage.
View details for DOI 10.1001/jamapsychiatry.2014.1259
View details for Web of Science ID 000349452800014
View details for PubMedID 25588123
View details for PubMedCentralID PMC4505620
Associations Between Antidepressant Adherence and Shared Decision-Making, Patient-Provider Trust, and Communication Among Adults with Diabetes: Diabetes Study of Northern California (DISTANCE)
JOURNAL OF GENERAL INTERNAL MEDICINE
2014; 29 (8): 1139–47
Depression and adherence to antidepressant treatment are important clinical concerns in diabetes care. While patient-provider communication patterns have been associated with adherence for cardiometabolic medications, it is unknown whether interpersonal aspects of care impact antidepressant medication adherence.To determine whether shared decision-making, patient-provider trust, or communication are associated with early stage and ongoing antidepressant adherence.Observational new prescription cohort study.Kaiser Permanente Northern California.One thousand five hundred twenty-three adults with type 2 diabetes who completed a survey in 2006 and received a new antidepressant prescription during 2006-2010.Exposures included items based on the Trust in Physicians and Interpersonal Processes of Care instruments and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) communication scale. Measures of adherence were estimated using validated methods with physician prescribing and pharmacy dispensing data: primary non-adherence (medication never dispensed), early non-persistence (dispensed once, never refilled), and new prescription medication gap (NPMG; proportion of time without medication during 12 months after initial prescription).After adjusting for potential confounders, patients' perceived lack of shared decision-making was significantly associated with primary non-adherence (RR = 2.42, p < 0.05), early non-persistence (RR = 1.34, p < 0.01) and NPMG (estimated 5% greater gap in medication supply, p < 0.01). Less trust in provider was significantly associated with early non-persistence (RRs 1.22-1.25, ps < 0.05) and NPMG (estimated NPMG differences 5-8%, ps < 0.01).All patients were insured and had consistent access to and quality of care.Patients' perceptions of their relationships with providers, including lack of shared decision-making or trust, demonstrated strong associations with antidepressant non-adherence. Further research should explore whether interventions for healthcare providers and systems that foster shared decision-making and trust might also improve medication adherence.
View details for DOI 10.1007/s11606-014-2845-6
View details for Web of Science ID 000339874600013
View details for PubMedID 24706097
View details for PubMedCentralID PMC4099457
Changes in Use of Lipid-lowering Medications Among Black and White Dual Enrollees With Diabetes Transitioning From Medicaid to Medicare Part D Drug Coverage
2014; 52 (8): 695–703
The use of lipid-lowering agents is suboptimal among dual enrollees, particularly blacks.To determine whether the removal of restrictive drug caps under Medicare Part D reduced racial differences among dual enrollees with diabetes.An interrupted time series with comparison series design (ITS) cohort study.A total of 8895 black and white diabetes patients aged 18 years and older drawn from a nationally representative sample of fee-for-service dual enrollees (January 2004-December 2007) in states with and without drug caps before Part D.We examined the monthly (1) proportion of patients with any use of lipid-lowering therapies; and (2) intensity of use. Stratification measures included age (less than 65, 65 y and older), race (white vs. black), and sex.At baseline, lipid-lowering drug use was higher in no drug cap states (drug cap: 54.0% vs. nondrug cap: 66.8%) and among whites versus blacks (drug cap: 58.5% vs. 44.9%, no drug cap: 68.4% vs. 61.9%). In strict drug cap states only, Part D was associated with an increase in the proportion with any use [nonelderly: +0.07 absolute percentage points (95% confidence interval, 0.06-0.09), P<0.001; elderly: +0.08 (0.06-0.10), P<0.001] regardless of race. However, we found no evidence of a change in the white-black gap in the proportion of users despite the removal of a significant financial barrier.Medicare Part D was associated with increased use of lipid-lowering drugs, but racial gaps persisted. Understanding non-coverage-related barriers is critical in maximizing the potential benefits of coverage expansions for disparities reduction.
View details for DOI 10.1097/MLR.0000000000000159
View details for Web of Science ID 000339332900005
View details for PubMedID 24988304
View details for PubMedCentralID PMC4135389
Initial Persistence With Antihypertensive Therapies Is Associated With Depression Treatment Persistence, But Not Depression
JOURNAL OF CLINICAL HYPERTENSION
2014; 16 (6): 412–17
The purpose of this study was to examine the relationship between the presence of clinical depression and persistence to drug therapy treatment for depression with early nonpersistence to antihypertensive therapies in a large, diverse cohort of newly treated hypertension patients. Using a hypertension registry at Kaiser Permanente Northern California, the authors conducted a retrospective cohort study of 44,167 adults (18 years and older) with hypertension who were new users of antihypertensive therapy in 2008. We used multivariate logistic regression analysis to model the relationships between the presence of clinical depression and early nonpersistence (defined as failing to refill the first prescription within 90 days after the end of the first fill days' supply) to antihypertensive therapies, controlling for sociodemographic and clinical risk factors. Within the group of 1484 patients who had evidence of clinical depression in the 12 months prior to the initiation of antihypertensive therapy, the authors examined the relationship between drug therapy treatment for depression and 6-month persistence with antidepressant therapy with early nonpersistence with antihypertensive therapies. No association was found between the presence of clinical depression and early nonpersistence to antihypertensive therapies after adjustment for individual demographic and clinical characteristics and neighborhood-level socioeconomic status. However, among the subset of 1484 patients with documented evidence of clinical depression in the 12 months prior to the initiation of antihypertensive therapy, being prescribed and persistence with antidepressant therapy was strongly associated with lower odds of early nonpersistence to antihypertensive medications (odds ratio, 0.64; confidence interval, 0.42-0.96). In an integrated delivery system, the authors found that treatment for depression was associated with higher levels of antihypertensive persistence. Improving quality of depression care in patients with comorbid hypertension may be an important strategy in decreasing cardiovascular disease risk in these patients.
View details for DOI 10.1111/jch.12300
View details for Web of Science ID 000337600400007
View details for PubMedID 24716533
View details for PubMedCentralID PMC4061252
Diabetes care and outcomes for American Indians and Alaska natives in commercial integrated delivery systems: a SUrveillance, PREvention, and ManagEment of Diabetes Mellitus (SUPREME-DM) Study
BMJ OPEN DIABETES RESEARCH & CARE
2014; 2 (1): e000043
To compare cardiovascular disease risk factor testing rates and intermediate outcomes of care between American Indian/Alaska Native (AI/AN) patients with diabetes and non-Hispanic Caucasians enrolled in nine commercial integrated delivery systems in the USA.We used modified Poisson regression models to compare the annual testing rates and risk factor control levels for glycated haemoglobin (HbA1c), low-density lipoprotein cholesterol (LDL-C), and systolic blood pressure (SBP); number of unique diabetes drug classes; insulin use; and oral diabetes drug medication adherence between insured AI/AN and non-Hispanic white adults with diabetes aged ≥18 in 2011.5831 AI/AN patients (1.8% of the cohort) met inclusion criteria. After adjusting for age, gender, comorbidities, insulin use, and geocoded socioeconomic status, AI/AN patients had similar rates of annual HbA1c, LDL-C, and SBP testing, and LDL-C and SBP control, compared with non-Hispanic Caucasians. However, AI/AN patients were significantly more likely to have HbA1c >9% (>74.9 mmol/mol; RR=1.47, 95% CI 1.38 to 1.58), and significantly less likely to adhere to their oral diabetes medications (RR=0.90, 95% CI 0.88 to 0.93) compared with non-Hispanic Caucasians.AI/AN patients in commercial integrated delivery systems have similar blood pressure and cholesterol testing and control, but significantly lower rates of HbA1c control and diabetes medication adherence, compared with non-Hispanic Caucasians. As more AI/ANs move to urban and suburban settings, clinicians and health plans should focus on addressing disparities in diabetes care and outcomes in this population.
View details for DOI 10.1136/bmjdrc-2014-000043
View details for Web of Science ID 000217027600027
View details for PubMedID 25452877
View details for PubMedCentralID PMC4246918
Effects of Medicare Part D on Guideline-Concordant Pharmacotherapy for Bipolar I Disorder Among Dual Beneficiaries
2014; 65 (3): 323-329
In January 2006 insurance coverage for medications shifted from Medicaid to Medicare Part D private drug plans for the six million individuals enrolled in both programs. Dual beneficiaries faced new formularies and utilization management policies. It is unclear whether Part D, compared with Medicaid, relaxed or tightened psychiatric medication management, which could affect receipt of recommended pharmacotherapy, and emergency department use related to treatment discontinuities. This study examined the impact of the transition from Medicaid to Part D on guideline-concordant pharmacotherapy for bipolar I disorder and emergency department use.Using interrupted-time-series analysis and Medicaid and Medicare administrative data from 2004 to 2007, the authors analyzed the effect of the coverage transition on receipt of guideline-concordant antimanic medication, guideline-discordant antidepressant monotherapy, and emergency department visits for a nationally representative continuous cohort of 1,431 adults with diagnosed bipolar I disorder.Sixteen months after the transition to Part D, the proportion of the population with any recommended use of antimanic drugs was an estimated 3.1 percentage points higher than expected once analyses controlled for baseline trends. The monthly proportion of beneficiaries with seven or more days of antidepressant monotherapy was 2.1 percentage points lower than expected. The number of emergency department visits per month temporarily increased by 19% immediately posttransition.Increased receipt of guideline-concordant pharmacotherapy for bipolar I disorder may reflect relatively less restrictive management of antimanic medications under Part D. The clinical significance of the change is unclear, given the small effect sizes. However, increased emergency department visits merit attention for the Medicaid beneficiaries who continue to transition to Part D.
View details for DOI 10.1176/appi.ps.201300123
View details for Web of Science ID 000332048500009
View details for PubMedID 24337444
View details for PubMedCentralID PMC4038978
Health Literacy and Antidepressant Medication Adherence Among Adults with Diabetes: The Diabetes Study of Northern California (DISTANCE)
JOURNAL OF GENERAL INTERNAL MEDICINE
2013; 28 (9): 1181–87
Previous studies have reported that health literacy limitations are associated with poorer disease control for chronic conditions, but have not evaluated potential associations with medication adherence.To determine whether health literacy limitations are associated with poorer antidepressant medication adherence.Observational new prescription cohort follow-up study.Adults with type 2 diabetes who completed a survey in 2006 and received a new antidepressant prescription during 2006-2010 (N = 1,366) at Kaiser Permanente Northern California.Validated three-item self-report scale measured health literacy. Discrete indices of adherence based on pharmacy dispensing data according to validated methods: primary non-adherence (medication never dispensed); early non-persistence (dispensed once, never refilled); non-persistence at 180 and 365 days; and new prescription medication gap (NPMG; proportion of time that the person is without medication during 12 months after the prescription date).Seventy-two percent of patients were classified as having health literacy limitations. After adjusting for sociodemographic and clinical covariates, patients with health literacy limitations had significantly poorer adherence compared to patients with no limitations, whether measured as early non-persistence (46 % versus 38 %, p < 0.05), non-persistence at 180 days (55 % versus 46 %, p < 0.05), or NPMG (41 % versus 36%, p < 0.01). There were no significant associations with primary adherence or non-persistence at 365 days.Poorer antidepressant adherence among adults with diabetes and health literacy limitations may jeopardize the continuation and maintenance phases of depression pharmacotherapy. Findings underscore the importance of national efforts to address health literacy, simplify health communications regarding treatment options, improve public understanding of depression treatment, and monitor antidepressant adherence.
View details for DOI 10.1007/s11606-013-2402-8
View details for Web of Science ID 000323254700018
View details for PubMedID 23512335
View details for PubMedCentralID PMC3744297
- The Top Patient Safety Strategies That Can Be Encouraged for Adoption Now ANNALS OF INTERNAL MEDICINE 2013; 158 (5): 365-+
Elevated Rates of Diabetes in Pacific Islanders and Asian Subgroups The Diabetes Study of Northern California (DISTANCE)
2013; 36 (3): 574-579
We estimated the prevalence and incidence of diabetes among specific subgroups of Asians and Pacific Islanders (APIs) in a multiethnic U.S. population with uniform access to care.This prospective cohort analysis included 2,123,548 adult members of Kaiser Permanente Northern California, including 1,704,363 with known race/ethnicity (white, 56.9%; Latino, 14.9%; African American, 8.0%; Filipino, 4.9%; Chinese, 4.0%; multiracial, 2.8%; Japanese, 0.9%; Native American, 0.6%; Pacific Islander, 0.5%; South Asian, 0.4%; and Southeast Asian, Korean, and Vietnamese, 0.1% each). We calculated age-standardized (to the 2010 U.S. population) and sex-adjusted diabetes prevalence at baseline and incidence (during the 2010 calendar year). Poisson models were used to estimate relative risks.There were 210,632 subjects with prevalent diabetes as of 1 January 2010 and 15,357 incident cases of diabetes identified during 2010. The crude diabetes prevalence was 9.9% and the incidence was 8.0 cases per 1,000 person-years and, after standardizing by age and sex to the 2010 U.S. Census, 8.9% and 7.7 cases per 1,000 person-years. There was considerable variation among the seven largest API subgroups. Pacific Islanders, South Asians, and Filipinos had the highest prevalence (18.3, 15.9, and 16.1%, respectively) and the highest incidence (19.9, 17.2, and 14.7 cases per 1,000 person-years, respectively) of diabetes among all racial/ethnic groups, including minorities traditionally considered high risk (e.g., African Americans, Latinos, and Native Americans).High rates of diabetes among Pacific Islanders, South Asians, and Filipinos are obscured by much lower rates among the large population of Chinese and several smaller Asian subgroups.
View details for DOI 10.2337/dc12-0722
View details for Web of Science ID 000315928700024
View details for PubMedID 23069837
View details for PubMedCentralID PMC3579366
Health System Factors and Antihypertensive Adherence in a Racially and Ethnically Diverse Cohort of New Users
JAMA INTERNAL MEDICINE
2013; 173 (1): 54–61
The purpose of this study was to identify potential health system solutions to suboptimal use of antihypertensive therapy in a diverse cohort of patients initiating treatment.Using a hypertension registry at Kaiser Permanente Northern California, we conducted a retrospective cohort study of 44 167 adults (age, ≥18 years) with hypertension who were new users of antihypertensive therapy in 2008. We used multivariate logistic regression analysis to model the relationships between race/ethnicity, specific health system factors, and early nonpersistence (failing to refill the first prescription within 90 days) and nonadherence (<80% of days covered during the 12 months following the start of treatment), respectively, controlling for sociodemographic and clinical risk factors.More than 30% of patients were early nonpersistent and 1 in 5 were nonadherent to therapy. Nonwhites were more likely to exhibit both types of suboptimal medication-taking behavior compared with whites. In logistic regression models adjusted for sociodemographic, clinical, and health system factors, nonwhite race was associated with early nonpersistence (black: odds ratio, 1.56 [95% CI, 1.43-1.70]; Asian: 1.40 [1.29-1.51]; Hispanic: 1.46 [1.35-1.57]) and nonadherence (black: 1.55 [1.37-1.77]; Asian: 1.13 [1.00-1.28]; Hispanic: 1.46 [1.31-1.63]). The likelihood of early nonpersistence varied between Asians and Hispanics by choice of first-line therapy. In addition, racial and ethnic differences in nonadherence were appreciably attenuated when medication co-payment and mail-order pharmacy use were accounted for in the models.Racial/ethnic differences in medication-taking behavior occur early in the course of treatment. However, health system strategies designed to reduce patient co-payments, ease access to medications, and optimize the choice of initial therapy may be effective tools in narrowing persistent gaps in the use of these and other clinically effective therapies.
View details for DOI 10.1001/2013.jamainternmed.955
View details for Web of Science ID 000317238800013
View details for PubMedID 23229831
View details for PubMedCentralID PMC5105889
Differences in the clinical recognition of depression in diabetes patients: the Diabetes Study of Northern California (DISTANCE).
The American journal of managed care
2013; 19 (5): 344–52
It is unknown to what extent the gap between need and care for depression among patients with diabetes differs across racial/ethnic groups. We compared, by race/ethnicity, the likelihood of clinical recognition of depression (diagnosis or treatment) of patients who reported depressive symptoms in a well-characterized community-based population with diabetes.We used a survey follow-up study of 20,188 patients with diabetes from Kaiser Permanente Northern California. Analyses were limited to 910 patients who scored 10 or higher on the Patient Health Questionnaire (PHQ-8) which was included in the survey and who had no clinical recognition of depression in the 12 months prior to survey. Clinical recognition of depression was defined by a depression diagnosis, referral to mental health services, or antidepressant medication prescription.Among the 910 patients reporting moderate to severe depressive symptoms on the survey and who had no clinical recognition in the prior year, 12%, 8%, 8%, 14%, and 15% of African American, Asian, Filipino, Latino, and white patients, respectively, were clinically recognized for depression in the subsequent 12 months. After adjusting for sociodemographics, limited English proficiency, and depressive symptom severity, racial/ethnic minorities were less likely to be clinically recognized for depression compared with whites (relative risk: Filipino: 0.30, African American: 0.62).More work is needed to understand the modifiable patient and provider factors that influence clinical recognition of depression among diabetes patients from different racial/ethnic groups, and the potential impact of low rates of clinical recognition on quality of care.
View details for PubMedID 23781889
View details for PubMedCentralID PMC3703822
Health-Plan and Employer-Based Wellness Programs to Reduce Diabetes Risk: The Kaiser Permanente Northern California NEXT-D Study
PREVENTING CHRONIC DISEASE
2013; 10: E15
Primary prevention of diabetes is increasingly recognized by both health plans and employers as an important strategy to improve the health of insured populations. As a part of the Natural Experiments in Translation for Diabetes (NEXT-D) network, the Kaiser Permanente Northern California (KPNC) Division of Research is assessing the effectiveness of 2 health plan-initiated programs to prevent the onset of diabetes in patients at high risk. The first study evaluates a telephonic health-coaching program that provides counseling on healthful eating, active living, and weight loss to KPNC members. The second evaluation examines a postpartum glucose screening and educational diabetes prevention program for women with gestational diabetes mellitus that KPNC implemented in 2006. Identifying effective approaches to preventing diabetes will be of value to health care systems, policy makers, and public health officials seeking to understand the roles systems and employers can play in preventing chronic illness.
View details for DOI 10.5888/pcd10.120146
View details for Web of Science ID 000329388600015
View details for PubMedID 23369768
View details for PubMedCentralID PMC3562174
Symptom Burden of Adults with Type 2 Diabetes Across the Disease Course: Diabetes & Aging Study
JOURNAL OF GENERAL INTERNAL MEDICINE
2012; 27 (12): 1674-1681
Reducing symptom burden is paramount at the end-of-life, but typically considered secondary to risk factor control in chronic disease, such as diabetes. Little is known about the symptom burden experienced by adults with type 2 diabetes and the need for symptom palliation.To examine pain and non-pain symptoms of adults with type 2 diabetes over the disease course - at varying time points before death and by age.Survey follow-up study.13,171 adults with type 2 diabetes, aged 30-75 years, from Kaiser Permanente, Northern California, who answered a baseline symptom survey in 2005-2006.Pain and non-pain symptoms were identified by self-report and medical record data. Survival status from baseline was categorized into ≤ 6, >6-24, or alive >24 months.Mean age was 60 years; 48 % were women, and 43 % were non-white. Acute pain was prevalent (41.8 %) and 39.7 % reported chronic pain, 24.6 % fatigue, 23.7 % neuropathy, 23.5 % depression, 24.2 % insomnia, and 15.6 % physical/emotional disability. Symptom burden was prevalent in all survival status categories, but was more prevalent among those with shorter survival, p< .001. Adults ≥ 60 years who were alive >24 months reported more physical symptoms such as acute pain and dyspnea, whereas participants <60 years reported more psychosocial symptoms, such as depressed mood and insomnia. Adjustment for duration of diabetes and comorbidity reduced the association between age and pain, but did not otherwise change our results.In a diverse cohort of adults with type 2 diabetes, pain and non-pain symptoms were common among all patients, not only among those near the end of life. However, symptoms were more prevalent among patients with shorter survival. Older adults reported more physical symptoms, whereas younger adults reported more psychosocial symptoms. Diabetes care management should include not only good cardiometabolic control, but also symptom palliation across the disease course.
View details for DOI 10.1007/s11606-012-2132-3
View details for Web of Science ID 000312072200017
View details for PubMedID 22854982
View details for PubMedCentralID PMC3509316
Medicare Part D and Changes in Prescription Drug Use and Cost Burden National Estimates for the Medicare Population, 2000 to 2007
2011; 49 (9): 834-841
The full effect of Medicare Part D, after the initial policy transition period and across the United States Medicare population, remains unclear.To estimate nationally representative changes in prescription drug use and out-of-pocket drug costs 2 years after implementation of Part D.We examined study outcomes over 8 years (2000 to 2007) and estimated changes after Part D, accounting for earlier trends. Our analyses used the community-dwelling sample of the Medicare Current Beneficiary Survey (unweighted unique n=38,798). Actual post-Part D outcomes were compared with projected values using 2000 to 2005 data. Subgroup analyses and standardization weights were used to address population-level shifts over time in health status and demographic characteristics.Annual prescription drug fills and out-of-pocket drug costs.We observed significant average per person increases of 1.8 prescription fills [95% confidence interval (CI), 1.1-2.5] in 2006 and 3.4 prescription fills (95% CI, 2.7-4.1) in 2007 above pre-Part D increases of 0.9 prescription fills per year. Average out-of-pocket drug costs decreased significantly by $143 (95% CI, -182.5--103.1) in 2006 and $148 (95% CI, -181.2--114.1) in 2007 above average pre-Part D increases of $12 per year. Prescription fills did not change for beneficiaries with fair to poor health until 2007 when large increases occurred (increases of 3.7 to 11.0 fills above pre-Part D trends). Significant reductions in OOP drug costs occurred in 2006 and persisted into 2007 across all groups except for sick and poor beneficiaries without Medicaid.After the transition year of 2006, the impact of Part D seemed larger and more consistent across the Medicare population. Of note, sick and poor beneficiaries experienced significant improvements in prescription drug use in 2007.
View details for DOI 10.1097/MLR.0b013e3182162afb
View details for Web of Science ID 000294206700013
View details for PubMedID 21544002
View details for PubMedCentralID PMC3151472
Racial and Ethnic Disparities in Postpartum Depression Care Among Low-Income Women
2011; 62 (6): 619-625
The goal of this study was to characterize racial-ethnic differences in mental health care utilization associated with postpartum depression in a multiethnic cohort of Medicaid recipients.In a retrospective cohort study, administrative claims data from New Jersey's Medicaid program were obtained for 29,601 women (13,001 whites, 13,416 blacks, and 3,184 Latinas) who delivered babies between July 2004 and October 2007. Racial-ethnic differences were estimated with logistic regression for initiation of antidepressant medication or outpatient mental health visits within six months of delivery, follow-up (a prescription refill or second visit), and continued mental health care (at least three visits or three filled antidepressant prescriptions within 120 days).Nine percent (N=1,120) of white women initiated postpartum mental health care, compared with 4% (N=568) of black women and 5% (N=162) of Latinas. With analyses controlling for clinical factors, the odds of initiating treatment after delivery were significantly (p<.001) lower for blacks (adjusted odds ratio [AOR]=.43) and Latinas (AOR=.59) compared with whites. Among those who initiated treatment, blacks and Latinas were less likely than whites to receive follow-up treatment (blacks, AOR=.66, p<.001; Latinas, AOR=.67, p<.05) or continued care (blacks, AOR=.81, p=.069; Latinas, AOR=.67, p<.05). Among those who initiated antidepressant treatment, black women and Latinas were less likely than whites to refill a prescription.There were significant racial-ethnic differences in depression-related mental health care after delivery. Suboptimal treatment was prevalent among all low-income women in the study. However, racial and ethnic disparities in the initiation and continuation of postpartum depression care were particularly troubling and warrant clinical and policy attention.
View details for DOI 10.1176/appi.ps.62.6.619
View details for Web of Science ID 000291406600009
View details for PubMedID 21632730
View details for PubMedCentralID PMC3733216
Advancing the Science of Patient Safety
ANNALS OF INTERNAL MEDICINE
2011; 154 (10): 693-W248
Despite a decade's worth of effort, patient safety has improved slowly, in part because of the limited evidence base for the development and widespread dissemination of successful patient safety practices. The Agency for Healthcare Research and Quality sponsored an international group of experts in patient safety and evaluation methods to develop criteria to improve the design, evaluation, and reporting of practice research in patient safety. This article reports the findings and recommendations of this group, which include greater use of theory and logic models, more detailed descriptions of interventions and their implementation, enhanced explanation of desired and unintended outcomes, and better description and measurement of context and of how context influences interventions. Using these criteria and measuring and reporting contexts will improve the science of patient safety.
View details for DOI 10.1059/0003-4819-154-10-201105170-00011
View details for Web of Science ID 000290620300019
View details for PubMedID 21576538
Heterogeneity of Diabetes Outcomes Among Asians and Pacific Islanders in the US The Diabetes Study of Northern California (DISTANCE)
2011; 34 (4): 930-937
Ethnic minorities with diabetes typically have lower rates of cardiovascular outcomes and higher rates of end-stage renal disease (ESRD) compared with whites. Diabetes outcomes among Asian and Pacific Islander subgroups have not been disaggregated.We performed a prospective cohort study (1996-2006) of patients enrolled in the Kaiser Permanente Northern California Diabetes Registry. There were 64,211 diabetic patients, including whites (n = 40,286), blacks (n = 8,668), Latinos (n = 7,763), Filipinos (n = 3,572), Chinese (n = 1,823), Japanese (n = 951), Pacific Islanders (n = 593), and South Asians (n = 555), enrolled in the registry. We calculated incidence rates (means ± SD; 7.2 ± 3.3 years follow-up) and created Cox proportional hazards models adjusted for age, educational attainment, English proficiency, neighborhood deprivation, BMI, smoking, alcohol use, exercise, medication adherence, type and duration of diabetes, HbA(1c), hypertension, estimated glomerular filtration rate, albuminuria, and LDL cholesterol. Incidence of myocardial infarction (MI), congestive heart failure, stroke, ESRD, and lower-extremity amputation (LEA) were age and sex adjusted.Pacific Islander women had the highest incidence of MI, whereas other ethnicities had significantly lower rates of MI than whites. Most nonwhite groups had higher rates of ESRD than whites. Asians had ~60% lower incidence of LEA compared with whites, African Americans, or Pacific Islanders. Incidence rates in Chinese, Japanese, and Filipinos were similar for most complications. For the three macrovascular complications, Pacific Islanders and South Asians had rates similar to whites.Incidence of complications varied dramatically among the Asian subgroups and highlights the value of a more nuanced ethnic stratification for public health surveillance and etiologic research.
View details for DOI 10.2337/dc10-1964
View details for Web of Science ID 000289221800025
View details for PubMedID 21350114
View details for PubMedCentralID PMC3064053
New Jersey's Efforts To Improve Postpartum Depression Care Did Not Change Treatment Patterns For Women On Medicaid
2011; 30 (2): 293-301
Identification and treatment of postpartum depression are the increasing focus of state and national legislation, including portions of the Affordable Care Act. Some state policies and proposals are modeled directly on programs in New Jersey, the first state to require universal screening for postpartum depression among mothers who recently delivered babies. We examined the impact of these policies on a particularly vulnerable population, Medicaid recipients, and found that neither the required screening nor the educational campaign that preceded it was associated with improved treatment initiation, follow-up, or continued care. We argue that New Jersey's policies, although well intentioned, were predicated on an inadequate base of evidence and that efforts should now be undertaken to build that base. We also argue that to improve detection and treatment, policy makers contemplating or implementing postpartum depression mandates should consider additional measures. These could include requiring mechanisms to monitor and enforce the screening requirement; paying providers to execute screening and follow-up; and preliminary testing of interventions before policy changes are enacted.
View details for DOI 10.1377/hlthaff.2009.1075
View details for Web of Science ID 000286883900014
View details for PubMedID 21289351
View details for PubMedCentralID PMC3736568
Association Between Prior Authorization for Medications and Health Service Use by Medicaid Patients With Bipolar Disorder
2011; 62 (2): 186-193
This study examined the association between a Medicaid prior-authorization policy for second-generation antipsychotic and anticonvulsant agents and medication discontinuation and health service use by patients with bipolar disorder.A pre-post design with a historical comparison group was used to analyze Maine Medicaid and Medicare claims data. A total of 946 newly treated patients were identified during the eight-month policy (July 2003-February 2004), and a comparison group of 1,014 was identified from the prepolicy period (July 2002-February 2003). Patients were stratified by number of visits to community mental health centers (CMHCs) before medication initiation (proxy for illness severity): CMHC attenders, at least two visits; nonattenders, fewer than two. Changes in rates of medication discontinuation and outpatient, emergency room, and hospital visits were estimated.Compared with nonattenders, at baseline CMHC attenders had substantially higher rates of comorbid mental disorders and use of medications and health services. The policy was associated with increased medication discontinuation among attenders and nonattenders, reductions in mental health visits after discontinuation among attenders (-.64 per patient per month; p<.05), and increases in emergency room visits after discontinuation among nonattenders (.16 per patient per month; p<.05). During the eight-month policy period, the policy had no detectable impact on hospitalization risk.The prior-authorization policy was associated with increased medication discontinuation and subsequent changes in health service use. Although small, these unintended effects raise concerns about quality of care for a group of vulnerable patients. Long-term consequences of prior-authorization policies on patient outcomes warrant further investigation.
View details for DOI 10.1176/appi.ps.62.2.186
View details for Web of Science ID 000286809500012
View details for PubMedID 21285097
View details for PubMedCentralID PMC3053119
Adherence to laboratory test requests by patients with diabetes: the Diabetes Study of Northern California (DISTANCE).
The American journal of managed care
2011; 17 (5): 339–44
To estimate rates and predictors of clinical laboratory test completion by patients with diabetes after provider referral.Prospective cohort study.Among 186,306 adult members with diabetes in Kaiser Permanente Northern California, we searched the electronic medical records (July 1, 2008, to June 30, 2009) of each patient for the first outpatient order to obtain the following laboratory tests commonly used to measure risk factor control or adverse effects of pharmacotherapy: levels of glycosylated hemoglobin, low density lipoprotein cholesterol, serum creatinine, urinary albumin, or creatine kinase (the latter only among persons using statins). We measured laboratory test attendance as completion of an order (including time to results) within 6 months of the referral date and looked for variations by subgroups.Laboratory test attendance ranged from 86% for glycosylated hemoglobin level to 73% for serum creatinine level. Time to laboratory test attendance was a median of 7 to 11 days and a mean of 25 to 30 days. Laboratory test attendance was more likely for women and older patients or for orders after a face-to-face provider visit and was less likely for orders by a pharmacist. However, most variations (even by laboratory copayment) were small or not clinically substantive. In subanalyses, we observed no clinically significant variations by race/ethnicity, socioeconomic status, trust in provider, or patient-provider communication and found no association with depressive symptoms, health literacy, or English fluency.The fact that 1 in 7 patients did not complete laboratory tests within 6 months of the provider referral may help explain why healthcare services seem to fall short of optimal diabetes care.
View details for PubMedID 21718081
View details for PubMedCentralID PMC3189790
Impact of Prior Authorization on the Use and Costs of Lipid-Lowering Medications Among Michigan and Indiana Dual Enrollees in Medicaid and Medicare: Results of a Longitudinal, Population-Based Study
2011; 33 (1): 135-144
Some Medicaid programs have adopted prior-authorization (PA) policies that require prescribers to request approval from Medicaid before prescribing drugs not included on a preferred drug list.This study examined the association between PA policies for lipid-lowering agents in Michigan and Indiana and the use and cost of this drug class among dual enrollees in Medicare and Medicaid.Michigan and Indiana claims data from the Centers for Medicare and Medicaid Services were assessed. Michigan Medicaid instituted a PA requirement for several lipid-lowering medications in March 2002; Indiana implemented a PA policy for drugs in this class in September 2002. Although the PA policies affected some statins, they predominantly targeted second-line treatments, including bile acid sequestrants, fibrates, and niacins. Individuals aged ≥18 years who were continuously dually enrolled in both Medicare and Medicaid from July 2000 through September 2003 were included in this longitudinal, population-based study, which included a 20-month observation period before the implementation of PA in Michigan and a 12-month follow-up period after the Indiana PA policy was initiated. Interrupted time series analysis was used to examine changes in prescription rates and pharmacy costs for lipid-lowering drugs before and after policy implementation.A total of 38,684 dual enrollees in Michigan and 29,463 in Indiana were included. Slightly more than half of the cohort were female (Michigan, 53.3% [20,614/38,684]; Indiana, 56.3% [16,595/29,463]); nearly half were aged 45 to 64 years (Michigan, 43.7% [16,921/38,684]; Indiana, 45.2% [13,321/29,463]). Most subjects were white (Michigan, 77.4% [29,957/38,684]; Indiana: 84.9% [25,022/29,463]). The PA policy was associated with an immediate 58% reduction in prescriptions for nonpreferred medications in Michigan and a corresponding increase in prescriptions for preferred agents. However, the PA policy had no apparent effect in Indiana, where there had been little use of nonpreferred medications before the policy was implemented (3.3%). The policies were associated with an immediate reduction of $24,548 in prescription expenditures in Michigan and an immediate reduction of $16,070 in Indiana.The PA policy was associated with substantially lower use of nonpreferred lipid-lowering drugs in Michigan, offset by increases in the use of preferred medications, but there was less change in Indiana. Data limitations did not permit the evaluation of the impact of policy-induced switching on clinical outcomes such as cholesterol levels. The monetary benefit of PA policies for lipid-lowering agents should be weighed against administrative costs and the burden on patients and health care providers.
View details for DOI 10.1016/j.clinthera.2011.01.012
View details for Web of Science ID 000288924800011
View details for PubMedID 21397779
View details for PubMedCentralID PMC3980661
- Primary Non-adherence to Prescribed Medications JOURNAL OF GENERAL INTERNAL MEDICINE 2010; 25 (8): 763
Impact of Two Medicaid Prior-Authorization Policies on Antihypertensive Use and Costs Among Michigan and Indiana Residents Dually Enrolled in Medicaid and Medicare: Results of a Longitudinal, Population-Based Study
2010; 32 (4): 729-741
In response to rising pharmaceutical costs, many state Medicaid programs have implemented policies requiring prior authorization for high-cost medications, even for established users. However, little is known about the impact of these policies on the use of antihypertensive medicines in the United States.The aim of this longitudinal, population-based study was to assess comprehensive prior-authorization programs for antihypertensives on drug use and costs in a vulnerable Medicaid population in Michigan and Indiana.A prior-authorization policy for antihypertensives was implemented in Michigan in March 2002 and in Indiana in September 2002; Indiana also implemented an antihypertensive stepwise-therapy requirement in July 2003. Our study cohort included individuals aged >or=18 years in Michigan and Indiana who were continuously enrolled in both Medicaid and Medicare from July 2000 through September 2003. Claims data were obtained from the Centers for Medicare and Medicaid Services. We included all antihypertensive medications, including diuretics, angiotensin-converting enzyme inhibitors, calcium channel blockers, beta-blockers, alpha-blockers, and angiotcnsin II receptor blockers. We used interrupted time-series analysis to study policy-related changes in the total number and cost of antihypertensive prescriptions.Overall, 38,684 enrollees in Michigan and 29,463 in Indiana met our inclusion criteria. Slightly more than half of our cohort in both states was female (53.29%in Michigan and 56.32%in Indiana). In Michigan, 20.23% of patients were aged >or=65 years; 77.44% were white, 20.11% were black, and the remainder were Hispanic, Native American, Asian, or of other or unknown race. In Indiana, 20.07% were aged >or=65 years; 84.93% were white, 13.64% were black, and the remainder were Hispanic, Native American, Asian, or of other or unknown race. The implementation of both policies was associated with large and immediate reductions in the use of nonpreferred medications: 83.33% reduction in the use of such drugs in Michigan (-84.30 prescriptions per 1000 enrollees per month; P < 0.001) and 35.76% in Indiana (-64.45 prescriptions per 1000 enrollees per month; P < 0.001). As expected, use of preferred medications also increased substantially in both states (P < 0.001). Overall, antihypertensive therapy immediately dropped 0.16% in Michigan (P = 0.04) and 1.82% in Indiana (P = 0.02). Implementation of the policies was also associated with reductions in pharmacy reimbursement of $616,572.43 in Michigan and $868,265.97 in Indiana in the first postpolicy year.Prior authorization was associated with lower use of nonpreferred antihypertensive drugs that was largely offset by increases in the use of preferred drugs. The possible clinical consequences of policy-induced drug switching for individual patients remain unknown because the present study did not include access to medical record data. Further research is needed to establish whether large-scale switches in medicines following the inception of prior-authorization policies have any long-term health effects.
View details for DOI 10.1016/j.clinthera.2010.04.007
View details for Web of Science ID 000277486600013
View details for PubMedID 20435243
View details for PubMedCentralID PMC3844690
Use of well-child visits in high-deductible health plans.
The American journal of managed care
2010; 16 (11): 833–40
To examine how enrollment in high-deductible health plans (HDHPs) affects use of well-child visits relative to traditional plans, when preventive care is exempt from the deductible.Pre-post comparison between groups.We selected children aged <18 years enrolled in a large Massachusetts health plan through employers offering only 1 type of plan. Children were in traditional plans for a 12-month baseline period between 2001 and 2004, then were either switched by a decision of the parent's employer to an HDHP or kept in the traditional plan (controls) for a 12-month follow-up period. Preventive and other office visits were exempt from the deductible and subject to copayments, as in traditional plans. The primary outcome was whether the child received well-child visits recommended for the 12-month period. Using generalized linear mixed models, we compared the change in receipt of recommended well-child visits between baseline and follow-up for the HDHP group relative to controls.We identified 1598 children who were switched to HDHPs and 10,093 controls. Between baseline and follow-up, the mean proportion of recommended well-child visits received by HDHP children decreased slightly from 0.846 to 0.841, and from 0.861 to 0.855 for controls. In adjusted models, there was no significant difference in the change in probability that recommended well-child visits were received by HDHP children compared with controls (P = .69).Receipt of recommended well-child visits did not change for children switching from traditional plans to HDHPs that exempt preventive care from the deductible.
View details for PubMedID 21348554
View details for PubMedCentralID PMC3984915
Unintended Impacts of a Medicaid Prior Authorization Policy on Access to Medications for Bipolar Illness
2010; 48 (1): 4-9
Prior authorization policies (PA) are widely used to control psychotropic medication costs by state Medicaid programs and Medicare Part D plans. The objective of this study was to examine the impact of a Maine Medicaid PA policy on initiation and switching of anticonvulsant and atypical antipsychotic treatments among patients with bipolar disorder.We obtained Maine and New Hampshire (comparison state) Medicaid and Medicare claims data for 2001 to 2004; the Maine PA policy was implemented in July 2003. Among continuously enrolled patients with bipolar disorder (Maine: n = 5336; New Hampshire: n = 1376), we used an interrupted times series with comparison group design to estimate changes in rates of initiating new episodes of bipolar treatment and generalized estimating equations models to examine rates of switching therapies among patients under treatment.The Maine PA policy was associated with a marked decrease in rates of initiation of bipolar treatments; a relative reduction of 32.3% (95% CI: 24.8, 39.9) compared with expected rates at 4 months after policy implementation. This decrease was driven primarily by reductions in the initiation of nonpreferred agents. The policy had no discernable impact on rates of switching therapy among patients currently on treatment (RR: 1.03; 95% CI: 0.76, 1.39).The findings of this study provide evidence that PA implementation can be a barrier to initiation of nonpreferred agents without offsetting increases in initiation of preferred agents, which is a major concern. There is a critical need to evaluate the possible unintended effects of PA policies to achieve optimal health outcomes among low-income patients with chronic mental illness. In addition, more research is needed to understand how these barriers arise and whether specific seriously mentally ill populations or drug classes should be exempted from PA policies.
View details for DOI 10.1097/MLR.0b013e3181bd4c10
View details for Web of Science ID 000273149500002
View details for PubMedID 19956079
View details for PubMedCentralID PMC6524522
Costs and Consequences of Direct-to-Consumer Advertising for Clopidogrel in Medicaid
ARCHIVES OF INTERNAL MEDICINE
2009; 169 (21): 1969-1974
Direct-to-consumer advertising (DTCA) is assumed to be a major driver of rising pharmaceutical costs. Yet, research on how it affects costs is limited. Therefore, we studied clopidogrel, a commonly used and heavily marketed antiplatelet agent, which was first sold in 1998 and first direct-to-consumer advertised in 2001.We examined pharmacy data from 27 Medicaid programs from 1999 through 2005. We used interrupted time series analysis to analyze changes in the number of units dispensed, cost per unit dispensed, and total pharmacy expenditures after DTCA initiation.In 1999 and 2000, there was no DTCA for clopidogrel; from 2001 through 2005, DTCA spending exceeded $350 million. Direct-to-consumer advertising did not change the preexisting trend in the number of clopidogrel units dispensed per 1000 enrollees (P = .10). However, there was a sudden and sustained increase in cost per unit of $0.40 after DTCA initiation (95% confidence interval, $0.31-$0.49; P < .001), leading to an additional $40.58 of pharmacy costs per 1000 enrollees per quarter thereafter (95% confidence interval, $22.61-$58.56; P < .001). Overall, this change resulted in an additional $207 million in total pharmacy expenditures.Direct-to-consumer advertising was not associated with an increase in clopidogrel use over and above preexisting trends. However, Medicaid pharmacy expenditures increased substantially after the initiation of DTCA because of a concomitant increase in the cost per unit. If drug price increases after DTCA initiation are common, there are important implications for payers and for policy makers in the United States and elsewhere.
View details for DOI 10.1001/archinternmed.2009.320
View details for Web of Science ID 000272036900007
View details for PubMedID 19933958
The population-level impacts of a national health insurance program and franchise midwife clinics on achievement of prenatal and delivery care standards in the Philippines
2009; 92 (1): 55-64
Adequate prenatal and delivery care are vital components of successful maternal health care provision. Starting in 1998, two programs were widely expanded in the Philippines: a national health insurance program (PhilHealth); and a donor-funded franchise of midwife clinics (Well Family Midwife Clinics). This paper examines population-level impacts of these interventions on achievement of minimum standards for prenatal and delivery care.Data from two waves of the Demographic and Health Surveys, conducted before (1998) and after (2003) scale-up of the interventions, are employed in a pre/post-study design, using longitudinal multivariate logistic and linear regression models.After controlling for demographic and socioeconomic characteristics, the PhilHealth insurance program scale-up was associated with increased odds of receiving at least four prenatal visits (OR 1.04 [95% CI 1.01-1.06]) and receiving a visit during the first trimester of pregnancy (OR 1.03 [95% CI 1.01-1.06]). Exposure to midwife clinics was not associated with significant changes in achievement of prenatal care standards. While both programs were associated with slight increases in the odds of delivery in a health facility, these increases were not statistically significant.These results suggest that expansion of an insurance program with accreditation standards was associated with increases in achievement of minimal standards for prenatal care among women in the Philippines.
View details for DOI 10.1016/j.healthpol.2009.02.009
View details for Web of Science ID 000269273000008
View details for PubMedID 19327862
View details for PubMedCentralID PMC2719679
Prior Authorization for Antidepressants in Medicaid Effects Among Disabled Dual Enrollees
ARCHIVES OF INTERNAL MEDICINE
2009; 169 (8): 750-756
Prior authorization is a popular, but understudied, strategy for reducing medication costs. We evaluated the impact of a controversial prior authorization policy in Michigan Medicaid on antidepressant use and health outcomes among dual Medicaid and Medicare enrollees with a Social Security Disability Insurance designation of permanent disability.We linked Medicaid and Medicare (2000-2003) claims for dual enrollees in Michigan and a comparison state, Indiana. Using interrupted time-series and longitudinal data analysis, we estimated the impact of the policy on antidepressant medication use, treatment initiation, disruptions in therapy, and adverse health events among continuously enrolled (Michigan, n = 28 798; Indiana, n = 21 769) and newly treated (Michigan, n = 3671; Indiana, n = 2400) patients.In Michigan, the proportion of patients starting nonpreferred agents declined from 53% prepolicy to 20% postpolicy. The prior authorization policy was associated with a small sustained decrease in therapy initiation overall (9 per 10,000 population; P = .007). We also observed a short-term increase in switching among established users of nonpreferred agents overall (risk ratio, 2.88; 95% confidence interval, 1.87-4.42) and among those with depression (2.04; 1.22-3.42). However, we found no evidence of increased disruptions in treatment or adverse events (ie, hospitalization, emergency department use) among newly treated patients.Prior authorization was associated with increased use of preferred agents with no evidence of disruptions in therapy or adverse health events among new users. However, unintended effects on treatment initiation and switching among patients already taking the drug were also observed, lending support to the state's previous decision to discontinue prior approval for antidepressants in 2003.
View details for DOI 10.1001/archinternmed.2009.39
View details for Web of Science ID 000265540500004
View details for PubMedID 19398686
View details for PubMedCentralID PMC2681242
Effects of Prior Authorization on Medication Discontinuation Among Medicaid Beneficiaries With Bipolar Disorder
2009; 60 (4): 520-527
Few data exist on the cost and quality effects of increased use of prior-authorization policies to control psychoactive drug spending among persons with serious mental illness. This study examined the impact of a prior-authorization policy in Maine on second-generation antipsychotic and anticonvulsant utilization, discontinuations in therapy, and pharmacy costs among Medicaid beneficiaries with bipolar disorder.Using Medicaid and Medicare utilization data for 2001-2004, the authors identified 5,336 patients with bipolar disorder in Maine (study state) and 1,376 in New Hampshire (comparison state). With an interrupted time-series and comparison group design, longitudinal changes were measured in second-generation antipsychotic and anticonvulsant use; survival analysis was used to examine treatment discontinuations and rates of switching medications.The prior-authorization policy resulted in an 8-percentage point reduction in the prevalence of use of nonpreferred second-generation antipsychotic and anticonvulsant medications (those requiring prior authorization) but did not increase use of preferred agents (no prior authorization) or rates of switching. The prior-authorization policy reduced total pharmacy reimbursements for bipolar disorder by $27 per patient during the eight-month policy period. However, the hazard rate of treatment discontinuation (all bipolar drugs) while the policy was in effect was 2.28 (95% confidence interval=1.36-4.33) higher than during the prepolicy period, with adjustment for trends in the comparison state.The small reduction in pharmacy spending for bipolar treatment after the policy was implemented may have resulted from higher rates of medication discontinuation rather than switching. The findings indicate that the prior-authorization policy in Maine may have increased patient risk without appreciable cost savings to the state.
View details for DOI 10.1176/ps.2009.60.4.520
View details for Web of Science ID 000264793500017
View details for PubMedID 19339328
View details for PubMedCentralID PMC6498839
Racial differences in long-term adherence to oral antidiabetic drug therapy: a longitudinal cohort study
BMC. 2009: 24
Adherence to oral antidiabetic medications is often suboptimal. Adherence differences may contribute to health disparities for black diabetes patients, including higher microvascular event rates, greater complication-related disability, and earlier mortality.In this longitudinal retrospective cohort study, we used 10 years of patient-level claims and electronic medical record data (1/1/1992-12/31/2001) to assess differences in short- and long-term adherence to oral antidiabetic medication among 1906 newly diagnosed adults with diabetes (26% black, 74% white) in a managed care setting in which all members have prescription drug coverage. Four main outcome measures included: (1) time from diabetes diagnosis until first prescription of oral antidiabetic medication; (2) primary adherence (time from first prescription to prescription fill); (3) time until discontinuation of oral antidiabetic medication from first prescription; and (4) long-term adherence (amount dispensed versus amount prescribed) over a 24-month follow-up from first oral antidiabetic medication prescription.Black patients were as likely as whites to initiate oral therapy and fill their first prescription, but experienced higher rates of medication discontinuation (HR: 1.8, 95% CI: 1.2, 2.7) and were less adherent over time. These black-white differences increased over the first six months of therapy but stabilized thereafter for patients who initiated on sulfonylureas. Significant black-white differences in adherence levels were constant throughout follow-up for patients initiated on metformin therapy.Racial differences in adherence to oral antidiabetic drug therapy persist even with equal access to medication. Early and continued emphasis on adherence from initiation of therapy may reduce persistent racial differences in medication use and clinical outcomes.
View details for DOI 10.1186/1472-6963-9-24
View details for Web of Science ID 000264148700001
View details for PubMedID 19200387
View details for PubMedCentralID PMC2645384
A New Measure of Medication Affordability
SOCIAL WORK IN PUBLIC HEALTH
2009; 24 (6): 600-612
This study developed a new measure of medication affordability that examines out-of-pocket drug expenses relative to available household resources. The authors assessed the spending patterns of approximately 2.1 million poor households (< or =100% federal poverty level) of adults aged 51 and older by Medicaid status. The data were drawn from the 2000-2001 Health and Retirement Study. Household spending was categorized into three broad types: basic living, health care, and discretionary. Older (aged 51 or older) poor households without Medicaid allocated about 72% of their total resources ($17,421, SE $783) to basic living needs. In comparison, those with Medicaid had scarcer total resources ($12,498, SE $423) and allocated 85% to basic living needs. Medication costs consumed the largest proportion of health care expenses for both types of poor households (Medicaid: $463, SE $67; non-Medicaid: $970, SE $102). After paying for basic living needs and health care costs, these families had, on average, only $16 left each week. Poor families have very few resources available for anything beyond basic living needs, even when they have Medicaid coverage. There is no great reservoir of discretionary funds to pay for increases in cost-sharing under Medicaid and Medicare Part D.
View details for DOI 10.1080/19371910802672346
View details for Web of Science ID 000208103800008
View details for PubMedID 19821195
View details for PubMedCentralID PMC2893303
Medication adherence and racial differences in AlC control
2008; 31 (5): 916–21
The purpose of this study was to examine medication adherence and other self-management practices as potential determinants of higher glycemic risk among black relative to white patients.We used a retrospective, longitudinal repeated-measures design to model the contribution of medication adherence to black-white differences in A1C among type 2 diabetic patients at a large multispecialty group practice. We identified 1,806 adult (aged >/=18 at diagnosis) patients (467 black and 1,339 white) with newly initiated oral hypoglycemic therapy between 1 December 1994 and 31 December 2000. Race was identified using an electronic medical record and patient self-report. Baseline was defined as the 13 months preceding and included the month of therapy initiation. All patients were required to have at least 12 months of follow-up.At initiation of therapy, black patients had higher average A1C values compared with whites (9.8 vs. 8.9, a difference of 0.88; P < 0.0001). Blacks had lower average medication adherence during the first year of therapy (72 vs. 78%; P < 0.0001). Although more frequent medication refills were associated with lower average A1C values, adjustment for adherence did not eliminate the black-white gap.We found persistent racial differences in A1C that were not explained by differences in medication adherence. Our findings suggest that targeting medication adherence alone is unlikely to reduce disparities in glycemic control in this setting. Further research is needed to explore possible genetic and environmental determinants of higher A1C among blacks at diagnosis, which may represent a critical period for more intensive intervention.
View details for DOI 10.2337/dc07-1924
View details for Web of Science ID 000256016300016
View details for PubMedID 18235050
View details for PubMedCentralID PMC2563955
Use of atypical antipsychotic drugs for schizophrenia in Maine Medicaid following a policy change
PROJECT HOPE. 2008: W185-W195
More than one-third of Medicaid programs and Medicare Part D plans use prior authorization (PA) policies to control the use of atypical antipsychotics (AAs). We used Medicaid and Medicare claims data to investigate how Maine's PA policy affected AA use, treatment discontinuities, and spending among schizophrenia patients initiating AA therapy. Patients initiating AAs during Maine's policy experienced a 29 percent greater risk of treatment discontinuity than patients initiating AAs before the policy took effect; no change occurred in a comparison state. AA spending was slightly lower in both states. Observed increases in treatment discontinuities without cost savings suggest that AAs should be exempt from PA for patients with severe mental illnesses.
View details for DOI 10.1377/hlthaff.27.3.w185
View details for Web of Science ID 000255579900062
View details for PubMedID 18381404
Cost-related medication nonadherence and spending on basic needs following implementation of Medicare Part D
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
2008; 299 (16): 1922-1928
Cost-related medication nonadherence (CRN) has been a persistent problem for individuals who are elderly and disabled in the United States. The impact of Medicare prescription drug coverage (Part D) on CRN is unknown.To estimate changes in CRN and forgoing basic needs to pay for drugs following Part D implementation.In a population-level study design, changes in study outcomes between 2005 and 2006 before and after Medicare Part D implementation were compared with historical changes between 2004 and 2005. The community-dwelling sample of the nationally representative Medicare Current Beneficiary Survey (unweighted unique n = 24,234; response rate, 72.3%) was used, and logistic regression analyses were controlled for demographic characteristics, health status, and historical trends.Self-reports of CRN (skipping or reducing doses, not obtaining prescriptions) and spending less on basic needs to afford medicines.The unadjusted, weighted prevalence of CRN was 15.2% in 2004, 14.1% in 2005, and 11.5% after Part D implementation in 2006. The prevalence of spending less on basic needs was 10.6% in 2004, 11.1% in 2005, and 7.6% in 2006. Adjusted analyses comparing 2006 with 2005 and controlling for historical changes (2005 vs 2004) demonstrated significant decreases in the odds of CRN (ratio of odds ratios [ORs], 0.85; 95% confidence interval [CI], 0.74-0.98; P = .03) and spending less on basic needs (ratio of ORs, 0.59; 95% CI, 0.48-0.72; P < .001). No significant changes in CRN were observed among beneficiaries with fair to poor health (ratio of ORs, 1.00; 95% CI, 0.82-1.21; P = .97), despite high baseline CRN prevalence for this group (22.2% in 2005) and significant decreases among beneficiaries with good to excellent health (ratio of ORs, 0.77; 95% CI, 0.63-0.95; P = .02). However, significant reductions in spending less on basic needs were observed in both groups (fair to poor health: ratio of ORs, 0.60; 95% CI, 0.47-0.75; P < .001; and good to excellent health: ratio of ORs, 0.57; 95% CI, 0.44-0.75; P < .001).In this survey population, there was evidence for a small but significant overall decrease in CRN and forgoing basic needs following Part D implementation. However, no net decrease in CRN after Part D was observed among the sickest beneficiaries, who continued to experience higher rates of CRN.
View details for DOI 10.1001/jama.299.16.1922
View details for Web of Science ID 000255163800026
View details for PubMedID 18430911
View details for PubMedCentralID PMC3781951
Reliability of new measures of cost-related medication nonadherence
2008; 46 (4): 444–48
Although several national studies have attempted to measure medication nonadherence due to cost in cross-sectional studies of the elderly and disabled, little information exists on the psychometric properties of these measures over time.Examine the test-retest reliability of several recently published measures of cost-related medication nonadherence, among elderly community.We developed a questionnaire and tested the reliability of measures of cost-related medication nonadherence and general cost-reduction strategies in a sample of 185 elderly in eastern Massachusetts surveyed twice (1-2 months apart). General and medicine-specific cost-related nonadherence measures included: failure to fill or delayed refilling of a prescription due to its cost, skipping doses, or taking smaller doses to make a medicine last longer. We also tested the reliability of reported drug cost-reduction strategies, such as: using generic drugs; purchasing prescriptions via mail/internet or from outside the United States; receiving prescription samples from a doctor; and spending less on food, heat, or other basic needs to afford medicines. We used the McNemar test, a matched pair chi analysis, and Kappa statistics to examine the association of responses within patients between identical items asked at 2 points in time.Kappa statistics for test-retest reliability ranged from 0.6 to 0.9 for all but one measure of cost-related nonadherence, and McNemar test statistics indicated no systematic change in the measures over time.The estimated test-retest reliability of the measures of cost-related medication nonadherence were generally high. The measures have been integrated into the nationally representative Medicare Current Beneficiary Survey (MCBS), an ongoing national panel survey of Medicare beneficiaries, which will allow researchers and policymakers to identify changes in cost-related nonadherence among disabled and elderly Medicare beneficiaries.
View details for DOI 10.1097/MLR.0b013e31815dc59a
View details for Web of Science ID 000254571100016
View details for PubMedID 18362826
Why is the developed world obese?
ANNUAL REVIEW OF PUBLIC HEALTH
2008; 29: 273–95
Obesity has risen dramatically in the past few decades. However, the relative contribution of energy intake and energy expenditure to rising obesity is not known. Moreover, the extent to which social and economic factors tip the energy balance is not well understood. This exploratory study estimates the relative contribution of increased caloric intake and reduced physical activity to obesity in developed countries using two methods of energy accounting. Results show that rising obesity is primarily the result of consuming more calories. We estimate multivariate regression models and use simulation analysis to explore technological and sociodemographic determinants of this dietary excess. Results indicate that the increase in caloric intake is associated with technological innovations as well as changing sociodemographic factors. This review offers useful insights to future research concerned with the etiology of obesity and suggests that obesity-related policies should focus on encouraging lower caloric intake.
View details for DOI 10.1146/annurev.publhealth.29.020907.090954
View details for Web of Science ID 000255349400020
View details for PubMedID 18173389
A longitudinal study of medication nonadherence and hospitalization risk in schizophrenia
JOURNAL OF CLINICAL PSYCHIATRY
2008; 69 (1): 47-53
Previous cross-sectional studies have suggested an association between medication nonadherence and hospitalization for individuals with schizophrenia. However, such analyses typically measure adherence averaged over long time periods. We investigated the temporal relationship between nonadherence and hospitalization risk using a daily measure of medication availability.Our observational cohort included 1191 patients with schizophrenia (ICD-9 criteria) enrolled in Maine and New Hampshire Medicaid programs who initiated atypical antipsychotic therapy between January 1, 2001, and December 31, 2003. Pharmacy claims were used to define days with gaps in medication availability. We tested the association of gaps in medication availability with all-cause, mental health, and schizophrenia-specific hospitalization using a Cox regression model.Compared to individuals with available medication, individuals in the first 10 days following a missed prescription refill had a hazard ratio of 1.54 (95% CI = 1.02 to 2.32) for mental health hospitalization and 1.77 (95% CI = 1.16 to 2.71) for schizophrenia hospitalization. Similarly, medication gaps of more than 30 days were associated with 50% increased hazard for all 3 hospitalization outcomes. Switching and augmenting therapy, previous hospitalization, and clinical severity measures were also associated with substantially increased hazard of hospitalization.Our findings indicate that patients may be at significantly increased risk for hospitalization as early as the first 10 days following a missed medication refill. Patients who switched or augmented medications or were previously hospitalized also demonstrated increased hospitalization risk. Clinicians and Medicaid programs should consider using pharmacy claims to monitor medication use and target adherence interventions to reduce relapses in this vulnerable population.
View details for DOI 10.4088/JCP.v69n0107
View details for Web of Science ID 000252908400006
View details for PubMedID 18312037
Racial differences in long-term self-monitoring practice among newly drug-treated diabetes patients in an HMO
JOURNAL OF GENERAL INTERNAL MEDICINE
2007; 22 (11): 1506-1513
One approach to improving outcomes for minority diabetics may be through better self-care. However, minority patients may encounter barriers to better self-care even within settings where variations in quality of care and insurance are minimized.The objective of the study was to evaluate racial differences in long-term glucose self-monitoring and adherence rates in an HMO using evidence-based guidelines for self-monitoring.Retrospective cohort study using 10 years (1/1/1993-12/31/2002) of electronic medical record data was used.Patients were 1,732 insured adult diabetics of black or white race newly initiated on hypoglycemic therapy in a large multi-specialty care group practice.Outcomes include incidence and prevalence of glucose self-monitoring, intensity of use, and rate of adherence to national recommended standards.We found no evidence of racial differences in adjusted initiation rates of glucose self-monitoring among insulin-treated patients, but found lower rates of initiation among black patients living in low-income areas. Intensity of glucose self-monitoring remained lower among blacks than whites throughout follow-up [IRR for insulin = 0.41 (0.27-0.62); IRR for oral hypoglycemic = 0.75 (0.63, 0.90)], with both groups monitoring well below recommended standards. Among insulin-treated patients, <1% of blacks and <10% of whites were self-monitoring 3 times per day; 36% of whites and 10% of blacks were self-monitoring at least once per day.Adherence to glucose self-monitoring standards was low, particularly among blacks, and racial differences in self-monitoring persisted within a health system providing equal access to services for diabetes patients. Early and continued emphasis on adherence among black diabetics may be necessary to reduce racial differences in long-term glucose self-monitoring.
View details for DOI 10.1007/s11606-007-0339-5
View details for Web of Science ID 000250139200004
View details for PubMedID 17763913
View details for PubMedCentralID PMC2219792
Impact of insurance and supply of health professionals on coverage of treatment for hypertension in Mexico: population based study
BMJ-BRITISH MEDICAL JOURNAL
2007; 335 (7625): 875-B878
To examine the independent and combined contributions of insurance status and supply of health professionals on coverage of antihypertensive treatment among adults in Mexico.Population based study.Mexico.4032 hypertensive adults (2967 uninsured and 1065 insured): 1065 uninsured adults matched with 1065 adults insured through Seguro Popular, a programme to expand health insurance coverage to uninsured people in Mexico.Coverage of antihypertensive treatment and coverage of antihypertensive treatment with control of blood pressure.Rates of treatment for hypertension varied by insurance status and supply of health professionals. Hypertensive adults insured through Seguro Popular had a significantly higher probability of receiving antihypertensive treatment (odds ratio 1.50, 95% confidence interval 1.27 to 1.78) and receiving antihypertensive treatment with control of blood pressure (1.35, 1.00 to 1.82). Greater supply of health professionals in areas with coverage through Seguro Popular was a significant predictor of antihypertensive treatment after adjusting for covariates (1.49, 1.00 to 2.20).Expansion of healthcare coverage to uninsured people in Mexico was associated with greater use of antihypertensive treatment and blood pressure control, particularly in areas with a greater supply of health professionals.
View details for DOI 10.1136/bmj.39350.617616.BE
View details for Web of Science ID 000250631000041
View details for PubMedID 17954519
View details for PubMedCentralID PMC2043407
Trust in scientific experts on obesity: Implications for awareness and behavior change
2007; 15 (8): 2145-2156
To explore the relationship between public trust in scientific experts on obesity and public attention to nutrition recommendations, to investigate trust as a predictor of weight-related behaviors, and to identify the sociodemographic characteristics associated with high and low trust in scientific experts on obesity.This analysis used survey data from two sources: 1) a 2005 Harvard School of Public Health Obesity Survey (N = 2033), and 2) the 2004 General Social Survey (N = 2812). Five outcome measures were used. Three were used to explore trust as a predictor of attention and weight-related behaviors. Two were used to identify the sociodemographic predictors of trust. Logistic regression analysis was used to model the outcome variables.Trust in scientific experts was the strongest predictor of public attention to nutritional recommendations from scientific experts, but it was not directly related to weight-related behaviors. Public attention was significantly associated with two weight-related behaviors: tracking fruit and vegetable intake and exercise. Women and more educated individuals had significantly higher odds of trusting scientific experts. Characteristics associated with distrust in scientific experts included Hispanic race and older age (over 50).Public health experts should work toward building trust as an important step in stemming the obesity epidemic. Further, more research is necessary to better understand the factors driving trust in scientific experts on obesity. A deeper insight in this area will certainly be of great benefit to obesity-related risk communication and potentially lead to positive behavior change.
View details for DOI 10.1038/oby.2007.255
View details for Web of Science ID 000249001800031
View details for PubMedID 17712134
Provider and patient characteristics associated with antidepressant nonadherence: The impact of provider specialty
PHYSICIANS POSTGRADUATE PRESS. 2007: 867-873
Given the widespread use of anti-depressants in primary care and specialty populations, we sought to examine whether provider specialty and patient demographic and clinical characteristics were associated with nonadherence to antidepressant therapy.We conducted an observational cohort study of 11,878 patients enrolled in Harvard Pilgrim Health Care who were newly treated with antidepressants between May 2002 and May 2004. Using generalized estimating equations, we examined predictors of 2 types of anti-depressant nonadherence: (1) immediate non-adherence: never refilling an antidepressant prescription; and (2) 6-month nonadherence: refilling an antidepressant prescription at least once, but not satisfactorily completing a 6-month treatment episode.Compared with patients treated by primary care physicians (PCP), being treated by a psychiatrist was associated with significantly lower odds of immediate nonadherence (PCP 18% vs. psychiatrist 13%). Being treated by another type of specialist was associated with significantly higher odds of both immediate (other specialist 23%) and 6-month nonadherence (PCP 53%, psychiatrist 49%, other specialist 62%). Treatment by multiple providers was associated with lower odds of nonadherence than being treated by only 1 provider. Younger patient age and use of pain medication were associated with greater nonadherence.Rates of both immediate and 6-month nonadherence are high, and clinicians should emphasize the importance of continuing antidepressant treatment for a sufficient duration. Patients whose depression treatment is initiated by nonpsychiatric specialists may benefit from collaborative care models. These strategies may enable providers to better manage the long-term disability associated with their patients' depression.
View details for DOI 10.4088/JCP.v68n0607
View details for Web of Science ID 000247558800007
View details for PubMedID 17592910
Strategies for coping in a complex world: Adherence behavior among older adults with chronic illness
SPRINGER. 2007: 805-810
Increasing numbers of medicines increase nonadherence. Little is known about how older adults manage multiple medicines for multiple illnesses.To explore how older adults with multiple illnesses make choices about medicines.Semistructured interviews with older adults taking several medications. Accounts of respondents' medicine-taking behavior were collected.Twenty community-dwelling seniors with health insurance, in Eastern Massachusetts, aged 67-90, (4-12 medicines, 3-9 comorbidities).Qualitative analysis using constant comparison to explain real choices made about medicines in the past ("historical") and hypothetical ("future") choices.Respondents reported both past ("historical") choices and hypothetical ("future") choices between medicines. Although people discussed effectiveness and future risk of the disease when prompted to prioritize their medicines (future choices), key factors leading to nonadherence (historical choices) were costs and side effects. Specific choices were generally dominated by 1 factor, and respondents rarely reported making explicit trade-offs between different factors. Factors affecting 1 choice were not necessarily the same as those affecting another choice in the same person. There was no evidence of "adherent" personalities.Prescribing a new medicine, a change in provider or copayment can provoke new choices about both new and existing medications in older adults with multiple morbidities.
View details for DOI 10.1007/s11606-007-0193-5
View details for Web of Science ID 000246563900015
View details for PubMedID 17406952
View details for PubMedCentralID PMC2219857
Depression and cost-related medication nonadherence in Medicare beneficiaries
ARCHIVES OF GENERAL PSYCHIATRY
2007; 64 (5): 602–8
Treatment for depression can be expensive and depression can affect the use of other medical services, yet there is little information on how depression affects the prevalence of cost-related medication nonadherence (CRN) in elderly patients and patients with disabilities.To quantify the presence of CRN in depressed and nondepressed elderly Medicare beneficiaries and nonelderly Medicare beneficiaries with disabilities prior to the implementation of the Medicare Drug Benefit.2004 Medicare Current Beneficiary Survey.Depressed and nondepressed elderly Medicare beneficiaries and beneficiaries with disabilities.Cost-related medication nonadherence included taking smaller doses or skipping doses of a prescription to make it last longer, or failing to fill a prescription because of cost, controlling for health insurance status, comorbid conditions, age, race, sex, and functional status.In a nationally representative sample of 13 835 noninstitutionalized elderly Medicare enrollees and Medicare enrollees with disabilities, 44% of beneficiaries with disabilities and 13% of elderly beneficiaries reported being depressed during the previous year. Among enrollees with disabilities reporting depressive symptoms, 38% experienced CRN compared with 22% of enrollees with disabilities who did not report depressive symptoms. Among elderly enrollees who reported depressive symptoms, 19% experienced CRN, compared with 12% of elderly enrollees who did not report such symptoms. In adjusted analyses, depressive symptoms remained a significant predictor of CRN in both groups (persons with disabilities: odds ratio, 1.7; 95% confidence interval, 1.3-2.3; elderly persons: odds ratio, 1.4; 95% confidence interval, 1.1-1.7).Depressive symptoms were associated with CRN in elderly Medicare enrollees and Medicare enrollees with disabilities. Providers should elicit information on economic barriers that might interfere with treatment of Medicare beneficiaries with depression.
View details for DOI 10.1001/archpsyc.64.5.602
View details for Web of Science ID 000246263300011
View details for PubMedID 17485612
Relationship between patient medication adherence and subsequent clinical inertia in type 2 diabetes glycemic management
2007; 30 (4): 807-812
Clinical inertia has been identified as a critical barrier to glycemic control in type 2 diabetes. We assessed the relationship between patients' initial medication adherence and subsequent regimen intensification among patients with persistently elevated A1C levels.We analyzed an inception cohort of 2,065 insured patients with type 2 diabetes who were newly started on hypoglycemic therapy and were followed for at least 3 years between 1992 and 2001. Medication adherence was assessed by taking the ratio of medication days dispensed (from pharmacy records) to medication days prescribed (as documented in the medical record) for the first prescribed hypoglycemic drug. Adherence was measured for the period between medication initiation and the next elevated A1C result measured at least 3 months later; intensification was defined as a dose increase or the addition of a second hypoglycemic agent.Patients were aged (mean +/- SD) 55.4 +/- 12.2 years; 53% were men, and 19% were black. Baseline medication adherence was 79.8 +/- 19.3%. Patients in the lowest quartile of adherence were significantly less likely to have their regimens increased within 12 months of their first elevated A1C compared with patients in the highest quartile (27 vs. 37%, respectively, with increased regimens if A1C is elevated, P < 0.001). In multivariate models adjusting for patient demographic and treatment factors, patients in the highest adherence quartile had 53% greater odds of medication intensification after an elevated A1C (95% CI 1.11-1.93, P = 0.01).Among insured diabetic patients with elevated A1C, level of medication adherence predicted subsequent medication intensification. Poor patient self-management behavior increases therapeutic clinical inertia.
View details for DOI 10.2337/dc06-2170
View details for Web of Science ID 000245697600007
View details for PubMedID 17259469
Cost-related medication nonadherence among elderly and disabled medicare beneficiaries - A national survey 1 year before the medicare drug benefit
ARCHIVES OF INTERNAL MEDICINE
2006; 166 (17): 1829-1835
Prior to implementation of the Medicare drug benefit, we estimated the prevalence of cost-related medication nonadherence (CRN) among Medicare enrollees, including elderly and nonelderly disabled beneficiaries.In the fall of 2004, detailed measures of CRN (skipping or reducing doses or not filling prescriptions because of cost) were added to the Medicare Current Beneficiary Survey. We examined the prevalence of CRN nationally and by Medicare eligibility subgroups (elderly vs nonelderly disabled beneficiaries), drug coverage status, socioeconomic status, self-rated health, and number of chronic medical conditions.In a national sample of 13 835 noninstitutionalized Medicare enrollees, 29% of the disabled and 13% of the elderly beneficiaries reported CRN; those in fair to poor health with multiple comorbidities and without coverage were most at risk. Among the disabled enrollees with 4 or more morbidities, 52% (95% confidence interval [CI], 43.3%-60.3%) without drug coverage skipped prescriptions or doses compared with 26% (95% CI, 17.7%-34.8%) with Medicaid drug coverage. Those with partial drug coverage through Medigap policies or Medicare health maintenance organizations reported intermediate rates of CRN. The adjusted odds ratio of CRN among disabled enrollees in poor (vs good) health was 3.9 (95% CI, 1.7-9.2), whereas for those with 4 or more (vs <4) comorbidities, the odds ratio of CRN was 2.7 (95% CI, 1.7-4.1).One year before Medicare Part D implementation, Medicare beneficiaries reported high rates of CRN. Rates are highest among nonelderly disabled beneficiaries, but among both elderly and disabled beneficiaries, CRN is exacerbated by poor health, multiple morbidities, and limited drug coverage. Given the high cost sharing under Part D, it is important to closely monitor CRN in high-risk subgroups.
View details for DOI 10.1001/archinte.166.17.1829
View details for Web of Science ID 000240730500006
View details for PubMedID 17000938
- Race differences in long-term diabetes management in an HMO - Response to Hart DIABETES CARE 2006; 29 (6): 1462
Racial differences in impact of coverage on diabetes self-monitoring in a health maintenance organization
LIPPINCOTT WILLIAMS & WILKINS. 2006: 392-397
Insurance coverage of patient self-management devices like self-monitoring blood glucose (SMBG) equipment may help to reduce race-related barriers to effective care.We examined whether providing free home glucose monitors had greater impacts on self-monitoring among black versus white patients with diabetes.Using electronic medical record data (1992-1996), we used longitudinal survival analysis to examine racial differences in rates of initiation of SMBG after coverage and rates of discontinuation of SMBG 18 months after initiation. We used piecewise Cox models to compare relative rates of SMBG initiation between black and white patients before and after the policy.The study cohort included 2275 continuously enrolled adult patients with diabetes in a large, staff model HMO. Multivariate models were restricted to patients using oral therapy.Controlling for time-dependent and fixed effects, black patients were as likely to initiate SMBG as white patients before the policy (hazard ratio 1.14; 95% confidence interval 0.86-1.50) but more likely after the policy (hazard ratio 1.33; 95% confidence interval 1.01-1.76). Among postpolicy SMBG initiators, black patients were consistently at higher risk of SMBG discontinuation than white patients over time (P < 0.05). By the end of follow-up, discontinuation rates were 78% among black patients and 64% among white patients.The policy is effective in triggering additional diabetes patients to self-manage, particularly black patients. However, persistence after initiation of monitoring is short-lived. Although our results show the potential of such policies to narrow racial gaps in self-management among racial minority groups, further interventions may be needed to promote long-term adherence.
View details for DOI 10.1097/01.mlr.0000207488.80213.74
View details for Web of Science ID 000237150000002
View details for PubMedID 16641656
Effect of quality improvement on racial disparities in diabetes care
AMER MEDICAL ASSOC. 2006: 675-681
Racial disparities in care are well documented; information regarding solutions is limited. We evaluated whether generic quality improvement efforts were associated with changes in racial disparities in diabetes care.Using insurance claims and electronic medical record data, we identified 5101 whites and 1987 blacks with diabetes mellitus receiving care within a multispecialty group practice from 1997 to 2001. We assessed rates of annual low-density lipoprotein cholesterol level testing, low-density lipoprotein cholesterol level control (<130 mg/dL [<3.37 mmol/L]), statin therapy, annual glycosylated hemoglobin level testing, glycosylated hemoglobin level control (<7.0%), and annual dilated eye examinations. We used logistic regression models with generalized estimating equations to adjust for race, year, race x year interactions, age, and sex.Rates of annual low-density lipoprotein cholesterol level testing increased from 39% to 64%, while the white-black disparity decreased from 14% to 4%; rates of low-density lipoprotein cholesterol level control increased from 15% to 43%, while the white-black disparity decreased from 9% to 6% (P<.001 for both race x year interactions). Statin therapy rates increased from 20% to 37%; however, black patients remained less likely than white patients to receive therapy. The 1997 rates of annual glycosylated hemoglobin level testing (76%) and annual eye examinations (74%) were high, and there was no white-black disparity over time. Rates of glycosylated hemoglobin level control remained low (31%), and the white-black disparity remained constant at 10%.Racial disparities were diminished in some aspects of diabetes care following variably successful quality improvement, but differences in the use of statins and glycemic level control persisted. Reducing disparities may require a focus on minority health.
View details for DOI 10.1001/archinte.166.6.675
View details for Web of Science ID 000236284100013
View details for PubMedID 16567608
Physician alerts to increase antidepressant adherence - Fax or fiction?
ARCHIVES OF INTERNAL MEDICINE
2006; 166 (5): 498-504
Many managed care organizations use feedback based on electronically maintained claims data to alert physicians to potential treatment problems, including patient medication nonadherence. However, the efficacy of such interventions for improving adherence among patients treated for depression is unknown.We examined an antidepressant compliance program consisting of faxed alerts to physicians beginning May 2003 using interrupted time series analysis to evaluate its impact on rates of antidepressant adherence between May 2002 and May 2004 among members of the managed care plan of Harvard Pilgrim Health Care, which is a health plan operating in 3 states in New England, with corporate headquarters in Wellesley, Mass. The program alerted prescribing physicians to patients with gaps of more than 10 days in refilling antidepressant prescriptions during the first 180 days of treatment. Our outcome measures were rates of nonadherence among patients with refill gaps of more than 10 days ("delayed refill") and proportion of days without treatment within the first 180 days of treatment.A total of 13 128 patients (> or = 18 years of age) who were starting treatment with antidepressants met the study criteria. Rates of nonadherence among patients with delayed refills remained constant (P = .22) over the 2-year study period, averaging 75% (95% confidence interval, 72.7%-77.3%). Rates of antidepressant nonadherence significantly increased over time (P = .04), with an average of 40% (95% confidence interval, 38.4%-41.6%) of days without dispensed antidepressants available during treatment episodes.Using real-time pharmacy information to alert physicians regarding patient adherence was not successful in increasing antidepressant adherence rates among members of the managed care plan. Effectiveness of electronically triggered, patient-specific, faxed feedback should be carefully evaluated before widespread implementation, because faxes are insufficient as a stand-alone policy tool.
View details for DOI 10.1001/archinte.166.5.498
View details for Web of Science ID 000236032300004
View details for PubMedID 16534035
Race differences in long-term diabetes management in an HMO
2005; 28 (12): 2844-2849
We examined race differences in diabetes outcomes over 4-8 years in a single HMO.We identified black and white adult diabetic patients who were continuously enrolled (1992-2001) and in whom diabetes was 1) diagnosed before 1994 (n = 1,686) or 2) newly diagnosed in 1994-1997 (n = 1,280). We used hierarchical models to estimate the effect of race on average annual HbA(1c) (A1C) controlling for baseline A1C, BMI, and age, as well as annual measures of type of diabetes medications, diabetes-related hospitalization, time and the number of A1C tests, physician visits, and nondiabetes medications. Stratifying by sex accounted for significant interactions between sex and race.At baseline, black and white patients had similar rates of A1C testing and physician visits, but blacks had higher unadjusted A1C values. In multivariate models, among patients with previously diagnosed diabetes, average A1C was nonsignificantly 0.11 higher (95% CI -0.12 to 0.34) in black than in white men but was 0.30 higher (0.14-0.46; P = 0.0007) in black than in white women. Among patients with newly diagnosed diabetes, the adjusted black-white gap was 0.49 among men (0.17-0.80; P = 0.007) and was 0.05 among women (-0.20 to -0.31), which was positive but not significant.Factors other than the quality of care may explain persistent race differences in A1C in this setting. Future interventions should target normalization of A1C by identifying potential psychosocial barriers to therapy intensification among patients and clinicians and development of culturally appropriate interventions to aid patients in successful self-management.
View details for DOI 10.2337/diacare.28.12.2844
View details for Web of Science ID 000233583500005
View details for PubMedID 16306543
Antibiotic use following a Korean national policy to prohibit medication dispensing by physicians
HEALTH POLICY AND PLANNING
2005; 20 (5): 302-309
This study investigated whether a Korean national policy prohibiting doctors from dispensing drugs as of 2000 selectively reduced inappropriate antibiotic prescribing in viral illness compared with bacterial illness. We assessed the proportions of episodes prescribed an antibiotic and the number of different antibiotics prescribed for patients with viral and bacterial illness episodes before and after the policy. The nationally representative sample consisted of 50,999 episodes (18,656 viral and 7758 bacterial pre-policy, 16,736 viral and 7849 bacterial post-policy) from 1372 primary care clinics. We used generalized estimating equations to investigate changes in antibiotic prescribing after the policy, and multiple linear regression to determine provider factors associated with reductions in inappropriate antibiotic prescribing for viral illness. After the dispensing restriction, antibiotic prescribing declined substantially for patients with viral illness (from 80.8 to 72.8%, relative risk (RR) = 0.89, [95% confidence interval: 0.86, 0.91], p<0.001), and only minimally for patients with bacterial illness (from 91.6 to 89.7%, RR = 0.98, [0.97, 0.99], p = 0.017). Reductions in antibiotic prescribing were significantly larger (RR = 0.90, [0.87, 0.93], p<0.001) for patients with viral illness. The number of different antibiotics prescribed per episode also decreased significantly after the policy, but there were no significant differences in these reductions between viral and bacterial illness. The dispensing restriction also reduced prescribing of non-antibiotic drugs, with no difference by diagnosis. Provider factors found to be associated with reduced inappropriate antibiotic prescribing were younger age and practice location in an urban area. Prohibiting doctors from dispensing drugs reduced prescribing overall, both of antibiotics and other drugs, and selectively reduced inappropriate antibiotic prescribing in viral illness.
View details for DOI 10.1093/heapol/czi033
View details for Web of Science ID 000231473100005
View details for PubMedID 16000369
Effect of switching antipsychotics on antiparkinsonian medication use in schizophrenia - Population-based study
BRITISH JOURNAL OF PSYCHIATRY
2005; 187: 137-142
The extent to which atypical antipsychotics have a lower incidence of extrapyramidal symptoms than typical antipsychotics has not been well-evaluated in community practice.To examine the effects of switching antipsychotics on antiparkinsonian medication use among individuals with schizophrenia in UK general practices.We included those switched from typical to atypical antipsychotics (n=209) or from one typical antipsychotic to another (n=261) from 1994 to 1998.Antiparkinsonian drug prescribing dropped by 9.2% after switching to atypical antipsychotics (P<0.0001). Switching to olanzapine decreased the rate by 19.2% (P<0.0001), but switching to risperidone had no impact. After switching from one typical antipsychotic to another, antiparkinsonian drug prescribing increased by 12.9% (P<0.0001).Reduction in antiparkinsonian medication use after switching to atypical antipsychotics was substantial in community practice but not as large as in randomised controlled trials. The rate of reduction varied according to the type of medication.
View details for DOI 10.1192/bjp.187.2.137
View details for Web of Science ID 000231226600008
View details for PubMedID 16055824
Effects of health maintenance organisation coverage of self-monitoring devices on diabetes self-care and glycemic control
AMER MEDICAL ASSOC. 2004: 645-652
Increasingly, government mandates require insurance coverage of blood glucose monitors and test strips for patients with type 1 and type 2 diabetes. No data exist on the effects of such coverage on self-monitoring of blood glucose (SMBG), medication compliance, or blood glucose control. We evaluated whether a policy providing free blood glucose monitors increased SMBG and whether initiating SMBG was associated with increased regularity of medication use and improved glucose control (hemoglobin A(1c) [HbA(1c)] level).Using interrupted time-series analysis and controlling for preintervention trends, we determined changes in rates of SMBG 2 years before and after the policy among 3219 continuously enrolled patients with diabetes receiving drug therapy within a multispecialty medical group (part of a health maintenance organization) serving approximately 300 000 patients. We also compared changes over time in regularity of medication use (mean days between dispensings) and mean HbA(1c) level among initiators and noninitiators of SMBG.The policy resulted in a small, significant increase in SMBG among insulin-treated patients (n = 1428). Among sulfonylurea-treated patients (n = 1791), the monthly initiation rate of SMBG increased by 14 new patients per 1000 (95% confidence interval [CI], 10 to 17), a doubling of the expected initiation rate. Test strip consumption increased during the first 6 months after the policy by 17.9 strips per cohort member (75% relative increase by 6 months; 95% CI, 50% to 101%). Compared with noninitiators of SMBG, initiators (n = 593) showed sudden, significant improvements in regularity of medication use by 6 months after initiation (-19.5 days between dispensings among those with low refill regularity [95% CI, -27.7 to -11.3]; -9.7 days among those with moderate regularity [95% CI, -12.3 to -7.1]), and in glucose control (-0.63% mean HbA(1c) level [as percentage of total hemoglobin] among those with poor baseline glycemic control [HbA(1c) >10%; 95% CI, -1.14% to -0.12%]).Providing free glucose monitors improved rates of self-monitoring in this health maintenance organization population, possibly by offering an initial incentive for patients to engage in more desirable patterns of care. Initiating SMBG was associated with increased regularity of medication use and a reduction in high blood glucose levels.
View details for DOI 10.1001/archinte.164.6.645
View details for Web of Science ID 000220313600009
View details for PubMedID 15037493
Does antidepressant adherence have an effect on glycemic control among diabetic antidepressant users?
SAGE PUBLICATIONS INC. 2004: 291-304
To examine the relationship between adherence to antidepressant medications and HbA1c levels among patients with diabetes in a managed care setting.The analysis included measures of HbA1c levels before, during, and after initial antidepressant use among 568 patients with diabetes enrolled in the Harvard Pilgrim Health Care insurance plan from 1991-1995. Adherence was defined as four refills in a six-month period after the first antidepressant prescription. General linear models using SAS PROC MIXED were used to estimate the effects of covariates including antidepressant adherence on HbA1c levels over time, comparing patients who were adherent to antidepressant medications to those patients who were non-adherent to antidepressant medications.Adherence to antidepressant treatment was not significantly associated with HbA1c levels among diabetic patients who are antidepressant users. Younger age, use of insulin and oral medications, and female gender were all significantly associated with HbA1c levels over time.Although we did not observe any association between level of adherence to antidepressant therapy among diabetic patients and levels of glucose control, our results confirm previously established associations between patient characteristics and glycemic control. Further research is needed to disentangle the complex relationship among antidepressant treatment adherence and diabetes outcomes.
View details for DOI 10.2190/KKGW-Y42P-BAAB-JDJ0
View details for Web of Science ID 000227788300001
View details for PubMedID 15825580
- Evidence needed before action HEALTH AFFAIRS 2003; 22 (5): 261-262
Barriers to self-monitoring of blood glucose among adults with diabetes in an HMO: A cross sectional study
BMC HEALTH SERVICES RESEARCH
2003; 3: 6
Recent studies suggest that patients at greatest risk for diabetes complications are least likely to self-monitor blood glucose. However, these studies rely on self-reports of monitoring, an unreliable measure of actual behavior. The purpose of the current study was to examine the relationship between patient characteristics and self-monitoring in a large health maintenance organization (HMO) using test strips as objective measures of self-monitoring practice.This cross-sectional study included 4,565 continuously enrolled adult managed care patients in eastern Massachusetts with diabetes. Any self-monitoring was defined as filling at least one prescription for self-monitoring test strips during the study period (10/1/92-9/30/93). Regular SMBG among test strip users was defined as testing an average of once per day for those using insulin and every other day for those using oral sulfonylureas only. Measures of health status, demographic data, and neighborhood socioeconomic status were obtained from automated medical records and 1990 census tract data.In multivariate analyses, lower neighborhood socioeconomic status, older age, fewer HbA1c tests, and fewer physician visits were associated with lower rates of self-monitoring. Obesity and fewer comorbidities were also associated with lower rates of self-monitoring among insulin-managed patients, while black race and high glycemic level (HbA1c>10) were associated with less frequent monitoring. For patients taking oral sulfonylureas, higher dose of diabetes medications was associated with initiation of self-monitoring and HbA1c lab testing was associated with more frequent testing.Managed care organizations may face the greatest challenges in changing the self-monitoring behavior of patients at greatest risk for poor health outcomes (i.e., the elderly, minorities, and people living in low socioeconomic status neighborhoods).
View details for DOI 10.1186/1472-6963-3-6
View details for Web of Science ID 000182161700001
View details for PubMedID 12659642
View details for PubMedCentralID PMC153532
Supplemental insurance and use of effective cardiovascular drugs among elderly Medicare beneficiaries with coronary heart disease
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
2001; 286 (14): 1732-1739
Cost-sharing in US prescription drug coverage plans for elderly persons varies widely. Evaluation of prescription drug use among elderly persons by type of health insurance could provide useful information for designing a Medicare drug program.To determine use of effective cardiovascular drugs among elderly persons with coronary heart disease (CHD) by type of health insurance.Cross-sectional evaluation of 1908 community-dwelling adults, aged 66 years or older, with a history of CHD or myocardial infarction from the 1997 Medicare Current Beneficiary Survey, a nationally representative sample of Medicare beneficiaries.Use of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins), beta-blockers, and nitrates, and out-of-pocket expenditures for prescription drugs, stratified by type of health insurance: Medicare without drug coverage (Medicare only or self-purchased supplemental insurance) or with drug coverage (Medicaid, other public program, Medigap, health maintenance organization, or employer-sponsored plan).Statin use ranged from 4.1% in Medicare patients with no drug coverage to 27.4% in patients with employer-sponsored drug coverage (P<.001). Less variation between these 2 types occurred for beta-blockers (20.7% vs 36.1%; P =.003) and nitrates (20.4% vs 38.0%; P =.005). In multivariate analyses, statin use remained significantly lower for patients with Medicare only (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.05-0.49) and beta-blocker use was lower for Medicaid patients (OR, 0.55; 95% CI, 0.34-0.88) vs those with employer-sponsored coverage. Nitrate use occurred less frequently in persons lacking drug coverage (patients with Medicare only, P =.049; patients with supplemental insurance without drug coverage, P =.03). Patients with Medicare only spent a much larger fraction of income on prescription drugs compared with those with employer-sponsored drug coverage (7.9% vs 1.7%; adjusted P<.001).Elderly Medicare beneficiaries with CHD who lack drug coverage have disproportionately large drug expenditures and lower use rates of statins, a class of relatively expensive drugs that improve survival.
View details for DOI 10.1001/jama.286.14.1732
View details for Web of Science ID 000171466800023
View details for PubMedID 11594898