Health-plan and employer-based wellness programs to reduce diabetes risk: The Kaiser Permanente Northern California NEXT-D Study

Primary prevention of diabetes is increasingly recognized by both health plans and employers as an important strategy to improve the health of insured populations. As a part of the Natural Experiments in Translation for Diabetes (NEXT-D) network, the Kaiser Permanente Northern California (KPNC) Division of Research is assessing the effectiveness of 2 health plan-initiated programs to prevent the onset of diabetes in patients at high risk. The first study evaluates a telephonic health-coaching program that provides counseling on healthful eating, active living, and weight loss to KPNC members. The second evaluation examines a postpartum glucose screening and educational diabetes prevention program for women with gestational diabetes mellitus that KPNC implemented in 2006. Identifying effective approaches to preventing diabetes will be of value to health care systems, policy makers, and public health officials seeking to understand the roles systems and employers can play in preventing chronic illness.

Differences in the clinical recognition of depression in diabetes patients: the Diabetes Study of Northern California (DISTANCE)

BACKGROUND

It is unknown to what extent the gap between need and care for depression among patients with diabetes differs across racial/ethnic groups. We compared, by race/ethnicity, the likelihood of clinical recognition of depression (diagnosis or treatment) of patients who reported depressive symptoms in a well-characterized community-based population with diabetes.

DESIGN

We used a survey follow-up study of 20,188 patients with diabetes from Kaiser Permanente Northern California. Analyses were limited to 910 patients who scored 10 or higher on the Patient Health Questionnaire (PHQ-8) which was included in the survey and who had no clinical recognition of depression in the 12 months prior to survey. Clinical recognition of depression was defined by a depression diagnosis, referral to mental health services, or antidepressant medication prescription.

RESULTS

Among the 910 patients reporting moderate to severe depressive symptoms on the survey and who had no clinical recognition in the prior year, 12%, 8%, 8%, 14%, and 15% of African American, Asian, Filipino, Latino, and white patients, respectively, were clinically recognized for depression in the subsequent 12 months. After adjusting for sociodemographics, limited English proficiency, and depressive symptom severity, racial/ethnic minorities were less likely to be clinically recognized for depression compared with whites (relative risk: Filipino: 0.30, African American: 0.62).

CONCLUSIONS

More work is needed to understand the modifiable patient and provider factors that influence clinical recognition of depression among diabetes patients from different racial/ethnic groups, and the potential impact of low rates of clinical recognition on quality of care.

Elevated rates of diabetes in Pacific Islanders and Asian subgroups: The Diabetes Study of Northern California (DISTANCE)

OBJECTIVE

We estimated the prevalence and incidence of diabetes among specific subgroups of Asians and Pacific Islanders (APIs) in a multiethnic U.S. population with uniform access to care.

RESEARCH DESIGN AND METHODS

This prospective cohort analysis included 2,123,548 adult members of Kaiser Permanente Northern California, including 1,704,363 with known race/ethnicity (white, 56.9%; Latino, 14.9%; African American, 8.0%; Filipino, 4.9%; Chinese, 4.0%; multiracial, 2.8%; Japanese, 0.9%; Native American, 0.6%; Pacific Islander, 0.5%; South Asian, 0.4%; and Southeast Asian, Korean, and Vietnamese, 0.1% each). We calculated age-standardized (to the 2010 U.S. population) and sex-adjusted diabetes prevalence at baseline and incidence (during the 2010 calendar year). Poisson models were used to estimate relative risks.

RESULTS

There were 210,632 subjects with prevalent diabetes as of 1 January 2010 and 15,357 incident cases of diabetes identified during 2010. The crude diabetes prevalence was 9.9% and the incidence was 8.0 cases per 1,000 person-years and, after standardizing by age and sex to the 2010 U.S. Census, 8.9% and 7.7 cases per 1,000 person-years. There was considerable variation among the seven largest API subgroups. Pacific Islanders, South Asians, and Filipinos had the highest prevalence (18.3, 15.9, and 16.1%, respectively) and the highest incidence (19.9, 17.2, and 14.7 cases per 1,000 person-years, respectively) of diabetes among all racial/ethnic groups, including minorities traditionally considered high risk (e.g., African Americans, Latinos, and Native Americans).

CONCLUSIONS

High rates of diabetes among Pacific Islanders, South Asians, and Filipinos are obscured by much lower rates among the large population of Chinese and several smaller Asian subgroups.

Health system factors and antihypertensive adherence in a racially and ethnically diverse cohort of new users

BACKGROUND

The purpose of this study was to identify potential health system solutions to suboptimal use of antihypertensive therapy in a diverse cohort of patients initiating treatment.

METHODS

Using a hypertension registry at Kaiser Permanente Northern California, we conducted a retrospective cohort study of 44 167 adults (age, ≥18 years) with hypertension who were new users of antihypertensive therapy in 2008. We used multivariate logistic regression analysis to model the relationships between race/ethnicity, specific health system factors, and early nonpersistence (failing to refill the first prescription within 90 days) and nonadherence (<80% of days covered during the 12 months following the start of treatment), respectively, controlling for sociodemographic and clinical risk factors.

RESULTS

More than 30% of patients were early nonpersistent and 1 in 5 were nonadherent to therapy. Nonwhites were more likely to exhibit both types of suboptimal medication-taking behavior compared with whites. In logistic regression models adjusted for sociodemographic, clinical, and health system factors, nonwhite race was associated with early nonpersistence (black: odds ratio, 1.56 [95% CI, 1.43-1.70]; Asian: 1.40 [1.29-1.51]; Hispanic: 1.46 [1.35-1.57]) and nonadherence (black: 1.55 [1.37-1.77]; Asian: 1.13 [1.00-1.28]; Hispanic: 1.46 [1.31-1.63]). The likelihood of early nonpersistence varied between Asians and Hispanics by choice of first-line therapy. In addition, racial and ethnic differences in nonadherence were appreciably attenuated when medication co-payment and mail-order pharmacy use were accounted for in the models.

CONCLUSIONS

Racial/ethnic differences in medication-taking behavior occur early in the course of treatment. However, health system strategies designed to reduce patient co-payments, ease access to medications, and optimize the choice of initial therapy may be effective tools in narrowing persistent gaps in the use of these and other clinically effective therapies.

New Jersey's efforts to improve postpartum depression care did not change treatment patterns for women on medicaid

Identification and treatment of postpartum depression are the increasing focus of state and national legislation, including portions of the Affordable Care Act. Some state policies and proposals are modeled directly on programs in New Jersey, the first state to require universal screening for postpartum depression among mothers who recently delivered babies. We examined the impact of these policies on a particularly vulnerable population, Medicaid recipients, and found that neither the required screening nor the educational campaign that preceded it was associated with improved treatment initiation, follow-up, or continued care. We argue that New Jersey's policies, although well intentioned, were predicated on an inadequate base of evidence and that efforts should now be undertaken to build that base. We also argue that to improve detection and treatment, policy makers contemplating or implementing postpartum depression mandates should consider additional measures. These could include requiring mechanisms to monitor and enforce the screening requirement; paying providers to execute screening and follow-up; and preliminary testing of interventions before policy changes are enacted.

Impact of prior authorization on the use and costs of lipid-lowering medications among Michigan and Indiana dual enrollees in Medicaid and Medicare: results of a longitudinal, population-based study

BACKGROUND

Some Medicaid programs have adopted prior-authorization (PA) policies that require prescribers to request approval from Medicaid before prescribing drugs not included on a preferred drug list.

OBJECTIVE

This study examined the association between PA policies for lipid-lowering agents in Michigan and Indiana and the use and cost of this drug class among dual enrollees in Medicare and Medicaid.

METHODS

Michigan and Indiana claims data from the Centers for Medicare and Medicaid Services were assessed. Michigan Medicaid instituted a PA requirement for several lipid-lowering medications in March 2002; Indiana implemented a PA policy for drugs in this class in September 2002. Although the PA policies affected some statins, they predominantly targeted second-line treatments, including bile acid sequestrants, fibrates, and niacins. Individuals aged ≥18 years who were continuously dually enrolled in both Medicare and Medicaid from July 2000 through September 2003 were included in this longitudinal, population-based study, which included a 20-month observation period before the implementation of PA in Michigan and a 12-month follow-up period after the Indiana PA policy was initiated. Interrupted time series analysis was used to examine changes in prescription rates and pharmacy costs for lipid-lowering drugs before and after policy implementation.

RESULTS

A total of 38,684 dual enrollees in Michigan and 29,463 in Indiana were included. Slightly more than half of the cohort were female (Michigan, 53.3% [20,614/38,684]; Indiana, 56.3% [16,595/29,463]); nearly half were aged 45 to 64 years (Michigan, 43.7% [16,921/38,684]; Indiana, 45.2% [13,321/29,463]). Most subjects were white (Michigan, 77.4% [29,957/38,684]; Indiana: 84.9% [25,022/29,463]). The PA policy was associated with an immediate 58% reduction in prescriptions for nonpreferred medications in Michigan and a corresponding increase in prescriptions for preferred agents. However, the PA policy had no apparent effect in Indiana, where there had been little use of nonpreferred medications before the policy was implemented (3.3%). The policies were associated with an immediate reduction of $24,548 in prescription expenditures in Michigan and an immediate reduction of $16,070 in Indiana.

CONCLUSIONS

The PA policy was associated with substantially lower use of nonpreferred lipid-lowering drugs in Michigan, offset by increases in the use of preferred medications, but there was less change in Indiana. Data limitations did not permit the evaluation of the impact of policy-induced switching on clinical outcomes such as cholesterol levels. The monetary benefit of PA policies for lipid-lowering agents should be weighed against administrative costs and the burden on patients and health care providers.

Racial and ethnic disparities in postpartum depression care among low-income women

OBJECTIVE

The goal of this study was to characterize racial-ethnic differences in mental health care utilization associated with postpartum depression in a multiethnic cohort of Medicaid recipients.

METHODS

In a retrospective cohort study, administrative claims data from New Jersey's Medicaid program were obtained for 29,601 women (13,001 whites, 13,416 blacks, and 3,184 Latinas) who delivered babies between July 2004 and October 2007. Racial-ethnic differences were estimated with logistic regression for initiation of antidepressant medication or outpatient mental health visits within six months of delivery, follow-up (a prescription refill or second visit), and continued mental health care (at least three visits or three filled antidepressant prescriptions within 120 days).

RESULTS

Nine percent (N=1,120) of white women initiated postpartum mental health care, compared with 4% (N=568) of black women and 5% (N=162) of Latinas. With analyses controlling for clinical factors, the odds of initiating treatment after delivery were significantly (p<.001) lower for blacks (adjusted odds ratio [AOR]=.43) and Latinas (AOR=.59) compared with whites. Among those who initiated treatment, blacks and Latinas were less likely than whites to receive follow-up treatment (blacks, AOR=.66, p<.001; Latinas, AOR=.67, p<.05) or continued care (blacks, AOR=.81, p=.069; Latinas, AOR=.67, p<.05). Among those who initiated antidepressant treatment, black women and Latinas were less likely than whites to refill a prescription.

CONCLUSIONS

There were significant racial-ethnic differences in depression-related mental health care after delivery. Suboptimal treatment was prevalent among all low-income women in the study. However, racial and ethnic disparities in the initiation and continuation of postpartum depression care were particularly troubling and warrant clinical and policy attention.

Racial and ethnic disparities in postpartum depression care among low-income women

OBJECTIVE

The goal of this study was to characterize racial-ethnic differences in mental health care utilization associated with postpartum depression in a multiethnic cohort of Medicaid recipients.

METHODS

In a retrospective cohort study, administrative claims data from New Jersey's Medicaid program were obtained for 29,601 women (13,001 whites, 13,416 blacks, and 3,184 Latinas) who delivered babies between July 2004 and October 2007. Racial-ethnic differences were estimated with logistic regression for initiation of antidepressant medication or outpatient mental health visits within six months of delivery, follow-up (a prescription refill or second visit), and continued mental health care (at least three visits or three filled antidepressant prescriptions within 120 days).

RESULTS

Nine percent (N=1,120) of white women initiated postpartum mental health care, compared with 4% (N=568) of black women and 5% (N=162) of Latinas. With analyses controlling for clinical factors, the odds of initiating treatment after delivery were significantly (p<.001) lower for blacks (adjusted odds ratio [AOR]=.43) and Latinas (AOR=.59) compared with whites. Among those who initiated treatment, blacks and Latinas were less likely than whites to receive follow-up treatment (blacks, AOR=.66, p<.001; Latinas, AOR=.67, p<.05) or continued care (blacks, AOR=.81, p=.069; Latinas, AOR=.67, p<.05). Among those who initiated antidepressant treatment, black women and Latinas were less likely than whites to refill a prescription.

CONCLUSIONS

There were significant racial-ethnic differences in depression-related mental health care after delivery. Suboptimal treatment was prevalent among all low-income women in the study. However, racial and ethnic disparities in the initiation and continuation of postpartum depression care were particularly troubling and warrant clinical and policy attention.

Advancing the science of patient safety

Despite a decade's worth of effort, patient safety has improved slowly, in part because of the limited evidence base for the development and widespread dissemination of successful patient safety practices. The Agency for Healthcare Research and Quality sponsored an international group of experts in patient safety and evaluation methods to develop criteria to improve the design, evaluation, and reporting of practice research in patient safety. This article reports the findings and recommendations of this group, which include greater use of theory and logic models, more detailed descriptions of interventions and their implementation, enhanced explanation of desired and unintended outcomes, and better description and measurement of context and of how context influences interventions. Using these criteria and measuring and reporting contexts will improve the science of patient safety.

Adherence to laboratory test requests by patients with diabetes: the Diabetes Study of Northern California (DISTANCE)

OBJECTIVES

To estimate rates and predictors of clinical laboratory test completion by patients with diabetes after provider referral.

STUDY DESIGN

Prospective cohort study.

METHODS

Among 186,306 adult members with diabetes in Kaiser Permanente Northern California, we searched the electronic medical records (July 1, 2008, to June 30, 2009) of each patient for the first outpatient order to obtain the following laboratory tests commonly used to measure risk factor control or adverse effects of pharmacotherapy: levels of glycosylated hemoglobin, low density lipoprotein cholesterol, serum creatinine, urinary albumin, or creatine kinase (the latter only among persons using statins). We measured laboratory test attendance as completion of an order (including time to results) within 6 months of the referral date and looked for variations by subgroups.

RESULTS

Laboratory test attendance ranged from 86% for glycosylated hemoglobin level to 73% for serum creatinine level. Time to laboratory test attendance was a median of 7 to 11 days and a mean of 25 to 30 days. Laboratory test attendance was more likely for women and older patients or for orders after a face-to-face provider visit and was less likely for orders by a pharmacist. However, most variations (even by laboratory copayment) were small or not clinically substantive. In subanalyses, we observed no clinically significant variations by race/ethnicity, socioeconomic status, trust in provider, or patient-provider communication and found no association with depressive symptoms, health literacy, or English fluency.

CONCLUSION

The fact that 1 in 7 patients did not complete laboratory tests within 6 months of the provider referral may help explain why healthcare services seem to fall short of optimal diabetes care.

Association between prior authorization for medications and health service use by Medicaid patients with bipolar disorder

OBJECTIVE

This study examined the association between a Medicaid prior-authorization policy for second-generation antipsychotic and anticonvulsant agents and medication discontinuation and health service use by patients with bipolar disorder.

METHODS

A pre-post design with a historical comparison group was used to analyze Maine Medicaid and Medicare claims data. A total of 946 newly treated patients were identified during the eight-month policy (July 2003-February 2004), and a comparison group of 1,014 was identified from the prepolicy period (July 2002-February 2003). Patients were stratified by number of visits to community mental health centers (CMHCs) before medication initiation (proxy for illness severity): CMHC attenders, at least two visits; nonattenders, fewer than two. Changes in rates of medication discontinuation and outpatient, emergency room, and hospital visits were estimated.

RESULTS

Compared with nonattenders, at baseline CMHC attenders had substantially higher rates of comorbid mental disorders and use of medications and health services. The policy was associated with increased medication discontinuation among attenders and nonattenders, reductions in mental health visits after discontinuation among attenders (-.64 per patient per month; p<.05), and increases in emergency room visits after discontinuation among nonattenders (.16 per patient per month; p<.05). During the eight-month policy period, the policy had no detectable impact on hospitalization risk.

CONCLUSIONS

The prior-authorization policy was associated with increased medication discontinuation and subsequent changes in health service use. Although small, these unintended effects raise concerns about quality of care for a group of vulnerable patients. Long-term consequences of prior-authorization policies on patient outcomes warrant further investigation.

Use of well-child visits in high-deductible health plans

OBJECTIVE

To examine how enrollment in high-deductible health plans (HDHPs) affects use of well-child visits relative to traditional plans, when preventive care is exempt from the deductible.

STUDY DESIGN

Pre-post comparison between groups.

METHODS

We selected children aged <18 years enrolled in a large Massachusetts health plan through employers offering only 1 type of plan. Children were in traditional plans for a 12-month baseline period between 2001 and 2004, then were either switched by a decision of the parent's employer to an HDHP or kept in the traditional plan (controls) for a 12-month follow-up period. Preventive and other office visits were exempt from the deductible and subject to copayments, as in traditional plans. The primary outcome was whether the child received well-child visits recommended for the 12-month period. Using generalized linear mixed models, we compared the change in receipt of recommended well-child visits between baseline and follow-up for the HDHP group relative to controls.

RESULTS

We identified 1598 children who were switched to HDHPs and 10,093 controls. Between baseline and follow-up, the mean proportion of recommended well-child visits received by HDHP children decreased slightly from 0.846 to 0.841, and from 0.861 to 0.855 for controls. In adjusted models, there was no significant difference in the change in probability that recommended well-child visits were received by HDHP children compared with controls (P = .69).

CONCLUSIONS

Receipt of recommended well-child visits did not change for children switching from traditional plans to HDHPs that exempt preventive care from the deductible.

Impact of two Medicaid prior-authorization policies on antihypertensive use and costs among Michigan and Indiana residents dually enrolled in Medicaid and Medicare: results of a longitudinal, population-based study

BACKGROUND

In response to rising pharmaceutical costs, many state Medicaid programs have implemented policies requiring prior authorization for high-cost medications, even for established users. However, little is known about the impact of these policies on the use of antihypertensive medicines in the United States.

OBJECTIVE

The aim of this longitudinal, population-based study was to assess comprehensive prior-authorization programs for antihypertensives on drug use and costs in a vulnerable Medicaid population in Michigan and Indiana.

METHODS

A prior-authorization policy for antihypertensives was implemented in Michigan in March 2002 and in Indiana in September 2002; Indiana also implemented an antihypertensive stepwise-therapy requirement in July 2003. Our study cohort included individuals aged >or=18 years in Michigan and Indiana who were continuously enrolled in both Medicaid and Medicare from July 2000 through September 2003. Claims data were obtained from the Centers for Medicare and Medicaid Services. We included all antihypertensive medications, including diuretics, angiotensin-converting enzyme inhibitors, calcium channel blockers, beta-blockers, alpha-blockers, and angiotcnsin II receptor blockers. We used interrupted time-series analysis to study policy-related changes in the total number and cost of antihypertensive prescriptions.

RESULTS

Overall, 38,684 enrollees in Michigan and 29,463 in Indiana met our inclusion criteria. Slightly more than half of our cohort in both states was female (53.29%in Michigan and 56.32%in Indiana). In Michigan, 20.23% of patients were aged >or=65 years; 77.44% were white, 20.11% were black, and the remainder were Hispanic, Native American, Asian, or of other or unknown race. In Indiana, 20.07% were aged >or=65 years; 84.93% were white, 13.64% were black, and the remainder were Hispanic, Native American, Asian, or of other or unknown race. The implementation of both policies was associated with large and immediate reductions in the use of nonpreferred medications: 83.33% reduction in the use of such drugs in Michigan (-84.30 prescriptions per 1000 enrollees per month; P < 0.001) and 35.76% in Indiana (-64.45 prescriptions per 1000 enrollees per month; P < 0.001). As expected, use of preferred medications also increased substantially in both states (P < 0.001). Overall, antihypertensive therapy immediately dropped 0.16% in Michigan (P = 0.04) and 1.82% in Indiana (P = 0.02). Implementation of the policies was also associated with reductions in pharmacy reimbursement of $616,572.43 in Michigan and $868,265.97 in Indiana in the first postpolicy year.

CONCLUSIONS

Prior authorization was associated with lower use of nonpreferred antihypertensive drugs that was largely offset by increases in the use of preferred drugs. The possible clinical consequences of policy-induced drug switching for individual patients remain unknown because the present study did not include access to medical record data. Further research is needed to establish whether large-scale switches in medicines following the inception of prior-authorization policies have any long-term health effects.

Prior authorization for antidepressants in Medicaid: effects among disabled dual enrollees

BACKGROUND

Prior authorization is a popular, but understudied, strategy for reducing medication costs. We evaluated the impact of a controversial prior authorization policy in Michigan Medicaid on antidepressant use and health outcomes among dual Medicaid and Medicare enrollees with a Social Security Disability Insurance designation of permanent disability.

METHODS

We linked Medicaid and Medicare (2000-2003) claims for dual enrollees in Michigan and a comparison state, Indiana. Using interrupted time-series and longitudinal data analysis, we estimated the impact of the policy on antidepressant medication use, treatment initiation, disruptions in therapy, and adverse health events among continuously enrolled (Michigan, n = 28 798; Indiana, n = 21 769) and newly treated (Michigan, n = 3671; Indiana, n = 2400) patients.

RESULTS

In Michigan, the proportion of patients starting nonpreferred agents declined from 53% prepolicy to 20% postpolicy. The prior authorization policy was associated with a small sustained decrease in therapy initiation overall (9 per 10,000 population; P = .007). We also observed a short-term increase in switching among established users of nonpreferred agents overall (risk ratio, 2.88; 95% confidence interval, 1.87-4.42) and among those with depression (2.04; 1.22-3.42). However, we found no evidence of increased disruptions in treatment or adverse events (ie, hospitalization, emergency department use) among newly treated patients.

CONCLUSIONS

Prior authorization was associated with increased use of preferred agents with no evidence of disruptions in therapy or adverse health events among new users. However, unintended effects on treatment initiation and switching among patients already taking the drug were also observed, lending support to the state's previous decision to discontinue prior approval for antidepressants in 2003.

Effects of prior authorization on medication discontinuation among Medicaid beneficiaries with bipolar disorder

OBJECTIVE

Few data exist on the cost and quality effects of increased use of prior-authorization policies to control psychoactive drug spending among persons with serious mental illness. This study examined the impact of a prior-authorization policy in Maine on second-generation antipsychotic and anticonvulsant utilization, discontinuations in therapy, and pharmacy costs among Medicaid beneficiaries with bipolar disorder.

METHODS

Using Medicaid and Medicare utilization data for 2001-2004, the authors identified 5,336 patients with bipolar disorder in Maine (study state) and 1,376 in New Hampshire (comparison state). With an interrupted time-series and comparison group design, longitudinal changes were measured in second-generation antipsychotic and anticonvulsant use; survival analysis was used to examine treatment discontinuations and rates of switching medications.

RESULTS

The prior-authorization policy resulted in an 8-percentage point reduction in the prevalence of use of nonpreferred second-generation antipsychotic and anticonvulsant medications (those requiring prior authorization) but did not increase use of preferred agents (no prior authorization) or rates of switching. The prior-authorization policy reduced total pharmacy reimbursements for bipolar disorder by $27 per patient during the eight-month policy period. However, the hazard rate of treatment discontinuation (all bipolar drugs) while the policy was in effect was 2.28 (95% confidence interval=1.36-4.33) higher than during the prepolicy period, with adjustment for trends in the comparison state.

CONCLUSIONS

The small reduction in pharmacy spending for bipolar treatment after the policy was implemented may have resulted from higher rates of medication discontinuation rather than switching. The findings indicate that the prior-authorization policy in Maine may have increased patient risk without appreciable cost savings to the state.

Effects of prior authorization on medication discontinuation among Medicaid beneficiaries with bipolar disorder

OBJECTIVE

Few data exist on the cost and quality effects of increased use of prior-authorization policies to control psychoactive drug spending among persons with serious mental illness. This study examined the impact of a prior-authorization policy in Maine on second-generation antipsychotic and anticonvulsant utilization, discontinuations in therapy, and pharmacy costs among Medicaid beneficiaries with bipolar disorder.

METHODS

Using Medicaid and Medicare utilization data for 2001-2004, the authors identified 5,336 patients with bipolar disorder in Maine (study state) and 1,376 in New Hampshire (comparison state). With an interrupted time-series and comparison group design, longitudinal changes were measured in second-generation antipsychotic and anticonvulsant use; survival analysis was used to examine treatment discontinuations and rates of switching medications.

RESULTS

The prior-authorization policy resulted in an 8-percentage point reduction in the prevalence of use of nonpreferred second-generation antipsychotic and anticonvulsant medications (those requiring prior authorization) but did not increase use of preferred agents (no prior authorization) or rates of switching. The prior-authorization policy reduced total pharmacy reimbursements for bipolar disorder by $27 per patient during the eight-month policy period. However, the hazard rate of treatment discontinuation (all bipolar drugs) while the policy was in effect was 2.28 (95% confidence interval=1.36-4.33) higher than during the prepolicy period, with adjustment for trends in the comparison state.

CONCLUSIONS

The small reduction in pharmacy spending for bipolar treatment after the policy was implemented may have resulted from higher rates of medication discontinuation rather than switching. The findings indicate that the prior-authorization policy in Maine may have increased patient risk without appreciable cost savings to the state.

The population-level impacts of a national health insurance program and franchise midwife clinics on achievement of prenatal and delivery care standards in the Philippines

OBJECTIVES

Adequate prenatal and delivery care are vital components of successful maternal health care provision. Starting in 1998, two programs were widely expanded in the Philippines: a national health insurance program (PhilHealth); and a donor-funded franchise of midwife clinics (Well Family Midwife Clinics). This paper examines population-level impacts of these interventions on achievement of minimum standards for prenatal and delivery care.

METHODS

Data from two waves of the Demographic and Health Surveys, conducted before (1998) and after (2003) scale-up of the interventions, are employed in a pre/post-study design, using longitudinal multivariate logistic and linear regression models.

RESULTS

After controlling for demographic and socioeconomic characteristics, the PhilHealth insurance program scale-up was associated with increased odds of receiving at least four prenatal visits (OR 1.04 [95% CI 1.01-1.06]) and receiving a visit during the first trimester of pregnancy (OR 1.03 [95% CI 1.01-1.06]). Exposure to midwife clinics was not associated with significant changes in achievement of prenatal care standards. While both programs were associated with slight increases in the odds of delivery in a health facility, these increases were not statistically significant.

CONCLUSIONS

These results suggest that expansion of an insurance program with accreditation standards was associated with increases in achievement of minimal standards for prenatal care among women in the Philippines.

Racial differences in long-term adherence to oral antidiabetic drug therapy: a longitudinal cohort study

Background

Adherence to oral antidiabetic medications is often suboptimal. Adherence differences may contribute to health disparities for black diabetes patients, including higher microvascular event rates, greater complication-related disability, and earlier mortality.

Methods

In this longitudinal retrospective cohort study, we used 10 years of patient-level claims and electronic medical record data (1/1/1992–12/31/2001) to assess differences in short- and long-term adherence to oral antidiabetic medication among 1906 newly diagnosed adults with diabetes (26% black, 74% white) in a managed care setting in which all members have prescription drug coverage. Four main outcome measures included: (1) time from diabetes diagnosis until first prescription of oral antidiabetic medication; (2) primary adherence (time from first prescription to prescription fill); (3) time until discontinuation of oral antidiabetic medication from first prescription; and (4) long-term adherence (amount dispensed versus amount prescribed) over a 24-month follow-up from first oral antidiabetic medication prescription.

Results

Black patients were as likely as whites to initiate oral therapy and fill their first prescription, but experienced higher rates of medication discontinuation (HR: 1.8, 95% CI: 1.2, 2.7) and were less adherent over time. These black-white differences increased over the first six months of therapy but stabilized thereafter for patients who initiated on sulfonylureas. Significant black-white differences in adherence levels were constant throughout follow-up for patients initiated on metformin therapy.

Conclusion

Racial differences in adherence to oral antidiabetic drug therapy persist even with equal access to medication. Early and continued emphasis on adherence from initiation of therapy may reduce persistent racial differences in medication use and clinical outcomes.

Symbioses: a key driver of insect physiological processes, ecological interactions, evolutionary diversification, and impacts on humans

Symbiosis is receiving increased attention among all aspects of biology because of the unifying themes it helps construct across ecological, evolutionary, developmental, semiochemical, and pest management theory. Insects show a vast array of symbiotic relationships with a wide diversity of microorganisms. These relationships may confer a variety of benefits to the host (macrosymbiont), such as direct or indirect nutrition, ability to counter the defenses of plant or animal hosts, protection from natural enemies, improved development and reproduction, and communication. Benefits to the microsymbiont (including a broad range of fungi, bacteria, mites, nematodes, etc.) often include transport, protection from antagonists, and protection from environmental extremes. Symbiotic relationships may be mutualistic, commensal, competitive, or parasitic. In many cases, individual relationships may include both beneficial and detrimental effects to each partner during various phases of their life histories or as environmental conditions change. The outcomes of insect-microbial interactions are often strongly mediated by other symbionts and by features of the external and internal environment. These outcomes can also have important effects on human well being and environmental quality, by affecting agriculture, human health, natural resources, and the impacts of invasive species. We argue that, for many systems, our understanding of symbiotic relationships will advance most rapidly where context dependency and multipartite membership are integrated into existing conceptual frameworks. Furthermore, the contribution of entomological studies to overall symbiosis theory will be greatest where preoccupation with strict definitions and artificial boundaries is minimized, and integration of emerging molecular and quantitative techniques is maximized. We highlight symbiotic relations involving bark beetles to illustrate examples of the above trends.

Medication adherence and racial differences in A1C control

OBJECTIVE

The purpose of this study was to examine medication adherence and other self-management practices as potential determinants of higher glycemic risk among black relative to white patients.

RESEARCH DESIGN AND METHODS

We used a retrospective, longitudinal repeated-measures design to model the contribution of medication adherence to black-white differences in A1C among type 2 diabetic patients at a large multispecialty group practice. We identified 1,806 adult (aged >/=18 at diagnosis) patients (467 black and 1,339 white) with newly initiated oral hypoglycemic therapy between 1 December 1994 and 31 December 2000. Race was identified using an electronic medical record and patient self-report. Baseline was defined as the 13 months preceding and included the month of therapy initiation. All patients were required to have at least 12 months of follow-up.

RESULTS

At initiation of therapy, black patients had higher average A1C values compared with whites (9.8 vs. 8.9, a difference of 0.88; P < 0.0001). Blacks had lower average medication adherence during the first year of therapy (72 vs. 78%; P < 0.0001). Although more frequent medication refills were associated with lower average A1C values, adjustment for adherence did not eliminate the black-white gap.

CONCLUSIONS

We found persistent racial differences in A1C that were not explained by differences in medication adherence. Our findings suggest that targeting medication adherence alone is unlikely to reduce disparities in glycemic control in this setting. Further research is needed to explore possible genetic and environmental determinants of higher A1C among blacks at diagnosis, which may represent a critical period for more intensive intervention.

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.

Use of atypical antipsychotic drugs for schizophrenia in Maine Medicaid following a policy change

More than one-third of Medicaid programs and Medicare Part D plans use prior authorization (PA) policies to control the use of atypical antipsychotics (AAs). We used Medicaid and Medicare claims data to investigate how Maine's PA policy affected AA use, treatment discontinuities, and spending among schizophrenia patients initiating AA therapy. Patients initiating AAs during Maine's policy experienced a 29 percent greater risk of treatment discontinuity than patients initiating AAs before the policy took effect; no change occurred in a comparison state. AA spending was slightly lower in both states. Observed increases in treatment discontinuities without cost savings suggest that AAs should be exempt from PA for patients with severe mental illnesses.

A longitudinal study of medication nonadherence and hospitalization risk in schizophrenia

OBJECTIVE

Previous cross-sectional studies have suggested an association between medication nonadherence and hospitalization for individuals with schizophrenia. However, such analyses typically measure adherence averaged over long time periods. We investigated the temporal relationship between nonadherence and hospitalization risk using a daily measure of medication availability.

METHOD

Our observational cohort included 1191 patients with schizophrenia (ICD-9 criteria) enrolled in Maine and New Hampshire Medicaid programs who initiated atypical antipsychotic therapy between January 1, 2001, and December 31, 2003. Pharmacy claims were used to define days with gaps in medication availability. We tested the association of gaps in medication availability with all-cause, mental health, and schizophrenia-specific hospitalization using a Cox regression model.

RESULTS

Compared to individuals with available medication, individuals in the first 10 days following a missed prescription refill had a hazard ratio of 1.54 (95% CI = 1.02 to 2.32) for mental health hospitalization and 1.77 (95% CI = 1.16 to 2.71) for schizophrenia hospitalization. Similarly, medication gaps of more than 30 days were associated with 50% increased hazard for all 3 hospitalization outcomes. Switching and augmenting therapy, previous hospitalization, and clinical severity measures were also associated with substantially increased hazard of hospitalization.

CONCLUSION

Our findings indicate that patients may be at significantly increased risk for hospitalization as early as the first 10 days following a missed medication refill. Patients who switched or augmented medications or were previously hospitalized also demonstrated increased hospitalization risk. Clinicians and Medicaid programs should consider using pharmacy claims to monitor medication use and target adherence interventions to reduce relapses in this vulnerable population.

Racial differences in long-term self-monitoring practice among newly drug-treated diabetes patients in an HMO

BACKGROUND

One approach to improving outcomes for minority diabetics may be through better self-care. However, minority patients may encounter barriers to better self-care even within settings where variations in quality of care and insurance are minimized.

OBJECTIVE

The objective of the study was to evaluate racial differences in long-term glucose self-monitoring and adherence rates in an HMO using evidence-based guidelines for self-monitoring.

DESIGN

Retrospective cohort study using 10 years (1/1/1993-12/31/2002) of electronic medical record data was used.

PATIENTS

Patients were 1,732 insured adult diabetics of black or white race newly initiated on hypoglycemic therapy in a large multi-specialty care group practice.

MEASUREMENTS

Outcomes include incidence and prevalence of glucose self-monitoring, intensity of use, and rate of adherence to national recommended standards.

RESULTS

We found no evidence of racial differences in adjusted initiation rates of glucose self-monitoring among insulin-treated patients, but found lower rates of initiation among black patients living in low-income areas. Intensity of glucose self-monitoring remained lower among blacks than whites throughout follow-up [IRR for insulin = 0.41 (0.27-0.62); IRR for oral hypoglycemic = 0.75 (0.63, 0.90)], with both groups monitoring well below recommended standards. Among insulin-treated patients, <1% of blacks and <10% of whites were self-monitoring 3 times per day; 36% of whites and 10% of blacks were self-monitoring at least once per day.

CONCLUSIONS

Adherence to glucose self-monitoring standards was low, particularly among blacks, and racial differences in self-monitoring persisted within a health system providing equal access to services for diabetes patients. Early and continued emphasis on adherence among black diabetics may be necessary to reduce racial differences in long-term glucose self-monitoring.