Care Coordination Challenges Among High-Needs, High-Costs Older Adults in a Medigap Plan.

PURPOSE OF THE STUDY: Many adults 65 years or older have high health care needs and costs. Here, we describe their care coordination challenges. PRIMARY PRACTICE SETTING: Individuals with an AARP Medicare Supplement Insurance plan insured by UnitedHealthcare Insurance Company (for New York residents, UnitedHealthcare Insurance Company of New York). METHODOLOGY AND SAMPLE: The three groups included the highest needs, highest costs (the "highest group"), the high needs, high costs (the "high group"), and the "all other group." Eligibility was determined by applying an internally developed algorithm based upon a number of criteria, including hierarchical condition category score, the Optum ImpactPro prospective risk score, as well as diagnoses of coronary artery disease, congestive heart failure, or diabetes. RESULTS: The highest group comprised 2%, although consumed 12% of health care expenditures. The high group comprised 20% and consumed 46% of expenditures, whereas the all other group comprised 78% and consumed 42% of expenditures. On average, the highest group had $102,798 in yearly health care expenditures, compared with $34,610 and $7,634 for the high and all other groups, respectively. Fifty-seven percent of the highest group saw 16 or more different providers annually, compared with 21% and 2% of the high and all other groups, respectively. Finally, 28% of the highest group had prescriptions from at least seven different providers, compared with 20% and 5% of the high and all other groups, respectively. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Individuals with high health care needs and costs have visits to numerous health care providers and receive multiple prescriptions for pharmacotherapy. As a result, these individuals can become overwhelmed trying to manage and coordinate their health care needs. Care coordination programs may help these individuals coordinate their care.

Use of anticholinergic medications by older adults with dementia.

OBJECTIVES: To compare the prevalence of anticholinergic use in older adults with probable dementia with that of a matched comparison group of older adults who were unlikely to have dementia and to examine the extent to which patients taking donepezil concomitantly use anticholinergic medications. DESIGN: Retrospective study. SETTING: Community-based older adults receiving medications through a pharmacy benefit management company. PARTICIPANTS: Eight hundred thirty-six patients aged 65 and older. Patients taking donepezil (n = 418) constituted the treatment group. Patients not taking donepezil (n = 418) constituted the comparison group. Each treatment group member was matched with a comparison group member on the basis of age, sex, and number of drugs taken for chronic conditions. MEASUREMENTS: The prevalence of anticholinergic use was compared in the treatment and comparison groups over a 3- to 12-month follow-up period using pharmacy claims data. The proportion of follow-up period days that treatment group members concomitantly used donepezil and anticholinergics was also examined. RESULTS: Older adults with probable dementia were more likely to use anticholinergics than matched comparison group patients (33.0% vs 23.4%; P =.001). Of treatment group members receiving anticholinergics, 26.1% used multiple anticholinergic medications. Treatment group members who received anticholinergics used those drugs concomitantly with donepezil on a mean of 28.4% of follow-up period days. CONCLUSIONS: Community-based, commercially insured, older adults with probable dementia are more likely to take anticholinergics than matched controls. Patients taking donepezil frequently use an anticholinergic medication concomitantly. This study suggests that prescribing for older adults with dementia could be improved, especially if cognitive enhancing agents are being considered.

How many patients complete an adequate trial of donepezil?

Pharmacy claims data were used to evaluate medication adherence among 59 new users of donepezil aged 65 to 94 years. The probability (+/- 95% confidence interval) of a new user continuing donepezil at 90 days was.797 +/-.103 and at 180 days was.627 +/-.124. Additionally, 13.9% of those who continued therapy for at least 180 days showed gaps in treatment of six weeks or more. These results suggest that adherence with donepezil could be improved in clinical practice.