Survivors of Aortic Dissection: Activity, Mental Health, and Sexual Function

BACKGROUND

Currently no research exists assessing lifestyle modifications and emotional state of acute aortic dissection (AAD) survivors. We sought to assess activity, mental health, and sexual function in AAD survivors.

HYPOTHESIS

Physical and sexual activity will decrease in AAD survivors compared to pre-dissection. Incidence of anxiety and depression will be significant after AAD.

METHODS

A cross sectional survey was mailed to 197 subjects from a single academic medical center (part of larger IRAD database). Subjects were ≥18 years of age surviving a type A or B AAD between 1996 and 2011. 82 surveys were returned (overall response rate 42%).

RESULTS

Mean age ± SD was 59.5 ± 13.7 years, with 54.9% type A and 43.9% type B patients. Walking remained the most prevalent form of physical activity (49 (60%) pre-dissection and 47 (57%) post-dissection). Physical inactivity increased from 14 (17%) before AAD to 20 (24%) after AAD; sexual activity decreased from 31 (38%) to 9 (11%) mostly due to fear. Most patients (66.7%) were not exerting themselves physically or emotionally at AAD onset. Systolic blood pressure (SBP) at 36 months post-discharge for patients engaging in ≥2 sessions of aerobic activity/week was 126.67 ± 10.30 vs. 141.10 ± 11.87 (p-value 0.012) in those who did not. Self-reported new-onset depression after AAD was 32% and also 32% for new-onset anxiety.

CONCLUSIONS

Alterations in lifestyle and emotional state are frequent in AAD survivors. Clinicians should screen for unfounded fears or beliefs after dissection that may reduce function and/or quality of life for AAD survivors.

Evaluation of ACE Inhibitor Therapy for Congestive Heart Failure in an Outpatient Setting

Objective:

Angiotensin-converting enzyme (ACE) inhibitor therapy is considered the standard of care for the treatment of congestive heart failure. Despite this, clinical experience suggests that not all patients may be receiving ACE inhibitor therapy or may be receiving low dosages. This study was performed to better understand the use of ACE inhibitor therapy in clinical practice.

Design and Participants:

We reviewed the medical therapy of 110 patients with a history of congestive heart failure referred to an outpatient heart failure clinic at a university teaching hospital.

Outcome Measures:

This observational study evaluated the use of ACE inhibitors, including dosage, as well as other drugs to treat congestive heart failure.

Results:

Approximately 85% (93/110) of patients were receiving an ACE inhibitor. Twenty percent (22/110) were receiving enalapril 20 mg/d or more, captopril 150 mg/d or more, lisinopril 20 mg/d or more, or quinapril 40 mg/d or more. The remaining patients (n = 71) were receiving these drugs at lower dosages. However, 21 of the remaining patients (19% of all patients) were receiving lower dosages based on patient-specific parameters; 47 of the remaining patients (43% of all patients) were eligible to have their dosage increased. Ten eligible patients were not receiving an ACE inhibitor. The majority of patients were also receiving digoxin (70%) and loop diuretic (80%) therapy.

Conclusions:

Approximately 85% of patients were receiving ACE inhibitor therapy, with 9% of eligible patients not receiving an ACE inhibitor. In the patients receiving ACE inhibitor therapy, approximately 50% (47/93) were receiving dosages below those suggested in the guidelines. Overall, the use of ACE inhibitor therapy is varied and intervention appears required to ensure that all patients receive appropriate therapy for the treatment of congestive heart failure.

The association between comorbid anxiety disorders and the risk of stroke among patients with diabetes: An 11-year population-based retrospective cohort study

BACKGROUND

Diabetes and anxiety disorders are independent risk factors for stroke. However, it remains unclear whether the risk of stroke is higher among diabetic patients with comorbid anxiety than without comorbid anxiety. Therefore, the purpose of this study was to investigate the association between comorbid anxiety and the risk of stroke among patients with diabetes.

METHODS

This is a retrospective cohort study. We used the National Health Insurance Research Database in Taiwan to identify a diabetes cohort with a new diagnosis of an anxiety disorder but without a history of stroke. The enrollment period was 2001-2006 with up to 11 years of follow-up data. Comorbid anxiety was defined by both a clinical diagnosis of the DSM-IV (ICD-9-CM) and prescriptions for anxiolytic medications. Propensity score matching was performed to balance the selected confounders between the anxiety-exposed group and anxiety non-exposed group. Cox-propositional hazard regression models were used to evaluate the association between comorbid anxiety and the risk of stroke.

RESULTS

Among patients with diabetes (N=40,846), an estimated 5.8% (N=2374) of patients had comorbid anxiety disorders. Diabetic patients with comorbid anxiety were significantly associated with a higher risk of stroke compared to patients without comorbid anxiety (hazard ratio: 1.33, 95% confidence interval: 1.02-1.72).

LIMITATIONS

The severity of anxiety or diabetes could not be measured from the claims data. Residual confounding may still exist.

CONCLUSION

A significantly elevated risk of stroke was observed in association with comorbid anxiety among patients with diabetes. Psychiatrists should consider routine screening for anxiety disorders to prevent a stroke event among patients with diabetes.

Blood Pressure Screening, Control, and Treatment for Patients With Developmental Disabilities in General Medicine Practices

Background: Little is known about the adequacy of screening for and treatment of hypertension for people with developmental disabilities (DD). Pharmacists may assist in identifying and treating this special patient population. Objective: To characterize and compare the screening, treatment, and control of blood pressure (BP) in patients with DD to patients without DD. Methods: This retrospective study identified adult patients of primary care practices within a large academic health system who had DD (DD group) and a comparator group without DD (GenMed group). Outcomes assessed included percentage of patients screened, mean BP, percentage of patients with controlled BP, and antihypertensive medications prescribed. Results: The DD (n = 183) and GenMed groups (n = 497) were nearly all screened for BP. Mean systolic BP was significantly lower in the DD group (119.9 ± 14.6 mm Hg vs 122.8 ± 15.4 mm Hg GenMed, P = .03), while diastolic BP was no different ( P = .7). Stroke was documented significantly more often in the DD group (5.5% vs 1.4%, P = .005). Of patients with uncontrolled BP, the DD group had significantly higher systolic BP (155.8 ± 14.1 mm Hg vs 147.4 ± 9.5 mm Hg GenMed, P = .02). Hypertension was documented in 32% of DD group versus 38.5% of GenMed group, P = .15. Of this group, 88.1% of the DD group had controlled BP versus 78.0% of the GenMed group, P = .09. Antihypertensive prescribing was not different between the groups. Conclusion: DD group patients had similar outcomes for hypertension therapy compared to patients without DD. Those with uncontrolled BP in the DD group tended to have higher systolic BP. Significantly more DD patients had a history of stroke.

Comparison of Community Pharmacy Services in Urban and Suburban Areas, with Emphasis on Those for Older People

Objective:

To document and compare the availability and type of pharmacy services provided by community pharmacies to the elderly in an urban area (central city) and a suburban area of a large metropolitan area, as well as the use of pharmacy services by elderly people living in the study areas.

Design:

Questionnaire.

Setting:

Metropolitan Detroit, MI.

Subjects:

Pharmacies, pharmacists, and elderly people.

Data Collection:

Data were collected from the 1990 census and surveys of pharmacies, pharmacists, and elderly patients in the study areas.

Results:

There were fewer pharmacists, pharmacies, and pharmacy business hours available for the elderly living in the central city compared with the suburban area. Overall, the elderly generally felt satisfied with their pharmacists. Pharmacists indicated that less than half of their elderly patients with new prescriptions receive verbal/written information and few do little in the area of follow-up monitoring for elderly patients. The elderly in the central city are concerned with neighborhood crime, use mass transportation, have significantly lower incomes, and live alone more often than the suburban area elderly.

Conclusions:

Overall there was no significant difference in access to available pharmacy services. Urban and suburban area respondents did have some differences that may affect their ability to access pharmacies.

The association between regular use of aspirin and the prevalence of prostate cancer: Results from the National Health Interview Survey

Prostate cancer is prevalent with significant morbidity in the United States. Aspirin previously has been found to be associated with reduced carcinogenesis of prostate cells. However, it remains unclear whether regularly taking aspirin could lower the risk of prostate cancer. Therefore, our aim was to examine the association between self-reported regular use of aspirin and the prevalence of prostate cancer in a national sample of the US adult population.The National Health Interview Survey is an annual survey conducted by the National Center for Health Statistics to investigate health and healthcare use of the US population. The current study is a population-based cross-sectional study using the 2010 National Health Interview Survey data. Adult male respondents who self-reported regularly taking aspirin at least 3 times per week were grouped as regular users. The prostate cancer prevalence was measured by respondents' self-report of prostate cancer. Multivariable logistic regression models were used to evaluate the association between these 2 factors by adjusting for covariates selected based on Andersen Behavioral Model of Health Services Use.An estimated 23 million (23.7%) males in the United States reported that they took aspirin regularly. Of them, 5.0% had prostate cancer. Regular aspirin use was significantly associated with a lower self-reported prevalence of prostate cancer after adjusting for predisposing, enabling, and need factors (odds ratio 0.60, 95% confidence interval 0.38-0.94).Regular aspirin use was found to be significantly associated with a lower self-reported prevalence of prostate cancer in the United States in 2010. Further clinical trials and longitudinal studies are needed to confirm the causality between regular aspirin use and prostate cancer.

Refined comorbidity index based on dimensionality of comorbidity for use in studies of health-related quality of life

PURPOSE

To refine two subscales of the health-related quality of life comorbidity index (HRQoL-CI) into a single index measure.

METHODS

The 2010 and 2012 Medical Expenditure Panel Surveys were utilized as development and validation datasets, respectively. The least absolute shrinkage and selection operator was applied to select important comorbidity candidates associated with HRQoL. Exploratory factor analysis and confirmatory factor analysis (CFA) were used to assess dimensionality in comorbidity. Statistical weights were derived based on standardized factor loadings from CFA and regression coefficients from the model predicting HRQoL. Prediction errors and model R(2) values were compared between HRQoL-CI and Charlson CI (CCI).

RESULTS

Eighteen comorbid conditions were identified. CFA models indicated that the second-order multidimensional comorbidity structure had a better fit to the data than did the first-order unidimensional structure. The predictive performance of the refined scale under a multidimensional structure utilizing statistical weights outperformed the original scale and CCI in terms of average prediction error and R(2) in the prediction models (R(2) values from refined scale model are 0.25, 0.30, and 0.28 versus those from CCI of 0.10, 0.09, and 0.06 for general health, SF-6D, and EQ-5D, respectively).

CONCLUSION

The dimensionality of comorbidity and the weight scheme significantly improved the performance of the refined HRQoL-CI. The refined single HRQoL-CI measure appears to be an appropriate and valid instrument specific for risk adjustment in studies of HRQoL. Future research that validates the refined scales for different cultures, age groups, and healthcare settings is warranted.

Predictors of medication adherence and persistence in Medicaid enrollees with developmental disabilities and type 2 diabetes

BACKGROUND

The prevalence of diabetes mellitus is high among patients with developmental disabilities (cerebral palsy, autism, Down's syndrome and cognitive disabilities).

OBJECTIVES

The purpose of this study was to examine the racial health disparities in medication adherence and medication persistence in developmentally disabled adults with type 2 diabetes enrolled in Medicaid.

METHODS

This was a retrospective cohort study using the MarketScan(®) Multi-State Medicaid Database. Adults aged 18-64 years with a prior diagnosis of a developmental disability (cerebral palsy/autism/down's/cognitive disabilities) and a new diagnosis of type 2 diabetes enrolled in Medicaid from January 1, 2004 and December 31, 2006, were included. Adults were included if they had a continuous enrollment for at least 12 months and were excluded if they were dual eligible. Anti-diabetes medication adherence and diabetes medication persistence were measured using multivariate logistic regression and the Cox-proportional hazard regression, respectively.

RESULTS

The study population comprised of 1529 patients. Although overall diabetes medication adherence in this population was optimal, African Americans had significantly lower odds (25%) of adhering to anti-diabetes medications compared to Caucasians (OR = 0.75, 95% CI = 0.58-0.97, P < 0.05). Also, after controlling for other covariates, the rate of discontinuation was higher in African Americans compared to Caucasians (hazard ratio = 1.03, 95% CI = 0.91-1.18, P < 0.629).

CONCLUSION

In this study, racial disparities were found in anti-diabetes medication adherence among Medicaid enrollees with developmental disabilities (DD). Studies conducted in the future should examine predictors that impact access to care, availability of primary and specialized care, social support as well as beliefs of racial minority populations with developmental disabilities and chronic conditions like diabetes to optimize medication use outcomes in this especially vulnerable population.

Health literacy and medication administration performance by caregivers of adults with developmental disabilities

OBJECTIVES

To measure health literacy (HL) of caregivers of adults with intellectual/developmental disabilities (IDDs); to determine the association between HL and a medication administration task (MAT) assessment; and to identify caregiver characteristics associated with higher HL and MAT scores.

DESIGN

Cross-sectional study.

SETTING

Southeastern Michigan.

PARTICIPANTS

Caregivers, aged 18 years or older, who provided supportive care of adults with IDDs.

INTERVENTIONS

Survey and demonstration.

MAIN OUTCOME MEASURES

Short Test of Functional Health Literacy in Adults (STOFHLA); a MAT assessment consisting of interpretation of five sets of medication instructions followed by demonstration of understanding using a pill box; and a survey of caregivers' demographics, medication-related experiences, education, characteristics of persons for whom they provide care, and care-related activities performed.

RESULTS

A total of 47 caregivers provided data. Caregivers had a mean age of 45.7 ± 14.6 years; 41 (87.2%) were women and 38 (80.9%) had education beyond high school. Caregivers were involved in obtaining medication from pharmacies, reminded the person with IDD to take medications and/or administered them to the person, documented medication and health information, and accompanied persons with IDD to physician offices. Most did not conduct monitoring procedures. The STOFHLA mean score was 34.5 ± 2.5 (median, 35; range, 22-36), while the MAT mean score was 12.0 ± 2.2 (median, 12; range, 6-15). Compared with family caregivers, direct support staff more frequently had undergone some medication training and had other people with whom they could discuss medication questions, but they had worked with the person with IDD a significantly shorter amount of time. No significant differences in STOFHLA and MAT scores between the family caregivers and direct support staff were observed. Caregiver education was significantly correlated with the STOFHLA score. MAT scores were not significantly correlated with caregiver characteristics.

CONCLUSION

Caregivers are involved in the medication use process for people who have IDD. Ensuring caregiver understanding of medication regimens and/or improving medication-related HL may be an important step to ensure safe and effective use of medications by people with IDD.

Services provided by community pharmacies in Wayne County, Michigan: a comparison by ZIP code characteristics

OBJECTIVE

To document the availability of selected pharmacy services and out-of-pocket cost of medication throughout a diverse county in Michigan and to assess possible associations between availability of services and price of medication and characteristics of residents of the ZIP codes in which the pharmacies were located.

DESIGN

Cross-sectional telephone survey of pharmacies coupled with ZIP code-level census data.

SETTING

503 pharmacies throughout the 63 ZIP codes of Wayne County, MI.

MAIN OUTCOME MEASURES

The out-of-pocket cost for a 30 days' supply of levothyroxine 50 mcg and brand-name atorvastatin (Lipitor-Pfizer) 20 mg, availability of discount generic drug programs, home delivery of medications, hours of pharmacy operation, and availability of pharmacy-based immunization services. Census data aggregated at the ZIP code level included race, annual household income, age, and number of residents per pharmacy.

RESULTS

The overall results per ZIP code showed that the average cost for levothyroxine was $10.01 ± $2.29 and $140.45 + $14.70 for Lipitor. Per ZIP code, the mean (± SD) percentages of pharmacies offering discount generic drug programs was 66.9% ± 15.0%; home delivery of medications was 44.5% ± 22.7%; and immunization for influenza was 46.7% ± 24.3% of pharmacies. The mean (± SD) hours of operation per pharmacy per ZIP code was 67.0 ± 25.2. ZIP codes with higher household income as well as higher percentage of residents being white had lower levothyroxine price, greater percentage of pharmacies offering discount generic drug programs, more hours of operation per week, and more pharmacy-based immunization services. The cost of Lipitor was not associated with any ZIP code characteristic.

CONCLUSION

Disparities in the cost of generic levothyroxine, the availability of services such as discount generic drug programs, hours of operation, and pharmacy-based immunization services are evident based on race and household income within this diverse metropolitan county.

The impact of tailored text messages on health beliefs and medication adherence in adults with diabetes: A randomized pilot study

BACKGROUND

Inadequate medication adherence reduces optimal health outcomes and can lead to increased costs, particularly in patients with diabetes. Efforts to improve adherence have resulted in limited effects; approaches leveraging mobile technology have emerged, but their focus has mainly been limited to simple reminder messages.

OBJECTIVE

The purpose of this pilot study was to test the effectiveness of tailored text messages focusing on improving medication adherence and health beliefs in adults with diabetes.

METHODS

Adults aged 21-64, with uncontrolled diabetes, and taking at least one anti-diabetic medication were recruited and randomized into 2 study arms: daily tailored text messaging for 90 days or standard care. Comparing baseline and endpoint survey responses, changes in theory-driven health beliefs and attitudes were assessed. The impact on medication adherence was evaluated using pharmacy claims by calculating the percent of days covered (PDC).

RESULTS

A total of 75 subjects were consented, and 48 were randomized. Mean PDC at baseline were comparable between cohorts (84.4% and 87.1%, respectively). Declines in adherence were observed in both groups over time but no significant differences were observed between groups or from baseline to the end of the active study period. Unadjusted tests suggested that perceived benefits and competence might have improved in the intervention arm.

CONCLUSIONS

Tailoring mobile phone text messages is a novel way to address medication nonadherence and health beliefs; further investigation to this combined technique is needed to better understand its impact on behavior change in adults with diabetes.

Geospatial analysis of statin adherence using pharmacy claims data in the state of Michigan

BACKGROUND

Research has demonstrated that variation in availability and utilization of health care resources exist on a range of scales, from regions of the United States, hospital referral regions, ZIP codes, and census tracts. Limited research using spatial analyses has found that variation in medication adherence exists across census tracts. Using spatial analysis, researchers may be able to effectively analyze geographically dispersed data to determine whether factors such as sociodemographics, local shared beliefs and attitudes, barriers to access such as availability of prescribers or pharmacies, or others are associated with variations in medication adherence in a defined geographic area. 

OBJECTIVES

To (a) demonstrate that medication adherence may be mapped across an entire state using medication possession ratios and (b) determine whether a geographic pattern of adherence to statins could be identified at the ZIP code level for members of a statewide insurer.

METHODS

This study utilized pharmacy claims data from a statewide insurer. Insured statin users were aged greater than 30 years, had at least 1 statin prescription, and were continuously enrolled for the observation year. Patient medication possession ratios (MPR) were derived, which were then aggregated as a mean MPR for each ZIP code. ZIP codes were categorized as higher (MPR  greater than 0.80) or lower (MPR  less than  0.80) adherence and mapped using Arc GIS, a platform for designing and managing solutions through the application of geographic knowledge. Analysis included a determination of whether the MPRs of higher and lower adherence ZIP codes were significantly different. Hot spot analysis was conducted to identify clustering of higher, midrange, and lower adherent ZIP codes using the GetisORD Gi* Statistic. This test provides z-scores and P values to indicate where features with either high or low values cluster spatially. MPRs for these 3 categories were compared using one-way analysis of variance (ANOVA). 

RESULTS

Of 1,154 Michigan ZIP codes, 907 were represented by 212,783 insured statin users. The mean statin MPR by ZIP code was 0.79 ± 0.4. The mean MPR for higher adherent ZIP codes was 0.83 ± 0.03 and 0.76 ± 0.03 for lower adherent ZIP codes (P  less than  0.001). Significant clustering of ZIP codes by adherence levels was evident from the hot spot analysis. The mean MPR was 0.84 ± 0.04 for high adherence areas, 0.79 ± 0.03 for midrange areas, and 0.74 ± 0.04 for lower adherent areas (overall P  less than  0.001). 

CONCLUSIONS

Significant variations in adherence exist across ZIP codes at a state level. Future research is needed to determine locally relevant factors associated with this finding, which may be used to derive locally meaningful interventions.

Addressing medication nonadherence by mobile phone: development and delivery of tailored messages

BACKGROUND

Medication nonadherence remains a significant public health problem, and efforts to improve adherence have shown only limited impact. The tailoring of messages has become a popular method of developing communication to influence specific health-related behaviors but the development and impact of tailored text messages on medication use is poorly understood.

OBJECTIVES

The aim of this paper is to describe an approach to developing theory-based tailored messages for delivery via mobile phone to improve medication adherence among patients with diabetes.

METHODS

Kreuter's five-step tailoring process was followed to create tailored messages for mobile phone delivery. Two focus group sessions, using input from 11 people, and expert review of message content were used to adapt the survey instrument on which the messages were tailored and edit the developed messages for the target population.

RESULTS AND CONCLUSIONS

Following established tailoring methods a library of 168 theory-driven and 128 medication-specific tailored messages were developed and formatted for automated delivery to mobile phones. Concepts from the Health Belief Model and Self-Determination Theory were used to craft the messages and an algorithm was applied to determine the order and timing of messages with the aim of progressively influencing disease and treatment-related beliefs driving adherence to diabetes medication. The process described may be applied to future investigations aiming to improve medication adherence in patients with diabetes and the effectiveness of the current messages will be tested in a planned analysis.

Comparisons of health care utilization outcomes in children with asthma enrolled in private insurance plans versus medicaid

OBJECTIVES

Very few studies have captured the differences in the outcomes of pediatric patients based on the patients' type of health insurance plan. The purpose of this retrospective cohort study was to examine the impact of the type of health insurance plan (public insurance vs. private insurance) on outcomes (health care utilization and medication adherence) in children with asthma.

METHODS

This retrospective cohort study analyzed Medicaid/commercial data from eight states licensed under Thomson Medstat. Subjects were 11,027 children with asthma (6435 enrolled in Medicaid and 4592 enrolled in a commercial health maintenance organization) who newly started asthma pharmacotherapy and were followed up for 12 months before and after the index anti-asthmatic medication fill. Data on health care utilization and medication adherence were examined to compare health care utilization-based outcomes. Quantile regression analysis was used to study medication adherence, and Poisson regression was used to determine health care utilization.

RESULTS

Patients with a private insurance plan had significantly higher medication adherence rates (p < .01) compared with those who had a Medicaid plan. Patients with Medicaid plans also were associated with 20% more inpatient hospitalizations and 48% increased odds of emergency department visits, but they had 42% fewer outpatient visits compared with those who had a private plan (all p < .05).

CONCLUSION

Children with asthma who are enrolled in Medicaid receive fairly comprehensive coverage of medical services, and thus further research is needed to determine the reasons for poor health care utilization-related outcomes in this population.

Associations between physician financial incentives and the prescribing of anti-asthmatic medications in children in US outpatient settings

This study examined how sociological factors including financial incentives influenced whether asthmatic children received a controller medication, a reliever medication or both. The 2007 National Ambulatory Medical Care Survey was used for this analysis. A logistic regression was applied to capture the physician's decision-making and to analyze anti-asthmatic medication choice. Children with asthma seeing a pediatrician were approximately 69% more likely than children seeing a family doctor to receive a controller medication than reliever medication (p<0.01). Children with asthma enrolled in a capitated plan were 23% more likely to receive controller medications than reliever medications (p<0.01). Children with asthma of Hispanic ethnicity were 28% less likely to receive controller medication compared to non-Hispanic white (p<0.05) children. Compared with physicians with lower financial incentives, physicians who received medium (39%, p<0.05) or higher (42%, p<0.01) financial incentives from payers were more likely to prescribe controller medication than reliever medication for asthmatic children. An important finding of this study is that physicians who had medium or higher financial incentives from payers were about 40% more likely to prescribe a controller medication in asthmatic children. Findings suggest that physician incentives and capitated plans are associated with an increase in physicians prescribing controller medications or preventive care in children with asthma.

Demographic characteristics and estimated prevalence of Fontan-associated plastic bronchitis

Plastic bronchitis (PB) is a poorly understood disease that can complicate any underlying pulmonary disease. However, it appears to most often occur in patients with surgically palliated congenital heart disease, particularly after the Fontan procedure. Few data exist about the prevalence and etiology of PB in this population. In an effort to establish data about prevalence, we conducted a retrospective study of an existing Fontan surgery database (n = 654) comprised of data, including sex, age at date of surgery, alive/dead status, New York Heart Association classification at last follow-up, right-ventricular end-diastolic pressure and pulmonary artery pressure before Fontan surgery, and the presence of a Fontan fenestration. An initial medical record review of 173 patients in the database who were followed at the University of Michigan identified seven patients with PB resulting in an estimated prevalence of 4 %. Subsequently, 14 % of 211 surveyed patients reported that they presently expectorate mucus or fibrin plugs (casts). Demographic and clinical variables did not differ between patients with or without possible PB. Collectively, these findings suggest that Fontan patients presently with PB may range from 4 to 14 %, indicating potential under-diagnosis of the disease. There were no remarkable physical or hemodynamic indicators that differentiated patients with or without possible PB. These data also highlight the need for more elaborate, prospective studies to improve our understanding of PB pathogenesis so that more definitive diagnostic criteria for this devastating disease can be established and its prevalence more accurately determined.

Potential impact of pharmacist interventions to reduce cost for Medicare Part D beneficiaries

The objective was to determine the impact of simulated pharmacist interventions on out-of-pocket cost, time to coverage gap, and cost per patient to the Medicare Part D program using actual patient cases from an adult general medicine clinic. Medication profiles of 100 randomly selected Medicare-eligible patients from a university-affiliated general internal medicine clinic were reviewed by a pharmacist to identify opportunities to cost-maximize the patients' therapies based on the plan. An online Part-D calculator, Aetna Medicare Rx Essentials, was used as the standard plan to determine medication cost and time to gap. The primary analysis was comparison of the patients' pre-review and post-review out-of-pocket cost, time to coverage gap, and cost to Medicare. A total of 65 patients had at least 1 simulated pharmacist cost intervention. The most common intervention was substituting for a less costly generic, followed by substituting a generic for a brand name. Projected patient cost savings was $476 per year. The average time to coverage gap was increased by 0.7 ±1.2 months. This study illustrates that the pharmacists may be able to reduce cost to some patients as well as to the Medicare Part D program.

The association between asthma and absenteeism among working adults in the United States: results from the 2008 medical expenditure panel survey

OBJECTIVE

The purpose of this study was to evaluate the association between asthma status and the occurrence and length of work absences among the US working adults.

METHODS

A cross-sectional study was conducted using the 2008 Medical Expenditure Panel Survey (MEPS). Employed respondents between ages 18 and 55 years were included. The association between asthma status (whether respondents have asthma or not) and occurrence of absences and the length of time per absence was evaluated using a two-part model. A multivariate logistic regression as the first part of the model was to estimate the probability of being absent from work at least once during the observation period as a function of asthma status. A multivariate negative binomial regression as the second part of the model was used to assess whether the length of each absence from work was associated with asthma status among respondents who reported at least one absence from work. Sociodemographic, socioeconomic, employment-related, health status, and comorbidity variables were included in each model as covariates.

RESULTS

Of 12,161 respondents, 8.2% reported having asthma, which accounted for 10.4 million working adults in the United States in 2008. Employed adults with asthma were more likely to report having at least one absence from work compared to those without asthma in bivariate analyses (26.2% vs. 16.2%, p < .01). After adjusting for the number of comorbid chronic conditions and other covariates, there was no significant difference between having asthma and absenteeism among respondents (odds ratio (OR) = 1.31, 95% confidence interval (CI) = 0.99-1.72, rate ratio (RR) = 1.25, 95% CI = 0.91-1.72).

CONCLUSIONS

Overall burden of illness as measured by comorbidity indices and perceived health status, but not asthma alone, contributes to absenteeism as well as the number of days off during each occurrence among employed people. It is important for health services researchers to consider overall burden of illness when examining the association between a general outcome such as absence from work and specific conditions such as asthma.

Mental health resource utilization and health care costs associated with race and comorbid anxiety among Medicaid enrollees with major depressive disorder

OBJECTIVE

The objective of this study was to assess the association among race, comorbid anxiety, and mental health resource utilization among Medicaid enrollees with major depressive disorder (MDD).

METHODS

A retrospective cross-sectional study design was used to identify adult patients with MDD newly initiating an antidepressant between January 1, 2004, and December 31, 2006, from the MarketScan Multi-State Medicaid Database. Measures of mental health resource utilization included mental health-related office visits, hospitalizations, emergency department visits, and health care costs. The associations of mental health resource utilization with race and comorbid anxiety were examined respectively using multivariable logistic regression, negative binominal regression, and log-transformed linear regression models.

RESULTS

A total of 3083 Medicaid enrollees with MDD were included. Approximately 25% of patients had comorbid anxiety. Caucasians were more likely to have comorbid anxiety than African Americans (30.2% vs 16.4%, p < .01). After controlling for covariates, comorbid anxiety was significantly associated with more frequent mental health resource utilization. African Americans were significantly less likely than Caucasians to have mental health-related office visits (OR, 0.54; 95% CI, 0.45-0.66) but more likely to be hospitalized (OR, 2.57; 95% CI, 1.84-3.60) and to have emergency department visits (OR, 1.52; 95% CI, 1.05-2.19).

CONCLUSIONS

Comorbid anxiety was positively associated with mental health resource utilization among Medicaid enrollees with MDD. Health disparities in health care utilization between African Americans and Caucasians still exist.

Comparative performance of comorbidity indices in predicting health care-related behaviors and outcomes among Medicaid enrollees with type 2 diabetes

No single gold standard of comorbidity measure has been identified, and the performance of comorbidity indices vary according to the outcome of interest. The authors compared the Charlson Comorbidity Index, Elixhauser Index (EI), Chronic Disease Score (CDS), and Health-related Quality of Life Comorbidity Index (HRQL-CI) in predicting health care-related behaviors (physicians' concordance with diabetes care standards and patients' oral antidiabetic drug [OAD] adherence) and outcomes (health care utilization and expenditures) among Medicaid enrollees with type 2 diabetes. A total of 9832 diabetes patients who used OAD were identified using data from the MarketScan Medicaid database from 2003 to 2007. Predictive performance of the comorbidity index was assessed using multiple regression models controlling for patient demographics, diabetes severity, and baseline health care characteristics. Among the 4 indices, the CDS was best at predicting physician's concordance with care standards. The CDS and HRQL-CI mental index performed better than other indices as predictors of medication adherence. The EI was best at predicting health care utilization and expenditures. These results suggest that, for these low-income diabetes patients, the CDS and HRQL-CI mental index were relatively better risk-adjustment tools for health care-related behavior data evaluation and the EI was the first choice for health care utilization and expenditures data.

Physician prescribing patterns of innovative antidepressants in the United States: the case of MDD patients 1993-2007

OBJECTIVE

Innovative antidepressants such as SSRIs and SNRIs have been widely adopted. However, the differences in their adoption across patients' and physicians' characteristics, geographic regions, and insurance status need to be further explored. This study was trying to disentangle the patterns of physician antidepressant prescribing and medication choice for major depressive disorder treatment.

METHOD

A retrospective cross-sectional study was conducted using the 1993-2007 National Ambulatory Medical Care Survey database. A multinomial logistic regression with the Heckman two-step selection procedure was applied to capture the two-step nature of physician prescription decision making.

RESULTS

The weighted logistic regression indicated that patients' race/ethnicity and primary source of payment for services, physician ownership status, and physicians' practice regions were associated with differential likelihood of physician' antidepressant prescribing. Non-Hispanic white patients were more likely to be prescribed antidepressants compared to Hispanic patients (OR = 1.52, 95% CI 1.24-1.87). Physicians' choice on antidepressant varied across with patient age and health insurance status. Compared to private insurance, patients who were primarily covered by Medicare were less likely to be prescribed only SSRIs/SNRIs or other newer antidepressants (RRRs = 0.42 and 0.39; 95% CIs 0.21-0.83 and 0.18-0.84, respectively).

CONCLUSIONS

We observed strong associations between sociological factors and physicians' antidepressant prescribing patterns. Possible health disparities and gaps between optimal and suboptimal healthcare for patient mental health caused by systematic differences in sociological factors need to be mitigated. We need policy makers to design effective policy interventions to improve physician practice guidelines adherence to eliminate possible variations among physician practices.