Screening for Sexually Transmitted Infections After Cervical Cancer Screening Guideline and Medicaid Policy Changes: A Population-based Analysis.

BACKGROUND: Sexually transmitted infection (STI) screening prevents complications and is cost-effective. Annual screening is recommended in sexually active women below 25 years and older women at increased risk. Cervical cancer (CC) screening guideline changes in 2009 and 2012 recommended less frequent screening, causing concern that STI screening would decrease. Pennsylvania Medicaid implemented a family planning program in 2007 which covered women's health services (including STI testing) for uninsured women. It is unclear how STI screening was affected by these countervailing forces. OBJECTIVE: The main objective of this study was to assess STI screening before and after CC screening guideline changes and family planning program implementation, and to determine factors associated with STI screening. RESEARCH DESIGN: This study was an observational cross-sectional study of Pennsylvania Medicaid administrative claims from 2007 to 2013. SUBJECTS: Sixteen-year-old to 30-year-old women enrolled in Pennsylvania Medicaid. MEASURES: Annual STI screening, defined as receipt of ≥1 STI test in respective 1-year periods. RESULTS: Our population included 1,226,079 women-years for 467,143 women. STI screening increased by 48% between 2007 and 2011, and stabilized by 2013. Odds for STI screening were higher among black compared with white women [adjusted odds ratio (AOR), 2.56; 95% confidence interval (CI), 2.60-3.10]; Hispanic compared with non-Hispanic women (AOR, 1.42; 95% CI, 1.39-1.46); family planning program enrollees (AOR, 1.42; 95% CI, 1.40-1.45); and urban compared with rural residents (AOR, 1.05; 95% CI, 1.03-1.06). CONCLUSIONS: STI screening dramatically increased between 2007 and 2011. Potential reasons are family planning program implementation, increased urine/vaginal testing, and reporting improvements. It is reassuring that STI screening did not decrease despite CC screening guideline changes. Between 2011 and 2013, rates stabilized at 45% among all women and 60% among sexually active women below 25 years, suggesting opportunities for improvement.

Satisfaction of Discharged Nursing Home Residents.

The psychometric properties of The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Nursing Home survey: Discharged Resident Instrument (NHCAHPS-D) are examined. A random sample of 550 nursing homes was selected from across the United States and 365 agreed to participate (participation rate = 66%). From 7,020 surveys sent to discharged residents, 4,926 were returned (response rate = 70%). The psychometric properties of the resident responses and the survey items were robust. Confirmatory factor analyses model fit statistics met the criterion for good conformance. Five of the initial NHCAHPS-D instrument domains were identified (environment, care, communication and respect, autonomy, and activities), along with a sixth (transitions) added by the authors. The standardization and reliability that NHCAHPS-D provides could facilitate the same benefits we have seen in other industries for the CAHPS family of instruments (i.e., quality improvement, reimbursement, public reporting, and benchmarking) and also become an industry standard.

Cervical Cancer Screening Guideline Adherence Before and After Guideline Changes in Pennsylvania Medicaid.

OBJECTIVE: To assess changes in cervical cancer screening after the 2009 American College of Obstetricians and Gynecologists' guideline change and to determine predictors associated with underscreening and overscreening among Medicaid-enrolled women. METHODS: We performed an observational cohort study of Pennsylvania Medicaid claims from 2007 to 2013. We evaluated guideline adherence of 18- to 64-year-old continuously enrolled women before and after the 2009 guideline change. To define adherence, we categorized intervals between Pap tests as longer than (underscreening), within (appropriate screening), or shorter than (overscreening) guideline-recommended intervals (±6-month). We stratified results by age and assessed predictors of underscreening and overscreening through logistic regression. RESULTS: Among 29,650 women, appropriate cervical cancer screening significantly decreased after the guideline change (from 45% [95% confidence interval (CI) 44-46%] to 11% [95% CI 11-12%] among 17,360 younger than 30 year olds and from 27% [95% CI 26-28%] to 6% [95% CI 6-7%] among 12,290 women 30 years old or older). Overscreening significantly increased (from 6% [95% CI 5-6%] to 67% [95% CI 66-68%] in those younger than 30 years old and from 54% [95% CI 52-55%] to 65% [95% CI 64-67%] in those 30 years old or older), whereas underscreening significantly increased only in those 30 years old or older (from 20% [95% CI 19-21%] to 29% [95% CI 27-30%]). Pap tests after guideline change, pregnancy, Managed Care enrollment (in those younger than 30 years old), and black race (in those younger than 30 years old) were associated with underscreening. Pap tests after guideline change, more visits, more sexually transmitted infection testing, and white race (in those 30 years old or older) were associated with overscreening. CONCLUSION: We observed high rates of cervical cancer overscreening and underscreening and low rates of appropriate screening after the guideline change. Interventions should target both underscreening and overscreening to address these separate yet significant issues.

Regional Variation in Physician Adoption of Antipsychotics: Impact on US Medicare Expenditures.

BACKGROUND: Regional variation in US Medicare prescription drug spending is driven by higher prescribing of costly brand-name drugs in some regions. This variation likely arises from differences in the speed of diffusion of newly-approved medications. Second-generation antipsychotics were widely adopted for treatment of severe mental illness and for several off-label uses. Rapid diffusion of new psychiatric drugs likely increases drug spending but its relationship to non-drug spending is unclear. The impact of antipsychotic diffusion on drug and medical spending is of great interest to public payers like Medicare, which finance a majority of mental health spending in the US. AIMS: We examine the association between physician adoption of new antipsychotics and antipsychotic spending and non-drug medical spending among disabled and elderly Medicare enrollees. METHODS: We linked physician-level data on antipsychotic prescribing from an all-payer dataset (IMS Health's XponentTM) to patient-level data from Medicare. Our physician sample included 16,932 US. psychiatrists and primary care providers with > 10 antipsychotic prescriptions per year from 1997-2011. We constructed a measure of physician adoption of 3 antipsychotics introduced during this period (quetiapine, ziprasidone and aripiprazole) by estimating a shared frailty model of the time to first prescription for each drug. We then assigned physicians to one of 306 U.S. hospital referral regions (HRRs) and measured the average propensity to adopt per region. Using 2010 data for a random sample of 1.6 million Medicare beneficiaries, we identified 138,680 antipsychotic users. A generalized linear model with gamma distribution and log link was used to estimate the effect of region-level adoption propensity on beneficiary-level antipsychotic spending and non-drug medical spending adjusting for patient demographic and socioeconomic characteristics, health status, eligibility category, and whether the antipsychotic was for an on- vs. off-label use. RESULTS: In our sample, mean patient age was 62 years, 42% were male, and 86% had low-income. Half of antipsychotic users in Medicare had an on-label indication. The weighted average propensity to adopt the three new antipsychotics varied four-fold across HRRs. For every one standard deviation increase in the propensity to adopt there was a 5% increase in antipsychotic spending after adjusting for covariates (adjusted ratio of spending 1.05, 95% CI 1.01-1.08, p = 0.005). Physician propensity to adopt new antipsychotics was not associated with non-drug medical spending (adjusted ratio 0.96, 95% CI 0.91-1.01, p < 0.117). DISCUSSION: These findings suggest wide regional variation in physicians' propensity to adopt new antipsychotic medications. While physician adoption of new antipsychotics was positively associated with antipsychotic expenditures, it was not associated with non-drug spending. Our analysis is limited to Medicare and may not generalize to other payers. Also, claims data do not allow for the measurement of health outcomes, which would be important to evaluate when calculating the value of rapid vs. slow technology adoption.

Antipsychotic prescribing: do conflict of interest policies make a difference?

BACKGROUND: Academic medical centers (AMCs) have increasingly adopted conflict of interest policies governing physician-industry relationships; it is unclear how policies impact prescribing. OBJECTIVES: To determine whether 9 American Association of Medical Colleges (AAMC)-recommended policies influence psychiatrists' antipsychotic prescribing and compare prescribing between academic and nonacademic psychiatrists. RESEARCH DESIGN: We measured number of prescriptions for 10 heavily promoted and 9 newly introduced/reformulated antipsychotics between 2008 and 2011 among 2464 academic psychiatrists at 101 AMCs and 11,201 nonacademic psychiatrists. We measured AMC compliance with 9 AAMC recommendations. Difference-in-difference analyses compared changes in antipsychotic prescribing between 2008 and 2011 among psychiatrists in AMCs compliant with ≥ 7/9 recommendations, those whose institutions had lesser compliance, and nonacademic psychiatrists. RESULTS: Ten centers were AAMC compliant in 2008, 30 attained compliance by 2011, and 61 were never compliant. Share of prescriptions for heavily promoted antipsychotics was stable and comparable between academic and nonacademic psychiatrists (63.0%-65.8% in 2008 and 62.7%-64.4% in 2011). Psychiatrists in AAMC-compliant centers were slightly less likely to prescribe these antipsychotics compared with those in never-compliant centers (relative odds ratio, 0.95; 95% CI, 0.94-0.97; P < 0.0001). Share of prescriptions for new/reformulated antipsychotics grew from 5.3% in 2008 to 11.1% in 2011. Psychiatrists in AAMC-compliant centers actually increased prescribing of new/reformulated antipsychotics relative to those in never-compliant centers (relative odds ratio, 1.39; 95% CI, 1.35-1.44; P < 0.0001), a relative increase of 1.1% in probability. CONCLUSIONS: Psychiatrists exposed to strict conflict of interest policies prescribed heavily promoted antipsychotics at rates similar to academic psychiatrists and nonacademic psychiatrists exposed to less strict or no policies.

Twelve-month cost-effectiveness of telephone-delivered collaborative care for treating depression following CABG surgery: a randomized controlled trial.

OBJECTIVE: To determine the 12-month cost-effectiveness of a collaborative care (CC) program for treating depression following coronary artery bypass graft (CABG) surgery versus physicians' usual care (UC). METHODS: We obtained 12 continuous months of Medicare and private medical insurance claims data on 189 patients who screened positive for depression following CABG surgery, met criteria for depression when reassessed by telephone 2 weeks following hospitalization (nine-item Patient Health Questionnaire ≥10) and were randomized to either an 8-month centralized, nurse-provided and telephone-delivered CC intervention for depression or to their physicians' UC. RESULTS: At 12 months following randomization, CC patients had $2068 lower but statistically similar estimated median costs compared to UC (P=.30) and a variety of sensitivity analyses produced no significant changes. The incremental cost-effectiveness ratio of CC was -$9889 (-$11,940 to -$7838) per additional quality-adjusted life-year (QALY), and there was 90% probability it would be cost-effective at the willingness to pay threshold of $20,000 per additional QALY. A bootstrapped cost-effectiveness plane also demonstrated a 68% probability of CC "dominating" UC (more QALYs at lower cost). CONCLUSIONS: Centralized, nurse-provided and telephone-delivered CC for post-CABG depression is a quality-improving and cost-effective treatment that meets generally accepted criteria for high-value care.

Impact of medicare part D plan features on use of generic drugs.

BACKGROUND: Little is known about how Medicare Part D plan features influence choice of generic versus brand drugs. OBJECTIVES: To examine the association between Part D plan features and generic medication use. METHODS: Data from a 2009 random sample of 1.6 million fee-for-service, Part D enrollees aged 65 years and above, who were not dually eligible or receiving low-income subsidies, were used to examine the association between plan features (generic cost-sharing, difference in brand and generic copay, prior authorization, step therapy) and choice of generic antidepressants, antidiabetics, and statins. Logistic regression models accounting for plan-level clustering were adjusted for sociodemographic and health status. RESULTS: Generic cost-sharing ranged from $0 to $9 for antidepressants and statins, and from $0 to $8 for antidiabetics (across 5th-95th percentiles). Brand-generic cost-sharing differences were smallest for statins (5th-95th percentiles: $16-$37) and largest for antidepressants ($16-$64) across plans. Beneficiaries with higher generic cost-sharing had lower generic use [adjusted odds ratio (OR)=0.97, 95% confidence interval (CI), 0.95-0.98 for antidepressants; OR=0.97, 95% CI, 0.96-0.98 for antidiabetics; OR=0.94, 95% CI, 0.92-0.95 for statins]. Larger brand-generic cost-sharing differences and prior authorization were significantly associated with greater generic use in all categories. Plans could increase generic use by 5-12 percentage points by reducing generic cost-sharing from the 75th ($7) to 25th percentiles ($4-$5), increasing brand-generic cost-sharing differences from the 25th ($25-$26) to 75th ($32-$33) percentiles, and using prior authorization and step therapy. CONCLUSIONS: Cost-sharing features and utilization management tools were significantly associated with generic use in 3 commonly used medication categories.

The impact of Medicare prescription drug coverage on the use of antidementia drugs.

BACKGROUND: Cholinesterase inhibitors and memantine are prescribed to slow the progression dementia. Although the efficacy of these drugs has been demonstrated, their effectiveness, from the perspective of patients and caregivers, has been questioned. Little is known about whether the demand for cholinesterase inhibitors and memantine are sensitive to out-of-pocket cost. Using the 2006 implementation of Medicare Part D as a natural experiment, this study examines the impact of changes in drug coverage on use of cholinesterase inhibitors and memantine by comparing use before and after Medicare Part D implementation among older adults who did and did not experience a change in coverage. METHODS: Retrospective analyses of claims data from 35,102 community-dwelling Medicare beneficiaries in Pennsylvania aged 65 or older. Beneficiaries were continuously enrolled in a Medicare Advantage plan from 2004 to 2007. Outcome variables were any use of donepezil (Aricept(®)), galantamine (Razadyne(®)), rivastigmine (Exelon(®)), tacrine (Cognex(®)), or memantine (Namenda(®)) each year and the number of 30-day prescriptions filled for these drugs. Independent variables included type of drug benefit pre-Part D (No coverage, $150 cap, $350 cap, and No cap as the reference group), time period, and their interaction. Sensitivity analyses were conducted to test if there are differences in use by drug class or if beneficiaries with a diagnosis of dementia pre-Part D experienced an increase in use post-Part D. RESULTS: The No coverage group had a 38% increase in the odds ratio of any use of antidementia medications (P = 0.0008) post-Part D relative to the No cap group. All four coverage groups had significant increases in number of 30-day prescriptions (P < 0.001) over the study period. In adjusted models that included the sub-sample with any use pre-Part D, the No coverage group had a 36% increase in prescriptions (P = 0.002) and the $350 cap group had a 15% increase (P = 0.003) after adjusting for trends in the No cap group. Results from the sensitivity analysis for the sub-sample with a diagnosis of dementia pre-Part D show that each group had significant increases in 30-day prescriptions compared to the No cap control group (P < 0.05). CONCLUSIONS: Use of cholinesterase inhibitors and memantine in our sample increased and a greater increase in use was observed among Medicare beneficiaries who experienced improvements in drug coverage under Medicare Part D.

Medicare Part D and potentially inappropriate medication use in the elderly.

OBJECTIVES: Inappropriate medication use, which is common in older adults, may be responsive to out-of-pocket costs. We examined the impact of Medicare Part D on inappropriate medication use among Medicare beneficiaries. STUDY DESIGN: Pre-post with comparison group. METHODS: Using data from 34,679 elderly beneficiaries in Medicare plans from 2004 to 2007, we used Healthcare Effectiveness Data and Information Set measures of prescribing quality: (1) any use of Drugs to Avoid in the Elderly (DAE), (2) a proportion of total medication use attributable to DAEs, and (3) any Potentially Harmful Drug-Disease Interactions in the Elderly (DDE). Rates of inappropriate use among 3 groups transitioning from no drug coverage or limited coverage ($150 or $350 quarterly caps) to Part D in 2006 were compared with those with constant drug coverage. RESULTS: DAE use increased slightly among those moving from no coverage to Part D (from 15.72%-17.61%) whereas the comparison group's use decreased (20.97%-18.32%) [relative odds ratio (ROR) = 1.34, 95% confidence interval [CI] 1.22-1.48, P <.0001]. However, the proportion of total drug use attributable to DAEs declined among the no coverage group after Part D (3.01%-1.98%), a significant difference relative to the comparison group (ROR = 0.84, 95% CI 0.72-0.98, P = .03). Rates of DDE were low (1%) both before and after Part D. CONCLUSIONS: While use of high-risk drugs increased slightly among those gaining Part D drug coverage, high-risk drug use actually declined as a proportion of total drug use, and the prevalence of drug-disease interactions remained stable.

Nursing home deficiency citations for infection control.

BACKGROUND: This study examined the deficiency citation for infection control (ie, F-Tag 441). This information represents potential problems in infection control as identified in the yearly certification process of almost all US nursing homes. METHODS: The data used came primarily from the Online Survey, Certification, and Reporting data base, which contains information on both deficiency citations and characteristics of nursing homes. The data for each nursing home from 2000 through 2007 were combined, providing a panel of 100,000 observations. Multivariate analyses and generalized estimating equations with a logit link were used. RESULTS: An average of 15% of all nursing homes received a deficiency citation for infection control each year from 2000 to 2007. In the multivariate analyses, several staffing levels were robust in their significance. For all 3 types of caregiver examined (ie, nurse aides, Licensed Practical Nurses, and Registered Nurses), low staffing levels were associated with receipt of a deficiency citation for infection control. CONCLUSION: The high number of deficiency citations for infection control problems identified in this study suggests the need for increased emphasis on these programs in nursing homes to protect vulnerable elders.

Employee choice of a high-deductible health plan across multiple employers.

OBJECTIVE: To determine factors associated with selecting a high-deductible health plan (HDHP) rather than a preferred provider plan (PPO) and to examine switching and market segmentation after initial selection. DATA SOURCES/STUDY SETTING: Claims and benefit information for 2005-2007 from nine employers in western Pennsylvania first offering HDHP in 2006. STUDY DESIGN: We examined plan growth over time, used logistic regression to determine factors associated with choosing an HDHP, and examined the distribution of healthy and sick members across plan types. DATA EXTRACTION: We linked employees with their dependents to determine family-level variables. We extracted risk scores, covered charges, employee age, and employee gender from claims data. We determined census-level race, education, and income information. PRINCIPAL FINDINGS: Health status, gender, race, and education influenced the type of individual and family policies chosen. In the second year the HDHP was offered, few employees changed plans. Risk segmentation between HDHPs and PPOs existed, but it did not increase. CONCLUSIONS: When given a choice, those who are healthier are more likely to select an HDHP leading to risk segmentation. Risk segmentation did not increase in the second year that HDHPs were offered.

The Medicare drug benefit (Part D) and treatment of heart failure in older adults.

BACKGROUND: Adherence to pharmacotherapy for heart failure is poor among older adults in part because of high prescription drug costs. We examined the impact of improvements in drug coverage under Medicare Part D on utilization of, and adherence to, medications for heart failure in older adults. METHODS: We used a quasi-experimental approach to analyze pharmacy claims for 6,950 individuals aged >or=65 years with heart failure enrolled in a Medicare managed care organization 2 years before and after Part D's implementation. We compared prescription fill patterns among individuals who moved from limited (quarterly benefits caps of USD 150 or USD 350) or no drug coverage to Part D in 2006 with those who had generous employer-sponsored coverage throughout the study period. RESULTS: Individuals who previously lacked drug coverage filled approximately 6 more heart failure prescriptions annually after Part D (adjusted ratio of prescription counts = 1.36, 95% CI 1.29-1.44, P < .0001 relative to the comparison group). Those previously lacking drug coverage were more likely to fill prescriptions for an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker plus a beta-blocker after Part D (adjusted ratio of odds ratios = 1.73, 95% CI 1.42-2.10, P < .0001) and more likely to be adherent to such pharmacotherapy (adjusted ratio of odds ratios = 2.95, 95% CI 1.85-4.69, P < .0001) relative to the comparison group. CONCLUSIONS: Medicare Part D was associated with improved access to medications and adherence to pharmacotherapy in older adults with heart failure.

Certified nursing assistants' perceptions of nursing home patient safety culture: is there a relationship to clinical outcomes?

OBJECTIVES: The main objective of this study was to examine whether certified nursing assistants' (CNAs') perceptions of patient safety culture (PSC) were correlated with clinical outcomes (rates of falls, pressure ulcers, and daily restraint use) in a random sample of nursing homes. An additional objective was to describe facility-level and CNA-level characteristics that were associated with CNA PSC scores. DESIGN: We conducted a secondary data analysis using data that adapted the Hospital Survey of Patient Safety Culture (HSOPSC) for nursing homes. The HSOPSC data were merged with data from the Minimum Data Set (MDS), Online Survey Certification and Reporting (OSCAR) system, and Area Resource File (ARF). PARTICIPANTS AND SETTING: CNAs from a random sample of 72 nursing homes in 5 randomly selected states during the first 2 quarters of 2005. MEASUREMENTS: The relationships between clinical outcomes and CNA PSC scores were evaluated. The relationships between CNA PSC and facility characteristics, such as profit status and bed occupancy, and CNA characteristics such as education and tenure were also assessed. Data were analyzed using Poisson, multinomial logistic, and linear regression, and generalized estimating equations (GEE); descriptive statistics were compiled for demographic data. RESULTS: Of 2872 CNAs, 1579 completed the survey, for a 55% response rate. Results of regression analyses suggest that higher (more developed and more desirable) CNA PSC scores were associated with increased reporting of falls (B = 0.015; P = .000). Facilities with higher total CNA PSC scores were more likely to report moderate restraint use, whereas facilities with lower CNA PSC scores were more likely to report high restraint use (B = 0.172; P = .017). CNA PSC scores were not associated with differences in pressure ulcer rates. CONCLUSIONS: This study represents an important step in the evaluation of CNA PSC in nursing homes and shows that a relationship exists between PSC and selected clinical outcomes. Future work on nursing home PSC and additional clinical as well as workforce outcomes is indicated.

Nursing home staff turnover: impact on nursing home compare quality measures.

PURPOSE: We used data from a large sample of nursing homes to examine the association between staff turnover and quality. DESIGN AND METHODS: The staff turnover measures came from primary data collected from 2,840 nursing homes in 2004 (representing a 71% response rate). Data collection included measures for nurse aides, licensed practical nurses, and registered nurses. We examined 14 indicators of care quality that came from the Nursing Home Compare Web site. RESULTS: We found that reducing turnover from high to medium levels was associated with increased quality, but the evidence was mixed regarding the quality improvements from further lowering turnover to low levels. IMPLICATIONS: Our investigation shows that the relationship between turnover and quality might not be linear. Nevertheless, in general, high turnover is associated with poor quality.

Job satisfaction of nurse aides in nursing homes: intent to leave and turnover.

PURPOSE: The relationship between job satisfaction of nurse aides and intent to leave and actual turnover after 1 year is examined. DESIGN AND METHODS: Data came from a random sample of 72 nursing homes from 5 states (Colorado, Florida, Michigan, New York, and Oregon). From these nursing homes, we collected 1,779 surveys from nurse aides (a response rate of 62%). We used a job satisfaction instrument specifically developed for use with nurse aides, as well as previously validated measures of intent to leave and turnover. We used ordered logistic regression and logistic regression to examine the data. RESULTS: High overall job satisfaction was associated with low scores on thinking about leaving, thinking about a job search, searching for a job, and turnover. In examining the association between the job satisfaction subscales and intent to leave and turnover, we found that high Work Schedule subscale scores, high Training subscale scores, and high Rewards subscale scores were associated with low scores on thinking about leaving, thinking about a job search, searching for a job, and turnover. High scores on the Quality of Care subscale were associated with low turnover after 1 year. IMPLICATIONS: These results are important in clearly showing the relationship between job satisfaction and intent to leave and turnover of nurse aides. Training, rewards, and workload are particularly important aspects of nurse aides' jobs.

Variation in the use of nursing home deficiency citations.

Several sources of variation are associated with the number of survey deficiencies that can be received by nursing homes in the yearly survey and certification process. One source is variation across states. A second source of variation occurs within states. A third source of variation occurs for each facility across time. As measures of quality, large degrees of inconsistency are likely inappropriate and inefficient; thus, in this study survey deficiency variability was examined. The data used came from the 1991 through 2003 Online Survey, Certification, and Reporting system. We used two measures of deficiencies: (1) the number of quality-of-care deficiency citations (19 citations) and (2) all 185 deficiency citations. The results of the analyses suggest that recent changes by the Centers for Medicare & Medicaid Services (CMS) in the survey and certification process have had little impact on the considerable variation in the use of deficiency citations. The high degree of variation limits the usefulness of deficiency citations not only for CMS but also for consumers and providers.

Downsizing in the nursing home industry.

Downsizing in the nursing home industry from 1992 to 2003 was examined. Most significantly, we show that downsizing is subsequently associated with improved quality.