Bruce Stuart

ABILITY TO PAY AND THE DECISION TO MEDICATE

OBJECTIVES It is widely recognized that ability to pay affects access to hospital and physician services. Much less is known about the economic determinants of prescription drug use, particularly among the elderly. The authors hypothesize that persons with higher incomes and better health insurance coverage are more likely to medicate common health problems than those with lower incomes and less comprehensive coverage. METHODS A random sample of 4,066 elderly Pennsylvania Medicare beneficiaries were asked to complete a mail survey on health insurance, income, and medicine use for 23 common health problems. The relationship between ability to pay and medication decisions was analyzed using logistic and Poisson regression models with covariates for sociodemographic characteristics and health status. RESULTS A strong and consistent relationship was found in the hypothesized direction. Other things being equal, elderly persons with Medicare supplementation were between 6% and 17% more likely to use prescription medicine to treat their health problems than are persons with Medicare coverage alone. The presence of prescription drug coverage significantly increased the odds of prescription treatment for 10 of the 22 conditions examined. The insurance effects were generally--but not exclusively--more pronounced for less serious compared with serious health problems. Income also was shown to have a strong independent effect on medication decisions. Elderly with annual incomes greater than

Out-of-pocket health care expenditure burden for Medicare beneficiaries with cancer

18,000 were 18% more likely to treat problems with prescription drugs than were persons with annual incomes less than

Association of chronic obstructive pulmonary disease maintenance medication adherence with all-cause hospitalization and spending in a Medicare population.

6,000. CONCLUSIONS In sum, economic factors appeared to play an important role in medication decisions by the elderly. The magnitude of the impact was sufficiently high that it could have major negative consequences on the health of elderly persons who are poor and lack drug coverage.

Treatment of Dementia in Community‐Dwelling and Institutionalized Medicare Beneficiaries

BACKGROUND: There is increasing concern regarding the financial burden of care on cancer patients and their families. Medicare beneficiaries often have extensive comorbidities and limited financial resources, and may face substantial cost sharing even with supplemental coverage. In the current study, the authors examined out‐of‐pocket (OOP) spending and burden relative to income for Medicare beneficiaries with cancer.

Trends in the prescription of inappropriate drugs for the elderly between 1995 and 1999

BACKGROUND Although maintenance medications are a cornerstone of chronic obstructive pulmonary disease (COPD) management, adherence remains suboptimal. Poor medication adherence is implicated in poor outcomes with other chronic conditions; however, little is understood regarding links between adherence and outcomes in COPD patients. OBJECTIVE This study investigates the association of COPD maintenance medication adherence with hospitalization and health care spending. METHODS Using the 2006 to 2007 Chronic Condition Warehouse administrative data, this retrospective cross-sectional study included 33,816 Medicare beneficiaries diagnosed with COPD who received at least 2 prescriptions for ≥1 COPD maintenance medications. After a 6-month baseline period (January 1, 2006 to June 30, 2006), beneficiaries were followed through to December 31, 2007 or death. Two medication adherence measures were assessed: medication continuity and proportion of days covered (PDC). PDC values ranged from 0 to 1 and were calculated as the number of days with any COPD maintenance medication divided by duration of therapy with these agents. The association of adherence with all-cause hospital events and Medicare spending were estimated using negative binomial and γ generalized linear models, respectively, adjusting for sociodemographics, Social Security disability insurance status, low-income subsidy status, comorbidities, and proxy measures of disease severity. RESULTS Improved adherence using both measures was significantly associated with reduced rate of all-cause hospitalization and lower Medicare spending. Patients who continued with their medications had lower hospitalization rates (relative rate [RR] = 0.88) and lower Medicare spending (-

ASSESSMENT AND CONTROL OF NONRESPONSE BIAS IN A SURVEY OF MEDICINE USE BY THE ELDERLY

3764), compared with patients who discontinued medications. Similarly, patients with PDC ≥0.80 exhibited lower hospitalization rates (RR = 0.90) and decreased spending (-

Prevalence of Diabetes and the Burden of Comorbid Conditions Among Elderly Nursing Home Residents

2185), compared with patients with PDC <0.80. CONCLUSIONS COPD patients with higher adherence to prescribed regimens experienced fewer hospitalizations and lower Medicare costs than those who exhibited lower adherence behaviors. Findings suggested the clinical and economic importance of medication adherence in the management of COPD patients in the Medicare population.

Increased persistency in medication use by U.S. Medicare beneficiaries with diabetes is associated with lower hospitalization rates and cost savings.

OBJECTIVES: To establish nationally representative estimates of the use of agents to treat Alzheimers disease and related dementias (ADRDs) and related behavioral symptoms in Medicare beneficiaries and to describe medication use according to residential status and other patient characteristics.

Assessing the Impact of Drug Use on Hospital Costs

BACKGROUND Using criteria developed by Beers et al between 1991 and 1997, previous studies have reported high levels of inappropriate drug prescribing for community-dwelling elderly patients (age>or=65 years). However, it is not known whether the Beers criteria have had a beneficial effect on prescribing practices. OBJECTIVES The aims of this study were to compare the prevalence of potentially inappropriate drug use (based on the Beers list) among older Americans between 1995 and 1999; to determine whether any decreases in such use were more likely to be the result of improved adherence to guidelines or of replacement of older medications by newer drugs; and to examine individual characteristics that place elderly patients at increased risk for inappropriate drug use. METHODS This was a panel study involving nationally representative samples of community-dwelling elderly persons from the 1995 and 1999 Medicare Current Beneficiary Surveys (MCBS). For comparison, data were analyzed from samples of disabled Medicare beneficiaries aged <65 years for the same periods. The samples were assessed for the use of 36 individual drugs, drug classes, and combinations carrying a risk for adverse out comes in the elderly based on the 1997 Beers criteria for drugs to be avoided in this population. RESULTS The study samples contained 7628 community-dwelling elderly persons from the 1995 MCBS and 8902 from the 1999 MCBS, and 1863 and 1851 disabled Medicare beneficiaries aged <65 years for the respective survey years. The proportion of elderly patients taking >or=1 drug on the Beers list declined from 24.8% in 1995 to 21.3% in 1999 (P<0.05). There was a nonsignificant increase in the proportion of disabled Medicare beneficiaries taking >or=1 drug on the Beers list from 31.1% in 1995 to 31.5% in 1999. CONCLUSIONS There was a significant decline in the use of potentially inappropriate drugs by elderly patients between 1995 and 1999, particularly in the use of those drugs linked to the most severe outcomes. However, approximately 7 million elderly patients still received potentially inappropriate drugs in 1999, underscoring the continued need for effective interventions to improve prescribing for this vulnerable population.

Are prescribed and over-the-counter medicines economic substitutes? A study of the effects of health insurance on medicine choices by the elderly.

Health services research based on survey data is subject to potentially serious selection bias because observations are typically available only for survey respondents. This study describes a method of assessing and controlling for selection bias in the context of a survey of prescription and over-the-counter drug use by the elderly. A random sample of 6,500 Pennsylvania Medicare enrollees was sent a questionnaire regarding medicine use, insurance coverage, and health status in 1990. Applying a two-stage, limited dependent variable selection model developed by Heckman to baseline Medicare enrollment and utilization data for both respondents (70%) and nonrespondents (30%) allowed us to detect and control for negative and significant nonresponse bias in estimates of prescription drug use. Purchase of over-the-counter medication was free of such bias. The report describes how the Heckman method can be applied in other cases where health services survey samples are generated from program or organizational files that contain person-level data on all members of the sample frame.