Quality of care, health care costs, and utilization among Medicare Part D enrollees with and without low-income subsidy.

The objective of this cross-sectional, retrospective, claims-based analysis was to evaluate disease-specific quality measures, use of acceptable therapies, and health care cost and utilization among Medicare Advantage Part D (MAPD) enrollees overall and by income/subsidy eligibility status. Individuals aged ≥65 years with evidence of ≥1 of 8 common conditions and continuously enrolled in a MAPD plan throughout 2007 were assigned to low-income/dually eligible (LI/DE) or non-LI/DE cohorts. Quality of care metrics were calculated for asthma, chronic obstructive pulmonary disease (COPD), diabetes, and new episode depression. Persistence (proportion with percentage of days covered ≥80%), compliance (proportion with medication possession ratio ≥80%), health care costs, and utilization metrics were assessed by condition. All measures were evaluated for calendar year 2007. Bivariate comparisons were made between all LI/DE and non-LI/DE subgroups. A total of 183,213 patients were included. Metrics showed deficiencies in quality of care overall but generally favored non-LI/DE patients. The proportion of patients filling acceptable medication was suboptimal for most conditions, ranging from 40% to 96% across conditions and cohorts, with COPD the lowest and heart failure (HF) the highest. LI/DE patients were significantly more likely than non-LI/DE patients to fill acceptable therapy in each disease group (P<0.001) except HF. Percentages persistent and compliant with acceptable therapies were lowest for asthma and COPD, and highest for HF; percentages were generally higher among LI/DE patients. Mean disease-specific health care costs ranged from $345 (hyperlipidemia) to $2086 (HF) and were significantly higher for LI/DE than for non-LI/DE enrollees (P<0.001) for all diseases except coronary artery disease and HF. Overall, quality indicators, use of acceptable medications, and persistence/compliance metrics were suboptimal. Quality metrics favored non-LI/DE patients but medication metrics favored LI/DE patients. With an aging population and increasing health care costs, the deficits identified highlight the need for comprehensive strategies to improve clinical and economic outcomes across diseases.

How patient cost-sharing trends affect adherence and outcomes: a literature review.

OBJECTIVE: We sought to assess the relationship between patient cost sharing; medication adherence; and clinical, utilization, and economic outcomes. METHODOLOGY: We conducted a literature review of articles and abstracts published from January 1974 to May 2008. Articles were identified using PubMed, Ovid, medline, Web of Science, and Google Scholar databases. The following terms were used in the search: adherence, compliance, copay, cost sharing, costs, noncompliance, outcomes, hospitalization, utilization, economics, income, and persistence. RESULTS: We identified and included 160 articles in the review. Although the types of interventions, measures, and populations studied varied widely, we were able to identify relatively clear relationships between cost sharing, adherence, and outcomes. Of the articles that evaluated the relationship between changes in cost sharing and adherence, 85% showed that an increasing patient share of medication costs was significantly associated with a decrease in adherence. For articles that investigated the relationship between adherence and outcomes, the majority noted that increased adherence was associated with a statistically significant improvement in outcomes. CONCLUSION: Increasing patient cost sharing was associated with declines in medication adherence, which in turn was associated with poorer health outcomes.

Costs of asthma among US working adults.

OBJECTIVES: To evaluate the effect of asthma on direct and indirect costs among US working adults. STUDY DESIGN: A case-control retrospective analysis was conducted. Data between January 1, 2003, and December 31, 2006, among patients aged 18 to 64 years with vs without asthma were extracted from MarketScan Research Databases. Patients with chronic obstructive pulmonary disease or emphysema were excluded, and all patients were required to have 12-month continuous enrollment before and after the index date. Outcomes included direct medical costs, the number of absence days, the number of short-term disability days, and associated indirect costs. METHODS: Patients with asthma were propensity score-matched to patients without asthma using nearest neighbor 1:1 with caliper. Subsequent multivariate analysis was conducted on matched samples to examine the marginal effect of asthma on direct and indirect costs. RESULTS: A total of 13,379 patients with asthma were propensity score-matched to 13,379 patients without asthma; in each cohort, 3453 patients had absence eligibility, and 8497 patients had short-term disability eligibility. Direct costs for patients with asthma were $3762, and indirect costs were $4572. Compared with the matched cohort without asthma, patients with asthma had $1785 higher direct medical expenditures (P <.001). Incremental indirect costs were $191 for absenteeism (P = .007) and $172 for short-term disability (P<.001). CONCLUSIONS: Compared with patients without asthma, patients with asthma experience significantly higher direct medical costs and, although modest, significantly higher work loss. Treatments or interventions that prevent or reduce asthma symptoms may have a beneficial effect on medical costs and work absenteeism.

Quality of care associated with common chronic diseases in a 9-state Medicaid population utilizing claims data: an evaluation of medication and health care use and costs.

The objective of this cross-sectional, retrospective study was to utilize claims data to establish a quality-of-care benchmark in a large multistate Medicaid population overall and by race. Quality of care and medication adherence (persistence and compliance) per national treatment guidelines, and health care costs/utilization were assessed across common chronic conditions in a large, 9-state Medicaid population. Overall, quality of care was suboptimal across conditions. Over 15% of asthma patients had ≥ 1 asthma-related emergency room/hospital event and 12% of chronic obstructive pulmonary disease patients had a Level II or III exacerbation. Only 36% of depression patients filled any antidepressant medication within 90 days of new episode. Only 45% of diabetes patients received ≥ 2 A1c tests. Patients who filled a prescription for any acceptable pharmacotherapy ranged from 35% (depression) to 83% (heart failure [HF]). Persistence for those filling any acceptable medication ranged from 16% (asthma) to 68% (HF). Compliance for patients filling ≥ 2 prescriptions ranged from 27% (asthma) to 75% (HF). Blacks had the lowest medication compliance and persistence for all conditions except hyperlipidemia. The results highlight the need to assess and improve quality across the spectrum of care, both overall and by race.

Adherence to treatment guidelines and therapeutic regimens: a US claims-based benchmark of a commercial population.

The objective of this cross-sectional, retrospective study assessing commercially insured patients was to provide a useful benchmark to US health care payers and decision makers to assess quality of care, medication use and adherence, and health care resource utilization/costs associated with common chronic diseases. Measures of quality of care were suboptimal and substantial numbers of patients were not using any pharmacotherapy considered acceptable according to treatment guidelines. The widespread nature of undertreatment, poor medication adherence, and substantial health care costs highlights deficits and points to the need for comprehensive, multifaceted strategies to improve clinical and economic outcomes for chronic diseases.

Quality of care for veterans with chronic diseases: performance on quality indicators, medication use and adherence, and health care utilization.

This study was conducted to assess and benchmark the quality of care, in terms of adherence to nationally recognized treatment guidelines, for veterans with common chronic diseases (ie, asthma, chronic obstructive pulmonary disease [COPD], coronary artery disease [CAD], diabetes, heart failure, hyperlipidemia [HL]) in a Veterans Health Administration (VHA) system. Patients with at least 1 of the target diagnoses in the period between January 2002 and mid-year 2006 were identified using electronic medical records of patients seen at the James A. Haley Veterans' Hospital in Tampa, Florida. The most common diseases identified were HL (34%), CAD (21%), and diabetes (19%). The percentage of patients filling a prescription for any guidelines-sanctioned pharmacotherapy ranged from 28% (heart failure) to 91% (asthma). Persistence to medication ranged from 21% (HL) to 63% (asthma), while compliance ranged from 49% (COPD) to 85% (CAD). Most patients with diabetes (88%) had at least 1 A1c test in a year, but only 47% of patients had A1c values <7%. This study found that quality of care was generally good for conditions such as cardiovascular disease and diabetes, but quality care for conditions that have not been a primary focus of previous VHA quality improvement efforts, such as asthma and COPD, has room for improvement.

Nonadherence to clinical practice guidelines and medications for multiple chronic conditions in a California Medicaid population.

OBJECTIVES: To assess and profile quality of care in California Medicaid beneficiaries with chronic conditions. DESIGN: Retrospective cohort study. SETTING: California from 2002 to 2004. PATIENTS: 1,123,577 beneficiaries. INTERVENTION: Eligibility and claims data (2002-2004) were used to identify beneficiaries with dyslipidemia, hypertension, coronary artery disease (CAD), heart failure, or diabetes. MAIN OUTCOME MEASURES: Quality of care was based on nonadherence with clinical practice guidelines including recommended medications. Chi-square was used to evaluate nonadherence and patient characteristics. RESULTS: The proportion of patients without a prescription fill for recommended medications varied by disease (43% hypertension, 40% dyslipidemia and CAD, and 25% diabetes and heart failure). For Medicaid-only beneficiaries with diabetes, 78% lacked glycosylated hemoglobin tests, 62% lacked low-density lipoprotein cholesterol tests, and 50% lacked eye exams. Medication nonadherence was high (69% hypertension, 64% CAD, 57% heart failure, 48% dyslipidemia, 41% diabetes). Overall, younger age, Medicaid-only status, and black/other race were associated with poorer rates. CONCLUSION: Quality of care was suboptimal, with nonadherence varying by condition. Programs targeting both patients and providers and addressing patient-related characteristics (e.g., age, race) and policy reform addressing alterable factors (e.g., insurance eligibility) should be developed to improve guideline adherence.

In chronic disease, nationwide data show poor adherence by patients to medication and by physicians to guidelines.

PURPOSE: It is widely acknowledged in small studies that provider variation from evidence-based care guidelines and patient medication nonadherence lead to less than optimal health outcomes, increasing costs, and higher utilization. The research presented here aims to determine the prevalence of patient adherence to a medication regimen and provider adherence to guidelines for a variety of chronic conditions, using nationally representative data. DESIGN: A retrospective analysis of administrative claims data from a large national insurer was conducted. METHODOLOGY: The study examined multiple quality indicators exemplifying evidence-based medicine and medication adherence for several chronic conditions. Medication possession ratio (MPR) determined patient adherence. Using EBM Connect software created by Ingenix, we measured adherence to guidelines by applying a series of clinical rules and algorithms. PRINCIPAL FINDINGS: Adherence to the evidence-based practice guidelines examined in this study averaged approximately 59 percent, while patient medication nonadherence rates for all the conditions studied averaged 26.2 percent, with a range of 11 percent to 42 percent. Physician adherence to guidelines was highest in the prescribing of inhaled corticosteroids for persistent asthma. Ironically, medication adherence rates for inhaled corticosteroids were the worst identified. The best medication adherence rate was observed in patients with hypertension. CONCLUSION: Like earlier studies, this analysis finds that poor adherence is common across the nation and across common chronic conditions.

Direct economic effect following mupirocin therapy failure among patients with uncomplicated skin and skin-structure infections in a large population-based cohort.

The goal of the study was to derive initial costs associated with failure of initial mupirocin therapy among patients diagnosed with uncomplicated skin and skin-structure infections (uSSSIs). A retrospective observational analysis of medical, pharmacy, and enrollment records was conducted using data from the National Managed Care Benchmark Database. Patients were classified as failing treatment with mupirocin if they either filled a second antibiotic commonly used to treat uSSSIs five to 30 days after their index mupirocin prescription fill or experienced a uSSSI-related hospitalization within 30 days after the index mupirocin prescription fill. Among 12,650 failure episodes, 11,867 (93.8%) required a second antibiotic contributing a mean cost of $62 per prescription. Approximately 4,782 (37.8%) had an associated outpatient encounter resulting in a mean cost of $221 per encounter. Nine percent of failures required a hospitalization with a mean cost of $6,597 per hospitalization. These medical, hospital, and pharmacy costs translated into an expected cost of $735.45 per mupirocin failure among patients with uSSSIs. The management of uSSSIs is costly in terms of health care resource use and direct health care expenditures when initial therapy with mupirocin fails.

Prevalence and factors associated with self-reported vaccination rates among US adults at high risk of vaccine-preventable hepatitis.

BACKGROUND: Despite a routine vaccination for preventing HAV and HBV in young age groups during the past decade, adults at high risk of hepatitis are not reached effectively by vaccination programs. This study sought to estimate the prevalence of adults at higher risk of vaccine-preventable hepatitis (hepatitis A virus (HAV) and hepatitis B virus (HBV)) in the US and their vaccination rates. Also, the association between vaccination rates and selected demographic, socio-economic characteristics and comorbidities was investigated. METHODS: Four years, 1999-2002, of publicly available National Health and Nutrition Examination Survey (NHANES) data were utilized. Survey participants aged 20-59 years were selected. A survey participant was considered at higher risk when their situation and/or behavior placed them at a greater risk of contracting hepatitis as identified by the Centers for Disease Control and Prevention. All prevalence estimates were weighted to represent the total US population using 4-year interview and examination weights. Logistic regression was utilized to identify factors associated with vaccination rates. RESULTS: The study included 6237 survey participants who represent over 153 million adults age 20-59 years. Of these adults, 8.0%, 12.3% and 1.4% were at higher risk of HAV, HBV or both respectively. The self-reported vaccination rates among the higher risk population groups were 13%, 23.6% and 13.4% respectively. The most prevalent risk groups were persons with sexually transmitted diseases and persons using noninjection illegal drugs. Within the higher risk population, being single, male, aged 50-59 years and uninsured were all significantly (p < 0.05) less likely to be vaccinated than their counterparts. LIMITATIONS: The results of this study should be interpreted within the context of the following limitations: (1) the potential biases associated with participants' self-reported vaccination rates; (2) institutionalized US population with high prevalence rates of hepatitis infection are not included in the NHANES data. CONCLUSIONS: Among the population identified at higher risk of vaccine-preventable hepatitis (HAV, HBV or both), only a small proportion of this group had evidence of hepatitis vaccination.