Theresa I. Shireman

Costs and health effects of osteoporotic fractures

The objective of this study is to estimate the short- and long-term direct health care costs of hip, spine, and forearm fractures occurring during the remaining lifetimes of white post-menopausal women and to provide a prototype for estimating avoided costs of fractures in future cost-effectiveness analyses. A Markov model that uses population-based data and Monte Carlo simulations to estimate lifetime fracture risk, fracture-related functional impairment, and fracture-related costs for cohorts of individuals while controlling for competing causes of functional impairment and, hence, long-term costs is presented. Five cohorts of 10,000 women, each of a different age group, were simulated to obtain estimates of remaining lifetime fractures, functional impairment, and costs. Additional simulations tested the impact of discharge rates to and continued residence in nursing homes. Acute fracture care costs, nursing home annual cost, cost of community-based long-term care, and discount rates were varied in sensitivity analyses. Cohort costs were applied to the 1990 population distribution of U.S. white women to project future costs of women currently aged 45 years of age and older. Among hip, spine, and forearm fractures, hip fractures were determined to account for 36-50% of remaining lifetime fractures depending on age group of the cohort. Similarly, hip fractures were determined to account for 67-79% of fracture-related dependent functioning, 87-100% of fracture-related nursing home placement, and 87-96% of short-term fracture costs. Among white U.S. women aged 45 or older, an estimated 5.2 million hip, spine, and forearm fractures; 2 million person-years of fracture-related functional impairment; and

Combined Anticoagulant–Antiplatelet Use and Major Bleeding Events in Elderly Atrial Fibrillation Patients

45.2 billion total direct medical costs can be expected in the next 10 years. Women aged 65-84 were estimated to experience the largest number of fractures, person-years of fracture-related impaired function, and fracture care costs in the next 10 years. Estimated lifetime cost was particularly sensitive to assumptions about fracture-related nursing home utilization rates. The future health and economic impact of established osteoporosis is expected to be substantial. Because we have included only three fracture sites, our estimates are likely to be conservative. Osteoporosis interventions that can reduce the need for fracture-related extended nursing home care and that are effective among women aged 65-84 are likely to be particularly cost-effective.

Relationship between Asthma Drug Therapy Patterns and Healthcare Utilization

Background and Purpose— Bleeding risks from combined antiplatelet-warfarin therapy have not been well-described in clinical practice. We examined antiplatelet therapy among warfarin users and the impact on major bleeding rates. Methods— Retrospective cohort analysis of persons discharged on warfarin after an atrial fibrillation admission using data from Medicares National Stroke Project. Data included Medicare claims, enrollment information, and medical record abstracted data. Logistic regression and Cox proportional hazards models were used to predict concurrent antiplatelet use and hospitalization with a major acute bleed within 90 days after discharge from the index AF admission. Results— 10 093 warfarin patients met inclusion criteria with a mean age of 77 years; 19.4% received antiplatelet therapy. Antiplatelet use was less common among women, older persons, and persons with cancer, terminal diagnoses, dementia, and bleeding history. Persons with coronary disease were more likely to receive an antiplatelet agent. Antiplatelets increased major bleeding rates from 1.3% to 1.9% (P=0.052). In the multivariate analysis, factors associated with bleeding events included age (OR, 1.03; 95% CI, 1.002 to 1.05), anemia (OR, 2.52; 95% CI, 1.64 to 3.88), a history of bleeding (OR, 2.40; 95% CI, 1.71 to 3.38), and concurrent antiplatelet therapy (OR, 1.53; 95% CI, 1.05 to 2.22). Conclusions— Although concerns about increased bleeding risk with combined warfarin-antiplatelet therapy are not unfounded, the risk of bleeding is moderately increased. The decision to use concurrent antiplatelet therapy appears to be tempered by cardiac and bleeding risk factors.

The prevalence of and factors associated with chronic atrial fibrillation in Medicare/Medicaid-eligible dialysis patients

BACKGROUND AND OBJECTIVE: Asthma drug therapy problems contribute significantly to preventable hospitalizations and increased healthcare use in asthmatics. Since asthma patients often require >1 medication for control of symptoms, concurrent asthma drug therapies may be important in predicting excessive healthcare utilization. The purpose of this study was to link inappropriate asthma drug therapy patterns and selected patient demographics to healthcare utilization. METHODS: This study was a retrospective, cross-sectional analysis of Ohio Medicaid medical, institutional, and prescription claims. We included ambulatory patients aged 15–65 years who had ≥2 claims for asthma (493.x) and who were continuously enrolled in the Medicaid fee-for-service program for the 12-month period from April 1998 through March 1999. We examined age, race, gender, metropolitan residence, presence of gastroesophageal reflux disease, and the usage patterns of inhaled corticosteroids, short-acting β2-agonists, long-acting β2-agonists, theophylline, and leukotriene receptor modifiers to identify asthma drug therapy problems based on national guidelines. The primary outcomes included the number of asthma-related hospitalizations, asthma-related emergency department visits, and oral steroid bursts. RESULTS: Among 10 959 asthma patients, only 46.8% of the study patients received >1 puff of inhaled corticosteroid per day. Forty-four percent of the patients received >3 puffs of short-acting β2-agonists per day. The most common outcome was an oral steroid burst (46.5%). Patients on high doses of short-acting β2-agonists had the greatest odds of receiving an oral steroid burst and were most likely to be hospitalized. African Americans were more likely to incur a hospitalization or emergency department visit. Women had greater odds of any undesirable asthma outcome. Higher use of short-acting β2-agonists led to higher odds of receiving a steroid burst or being hospitalized. Leukotriene receptor modifier use was related to higher levels of all outcomes. CONCLUSIONS: A large percentage of Ohio Medicaid patients were not receiving asthma medications in compliance with the National Heart, Lung, and Blood Institute guidelines. Despite nearly a decade of national efforts, asthma drug therapy patterns still have substantial room for improvement and continue to be associated with excess healthcare utilization.

Effect of varying levels of disease management on smoking cessation: a randomized trial.

Atrial fibrillation is an important comorbidity with substantial therapeutic implications in dialysis patients but its prevalence varies in different studies. We used a database that includes patients in the United States on hemodialysis who were eligible for government assistance with prescription drugs. We then used ICD-9 codes from billing claims in this database to identify patients with chronic atrial fibrillation. Multivariable logistic regression was used to determine adjusted prevalence odds ratios for associated factors. Of 63,884 individuals, the prevalence of chronic atrial fibrillation was 7%. The factors of age over 60 years, male, Caucasian, body mass index over 25 kg/m(2), coronary artery disease, and heart failure were all significantly associated with chronic atrial fibrillation. Prevalence rates, particularly in younger patients, were far higher than those reported in an age group-matched nondialysis population. Thus, given its clinical impact, future efforts are needed to examine risk factors for adverse outcomes in chronic atrial fibrillation, and to identify appropriate management strategies for this disorder, as well as opportunities for quality improvement in this vulnerable population.

Time costs associated with cervical cancer screening.

Context Smoking cessation is difficult and may require repeated or intensive interventions. Contribution In this multicenter trial, 750 primary care patients who smoked at least 10 cigarettes per day were randomly assigned to pharmacotherapy (nicotine patch or bupropion), pharmacotherapy supplemented with up to 2 calls from trained counselors, or pharmacotherapy supplemented with up to 6 counseling calls. Utilization of the interventions, which were offered every 6 months for 2 years, declined over time. Smoking abstinence rates at 2 years were 23%, 24%, and 28% in the 3 groups. Caution Pharmacotherapy was free. Smoking abstinence was self-reported. The Editors Cigarette smoking is a chronic illness characterized by repeated cycles of quit attempts and relapse. Most models for addressing smoking cessation are based on single, short-term interventions lasting only a few weeks or months (1). Although most smokers will not quit after a single intervention, few studies have addressed the chronic nature of nicotine dependence by providing systematic, repetitive treatment opportunities (1). Providing treatment only to smokers who are already prepared to quit further limits the reach of current smoking cessation interventions (2). New models of chronic disease care might provide an alternative approach for expanding the reach and effectiveness of smoking cessation efforts (3). Physicians are in direct contact with approximately 70% of smokers each year (4, 5). Their potential role in promoting smoking cessation has been well delineated and incorporated into current clinical practice guidelines (1). With the development of new, more effective prescription pharmacotherapy for smoking cessation, the role of primary care practices in promoting smoking cessation is now more important than ever. Unfortunately, only half of the smokers who see their physicians are asked about their smoking (6), and even fewer receive advice from their health care provider to quit or receive pharmacotherapy or follow-up (4, 7). Smoking cessation counseling competes with other pressing clinical tasks, and beyond brief advice, many physicians feel they are too busy to routinely and repeatedly counsel participants who smoke (810). To assist primary care physicians in the treatment of rural smokers, we developed KanQuit, a smoking cessation program based on the chronic care model (4), which integrates principles of disease management into the treatment of smokers seen in rural primary care. Our objective was to enroll smokers, regardless of their willingness to quit, into a disease registry and compare cessation rates among smokers who received pharmacotherapy alone or combined with either moderate-intensity or high-intensity disease management that includes counseling and provider feedback. Methods Design Overview We did a randomized, single-blind trial of varying levels of disease management for smoking cessation. We recruited participants who smoked more than 10 cigarettes per day from rural primary care clinics across Kansas and randomly assigned them to receive pharmacotherapy alone, pharmacotherapy supplemented by 1 to 2 counseling calls every 6 months (moderate-intensity disease management), or pharmacotherapy supplemented by up to 6 counseling calls every 6 months (high-intensity disease management). For recipients of moderate-intensity and high-intensity disease management, we faxed periodic progress reports to their physician. We offered all participants free pharmacotherapy (either bupropion or transdermal nicotine patch) every 6 months. We enrolled participants from June 2004 to October 2005 and followed them for 24 months, completing follow-up in December 2007. All participants provided written informed consent. The University of Kansas Medical Centers Human Subjects Committee approved the study. Setting and Participants We conducted our study in 50 rural primary care practices in the Kansas Physicians Engaged in Prevention Research network (11). As part of a rural primary care research experience, trained medical students systematically screened participants, identified smokers, and recruited them for this study, regardless of their interest in quitting (12). We considered smokers eligible if they had a primary care physician who participated in this study; were older than 18 years; smoked more than 10 cigarettes per day for at least 1 year and for at least 25 of the past 30 days; spoke English; and had a telephone. We excluded smokers if they were pregnant or planned to become pregnant, planned to move out of the study area, had signs of dementia or mental illness that would preclude participation, or lived with a smoker already enrolled in the study. Of the 1827 smokers we screened, 61% met criteria for study entry (Figure 1). Of these, we enrolled 67%. Figure 1. Study flow diagram. HDM = high-intensity disease management; MDM = moderate-intensity disease management; PM = pharmacotherapy management. Randomization and Interventions Participant Randomization Randomization occurred at the participant level. A computer-generated random-number table was used to generate allocation cards in blocks of 24, with allocation equally distributed across treatment groups. To conceal allocation, we placed these cards in sequentially numbered, opaque, sealed envelopes. After research assistants verified participant eligibility and completed the baseline assessment, the project director opened the next sequential sealed envelope and determined the participants treatment allocation. One of 9 counselors trained in smoking cessation and motivational interviewing (12) conducted all interventions from a single central site. We assigned participants to counselors without regard to practice site. Pharmacotherapy At baseline, all smokers received a health education mailing that consisted of a welcome letter, information about the use of bupropion and the nicotine patch for smoking cessation, and copies of You Can Quit Smoking: Consumer Guide (13) and When Smokers QuitThe Health Benefits Over Time (14). At baseline and at 6, 12, and 18 months, participants received a mailed offer for free pharmacotherapy that consisted of either a 6-week course of a nicotine patch (21 mg/d) or a 7-week course of sustained-release bupropion (150 mg twice daily). Participants interested in using either medication could return a postage-paid postcard or call a toll-free number. We screened all participants who requested pharmacotherapy for potential contraindications (15). Participants with absolute contraindications for a given drug were ineligible to receive that drug but were offered the option of receiving the other drug. Participants with contraindications to both drugs were not eligible to receive medication from the study but could participate in all other aspects of the intervention. For participants who requested bupropion and those with relative contraindications to the nicotine patch, research staff faxed a prescription request to their primary care physicians. This prescription request delineated any relative contraindications or potential drug interactions. For these participants, their physicians made the final assessment of the appropriateness of the bupropion or the patch. For participants without contraindications to the nicotine patch or on receipt of a faxed, signed prescription, the bupropion or patches were mailed to the participant along with instructions for use. Disease Management In addition to pharmacotherapy, the moderate-intensity and high-intensity disease management groups received educational support, telephone counseling, and periodic progress reports with counseling suggestions faxed to their physician. Every 6 months, they received a KanQuit newsletter that addressed tips on quitting smoking, talking with their physician about smoking, and using pharmacotherapy for cessation. The newsletters were personalized to include study updates, counselor photographs, physician feature stories, and testimonials of participants who had quit smoking. We offered participants assigned to moderate-intensity disease management up to 2 telephone-based counseling sessions every 6 months (1 session to promote a quit attempt and 1 additional follow-up session for those who made a quit attempt). We offered participants assigned to high-intensity disease management up to 6 counseling calls every 6 months to either promote quitting or prevent relapse. We scheduled calls at the participants convenience, and they varied according to the participants quit plan but followed a rough schedule of calls at 1, 3, 6, 9, and 16 weeks after the onset of each 6-month treatment cycle. Counselors used motivational interviewing techniques and followed a semistructured protocol to promote a cessation attempt or, for abstinent smokers, to encourage relapse prevention. During counseling calls, case managers reminded participants about the availability of pharmacotherapy and, for interested participants, provided immediate support for acquiring either the nicotine patch or bupropion, as described previously. We faxed personalized progress reports with suggestions for interventions to the participants physician after the first counseling call (both moderate-intensity and high-intensity disease management participants) and after the last counseling call (high-intensity disease management participants only) during each 6-month cycle. We faxed additional progress reports to the participants physician whenever the moderate-intensity or high-intensity disease management participant set a quit date. Outcomes, Measurements, and Follow-up Research assistants who were blinded to treatment group assignment conducted assessments by telephone at baseline and at 6, 12, 18, and 24 months. Primary Outcome The primary outcome measure was self-reported 7-day abstinence at 24 months, defined as not having smoked a cigarette during the previous 7 days. Although self-reported abstinence has been co

Quality of diabetes care for adults with developmental disabilities

OBJECTIVES Time costs borne by women when undergoing cervical cancer screening have rarely been elucidated, although such costs may pose substantial barriers to care. The purpose of this project was to quantify the opportunity costs associated with cervical cancer screening in young women attending Planned Parenthood Clinics. METHODS We conducted a self-report survey of 105 women from six clinics to measure travel, waiting, and exam times associated with cervical cancer screening. Respondents recorded their time of arrival and departure, length of time in the waiting room, age, income level, and hours per week they worked outside of the home. Time costs were valued three ways: through self-reported hourly wage, age- and gender-adjusted minimum earnings, and national age- and gender-adjusted hourly wages. RESULTS Respondents were on average 24 years old, worked 29 hours per week outside the home, and earned less than

Differing patterns of antiresorptive pharmacotherapy in nursing facility residents and community dwellers.

20,000 per year. Mean time for one-way travel was 18.7 minutes; waiting room time was 16.9 minutes; and exam time was 50.8 minutes. Time costs were estimated to be

Patterns of Potentially Inappropriate Medication Use Across Three Cohorts of Older Medicaid Recipients

14.08 per visit based upon the self-reported hourly wage;

Improving refill adherence and hypertension control in black patients: Wisconsin TEAM trial

16.46 per visit based upon age- and gender-adjusted minimum earnings; and