Kimberly A. McGuigan

Impact of Medication Adherence on Hospitalization Risk and Healthcare Cost

Objective:The objective of this study was to evaluate the impact of medication adherence on healthcare utilization and cost for 4 chronic conditions that are major drivers of drug spending: diabetes, hypertension, hypercholesterolemia, and congestive heart failure. Research Design:The authors conducted a retrospective cohort observation of patients who were continuously enrolled in medical and prescription benefit plans from June 1997 through May 1999. Patients were identified for disease-specific analysis based on claims for outpatient, emergency room, or inpatient services during the first 12 months of the study. Using an integrated analysis of administrative claims data, medical and drug utilization were measured during the 12-month period after patient identification. Medication adherence was defined by days’ supply of maintenance medications for each condition. Patients:The study consisted of a population-based sample of 137,277 patients under age 65. Measures:Disease-related and all-cause medical costs, drug costs, and hospitalization risk were measured. Using regression analysis, these measures were modeled at varying levels of medication adherence. Results:For diabetes and hypercholesterolemia, a high level of medication adherence was associated with lower disease-related medical costs. For these conditions, higher medication costs were more than offset by medical cost reductions, producing a net reduction in overall healthcare costs. For diabetes, hypercholesterolemia, and hypertension, cost offsets were observed for all-cause medical costs at high levels of medication adherence. For all 4 conditions, hospitalization rates were significantly lower for patients with high medication adherence. Conclusions:For some chronic conditions, increased drug utilization can provide a net economic return when it is driven by improved adherence with guidelines-based therapy.

Preventing adolescent drug use: long-term results of a junior high program.

OBJECTIVES Although several studies have reported short-term gains for drug-use prevention programs targeted at young adolescents, few have assessed the long-term effects of such programs. Such information is essential for judging how long prevention benefits last. This paper reports results over a 6-year period for a multisite randomized trial that achieved reductions in drug use during the junior high school years. METHODS The 11-lesson curriculum, which was tested in 30 schools in eight highly diverse West Coast communities, focused on helping 7th and 8th grade students develop the motivation and skills to resist drugs. Schools were randomly assigned to treatment and control conditions. About 4000 students were assessed in grade 7 and six times thereafter through grade 12. Program effects were adjusted for pretest covariates and school effects. RESULTS Once the lessons stopped, the programs effects on drug use stopped. Effects on cognitive risk factors persisted for a longer time (many through grade 10), but were not sufficient to produce corresponding reductions in use. CONCLUSIONS It is unlikely that early prevention gains can be maintained without additional prevention efforts during high school. Future research is needed to develop and test such efforts.

A Randomized Clinical Trial of Outpatient Comprehensive Geriatric Assessment Coupled with an Intervention to Increase Adherence to Recommendations

BACKGROUND: Although comprehensive geriatric assessment (CGA) has been demonstrated to confer health benefits in some settings, its value in outpatient or office settings is uncertain.

Profiles of violent youth: substance use and other concurrent problems.

OBJECTIVES This study examined the prevalence of various violent behaviors among high school-age adolescents, the co-occurrence of teenage violence with other public health problems, and gender differences in violence. METHODS Longitudinal data for more than 4500 high school seniors and dropouts from California and Oregon were used to develop weighted estimates of the prevalence of violent behavior and its co-occurrence with other emotional and behavioral problems. RESULTS More than half the sample had engaged in violence during the last year, and one in four had committed predatory violence. Boys were more likely than girls to engage in most types of violence, but both were equally prone to violence within the family. Violent youth were more likely than their peers to have poor mental health, use drugs, drop out of school, and be delinquent. Violent boys were more likely than violent girls to commit nonviolent felonies and sell drugs, but less likely to have poor mental health or become a parent. Prevalence estimates for violence co-occurring with three or more other problems ranged from 4% to 21%. CONCLUSIONS Teenage violence typically coexists with additional emotional and behavioral problems. Programs must consider the broader public health context in which violence occurs.

Accuracy of Recall in Health-Related Quality-of-Life Assessment Among Men Treated for Prostate Cancer

PURPOSE To determine the accuracy of patient recall of health-related quality of life (HRQOL) in men who have undergone radical prostatectomy for early-stage prostate cancer. PATIENTS AND METHODS Patients enrolled onto a longitudinal, observational cohort study of HRQOL after radical prostatectomy for early-stage prostate cancer were asked to assess their baseline HRQOL before surgery. They were later asked to recall their baseline HRQOL at intervals of 7 to 37 months after surgery. The two views of baseline HRQOL (actual and recall) were compared. HRQOL was measured with established instruments (the RAND 12-Item Short-Form Health Survey and a validated short form of the University of California Los Angeles Prostate Cancer Index) that addressed impairment in the physical, mental, urinary, bowel, and sexual domains. RESULTS Overall, recall was poor. Patients tended to remember their baseline HRQOL as being better than it actually was. This effect was particularly striking for urinary and sexual function. Greater education and younger age diminished this effect in some domains. The effect did not vary with time since surgery. CONCLUSION Men undergoing radical prostatectomy for early-stage prostate cancer do not accurately recall their pretreatment HRQOL when asked several months or years later. This recall bias is constant throughout a period of 6 months to 3 years after surgery. By collecting data before treatment and observing subjects longitudinally, investigators can ensure that HRQOL changes are analyzed in the context of any impairment that may have been present at baseline. If a longitudinal study is not feasible, then great caution must be used if patients are asked to recall their pretreatment HRQOL.

Does Early Drug Use Increase the Risk of Dropping out of High School

This study examines the impact of early adolescent drug use on subsequent dropping out of high school in a sample of 4,390 adolescents from California and Oregon. Participants were initially surveyed in 7th grade in 1985 and again in 1990 when they should have completed 12th grade. Logistic regression analyses show that frequency of cigarette use during 7th grade predicts dropping out of high school, controlling for demographics, family structure, academic orientation, early deviance, and school environment. Separate analyses by race/ethnicity replicate this finding for Asians, Blacks, and whites, but not for Latinos. For Latinos, early marijuana use predicts dropping out. The results suggest that preventing or reducing the incidence of early smoking and marijuana use may help reduce the probability of dropping out of high school.

Predictors of Late-Onset Smoking and Cessation Over 10 Years

PURPOSE To identify predictors of smoking onset and cessation between early (age 13 years) and late adolescence (age 18 years) and between late adolescence (age 18 years) and young adulthood (age 23 years). METHODS We employed logistic regression to predict smoking initiation and cessation for an ethnically diverse sample of 3056 adolescents recruited from 30 West Coast schools in 1985 and observed from age 13 to age 23 years. Fifty-six percent of the sample was female. Predictors tapping sociodemographic characteristics, environmental influences, attitudes and beliefs about smoking, bonds with school, and problem behavior were measured at age 13 years (older teenager models) and at age 18 years (young adult models). RESULTS Robust predictors of both initiation and cessation across the two developmental periods included doing poorly in middle/high school and prior smoking behavior. Predictors common to three of the four models included being young for ones grade cohort and intending to smoke in the next 6 months. Early deviant behavior and drinking fostered initiation among older teenagers, but problem behavior as an older teenager did not predict young adult initiation. Smokers who had few or no high school friends who smoked and felt able to resist prosmoking pressures at age 18 years were more likely to quit by age 23 years. Being female predicted initiation by age 18 years; being African-American, Hispanic, or Asian inhibited it. CONCLUSIONS The strong association of prior smoking behavior and intentions with later smoking status among both adolescents and young adults underscores the importance of starting smoking prevention early and continuing it through high school. Such programs might also consider the greater vulnerability of females, youth who are young for their grade cohort, and those who are doing poorly in school.

Physician Attitudes and Experience Regarding the Care of Patients With Acquired Immunodeficiency Syndrome (aids) and Related Disorders (arc)

The number of patients with acquired immunodeficiency syndrome (AIDS) continues to increase. These patients require medical care from physicians who are well trained and who are willing to provide that care. In 1985, we undertook a survey of 314 heterosexual and homosexual physicians in Los Angeles County to determine their willingness and perceived ability to care for patients with AIDS. This survey indicates that most physicians believe that special clinics staffed by physicians who have a particular expertise in caring for AIDS patients should be established. Many of the physicians surveyed indicated that concerns about the risk of contagion with AIDS is a deterrent to treating AIDS patients. Current evidence indicates this concern is unfounded. Both heterosexual and homosexual physicians indicated a lack of medical knowledge and experience regarding the opportunistic infections and cancers that are associated with AIDS, although many physicians in both groups expressed a desire to receive more training in this regard. Our survey indicates that there is a definite need for more clinically based training opportunities for physicians who would like to provide care for AIDS patients. If such training were to become available, it is likely that sufficient numbers of physicians would be willing to care for AIDS patients.

The Effects of Antidepressant Step Therapy Protocols on Pharmaceutical and Medical Utilization and Expenditures

OBJECTIVE This study examined the effects of step therapy for antidepressants on prescription drug and other medical utilization and spending. Step therapy is a type of pharmaceutical benefit design that requires that patients try certain specified medications (typically generic medications) prior to using alternative, more expensive medications within the same medication class. Step therapy is not the same as generic substitution. METHOD Using the 2003-2006 Thomson Reuters MarketScan claims databases, antidepressant users enrolled in employer plans that implemented antidepressant step therapy were compared with antidepressant users enrolled in employer plans that had not implemented step therapy. Multivariate generalized estimating equation models were used to analyze the relationship between step therapy for antidepressants and 1) pharmacy and medical utilization and 2) spending. RESULTS Antidepressant days supplied and medication costs decreased after step therapy was implemented, relative to the comparison group. However, overall and mental health-specific inpatient and emergency room utilization and costs increased. CONCLUSIONS Step therapy may have the unintended effect of reducing overall antidepressant use and increasing medical use and costs.

Rationing or rationalizing children's medical care: comparison of a Medicaid HMO with fee-for-service care.

OBJECTIVES This paper examines how medical care obtained by children enrolled in a Medicaid health maintenance organization (HMO) differs from that obtained by similar children who receive care from fee-for-service Medicaid providers. METHODS In a randomized trial, some Medicaid households were assigned to remain in a traditional fee-for-service arrangement and others were randomly selected to join a Medicaid prepaid plan (an HMO). Participating households recorded data on childrens health status and use of medical care. RESULTS The prepaid plan members and the fee-for-service recipients received equivalent numbers of checkup visits, but the children in the prepaid plan made significantly fewer acute care visits. This plan appeared to target its services to children with the greatest health care needs. However, the content of health visits in the two systems did not differ, nor did prepaid and fee-for-service enrollees use the emergency room differently. CONCLUSIONS It is possible to design a Medicaid HMO that achieves financial savings without reducing services to the most vulnerable patients. However, these findings alone do not provide a basis for widespread policy change in the direction of Medicaid HMOs. Further research is needed to establish whether the children treated in the HMO differed in health outcomes from those treated by fee-for-service care.