Health literacy and health care spending and utilization in a consumer-driven health plan.

We examined health literacy and health care spending and utilization by linking responses of three health literacy questions to 2006 claims data of enrollees new to consumer-driven health plans (n = 4,130). Better health literacy on all four health literacy measures (three item responses and their sum) was associated with lower total health care spending, specifically, lower emergency department and inpatient admission spending (p < .05). Similarly, fewer inpatient admissions and emergency department visits were associated with higher adequate health literacy scores and better self-reports of the ability to read and learn about medical conditions (p-value <.05). Members with lower health literacy scores appear to use services more appropriate for advanced health conditions, although office visit rates were similar across the range of health literacy scores.

Behavioral healthcare services use in health savings accounts versus traditional health plans.

BACKGROUND: Numerous studies have examined behavioral health services via employer-sponsored health insurance cost-sharing measures. Their results clearly indicate that health plan design matters a great deal with respect to behavioral health utilization. It is also clear that there remain a number of unresolved issues, particularly with respect to the effects of a switch from traditional plan designs to high deductible, consumer-driven policies. Health Savings Accounts (HSA) have been well described in the literature with some comparisons to traditional healthcare plans, however no reports have been made about their use for behavioral health treatment. AIMS: We sought to estimate the impact switching to a consumer driven health plan (CDHP) with a health savings account had upon the utilization of behavioral health care. Utilization of behavioral health services were reviewed from claims data over three years (2005 through 2007). Comparisons were made between members who switched from traditional health plans to consumer driven health plans in 2007 with health savings accounts and members who remained in traditional health plans. METHODS: A pre-post study design was applied to two cohorts, stayers and switchers. The stayer cohort consisted of traditional health plan members enrolled from 2005 through 2007. Stayers were offered a health savings account in 2006 and 2007, but opted to remain in traditional health plans. The switcher cohort consisted of members enrolled in traditional plans in 2005 who opted to switch to a health savings account for two years thereafter (2006 and 2007). The use and intensity of behavioral health services in each study year were generated from claims data. Logistic and OLS regression analyses were applied to behavioral health services use and outpatient intensity measures respectively with independent variables post years, cohort and their interaction terms. Both analyses controlled for demographic variables. Additional behavioral disorder variables were added to the intensity regression. RESULTS: Members who switched to a health savings account plan were slightly less likely to initiate behavioral health services in each post year relative to members who stayed in traditional health plans. Of those who sought outpatient behavioral services, there was no difference between cohorts in the intensity of behavioral health services they received. DISCUSSION: Our results suggest enrollment in CDHPs moderately affects the use of behavioral health services but do not affect the intensity of outpatient behavioral health services conditioned on initiating these services. These finding are somewhat limited in that specific information about benefits were not included in the study. These results are also subject to self-selection bias. Members who switched to CDHP may be influenced to do so by other unknown factors that bear on their behavioral health. IMPLICATIONS FOR FURTHER RESEARCH: Recent growth in the number of health savings accounts and current attention to mental health legislation warrant answers about behavioral health spending and efficacious utilization of behavioral health services. Further studies which include behavioral health services outcomes and quality of care gleaned from claims data can answer questions about the efficiency of health savings accounts.

Population pharmacokinetics of valproic acid concentrations in elderly nursing home residents.

The objective of this study was to identify factors that affect valproic acid (VPA) apparent clearance (CL/F) in elderly nursing home residents. Inclusion criteria included residency in a nursing home for at least 2 months, aged 65 years or older, a stable dosing regimen of VPA for at least 4 weeks, VPA concentration, and complete dosing information. CL/F was analyzed by a nonlinear mixed effects model. A one-compartment model with first-order absorption and elimination was used. Both volume and absorption rate constant were fixed (14 L and 1 hr, respectively). Covariates were tested by forward inclusion and backward elimination. Interindividual variability in clearance was estimated using an exponential error model and expressed as a coefficient of variation. Residual error was estimated using a combined additive and constant coefficient of variation error model. The study consisted of 405 observations from 146 (52 men, 94 women) elderly nursing home residents. CL/F was not affected by age or weight. The population CL/F was 0.843 L/hr. CL/F was 1) 27% lower in female residents; 2) 41% greater when the resident was on concomitant metabolic inducers carbamazepine or phenytoin cotherapy; and 3) 25% greater when the syrup formulation was used. Variability in CL/F was 32.9%. Coefficient of variation and standard deviation of the residual error were 18.2% and 10.6 mg/L, respectively. The increased CL/F in patients taking VPA syrup may be the result of a decreased bioavailability (F) rather than an increased CL that could be associated with pathology requiring use of the syrup rather than an inherent property of the drug formulation. The results from this study may be useful for individualizing dose regimens in the nursing home population based on patient-specific factors.

Carbamazepine dose-concentration relationship in elderly nursing home residents.

PURPOSE: To describe the dose-concentration relationships of carbamazepine (CBZ) in elderly nursing home residents and the effect of sex, age, and type of co-medications. RESULTS: This is a cross-sectional study of elderly (> or = 65 years) nursing home residents across the United States (N=92). Data collection was from 1 June 1998 to 31 December 2000. The mean CBZ dose was 9.2+/-5.4 mg/(kg day(-1)) (+/-Standard Deviation) and serum concentration was 5.9+/-2.2mg/L. The daily dose was significantly lower in the oldest-old age group (> or = 85 years, mean 476.9 mg/day (95% confidence interval CI) 326.5-627.3) as compared to the dose in the young-old (65-74 years, mean 724.4 mg/day (CI) 603.4-845.4) (p=0.016). Adjusted for body weight, doses were similar on a mg/(kg day(-1)) basis. The majority of observed CBZ serum concentrations were at the lower end (67.4%) or below (20.7%) the suggested therapeutic range for younger adult outpatients. CONCLUSIONS: Total daily CBZ doses and patient weight decreased with age. The average dose for elderly nursing home residents was approximately 9 mg/(kg day(-1)). Carbamazepine serum concentrations were lower than those used for younger adults, suggesting that these patients may be more sensitive to CBZ.

The validity of epilepsy or seizure documentation in nursing homes.

Recent studies have reported that epilepsy and seizures are common in nursing homes. Prevalence has been reported to range from 5 to 9% and antiepileptic drug (AED) use is even more common. Most of these studies have relied on various forms of nursing home records, but the validity of this source data, while assumed, has not been verified. This study evaluated the degree of agreement between the Minimum Data Set (MDS), both paper and electronic versions, and actual medical records available at the nursing home. Records of 144 residents were evaluated; agreement between paper and electronic versions of the MDS was 97.8%. Agreement between the paper version of the MDS and neurologists review of the nursing home record was 92.3%. However, the criteria for diagnosing epilepsy or seizure were not well documented. Nevertheless, the agreement among nursing home records, paper MDS and electronic MDS is great enough to allow the electronic MDS to be used as a research tool, but more investigation of the actual criteria used by nursing home physicians in diagnosing epilepsy and seizures is necessary.

Effects of collaborative drug therapy management on patients' perceptions of care and health-related quality of life.

BACKGROUND: It has been demonstrated that collaborative drug therapy management may result in enhanced medication adherence and improved clinical outcomes. It is not yet known whether CDTM is associated with patients' perceptions of care or self-reports of health-related quality of life. OBJECTIVES: Examine the impact of collaborative drug therapy management (CDTM) on patients' perceptions of care and health-related quality of life in 15 ambulatory clinics (6 intervention, 9 comparison) in the Fairview system of Minneapolis-St Paul, Minn. METHODS: The intervention was medication therapy management provided by pharmacists in collaboration with physicians (CDTM) for a 12-month period. Subjects were selected by age, gender, and presence of one of 12 medical conditions in the intervention (n=285) and comparison (n=285) group of patients. Comparison patients received usual care while intervention patients received at least 2 CDTM encounters. The CAHPS (formerly called the Consumer Assessment of Health Plans) 2.0 survey was administered to both the intervention and comparison groups poststudy to analyze patients' perceptions of care. The Short Form-12 (SF-12v2) was administered to intervention group patients pre-CDTM and 6 months post-CDTM to measure health-related quality of life in the intervention group. RESULTS: Differences in CAHPS scores were not statistically significant (P>.05), although there was a trend toward higher ratings of patients' personal doctor/nurse and doctors' communication in the CDTM intervention group relative to the comparison group. Physical role, social functioning, and physical component summary scales of the SF-12v2 improved significantly (P=.001, P=.014, and P=.024, respectively; P< or =.025 level). CONCLUSIONS: A trend toward improvements in patient perceptions of effectiveness of care using CAHPS suggests a need for further study. Health-related quality of life improvements in this study meet or exceed previous results incorporating pharmacists into primary care. Intensity and integration of CDTM services may be an explanation; however, prepost study design limits inferences.

Demographic factors associated with dental utilization among community dwelling elderly in the United States, 1997.

OBJECTIVES: The purpose of this study was to characterize dental service utilization in 1997 by community dwelling Medicare beneficiaries. METHODS: The Medicare Current Beneficiary Survey, or MCBS, is a continuous annual series of nationally representative surveys of Medicare beneficiaries. Univariate comparisons were made between dependent variables (dental utilization and types of dental services) by each of the independent variables (age group, gender, race, income, education, population density, marital status and U.S. Census Bureau regions using weighted proportions to test for independence between dependent and independent variables. RESULTS: Overall, an estimated 41% of the population had a dental visit. Although utilization declined with aging, 24% of those 85 and older visited a dentist. CONCLUSIONS: This descriptive study provides important information about dental utilization and services in the American elderly population. Younger, high income, white or educated elderly Americans had higher dental utilization.

Prevalence of appropriate and problematic antiepileptic combination therapy in older people in the nursing home.

OBJECTIVES: To determine the prevalence of mono- and poly-antiepileptic drug (AED) therapy in a cohort of nursing home (NH) residents and to describe specific AED combinations used, as well as demographic, clinical, and functional factors associated with poly-AED therapy and the most common AED combination. DESIGN: Retrospective, point prevalence study. SETTING: All NHs owned/managed by Beverly Enterprises. PARTICIPANTS: All residents aged 65 and older residing in one of the study NHs on July 1, 1999, and receiving an AED (N=3,881). MEASUREMENTS: Data were gathered using two secondary source data sets: physicians' orders (AED use) and the Minimum Data Set (health status indicators). RESULTS: Of residents taking AEDs, 370 (9.5%) were taking two or more; 268 of those (72%) were taking problematic AED combinations (those with the potential of undesirable pharmacokinetic or pharmacodynamic interactions). Phenytoin (PHT) with phenobarbital (PB) was the most common combination (27.0%). Logistic regression indicated that poly-AED subjects were more likely to have a diagnosis of epilepsy/seizure (epi/sz) and less likely to have a diagnosis of cerebrovascular accident (CVA). Residents taking the PHT/PB combination were more likely to have an epi/sz diagnosis and longer NH stay. The association between CVA and PHT/PB polytherapy differed by presence or absence of aphasia. CONCLUSION: The overall prevalence of poly-AED therapy is less than 10% in NH residents, but 72% of those residents were receiving problematic polytherapy combinations, thereby exposing them to potential risk of adverse reactions and toxicity.

Valproic acid doses, concentrations, and clearances in elderly nursing home residents.

VPA daily dose and total VPA concentrations for 146 elderly (> or =65 years) nursing home residents collected from June 1998 to December 2000 in homes located throughout the United States are presented. Average age was 78.5+/-8.0 years old. The mean VPA daily dose was 16.2+/-11.2mg/kg and mean total VPA concentration was 48.5+/-24.8 mg/L. The majority (56.2%) of the VPA residents are being maintained at total VPA levels <50mg/L. Mean daily dose (19.4+/-11.4, 16.3+/-12.1, and 11.3+/-7.6 mg/kg/day; p=0.003) and total VPA concentration (56.4+/-25.8, 47.7+/-22.6, and 38.7+/-23.1mg/kg/day; p=0.003) decreased by age groups (65-74, 75-84, and > or =85 years). Daily dose and total VPA concentration were not different in residents receiving inhibitory or inducing co-medications, between men and women, or by albumin level. Total VPA clearance was similar between men and women, among age groups, or according to inducing or inhibiting co-medications.

Phenytoin use in elderly nursing home residents.

BACKGROUND: Phenytoin (PHT) dosing regimens are often determined based on experience in those aged <65 years rather than in those aged >or=65 years. OBJECTIVE: The goal of this study was to determine the impact of sex, age, receipt of concomitant inhibitors or inducers of PHT metabolism, and albumin levels on doses and total serum concentrations of PHT in elderly nursing home residents. METHODS: Consulting pharmacists to nursing homes located throughout the United States collected data from June 1998 to December 2000. The mean daily dose per person and mean total serum PHT concentration were tested for statistical differences by sex, age group (6-74, 75-84, and >or=85 years), coadministration of PHT inhibitors or inducers, and albumin levels. RESULTS: Data were collected from 387 residents (259 women, 128 men) of 112 nursing homes in 19 states who received PHT and for whom PHT concentrations were available. The mean (SD) age of the study population was 79.4 (7.8) years; women constituted 67.0% of the study population. The mean (SD) total daily dose and total PHT concentration were 4.9 (1.8) mg/kg and 11.7 (6.4) mg/L, respectively. In general, women received higher mean (SD) daily doses of PHT compared with men (5.1 [1.8] vs 4.6 [1.6] mg/kg, respectively; P=0.017) to achieve similar total serum concentrations (11.6 [6.4] and 12.0 [6.6] mg/L). PHT doses and serum concentrations were similar between age groups. There were no differences in daily doses (mg/kg or mg/d) or total serum concentrations of PHT based on concomitant use of inhibitors or inducers of PHT metabolism or on albumin levels, CONCLUSIONS: In this study in elderly nursing home residents, women received higher doses of PHT than men to achieve similar total serum PHT concentrations. There were no differences in doses or total serum PHT concentrations by age group, use of concomitant inducers or inhibitors of PHT metabolism, or albumin levels.