Linda Simoni-Wastila

Trends and geographic variation of opiate medication use in state medicaid fee-for-service programs, 1996 to 2002

Background:Although studies have documented hospital and surgical service geographic variability, prescription use geographic variability is largely unknown. Opiate pain medications are widely used, particularly because the promulgation of clinical guidelines promoting aggressive pain treatment. This study describes temporal and interstate variability in aggregate prescription opiate medication use within U.S. Medicaid programs. Methods:A dataset of 49 states’ fee-for-service (FFS) Medicaid prescription drug dispensing records from 1996 to 2002 was compiled and used to quantify medication dispensing examining all opiates, controlled release oxycodone, and methadone. The defined daily dose (DDD) per 1000 FFS Medicaid adult enrollees per day was calculated for all opiate medication categories. A market basket of nonpain prescription medications was constructed for comparison. Rates, trends, and the coefficient of variation were determined overall, by year and for each state. Results:From 1996 to 2002, overall use of opiate pain medications increased 309%. The market basket use increased 170%. Total opiate dispensing varied widely from state to state, with a range of 6.9 to 44.1 DDD/1000/d in 1996, and 7.1 to 165.0 DDD/1000/d (a 23-fold difference) in 2002. The coefficient of variation was 49.6 in 2002. Controlled release oxycodone and methadone had a greater rate of increase compared with all opiates. Conclusions:The dispensing of opiate medications in Medicaid programs increased at almost twice the rate of nonpain-related medications during the 7-year study period. Large, unexplained geographic variation in aggregate use exists. The impact of Medicaid cost-containment strategies on utilization and outcomes should be investigated.

GENDER AND PSYCHOTROPIC DRUG USE

OBJECTIVESnAlthough studies have documented womens greater use of prescribed psychotropic drugs, few have explicitly examined how women and men differ in psychotropic drug use. This study examines gender differences in aggregate psychotropic drug use, as well as use of specific therapeutic categories, and explores how other factors explaining psychotropic drug use vary by gender.nnnMETHODSnUsing 1989 National Ambulatory Medical Care Survey (NAMCS) data, logistic regression analysis is used to estimate the probability of psychotropic drug use in aggregate and for four therapeutic categories--anxiolytics, sedative-hypnotics, antidepressants, and antipsychotics. For equations where gender is statistically significant, separate logistic regression equations are estimated to determine the explanatory variables that vary by gender.nnnRESULTSnThe probability of receiving any psychotropic drug is 55% greater in office visits by women than those by men, all else constant. Further, gender is a positive and significant predictor of anxiolytic and antidepressant use. Variables estimating anxiolytic and antidepressant use that differ by gender include diagnosis, physician specialty, and payment source for the office visit.nnnCONCLUSIONSnFindings confirm research that has demonstrated that women are more likely than men to receive any psychotropic drug in office-based care. This gender differential holds only for anxiolytics and antidepressants. In addition, there were significant differences in the predictors of drug use for women and men.

Inappropriate drug use and risk of transition to nursing homes among community-dwelling older adults.

Background:Adverse events from inappropriate medications are preventable risk factors for nursing home admissions. Objective:We sought to investigate the relationship between inappropriate medications in older adults and transitions to nursing home. Methods:A retrospective cohort of Medicare beneficiaries with employer-sponsored supplemental health insurance was analyzed using a longitudinal data set of Medicare supplemental insurance claims. After a baseline year with no nursing home admissions, subjects were followed until the first month of transition to nursing home, loss to follow-up, or the end of the 24-month follow-up period. Survival analysis was used to compare the risk of nursing home transition among those with and without inappropriate drug use in the previous 3 months. Results:Of the 487,383 subjects in the cohort, 22,042 (4.5%) had a nursing home admission. Use of inappropriate drugs was associated with a 31% increase in risk of nursing home admission, compared with no use of inappropriate drugs (adjusted relative risk 1.31, 99% confidence interval [CI] 1.26–1.36). Analyses of individual drug classes showed the risk of nursing home admission was similar, or lower, for inappropriate drugs versus other drugs of the same class. For example, the relative risk of nursing home admission was 2.34 (99% CI 2.20–2.47) for inappropriate narcotics and 2.68 (99% CI 2.55–2.82) for other narcotics, compared with no narcotic use. Conclusion:Inappropriate drug use was associated with increased risk of nursing home transition, but the increased risk may be explained by underlying patient conditions for which the drugs were prescribed rather than the inappropriate drug.

A controlled study of the effects of state surveillance on indicators of problematic and non-problematic benzodiazepine use in a Medicaid population.

Objective: Benzodiazepines (BZs) are safe, effective drugs for treating anxiety, sleep, bipolar, and convulsive disorders, but concern is often expressed about their overuse and potential for abuse. We evaluated the effects of physician surveillance through a Triplicate Prescription Program (TPP) on problematic and non-problematic BZ use. Method: This study uses interrupted time series analyses of BZ use in the New York (intervention) and New Jersey (control) Medicaid programs for 12 months before and 24 months after the New York BZ TPP. The regulation required NY physicians to order BZs on triplicate prescription forms with one copy forwarded by pharmacies to a state surveillance unit. Study participants were community-dwelling persons over age 18 continuously enrolled between January 1988 and December 1990 in New York (n = 125,837) or New Jersey Medicaid (n = 139,405). Results: During the baseline year, 20.2% of New York and 19.3% of New Jersey cohort members received at least one BZ prescription. After the TPP, there was a sudden, sustained reduction in BZ use of 54.8% (95% CI = [51.4%, 58.3%]) in New York with no changes in New Jersey. Significantly greater reductions were experienced by young women, and persons living in zip codes that were urban, predominantly Black, or with a high density of poor households. Increases in potential substitute medications were modest. At baseline, nearly 60% of BZ recipients had no evidence of potentially problematic use. Despite a somewhat greater likelihood of discontinuation of BZ therapy among those with potentially problematic use, the largest impact of the TPP was a substantially greater relative reduction in access to BZs among non-problematic users. Conclusions: State-mandated physician surveillance dramatically reduces BZ use with limited substitution of alternative drugs, lowers rates of possible abuse, but may severely limit non-problematic BZ use.

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

OBJECTIVE To assess the relationship between annual fills for antidiabetes medications, ACE inhibitors, angiotensin II receptor blockers (ARBs), and lipid-lowering agents on hospitalization and Medicare spending for beneficiaries with diabetes. RESEARCH DESIGN AND METHODS Using Medicare Current Beneficiary Survey data from 1997 to 2004, we identified 7,441 community-dwelling beneficiaries with diabetes, who contributed 14,317 person-years of data for the analysis. We used multivariate regression analysis to estimate the effect of persistency in medication fills on hospitalization risk, hospital days, and Medicare spending. RESULTS For users of older oral antidiabetes agents, ACE inhibitors, ARBs, and statins, each additional prescription fill was associated with significantly lower risk of hospitalization, fewer hospital days, and lower Medicare spending. CONCLUSIONS These results suggest an economic case for promoting greater persistency in use of drugs with approved indications by Medicare beneficiaries with diabetes; however, additional research is needed to corroborate the studys cross-sectional findings.

A retrospective data analysis of the impact of the New York triplicate prescription program on benzodiazepine use in medicaid patients with chronic psychiatric and neurologic disorders

BACKGROUNDnBenzodiazepines are treatment mainstays for several disorders, but there is often concern about dependency and addiction. In January 1989, New York implemented regulations requiring physicians to order benzodiazepines using state-monitored triplicate prescription forms.nnnOBJECTIVEnThe purpose of this study was to assess the effects of the triplicate prescription program (TPP) on changes in use of benzodiazepines and other psychoactive drugs in clinically vulnerable Medicaid populations.nnnMETHODSnUsing an interrupted time series with comparison series design, psychoactive medication use was examined in the New York (intervention) and New Jersey (control) Medicaid programs before and after implementation of the New York benzodiazepine TPP among community-dwelling Medicaid beneficiaries aged >/=19 years continuously enrolled from January 1988 through December 1990 in New York or New Jersey with diagnoses of schizophrenia, schizophreniform disorder, schizoaffective disorder, schizoid personality disorder, or schizotypal personality disorder; bipolar disorder; epilepsy; and/or panic disorder, agoraphobia without history of panic disorder, social phobia, or specific phobia.nnnRESULTSnA total of 125,837 New York and 139,405 New Jersey Medicaid beneficiaries were continuously enrolled and met the study inclusion criteria. Of these, there were 6054 Medicaid enrollees in New York and 6875 enrollees in New Jersey who were clinically vulnerable patients with >/=1 of the specified diagnoses. New York Medicaid patients with any of these diagnoses experienced a -48.1% relative change (95% CI, -50.0% to -46.2%) in benzodiazepine use at 6 months after TPP implementation, with no decline in use in New Jersey patients. The largest reduction in benzodiazepine use was seen among patients with seizure disorder (-59.9% at 6 months; 95% CI, -63.9% to -55.9%). Although use of substitute drugs increased slightly in New York after the TPP, it did not offset reductions in benzodiazepine use. The effects of TPP were sustained for 7 years of follow-up and had the greatest impact on nonproblematic benzodiazepine use.nnnCONCLUSIONSnDuring the time period studied in this analysis, the New York TPP reduced benzodiazepine use among chronically ill patients for whom these agents represent effective treatment. Our findings suggest that many patients previously receiving benzodiazepines did not receive any pharmacologic intervention.

Algorithm for Identifying Nursing Home Days Using Medicare Claims and Minimum Data Set Assessment Data.

Background:No consensus exists about methods of measuring nursing home (NH) length-of-stay for Medicare beneficiaries to identify long-stay and short-stay NH residents. Objectives:To develop an algorithm measuring NH days of stay to differentiate between residents with long and short stay (≥101 and <101 consecutive days, respectively) and to compare the algorithm with Minimum Data Set (MDS) alone and Medicare claims data. Research Design:We linked 2006–2009 MDS assessments to Medicare Part A skilled nursing facility (SNF) data. This algorithm determined the daily NH stay evidence by MDS and SNF dates. NH length-of-stay and characteristics were reported in the total, long-stay, and short-stay residents. Long-stay residents identified by the algorithm were compared with the NH evidence from MDS-alone and Medicare parts A and B data. Results:Of 276,844 residents identified by our algorithm, 40.8% were long stay. Long-stay versus short-stay residents tended to be older, male, white, unmarried, low-income subsidy recipients, have multiple comorbidities, and have higher mortality but have fewer hospitalizations and SNF services. Higher proportions of long-stay and short-stay residents identified by the MDS/SNF algorithm were classified in the same group using MDS-only (98.9% and 100%, respectively), compared with the parts A and B data (95.0% and 67.1%, respectively). NH length-of-stay was similar between MDS/SNF and MDS-only long-stay residents (mean±SD: 717±422 vs. 720±441 d), but the lengths were longer compared with the parts A and B data (approximately 474±393 d). Conclusions:Our MDS/SNF algorithm allows the differentiation of long-stay and short-stay residents, resulting in an NH group more precise than using Medicare claims data only.

Impact of Part D low-income subsidies on medication patterns for Medicare beneficiaries with diabetes.

Background:It is not known whether low-income subsidies (LIS) under Medicare Part D help beneficiaries overcome impediments to medication use associated with poor socioeconomic status and high disease burden. Objectives:To compare Medicare beneficiaries with LIS and Medicaid (duals), LIS without dual eligibility, and non-LIS recipients on use of medications recommended in diabetes treatment. Research Design:Fixed-effect comparisons among beneficiaries in the same Part D plans in 2006–2007. Subjects:Nationally representative sample of enrollees in Part D prescription drug plans. A total of 109,292 beneficiaries were in 204 prescription drug plans; 47.5% non-LIS, 44.4% duals, and 8.1% nondual LIS recipients. Measures:Medications included antidiabetic agents, renin-angiotensin-aldosterone system inhibitors, and antihyperlipidemics. Drug use was measured by exposure, duration of therapy, and medication possession ratio. Results:The LIS dual cohort had significantly higher comorbidity compared with non-LIS comparisons, LIS nonduals were significantly more likely to take medications in all 3 drug classes compared with non-LIS recipients, but differences were small (between 2% and 4%; P<0.05). Non-LIS recipients and duals had equivalent exposure to any antidiabetic drug and antihyperlipidemics, but duals were 3% less likely to receive renin-angiotensin-aldosterone system inhibitors compared with non-LIS recipients (P<0.05). Small differences in adjusted values for duration of therapy and medication possession ratio among the 3 cohorts were also observed, none of which were clinically meaningful. Conclusions:Similarities in medication utilization among Part D enrollees with and without LIS coverage supports the program objective of providing enhanced access to needed medications for diverse groups of Medicare beneficiaries.

Association between Depression and Maintenance Medication Adherence among Medicare Beneficiaries with COPD

Depression is a significant comorbidity in patients with chronic obstructive pulmonary disease (COPD). Although comorbid depression is associated with low use and poor adherence to medications treating other chronic conditions, evidence of the relationship between depression and COPD management is limited. This study estimated the association between depression and COPD maintenance medication (MM) adherence among patients with COPD.

Health care use in depressed, elderly, cardiac patients and the effect of antidepressant use

PURPOSEnThe association between a diagnosis of depression after a thromboembolic event (TEE) and an increase in acute health care use was examined.nnnMETHODSnA cohort of Medicare beneficiaries who were 65 years of age and older, who resided in the community, and who also experienced a TEE was constructed from the 1997-2001 Medicare Current Beneficiary Survey. Beneficiaries were assessed for TEEs and depression using the International Classification of Diseases, 9th Revision, Clinical Modification codes listed on Medicare claims. Time to first emergency department (ED) visit, inpatient hospitalization, and outpatient hospital visit were assessed using Cox-proportional hazard models. Counts of offices visits were assessed using negative binomial-regression models.nnnRESULTSnOf the 7051 elderly patients included in the analysis, the total number with a claim for depression within 6 months of having a TEE was 380 (5.4%), including 259 antidepressant users (68.2% of depressed elders) and 198 selective serotonin-reuptake inhibitor (SSRI) users (76.4% of antidepressant users). Over half of elders with a depression claim (52.4%) had an inpatient hospitalization within 12 months of having a TEE compared to one third of the entire study sample (36.4%). Depressed elders had a 51% greater risk of hospitalization, a 56% greater risk of ED visits, and a 19% greater risk of outpatient visits. Antidepressant use did not affect the findings and was not found to be associated with health care use.nnnCONCLUSIONnA claim for depression by Medicare patients was associated with the increased use of acute health care services, including hospitalizations and ED visits, in the 12 months following a TEE. Neither antidepressant use nor SSRI use was associated with an increase or reduction in risk of using such services.