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1.  How quickly do physicians adopt new drugs? The case of second-generation antipsychotics 
To examine physician adoption of second-generation antipsychotic medications and identify physician-level factors associated with early adoption.
Using IMS Health Xponent™ data, which captures over 70% of all prescriptions filled in the U.S., and AMA Masterfile data on prescriber characteristics for each of 9 second-generation antipsychotics introduced from 1996–2008 for 30,369 physicians who prescribed antipsychotics, we estimate drug-specific Cox proportional hazards models of time to adoption and conduct descriptive analysis of the total number of agents prescribed.
On average, physicians waited two or more years before prescribing new second-generation antipsychotics, but there was substantial heterogeneity across products in time to adoption. General practitioners were much slower to adopt second-generation antipsychotics than psychiatrists (hazard ratios (HRs) ranged from 0.10–0.35); solo practitioners were slower to adopt most products than group practitioners (HRs ranged from 0.77–0.89). Physicians in the highest quartile of antipsychotic prescribing volume adopted second-generation antipsychotics much faster than physicians in the lowest quartile (HRs ranged from 0.15–0.39). Psychiatrists tended to prescribe a broader set of antipsychotics (median of 6) than other specialties (median of 2 for general practitioners and neurologists and 1 for pediatricians).
Policymakers are searching for ways to control rapid health spending growth, which is driven primarily by use of new technologies such as second-generation antipsychotics. Understanding the factors that influence physician adoption of new medications will be crucial in the implementation of efforts aimed at maximizing value of care received by individuals with mental disorders as well as efforts to improve medication safety.
PMCID: PMC3907700  PMID: 23280376
prescription drugs; mental health; antipsychotics
2.  Parity and Out-of-Pocket Spending for Children With High Mental Health or Substance Abuse Expenditures 
Pediatrics  2013;131(3):e903-e911.
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act required health plans to provide mental health and substance use disorder (MH/SUD) benefits on par with medical benefits beginning in 2010. Previous research found that parity significantly lowered average out-of-pocket (OOP) spending on MH/SUD treatment of children. No evidence is available on how parity affects OOP spending by families of children with the highest MH/SUD treatment expenditures.
We used a difference-in-differences study design to examine whether parity reduced families’ (1) share of total MH/SUD treatment expenditures paid OOP or (2) average OOP spending among children whose total MH/SUD expenditures met or exceeded the 90th percentile. By using claims data, we compared changes 2 years before (1999–2000) and 2 years after (2001–2002) the Federal Employees Health Benefits Program implemented parity to a contemporaneous group of health plans that did not implement parity over the same 4-year period. We examined those enrolled in the Federal Employees Health Benefits Program because their parity directive is similar to and served as a model for the new federal parity law.
Parity led to statistically significant annual declines in the share of total MH/SUD treatment expenditures paid OOP (−5%, 95% confidence interval: −6% to −4%) and average OOP spending on MH/SUD treatment (−$178, 95% confidence interval: −257 to −97).
This study provides the first empirical evidence that parity reduces the share and level of OOP spending by families of children with the highest MH/SUD treatment expenditures; however, these spending reductions were smaller than anticipated and unlikely to meaningfully improve families’ financial protection.
PMCID: PMC3581843  PMID: 23420919
mental health; substance use disorder; parity; insurance
3.  Trends in Co-Prescribing of Antidepressants and Tamoxifen among Women with Breast Cancer, 2004 – 2010 
Nearly a decade ago, researchers identified a potential interaction between tamoxifen and strong CYP2D6 inhibitors, including several frequently used antidepressants. Based on evidence available at that time, a United States Food and Drug Administration advisory committee recommended tamoxifen’s label be changed in October 2006, noting that postmenopausal women with estrogen receptor-positive breast cancer who are poor CYP2D6 metabolizers by genotype or drug interactions may be at increased risk of cancer recurrence. The impact of accumulating drug risk information on antidepressant use is unknown.
Retrospective, longitudinal cohort study of 13,205 women aged 50–95 with breast cancer initiating tamoxifen between July 2004–December 2009. We evaluate trends in strong, moderate, and weak CYP2D6-inhibitor antidepressants and tamoxifen co-prescribing and factors associated with ongoing strong inhibitor use. A propensity-score matched control group (aromatase inhibitor initiators) was used to estimate changes in co-prescribing, accounting for secular trends.
In each month, approximately 24% of tamoxifen and aromatase inhibitor users were prescribed antidepressants. Among women using tamoxifen and antidepressants, 34% used strong inhibitors between 2004 and 2006 versus 15% in 2010. Strong inhibitor use decreased more among tamoxifen users than aromatase inhibitor users (Difference-in-Differences, [DD]: −0.09, 95% Confidence Interval, [CI]: −0.15, −0.03). Weak inhibitor use increased among tamoxifen users from 32% between 2004 and 2006 to 52% in 2010, more rapidly than among aromatase inhibitor users (DD:0.15, CI:0.08, 0.23). The factor most strongly associated with strong inhibitor and tamoxifen co-prescribing after 2006 was prior strong inhibitor use (RR:4.73, CI:3.62–6.18).
There were substantial declines in strong CYP2D6-inhibitor use among tamoxifen users following dissemination of information suggesting a potential for increased risk with co-prescribing. Whether patients and providers will continue to avoid strong inhibitor antidepressants is yet to be seen, but clinicians appear to be responsive to drug interaction risk information in this setting.
PMCID: PMC3529777  PMID: 23149465
Tamoxifen; CYP2D6; drug interaction; FDA Advisories; drug utilization
4.  Racial-Ethnic Differences in Incident Olanzapine Use After an FDA Advisory for Patients With Schizophrenia 
Prior investigations suggest that olanzapine use declined rapidly after a U.S. Food and Drug Administration (FDA) communication and consensus statement warning of the drug’s increased metabolic risks, but whether declines differed by racial-ethnic groups is unknown.
Changes in olanzapine use over time by race-ethnicity was assessed among 7,901 Florida Medicaid enrollees with schizophrenia.
Prior to the advisory, 57% of second-generation antipsychotic fills among Hispanics were for olanzapine, compared with 40% for whites or blacks (adjusted risk difference [ARD]=.17, 95% confidence interval [CI]=.13–.20). Olanzapine use declined among all racial-ethnic groups. Although Hispanics had greater olanzapine use than whites in each period, the differences in absolute risk were only 3% by the latest study period (ARD=.03, CI=.01–.04).
After the FDA communication and consensus statement were issued, differences in olanzapine use between white and Hispanic enrollees narrowed considerably. Identifying high-use subgroups for targeted delivery of drug safety information may help eliminate any existing differences in prescribing.
PMCID: PMC3572912  PMID: 23280461
5.  Associations Between End-of-Life Discussion Characteristics and Care Received Near Death: A Prospective Cohort Study 
Journal of Clinical Oncology  2012;30(35):4387-4395.
National guidelines recommend that discussions about end-of-life (EOL) care planning happen early for patients with incurable cancer. We do not know whether earlier EOL discussions lead to less aggressive care near death. We sought to evaluate the extent to which EOL discussion characteristics, such as timing, involved providers, and location, are associated with the aggressiveness of care received near death.
Patients and Methods
We studied 1,231 patients with stage IV lung or colorectal cancer in the Cancer Care Outcomes Research and Surveillance Consortium, a population- and health system–based prospective cohort study, who died during the 15-month study period but survived at least 1 month. Our main outcome measure was the aggressiveness of EOL care received.
Nearly half of patients received at least one marker of aggressive EOL care, including chemotherapy in the last 14 days of life (16%), intensive care unit care in the last 30 days of life (9%), and acute hospital-based care in the last 30 days of life (40%). Patients who had EOL discussions with their physicians before the last 30 days of life were less likely to receive aggressive measures at EOL, including chemotherapy (P = .003), acute care (P < .001), or any aggressive care (P < .001). Such patients were also more likely to receive hospice care (P < .001) and to have hospice initiated earlier (P < .001).
Early EOL discussions are prospectively associated with less aggressive care and greater use of hospice at EOL.
PMCID: PMC3675701  PMID: 23150700
6.  Changes in Antipsychotic Use among Patients with Severe Mental Illness after an FDA Advisory 
Pharmacoepidemiology and drug safety  2012;21(12):1251-1260.
A 2003 FDA advisory warned of increased hyperlipidemia and diabetes risk for patients taking second-generation antipsychotics (SGAs). Following the advisory a professional society consensus statement provided treatment recommendations and stratified SGAs into high, intermediate, and low metabolic risk. We examine subsequent changes in incident and prevalent SGA use among individuals with severe mental illness.
Retrospective, observational study using Florida Medicaid’s claims from 2001–2006. We include non-Medicare eligible adults with bipolar disorder or schizophrenia who filled a SGA prescription. Among prevalent users we assess changes in overall and agent-specific use; discontinuations; interruptions; and therapeutic alternative use; among incident users, agent-specific use. Pre-advisory utilization was compared with utilization initially following the advisory and two subsequent periods.
Among prevalent users, overall SGA use declined slightly and no increases in treatment interruptions or discontinuations were observed following the advisory and consensus statement publication. Compared with the pre-advisory period, in the months immediately following use of the highest metabolic-risk agent, olanzapine, decreased by 34% among prevalent users with bipolar disorder (adjusted risk ratio [aRR]=0.66; 95% confidence intervals [CI]=0.59–0.74) and 26% among prevalent users with schizophrenia (aRR=0.74, CI=0.72–0.76). A greater decline was estimated among incident users with bipolar disorder (aRR=0.37; CI=0.29–0.47) and schizophrenia (aRR=0.42; CI=0.35–0.51) during this period. During each subsequent post-advisory period, olanzapine use continued to decline while quetiapine, ziprasidone, and aripiprazole use increased.
The metabolic risk advisory and published consensus statement were associated with a selective reduction in olanzapine use without evidence of treatment disruptions among this population.
PMCID: PMC3431449  PMID: 22553074
Drug Utilization; FDA Advisory; Metabolic Risk; Second Generation Antipsychotics
7.  Medicare Part D Claims Rejections for Nursing Home Residents, 2006 to 2010 
Much has been written about trends in Medicare Part D formulary design and consumers’ choice of plans, but little is known about the magnitude of claims rejections or their clinical and administrative implications. Our objective was to study the overall rate at which Part D claims are rejected, whether these rates differ across plans, drugs, and medication classes, and how these rejection rates and reasons have evolved over time.
Study Design and Methods
We performed descriptive analyses of data on paid and rejected Part D claims submitted by 1 large national long-term care pharmacy from 2006 to 2010. In each of the 5 study years, data included approximately 450,000 Medicare beneficiaries living in long-term care settings with approximately 4 million Part D drug claims. Claims rejection rates and reasons for rejection are tabulated for each study year at the plan, drug, and class levels.
Nearly 1 in 6 drug claims was rejected during the first 5 years of the Medicare Part D program, and this rate has increased over time. Rejection rates and reasons for rejection varied substantially across drug products and Part D plans. Moreover, the reasons for denials evolved over our study period. Coverage has become less of a factor in claims rejections than it was initially and other formulary tools such as drug utilization review, quantity-related coverage limits, and prior authorization are increasingly used to deny claims.
Examining claims rejection rates can provide important supplemental information to assess plans’ generosity of coverage and to identify potential areas of concern.
PMCID: PMC3540110  PMID: 23145808
8.  Economic Grand Rounds 
The impact of parity coverage on the quantity of behavioral health services used by enrollees and on the prices of these services was examined in a set of Federal Employees Health Benefit (FEHB) Program plans. After parity implementation, the quantity of services used in the FEHB plans declined in five service categories, compared with plans that did not have parity coverage. The decline was significant for all service types except inpatient care. Because a previous study of the FEHB Program found that total spending on behavioral health services did not increase after parity implementation, it can be inferred that average prices must have increased over the period. The finding of a decline in service use and increase in prices provides an empirical window on what might be expected after implementation of the federal parity law and the parity requirement under the health care reform law.
PMCID: PMC3773179  PMID: 22302324
9.  New Jersey’s Efforts To Improve Postpartum Depression Care Did not Change Treatment Patterns for Women on Medicaid 
Health affairs (Project Hope)  2011;30(2):293-301.
Identification and treatment of postpartum depression are the increasing focus of state and national legislation, including portions of the Affordable Care Act. Some state policies and proposals are modeled directly on programs in New Jersey, the first state to require universal screening of mothers who recently delivered babies for postpartum depression. We examined the impact of these policies on a particularly vulnerable population, Medicaid recipients, and found that neither the required screening, nor the educational campaign that preceded it, was associated with improved treatment initiation, follow-up, or continued care. We argue that New Jersey’s policies, although well intentioned, were predicated on an inadequate base of evidence, and that efforts should now be undertaken to build that base. We also argue that, to improve detection and treatment, policy makers contemplating or implementing postpartum depression mandates should consider additional measures. These could include requiring mechanisms to monitor and enforce the screening requirement; payment of providers to execute screening and follow up; and preliminary testing of interventions before policy changes are enacted.
PMCID: PMC3736568  PMID: 21289351
10.  Racial and Ethnic Disparities in Postpartum Depression Care Among Low-Income Women 
The goal of this study was to characterize racial-ethnic differences in mental health care utilization associated with postpartum depression in a multiethnic cohort of Medicaid recipients.
In a retrospective cohort study, administrative claims data from New Jersey’s Medicaid program were obtained for 29,601 women (13,001 whites, 13,416 blacks, and 3,184 Latinas) who delivered babies between July 2004 and October 2007. Racial-ethnic differences were estimated with logistic regression for initiation of antidepressant medication or outpatient mental health visits within six months of delivery, follow-up (a prescription refill or second visit), and continued mental health care (at least three visits or three filled antidepressant prescriptions within 120 days).
Nine percent (N=1,120) of white women initiated postpartum mental health care, compared with 4% (N=568) of black women and 5% (N=162) of Latinas. With analyses controlling for clinical factors, the odds of initiating treatment after delivery were significantly (p<.001) lower for blacks (adjusted odds ratio [AOR]=.43) and Latinas (AOR=.59) compared with whites. Among those who initiated treatment, blacks and Latinas were less likely than whites to receive follow-up treatment (blacks, AOR=.66, p<.001; Latinas, AOR=.67, p<.05) or continued care (blacks, AOR=.81, marginal difference at p<.10; Latinas, AOR=.67, p<.05). Among those who initiated antidepressant treatment, black women and Latinas were less likely than whites to refill a prescription.
There were significant racial-ethnic differences in depression-related mental health care after delivery. Suboptimal treatment was prevalent among all low-income women in the study. However, racial and ethnic disparities in the initiation and continuation of postpartum depression care were particularly troubling and warrant clinical and policy attention.
PMCID: PMC3733216  PMID: 21632730
11.  Association Between the Part D Coverage Gap and Adverse Health Outcomes 
Part D coverage gap entry is associated with a two-fold increased rate of drug discontinuation among beneficiaries now fully responsible for drug costs. Reduced adherence to drugs has been associated with adverse outcomes. We evaluated whether coverage gap entry is associated with risk of death or hospitalization for cardiovascular outcomes.
Prospective cohort study. Beneficiaries entered the study upon reaching the coverage gap spending threshold and were observed until an event, reaching the threshold for catastrophic coverage, or year’s end. Exposed patients were responsible for drug costs in the gap; unexposed patients received financial assistance. We matched 9,436 exposed patients to 9,436 unexposed patients based on propensity score (PS) or high-dimensional propensity score (hdPS).
Medicare Part D drug insurance.
303,978 Medicare beneficiaries aged 65+ in 2006 and 2007 with linked prescription and medical claims who enrolled in stand-alone Part D or retiree drug plans and reached the gap spending threshold.
Rates of death and hospitalization for any of 5 cardiovascular outcomes, including acute coronary syndrome+revascularization (ACS), after reaching the coverage gap spending threshold were compared using Cox proportional hazards models.
In PS-matched analyses, exposed beneficiaries had elevated but non-significant hazards of death (HR=1.25; 95% CI 0.98–1.59) and ACS (HR=1.16; 0.83–1.62) compared with unexposed patients. hdPS-matched analyses minimized residual confounding and confirmed results: death (HR=0.99; 0.78–1.24); ACS (HR=1.07; 0.81–1.41). Exposed beneficiaries were no more or less likely to experience other outcomes than were the unexposed.
During the short-term coverage gap period, having no financial assistance to pay for drugs was not associated with an increased risk of death or hospitalization for cardiovascular causes. However, long-term health consequences remain unclear.
PMCID: PMC3419279  PMID: 22788544
Medicare Part D; coverage gap; adverse health outcomes; cardiovascular disease; drug discontinuation
12.  Uninsurance and its Correlates among Poor Adults with Disabilities 
States must offer Medicaid coverage to poor adults with disabilities; however, they have discretion in the design of eligibility criteria and enrollment processes. Using the American Community Survey, we examined the health insurance status of adults enrolled in the Supplemental Security Income (SSI) disability program including (1) the national rate of health insurance coverage; (2) state rates of uninsurance and Medicaid; and (3) the correlates of uninsurance. Uninsurance and Medicaid rates varied across states from 1% to 12% and from 63% to 91%, respectively. Nationally, 5% of the SSI population was uninsured; 77% was enrolled in Medicaid. Limited English proficiency, Black race, lack of U.S. citizenship, and residence in a state that used an enrollment process and/or eligibility criteria distinct from the SSI program were associated with uninsurance. As states streamline Medicaid enrollment processes to meet requirements of the Affordable Care Act, they should consider the needs of this vulnerable population.
PMCID: PMC3671490  PMID: 23698677
Medicaid; disability; uninsured
13.  Characteristics of Adults With Substance Use Disorders Expected to Be Eligible for Medicaid Under the ACA 
Provisions in the Affordable Care Act (ACA) are likely to expand access to substance use disorder treatment for low-income individuals. The aim of the study was to provide information on the need for substance use disorder treatment among individuals who may be eligible for Medicaid under the ACA.
The 2008 and 2009 National Survey on Drug Use and Health provided data on demographic characteristics, health status, and substance use disorders for comparison of current low-income Medicaid enrollees (N=3,809) with currently uninsured individuals with household incomes that may qualify them for Medicaid coverage beginning in 2014 (N=5,049). The incomes of the groups compared were 138% of the federal poverty level (133% provided in the ACA plus a 5% income “disregard” allowed by the law).
The rate of substance use disorders among currently uninsured income-eligible individuals was slightly higher than the rate among current Medicaid enrollees (14.6% versus 11.5%, p=.03). Although both groups had significant unmet need for substance use disorder treatment, the treatment rate among those who needed treatment was significantly lower in the income-eligible group than in the currently enrolled group (31.3% versus 46.8%, p<.01). When the analysis excluded informal care received outside the medical sector, treatment rates among those with treatment needs were much lower in both groups (12.8% in the income-eligible group and 30.7% among current enrollees).
Findings suggest that Medicaid insurance expansions under the ACA will reduce unmet need for substance use disorder treatment.
PMCID: PMC3672321  PMID: 23450343
Medical Care  2012;50(6):466-478.
To review literature on the impact of FDA drug risk communications on medication utilization, health care services use, and health outcomes.
Data Sources
The authors searched MEDLINE and the Web of Science for manuscripts published between January 1990 and November 2010 that included terms related to drug utilization, the FDA, and advisories or warnings. We manually searched bibliographies and works citing selected articles and consulted with experts to guide study selection.
Study Selection
Studies were included if they involved an empirical analysis evaluating the impact of an FDA risk communication.
Data Extraction
We extracted the drug(s) analyzed, relevant FDA communication(s), data source, analytical method, and main outcome(s) assessed.
Of the 1432 records screened, 49 studies were included. These studies covered sixteen medicines or therapeutic classes; one-third examined communications regarding antidepressants. Most used medical or pharmacy claims and few rigorously examined patient-provider communication, decision-making or risk perceptions. Advisories recommending increased clinical or laboratory monitoring generally led to decreased drug use, but only transient and modestly increased monitoring. Communications targeting specific subpopulations often spilled over to other groups. Repeated or sequential advisories tended to have larger but delayed effects and decreased incident more than prevalent use. Drug-specific warnings were associated with particularly large decreases in utilization, though the magnitude of substitution within therapeutic classes varied across clinical contexts.
While some FDA drug risk communications had immediate, strong impacts, many had either delayed or no impact on health care utilization or health behaviors. These data demonstrate the complexity of using risk communication to improve the quality and safety of prescription drug use, and suggest the importance of continued assessments of the effect of future advisories and label changes. Identifying factors that are associated with rapid and sustained responses to risk communications will be important for informing future risk communication efforts.
PMCID: PMC3342472  PMID: 22266704
15.  Beneficiaries with cardiovascular disease and the Part D coverage gap 
Medicare Part D improved access to cardiovascular medications. Increased cardiovascular drug utilization and resulting health improvements could be derailed when beneficiaries enter the coverage gap and must pay 100% of drug costs. The coverage gap remains the subject of Congressional debate; evidence regarding its impact on cardiovascular drug use and health outcomes is needed.
Methods and Results
We followed 122,255 Medicare beneficiaries with cardiovascular conditions with linked prescription and medical claims who reached the coverage gap spending threshold in 2006 or 2007. Beneficiaries entered the study upon reaching the threshold and were followed until an event, the catastrophic coverage spending threshold, or year’s end. We matched 3,980 beneficiaries who reached the threshold and received no financial assistance (exposed) to 3,980 with financial assistance during the gap period (unexposed) using propensity score (PS) and high-dimensional PS (hdPS) approaches. We compared rates of cardiovascular drug discontinuation, drug switching, and death or hospitalization for acute coronary syndrome+revascularization (ACS), congestive heart failure, or atrial fibrillation. In PS-matched analyses, exposed beneficiaries were more likely to discontinue (HR=1.57; 95% CI, 1.39–1.79, RD=13.76; 95% CI, 10.99-16.54 drugs/100 person-years) but no more or less likely to switch cardiovascular drugs. There were no significant differences in rates of death (PS-matched HR=1.23; 0.89-1.71) or other outcomes.
Part D beneficiaries with cardiovascular conditions with no financial assistance during the coverage gap were at increased risk for cardiovascular drug discontinuation. However, the impact of this difference on health outcomes is not clear.
PMCID: PMC3361758  PMID: 22511746
epidemiology; Part D coverage gap; cardiovascular drugs; cardiovascular morbidity and mortality
16.  End-of-life discussions among patients with advanced cancer: A cohort study 
Annals of internal medicine  2012;156(3):204-210.
National guidelines recommend that physicians discuss end-of-life (EOL) care planning with cancer patients whose life expectancy is less than one year.
To evaluate the incidence of EOL discussions for patients with stage IV lung or colorectal cancer, and where, when, and with whom discussions take place.
Prospective cohort study of patients diagnosed with lung or colorectal cancer from 2003 to 2005.
Subjects lived in Northern California, Los Angeles County, North Carolina, Iowa, or Alabama, or received care in one of five large health maintenance organizations or one of fifteen Veteran’s Health Administration sites.
2155 patients with stage IV lung or colorectal cancer.
EOL discussions reported in patient and surrogate interviews or documented in medical records through 15 months after diagnosis.
73% of patients had EOL discussions identified by at least one source. Among patients who died during follow-up (N=1470), 87% had EOL discussions, versus 41% of patients who were alive at the end of follow-up (N=685). Among first EOL discussions documented in records (N=1081), 55% occurred in the hospital. Oncologists documented EOL discussions with only 27% of their patients. Among patients with documented EOL discussions who died during follow-up (N=959), discussions took place a median of 33 days before death.
The depth and quality of EOL discussions was not evaluated. Much of the information about discussions came from surrogates of patients who died before baseline interviews could be obtained.
Although most patients with stage IV lung or colorectal cancer have discussions with physicians about EOL care planning before death, many discussions occur during acute hospital care, with non-oncology providers, and late in the course of illness.
PMCID: PMC3616320  PMID: 22312140
17.  A Prescription for Drug Formulary Evaluation: An Application of Price Indexes 
Forum for health economics & policy  2012;15(2):1558-9544.1296.
Existing economic approaches to the design and evaluation of health insurance do not readily apply to coverage decisions in the multi-tiered drug formularies characterizing drug coverage in private health insurance and Medicare. This paper proposes a method for evaluating a change in the value of a formulary to covered members based on the economic theory of price indexes. A formulary is cast as a set of demand-side prices, and our measure approximates the compensation (positive or negative) that would need to be paid to consumers to accept the new set of prices. The measure also incorporates any effect of the formulary change on plan drug acquisition costs and “offset effects” on non-drug services covered by the plan. Data needed to calculate formulary value are known or can be forecast by a health plan. We illustrate the method with data from a move from a two- to a three-tier formulary.
PMCID: PMC3556729  PMID: 23372543
Academic Pediatrics  2012;12(2):110-116.
Because of several recent clinical and regulatory changes regarding Attention Deficit Hyperactivity Disorder (ADHD) in the United States, we quantified changes in ADHD diagnosis and medication management from 2000 through 2010.
We used the IMS Health National Disease and Therapeutic Index™, a nationally representative audit of office-based providers, to examine aggregate trends among children and adolescents under 18. We also quantified how diagnosis and treatment patterns have evolved based on patient and physician characteristics and the therapeutic classes used.
From 2000 to 2010, the number of physician outpatient visits where ADHD was diagnosed increased 66% from 6.2 million [M] (95% confidence intervals [CI] 5.5- 6.9M) to 10.4M visits (CI 9.3-11.6M). Of these visits, psychostimulants have remained the dominant treatment, used in 96% of treatment visits in 2000 and 87% of treatment visits in 2010. Atomoxetine use declined from 15% of treatment visits upon product launch in 2003 to 6% of treatment visits by 2010. The use of potential substitute therapies – clonidine, guanfacine, and bupropion – remained relatively constant (between 5-9% of treatment visits) during most of the period examined. Over this period, the ADHD management shifted towards psychiatrists (from 24% to 36% of all visits) without large changes in illness severity or the proportion of ADHD treatment visits accounted for by males (73%-77%).
In ten years, the ambulatory diagnosis of ADHD increased by two-thirds and is increasingly managed by psychiatrists. The effects of these changing treatment patterns on children's health outcomes and their families are unknown.
PMCID: PMC3307907  PMID: 22326727
Attention deficit and hyperactivity disorder; pediatrics; pediatric workforce; mental health
19.  Use of Prescription Drug Samples and Patient Assistance Programs, and the Role of Doctor–Patient Communication 
Journal of General Internal Medicine  2011;26(12):1458-1464.
Cost-related underuse of medications is common among older adults, who seldom discuss medication costs with their physicians. Some older adults may use free drug samples or industry-sponsored patient assistance programs (PAP) in hopes of lowering out-of-pocket costs, although the long-term effect of these programs on drug spending is unclear.
To examine older adults’ use of industry-sponsored strategies to reduce out-of-pocket drug costs and the association between doctor–patient communication and use of these programs.
Cross-sectional analysis of a 2006 nationally representative survey of Medicare beneficiaries.
14,322 community-dwelling Medicare beneficiaries age ≥65.
We conducted bivariate and multivariate analyses of the association between receipt of free samples and participation in PAPs with sociodemographic characteristics, health status, access to care, drug coverage, medication cost burden, and doctor–patient communication.
51.4% of seniors reported receiving at least one free sample over the last 12 months and 29.2% reported receiving free samples more than once. In contrast, only 1.3% of seniors reported participating in an industry-sponsored PAP. Higher income respondents were more likely to report free sample receipt than low-income respondents (50.8% vs. 43.8%, p < 0.001) and less likely to report participating in a PAP (0.42% vs. 2.2%, p < 0.001). In multivariate analyses, those who reported talking to their doctor about the cost of their medications had more than twice the odds of receiving samples as those who did not (OR 2.17, 95% CI 1.95–2.42).
In 2006, over half of seniors in Medicare received free samples, but only 1.3% reported receiving any medications from a patient assistance program. Doctor–patient communication is strongly associated with use of these programs, which has important implications for clinical care regardless of whether these programs are viewed as drivers of prescription costs or a remedy for them.
PMCID: PMC3235606  PMID: 21751052
free drug samples; prescription assistance programs; Medicare; physician–patient communication
21.  Racial Variation in Willingness to Trade Financial Resources for Life Prolonging Cancer Treatment 
Cancer  2011;117(15):3476-3484.
Minority patients receive more aggressive care at the end of life, but it is unclear whether this trend is consistent with their preferences. We compared the willingness to use personal financial resources to extend life among White, Black, Hispanic and Asian cancer patients.
Patients with newly diagnosed lung or colorectal cancer participating in the Cancer Care Outcomes Research and Surveillance (CanCORS) observational study were interviewed about myriad aspects of their care including their willingness to expend personal financial resources in order to prolong life. We evaluated the association of race/ethnicity with preference for life-extending treatment controlling for clinical, sociodemographic, and psychosocial factors using logistic regression.
Among patients (N = 4214), 80% of Blacks reported a willingness to spend all resources to extend life, versus 54% of Whites, 69% of Hispanics and 72% of Asians (p < 0.001). In multivariable analyses, Blacks were more likely to opt for expending all financial resources to extend life than Whites (OR = 2.41, 95% CI 1.84–3.17, p <0.001).
Black cancer patients are more willing to exhaust personal financial resources to extend life. Delivering quality cancer care requires an understanding of how these preferences impact cancer care and outcomes.
PMCID: PMC3142305  PMID: 21523759
Treatment Preferences; Cancer; Race; Financial Resources; Trade Offs
22.  Using Multiple Control Groups and Matching to Address Unobserved Biases in Comparative Effectiveness Research: An Observational Study of the Effectiveness of Mental Health Parity 
Statistics in biosciences  2011;3(1):63-78.
Studies of large policy interventions typically do not involve randomization. Adjustments, such as matching, can remove the bias due to observed covariates, but residual confounding remains a concern. In this paper we introduce two analytical strategies to bolster inferences of the effectiveness of policy interventions based on observational data. First, we identify how study groups may differ and then select a second comparison group on this source of difference. Second, we match subjects using a strategy that finely balances the distributions of key categorical covariates and stochastically balances on other covariates. An observational study of the effect of parity on the severely ill subjects enrolled in the Federal Employees Health Benefits (FEHB) Program illustrates our methods.
PMCID: PMC3182124  PMID: 21966322
Causal Inference; Fine Balance; Quasi-Experiments; Testing in Order
23.  Massachusetts Health Reform and Disparities in Coverage, Access and Health Status 
Journal of General Internal Medicine  2010;25(12):1356-1362.
Massachusetts health reform has achieved near-universal insurance coverage, yet little is known about the effects of this legislation on disparities.
Since racial/ethnic minorities and low-income individuals are over-represented among the uninsured, we assessed the effects of health reform on disparities.
Cross-sectional survey data from the Behavioral Risk Factor Surveillance Survey (BRFSS), 2006–2008.
Adults from Massachusetts (n = 36,505) and other New England states (n = 63,263).
Main Measures
Self-reported health coverage, inability to obtain care due to cost, access to a personal doctor, and health status. To control for trends unrelated to reform, we compared adults in Massachusetts to those in all other New England states using multivariate logistic regression models to calculate adjusted predicted probabilities.
Key Results
Overall, the adjusted predicted probability of health coverage in Massachusetts rose from 94.7% in 2006 to 97.7% in 2008, whereas coverage in New England remained around 92% (p < 0.001 for difference-in-difference). While cost-related barriers were reduced in Massachusetts, there were no improvements in access to a personal doctor or health status. Although there were improvements in coverage and cost-related barriers for some disadvantaged groups relative to trends in New England, there was no narrowing of disparities in large part because of comparable or larger improvements among whites and the non-poor.
Achieving equity in health and health care may require additional focused intervention beyond health reform.
PMCID: PMC2988151  PMID: 20730503
health coverage; health care reform; Massachusetts
24.  Antipsychotic and Benzodiazepine Use Among Nursing Home Residents: Findings From the 2004 National Nursing Home Survey 
To document the extent and appropriateness of use of antipsychotics and benzodiazepines among nursing home residents using a nationally representative survey.
Cross-sectional analysis of the 2004 National Nursing Home Survey. Bivariate and multivariate analyses examined relationships between resident and facility characteristics and antipsychotic and benzodiazepine use by appropriateness classification among residents aged 60 years and older (N = 12,090). Resident diagnoses and information about behavioral problems were used to categorize antipsychotic and benzodiazepine use as appropriate, potentially appropriate, or having no appropriate indication.
More than one quarter (26%) of nursing home residents used an antipsychotic medication, 40% of whom had no appropriate indication for such use. Among the 13% of residents who took benzodiazepines, 42% had no appropriate indication. In adjusted analyses, the odds of residents taking an antipsychotic without an appropriate indication were highest for residents with diagnoses of depression (odds ratio [OR] = 1.31; 95% confidence interval [CI]: 1.12–1.53), dementia (OR = 1.82; 95% CI: 1.52–2.18), and with behavioral symptoms (OR = 1.97, 95% CI: 1.56–2.50). The odds of potentially inappropriate antipsychotic use increased as the percentage of Medicaid residents in a facility increased (OR = 1.08, 95% CI: 1.02–1.15) and decreased as the percentage of Medicare residents increased (OR = 0.46, 95% CI: 0.25–0.83). The odds of taking a benzodiazepine without an appropriate indication were highest among residents who were female (OR = 1.44; 95% CI: 1.18–1.75), white (OR = 1.95; 95% CI: 1.47–2.60), and had behavioral symptoms (OR = 1.69; 95% CI: 1.41–2.01).
Antipsychotics and benzodiazepines seem to be commonly prescribed to residents lacking an appropriate indication for their use.
PMCID: PMC3009456  PMID: 20808119
Nursing homes; antipsychotics; benzodiazepines
25.  A Political History of Federal Mental Health and Addiction Insurance Parity 
The Milbank quarterly  2010;88(3):404-433.
This article chronicles the political history of efforts by the U.S. Congress to enact a law requiring “parity” for mental health and addiction benefits and medical/surgical benefits in private health insurance. The goal of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity (MHPAE) Act of 2008 is to eliminate differences in insurance coverage for behavioral health. Mental health and addiction treatment advocates have long viewed parity as a means of increasing fairness in the insurance market, whereas employers and insurers have opposed it because of concerns about its cost. The passage of this law is viewed as a legislative success by both consumer and provider advocates and the employer and insurance groups that fought against it for decades.
Twenty-nine structured interviews were conducted with key informants in the federal parity debate, including members of Congress and their staff; lobbyists for consumer, provider, employer, and insurance groups; and other key contacts. Historical documentation, academic research on the effects of parity regulations, and public comment letters submitted to the U.S. Departments of Labor, Health and Human Services, and Treasury before the release of federal guidance also were examined.
Three factors were instrumental to the passage of this law: the emergence of new evidence regarding the costs of parity, personal experience with mental illness and addiction, and the political strategies adopted by congressional champions in the Senate and House of Representatives.
Challenges to implementing the federal parity policy warrant further consideration. This law raises new questions about the future direction of federal policymaking on behavioral health.
PMCID: PMC2950754  PMID: 20860577
parity; insurance; mental health; substance abuse

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