Factors associated with prescription drug expenditures among children: an analysis of the Medical Expenditure Panel survey

Factors Associated with Insured Children's Use of Physician Visits, Dentist Visits, Hospital Care, and Prescribed Medications in the United States: An Application of Behavioral Model of Health-Services Use

This study is the first to examine factors in the utilization of physician services, dentist services, hospital care, and prescribed medications focusing exclusively on insured children in the United States. Data describing 48,660 insured children were extracted from the 2021 National Survey of Children's Health. Children in the present sample were covered by private health insurance, public health insurance, or other health insurance. Logistic regression results showed self-reported health to be negatively associated with physician visits, hospital-care use, and prescription use, but teeth condition to be positively associated with dentist visits. Physician visits were associated negatively with age, Hispanic ethnicity, Asian ethnicity, family income at or below 200% of the federal poverty level, and other health insurance, but positively with parental education and metropolitan residency. Dentist visits were associated positively with girls, age, and parental education, but negatively with Asian ethnicity and public health insurance. Use of hospital care was associated negatively with age and Asian ethnicity, but positively with parental education and public health insurance. Use of prescriptions was associated positively with age, Black ethnicity, parental education, and public health insurance, but negatively with Hispanic ethnicity, Asian ethnicity, and family income at or below 200% of the federal poverty level. Implications included the expansion of public health insurance, promotion of awareness of medicine discount programs, and understanding of racial/ethnic minorities' cultural beliefs in health and treatment.

Main drivers of diabetes pharmaceuticals expenditures: evidence from OECD countries and Iran

Purpose

This study aimed to identify the impact of prominent drivers on drug expenditure for diabetes.

Method

Following the examination of previous studies, this study identified possible factors contributing to diabetes pharmaceutical expenditures. The explanatory variables for the study were the median population age, access to innovative drugs, GDP per capita, prevalence, price, and consumption of diabetes drugs. Then, to estimate the per capita expenditure among diabetic patients, this study developed the panel data model and two time-series regression models for OECD countries and Iran, respectively.

Results

In the panel data regression model, R2 was 0.43. The influence of the age, prevalence, consumption volume and GDP per capita coefficients were + 1.79, + 0.704, + 3.86057, + 0.00054, respectively. Also, the probability level of all variables was less than 0.05. In Iran's comparative time-series regression model, R2 was 0.9, and the only significant influence coefficient was the age (β=+0.91). In the another model for Iran, R2 was 0.99, the influence coefficient of age was + 0.249, the prevalence was + 0.131, innovation was + 0.029, and the price was + 0.00054; all the probability levels were less than 0.05.

Conclusion

Pharmaceutical per capita expenditure is affected by several factors. These factors are not the same in various counties. Passing a judgment on drug utilization only based on pharmaceutical per capita expenditure cannot be perfect. Also, judging whether the per capita drug expenditure in one country is desirable without attention to the affecting factors and only relying on the value of utilized medicines is defective.

Racial and ethnic differences in health care utilization for childhood eczema: An analysis of the 2001-2013 Medical Expenditure Panel Surveys

BACKGROUND

Eczema is a common chronic inflammatory disease of the skin. Studies suggest differences in disease prevalence and severity by race/ethnicity. Our knowledge of health care utilization for eczema among different racial/ethnic groups remains limited.

OBJECTIVE

To evaluate health care utilization for childhood eczema among different racial/ethnic groups in the United States.

METHODS

We performed a cohort study of non-Hispanic white (reference), non-Hispanic black, and Hispanic white individuals under the age of 18 years with caregiver-reported eczema (N = 2043) pooled from the 2-year longitudinal cohorts of the 2001-2013 Medical Expenditure Panel Surveys. Health care utilization outcomes were evaluated over the 2-year follow-up period by race/ethnicity using multivariable regression.

RESULTS

Among all children with eczema, non-Hispanic blacks were less likely than whites to report an ambulatory visit for eczema (adjusted odds ratio [OR_adj] 0.69; 95% confidence interval [CI] 0.51-0.92). Among those with ≥1 ambulatory visit for eczema, non-Hispanic blacks reported more visits (adjusted incidence rate ratio [IRR_adj] 1.68; 95% CI 1.10-2.55) and prescriptions (IRR_adj 1.22; 95% CI 1.01-1.46) than whites and were more likely than whites to report a dermatology visit (OR_adj 1.82; 95% CI 1.06-3.14) for eczema.

LIMITATIONS

We used caregiver- or self-reported data.

CONCLUSION

Our findings suggest disparities in health care utilization for eczema among non-Hispanic black children despite utilization patterns suggestive of more severe disease.

Examining psychotropic medication use among youth in the U.S. by race/ethnicity and psychological impairment

OBJECTIVE

Clinical practice guidelines underscore the need for careful evaluation of the risk-benefit ratio of psychotropic medications treating mental health disorders among youth. While it is well known that racial/ethnic disparities exist in psychotropic medication use, little is known about whether these differences are driven by over-prescribing among white youth, under-prescribing among minority youth, or both. To build evidence in this area, this study examined racial/ethnic differences in the prescription of psychotropic medications among youth with and without psychological impairment.

METHODS

Secondary data on two-year medication use from the 2004-2011 Medical Expenditure Panel Surveys were analyzed. We capitalized on two-year panel data, creating variables that allow for differential sequencing of psychological impairment and medication prescription (e.g., impairment in year 1 or year 2, and a psychotropic medication fill in year 2). Statistical differences were determined using unadjusted rate comparisons and logistic regression models, after adjustment for socio-contextual and health status characteristics.

RESULTS

Compared to Black and Latino youth with psychological impairment, White youth were more likely to be prescribed psychotropic medications when impaired. Among youth never having psychological impairment, White youth were also more likely to be prescribed medications compared to their racial/ethnic minority counterparts.

CONCLUSIONS

Differences in rates of medication use among youth with and without impairment suggest poor medication targeting across racial/ethnic groups. These results, combined with recent psychotropic medication risk warnings and concerns over increases in psychotropic medication use among youth, suggest that a continued emphasis on accurate targeting of prescribing patterns is needed across racial/ethnic groups.

Racial and Ethnic Disparities in Mental Health Care for Children and Young Adults: A National Study

Psychiatric and behavior problems are common among children and young adults, and many go without care or only receive treatment in carceral settings. We examined racial and ethnic disparities in children's and young adults' receipt of mental health and substance abuse care using nationally representative data from the 2006-2012 Medical Expenditure Panel Surveys. Blacks' and Hispanics' visit rates (and per capita expenditures) were about half those of non-Hispanic whites for all types and definitions of outpatient mental health services. Disparities were generally larger for young adults than for children. Black and white children had similar psychiatric inpatient and emergency department utilization rates, while Hispanic children had lower hospitalization rates. Multivariate control for mental health impairment, demographics, and insurance status did not attenuate racial/ethnic disparities in outpatient care. We conclude that psychiatric and behavioral problems among minority youth often result in school punishment or incarceration, but rarely mental health care.

Determinants of U.S. Prescription Drug Utilization using County Level Data

Prescription drugs are the third largest component of U.S. healthcare expenditures. The 2006 Medicare Part D and the 2010 Affordable Care Act are catalysts for further growths in utilization becuase of insurance expansion effects. This research investigating the determinants of prescription drug utilization is timely, methodologically novel, and policy relevant. Differences in population health status, access to care, socioeconomics, demographics, and variations in per capita number of scripts filled at retail pharmacies across the U.S.A. justify fitting separate econometric models to county data of the states partitioned into low, medium, and high prescription drug users. Given the skewed distribution of per capita number of filled prescriptions (response variable), we fit the variance stabilizing Box-Cox power transformation regression models to 2011 county level data for investigating the correlates of prescription drug utilization separately for low, medium, and high utilization states. Maximum likelihood regression parameter estimates, including the optimal Box-Cox λ power transformations, differ across high (λ = 0.214), medium (λ = 0.942), and low (λ = 0.302) prescription drug utilization models. The estimated income elasticities of -0.634, 0.031, and -0.532 in high, medium, and low utilization models suggest that the economic behavior of prescriptions is not invariant across different utilization levels.

Outpatient Visits and Medication Prescribing for US Children With Mental Health Conditions

OBJECTIVE

To compare the mental health care US children receive from primary care providers (PCPs) and other mental health care providers.

METHODS

Using nationally representative data from the Medical Expenditure Panel Survey (MEPS) from 2008 to 2011, we determined whether children and youth aged 2 to 21 years with outpatient visits for mental health problems in the past year saw PCPs, psychiatrists, and/or psychologists/social workers for these conditions. We compared the proportion of children prescribed psychotropic medications by provider type. Using logistic regression, we examined associations of provider type seen and medication prescribing with race/ethnicity, household income, insurance status, geographical area, and language at home.

RESULTS

One-third (34.8%) of children receiving outpatient care for mental health conditions saw PCPs only, 26.2% saw psychiatrists only, and 15.2% saw psychologists/social workers only. Nearly a quarter (23.8%) of children saw multiple providers. A greater proportion of children with attention-deficit/hyperactivity disorder (ADHD) versus children with anxiety/mood disorders saw a PCP only (41.8% vs 17.2%). PCPs prescribed medications to a higher percentage of children than did psychiatrists. Children seeing a PCP for ADHD were more likely to receive stimulants or α-agonists than children with ADHD seeing psychiatrists (73.7% vs 61.4%). We found only limited associations of sociodemographic characteristics with provider type or medication use.

CONCLUSIONS

PCPs appear to be sole physician managers for care of 4 in 10 US children with ADHD, and one-third with mental health conditions overall. Efforts supporting mental health in primary care will reach a substantial portion of children receiving mental health services.

Prescription Drug Use Among Adults With Chronic Conditions in South Korea: Dual Burden of Health Care Needs and Socioeconomic Vulnerability

The aim of this study is to identify the social determinants of prescription drug use among adults with chronic diseases by examining the associations between socioeconomic position and prescription medicine use and perceived burden for pharmaceutical expenditure, using a sample of the Korean population from the 2008 Korea Health Panel, with 4 analytic models. Controlled with health status and the type of health insurance, the probability of using prescription drugs and overall spending on drugs significantly increased with rising income level, while perceived burden for out-of-pocket payment significantly decreased. These results imply that the poor are likely to underuse prescription drugs compared with their wealthier counterparts with the same need for health care, probably due to economic barriers.

Predictors of primary health care pharmaceutical expenditure by districts in Uganda and implications for budget setting and allocation

Background

There is need for the Uganda Ministry of Health to understand predictors of primary health care pharmaceutical expenditure among districts in order to guide budget setting and to improve efficiency in allocation of the set budget among districts.

Methods

Cross sectional, retrospective observational study using secondary data. The value of pharmaceuticals procured by primary health care facilities in 87 randomly selected districts for the Financial Year 2011/2012 was collected. Various specifications of the dependent variable (pharmaceutical expenditure) were used: total pharmaceutical expenditure, Per capita district pharmaceutical expenditure, pharmaceutical expenditure per district health facility and pharmaceutical expenditure per outpatient department visit. Andersen’s behaviour model of health services utilisation was used as conceptual framework to identify independent variables likely to influence health care utilisation and hence pharmaceutical expenditure. Econometric analysis was conducted to estimate parameters of various regression models.

Results

All models were significant overall (P < 0.01), with explanatory power ranging from 51 to 82 %. The log linear model for total pharmaceutical expenditure explained about 80 % of the observed variation in total pharmaceutical expenditure (Adjusted R² = 0.797) and contained the following variables: Immunisation coverage, Total outpatient department attendance, Urbanisation, Total number of government health facilities and total number of Health Centre IIs. The model based on Per capita Pharmaceutical expenditure explained about 50 % of the observed variation in per capita pharmaceutical expenditure (Adjusted R² = 0.513) and was more balanced with the following variables: Outpatient per capita attendance, percentage of rural population below poverty line 2005, Male Literacy rate, Whether a district is characterised by MOH as difficult to reach or not and the Human poverty index.

Conclusions

The log-linear model based on total pharmaceutical expenditure works acceptably well and can be considered useful for predicting future total pharmaceutical expenditure following observed trends. It can be used as a simple tool for rough estimation of the potential overall national primary health pharmaceutical expenditure to guide budget setting. The model based on pharmaceutical expenditure per capita is a more balanced model containing both need and enabling factor variables. These variables would be useful in allocating any set budget to districts.

Out-of-pocket expenditures and the financial burden of healthcare among older adults: by nativity and length of residence in the United States

Newly arrived older immigrants in the United States tend to be greatly affected by increasing out-of-pocket healthcare expenditures due to their limited insurance options. To examine such disparities in the out-of-pocket expenditures, this study analyzed the Medical Expenditure Panel Survey by immigrant status. Major findings of this study indicated that although recent immigrants had lower total healthcare expenditures, they spent much higher proportions of their annual income on out-of-pocket medical payments, compared with their US-born counterparts. Dramatically higher out-of-pocket burdens among recent immigrants represent a barrier to necessary healthcare, which needs to be addressed from both public health and economic perspectives.

Access to medicines by child refugees in the East Midlands region of England: a cross-sectional study

OBJECTIVES

To explore access to primary healthcare and drug therapy by refugee children in the East Midlands region of England.

DESIGN

Interviews with refugees with children and a control group of British parents with children.

SETTING

East Midlands region of England.

PARTICIPANTS

50 refugees with children and a control group of 50 parents with children.

MAIN OUTCOME MEASURES

Number of medicines used by children in the last month and the past 6 months. Health of parents and children. Registration with a general practitioner (GP).

RESULTS

All families in both groups were registered with a GP. There was no difference in the number of children in the two groups experiencing illnesses .In the last month, 30 refugee children received 60 medicines and 31 control children 63 medicines. In the past 6 months, 48 refugee children received 108 medicines and 43 control children 96 medicines. There was no difference between the two groups of children in relation to the likelihood of receiving any medicines in either the last month (P=0.839) or the past 6 months (p=0.81). Children in the refugee group were more likely to receive prescribed medicines for the last month (p=0.008) and the past 6 months (p<0.001). They were also less likely to receive over the counter (OTC) medicines in the past 6 months (p=0.009).

CONCLUSIONS

The refugee children in this study in the East Midlands had access to primary healthcare, medicines and a family doctor. They were more likely to receive prescribed medicines and less likely to receive OTC medicines, especially paracetamol.

The development of differences in hospital costs accross income groups in Finland from 1998 to 2010

OBJECTIVE

To quantify differences in hospital costs between socioeconomic groups and the development over time.

METHODS

Register data on somatic specialised hospital admissions for patients aged between 25 and 84 in Finland in 1998-2010 were used with income data individually linked to them. The cost of an admission was calculated by multiplying the number of a patient's inpatient days by the inpatient day cost of the patient's DRG. We calculated age-standardised admission costs per resident and per user as well as costs per inpatient day and concentration indices separately for men and women.

RESULTS

Hospital admission costs reduced with increasing income. The difference between the extreme income quintiles was more than 50% throughout the study period, and this difference widened. However, the cost per inpatient day was more than 20% higher in the highest income group. The differences between income groups were the most prominent in disease categories involving surgery.

CONCLUSIONS

The growth between socioeconomic groups in hospital costs is presumably mainly due to increasing differences in morbidity. More attention needs to be paid to prevention of health inequalities and access to and content of primary care among low-income groups in order to decrease the need for hospitalisations.

Factors associated with a patient-centered medical home among children with behavioral health conditions

At some point in their lives, nearly one-half of all American children will have a behavioral health condition. Many will not receive the care they need from a fragmented health delivery system. The patient-centered medical home is a promising model to improve their care; however, little evidence exists. Our study aim was to examine the association between several behavioral health indicators and having a patient-centered medical home. 91,642 children's parents or guardians completed the 2007 National Survey of Children's Health. An indicator for patient-centered medical home was included in the dataset. Descriptive statistics, bivariate tests, and multivariate regression models were used in the analyses. Children in the sample were mostly Male (52 %), White (78 %), non-Hispanic (87 %), and did not have a special health care need (80 %). 6.2 % of the sample had at least one behavioral health condition. Conditions ranged from ADHD (6 %) to Autism Spectrum Disorder (ASD) (1 %). Frequency of having a patient-centered medical home also varied for children with a behavioral health condition (49 % of children with ADHD and 33 % of children with ASD). Frequency of having a patient-centered medical home decreased with multiple behavioral health conditions. Higher severity of depression, anxiety, and conduct disorder were associated with a decreased likelihood of a patient-centered medical home. Results from our study can be used to target patient-centered medical home interventions toward children with one or more behavioral health conditions and consider that children with depression, anxiety, and conduct disorder are more vulnerable to these disparities.

Disparity implications of the Medicare medication therapy management eligibility criteria: a literature review

The emphasis on eliminating racial and ethnic disparities in healthcare has received national attention, with various policy initiatives addressing this problem and proposing solutions. However, in the current economic era requiring tight monetary constraints, emphasis is increasingly being placed on economic efficiency, which often conflicts with the equality doctrine upon which many policies have been framed. The authors' review aims to highlight the disparity implications of one such policy provision - the predominantly utilization-based eligibility criteria for medication therapy management services under Medicare Part D - by identifying studies that have documented racial and ethnic disparities in health status and the use of and spending on prescription medications. Future design and evaluation of various regulations and legislations employing utilization-based eligibility criteria must use caution in order to strike an equity-efficiency balance.

Racial/ethnic disparities in chronic diseases of youths and access to health care in the United States

Racial/ethnic minorities are 1.5 to 2.0 times more likely than whites to have most of the major chronic diseases. Chronic diseases are also more common in the poor than the nonpoor and this association is frequently mediated by race/ethnicity. Specifically, children are disproportionately affected by racial/ethnic health disparities. Between 1960 and 2005 the percentage of children with a chronic disease in the United States almost quadrupled with racial/ethnic minority youth having higher likelihood for these diseases. The most common major chronic diseases of youth in the United States are asthma, diabetes mellitus, obesity, hypertension, dental disease, attention-deficit/hyperactivity disorder, mental illness, cancers, sickle-cell anemia, cystic fibrosis, and a variety of genetic and other birth defects. This review will focus on the psychosocial rather than biological factors that play important roles in the etiology and subsequent solutions to these health disparities because they should be avoidable and they are inherently unjust. Finally, this review examines access to health services by focusing on health insurance and dental insurance coverage and access to school health services.

Racial/ethnic disparity trends in children's mental health care access and expenditures from 2002 to 2007

OBJECTIVE

To examine trends in disparities in children's mental health care.

DATA

2002-2007 Medical Expenditure Panel Survey.

STUDY DESIGN

We used the Institute of Medicine (IOM) definition of health care disparities and estimated two-part expenditure models to examine disparity trends in any mental health care use, any outpatient care, and psychotropic drug use, as well as expenditures in these three categories, conditional on use. We used 2-year longitudinal panel data to determine disparities in care initiation among children with unmet need.

PRINCIPAL FINDINGS

Assessing trends over time between 2002 and 2007, we identified that disparities persist for blacks and Latinos in receipt of any mental health care, any outpatient care, and any psychotropic drug use. Among those with positive mental health care expenditures, Latino-white disparities in overall mental health care expenditures increased over time. Among children with unmet need, significant disparities in initiation of an episode of mental health care were found, with whites approximately twice as likely as blacks and Latinos to initiate care.

CONCLUSIONS

Disparities in children's mental health care use are persistent and driven by disparities in initiation, suggesting policies to improve detection or increase initial access to care may be critical to reducing disparities.

Trends in preventive asthma medication use among children and adolescents, 1988-2008

OBJECTIVE

To examine trends in preventive asthma medication (PAM) use among children with current asthma in the United States from 1988 to 2008.

METHODS

We performed a cross-sectional analysis of PAM use among 2499 children aged 1 to 19 years with current asthma using nationally representative data from the National Health and Nutrition Examination Survey (NHANES) during 3 time periods: 1988-1994, 1999-2002, and 2005-2008. PAMs included inhaled corticosteroids, leukotriene receptor antagonists, long-acting β-agonists, mast-cell stabilizers, and methylxanthines.

RESULTS

Among children with current asthma, there was an increase in the use of PAMs from 17.8% (SE: 3.3) in 1988-1994 to 34.9% (SE: 3.3) in 2005-2008 (P < .001 for trend). Adjusting for age, gender, race/ethnicity, and health insurance status, the odds of PAM use were higher in 2005-2008 compared with 1988-1994 (adjusted odds ratio [aOR] = 2.6; 95% confidence interval [CI]: 1.5-4.5). A multivariate analysis, combining all 3 time periods, showed lower use of PAMs among non-Hispanic black (aOR = 0.5 [95% CI: 0.4-0.7]) and Mexican American (aOR = 0.6 [95% CI: 0.4-0.9]) children compared to non-Hispanic white children. PAM use was also lower in 12 to 19 year olds compared with 1 to 5 year olds and also in children who did not have health insurance compared with those who did.

CONCLUSIONS

Between 1988 and 2008, the use of PAM increased among children with current asthma. Non-Hispanic black and Mexican American children, adolescents aged 12 to 19 years, and uninsured children with current asthma had lower use of PAM.

An explanatory model for state Medicaid per capita prescription drug expenditures

Rising prescription drug expenditure is a growing concern for publicly funded drug benefit programs like Medicaid. To be able to contain drug expenditures in Medicaid, it is important that cause(s) for such increases are identified. This study attempts to establish an explanatory model for Medicaid prescription drugs expenditure based on the impacts of key influencers/predictors identified using a comprehensive framework of drug utilization. A modified Andersen's behavior model of health services utilization is employed to identify potential determinants of pharmaceutical expenditures in state Medicaid programs. Level of federal matching funds, access to primary care, severity of diseases, unemployment, and education levels were found to be key influencers of Medicaid prescription drug expenditure. Increases in all, except education levels, were found to result in increases in drug expenditures. Findings from this study could better inform intervention policies and cost-containment strategies for state Medicaid drug benefit programs.

Use of prescribed and non-prescribed medications among children living in poor areas in the city of Salvador, Bahia State, Brazil

A cross-sectional study of children living in poor areas in the city of Salvador, Bahia State, Brazil, was carried out in 2006 to investigate the prevalence of use of prescribed and non-prescribed medication. This population-based study included 1,382 children aged 4-11 years. The use prescribed and non-prescribed medication during the 15 day period preceding the interview was adopted as the dependent variable. Of the 1,382 children, 663 (48%) had used at least one type of medication in the 15 days prior to the interview: in 267 cases (40.3%), mothers reported that the child had taken prescribed medication, while in 396 cases (59.7%), the child had taken medication that had not been prescribed by a physician. The most commonly prescribed drugs were analgesics (42.3%), systemic antibiotics (21.3%) and antiasthmatic (16.5%). With respect to non-prescribed drugs, the most common were analgesics (65.2%), antitussives (15.7%) and vitamins (9.3%). The results show a high prevalence of the use of non-prescription drugs among poor children, and large drug purchases of drugs by the head of household, highlighting deficiencies in coverage of the health system.

Explaining racial and ethnic differences in antidepressant use among adolescents

We investigate the extent to which antidepressant use among adolescents varies across racial and ethnic subgroups. Using a representative sample of U.S. adolescents, we find that non-Hispanic White adolescents are over twice as likely as Hispanic adolescents, and over five times as likely as non-Hispanic Black adolescents to use antidepressants. Results from a decomposition analysis indicate that racial/ethnic differences in characteristics, including household income, parental education, health insurance, and having a usual source of care explain between one half and two thirds of the gap in antidepressant use between Hispanics and non-Hispanic Whites. In contrast, none of the gap between Whites and Blacks in antidepressant use is explained by differences in observed characteristics. Further analysis suggests that there are large racial/ethnic differences in the extent to which behavioral and mental health problems prompt antidepressant use and that this may, in part, account for the large differences across race/ethnicity observed in our study.

Psychotropic medication use among children with autism spectrum disorders enrolled in a national registry, 2007-2008

Patterns of current psychotropic medication use among 5,181 children with autism spectrum disorders (ASD) enrolled in a Web-based registry were examined. Overall, 35% used at least one psychotropic medication, most commonly stimulants, neuroleptics, and/or antidepressants. Those who were uninsured or exclusively privately insured were less likely to use >or=3 medications than were those insured by Medicaid. Psychiatrists and neurologists prescribed the majority of psychotropic medications. In multivariate analysis, older age, presence of intellectual disability or psychiatric comorbidity, and residing in a poorer county or in the South or Midwest regions of the United States increased the odds of psychotropic medication use. Factors external to clinical presentation likely affect odds of psychotropic medication use among children with ASD.

[Observational study on drug spending in the immigrant and the indigenous population in the Lleida (Catalonia) health region]

OBJECTIVE

To evaluate whether there are differences in drug spending between immigrant and Spanish-born populations and to assess whether drug consumption is associated with living environment (urban/rural).

DESIGN

Observational cross-sectional study.

SETTING

Lleida Health Region (LHR).

PARTICIPANTS

22,847 immigrants and 174,768 native born subjects, aged 15 to 64 years, residing in the LHR.

MAIN MEASUREMENTS

Drug spending during the year 2007, demographical variables, region of origin and residence area (urban/rural).

RESULTS

Native-born subjects spent more in all therapeutic drug groups than immigrants. In men, the relative risk ratio (RRR) of being in the highest quartile of expenditure was 3.2 (95% CI: 2.96-3.44) for native born versus immigrant and in women it was 2.1 (95% CI: 1.97-2.27). Immigrants from eastern Europe had the lowest risk of being in the highest quartile of expenditure, with statistically significant differences. Residents in the rural environment were more likely to have a higher pharmaceutical consumption than residents in the urban environment.

CONCLUSION

Inequalities in drug spending were observed between immigrants and native born subjects. Further studies, either qualitative or mixed, should explore which factors are related to these differences and propose strategies addressed to reducing them.

Latino Disparities in Prescription Drug Use and Expenditures: A Nationally Representative Analysis

BACKGROUND

Latinos are disproportionately affected by the lack of affordable prescription drugs. Within the Latino population, there are significant heterogeneities in the patterns of prescription drug expenditures and use. However, studies have traditionally treated them as a single, monolithic group.

OBJECTIVES

gTo identify and quantify factors associated with disparities in drug use and expenditures between non-Latino whites and Latino subgroups.

METHODS

We examined trends in prescription drug use, total prescription drug expenditures, and the proportion of out-of-pocket (OOP) payment to total drug expenditures for whites and Latino subgroups using the Medical Expenditure Panel Survey from 1999 to 2006. Multivariate regressions were used to adjust for confounding factors that may also affect drug use and expenditures.

RESULTS

Latinos were significantly less likely to use drugs compared to whites. Mexicans had significantly lower prescription drug costs and a higher proportion of OOP expenditures compared to whites after socioeconomic and demographic factors were controlled. Usual source of care, health insurance, and limited English proficiency were the most important factors associated with these disparities. Among the Latino subgroups, Puerto Ricans had drug expenditures and use patterns most similar to those of whites.

CONCLUSIONS

Substantive disparities in prescription drug expenditures and use existed between whites and specific Latinos groups, with Mexicans faring the worst. Future health studies should examine Latino subgroups separately, rather than treating Latinos as a homogeneous group. Policies aimed at expanding insurance coverage and access to a usual source of care, as well as addressing language barriers, should substantially reduce these disparities.

Cluster analysis of state Medicaid prescription drug benefit programs based on potential determinants of per capita drug expenditure

BACKGROUND

Drug cost-containment strategies result in varied outcomes in different state Medicaid programs perhaps, because they differ in ways beyond the usual considerations of similarity among the states and their Medicaid populations.

OBJECTIVE

To classify state Medicaid programs into homogenous groups based on potential determinants of their prescription drug expenditures.

METHODS

Cluster analysis techniques were used to identify clusters of state Medicaid programs, and their characteristics, using variables identified as potential determinants of Medicaid prescription drug expenditures.

RESULTS

Five distinct clusters were identified with memberships ranging from 1 to 24 states. Sociodemographic factors like race/ethnicity and elderly persons in Medicaid, severity of diseases, state population covered by Medicaid, population below poverty level, and high-school graduates; access factors like access to hospitals, pharmacies, physicians, and prenatal care; and policy factors like support for publicly funded health care were identified as key characteristics that distinguished among these clusters. Per capita prescription drug expenditure was also found to be significantly different among these clusters.

CONCLUSION

Knowledge of clusters among state Medicaid programs and their characteristics could potentially increase the chances of success for Medicaid administrative policies and interventions at lower costs of targeted implementation.

Attention deficit hyperactivity disorder in African American children: what can be concluded from the past ten years?

Samuel et al. [Samuel, V. J., Curtis, S., Thornell, A., George, P., Taylor, A., Brome, D. R., et al. (1997). The unexplored void of ADHD and African-American research: A review of the literature. Journal of Attention Disorders, 1(4), 197-207.] reviewed the literature on Attention Deficit Hyperactivity Disorder (ADHD) in African Americans, and found a paucity of research. The present review of 73 articles updates this assessment of available research and presents the current understanding of ADHD symptoms, assessment, diagnosis, and treatment in African American children ages 3-18. The authors conducted a qualitative review, as well as a mini meta-analysis of 5 studies of ADHD symptoms and 5 studies of ADHD diagnosis to clarify the question of racial differences in prevalence. African American youth had more ADHD symptoms (Cohen's d=0.45, p<.001), yet were diagnosed with ADHD only two-thirds as often as Caucasian youth (OR=.66, p<.001). This pattern was not explained by teacher rating bias or by SES, but may be influenced by parent beliefs about ADHD, higher rates of risk, and lack of treatment access and utilization. Lower treatment rates may be related to high rates of classroom behavior problems among African American youth. Findings also suggest that existing assessment tools may not adequately capture ADHD manifestation in African Americans. Findings highlight the need for more investigation and awareness of relevant cultural issues to inform a culturally competent approach to assessment, diagnosis, and treatment of ADHD in African Americans.

Pill-poppers and dopers: a comparison of non-medical prescription drug use and illicit/street drug use among college students

Data from the 2001 College Alcohol Study, a national sample of U.S. college students, were used to conduct multinomial logistic regression analysis examining correlates of substance use. Students were divided into three groups based on their lifetime substance use: non-users, non-medical prescription drug use only, and illicit/street drug use only. The purpose of this analytic strategy was to examine the similarities/differences in the correlates of non-medical prescription drug use and illicit/street drug use. Findings indicate that race, age, G.P.A., sexual activity, health, binge drinking, marijuana use, social bonding and social learning measures are correlates of non-medical prescription drug use. Correlates of illicit/street drug use include gender, Hispanic ethnicity, sexual activity, binge drinking, marijuana use, social bonding and social learning measures. Finally, the focus of the paper is a comparison of students who report only non-medical prescription drug use to students who report only illicit/street drug use. Findings indicate that gender, race, marital status, sexual activity, marijuana use, and social bonding measures significantly distinguish illicit/street drug use from non-medical prescription drug use. Important implications, limitations, and future research needs were discussed.

Differences in pharmaceutical consumption and expenses between immigrant and Spanish-born populations in Lleida, (Spain): a 6-months prospective observational study

Background

There are few studies comparing pharmaceutical costs and the use of medications between immigrants and the autochthonous population in Spain. The objective of this study is to evaluate whether there are differences in pharmaceutical consumption and expenses between immigrant and Spanish-born populations.

Methods

Prospective observational study in 1,630 immigrants and 4,154 Spanish-born individuals visited by fifteen primary care physicians at five public Primary Care Clinics (PCC) during 2005 in the city of Lleida, Catalonia (Spain). Data on pharmaceutical consumption and expenses was obtained from a comprehensive computerized data-collection system. Multinomial regression models were used to estimate relative risks and confidence intervals of pharmaceutical expenditure, adjusting for age and sex.

Results

The percentage of individuals that purchased medications during a six-month period was 53.7% in the immigrant group and 79.2% in the autochthonous group. Pharmaceutical expenses and consumption were lower in immigrants than in autochthonous patients in all age groups and both genders. The relative risks of being in the highest quartile of expenditure, for Spanish-born versus immigrants, were 6.9, 95% CI = (4.2, 11.5) in men and 5.3, 95% CI = (3.5, 8.0) in women, with the reference category being not having any pharmaceutical expenditure.

Conclusion

Pharmaceutical expenses are much lower for immigrants with respect to autochthonous patients, both in the percentage of prescriptions filled at pharmacies and the number of containers of medication obtained, as well as the prices of the medications used. Future studies should explore which factors explain the observed differences in pharmaceutical expenses and if these disparities produce health inequalities.

Explaining racial and ethnic differences in children's use of stimulant medications

OBJECTIVES

To document and explain racial/ethnic differences in the use of stimulant drugs among US children.

DATA AND METHODS

We use a nationally representative sample of children ages 5-17 years old from the Medical Expenditure Panel Survey (MEPS) for the years 2000-2002. We estimate race-specific means and regressions to highlight differences across groups in individual/family characteristics that may affect stimulant use and differences in responses to these characteristics. Then, we use Oaxaca-Blinder decomposition methods to quantify the portion of differential use explained by differences in individual/family characteristics. Finally, we use pooled regressions with race/ethnicity interactions to formally test the hypothesis that responses to perceived mental health and behavioral problems vary across groups.

RESULTS

White children are about twice as likely to use stimulants as either Hispanic or Black children. Differences in individual/family characteristics account for about 25% of the difference between whites and Hispanics, but for none of the difference between whites and blacks. Pooled regressions show that racial/ethnic gaps in stimulant use persist among children with otherwise similar reported mental health conditions.

CONCLUSIONS

Our finding that the majority of racial/ethnic differences in children's stimulant use is explained by differences in responses to individual/family characteristics highlights the importance of further research to examine the reasons for these differences. It is striking that children with otherwise similar reports of mental health problems have such different outcomes in terms of stimulant use. Potential explanations range from discrimination to cultural differences by race/ethnicity or community.

Treatment differences between Aboriginal and white infants admitted to Canadian neonatal intensive care units

Previous studies reported differences in clinical treatments provided to ethnic minority children and white children. We examined whether there were differences in clinical treatments provided to Aboriginal and White infants in Canadian Neonatal Intensive Care Units (NICU) and whether these potential differences could be explained by differences in population characteristics, community size, maternal neighbourhood income and hospital treatment policies. The study population included 10 166 infants (n = 784 Aboriginal and n = 9382 white) admitted to 17 NICUs from all geographical regions of Canada participating in the Canadian Neonatal Network during January 1996-October 1997. We used logistic regression analyses to examine the association between ethnicity and each of seven clinical practices (surfactant treatment, antenatal steroids, blood transfusions, surgery, assisted ventilation, incubator use and transparental nutrition), after adjustment for potential confounders. We repeated theses analyses restricted to infants born <32 weeks gestation. In crude analyses, in the full sample, Aboriginal infants were less likely than white infants to receive surfactants, antenatal steroids, surgery, assisted ventilation, incubator and transparental nutrition. Among infants born <32 weeks gestation, Aboriginal infants were less likely than white infants to receive antenatal steroids, assisted ventilation, incubator and transparental nutrition. In both groups, adjusting for illness severity, gestational age and multiple births separately (model 2) and in combination with neighbourhood income and community size (model 3) resulted in non-significant associations between ethnicity and some of the treatments, but the addition of adjustment for the hospital variation in frequency of use of different treatments resulted in non-significant associations between ethnicity and all seven treatments. Additional studies are needed to explore the significance of hospital frequency of treatment and its relationship to ethnicity.

Utilizing new prescription drugs: disparities among non-Hispanic whites, non-Hispanic blacks, and Hispanic whites

OBJECTIVE

To examine racial and ethnic disparities in new prescription drug use.

DATA SOURCES/STUDY SETTING

Secondary data analyses of the Medical Expenditure Panel Survey (1996-2001), a national survey representative of U.S. noninstitutionalized civilian population. Drug approval dates were from the GenRx database of Mosby.

STUDY DESIGN

A negative binomial model was used to compare annual number of times when new drugs were obtained across racial and ethnic groups. Covariates in the model were demographic, economic characteristics, and health status. Drugs were considered new if approved within the past 5 years. We compared non-Hispanic whites with non-Hispanic blacks, and non-Hispanic whites with Hispanic whites, respectively, to examine racial and ethnic disparities separately.

PRINCIPAL FINDINGS

Descriptive analyses found smaller racial disparities than ethnic disparities: the average annual number of times when new drugs were obtained was higher among non-Hispanic whites than non-Hispanic blacks (1.71 versus 1.36; p<.01) and Hispanic whites (1.71 versus 1.11; p<.01). Multivariate analyses found smaller ethnic than racial disparities: the number was 22-33 percent lower among non-Hispanic blacks than non-Hispanic whites (significant), and 5-16 percent lower among Hispanic whites than non-Hispanic whites (not always significant), respectively. While the absolute racial disparities decreased over the early years of the life cycles of the products, the reduction in disparities over time was not significant.

CONCLUSIONS

There are racial disparities in the use of new medications, which persist during the first 5 years of marketing. Socioeconomic and health characteristics account for a larger share of ethnic disparities than racial disparities.

Disparities in access to essential new prescription drugs between non-Hispanic whites, non-Hispanic blacks, and Hispanic whites

Prior studies do not address racial and ethnic disparities in essential new drug use and whether disparities decrease through time. Using the Medical Expenditure Panel Survey (1996-2001), racial and ethnic disparities were examined separately by comparing non-Hispanic whites to non-Hispanic blacks and Hispanic whites, respectively. New drugs were defined as approved within the past 5 years, and an expert panel identified essential drugs. Negative binomial models adjusted for socioeconomic and health characteristics. The mean annual number of times essential new drugs were obtained among non-Hispanic whites, non-Hispanic blacks, and Hispanic whites were 1.02, 0.94, and 0.70, respectively. After adjusting for confounders, ethnic disparities generally were not significant, but racial disparities became significant. This study did not identify declining disparities during early years of drugs' life cycles. Disparities exist in new, essential drug acquisition between non-Hispanic whites and non-Hispanic blacks. Socioeconomic and health characteristics explain many of the observed disparities.

Dimensions of the local health care environment and use of care by uninsured children in rural and urban areas

OBJECTIVE

Despite concerted policy efforts, a sizeable percentage of children lack health insurance coverage. This article examines the impact of the health care safety net and health care market structure on the use of health care by uninsured children.

METHODS

We used the Medical Expenditure Panel Survey linked with data from multiple sources to analyze health care utilization among uninsured children. We ran analyses separately for children who lived in rural and urban areas and assessed the effects on utilization of the availability of safety net providers, safety net funding, supply of primary care physicians, health maintenance organization penetration, and the percentage of people who are uninsured, controlling for other factors that influence use.

RESULTS

Fewer than half of uninsured children had office-based visits to health care providers during the year, 8% of rural and 10% of urban children visited the emergency department at least once, and just over half of children had medical expenditures or charges during the year. Among uninsured children in rural areas, living closer to a safety net provider and living in an area with a higher supply of primary care physicians were positively associated with higher use and medical expenditures. In urban areas, the supply of primary care physicians and the level of safety net funding were positively associated with uninsured children's medical expenditures, whereas the percentage of the population that was uninsured was negatively associated with use of the emergency department.

CONCLUSIONS

Uninsured children had low levels of utilization over a range of different health care provider types and settings. The availability of safety net providers in the local area and the safety net's capacity to serve the uninsured influence access to care among children. Possible measures for ensuring access to health care among uninsured children include increasing the density of safety net providers in rural areas, enhancing funding for the safety net, and policies to increase primary care physician supply.

Health care expenditures of immigrants in the United States: a nationally representative analysis

OBJECTIVES

We compared the health care expenditures of immigrants residing in the United States with health care expenditures of US-born persons.

METHODS

We used the 1998 Medical Expenditure Panel Survey linked to the 1996-1997 National Health Interview Survey to analyze data on 18398 US-born persons and 2843 immigrants. Using a 2-part regression model, we estimated total health care expenditures, as well as expenditures for emergency department (ED) visits, office-based visits, hospital-based outpatient visits, inpatient visits, and prescription drugs.

RESULTS

Immigrants accounted for $39.5 billion (SE=$4 billion) in health care expenditures. After multivariate adjustment, per capita total health care expenditures of immigrants were 55% lower than those of US-born persons ($1139 vs $2546). Similarly, expenditures for uninsured and publicly insured immigrants were approximately half those of their US-born counterparts. Immigrant children had 74% lower per capita health care expenditures than US-born children. However, ED expenditures were more than 3 times higher for immigrant children than for US-born children.

CONCLUSIONS

Health care expenditures are substantially lower for immigrants than for US-born persons. Our study refutes the assumption that immigrants represent a disproportionate financial burden on the US health care system.

Attenuation of Racial Differences in Health Service Utilization Patterns for Previously Uninsured Children in the Delta

CONTEXT

A school-based health insurance program for children of the working poor was conducted in 2 isolated, rural communities in the Lower Mississippi Delta region. The larger of the 2 communities had an array of locally available health care providers, whereas the smaller community did not. In response to this lack of available care, the project designed and delivered outreach programs, including transportation to providers.

PURPOSE

The purpose of this paper is to examine the role of race, age, and gender in the relationships between the utilization of care and the impact of outreach programs.

METHOD

General estimating equation models are used to examine the response of utilization variables to race, age, gender, and community. Four years of insurance claims data are analyzed.

FINDINGS

Race is seen to be an important component of utilization. The majority of participants were African American; however, children receiving prescription services, emergency room care, routine physician visits, and hospital outpatient services were more likely to be white. Outreach programs in vision and dental services were found to eliminate racial differences and increase utilization. A relatively strong gender effect was found in prescription, wellness, vision, and dental services.

CONCLUSIONS

Previous research has shown differences by race in utilization of care. Our findings show that targeted outreach programs can significantly diminish these differences. Findings also suggest that barriers to health care for poor rural children are closely linked to transportation and availability of providers, not merely to cost of care or insurance.

Racial and ethnic differences in ADHD and LD in young school-age children: parental reports in the National Health Interview Survey

OBJECTIVES

Racial and ethnic disparities have been documented for many physical health outcomes in children. Less is known, however, about disparities in behavioral and learning disorders in children. This study uses data from a national health survey to examine racial and ethnic differences in identified attention deficit hyperactivity disorder (ADHD) and learning disability (LD).

METHODS

The 1997-2001 National Health Interview Surveys obtained information from parents about the health and sociodemographic characteristics of children. Using these data, prevalence rates of identified ADHD and/or LD were estimated for Hispanic, African American, and white children 6-11 years of age. Racial and ethnic differences in health conditions, income, and insurance coverage were examined as possible explanations for disparities in parental reports of ADHD and LD, as well as the use of any prescription medication among children with ADHD.

RESULTS

Hispanic and African American children, compared to white children, had parental reports of identified ADHD without LD less often, and adjustments for the confounding variables-birthweight, income, and insurance coverage-did not eliminate these differences. Hispanic and African American children, compared to white children, also had parental reports of ADHD with LD less often after adjustments for the effects of confounding variables. By contrast, after adjustments for confounding variables, Hispanic and African American children were as likely as white children to have LD without ADHD. Among children with ADHD, use of any prescription medication was reported less often for Hispanic and African American children than white children. These disparities in medication use persisted after adjustments for confounding variables.

CONCLUSIONS

The prevalence of ADHD and the use of any prescription medication among children with ADHD differed among Hispanic, African American, and white children. These disparities could not be explained by racial and ethnic differences in other health conditions and sociodemographic variables.

Prescriptions for Cyclooxygenase-2 Inhibitors and Other Nonsteroidal Anti-inflammatory Agents in a Medicaid Managed Care Population: African Americans Versus Caucasians

OBJECTIVE

To determine whether race is a predictor of a patient's likelihood of being prescribed selective cyclooxygenase-2 inhibitors (COX-2s) versus other nonsteroidal anti-inflammatory agents (NSAIDs) in Medicaid managed care plans (MCO).

DESIGN

All medical and prescription claims for Medicaid MCO enrollees receiving at least one prescription for a COX-2 or NSAID between January 2000 and June 2002 were retrieved. Selected for study were adults claiming at least one COX-2 prescription or NSAID prescription with a minimum 30 days of supply after June 2000; having 60 total days of supply or more over the study period was also required for study inclusion. The probability of being prescribed a COX-2 was estimated as a logistic function of patient age, gender, race, city/suburban/rural residence, and history of rheumatoid arthritis, osteoarthritis, chronic back pain, acute pains, gastrointestinal problems, use of anticoagulants or corticosteroids, and comorbidities.

RESULTS

Of the 16,868 enrollees meeting the selection criteria, 4,005 (24%) were prescribed a COX-2 and 12,863 another NSAID. Half of those studied were African American, three-quarters were female, and a third were 50-64 years old. After adjusting for confounders, odds of a COX-2 prescription were a third less for African Americans and other races compared to Caucasians (OR, 0.67; 95% confidence intervals, 0.62-0.73).

CONCLUSION

Patient race is a significant predictor of COX-2 prescriptions in the Medicaid population, even after adjusting for other demographic and clinical variables. Cost to the patient was not a factor, as the patient copayment was 1 US dollar for any prescription.

The Insurance Effect on Prescription Drug Expenditures Among the Elderly

BACKGROUND

Despite continuing debate over a prescription drug benefit for the Medicare program, there has been relatively little research estimating the potential cost of providing such a benefit.

OBJECTIVE

The objective of this study was to estimate the effect of prescription drug insurance on outpatient prescription drug expenditures among the elderly.

RESEARCH DESIGN

We studied respondents aged > or =65 years to the 1997 Medical Expenditure Panel Survey, a representative survey of the U.S. noninstitutionalized population. Survey-weighted linear regression models were used to estimate the probability of any expenditures and total expenditures while controlling for sociodemographic characteristics, chronic conditions, and health status.

MEASURES

We used prescription drug insurance status and outpatient prescription drug expenditures.

RESULTS

An estimated 34 million elderly people filled 630 million prescriptions in 1997. Thirty-seven percent did not have prescription drug insurance. Total prescription drug expenditures exceeded $23 billion. Persons without prescription drug insurance spent slightly less than $7 billion; those with insurance spent more than $16 billion. After controlling for health status, comorbidity, and demographic characteristics, prescription drug insurance increased expenditures by $183 per person. The marginal increase in total expenditures of extending the average observed benefit to those currently uninsured is $2.3 billion (95% confidence interval, $1.2-3.5 billion).

CONCLUSIONS

Proposals for a Medicare drug benefit provide high copayments to protect against insurance effects and to address uncertainty in cost estimates of the proposed benefit. By quantifying the insurance effect on expenditures among the elderly, the data reported here could reduce uncertainty in the budget estimation process.

Health care utilization and expenditures associated with child care attendance: a nationally representative sample

OBJECTIVE

Participation in center-based child care among preschool-aged children is associated with an increased incidence of communicable illness. Although estimates of health care utilization and costs associated with child care attendance exist in other countries with different health care systems, nationally representative data for the United States are lacking. The objective of this study was to determine the patterns of health care utilization and costs associated with attendance at different types of child care, among a nationally representative sample of preschool-aged children.

METHODS

A nationally representative sample of children aged 0 to 5 years enrolled in the Medical Expenditure Panel Survey, 1997 Cohort were studied. Data were analyzed by cross-sectional analysis within a single calendar year. The Rand Health Insurance experiment 2-part multivariate regression model was used to accommodate skewed expenditure data.

RESULTS

A total of 871 children were included in the study. A total of 484 (56%) attended no child care provided by anyone other than their primary caregiver; 134 (15%) attended center-based child care; 76 (9%) attended friend or neighbor care; and 170 (20%) attended in-home or relative care. In a weighted multivariate model, children in center-based child care were more likely than those not in child care to have attended at least 1 office-based visit (adjusted odds ratio [aOR]: 2.8; 95% confidence interval [CI]: 1.0-7.9) and emergency department visit (aOR: 2.0; 95% CI: 1.1-3.6) and to have received a medication prescription (aOR: 2.8; 95% CI: 1.2-6.1). The adjusted 2-part model predicted total health care expenditures for those not attending child care to be 642 dollars (95% CI: 508-813), versus 985 dollars (95% CI: 714-1336) for a similar population in center-based child care. Expenditure data for office-based visits and medication prescriptions mirrored these trends.

CONCLUSION

In the immediate term, children in center-based child care tend to use more health care services. This increased utilization translates into modest per-child differences in health care expenditures. We hypothesize that this pattern of utilization and expenditure is attributable primarily to a higher incidence of minor, self-limited, communicable illness among children in center-based child care.