[show abstract][hide abstract] ABSTRACT: OBJECTIVE: Recent economic and health policy changes may have affected the ability of chronically ill patients to afford their medications. We assessed changes in cost-related nonadherence to medication (CRN) before and after the implementation of Medicare Part D in 2006. METHODS: We used data from the National Health Interview Survey, an annual, population-based survey of community-dwelling, noninstitutionalized US adults, to estimate CRN in 8,673 stroke survivors aged 45 years or older, representing 4.8 million survivors, for the years 1999 to 2010. The main outcome measure was CRN, defined as self-reported inability to afford prescribed medication within the past 12 months. RESULTS: During the period 1999 to 2010, 11.4% of stroke survivors, approximately 543,000 individuals, reported CRN. From 1999 to 2010, CRN more than doubled among stroke survivors aged 45 to 64 years (from 12.7 to 26.5%; p(trend) = 0.01). CRN remained stable among those aged 65 years or older (from 3.8 to 7.0%; p(trend) = 0.21). From 1999-2005 to 2006-2010, CRN among uninsured stroke survivors aged 45 to 64 years increased from 43.1 to 57.1% (p = 0.03). Among stroke survivors aged 65 years or older with Medicare coverage, CRN was higher among Medicare Part D participants than those without the drug benefit (7.9 vs 4.8%; p = 0.02). After adjustment for sociodemographic and clinical factors, CRN was similar among Medicare Part D enrollees and nonenrollees. INTERPRETATION: From 1999 to 2010, CRN increased significantly among stroke survivors younger than 65 years, particularly among those without health insurance. There was no evidence that Medicare Part D decreased CRN among stroke survivors with Medicare. ANN NEUROL 2013.
Annals of Neurology 02/2013; · 11.19 Impact Factor
[show abstract][hide abstract] ABSTRACT: Objective. Study objectives were to assess temporal trends and identify patient- and practice-level predictors of the prescription of antiplatelet medications in a national sample of ischemic stroke (IS) patients seeking ambulatory care. Methods. IS-related outpatient visits by adults were identified using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey for the years 2000-2007. We assessed prescribing of antiplatelet medications using the generic drug code and drug entry codes in these data. Temporal trends in antiplatelet prescribing were assessed using the Cochran-Mantel-Haenszel test for trend. Results. We identified 9.5 million IS-related ambulatory visits. Antiplatelet medications were prescribed at 35.5% of visits. Physician office prescribing of the clopidogrel-aspirin combination increased significantly from 0.5% in 2000 to 22.0% in 2007 (P = 0.05), whereas prescribing of aspirin decreased from 17.9% to 7.0% (P = 0.50) during the same period. Conclusion. We observed a continued increase in prescription of the aspirin-clopidogrel combination from 2000 to 2007. Clinical trial evidence suggests that the aspirin-clopidogrel combination does not provide any additional benefit compared with clopidogrel alone; however, our study findings indicate that even with lack of adequate clinical evidence physician prescribing of this combination has increased in real-world community settings.
Advances in Pharmacological Sciences 01/2012; 2012:846163.
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Inpatient stroke utilization may be decreasing over time and may vary by patient demographics. Less is known about temporal trends and demographic variations in outpatient stroke utilization. We assessed ischemic stroke (IS)-related outpatient utilization across physician specialty and time, exploring any demographic variability, using recent US population-based data. METHODS: We identified all outpatient medical visits for IS by adults (≥18 years) using the National Ambulatory Medical Care Survey (NAMCS) years 1998 to 2009. Physician numbers were derived from American Medical Association or American Osteopathic Association data by NAMCS. We assessed IS-related outpatient visits to neurologists and generalists over time and by patient demographics. RESULTS: We identified 9.7 million IS-related visits from 1998 to 2009. The rate of IS-related visits to neurologists increased from 0.56 million visits in 1998 to 2000 to 0.90 million visits in 2007 to 2009, representing a 62% increase over the study period. The rate of IS-related visits to generalists declined from 2.0 million visits in 1998 to 2000 to 1.6 million visits in 2007 to 2009 (18% decrease). Between 1998 and 2009, the number of neurologists increased by 23% and the number of generalists grew by 19%. The IS visit rate per 100 physicians increased by 90% for neurologists but decreased by 31% for generalists. Fewer ambulatory IS-related visits to neurologists were reported among stroke survivors who were older, female, nonwhite, or living in rural areas. CONCLUSIONS: Between 1998 and 2009, IS-related outpatient utilization increased substantially to neurologists but declined to generalists. We identified demographic variations in outpatient utilization of neurologists that potentially lead to disparities in stroke evaluation and management.
Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association 12/2011;
[show abstract][hide abstract] ABSTRACT: Emergency department waiting time (EDWT), the time from arrival at the ED to evaluation by an emergency physician, is a critical component of acute stroke care. We assessed racial/ethnic differences in EDWT in a national sample of patients with ischemic or hemorrhagic stroke. We identified 543 ED visits for ischemic stroke (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 433.x1, 434.xx, and 436.xx) and hemorrhagic stroke (ICD-9-CM codes 430.xx, 431.xx, and 432.xx) in persons age ≥ 18 years representing 2.1 million stroke-related ED visits in the United States using the National Hospital Ambulatory Medical Care Survey for years 1997-2000 and 2003-2005. Using linear regression (outcome, log-transformed EDWT) and logistic regression (outcome, EDWT > 10 minutes, based on National Institute of Neurological Disorders and Stroke guidelines), we adjusted associations between EDWT and race/ethnicity (non-Hispanic whites [designated whites herein], non-Hispanic blacks [blacks], and Hispanics) for age, sex, region, mode of transportation, insurance, hospital characteristics, triage status, hospital admission, stroke type, and survey year. Compared with whites, blacks had a longer EDWT in univariate analysis (67% longer, P = .03) and multivariate analysis (62% longer, P = .03), but Hispanics had a similar EDWT in both univariate analysis (31% longer, P = .65) and multivariate analysis (5% longer, P = .91). Longer EDWT was also seen with nonambulance mode of arrival, urban hospitals, or nonemergency triage. Race was significantly associated with EDWT > 10 minutes (whites, 55% [referent]; blacks, 70% [P = .03]; Hispanics, 62% [P = .53]). These differences persisted after adjustment (blacks: odds ratio [OR] = 2.08, 95% confidence interval [CI] = 1.05-4.09; Hispanics: OR = 1.07, 95% CI = 0.52-2.22). Blacks, but not Hispanics, had significantly longer EDWT than whites. The longer EDWT in black stroke patients may lead to treatment delays and sub-optimal stroke care.
Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association 01/2011; 20(1):30-40.
[show abstract][hide abstract] ABSTRACT: Mexican Americans and non-Hispanic blacks have higher stroke recurrence rates and lower rates of secondary stroke prevention than non-Hispanic whites. As a potential explanation for this disparity, we assessed racial/ethnic differences in access to physician care and medications in a national sample of US stroke survivors.
Among all 4,864 stroke survivors aged≥45 years who responded to the National Health Interview Survey years 2000-2006, we compared access to care within the last 12 months by race/ethnicity before and after stratification by age (45-64 years vs ≥65 years). With logistic regression, we adjusted associations between access measures and race/ethnicity for sex, comorbidity, neurologic disability, health status, year, income, and health insurance.
Among stroke survivors aged 45-64 years, Mexican Americans, non-Hispanic blacks, and non-Hispanic whites reported similar rates of no generalist physician visit (approximately 15%) and inability to afford medications (approximately 20%). However, among stroke survivors aged≥65 years, Mexican Americans and blacks, compared with whites, reported greater frequency of no generalist visit (15%, 12%, 8%; p=0.02) and inability to afford medications (20%, 11%, 6%; p<0.001). Mexican Americans and blacks more frequently reported no medical specialist visit (54%, 49%, 40%; p<0.001) than did whites and rates did not differ by age. Full covariate adjustment did not fully explain these racial/ethnic differences.
Among US stroke survivors at least 65 years old, Mexican Americans and blacks reported worse access to physician care and medications than whites. This reduced access may lead to inadequate risk factor modification and recurrent stroke in these high-risk minority groups.
[show abstract][hide abstract] ABSTRACT: Objective: The aim of this study was to compare the predictive validity of eight different adherence measures by studying the variability explained between each measure and hospitalization episodes among Medicaid-eligible persons diagnosed with schizophrenia on antipsychotic monotherapy.Methods: This study was a retrospective analysis of the Arkansas Medicaid administrative claims data. Continuously eligible adult schizophrenia (ICD-9-CM = 295.**) patients on antipsychotic monotherapy were identified in the recruitment period from July 2000 through April 2004. Adherence rates to antipsychotic therapy in year 1 were calculated using eight different measures identified from the literature. Univariate and multivariable logistic regression models were used to prospectively predict all-cause and mental health-related hospitalizations in the follow-up year.Results: Adherence rates were computed for 3395 schizophrenic patients with a mean age of 42.9 years, of which 52.5% (n = 1782) were females, and 52.8% (n = 1793) were white. The proportion of days covered (PDC) and continuous measure of medication gaps measures of adherence had equal C-statistics of 0.571 in predicting both all-cause and mental health-related hospitalizations. The medication possession ratio (MPR) continuous multiple interval measure of oversupply were the second best measures with equal C-statistics of 0.568 and 0.567 for any-cause and mental health-related hospitalizations. The multivariate adjusted models had higher C-statistics but provided the same rank order results.Conclusions: MPR and PDC were among the best predictors of any-cause and mental health-related hospitalization, and are recommended as the preferred adherence measures when a single measure is sought for use with administrative claims data for patients not on polypharmacy.
Value in Health 08/2009; 12(6):989 - 995. · 2.19 Impact Factor
[show abstract][hide abstract] ABSTRACT: To identify the adherence value cut-off point that optimally stratifies good versus poor compliers using administratively derived adherence measures, the medication possession ratio (MPR) and the proportion of days covered (PDC) using hospitalization episode as the primary outcome among Medicaid eligible persons diagnosed with schizophrenia, diabetes, hypertension, congestive heart failure (CHF), or hyperlipidemia.
This was a retrospective analysis of Arkansas Medicaid administrative claims data. Patients > or =18 years old had to have at least one ICD-9-CM code for the study diseases during the recruitment period July 2000 through April 2004 and be continuously eligible for 6 months prior and 24 months after their first prescription for the target condition. Adherence rates to disease-specific drug therapy were assessed during 1 year using MPR and PDC. MAIN OUTCOME MEASURE AND ANALYSIS SCHEME: The primary outcome measure was any-cause and disease-related hospitalization. Univariate logistic regression models were used to predict hospitalizations. The optimum adherence value was based on the adherence value that corresponded to the upper most left point of the ROC curve corresponding to the maximum specificity and sensitivity.
The optimal cut-off adherence value for the MPR and PDC in predicting any-cause hospitalization varied between 0.63 and 0.89 across the five cohorts. In predicting disease-specific hospitalization across the five cohorts, the optimal cut-off adherence values ranged from 0.58 to 0.85.
This study provided an initial empirical basis for selecting 0.80 as a reasonable cut-off point that stratifies adherent and non-adherent patients based on predicting subsequent hospitalization across several highly prevalent chronic diseases. This cut-off point has been widely used in previous research and our findings suggest that it may be valid in these conditions; it is based on a single outcome measure, and additional research using these methods to identify adherence thresholds using other outcome metrics such as laboratory or physiologic measures, which may be more strongly related to adherence, is warranted.
Current Medical Research and Opinion 07/2009; 25(9):2303-10. · 2.26 Impact Factor
[show abstract][hide abstract] ABSTRACT: This study was conducted to assess the use of angiotensin receptor blockers (ARBs) in European paediatric patients experiencing essential hypertension. This was a retrospective analysis of the IMS MIDAS Prescribing Insight Medical Database. Five major important European markets, including France, Germany, Italy, Spain and the UK were studied for the usage of ARBs as either a monotherapy or fixed-dose combination (FDC) therapy . Paediatric patients with essential hypertension were identified using ICD-10 codes, and anatomical therapeutic chemical (ATC) classification was used to identify major classes of antihypertensives. Projected prescription data for paediatric patients (<18 years) in the time period of October 2005 to September 2006 were analysed. Special emphasis was placed on the category of 6-17 years of age, as many ARBs were recommended in children above 6 years of age. Out of 242,405 estimated paediatric patients with hypertension, 222,033 (91.6%) were diagnosed with essential hypertension. Out of 230,220 projected prescriptions dispensed in these essential hypertensives, approximately 76.2% were for patients in the category of 6-17 years of. In the age group of 6-17 years, ARBs constituted 25.5% of the projected prescriptions, with 10.6% in the form of FDC of ARBs with hydrochlorothiazides (HCTz). Projected ARB prescription usage, either as a monotherapy or as an FDC with HCTz, was higher in Italy (35.7%), France (30.9%) and Spain (28.1%), but was lower in Germany (5.3%), and non-existent in the United Kingdom. Valsartan-based and losartan-based FDCs were commonly used in the age range of 6-17 years, and accounted for 39. and 13.9% of the projected prescription volume in the ARB-FDC category, respectively. In a majority of the important European markets, paediatric hypertensive patients in the age range of 6-17 years are often treated with ARB monotherapy or FDC therapy. Some ARBs lack necessary clinical studies to support its use in treating essential hypertension in paediatric patients.
Journal of human hypertension 01/2009; 23(6):420-5. · 2.80 Impact Factor
[show abstract][hide abstract] ABSTRACT: Basal cell carcinoma (BCC) is regarded as the most prevalent malignant skin tumor in whites. A variety of surgical and nonsurgical interventions are available to treat BCC. In recent years, an immune response modifier drug, imiquimod, has been approved in treating superficial BCC (sBCC). The objective of the authors was to review the published literature to evaluate outcomes such as efficacy, safety, and quality of life associated with imiquimod treatment among patients with sBCC. A MEDLINE search of the literature was performed to identify studies published between January 1, 1995 and March 31, 2008 that evaluated imiquimod efficacy, safety, and quality of life in treating BCC. Overall, imiquimod 5% cream was associated with increased clinical and histologic clearance among patients with sBCC as compared to placebo. The findings from short-term cost effectiveness studies suggest that use of imiquimod 5% cream can be more cost-effective than surgical interventions such as excision surgery among patients with superficial BCC. Future studies evaluating long term cost effectiveness of imiquimod treatment are warranted.
Journal of drugs in dermatology: JDD 12/2008; 7(11):1044-51. · 1.16 Impact Factor
[show abstract][hide abstract] ABSTRACT: To compare the predictive validity of 8 different adherence measures by studying the variability explained between each measure and 2 outcome measures: hospitalization episodes and total nonpharmacy cost among Medicaid eligible persons diagnosed with diabetes.
This study was a retrospective analysis of the Arkansas Medicaid administrative claims data from January 2000 to December 2006.
Diabetic (ICD-9-CM = 250.0 x - 250.9 x, where x = 0 or 2) patients were identified in the recruitment period July 2000 through April 2004. Patients had to be >or=18 years old and have at least 2 prescription fills in the index period for an oral antidiabetic drug.
: Adherence rates to oral antidiabetic therapy were contrasted using the following 8 measures; including the medication possession ratio (MPR), proportion of days covered (PDC), refill compliance rate (RCR), compliance ratio (CR), medication possession ratio, modified (MPRm), continuous measure of medication gaps (CMG), and continuous multiple interval measure of oversupply (CMOS and continuous, single interval measure of medication acquisition (CSA). Multivariate and univariate linear and logistic regression models were used to prospectively predict nonpharmacy costs and hospitalizations in the follow-up year.
A total of 4943 diabetic patients were studied. In predicting any cause hospitalization, univariate models with PDC and CMG had the highest predictive validity (C-statistic: 0.544). Multivariate models with MPR, PDC, CMG or continuous multiple interval measure of oversupply (CMOS) as adherence measures had the highest C-statistics of 0.701 in predicting diabetes specific hospitalizations. None of the adherence measures were significantly associated with nonpharmacy cost.
MPR and PDC had the highest predictive validity for hospitalization episodes. These 2 measures should be considered first when selecting among adherence measures when using administrative prescription claims data.
Medical care 11/2008; 46(11):1125-33. · 3.24 Impact Factor
[show abstract][hide abstract] ABSTRACT: The objective of this observational study was to assess the status of glycemic control and associated patient-reported outcomes in ambulatory Hungarian patients with type 2 diabetes mellitus (T2DM) who were prescribed either a sulfonylurea (SU) or a thiazolidinedione (TZD) in addition to the prior metformin (MF) monotherapy.
Type 2 diabetics aged > or = 30 years and who had added an SU or TZD to previous MF monotherapy at least 1 year prior to the visit date were identified during January 2006 to March 2007. Information on HbA1c (A1C), medication use and co-morbid conditions was extracted from the medical record up to 6 months prior to the addition of SU or TZD to MF (baseline), and a minimum of one year after the initiation of either SU or TZD. Glycemic control (A1C < 6.5%) was assessed using the last available A1C value in the medical record. Self-reported hypoglycemia, health-related quality of life (HRQoL) and treatment satisfaction were also assessed.
A total of 414 patients (82% SU+MF and 18% TZD+MF) with a mean age of 60.5 years (SD = 9.4 years) participated in the study. About 27% of patients reported hypoglycemic episodes, with about one-third reporting episodes that resulted into interruption of activities or required medical/non-medical assistance. Three quarters of patients were not at glycemic goal and BMI was the only factor significantly associated with failure to have an A1C level < 6.5%. Patients' HRQoL was significantly associated with self-reported hypoglycemic episodes (p = 0.017), and duration of diabetes (p = 0.045).
Nearly 75% of patients were not at A1C goal of < 6.5% despite using two oral anti-hyperglycemic medications. Approximately 9% of patients reporting hypoglycemia required some kind of medical/non-medical assistance. Greater BMI at baseline was associated with an A1C level > or = 6.5%. Finally, self- reports of hypoglycemia and duration of diabetes were associated with low HRQoL.
Health and Quality of Life Outcomes 10/2008; 6:88. · 2.27 Impact Factor