Effectiveness of statins in Medicare-eligible patients and patients < 65 years using clinical practice data.

OBJECTIVE: This study compared effectiveness of rosuvastatin (RSV) with other statins on lowering LDL-C and LDL-C goal attainment among Medicare-eligible patients (age >or= 65 years) and patients with age < 65 years treated in usual clinical practice to provide evidence of real-world effectiveness of statins. METHODS: Retrospective cohort study was conducted in patients, newly prescribed statin therapy during August 2003 to May 2005. Patient inclusion criteria: no prior prescription for dyslipidaemic medication in the preceding 12 months, continuously enrolled for >or= 15 months and >or= 90-day supply of statin. Effectiveness of RSV in reducing LDL-C and attaining LDL-C goal when compared with other statins was evaluated using multivariate regression, adjusting for baseline LDL-C, age, gender, smoking, hypertension, coronary heart disease (CHD), systolic blood pressure and therapy duration. RESULTS: Adjusted per cent LDL-C reduction was significantly greater (p < 0.05) with RSV (24.3% for >or= 65 and 28.5% for < 65) compared with ATV (17.5%, 21.3%), SMV (14.8%, 18.4%), PRV (11.3%, 15.8%), FLV (10.7%, 20.6%) and LOV (13.3%, 14.4%). Among patients in both age groups at high or moderate CHD risk, a greater proportion of RSV patients attained LDL-C goal (76.0% for age group >or= 65 years and 78.4% for age group < 65 years) vs. 50.5-73.0% for >or= 65 and 51.3-71.5% for < 65 years of age on other statins (p < 0.0001). CONCLUSIONS: Rosuvastatin is more effective in lowering LDL-C in Medicare-eligible patients and patients < 65 years of age when compared with other statins in usual clinical practice. Moreover, RSV patients had higher LDL-C goal attainment rates when compared with other statins in high- and moderate-risk patients. The study results have implications for clinicians in selecting the optimal statin to meet individual patient care needs.

Determinants of hormone replacement therapy duration among postmenopausal women with intact uteri.

OBJECTIVE: To investigate factors associated with hormone replacement therapy (HRT) duration among postmenopausal women with intact uteri. DESIGN: A Cox proportional hazard model on time to HRT discontinuation is estimated for 2,632 postmenopausal HRT users with intact uteri who began a new episode of treatment between January 1990 and December 1994 in Saskatchewan, Canada. RESULTS: Major contraindicating medical events were highly associated with HRT discontinuation among postmenopausal women. Women who were diagnosed with uterine cancer while taking HRT were almost four times as likely to discontinue HRT, and women who were diagnosed with breast cancer while taking HRT were nearly five times as likely to discontinue HRT. Other statistically significant factors associated with the duration of HRT episodes include administration mode and the ability to try different types and strengths of HRT. Women initiating HRT with a transdermal patch were 50% more likely to discontinue it. Women who were willing and able to experiment with different HRT reduced their likelihood of discontinuing by one-half to three-fourths. CONCLUSIONS: Although some of the factors associated with the hazard of HRT discontinuation among postmenopausal women who are taking the treatment for preventive benefits are immutable, clinicians may influence HRT continuation rates through initial drug choice or modifications in drug type or regimen over the course of therapy.

Hormone replacement therapy in postmenopausal women: utilization of health care resources by new users.

OBJECTIVE: To determine health care resource use by new postmenopausal users of hormone replacement therapy. METHOD: We used the Saskatchewan Health administrative databases, which include a health insurance registration file, a cancer registry, and files with data on outpatient prescription drugs, hospital services, and physician services. Our population included postmenopausal women aged 55 years and over with intact uteri taking hormone replacement therapy for long-term prevention benefits, and an equal number of postmenopausal women with intact uteri with no medical contraindications to hormone replacement therapy but who did not use the therapy during the study period. RESULTS: The population in our analysis included 2632 women with new episodes of hormone replacement therapy, all with at least 3 years of follow-up. Only 42% of new hormone replacement therapy users continuously took HRT during the first year after initiation of their first new episode; a third of these were full-year users in the second year. New users of hormone replacement therapy over a 6-year follow-up period had significantly higher rates of medical care contact for diagnoses of menopausal disorders in the first year of HRT compared with subsequent years. We also found slightly elevated numbers of visits to primary care physicians and obstetrician-gynecologists and slightly increased use of endometrial biopsies and dilation and curettage procedures in the first year of hormone replacement therapy, compared with subsequent years. CONCLUSION: New users of hormone replacement therapy had higher rates of medical care for menopausal disorders in their first year of therapy compared with rates in subsequent years. After discontinuing hormone replacement therapy, utilization of medical care decreased dramatically.

Healthcare use among U.S. women aged 45 and older: total costs and costs for selected postmenopausal health risks.

The purpose of this study is to estimate the level of healthcare use and costs incurred by postmenopausal women overall and for these selected conditions: cardiovascular disease, osteoporosis, breast cancer, and gynecological cancers. National healthcare survey and discharge data were used to estimate healthcare use by women aged 45 and older. Clinical Classification for Health Policy Research (CCHPR) codes were used to identify patients whose primary diagnosis or procedure corresponded with the selected conditions. National weights were used to estimate resource use. Treatment costs were estimated using cost/charge ratios or the Medicare fee schedule to calculate costs for each individual procedure. Estimated total annual medical care treatment costs for women 45 and older were about $186 billion in 1997 dollars, including about $60.4 billion for cardiovascular disease, $12.9 billion for osteoporosis, and $5.0 billion for breast and gynecological cancers. For each condition, estimated resource use and costs are reported for hospitalization, outpatient, nursing home, and home healthcare services. Resource use and costs are also reported by age and expected source of payment. The economic burden of disease for conditions commonly affecting postmenopausal women is substantial. Prior research establishes that hormone replacement therapy (HRT) may be effective in reducing the burden of disease among women who continue preventive therapy for many years, but few at-risk women do so. New alternatives for prevention, such as selective estrogen receptor modulators (SERMs), may be effective in reducing the burden of disease among postmenopausal women.

The spread of state any willing provider laws.

OBJECTIVE: To describe the growth of any willing provider (AWP) and freedom of choice (FOC) laws applicable to managed care firms and to explore empirically the determinants of their enactment. STUDY SETTING: A 1996 compendium of state laws and state-level data from the 1991-1994 period. STUDY DESIGN: Pooled cross-section time-series logistic regression of the decision to enact various types of AWP and FOC laws. Analysis uses a public choice framework to examine enactment. Key variables include proxy measures of proponent and opponent strength and the political environment. PRINCIPAL FINDINGS: The model works well for laws affecting hospitals, but performs poorly for physician and pharmacy laws. More providers are associated with the enactment of AWP and FOC laws. More large employers are associated with a reduced likelihood of enactment of some forms of the laws but not others. Conservative states are more likely to enact laws limiting selective contracting with hospitals and physicians. States with greater interparty competition are also more likely to adopt some types of legislation. CONCLUSIONS: The empirical results generally are consistent with the view that AWP and FOC laws are often enacted as a defensive strategy on the part of providers, but additional research is needed to provide a more definitive assessment of the determinants of these laws. Suggestions for future research are provided.

Effects of tobacco excise taxes on the use of smokeless tobacco products in the USA.

Data from the September 1985 Current Population Survey are used to estimate the effects of tobacco excise taxes and state laws restricting smoking in public places on the likelihood of current use of cigarettes or smokeless tobacco (ST) products (moist snuff or chewing tobacco) among males in the USA. The results indicate that higher ST excise tax rates are associated with a reduced probability of ST use, whereas higher cigarette excise tax rates are associated with an increased probability of ST use, holding other factors constant. State laws restricting smoking have no apparent effect on ST use.

Simplifying the assessment of rural emergency medical services trauma transport.

OBJECTIVES: The authors determine whether assessments of effects of rural emergency medical service (EMS) system characteristics on trauma outcomes (using patient-level data) are significantly biased if the Injury Severity Score (ISS) is not available. METHODS: The data are from ambulance trip reports merged with the trauma registry data for the Georgia EMS region VI trauma center hospital, located in Augusta. All 294 trauma patients for the rural counties surrounding Richmond County for the calendar year 1991 who were not dead at the scene and were treated at the trauma center are included. A 20% random sample of trauma patients from Richmond county from May to September 1991 not dead at the scene and treated at the trauma center yielded an additional 96 cases. Excluding 43 patients with missing data yields 347 trauma cases with 18 trauma deaths. A logistic regression model for trauma mortality is estimated using the Revised Trauma Score (RTS), ISS, type of trauma, and patient age (analogous to the standard Trauma Related Injury Severity Score model). The predicted probability of patient mortality from this model is compared with the predicted probability of mortality when the logistic regression model omits ISS. Correlations between the difference in predicted probability (i.e., the error in predicted probability associated with the omitted ISS variable) and EMS system characteristics are determined. RESULTS: Although ISS adds to the predictive power of the trauma outcome model, the errors in predicted probabilities associated with the omission of ISS generally are small and uncorrelated with patient or EMS system characteristics, with the exception of patient gender. CONCLUSIONS: In rural settings, where a patient's ISS generally is not available, studies of rural EMS system characteristics and trauma outcomes may use RTS, patient age, and type of trauma to control for expected survival. The patient's ISS does not appear to be essential, at least for the rural area analyzed in this study.

Simplifying the assessment of rural emergency medical service trauma transport.

OBJECTIVES: The authors determine whether assessments of effects of rural emergency medical services (EMS) system characteristics on trauma outcomes using patient-level data are biased significantly if the Injury Severity Score (ISS) is not available. METHODS: Data are taken from ambulance trip reports merged with the trauma registry data for the Georgia EMS region VI trauma center hospital, located in Augusta. All 294 trauma patients for the rural counties surrounding Richmond County for the calendar year 1991 who were not dead at the scene and who were treated at the trauma center are included. A 20% random sample of trauma patients from Richmond county from May 1991 to September 1991 not dead at the scene and treated at the trauma center yielded an additional 96 cases. Excluding 43 patients with missing data yields 347 trauma cases with 18 trauma deaths. A logistic regression model for trauma mortality is estimated using the Revised Trauma Score, ISS, type of trauma, and patient age (analogous to the standard Trauma Related Injury Severity Score model). The predicted probability of patient mortality from this model is compared with the predicted probability of mortality when the logistic regression model omits ISS. Correlations between the difference in predicted probability (ie, the error in predicted probability associated with the omitted ISS variable) and EMS system characteristics are determined. RESULTS: Although ISS adds to the predictive power of the trauma outcome model, the errors in predicted probabilities associated with the omission of ISS generally are small and uncorrelated with patient or EMS system characteristics, with the exception of patient gender. CONCLUSIONS: In rural settings, where a patient's ISS generally is not available, studies of rural EMS system characteristics and trauma outcomes may use Revised Trauma Score, patient age, and type of trauma to control for expected survival. The patient's ISS does not appear to be essential, at least for the rural area analyzed in this study.

Trauma patients: an analysis of rural ambulance trip reports.

This study summarizes all 2,550 trauma-related rural ambulance trip reports filed for the period January 1 through December 31, 1991 from the 12 rural counties surrounding Augusta, Georgia. There were 13.1 trauma-related ambulance runs per 1,000 population. Nearly one third of all rural ambulance runs are trauma related. Severe trauma constituted less than 8.0% of trauma cases. Forty-one cases died at the scene and 19 additional cases died from any cause within 30 days of transport. The mean response time was 8.5 minutes and in 90% of all rural trauma runs the ambulance arrived in 17 minutes or less. Only 51.5% of runs had a rural hospital as a destination, 14.2% went directly to a trauma center, and nearly 20% to another urban hospital. Of the 71 severe trauma cases received by ambulance, rural hospitals transferred out only 13 cases, most of these to the regional trauma center. Of the 47 trauma cases transferred to the trauma center, 33 were not severe.

Rural emergency medical services: patients, destinations, times, and services.

This study sought to describe the volume of use, mix of patients, origin and destination of runs, times and distances to care, and the volume of clinical services provided in a rural emergency medical services region. This study summarizes all 6,080 rural emergency ambulance trip reports filed from April through September 1991 from the 12 rural counties surrounding Augusta, GA. Rural ambulances are regularly used and are used extensively by elderly populations. The pattern of services provided suggests that while advanced care may or may not have been indicated, it was rarely provided and that rural emergency medical service programs should consider a greater reliance on basic life support teams.

Effects of price and availability on abortion demand.

PIP: This study explained the variation in US state abortion demand due to the price of services, the net of insurance cost of birth services, the ability to pay, contraceptive use, individual attitudes regarding abortion, and government policy affecting cost of benefits of terminating an unintended pregnancy or of carrying to birth. The empirical model uses pooled data from 48 states for 1982, 1984, 1985, and 1987. Prices are deflated to 1977 dollars. Another two-staged least squares model is based on cross-sectional state level data for 1985. The dependent variable is the log of abortion per 1000 pregnancies. Other variables pertain to income, education, labor force, family planning, tax, aid to families with dependent children, religion, and abortion-related measures. The results of the cross-sectional analysis are consistent with Medoff's and Garbacz's findings. The estimated coefficient of per capita income is positive with a point elasticity ranging from 0.62 to 1.0. The model with the most complete specifications has an abortion price elasticity range from -0.75 to -1.3 and is statistically significant when religion measures are excluded. The Hausman test shows the pro-choice variable significantly correlated with the error term. The net price of birth services is not statistically significant. Catholic religion and no religion are only significant when the abortion provider variable is excluded. The suggestion is that the effect of Catholicism is ambiguous. In the pooled analysis, the fixed effects model is used to control for abortion attitudes and other unobserved factors. Abortion demand includes abortion per 1000 pregnancies, the ratio of abortions to pregnancies, and the logarithm of abortions per 1000 pregnancies. Higher income is associated with a higher abortion rate and elasticities of 0.76 and 0.35 and is associated with a higher pregnancy rate. The abortion ratio is found to be elastic with respect to price, and price elasticities are sensitive to choice of state abortion attitude measures. The availability of family planning services reduces the rate of pregnancy as well as the abortion rate and ratio.^ieng

Firearms, firearms injury, and gun control: a critical survey of the literature.

Firearm-related deaths are a major health problem in the United States. Legislation limiting the ownership, sale and use of firearms often is proposed as a means of reducing firearm-related deaths. There is a substantial and growing literature on the epidemiology of firearm-related death, as well as numerous studies grounded in the social sciences. Many of these directly address the issue of the impact of gun control on death rates. This paper provides a survey of existing knowledge of the effects of gun control legislation on firearm-related homicide, suicide, and unintentional fatal injury rates. We identify several major gaps in the literature that need to be addressed in future research.

Medicaid payment rates for nursing homes, 1979-86.

The issue of the cost containment effects of payment systems on per diem payments by Medicaid to nursing homes is addressed. Estimates of real payment rates as a function of broadly defined payment system classifications and economic and demographic variables using State-level data are presented. Little support for the notion that prospective payment systems substantially restrain payment rates for intermediate care facilities is found, but some model specifications indicate possible cost savings associated with prospective payment systems for skilled nursing facilities. Significant methodological concerns that need to be addressed in future research on the cost containment effects of payment systems are also discussed.

Physician integration strategies and hospital output. A comparison of rural and urban institutions.

Physician integration strategies are attempts to bring physicians into hospital administration by giving them a role on the hospital board, employing them in administrative or clinical capacities, or expanding the administration issues dealt with by medical staff committees. This study used a production function model to examine whether such strategies affect hospital output, measured as case mix-adjusted discharges. The article hypothesizes that less management depth, smaller medical staffs, and an absence of nearby hospitals make physician integration a more important strategy for rural than urban hospitals. American Hospital Association data on 1,309 hospitals from 1982 showed there is no statistically significant evidence that physician integration affects the output of urban hospitals. However, four of the five measures were associated with more patient discharges in rural hospitals. Furthermore, rural and urban hospitals differ in their use of other inputs. It was concluded that physician integration can be an effective mechanism to enhance rural hospital output and that more research on rural hospitals is needed.

Differences in income between male and female physicians.

Previous studies suggest that female physicians earn less on average from the practice of medicine than their male counterparts even after differences in personal characteristics are taken into account. In our study of sex differences in physician earnings, we estimate hourly earnings equations for 1982 using a specification that controls for differences in personal characteristics between male and female physicians more completely than the specification used in previous studies. We also employ more precise estimators for the unexplained earnings differential. Our results suggest that previous studies have overstated the unexplained differential in hourly earnings. We find that female physicians in 1982 earned 12-13 percent less than male physicians due to discrimination or unexplained factors.

Uncompensated medical services provided by physicians and hospitals.

This article examines the magnitude of uncompensated medical services provided by physicians and hospitals in 1982 as well as variations in uncompensated care among different types of physicians and hospitals. The data, which are from surveys conducted by the American Medical Association and the American Hospital Association, indicate that both physicians and hospitals provide significant amounts of uncompensated medical care. Although the distribution of uncompensated care among different types of physicians tends to be reasonably even, in most cases, the bulk of uncompensated care delivered by hospitals is delivered by public hospitals, with private hospitals (both voluntary and for-profit) delivering relatively less uncompensated care. The implications of changes in the economic environment of medicine for uncompensated medical care are also discussed.