Igor Choodnovskiy

Effects of Medicaid Drug-Payment Limits on Admission to Hospitals and Nursing Homes

BACKGROUND Many state Medicaid programs limit the number of reimbursable medications that a patient can receive. We hypothesized that such limitations may lead to exacerbations of illness or to admissions to institutions where there are no caps on drug reimbursements. METHODS We analyzed 36 months of Medicaid claims data from New Hampshire, which had a three-drug limit per patient for 11 of those months, and from New Jersey, which did not. The study patients in New Hampshire (n = 411) and a matched comparison cohort in New Jersey (n = 1375) were Medicaid recipients 60 years of age or older who in a base-line year had been taking three or more medications per month, including at least one maintenance drug for certain chronic diseases. Survival (defined as remaining in the community) and time-series analyses were conducted to determine the effect of the reimbursement cap on admissions to hospitals and nursing homes. RESULTS The base-line demographic characteristics of the cohorts were nearly identical. In New Hampshire, the 35 percent decline in the use of study drugs after the cap was applied was associated with an increase in rates of admission to nursing homes; no changes were observed in the comparison cohort (RR = 1.8; 95 percent confidence interval, 1.2 to 2.6). There was no significantly increased risk of hospitalization. Among the patients in New Hampshire who regularly took three or more study medications at base line, the relative risk of admission to a nursing home during the period of the cap was 2.2 (95 percent confidence interval, 1.2 to 4.1), and the risk of hospitalization was 1.2 (95 percent confidence interval, 0.8 to 1.6). When the cap was discontinued after 11 months, the use of medications returned nearly to base-line levels, and the excess risk of admission to a nursing home ceased. In general, the patients who were admitted to nursing homes did not return to the community. CONCLUSIONS Limiting reimbursement for effective drugs puts frail, low-income, elderly patients at increased risk of institutionalization in nursing homes and may increase Medicaid costs.

Aging and the anticoagulant response to warfarin therapy.

OBJECTIVE To assess the effect of aging on the anticoagulant response to warfarin. DESIGN Retrospective cohort study. SETTING A university hospital outpatient anticoagulation clinic. PATIENTS All patients (n = 530) monitored in the anticoagulation clinic over a 10-year period (1980 to 1990). The 530 study patients had a mean age of 61.5 (+/- 14.7) years (age range, 12 to 90 years). The patients were stratified into four age groups: younger than 50 years (n = 97); 50 to 59 years (n = 107); 60 to 69 years (n = 149); and 70 years or older (n = 177). MEASUREMENTS For each patient, a dose-adjusted mean prothrombin time ratio was calculated by dividing the mean prothrombin time ratio by the mean daily warfarin dose. RESULTS Older patients were more likely to be female (P less than 0.001), to have more medical problems (P less than 0.001), to be taking more medications (P less than 0.001), and to weigh less than younger patients (P less than 0.001). Across age groups, there were no significant differences in the use of medications that potentiated or inhibited the anticoagulant effects of warfarin. The prothrombin time ratio, when adjusted for dose, was significantly increased in older patients (P less than 0.001). The increased anticoagulant response to warfarin seen with increasing patient age persisted even after simultaneously controlling for relevant demographic and clinical variables in a multivariate model. Other factors significantly associated with an increased sensitivity to warfarin included use of a medication with a potentiating interactive effect with warfarin, female gender, and overall medication use. Increased body weight and duration of warfarin use exceeding 6 months were found to be inversely related to anticoagulant response. CONCLUSION The anticoagulant response to warfarin is exaggerated with advancing age. This finding emphasizes the need for close monitoring of older patients treated with warfarin therapy.

Constipation: Assessment and Management in an Institutionalized Elderly Population

OBJECTIVES: To examine prescribing and utilization patterns of laxatives, stool softeners, and enemas in a large, long‐term care facility, to compare self‐reports of constipation with specific, bowel‐related symptoms in residents of this facility, and to examine concordance between bowel symptoms reported by residents and the assessments of the nursing staff.

Epidemiologic and diagnostic aspects of bacteriuria: a longitudinal study in older women.

OBJECTIVE: To examine month‐by‐month variability of bacteriuria in a cohort of older women and to evaluate the performance of rapid diagnostic tests commonly used to indicate the presence of significant bacteriuria.

Aging, Comorbidity, and Reduced Rates of Drug Treatment for Diabetes Mellitus

Advanced age and its related comorbidity may affect both the patterns and goals of diabetes treatment. We examined the relationships of demographic variables and comorbidity with drug treatment for diabetes in the elderly. We studied both the 81,700 residents of New Jersey, aged 65-99 years, who were hospitalized between July 1, 1989 and June 30, 1991 and had prescription drug coverage either through Medicaid or the Pharmacy Assistance for the Aged and Disabled program, and a sample of 80,000 nonhospitalized elderly beneficiaries in these programs. Rates of utilization of insulin or oral hypoglycemic drugs in the 120 days before admission were substantially lower in those aged > or = 85 or in nursing homes. Among patients with previously treated and diagnosed diabetes, the likelihood of treatment after discharge declined with older age (odds ratio [OR] for treatment in those aged > or =85 relative to 65-74 years: 0.57; 95% confidence interval [CI]: 0.45-0.72), nursing home residence (OR: 0.30; CI: 0.22-0.41), and higher levels of comorbidity (OR for modified Charlson index > or = 5 relative to 0: 0.43; CI: 0.27-0.67). In patients who had a discharge diagnosis of diabetes but no prior treatment, those in nursing homes and those with greater comorbidity also had lower rates of diabetes treatment after discharge. Although the prevalence of diabetes increases with age and the risks of many consequences of diabetes remain high, the rate of drug treatment for diabetes declines with older age and greater comorbidity, perhaps because of concern about side effects or reduced treatment benefits due to competing risks of death. Absence of data from randomized clinical trials of diabetes treatment in the elderly appears to have resulted in considerable physician ambivalence on the benefits and risks of glycemic control in older diabetics.

Correlates of regular laxative use by frail elderly persons.

PURPOSE To examine the demographic, clinical, and pharmacological correlates of regular laxative use in elderly persons residing in a long-term care setting. METHODS This was a cross-sectional study using retrospective record review undertaken in an academically affiliated long-term care facility in the United States. All individuals residing in the institution for at least 1 month (n = 694) were characterized regarding use of laxatives. Regular laxative use was defined as more than 30 doses of laxatives, stool softeners, or enemas taken over the most recent 1-month period. RESULTS Residents with regular laxative use (n = 349) were compared with those who received no laxatives (n = 227). Factors significantly associated with regular laxative use at the P < 0.05 significance level were simultaneously included in a multiple logistic regression model. Factors associated with regular laxative use were immobility, Parkinsons disease, diabetes mellitus, and use of iron supplements, calcium channel blockers, and antidepressants with moderate to strong anticholinergic properties. CONCLUSION Regular laxative use is often associated with neurologic dysfunction that directly or indirectly affects the gut, or medications known to depress colonic motility. Identification of potentially modifiable correlates of regular laxative use in older individuals may suggest management strategies to avoid or reduce laxative, stool softener, and enema requirements, improve constipation symptoms, and enhance quality of life for the frail elderly population.

Definition of race and ethnicity in older people in medicare and medicaid

BACKGROUND: Race and ethnicity are important predictors of health care access and outcomes, but quality of their documentation in the healthcare system is often problematic.

Adverse pulmonary effects of topical Beta blockers used in the treatment of glaucoma.

We conducted a case-control study to measure the risk of pulmonary side effects following the use of topical glaucoma medications, particularly the β blockers, and to identify patients at highest risk for such side effects. Patients over age 55 who were active users of the New Jersey Medicaid system during the years 1981–1989 composed the study population. Two case groups were identified: (a) 21,096 patients who began new use of bronchodilator medications and (b) 3,382 patients who were users of a xanthine bronchodilator or inhaled steroid whose regimen was intensified through addition of another medication (generally a sympathomimetic). Controls were Medicaid enrollees with documented use of the Medicaid system. Use of glaucoma medications was measured in the 45 days preceding occurrence of the outcome for cases, and during a comparable period for controls. We found no consistent association between ongoing glaucoma therapy and new use of a bronchodilator; a definitive null result was obtained for timolol (odds ratio = 0.95; 95% CI = 0.84–1.09). However, nonselective topical β blockers remained commonly used among patients already on a bronchodilator regimen. Timolol users were 47% more likely to require addition of another class of bronchodilator than were patients using no glaucoma therapy (odds ratio = 1.47; 95% CI 1.04–2.09; p = 0.03). No increase in risk was found for other glaucoma drugs. These findings suggest that patients with bronchospasm requiring xanthines or inhaled steroids who are prescribed topical timolol for glaucoma may be at significantly increased risk of pulmonary symptom exacerbation requiring additional bronchodilator therapy. No risk was found for the initiation of bronchodilators in previously untreated patients.

Topical glaucoma medications and cardiovascular risk in the elderly.

To determine the frequency of congestive heart failure and cardiac conduction disturbances in elderly patients treated with topical glaucoma medications.