Seniors' perceptions of prescription drug advertisements: a pilot study of the potential impact on informed decision making

OBJECTIVE

To conduct a pilot study exploring seniors' perceptions of direct-to-consumer advertising (DTCA) of prescription drugs and how the advertisements might prepare them for making informed decisions with their physicians.

METHODS

We interviewed 15 seniors (ages 63-82) individually after they each watched nine prescription drug advertisements recorded from broadcast television. Grounded Theory methods were used to identify core themes related to the research questions.

RESULTS

Four themes emerged from the interviews about DTCA: (1) awareness of medications was increased, (2) information was missing or misleading and drugs were often perceived as more effective than clinical evidence would suggest, (3) most seniors were more strongly influenced by personal or vicarious experience with a drug - and by their physician - than by DTCA, and (4) most seniors were circumspect about the information in commercial DTCA.

CONCLUSIONS

DTCA may have some limited benefit for informed decision making by seniors, but the advertisements do not provide enough detailed information and some information is misinterpreted.

PRACTICAL IMPLICATIONS

Physicians should be aware that many patients may misunderstand DTCA, and that a certain amount of time may be required during consultations to correct these misconceptions until better advertising methods are employed by the pharmaceutical industry.

Cross-border utilization of health care: evidence from a population-based study in south Texas

OBJECTIVE

To assess the prevalence of health care utilization in Mexico by Texas border residents and to identify the main contributing factors to their cross-border utilization of health care services.

DATA AND METHODS

This study used primary data from a population-based telephone survey that was conducted in the whole Texas border area in 2008. The survey included responses from 1,405 adults. Multivariate logistic regression models were estimated to determine predictors of utilizing a wide range of health care services in Mexico.

PRINCIPAL FINDINGS

Forty-nine percent of the sample reported having ever purchased medications in Mexico, followed by 41 percent for dentist visits, 37.3 percent for doctor visits, and 6.7 percent for inpatient care. The most significant predictors of health care utilization in Mexico were lack of U.S. health insurance coverage, dissatisfaction with the quality of U.S. health care, and poor self-rated health status.

CONCLUSIONS

The high prevalence of use of health care services in Mexico by Texas border residents is suggestive of unmet needs in health care on the U.S. side of the border. Addressing these unmet needs calls for a binational approach to improve the affordability, accessibility, and quality of health care in the U.S.-Mexico border region.

An Integrated, Clinician-focused Telehealth Monitoring System to Reduce Hospitalization Rates for Home Health Care Patients with Diabetes

Diabetes is one of the leading causes of death and disability in the United States, and hospitalization rates related to this health condition are high and costly to the United States health care system. The purpose of this study was to examine the effect of an integrated, clinician-focused telehealth monitoring system on the probability of hospitalization for home health care patients with diabetes. The study included 2009 data from 699 Medicare beneficiaries receiving home health services in Texas and Louisiana. Propensity score matching, logistic regression, and post-estimation parameter simulation were used to assess how telehealth affects the probability of hospitalization during the first 30 days of home health care. The 30-day hospitalization probability for telehealth and non-telehealth patients was 7% and 19%, respectively. Patients in the telehealth group had a 12 (95% confidence interval = 4.2-20.3) percentage point-lower probability of hospitalization within the first 30 days of home health care than non-telehealth matched patients. The results suggest that telehealth monitoring systems that integrate skilled clinicians with critical care experience can lead to substantially lower hospitalization rates during the first 30 days of home health care, large cost savings, and more effective home health management of patients with diabetes.

Cross-border utilization of health care: evidence from a population-based study in south Texas

OBJECTIVE

To assess the prevalence of health care utilization in Mexico by Texas border residents and to identify the main contributing factors to their cross-border utilization of health care services.

DATA AND METHODS

This study used primary data from a population-based telephone survey that was conducted in the whole Texas border area in 2008. The survey included responses from 1,405 adults. Multivariate logistic regression models were estimated to determine predictors of utilizing a wide range of health care services in Mexico.

PRINCIPAL FINDINGS

Forty-nine percent of the sample reported having ever purchased medications in Mexico, followed by 41 percent for dentist visits, 37.3 percent for doctor visits, and 6.7 percent for inpatient care. The most significant predictors of health care utilization in Mexico were lack of U.S. health insurance coverage, dissatisfaction with the quality of U.S. health care, and poor self-rated health status.

CONCLUSIONS

The high prevalence of use of health care services in Mexico by Texas border residents is suggestive of unmet needs in health care on the U.S. side of the border. Addressing these unmet needs calls for a binational approach to improve the affordability, accessibility, and quality of health care in the U.S.-Mexico border region.

Assessing willingness to pay for cancer prevention

Cancer is the second leading cause of death in the U.S. and its economic cost is very high. The objective of this study is to analyze the socioeconomic and demographic factors that are related to the willingness to pay (WTP) for cancer prevention. Data from an experimental module in the 2002 Health and Retirement Study (HRS) were used to identify WTP differences across different population subgroups. Respondents were asked whether they were willing and able to pay different dollar amounts per month for a new cancer prevention drug. Years of age were negatively related to WTP whereas income and the probability of developing cancer were positively related to WTP. Risk-relevant numeracy skills were positively related to self-assessed cancer risk, which may suggest that adults with poor numeracy skills underestimate their cancer risk. This has consequences not only on the relative perceived value of different cancer treatments across different population subgroups but also on perceived value as captured by WTP.

Racial and ethnic disparities in awareness of genetic testing for cancer risk

BACKGROUND

Racial and ethnic disparities in awareness of genetic testing for cancer risk are substantial.

PURPOSE

This study assesses the relative importance of contributing factors to gaps in awareness of genetic testing for cancer risk across racial and ethnic groups.

METHODS

Data from the 2005 National Health Interview Survey (N=25,364) were analyzed in 2009 to evaluate the contribution of demographic factors, SES, health status, nativity/length of residency in the U.S., personal/family history of cancer, and perceived cancer risk to racial and ethnic disparities in genetic testing awareness for cancer risk. The contribution of each factor was assessed using the Fairlie decomposition technique.

RESULTS

About 48% of non-Hispanic whites reported that they had heard about genetic testing, followed by 31% of blacks, 28% of Asians, and 19% of Hispanics. Education and nativity/length of residency in the U.S. explained 26% and 30% of the gap between whites and Hispanics, respectively. Education accounted for 22% of the white-black gap, with residential region explaining another 11%. Nativity/length of residency in the U.S. explained 51% of the white-Asian gap.

CONCLUSIONS

The relative importance of factors contributing to racial and ethnic disparities in genetic testing awareness is specific to the particular groups under comparison. Diverse, culturally competent approaches are needed to improve awareness for different racial and ethnic groups.

Material resources and population health: disadvantages in health care, housing, and food among adults over 50 years of age

OBJECTIVES

We examined associations between material resources and late-life declines in health.

METHODS

We used logistic regression to estimate the odds of declines in self-rated health and incident walking limitations associated with material disadvantages in a prospective panel representative of US adults aged 51 years and older (N = 15,441).

RESULTS

Disadvantages in health care (odds ratio [OR] = 1.39; 95% confidence interval [CI] = 1.23, 1.58), food (OR = 1.69; 95% CI = 1.29, 2.22), and housing (OR = 1.20; 95% CI = 1.07, 1.35) were independently associated with declines in self-rated health, whereas only health care (OR = 1.43; 95% CI = 1.29, 1.58) and food (OR = 1.64; 95% CI = 1.31, 2.05) disadvantage predicted incident walking limitations. Participants experiencing multiple material disadvantages were particularly susceptible to worsening health and functional decline. These effects were sustained after we controlled for numerous covariates, including baseline health status and comorbidities. The relations between health declines and non-Hispanic Black race/ethnicity, poverty, marital status, and education were attenuated or eliminated after we controlled for material disadvantage.

CONCLUSIONS

Material disadvantages, which are highly policy relevant, appear related to health in ways not captured by education and poverty. Policies to improve health should address a range of basic human needs, rather than health care alone.

Context matters: where would you be the least worse off in the US if you were uninsured?

OBJECTIVES

We examined the health care access, quality, and cost experienced by uninsured Latino mothers in two communities in Minnesota and Texas. These communities differ substantially by the size of the local population without health insurance coverage.

METHODS

Four focus groups were conducted with uninsured Latino mothers who were caring for at least one child in their household. Seventeen mothers participated in each community. All focus groups were conducted by the same trained staff from a non-profit, community-based research organization.

RESULTS

Uninsured Latino mothers in Minnesota rated the quality of health care services in their community to be much higher than their Texas counterparts, but were more likely to emphasize the high costs of care and health insurance coverage. Participants in Texas also described having to go to Mexico to obtain health care services.

CONCLUSIONS

Policies making provision for health care services to the uninsured are likely to be more effective when they take into account the context or composition of each specific local health care system as well as the financial and non-financial spillovers that these uninsurance-related contexts generate.

Assessing quality across healthcare subsystems in Mexico

Recent healthcare reform efforts in Mexico have focused on the need to improve the efficiency and equity of a fragmented healthcare system. In light of these reform initiatives, there is a need to assess whether healthcare subsystems are effective at providing high-quality healthcare to all Mexicans. Nationally representative household survey data from the 2006 Encuesta Nacional de Salud y Nutrición (National Health and Nutrition Survey) were used to assess perceived healthcare quality across different subsystems. Using a sample of 7234 survey respondents, we found evidence of substantial heterogeneity in healthcare quality assessments across healthcare subsystems favoring private providers over social security institutions. These differences across subsystems remained even after adjusting for socioeconomic, demographic, and health factors. Our analysis suggests that improvements in efficiency and equity can be achieved by assessing the factors that contribute to heterogeneity in quality across subsystems.

Persistent disparities in the use of health care along the US-Mexico border: an ecological perspective

OBJECTIVES

We examined disparities in health care use among US-Mexico border residents, with a focus on the unique binational environment of the region, to determine factors that may influence health care use in Mexico.

METHODS

Data were from 2 waves of a population-based study of 1048 Latino residents of selected Texas border counties. Logistic regression models examined predictors of health insurance coverage. Results from these models were used to examine regional patterns of health care use.

RESULTS

Of the respondents younger than 65 years, 60% reported no health insurance coverage. The uninsured were 7 and 3 times more likely in waves 3 and 4, respectively, to use medical care in Mexico than were the insured. Preference for medical care in Mexico was an important predictor.

CONCLUSIONS

For those who were chronically ill, old, poor, or burdened by the lengthy processing of their documents by immigration authorities, the United States provided the only source of health care. For some, Mexico may lessen the burden at the individual level, but it does not lessen the aggregate burden of providing highly priced care to the region's neediest. Health disparities will continue unless policies are enacted to expand health care accessibility in the region.

Which physicians have access to electronic prescribing and which ones end up using it?

OBJECTIVES

This study examines the availability of electronic prescription and the utilization of e-prescribing by physicians in the US.

METHODS

Nationally representative data from the 2004-2005 Community Tracking Study Physician Survey were used to identify which subgroups of physicians have access to e-prescribing technology and which subgroups are using this technology more or less intensively. Exhaustive Chi-squared Automatic Interaction Detection (CHAID) was employed for statistical data segmentation.

RESULTS

Results indicate that the rapidly increasing adoption of electronic prescription is diminished by relatively low physician utilization. E-prescription utilization was segmented among practice size and type. There were also differences in e-prescription use by age, gender, and ethnicity/race in some subgroups. Actual use of e-prescription was very low for female physicians in surgical specialties, psychiatry, and obstetrics/gynecology, and for Hispanic physicians in pediatrics, internal medicine, and family/general practice in solo/two physician practices, medical schools, and hospitals.

CONCLUSIONS

Insights from segmentation analyses could be used to identify adoption barriers and to develop targeted interventions to accelerate the implementation of e-prescription systems in physician practices.

Effect of guidelines on primary care physician use of PSA screening: results from the Community Tracking Study Physician Survey

BACKGROUND

Little is known about the effect of guidelines that recommend shared decision making on physician practice patterns. The objective of this study was to determine the association between physicians' perceived effect of guidelines on clinical practice and self-reported prostate-specific antigen (PSA) screening patterns.

METHODS

This was a cross-sectional study using a nationally representative sample of 3914 primary care physicians participating in the 1998-1999 Community Tracking Study Physician Survey. Responses to a case vignette that asked physicians what proportion of asymptomatic 60-year-old white men they would screen with a PSA were divided into 3 distinct groups: consistent PSA screeners (screen all), variable screeners (screen 1%- 99%), and consistent nonscreeners (screen none). Logistic regression was used to determine the association between PSA screening patterns and physician-reported effect of guidelines (no effect v. any magnitude effect).

RESULTS

Only 27% of physicians were variable PSA screeners; the rest were consistent screeners (60%) and consistent nonscreeners (13%). Only 8% of physicians perceived guidelines to have no effect on their practice. After adjustment for demographic and practice characteristics, variable screeners were more likely to report any magnitude effect of guidelines on their practice when compared with physicians in the other 2 groups (adjusted odds ratio= 1.73; 95% confidence interval=1:25-2:38;P=0:001).

CONCLUSIONS

Physicians who perceive an effect of guidelines on their practice are almost twice as likely to exhibit screening PSA practice variability, whereas physicians who do not perceive an effect of guidelines on their practice are more likely to be consistent PSA screeners or consistent PSA nonscreeners.

Lack of community insurance and mammography screening rates among insured and uninsured women

PURPOSE

To evaluate whether the proportion of the local population without health insurance coverage is related to whether women undergo mammography screening.

METHODS

Survey data on 12,595 women 40 to 69 years of age from the 2000 to 2001 Community Tracking Study Household Survey were used to analyze the relation between community lack of insurance and whether the respondent had a mammogram within the past year.

RESULTS

Women age 40 to 69 were less likely to report that they had a mammogram within the last year if they resided in communities with a relatively high uninsurance rate, even after adjusting for other factors. After adjusting for individual insurance and other factors, a 10-percentage-point decrease in the proportion of the local insured population is associated with a 17% (95% CI, 13% to 21%) decrease in the odds that a woman age 40 to 69 years will undergo mammography screening within a year.

CONCLUSION

Women living in communities with high uninsurance are substantially less likely to undergo mammography screening. These results are consistent with the view that the negative impact of uninsurance extends to everyone in the community regardless of individual health insurance status.

End-of-life medical treatment choices: do survival chances and out-of-pocket costs matter?

BACKGROUND

Out-of-pocket medical expenditures incurred prior to the death of a spouse could deplete savings and impoverish the surviving spouse. Little is known about the public's opinion as to whether spouses should forego such end-of-life (EOL) medical care to prevent asset depletion.

OBJECTIVES

To analyze how elderly and near elderly adults assess hypothetical EOL medical treatment choices under different survival probabilities and out-of-pocket treatment costs.

METHODS

Survey data on a total of 1143 adults, with 589 from the Asset and Health Dynamics Among the Oldest Old (AHEAD) and 554 from the Health and Retirement Study (HRS), were used to study EOL cancer treatment recommendations for a hypothetical anonymous married woman in her 80s.

RESULTS

Respondents were more likely to recommend treatment when it was financed by Medicare than by the patient's own savings and when it had 60% rather than 20% survival probability. Black and male respondents were more likely to recommend treatment regardless of survival probability or payment source. Treatment uptake was related to the order of presentation of treatment options, consistent with starting point bias and framing effects.

CONCLUSIONS

Elderly and near elderly adults would recommend that the hypothetical married woman should forego costly EOL treatment when the costs of the treatment would deplete savings. When treatment costs are covered by Medicare, respondents would make the recommendation to opt for care even if the probability of survival is low, which is consistent with moral hazard. The sequence of presentation of treatment options seems to affect patient treatment choice.

Health insurance coverage and the use of preventive services by Mexican adults

The lack of health insurance coverage could be a potentially important deterrent to the use of preventive health care by older adults with high rates of chronic co-morbidities. We use survey data from 12 100 Mexican adults ages 50 and older who participated in the 2001 Mexican Health and Aging Study (MHAS) to analyze the relation between health insurance coverage and the use of preventive health-care services in Mexico. Uninsured adults were less likely to use preventive screenings for hypertension, high cholesterol, diabetes and (breast, cervical and prostate) cancer than insured adults. After adjusting for other factors affecting preventive care utilization in a logistic regression model, we found that these results still hold for high cholesterol and diabetes screening. Similar results hold for the population not working during the survey week and for adults earning below 200% of the poverty line. Our results suggest that insured adults are in a relatively better position to detect some chronic diseases - and have them treated promptly - than uninsured adults because they have better access to cost-effective preventive screenings. Recent public policy initiatives to increase health insurance coverage rates in Mexico could lead to substantially higher preventive health-care utilization rates and improvements in population health.

Sensitization to tomato peel and pulp extracts in the Mediterranean Coast of Spain: prevalence and co-sensitization with aeroallergens

BACKGROUND

Tomatoes (Lycopersicon esculentum) are consumed world-wide. The prevalence of sensitization to tomatoes remains unknown.

OBJECTIVE

To determine the prevalence of skin test reactivity to tomato and to describe the characteristics of tomato-sensitized subjects.

METHODS

Individuals attending for the first time during the period of the study to six Allergy centres, located along the Mediterranean coast of Spain, reporting respiratory and/or cutaneous symptoms, were included. All patients were skin prick tested with a battery of inhalant allergens and with peel and pulp of Canary tomato extracts.

RESULTS

The study included 1734 individuals (757 males, 977 females; 31.9+/-17.8 years old). The prevalence of sensitization to tomato was 6.52% (113 patients; 65 males, 48 females; 29.5+/-13 years old). The peel extract was positive in 110 patients and the pulp extract in 47 patients; three patients were positive exclusively to pulp. Only 1.8% of individuals reported symptoms with tomato; 44% of them had skin test negative to both extracts. Among tomato-sensitized subjects, 16% reported symptoms with tomato, 97% were sensitized to inhalant aeroallergens, including 84% to pollens (mainly Artemisia vulgaris and Platanus hybrida), with differences between Northern and Southern centres.

CONCLUSIONS

The prevalence found of skin test sensitivity to tomato is high. Peel extracts detected most of the sensitized subjects. Most of the sensitized subjects were asymptomatic and some patients reported symptoms without skin test sensitivity. Positive subjects were very frequently sensitized to pollens, suggesting allergen cross-reactivity. Regional differences may exist, possibly related to the pattern of sensitization to cross-reacting pollens.

Acculturation and the use of complementary and alternative medicine

The use of complementary and alternative medicine (CAM) has been growing substantially in the US in recent years. Such a growth in CAM use coincides with an ongoing increase in the proportion of the foreign-born population in the US. The main objective of this study is to examine the relation between acculturation and the use of CAM therapies among immigrants. Data from a CAM supplement to the 2002 National Health Interview Survey were analyzed to estimate the effects of acculturation on the likelihood of using different CAM therapies over the past 12 months prior to the survey. The results suggest that the level of acculturation-as measured by nativity/length of stay in the US and language of interview-is strongly associated with CAM use. As immigrants stay longer in the US or as their use of English becomes more proficient, the likelihood that they use CAM therapies increases as well, and it gradually approaches the level of CAM use by native-born Americans. Moreover, this relation between acculturation and CAM use generally persists even after the effects of socioeconomic status, health insurance coverage, self-reported health status, and other demographic variables have all been taken into consideration. The substantially lower rates of CAM use by recent immigrants and its possible causes warrant further research.

Spillovers And Vulnerability: The Case Of Community Uninsurance

This paper studies the uninsured as a vulnerable population. We contend that reducing the size of the uninsured population yields important spillover benefits to the insured population, benefits that go beyond a lower charity care burden. Evidence presented in this paper reinforces studies in the literature that show that problems of health services quality and access facing insured people increase when the proportion of uninsured people in their local communities is greater. The size of such spillover benefits is reduced if the local market is large enough to be segmented based on insurance status.

Managed care and the scale efficiency of US hospitals

Managed care penetration has been partly responsible for slowing down increases in health care costs in recent years. This study uses a 1992-1996 Health Care Utilization Project sample of hospitals to analyze the relationship between managed care penetration in local insurance markets and hospital scale efficiency. After controlling for hospital and market area variables, we find that managed care insurance, particularly the preferred provider type, is associated with increases in hospital scale efficiency in tertiary cases. The results presented here are consistent with the view that managed care can lead to reductions in health cost inflation by controlling the diffusion of technology via improvements in the scale efficiency of hospitals.

Community-level uninsurance and the unmet medical needs of insured and uninsured adults

OBJECTIVE

To examine the relationship between community-level uninsurance rates and the self-reported unmet medical needs of insured and uninsured adults in the U.S.

DATA SOURCES

2000-2001 Community Tracking Study, which includes data from 60 randomly selected U.S. communities. The sample is representative of the contiguous U.S. states.

STUDY DESIGN

Multilevel logistic regressions were employed to investigate whether the local uninsurance rate was related to having reported unmet medical needs within the last year. The models also included individual and community variables that could be potentially related to both community uninsurance rates and having reported unmet medical needs.

PRINCIPAL FINDINGS

The community uninsurance rate was positively associated with having reported unmet medical needs, but only for insured adults. On average, a five percentage point increment in the local uninsured population is associated with a 10.5 percent increase in the likelihood that an insured adult will report having unmet medical needs during the 12-month period studied.

CONCLUSION

Local health care delivery systems seem to be negatively affected by high uninsurance rates. These effects could have negative consequences for health care access, even for individuals who are themselves insured.

Access to health care for migrants returning to Mexico

Continued migration from Mexico over the past several decades has created a large population of elderly Mexicans in the U.S. There is no system in Mexico for those Mexicans who would like to retire there to obtain health insurance during their retirement years. Using a nationally representative dataset of Mexican elders, we explore the current state of health insurance status for Mexican elders with a history of migration to the U.S. We find a robust negative association between years spent in the U.S. and the probability of being insured. Coordination between the U.S. and Mexico on policy options to insure Mexicans migrants may prove beneficial to the social security systems in both countries as well as to migrants themselves.