"Quicker and sicker" under Medicare's prospective payment system for hospitals: new evidence on an old issue from a national longitudinal survey.

Medicare's prospective payment system for hospitals (PPS), introduced in the USA in 1983, replaced cost reimbursement with a system of fixed rates which created incentives for hospitals to control costs. Previous studies found that elderly patients were discharged from hospital "quicker and sicker" under PPS and concluded that families were coping at home. We analyse a national longitudinal survey, the first National Health and Nutrition Examination Survey and its Epidemiologic Followup Study, which includes data on more outcomes over a longer period than earlier studies. We find that the rate of admission to nursing homes from the community in the first weeks after a hospital discharge more than tripled under PPS, suggesting that families were not always able to cope. As another response to sicker patients, discharges directly to nursing homes from hospitals, which jumped initially under PPS, may have risen further when payment rates were tightened in the early 1990s. Hospital readmissions fell after the first few years. Our findings are strengthened by the fact that we control for patients' health using health information collected independently of hospital admission.

Sex differences in ambulatory visits for chronic obstructive pulmonary disease, based on the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey from 1995 to 2004.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a rapidly growing public health problem in the United States. It is unclear whether men and women differ in their utilization of ambulatory care or medications prescribed for COPD. OBJECTIVE: To evaluate sex-related trends in physician-office and out-patient department COPD visits from 1995 through 2004. METHODS: We pooled data from the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) to derive national estimates of out-patient ambulatory COPD visits. For trend analysis we stratified the data into 2-year periods and by sex. The main variables of interest were the number of out-patient visits for COPD, patient characteristics, comorbidities, and medications prescribed. RESULTS: From 1995 to 2004, COPD-related out-patient visits increased among women and men; oral corticosteroids and short-acting bronchodilators were the most commonly prescribed drugs for both women and men; and prescriptions for inhaled corticosteroid decreased in both women (from 20% to 11%) and men (from 20 to 17%). In 2004, women surpassed men in out-patient COPD visits. CONCLUSIONS: COPD visits increased among both sexes, but the upward trend in COPD visits among women indicates that COPD is no longer a male-dominated disease. Providers should be aware of this shift in patient demographics and the differences between the sexes in COPD management.

Effect of regulatory warnings on antipsychotic prescription rates among elderly patients with dementia: a population-based time-series analysis.

BACKGROUND: Three warnings of serious adverse events associated with the use of atypical antipsychotic drugs among elderly patients with dementia were sent to health care professionals in Canada. We assessed the impact of these warnings on prescription rates of antipsychotic drugs in this patient population. METHODS: We used prescription drug claims data from Ontario to calculate prescription rates of atypical and conventional antipsychotic drugs among elderly patients with dementia from May 1, 2000, to Feb. 28, 2007. We performed a time-series analysis to estimate the effect of each warning on rates of antipsychotic drug use. RESULTS: Before the first warning, growth in the use of atypical antipsychotics was responsible for an increasing rate of overall antipsychotic use. Each warning was associated with a small relative decrease in the predicted growth in the use of atypical antipsychotic drugs: a 5.0% decrease after the first warning, 4.9% after the second and 3.2% after the third (each p < 0.05). The overall prescription rate of antipsychotic drugs among patients with dementia increased by 20%, from 1512 per 100 000 elderly patients in September 2002, the month before the first warning, to 1813 per 100 000 in February 2007, 20 months after the last warning. INTERPRETATION: Although the warnings slowed the growth in the use of atypical antipsychotic drugs among patients with dementia, they did not reduce the overall prescription rate of these potentially dangerous drugs. More effective interventions are necessary to improve postmarket drug safety in vulnerable populations.

Lifestyle-related risk factors and risk of future nursing home admission.

BACKGROUND: While risks of disease, hospitalization, and death attributable to lifestyle-related factors such as smoking, inactivity, and obesity have been well studied, their associations with nursing home admission are less well known. These risk factors are usually established by middle age, but nothing is known about how they relate to long-term risk of nursing home admission in this age group. METHODS: Cox proportional hazards regressions were used to analyze risk of nursing home admission over 2 decades of follow-up (1971-1975 to 1992) in a nationally representative, longitudinal survey of community-dwelling adults aged 45 to 74 years at baseline. Middle-aged (45-64 years at baseline) and elderly persons (aged 65-74 years at baseline) were analyzed separately: 230 (6.5%) of 3526 middle-aged respondents and 728 (24.7%) of 2936 elderly ones had 1 or more nursing home admissions. Baseline risk factors included smoking, inactivity, obesity, elevated blood pressure, elevated total cholesterol level, and diabetes mellitus, which were defined according to national guidelines. RESULTS: All lifestyle-related factors, except total cholesterol level, were associated with higher risk of nursing home admission during follow-up in one or both age groups. Risk ratios were higher in middle-aged than in elderly persons. In those aged 45 to 64 years at baseline, diabetes more than tripled the risk of nursing home admission (relative risk, 3.25; 95% confidence interval, 2.04-5.19); smoking, inactivity, and elevated systolic blood pressure had relative risks of 1.56, 1.40, and 1.35, respectively. Obesity was a risk factor for those aged 65 to 74 years at baseline, but not for the middle-aged subjects. Persons with 2 lifestyle-related factors were at greatly increased risk, especially if 1 was diabetes. CONCLUSIONS: Lifestyle factors are important contributors to the long-term risk of nursing home admission. Modifying lifestyle, especially in middle age, may reduce the risk of admission.

Drug persistency of two cholinesterase inhibitors: rivastigmine versus donepezil in elderly patients with Alzheimer's disease.

OBJECTIVES: To compare persistency rates and persistency days in patients with Alzheimer's disease (AD) who initiated therapy with either rivastigmine or donepezil, and to identify factors influencing persistency in a real-world setting. DESIGN AND METHODS: This study used data collected by MarketScan from 1 January 1999 to 31 December 2002. Patients were included if they were newly diagnosed with AD and filled at least one prescription for rivastigmine or donepezil between 1 July 2000 and 30 June 2001, were > or =65 years of age on the index prescription date, and had continuous health and prescription insurance during the entire study period. Patients were excluded if they filled a prescription for any cholinesterase inhibitor during the 18 months prior to initiation of the study drugs. Patients who refilled their initial cholinesterase inhibitor prescription within a permissible gap of 60 days after depleting the drug supply from the prior prescription were considered to be persistent. Sensitivity analysis was performed to test the robustness of the persistency definition. The Kaplan-Meier method was used to determine persistency rates across time and Cox proportional hazards models were used to estimate relative risks of discontinuation or switch with adjustment for other covariates, and to identify factors significantly influencing persistency of the study drugs. RESULTS: Of the newly treated AD patients, the proportion of rivastigmine and donepezil patients who continued their medication was the same (47%; p = 0.5). On average, rivastigmine users continuously used their medication for 234 days (median 312 days) while those taking donepezil used their medication for 235 days (median 315 days) [p = 0.91]. Patients were more likely to discontinue or switch their initial cholinesterase inhibitor if they used a central nervous system (CNS) medication before initiation of therapy (relative risk [RR] = 1.23; 95% CI 1.01, 1.51 without adjustment for study variables; RR = 1.30; 95% CI 1.05, 1.60 with adjustment for study variables). On the other hand, patients were less likely to discontinue their cholinesterase inhibitor if they visited their physician office frequently (RR = 0.24; 95% CI 0.18, 0.32 without adjustment; RR = 0.23; 95% CI 0.17, 0.30 with adjustment) or if they were hospitalised after initiation of their cholinesterase inhibitor therapy (RR = 0.60; 95% CI 0.39, 0.91 without adjustment; RR = 0.65; 95% CI 0.42, 0.99 with adjustment). CONCLUSION: Patients who were newly diagnosed with AD and initiated therapy with either rivastigmine or donepezil had similar levels of persistency with their initial AD therapy in a real-world setting.

Hospitalizations, nursing home admissions, and deaths attributable to diabetes.

OBJECTIVE: To estimate all-cause hospitalizations, nursing home admissions, and deaths attributable to diabetes using a new methodology based on longitudinal data for a representative sample of older U.S. adults. RESEARCH DESIGN AND METHODS: A simulation model, based on data from the National Health and Nutrition Examination Survey (NHANES) I Epidemiologic Followup Study, was used to represent the natural history of diabetes and control for a variety of baseline risk factors. The model was applied to 6,265 NHANES III adults aged 45-74 years. The prevalence of risk factors in NHANES III, fielded in 1988-1994, better represents today's adults. RESULTS: For all NHANES III adults aged 45-74 years, a diagnosis of diabetes accounted for 8.6% of hospitalizations, 12.3% of nursing home admissions, and 10.3% of deaths in 1988-1994. For people with diabetes, diabetes alone was responsible for 43.4% of hospitalizations, 52.1% of nursing home admissions, and 47% of deaths. Adjusting for related cardiovascular conditions, which may provide more accurate estimates of attributable risks for people with diabetes, increased these estimates to 51.4, 57.1, and 56.8%, respectively. CONCLUSIONS: Risks of institutionalization and death attributable to diabetes are large. Efforts to translate recent trials of primary prevention into practice and continued efforts to prevent complications of diabetes could have a substantial impact on hospitalizations, nursing home admissions, and deaths and their societal costs.

Effects of prehypertension on admissions and deaths: a simulation.

BACKGROUND: The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recently released new clinical practice guidelines that target systolic blood pressure and identify persons with "prehypertension" (systolic blood pressure, 120-139 mm Hg), previously considered normal, as being at elevated risk and in need of intervention. METHODS: We used a simulation model, fitted to longitudinal data from the first NHANES (National Health and Nutrition Examination Survey) Epidemiologic Followup Study, to estimate the effects of prehypertension and residual hypertension (systolic blood pressure, > or =140 mm Hg). The term residual hypertension recognizes that many people with hypertension have lowered their pressures through treatment, but not to less than 140 mm Hg. We applied the model to a representative sample of US adults aged 25 to 74 years from NHANES III. RESULTS: Except for women aged 25 to 44 years, more than a third of each age group in NHANES III had prehypertension. Approximately two thirds of persons aged 45 to 64 years and 80% of persons aged 65 to 74 years had prehypertension or residual hypertension. Together, prehypertension and residual hypertension accounted for 4.7% of hospital admissions per 10 000 adults aged 25 to 74 years, 9.7% of nursing home admissions, and 13.7% of deaths. Prehypertension alone accounted for 3.4% of hospitalizations, 6.5% of nursing home stays, and 9.1% of deaths. Numbers of events attributable to prehypertension are greatest for men aged 45 to 64 years and persons aged 65 to 74 years. CONCLUSIONS: Our results confirm the substantial public health consequences of prehypertension. If prehypertension were eliminated, hospitalizations, nursing home admissions, and premature deaths could decline substantially.