Analysis of the North Carolina long-term care polypharmacy initiative: a multiple-cohort approach using propensity-score matching for both evaluation and targeting.

BACKGROUND: The high cost and undesirable consequences of polypharmacy are well-recognized problems among elderly long-term care (LTC) residents. Despite the implementation of the 1987 Omnibus Budget Reconciliation Act, which requires pharmacist review of drug regimens in this setting, medical and drug costs for LTC residents have continued to increase. OBJECTIVE: This study evaluates the North Carolina Long-Term Care Polypharmacy Initiative, a large-scale medication therapy management program (MTMP) that combined drug utilization review activities with drug regimen review techniques. METHODS: This was a prospective records-based study that used a difference-in-difference model with both historical and nonintervention group controls. To ensure equivalence among subjects, propensity scoring was used to match study subjects from participating LTC facilities with comparison subjects from nonparticipating facilities. Residents with interventions were grouped for analysis by intervention type-retrospective only, prospective only, or dual type (residents with both prospective and retrospective interventions)-and by intervention stage-review, recommendation, and drug change-plus an all-inclusive "all types" grouping that aggregated groups by intervention type, for a total of 10 total cohorts. RESULTS: In the overall population of 5255 study subjects identified, a US $21.63 per member per month drug-cost savings was observed. Although only 1 of 10 cohorts had a change in the number of drug fills, substantial reductions in 2 of 5 types of drug alerts were observed in all 10 cohorts. A reduction in the relative risk for hospitalization (0.84 [95% CI, 0.71-1.00]) was observed in the cohort of residents receiving a retrospective review. CONCLUSIONS: This Initiative suggests that an MTMP can be quickly launched in a large number of LTC facility residents to produce monetary drug-cost savings and improved health outcomes. Additionally, the evaluation of this program illustrates the utility of using propensity scoring techniques to target future intervention groups in a cost-effective manner.

Enhancing the medical homes model for children with asthma.

BACKGROUND: Medical Home is an evolving concept of patient-centered care yet little information is available on its effect on health care expenditures for children. OBJECTIVES: To quantify differences in patterns of care and costs to the North Carolina (NC) Medicaid program for children with asthma across 3 programs: fee-for-service (FFS), primary care case management (PCCM), and Medical Homes. RESEARCH DESIGN: NC Medicaid claims from 1998-2001 for children with asthma were used to examine monthly expenditures and patterns of health care use, including emergency department and hospital use. Children in the FFS program served as controls for trends in asthma care over the study period. Tests examined the potential for selection by program and fixed-effect 2-part model regressions were used to control for differences in program enrollees. SUBJECTS: Children under age 21 with asthma. MEASURES: Monthly Medicaid expenditures and measures of health service use. RESULTS: We found considerable evidence of quality improvement in patterns of care for children enrolled in both the PCCM and Medical Homes models in NC. After controlling for selection into these programs, use of maintenance as well as rescue medications increased, use of services increased, and emergency department and hospital use went down. Total spending (asthma and nonasthma related) on children in the Medical Homes program was $148 greater than spending for FFS children (95% bootstrapped confidence interval: $140-$158) per child per month and no difference in spending between Medical Homes and PCCM was detected. CONCLUSIONS: Our results indicate that enhancement of PCCM programs is one way for Medicaid programs to improve care, but may require substantial investments by states.

State Children's Health Insurance Program achievements, challenges, and policy recommendations.

This policy statement reviews the impressive progress of the State Children's Health Insurance Program since its enactment in 1997 and identifies outstanding challenges and state and federal policy recommendations. The American Academy of Pediatrics urges Congress to reauthorize SCHIP to strengthen its historic gains. The following set of recommended strategies for reauthorization pertain to funding, eligibility and enrollment, coverage, cost sharing, payment and provider-network capacity, and quality performance.

Determinants of blood-lead levels in children in Callao and Lima metropolitan area.

OBJECTIVES: To determine blood lead levels in urban populations of children (n = 2,510) and women (n = 874) in the early postpartum in certain districts of Lima and Callao, and to correlate those levels with particular exposures. MATERIAL AND METHODS: Between July 1998 and January 1999 cross sectional study was conducted. The study population was selected using three sampling strategies in the government operated school system and from public pediatric and maternity hospitals at Lima and Callao, Peru. Study personnel were trained to collect finger stick blood samples with a protocol that minimizes external lead contamination. Lead determinations in blood and environmental samples were performed at the study site using portable anodic striping voltamenters. To determine the simultaneous effects of different predictors on blood lead levels, multivariate regression models were used to estimate adjusted mean differences. RESULTS: The mean blood lead level in the children studied was 9.9 micrograms/dl ranging from 1 microgram/dl to 64 micrograms/dl with 29% of the children displaying values greater than 10 micrograms/dl and 9.4% at levels greater than 20 micrograms/dl. Among the women, the mean was 3.5 micrograms/dl (SD = 2.4 micrograms/dl), and 2.4% (n = 21) displayed levels greater than 10 micrograms/dl. Important differences were observed between the sample locations, and the highest levels were documented in the port region near Callao. The mean level of blood lead in this group was 25.6 micrograms/dl (SD = 4.6 micrograms/dl), while among the rest of the sample it was 7.1 micrograms/dl (SD = 5.1 micrograms/dl). The presence of a mineral storage area signified a difference in exposure in excess of 13 micrograms/dl for children living near the port area in contrast to the other children who were not as close to such fixed sources of lead exposure. For the participants in Lima, the risk of showing levels above 10 micrograms/dl was associated with exposure to high vehicular traffic. CONCLUSIONS: In metropolitan Lima, we conclude that the mean blood lead levels of the populations studied were not alarming and that a positive health impact can be made by a reduction of lead in gasoline. With regard to the port area, the study demonstrates that the presence of mineral storage areas pose a detrimental risk factor for the health of the children living in this area. The English version of this paper is available too at: http://www.insp.mx/salud/index.html.

Determinants of blood-lead levels in children in Callao and Lima metropolitan area

OBJETIVO: Determinar los niveles de plomo en sangre en una muestra compuesta por niños y mujeres en el posparto temprano, residentes en Lima y El Callao. Investigar los determinantes de estos niveles y algunas fuentes de exposición. MATERIAL Y MÉTODOS: Entre julio de 1998 y enero de 1999 se llevó a cabo una encuesta en el área metropolitana de Lima y en El Callao, Perú. La población de estudio fue identificada mediante tres estrategias de muestreo y con la cual se seleccionaron escuelas públicas y hospitales pediátricos y gineco-obstétricos. El personal que participó en el estudio recibió entrenamiento para la técnica de punción digital y puso especial énfasis en controlar la contaminación externa con plomo. Las determinaciones del metal en sangre y muestras ambientales se llevaron a cabo utilizando voltametría anódica. Para determinar los efectos simultáneos de diferentes predictores sobre los niveles de plomo en sangre se usaron modelos de regresión multivariada para estimar diferencias de media y ajustadas. RESULTADOS: Los niveles promedio de plomo en sangre fueron de 9.9 µg/dl de una variación entre 0 y 64 µg/dl. El 29 y 9.4% de los niños presentaron valores por encima de 10 µg/dl y 20 µg/dl,respectivamente. Para las mujeres el promedio de plomo en sangre fue de 3.5 µg/dl (DE=2.4) y 2.4% (n=2l) presentaron niveles superiores a 10 µg/dl. Se observaron diferencias importantes en relación con el sitio de residencia; los niveles más altos se documentaron en la zona de El Callao. Para este grupo la media de plomo en sangre fue de 25.6 µg/dl (DE=4.6) mientras que para el resto de la muestra el promedio de plomo en sangre fue de 7.1 µg/dl (DE=5.l). En esta zona se detectó un área de almacenamiento de minerales como una fuente importante de exposición. Los niños que viven cerca de esta área tenían en promedio un exceso de 13 µg/dl en sangre. Para los participantes de la zona de Lima el riesgo de presentar niveles por encima de 10 µg/dl se asoció con la exposición a tráfico vehicular. CONCLUSIONES: Para Lima Metropolitana se puede concluir que los niveles de plomo en sangre no representan un problema urgente, sin embargo, el reducir el plomo de la gasolina se acompaña de un beneficio importante. En contraste, para el área cercana al puerto de El Callao, nuestro estudio demuestra la presencia de sitios de almacenamiento de minerales que representan un riesgo importante para la salud de los niños que viven en esta zona.