Jeanne M. Madden

Cost-related medication nonadherence and spending on basic needs following implementation of Medicare Part D.

CONTEXT 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. OBJECTIVE To estimate changes in CRN and forgoing basic needs to pay for drugs following Part D implementation. DESIGN, SETTING, AND PARTICIPANTS 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. MAIN OUTCOME MEASURES Self-reports of CRN (skipping or reducing doses, not obtaining prescriptions) and spending less on basic needs to afford medicines. RESULTS 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). CONCLUSIONS 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.

Undercover careseekers: Simulated clients in the study of health provider behavior in developing countries

The simulated client method (SCM) has been used for over 20 years to study health care provider behavior in a first-hand way while minimizing observation bias. In developing countries, it has proven useful in the study of physicians, drug retailers, and family planning services. In SCM, research assistants with fictitious case scenarios (or with stable conditions or a genuine interest in the services) visit providers and request their assistance. Providers are not aware that these clients are involved in research. Simulated clients later report on the events of their visit and these data are analyzed. This paper reviews 23 developing country studies of physician, drug retail, and family planning services in order to draw conclusions about (1) the advantages and limitations of the methods; (2) considerations for design and implementation of a simulated client study; (3) validity and reliability; and (4) ethical concerns. Examples are also drawn from industrialized countries, related methodologies, and non-health fields to illustrate the issues surrounding SCM. Based on this review, we conclude that the information gathered through the use of simulated clients is unique and valuable for managers, intervention planners and evaluators, social scientist, regulators, and others. Areas that need to be explored in future work with this method include: ways to ensure data validity and reliability; research on additional types of providers and health care needs; and adaptation of the technique for routine use.

Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study

Objective To investigate if the widely publicized warnings in 2003 from the US Food and Drug Administration about a possible increased risk of suicidality with antidepressant use in young people were associated with changes in antidepressant use, suicide attempts, and completed suicides among young people. Design Quasi-experimental study assessing changes in outcomes after the warnings, controlling for pre-existing trends. Setting Automated healthcare claims data (2000-10) derived from the virtual data warehouse of 11 health plans in the US Mental Health Research Network. Participants Study cohorts included adolescents (around 1.1 million), young adults (around 1.4 million), and adults (around 5 million). Main outcome measures Rates of antidepressant dispensings, psychotropic drug poisonings (a validated proxy for suicide attempts), and completed suicides. Results Trends in antidepressant use and poisonings changed abruptly after the warnings. In the second year after the warnings, relative changes in antidepressant use were −31.0% (95% confidence interval −33.0% to −29.0%) among adolescents, −24.3% (−25.4% to −23.2%) among young adults, and −14.5% (−16.0% to −12.9%) among adults. These reflected absolute reductions of 696, 1216, and 1621 dispensings per 100 000 people among adolescents, young adults, and adults, respectively. Simultaneously, there were significant, relative increases in psychotropic drug poisonings in adolescents (21.7%, 95% confidence interval 4.9% to 38.5%) and young adults (33.7%, 26.9% to 40.4%) but not among adults (5.2%, −6.5% to 16.9%). These reflected absolute increases of 2 and 4 poisonings per 100 000 people among adolescents and young adults, respectively (approximately 77 additional poisonings in our cohort of 2.5 million young people). Completed suicides did not change for any age group. Conclusions Safety warnings about antidepressants and widespread media coverage decreased antidepressant use, and there were simultaneous increases in suicide attempts among young people. It is essential to monitor and reduce possible unintended consequences of FDA warnings and media reporting.

Cost-related medication nonadherence after implementation of Medicare Part D, 2006-2007.

To the Editor: High drug costs cause some elderly or disabled patients to take less medication than prescribed or forgo basic needs to pay for medicines.1,2,3 The 2006 Medicare Part D drug benefit was intended to increase economic access to medicines.4 Data from 2006 indicated modest nationwide decreases in cost-related medication non-adherence (CRN) and forgoing basic needs following Part D implementation, but no decline in high rates of CRN among the sickest beneficiaries.5 We analyzed more recent data to determine whether the reductions remained stable in 2007.

Cost-related medication nonadherence among beneficiaries with depression following Medicare Part D.

CONTEXT Cost-related medication nonadherence (CRN) was problematic for Medicare beneficiaries with depressive symptoms before Medicare Part D. OBJECTIVE To estimate changes in CRN and forgoing basic needs to pay for drugs among Medicare beneficiaries with and without depressive symptoms following Part D implementation. DESIGN AND SETTING The authors compared changes in outcomes between 2005 and 2006 before and after Part D with changes between 2004 and 2005 using logistic regression to control for demographic characteristics, health status, and historical trends. PARTICIPANTS The community-dwelling sample of the Medicare Current Beneficiary Survey (N = 24,234). MAIN OUTCOME MEASURES Self-reports of CRN (skipping or reducing doses and not obtaining prescriptions) and spending less on basic needs to afford medicines. RESULTS The unadjusted annual prevalence of CRN among beneficiaries with depressive symptoms was 27% (2004), 27% (2005), and 24% (2006), compared with 13%, 12%, and 9% among beneficiaries without depressive symptoms. The annual prevalence of spending less on basic needs was 22% (2004), 23% (2005), and 19% (2006), compared with 8%, 9%, and 5% among beneficiaries without depressive symptoms. Controlling for historical changes and demographic characteristics, CRN did not decline among beneficiaries with depressive symptoms compared with beneficiaries without depressive symptoms (ratio of Part D changes 0.98; 95% confidence interval [CI], 0.73-1.32). Respondents with depressive symptoms seemed less likely to spend less on basic needs compared with individuals without depressive symptoms (0.70; 95% CI, 0.49-1.01); however, this difference was not statistically significant. CONCLUSIONS Despite a Medicare Part D goal to improve medication adherence among mentally ill beneficiaries, the disparity in economic access to medications between beneficiaries with and without depressive symptoms did not improve after the start of Part D.

Medicare Part D and Changes in Prescription Drug Use and Cost Burden: National Estimates for the Medicare Population, 2000 to 2007

ContextThe full effect of Medicare Part D, after the initial policy transition period and across the United States Medicare population, remains unclear. ObjectiveTo estimate nationally representative changes in prescription drug use and out-of-pocket drug costs 2 years after implementation of Part D. Design, Setting, and ParticipantsWe 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. Main Outcome MeasuresAnnual prescription drug fills and out-of-pocket drug costs. ResultsWe 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

Use of antipsychotic medications in pediatric populations: what do the data say?

143 (95% CI, −182.5-−103.1) in 2006 and

Cost-Related Medication Nonadherence and Cost-Saving Strategies Used by Elderly Medicare Cancer Survivors

148 (95% CI, −181.2-−114.1) in 2007 above average pre-Part D increases of

Cost-related Medication Nonadherence in Older Patients with Rheumatoid Arthritis

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. ConclusionsAfter 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.

Measuring medicine prices in Peru: validation of key aspects of WHO/HAI survey methodology

Recent reports of antipsychotic medication use in pediatric populations describe large increases in rates of use. Much interest in the increasing use has focused on potentially inappropriate prescribing for non-Food and Drug Administration-approved uses and use amongst youth with no mental health diagnosis. Different studies of antipsychotic use have used different time periods, geographic and insurance populations of youth, and aggregations of diagnoses. We review recent estimates of use and comment on the similarities and dissimilarities in rates of use. We also report new data obtained on 11 health maintenance organizations that are members of the Mental Health Research Network in order to update and extend the knowledge base on use by diagnostic indication. Results indicate that most use in pediatric populations is for disruptive behaviors and not psychotic disorders. Differences in estimates are likely a function of differences in methodology; however, there is remarkable consistency in estimates of use by diagnosis.