A review of thromboembolic events in hospitalized COVID-19 patients.

CONTEXT: A higher incidence of thromboembolic disorders in COVID-19 has been reported by many clinicians worldwide. OBJECTIVE, DESIGN AND DATA SOURCES: Selected studies found in PubMed that reported thromboembolic events were included for meta-analysis using weighted fixed and random effects. Data from 19 articles on cohort studies in patients diagnosed with COVID-19 and thromboembolic events, including thrombosis and embolism were included in this review. RESULTS: The likelihood for developing thromboembolic disorders in hospitalized COVID-19 patients was 0.28 (95% CI 0.21-0.36). CONCLUSION: This study further validates the increased risk of VTE in COVID-19 patients when compared to healthy, non-hospitalized people, and hospitalized patients. These findings will be useful to researchers and medical practitioners caring for COVID-19 patients.

A Review of Thromboembolic Events in Hospitalized COVID-19 Patients.

Context: A higher incidence of thromboembolic disorders in COVID-19 has been reported by many clinicians worldwide. Objective, Design and Data Sources: Selected studies found in PubMed that reported thromboembolic events were included for meta-analysis using weighted fixed and random effects. Data from 19 articles on cohort studies in patients diagnosed with COVID-19 and thromboembolic events, including thrombosis and embolism were included in this review. Results: The likelihood for developing thromboembolic disorders in hospitalized COVID-19 patients was 0.28 (95% CI 0.21â€"0.36). Conclusion: This study further validates the increased risk of VTE in COVID-19 patients when compared to healthy, non-hospitalized people, and hospitalized patients. These findings will be useful to researchers and medical practitioners caring for COVID-19 patients.

Simulating Variation in Families' Spending across Marketplace Plans.

OBJECTIVE: To examine variations in premium and cost-sharing across marketplace plans available to eligible families. DATA SOURCES: 2011-2012 Medical Expenditure Panel Survey (MEPS), 2014 health plan data from healthcare.gov, and the 2011 Medicare Part D public formulary file. STUDY DESIGN: We identified a nationally representative cohort of individuals in the MEPS who would have been eligible for marketplace coverage. For each family, we simulated the total out-of-pocket payment (premium plus cost-sharing) under each available plan in their county of residence, assuming their premarketplace use. DATA COLLECTION/EXTRACTION METHODS: Confidential state and county of residence identifiers were merged onto MEPS public use files and used to match MEPS families to the plans available in their county as reported in the publicly available data from healthcare.gov. PRINCIPAL FINDINGS: We found substantial variation in total family health care spending, especially premium component, across marketplace plans. This is true even within a plan tier of the same minimum actuarial value, and for families eligible for subsidies. Variation among families with income below 250 percent of the FPL is larger than variation among families with higher income. CONCLUSIONS: Our simulations show substantial variations in net premium and out-of-pocket payments across marketplace plans, even within a plan tier.

Risk of Alzheimer's Disease Among Senior Medicare Beneficiaries Treated With Androgen Deprivation Therapy for Prostate Cancer.

Purpose To assess the relative risk of Alzheimer's disease (AD) among patients with prostate cancer who received androgen deprivation therapy (ADT), after adjustment for other cancer therapies. Methods Data from demographics, survival, diagnoses codes, procedure codes, and other information about beneficiaries age 67 years or older in the Medicare claims database was assessed to determine the unadjusted and adjusted risks of AD and of dementia from ADT. The prespecified survival analysis method was competing risk regression. Results Of the 1.2 million fee-for-service Medicare beneficiaries who developed prostate cancer in 2001 to 2014, 35% received ADT. Of these, 109,815 (8.9%) and 223,765 (18.8%) developed AD and dementia, respectively, and 26% to 33% died without either outcome. Unadjusted rates of AD and all-cause mortality per 1,000 patient-years were higher among ADT recipients; the unadjusted rates of AD were 17.0 and 15.5 per 1,000 person-years in recipients and nonrecipients, respectively, and the unadjusted rates of all-cause mortality were 73.0 and 51.6 per 1,000 person-years, respectively. The unadjusted rates for dementia in ADT recipients versus nonrecipients were 38.5 and 32.9, respectively, and the unadjusted rates of mortality were 60.2 versus 40.4, respectively. However, after analysis was adjusted for other cancer therapies and other covariates, patients with ADT treatment had no increased risk of AD (subdistribution hazard ratio [SHR], 0.98; 95% CI, 0.97 to 0.99) and had only a miniscule (1%) risk of dementia (SHR, 1.01; 95% CI, 1.01 to 1.02); patients treated with ADT were more likely to die before progression to AD (SHR, 1.24; 95% CI, 1.23 to 1.24) or dementia (SHR, 1.26; 95% CI, 1.25 to 1.26). The risks of AD and dementia were not associated with duration of ADT (ie, no dose effect). Other secondary analyses confirmed these results. Conclusion These data suggest that ADT treatment has no hazard for AD and no meaningful hazard for dementia among men age 67 years or older who are enrolled in Medicare.

Trends in Off-Label Use of Second-Generation Antipsychotics in the Medicare Population From 2006 to 2012.

OBJECTIVE: The study evaluated trends in the off-label use of second-generation antipsychotics in the Medicare population, a practice that has been identified as lacking adequate supporting evidence for many indications. METHODS: Medicare claims data from 2006 to 2012 were used to identify beneficiaries who filled at least one prescription for any second-generation antipsychotic. Any use that was not associated with a medical claim for an approved indication in a given year was classified as off-label use. Rates of off-label use and of diagnoses associated with off-label use were compared over time. Fill counts standardized for 30-day supply and costs were compared by type of use. RESULTS: On the basis of a sample of 490,314 patient-years, the rate of off-label use among beneficiaries prescribed a second-generation antipsychotic declined from 51% to 45%. Fill counts were 16% lower for off-label users compared with on-label users. Off-label users had higher out-of-pocket costs but lower total costs for second-generation antipsychotics. Off-label users most commonly had claims related to dementia, minor depression, anxiety disorders, and other psychosis. The proportion of off-label users without any claims for the most common off-label uses of second-generation antipsychotics declined from 45% in 2006 to 30% in 2012. CONCLUSIONS: Off-label use of second-generation antipsychotics has declined, especially among persons without any of the common off-label conditions. The diagnoses accompanying off-label use did not systematically reflect changes in the evidence base for the use of these drugs, suggesting a mismatch between evidence supporting the use of off-label second-generation antipsychotics and prescribing practices.

Evaluating the Initiation of Novel Oral Anticoagulants in Medicare Beneficiaries.

BACKGROUND: As alternatives to warfarin, 2 novel oral anticoagulants (NOACs), dabigatran and rivaroxaban, were approved in 2010 and 2011 to prevent stroke and other thromboembolic events in patients with atrial fibrillation. It is unclear how patient characteristics are associated with the initiation of anticoagulants. OBJECTIVE: To evaluate how patient demographics, clinical characteristics, types of insurance, and patient out-of-pocket spending affect the initiation of warfarin and 2 NOACs--dabigatran and rivaroxaban. METHODS: We used pharmacy claims data from a 5% random sample of Medicare beneficiaries to identify patients who were newly diagnosed with atrial fibrillation between October 1, 2010, and October 31, 2012, and who were prescribed an oral anticoagulant within 60 days of diagnosis. We identified key predictors of initiation of NOACs using a multinomial logistic regression model with generalized logit link. RESULTS: Patients who were black and who had a history of acute myocardial infarction, stroke or transient ischemic attack, chronic kidney disease, or congestive heart failure were significantly associated with lower odds of receiving NOACs compared with warfarin. Age greater than 65 years, a history of hypertension, and use of nonsteroidal anti-inflammatory drugs were positively associated with the initiation of NOACs. Rivaroxaban was most likely to be initiated among women, followed by warfarin and dabigatran. Individuals receiving a low-income subsidy were more likely to initiate warfarin than NOACs, even though they paid little copayment. Individuals with supplemental Part D drug coverage, such as national Programs for All-Inclusive Care for the Elderly or employer-sponsored plans, were more likely to initiate NOACs compared with warfarin. CONCLUSIONS: We found that race, sex, type of Part D plans, and some clinical conditions were associated with the initiation of NOACs relative to warfarin. But patient demographic and clinical characteristics did not appear to affect which particular NOAC patients initiated.

Part D Plan Switching Among Medicare Beneficiaries With Schizophrenia.

OBJECTIVE: Most Medicare schizophrenia patients were randomly assigned in 2006 to one of 409 benchmark plans. This study examined plan switching and factors affecting switching among beneficiaries with schizophrenia. METHODS: The data were 2006 Medicare pharmacy data for three groups of schizophrenia patients: those with Medicaid coverage ("dual eligibles"; N=93,705), Medicare beneficiaries with a low-income subsidy (N=56,148), and Medicare beneficiaries without the subsidy (N=36,107). Switching frequency and how patient and plan characteristics affected switching were examined. RESULTS: Beneficiaries who switched their Part D plan at least once included 10.7% of the dual eligibles, 9.8% of those with a subsidy, and 5.5% of those without. Several factors affected likelihood of switching, including age, geographic region, and proportion of prescriptions filled by beneficiaries who were covered or whose prescriptions required utilization review in the original plan. CONCLUSIONS: Plan switching among Medicare beneficiaries with schizophrenia was relatively infrequent but may be driven by the need for better drug coverage and less restrictive utilization policies.

Use of intelligent assignment to Medicare Part D plans for people with schizophrenia could produce substantial savings.

Medicare insures about half of the people in the United States diagnosed with schizophrenia. More than 90 percent of these beneficiaries are eligible for a low-income subsidy for their Part D prescription drug benefit, and the great majority of them are randomly assigned to a stand-alone drug plan. We simulated savings from replacing random assignment with an "intelligent assignment" algorithm that would assign beneficiaries to the least expensive plan in 2010 based on their drug usage in the previous year. Doing so generated projected annual drug savings of $379 per dual-eligible (those enrolled in both Medicaid and Medicare) beneficiary with a low-income subsidy; $404 per non-dual eligible with the subsidy; and $604 per beneficiary for those without the subsidy who chose their own plans. This translates into savings of $466 per beneficiary with schizophrenia. Intelligent assignment could have saved about $150 million for Medicare and beneficiaries with schizophrenia combined in 2010. We recommend that Medicare use intelligent assignment as the default approach for all beneficiaries with schizophrenia who receive a low-income subsidy, and consider it as an option for all Part D beneficiaries, regardless of their income.

Risk of bleeding with dabigatran in atrial fibrillation.

IMPORTANCE: It remains unclear whether dabigatran etexilate mesylate is associated with higher risk of bleeding than warfarin sodium in real-world clinical practice. OBJECTIVE: To compare the risk of bleeding associated with dabigatran and warfarin using Medicare data. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective cohort study, we used pharmacy and medical claims in 2010 to 2011 from a 5% random sample of Medicare beneficiaries. We identified participants as those newly diagnosed as having atrial fibrillation from October 1, 2010, through October 31, 2011, and who initiated dabigatran or warfarin treatment within 60 days of initial diagnosis. We followed up patients until discontinued use or switch of anticoagulants, death, or December 31, 2011. EXPOSURES: Dabigatran users (n = 1302) and warfarin users (n = 8102). MAIN OUTCOMES AND MEASURES: We identified any bleeding events and categorized them as major and minor bleeding by anatomical site. Major bleeding events included intracranial hemorrhage, hemoperitoneum, and inpatient or emergency department stays for hematuria, gastrointestinal, or other hemorrhage. We used a propensity score weighting mechanism to balance patient characteristics between 2 groups and Cox proportional hazards regression models to evaluate the risk of bleeding. We further examined the risk of bleeding for 4 subgroups of high-risk patients: those 75 years or older, African Americans, those with chronic kidney disease, and those with more than 7 concomitant comorbidities. RESULTS: Dabigatran was associated with a higher risk of bleeding relative to warfarin, with hazard ratios of 1.30 (95% CI, 1.20-1.41) for any bleeding event, 1.58 (95% CI, 1.36-1.83) for major bleeding, and 1.85 (95% CI, 1.64-2.07) for gastrointestinal bleeding. The risk of intracranial hemorrhage was higher among warfarin users, with a hazard ratio of 0.32 (95% CI, 0.20-0.50) for dabigatran compared with warfarin. Dabigatran was consistently associated with an increased risk of major bleeding and gastrointestinal hemorrhage for all subgroups analyzed. The risk of major bleeding among dabigatran users was especially high for African Americans and patients with chronic kidney disease. CONCLUSIONS AND RELEVANCE: Dabigatran was associated with a higher incidence of major bleeding (regardless of the anatomical site), a higher risk of gastrointestinal bleeding, but a lower risk of intracranial hemorrhage. Thus, dabigatran should be prescribed with caution, especially among high-risk patients.

A simple change to the Medicare Part D low-income subsidy program could save $5 billion.

Medicare Part D provides a subsidy to beneficiaries with incomes below 150 percent of the federal poverty level. Enrollees with the low-income subsidy accounted for 75 percent of the $60 billion in total federal Part D spending in 2013. The government randomly assigns any new beneficiary who automatically qualifies for the subsidy, or who successfully applies for it without indicating a preferred plan, to a stand-alone Part D plan whose premium is equal to or below the average premium for the basic Part D benefit in the region. We used an intelligent reassignment algorithm and 2008-09 Part D drug use and spending data to match enrollees to available plans according to their medication needs. We found that such a reassignment approach could have saved the federal government over $5 billion in 2009, for mean government savings of $710 (median: $368) per enrollee with a low-income subsidy. Implementing that simple change to reassign beneficiaries would have also lowered the proportion of prescriptions that required utilization review from 29 percent to 20 percent, and the proportion of prescriptions with quantity limits from 27 percent to 19 percent.

Medication adherence and readmission after myocardial infarction in the Medicare population.

OBJECTIVES: To examine the relationship between 6-month medication adherence and 1-year downstream heart disease-related readmission among patients who survived a myocardial infarction (MI). STUDY DESIGN: Retrospective, nested case-control analysis of Medicare fee-for-service beneficiaries who were discharged alive post MI in 2008 (n = 168,882). METHODS: Patients in the case group had their first heart-disease-related readmission post MI discharge during the 6-to-9-month period or the 9-to-12-month period. We then used propensity score matching to identify patients in the control group who had similar characteristics, but did not have a readmission in the same time window. Adherence was defined as the average 6-month medication possession ratio (MPR) prior to the first date of the time-window defining readmission. RESULTS: After controlling for demographics, insurance coverage, and clinical characteristics, patients who had a heart-disease-related readmission had worse adherence, with MPRs of 0.70 and 0.74 in the case and control groups, respectively. Odds ratio of MPR ≥ 0.75 was 0.79 (95% CI, 0.75-0.83) among those with a readmission relative to those without. CONCLUSIONS: Our study shows that better 6-month medication adherence may reduce heart-disease-related readmissions within a year after an MI.

Race/Ethnicity, disability, and medication adherence among medicare beneficiaries with heart failure.

BACKGROUND: Recent and national data on adherence to heart failure drugs are limited, particularly among the disabled and some small minority groups, such as Native Americans and Hispanics. OBJECTIVE: We compare medication adherence among Medicare patients with heart failure, by disability status, race/ethnicity, and income. DESIGN: Observational study. SETTING: US Medicare Parts A, B, and D data, 5% random sample, 2007-2009. PARTICIPANTS: 149,893 elderly Medicare beneficiaries and 21,204 disabled non-elderly beneficiaries. MAIN MEASURES: We examined 5% of Medicare fee-for-service beneficiaries with heart failure in 2007-2009. The main outcome was 1-year adherence to one of three therapeutic classes: ß-blockers, diuretics, and angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs). Adherence was defined as having prescriptions in possession for ≥ 75% of days. KEY RESULTS: Among aged beneficiaries, 1-year adherences to at least one heart failure drug were 63%, 57%, 53%, 50%, and 52% for Whites, Asians, Hispanics, Native Americans and Blacks, respectively; among the disabled, 1-year adherence was worse for each group: 57%, 53%, 48%, 44% and 43% respectively. The racial/ethnic difference persisted after adjustment for age, gender, income, drug coverage, location and health status. Patterns of adherence were similar among beneficiaries on all three therapeutic classes. Among beneficiaries with close-to-full drug coverage, minorities were still less likely to adhere relative to Whites, OR = 0.61 (95% CI 0.58-0.64) for Hispanics, OR = 0.59 (95% CI 0.57-0.62) for Blacks and OR = 0.57 (95% CI 0.47-0.68) for Native Americans. CONCLUSION: After the implementation of Medicare Part D, adherence to heart failure drugs remains problematic, especially among disabled and minority beneficiaries, including Native Americans, Blacks, and Hispanics. Even among those with close-to-full drug coverage, racial differences remain, suggesting that policies simply relying on cost reduction cannot eliminate racial differences.

Effects of Medicare Part D coverage gap on medication adherence.

OBJECTIVES: To evaluate the effects of the Medicare Part D coverage gap on pharmacy use among a national sample of Medicare beneficiaries and on medication adherence among 2 subsamples with heart failure and/or diabetes. STUDY DESIGN: Pre-post design, with comparison group and propensity score weighting. METHODS: We used a 5% random sample of elderly Medicare beneficiaries enrolled in stand-alone Part D plans in 2007. The comparison group had full coverage in the gap, whereas the 2 study groups had either no coverage or generic-only coverage in the gap. Main outcomes included probability of filling a prescription, monthly pharmacy spending and number of prescriptions filled, and adherence measured by medication possession ratios. RESULTS: Relative to the comparison group, beneficiaries without drug coverage in the gap reduced the number of prescriptions filled per month by 16.0% (95% confidence interval [CI], 15.5%-16.5%); those with generic drug coverage in the gap reduced it by 10.8% (95% CI, 10.3%-11.4%). Most of the reduction was attributable to reduced use of brand-name drugs. Beneficiaries with heart failure reduced adherence to heart failure drugs by 3.6% (95% CI, 2.9%-4.2%) and beneficiaries with diabetes reduced antidiabetic medication adherence by 10.3% (95% CI, 9.4%-11.3%). CONCLUSIONS: Medicare beneficiaries reduced medication use (mainly brand-name drugs) after entering the coverage gap. This result suggests that while beneficiaries' financial burden would continue because of the coverage gap, the gap would not result in a large reduction in medication adherence for essential drugs for diabetes and heart failure.

Cost-effectiveness of Medicare drug plans in schizophrenia and bipolar disorder.

BACKGROUND: Medicare Part D has a drug coverage gap, which imposes risks for discontinuing medications, particularly in mental health disorders where drug costs are high. However, some beneficiaries have generic drug coverage in the gap. OBJECTIVES: To examine the health outcomes and cost-effectiveness of generic-drug coverage compared with no gap coverage in patients with bipolar disorder and schizophrenia. STUDY DESIGN: Markov model-based cost-effectiveness analysis using identical hypothetical cohorts to examine drug coverage strategies. METHODS: The incremental cost-effectiveness of Part D coverage strategies was estimated, using differences in medical costs and quality-adjusted life years between plans. Coverage strategy-specific costs and hospitalization rates were obtained from 2007 Medicare data, adjusted for age, sex, race, and health status. RESULTS: When comparing generic-only coverage with no gap coverage, generic-only coverage cost less and was more effective than no gap coverage, due mainly to lower hospitalization rates. In sensitivity analyses, generic-only coverage continued to be favored over no gap coverage unless generic coverage costs increased > 3% in bipolar disorder and > 5% in schizophrenia; generic coverage in the gap was also favored in probabilistic sensitivity analyses. CONCLUSIONS: In Medicare Part D, generic drug coverage was cost saving compared with no coverage in bipolar disorder and schizophrenia while improving health outcomes. Policy makers and insurers might consider generic-only coverage, rather than no gap coverage, to both conserve healthcare resources and improve health.

Comparing local and regional variation in health care spending.

BACKGROUND: Wide geographic variation in health care spending has generated both concern about inefficiency and policy debate about geographic-based payment reform. Evidence regarding variation has focused on hospital referral regions (HRRs), which incorporate numerous local hospital service areas (HSAs). If there is substantial variation across local areas within HRRs, then policies focusing on HRRs may be poorly targeted. METHODS: Using prescription drug and medical claims data from a 5% random sample of Medicare beneficiaries from 2006 through 2009, we compared variation in health care spending and utilization among 306 HRRs and 3436 HSAs. We adjusted for beneficiary-level demographic characteristics, insurance status, and clinical characteristics. RESULTS: There was substantial local variation in health care (drug and nondrug) utilization and spending. Furthermore, many of the low-spending HSAs were located in high-spending HRRs, and many of the high-spending HSAs were in low-spending HRRs. For drug spending, only 50.7% of the HSAs located within the borders of the highest-spending quintile of HRRs were in the highest-spending quintile of HSAs; conversely, only 51.5% of the highest-spending HSAs were located within the borders of the highest-spending HRRs. Similar patterns were observed for nondrug spending. CONCLUSIONS: The effectiveness of payment reforms in reducing overutilization while maintaining access to high-quality care depends on the effectiveness of targeting. Our analysis suggests that HRR-based policies may be too crudely targeted to promote the best use of health care resources. (Funded by the Institute of Medicine and others.).

The effect of the US Medicare Part D coverage gaps on medication use among patients with depression and heart failure.

BACKGROUND: Medication use among Medicare beneficiaries has increased and adherence has improved since the implementation of the Medicare Part D prescription drug benefit in 2006. However, the structure of the benefit, particularly, the coverage gap, is still problematic. It is critical to understand how beneficiaries with coexisting conditions respond to the coverage gap and whether their response differs by type of medications. AIMS OF THE STUDY: The paper aims to evaluate the effects of Medicare Part D's coverage gap on drug regimens among beneficiaries with coexisting depression and heart failure (HF). METHODS: Drug utilization patterns and medication adherence of a 5% random sample of Medicare Part D beneficiaries with depression and HF in 2007 were observed. Drug utilization patterns were measured on the basis of reported drug claims and medication adherence was defined as the proportion of days of medication possession in a given period. We compared pre-post drug use patterns and medication adherence across three groups: no coverage, generic coverage, and full coverage due to low-income subsidies (LIS) and used propensity score weighting to adjust for difference across groups. RESULTS: Beneficiaries with some drug coverage in the gap were more likely to enter the gap: 82% for LIS, 79% for generic-only and 58% for no coverage. Beneficiaries without drug coverage reduced their use of antidepressants by 5.0% (95% CI 1.7%-8.2%), and HF drugs by 9.4% (95% CI 7.2%-11.5%) after they entered the coverage gap. Those with generic coverage cut their brand-name drugs more than generic drugs but did not shift to generic drugs. However, adherence to antidepressants did not change; adherence to HF drugs reduced slightly, 2.5% (95% CI 1.2%-3.7%) in the no-coverage group and 2.6% (95% CI 1.3%-3.9%) in the generic-coverage group. CONCLUSIONS: The coverage gap was associated with a modest reduction in number of prescriptions filled for depression and HF but it was not associated with a significant effect on adherence. IMPLICATIONS FOR HEALTH POLICY: We found that beneficiaries with coexisting depression and HF were less likely to reduce their drug use than beneficiaries in general. In addition, the gap was not associated with a large reduction in adherence. It suggests that concerns about the coverage gap's harmful effects on medication adherence, or comorbidities might be overstated. IMPLICATIONS FOR FURTHER RESEARCH: Further studies on how people make medication use decisions in the face of changes in benefits and how the coverage affects non-drug medical outcomes are warranted.

Disability, race/ethnicity, and medication adherence among Medicare myocardial infarction survivors.

BACKGROUND: Long-term medication therapy for patients with post-myocardial infarction (MI) can prolong life. However, recent data on long-term adherence are limited, particularly among some subpopulations. We compared medication adherence among Medicare MI survivors by disability status, race/ethnicity, and income. METHODS: We examined 100% of Medicare fee-for-service beneficiaries discharged post-MI in 2008. The outcomes were adherence to ß-blockers, statins, and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, for 1-year and 6-month postdischarge. Adherence was defined as having prescriptions in possession for ≥75% of days. RESULTS: Among aged beneficiaries who survived 1-year adherence to ß-blockers were 68%, 66%, 61%, 58%, and 57% for whites, Asians, Hispanics, Native Americans, and blacks, respectively; among persons with disability, 1-year adherence was worse for each group: 59%, 54%, 52%, 47%, and 43%, respectively. The racial/ethnic difference persisted after adjustment for age, gender, income, drug coverage, location, and health status. Patterns of adherence to statins and angiotensin-converting enzymes/angiotensin II receptor blockers were similar. Among beneficiaries with close-to-full drug coverage, minorities were still less likely to adhere relative to whites: odds ratio 0.70 (95% CI 0.65-0.75) for blacks and odds ratio 0.70 (95% CI 0.55-0.90) for Native Americans. CONCLUSIONS: Although ß-blockers at discharge has improved since the National Committee for Quality Assurance implemented quality measures, long-term adherence remains problematic, especially among persons with disability and minority beneficiaries. Quality measures for long-term adherence should be created to improve outcomes in patients with post-MI. Even among those with close-to-full drug coverage, racial differences remain, suggesting that policies simply relying on cost reduction cannot eliminate racial differences.

Effects of Medicare Part D coverage gap on medication and medical treatment among elderly beneficiaries with depression.

CONTEXT: Maintenance antidepressant pharmacotherapy in late life prevents recurrent episodes of major depression. The coverage gap in Medicare Part D could increase the likelihood of reducing appropriate use of antidepressants, thereby exposing older adults to an increased risk for relapse of depressive episodes. OBJECTIVES: To determine whether (1) beneficiaries reduce antidepressant use in the gap, (2) the reduction in antidepressant use is similar to the reduction in heart failure medications and antidiabetics, (3) the provision of generic coverage reduces the risk of reduction of medication use, and (4) medical spending increases in the gap. DESIGN: Observational before-after study with a comparison group design. SETTING AND PATIENTS: A 5% random sample of US Medicare beneficiaries 65 years or older with depression (n = 65,223) enrolled in stand-alone Part D plans in 2007. MAIN OUTCOME MEASURES: Antidepressant pharmacotherapy, physician, outpatient, and inpatient spending. RESULTS: Being in the gap was associated with comparable reductions in the use of antidepressants, heart failure medications, and antidiabetics. Relative to the comparison group (those who had full coverage in the gap because of Medicare coverage or low-income subsidies), the no-coverage group reduced their monthly antidepressant prescriptions by 12.1% (95% CI, 9.9%-14.3%) from the pregap level, whereas they reduced use of heart failure drugs and antidiabetics by 12.9% and 13.4%, respectively. Those with generic drug coverage in the gap reduced their monthly antidepressant prescriptions by 6.9% (95% CI, 4.8%-9.1%); this decrease was entirely attributable to the reduction in the use of brand-name antidepressants. Medicare spending on medical care did not increase for either group relative to the comparison group. CONCLUSIONS: The Medicare Part D coverage gap was associated with modest reductions in the use of antidepressants. Those with generic coverage reduced their use of brand-name drugs and did not switch from brand-name to generic drugs. The reduction in antidepressant use was not associated with an increase in nondrug medical spending.

Investigation of racial and ethnic disparities in service utilization among homeless adults with severe mental illnesses.

OBJECTIVE: This study examined whether there are service disparities among homeless adults with severe mental illnesses, a vulnerable population with a high level of unmet need. METHODS: Data were collected at baseline for 6,829 black, Latino, and non-Latino white participants in the Access to Community Care and Effective Services and Support study. Outcome variables were measures of utilization of psychiatric outpatient, housing, and case management services in the previous 60 days. The sample was divided into white-black and white-Latino cohorts. Within each cohort, participants were stratified into comparable groups by propensity scores that estimated log-odds of being black or Latino as a function of several confounding variables. White-black and white-Latino differences in mean number of visits (a measure of intensity) and in the mean probability of at least one visit (a measure of access) were subsequently estimated for each of the three services. RESULTS: The composition of the sample was 50% black, 6% Latino, and 44% white. Service utilization was low for the three services regardless of race-ethnicity. On multivariate analyses of service utilization in the previous 60 days, blacks made fewer psychiatric outpatient visits than whites (mean difference=.46, 95% confidence interval [CI]=.10 to .81]), yet Latinos had more case management visits than whites (mean difference=-.51, CI=-1.03 to -.05]). Analyses of access did not reveal racial-ethnic disparities. CONCLUSIONS: Whereas blacks used psychiatric outpatient services less frequently than whites, hence experiencing a service disparity, Latinos used case management services more than whites did. Possible contributors and clinical and methodological implications of these results are discussed.