Purpose of the Study:
This paper is a report of a study of the Assistance, Support, and Self-health Initiated through Skill Training (ASSIST) randomized control trial. The aim of this paper is to understand whether participating in ASSIST significantly changed the out-of-pocket (OOP) costs for family caregivers of Alzheimer’s disease (AD) or Parkinson's disease (PD) patients.
Design and Methods:
Secondary analysis of randomized control trial data, calculating average treatment effects of the intervention on OOP costs. Enrollment in the ASSIST trial occurred between 2002 and 2007 at 2 sites: Durham, North Carolina, and Birmingham, Alabama. We profile OOP costs for caregivers who participated in the ASSIST study and use 2-part expenditure models to examine the average treatment effect of the intervention on caregiver OOP expenditures.
ASSIST-trained AD and PD caregivers reported monthly OOP expenditures that averaged $500–$600. The intervention increased the likelihood of caregivers spending any money OOP by 26 percentage points over usual care, but the intervention did not significantly increase overall OOP costs.
The ASSIST intervention was effective and inexpensive to the caregiver in direct monetary outlays; thus, there are minimal unintended consequences of the trial on caregiver financial well-being.
Cost analysis; Intervention study; Nurses/midwives/nursing; Alzheimer’s disease; Parkinson's disease; Average treatment effect
The purpose of this study is to summarize recent literature on approaches to supporting healthy coping in diabetes, in two specific areas: 1) impact of different approaches to diabetes treatment on healthy coping; and 2) effectiveness of interventions specifically designed to support healthy coping.
A PubMed search identified 129 articles published August 1, 2006 – April 30, 2011, addressing diabetes in relation to emotion, quality of life, depression, adjustment, anxiety, coping, family therapy, behavior therapy, psychotherapy, problem-solving, couples therapy, or marital therapy.
Evidence suggests that treatment choice may significantly influence quality of life, with treatment intensification in response to poor metabolic control often improving quality of life. The recent literature provides support for a variety of healthy coping interventions in diverse populations, including diabetes self-management education, support groups, problem-solving approaches, and coping skills interventions for improving a range of outcomes, Cognitive Behavior Therapy and collaborative care for treating depression, and family therapy for improving coping in youths.
Healthy coping in diabetes has received substantial attention in the past five years. A variety of approaches show positive results. Research is needed to compare effectiveness of different approaches in different populations and determine how to overcome barriers to intervention dissemination and implementation.
To characterize beneficiaries who used a pharmacy or pharmacist as a Medicare Part D information source.
This cross-sectional descriptive study involved 4,724 Medicare Part D beneficiaries who graduated from Wisconsin high schools in 1957. The main outcome measure was beneficiary self-reported use of a pharmacy or pharmacist as a Medicare Part D information source.
Only 13% of the total sample and 15% of those with three or more medications used a pharmacy or pharmacist for Medicare Part D information. Adjusted logistic regression revealed that beneficiaries living in rural communities, compared with metropolitan areas, and with higher out-of-pocket prescription costs were more likely to use a pharmacy or pharmacist for Medicare Part D information. Beneficiaries with lower educational attainment were less likely to use a pharmacy or pharmacist for Medicare Part D information.
Pharmacists have the knowledge and are in the position in the community to effectively educate beneficiaries about the Medicare Part D program. However, this study suggests that few beneficiaries are using pharmacists or pharmacies for Medicare Part D information.
Medicare Part D; community pharmacies; pharmacists; information sources; rural setting; prescription costs
The risk of potentially inappropriate prescription and over-the-counter medication (PIM) use in dementia patients is high. Informal caregivers often facilitate patients’ use of medications, but the effect of caregiver factors on PIM use has not been a focus of prior research.
To examine PIM use in dementia patients and caregivers, and identify caregiver risk factors for PIM use in dementia patients.
We conducted a secondary data analysis of the baseline wave of the Resources for Enhancing Alzheimer's Caregiver's Health study. The sample was comprised of 566 persons with dementia aged 65 and older and their co-residing family caregiver. PIM was defined using the 2003 Beers criteria and was examined in both dementia patients and their caregivers. Caregiver and patient risk factors included a range of socio-demographic and health variables.
In dementia patients, 33% were taking at least 1 PIM, and 39% of their caregivers were also taking a PIM. In fully adjusted models, the following caregiver factors were associated with an increased risk of dementia patient PIM use: caregiver's own PIM use; spouse caregivers; Hispanic caregivers; and greater number of years the caregiver has lived in the United States. Increased caregiver age was associated with a decreased risk of PIM use in patients.
PIM use may be higher in dementia patients and their informal caregivers compared to the general older adult population. Further, patterns of medication use in one member of the dyad may influence PIM risk in the other dyad member. These results suggest that interventions to increase appropriate medication use in dementia patients and their caregivers should target both members of the dyad and target over-the-counter agents along with prescription medications.
Dementia; informal caregivers; inappropriate medications; care quality
Alzheimer’s patients living in rural communities may face significant barriers to effective outpatient medical care.
We sought to examine rural-urban differences in risk for ambulatory care sensitive hospitalizations (ACSH), an indicator of access to outpatient care, in community-dwelling veterans with dementia.
Medicare and VA inpatient claims for 1,186 United States veterans with dementia were linked to survey data from the 1998 National Longitudinal Caregiver Survey. ACSH were identified in inpatient claims over a one-year period following collection of independent variables. Urban Influence Codes were used to classify care-recipients into four categories of increasing county-level rurality: large metropolitan; small metropolitan; micropolitan; and non-core rural counties. We used the Andersen Behavioral Model of Health Services Use to identify veteran, caregiver, and community factors that may explain urban-rural differences in ACSH.
Thirteen percent of care-recipients had at least one ACSH. Likelihood of ACSH was greater for patients in non-core rural counties versus large metropolitan areas (22.6% versus 12.8%, unadjusted odds ratio [OR] = 1.99; p < .05). The addition of other Andersen behavioral model variables did not eliminate the disparity (adjusted OR = 1.97; p < .05).
We found that dementia patients living in the most rural counties were more likely to have an ACSH; this disparity was not explained by differences in caregiver, care-recipient, or community factors. Furthermore, the annual rate of ACSH was higher in community-dwelling dementia patients compared to previous reports on the general older adult population. Dementia patients in rural areas may face particular challenges in receiving timely, effective ambulatory care.
Preventable hospitalizations; rural; dementia; caregivers; access
Prior research has documented factors associated with non-traumatic dental condition (NTDC) visits to emergency departments (EDs), but little is known about the care received by patients in EDs for NTDC visits.
We examined national trends in prescription of analgesics and antibiotics in EDs for NTDC visits in the United States.
We analyzed data from the National Hospital Ambulatory Medical Care survey for 1997 to 2007. We used a multivariable logistic regression model to examine factors associated with receiving analgesics and antibiotics for NTDC visit in EDs.
Overall 74% received at least one analgesic, 56% at least one antibiotic and 13% received no medication at all during an NTDC visit to the ED. The prescription of medications at EDs for NTDC visits steadily increased over time for analgesics (OR=1.11/year, p=<.0001) and antibiotics (OR=1.06/year, p<0.0001). In the multivariable analysis, self-pay patients had significantly higher adjusted odds of receiving antibiotics, while those with non-dental reason for visit and children (0–4 years) had significantly lower adjusted odds of receiving a prescription for antibiotics in EDs for NTDC visits. Children 0–4 years, adults 53–72 years and older adults (73 years and older) had lower adjusted odds (p<0.001) of receiving analgesics.
Nationally, analgesic and antibiotic prescriptions for NTDC visits to EDs have increased substantially over time. Self-pay patients had significantly higher odds of being prescribed antibiotics. Adults over 53 years and especially those 73 years and older had significantly lower odds of receiving analgesics in EDs for NTDC visits.
Nontraumatic dental conditions; Emergency Department; Medications
A fundamental aim of primary care redesign and the patient-centered medical home is improving access to care. Patients who report having a usual site of care and usual provider are more likely to receive preventive services, but less is known about the influence of specific components of first-contact access (e.g., availability of appointments, advice by telephone) on preventive services receipt.
To examine the relationship between number of first-contact access components and receipt of recommended preventive services.
Secondary survey data analysis.
Five thousand five hundred and seven insured adults who had continuity with a usual primary care physician and participated in the 2003–2006 round of the Wisconsin Longitudinal Survey.
Using multivariable logistic regression, we calculated adjusted risk ratios, adjusted predicted probabilities and 95% confidence intervals for each preventive service.
Experiencing more first-contact access components was significantly associated with a higher rate of receiving cholesterol tests, flu shots and prostate exams but not mammography. There was variation in the number of components needed (between two and seven) to achieve a significant difference.
Having an increasing number of first-access components in a primary care office may improve preventive services receipt, and more components may be required for those services requiring greater provider contact (e.g., prostate exam) versus those that require less (e.g., mammography). In primary care redesign, the largest gains in preventive services receipt likely will come with redesign of multiple components simultaneously. While our study is a necessary step towards broadly understanding the relationship between first-contact access and preventive service receipt, other important questions remain. Certain components may drive greater improvements in the receipt of different services, and the effect of some of these components may depend on individual patient characteristics. Further research is critical for understanding redesign strategies that may optimize preventive service delivery.
patient-centered medical home; preventive medicine; access to care; continuity of care; primary care; health care utilization; aging
Depressive symptomatology is common in older adults and is associated with reduced adherence to recommended preventive care, but little is known as to why. Understanding how depressive symptoms may interfere with adherence can help identify leverage points for interventions to increase preventive service use.
This study examined perceived access to medical care as a possible mediator linking depressive symptomatology to reduced preventive service use in older adults.
We analyzed data from 5,465 respondents completing the 1993 and 2003/2004 waves of the Wisconsin Longitudinal Study. Depressive symptomatology was assessed using the Center for Epidemiologic Studies Depression Scale. Perceived access survey items were organized via factor analysis to represent key dimensions of access: availability/accessibility, affordability, acceptability, and accommodation. The primary outcome was the total number of seven recommended preventive services that respondents received. Multivariate path analysis was used to estimate direct and indirect effects between depressive symptomatology, perceived access, and preventive service use.
Older adults with depressive symptomatology received fewer recommended services. Depressive symptomatology reduced preventive service use by adversely affecting two dimensions of perceived access: (1) acceptability, pertaining to poor patient-provider trust and communication, and (2) accommodation, pertaining to inconveniently organized services.
Depressive symptomatology may negatively alter older adults’ perceptions of access and, in turn, negatively impact their preventive service use. In addition to treating depression, interventions designed to mitigate the impact of depression on the patient-provider relationship, and organizational changes to practice that better accommodate the needs of depressed patients, may increase adherence to preventive care guidelines in depressed older adults.
preventive care; depression; access; elderly
In diabetes patients with co-morbid dementia, continued monitoring of HbA1c, cardiovascular risk, and diabetes complications can inform treatment decisions and minimize further declines in cognition, function, and quality of life. However, a clinically dominant, symptomatic, and discordant condition such as dementia may inhibit efforts to monitor diabetes in accordance with guidelines for older, complex patients. We examined the extent to which receipt of recommended diabetes monitoring differed for patients with and without co-morbid dementia, as well as the effect of other co-morbidities on diabetes monitoring in patients with co-morbid dementia.
Retrospective cohort study.
Secondary analysis of 2005–2006 claims and enrollment data for a 5% national random sample of Medicare beneficiaries.
288,805 Medicare fee-for-service beneficiaries with a diabetes diagnosis prior to 2006; 44,717 (16%) of whom had evidence of co-morbid dementia in claims.
We used established algorithms to determine whether patients received at least one HbA1c test, one LDL cholesterol test, and one annual eye exam in 2006, and construct variables representing co-morbidities common in diabetes, socio-demographics, and patterns of health care utilization.
In unadjusted and fully adjusted models, the presence of dementia reduced patients’ likelihood of receiving HbA1c tests, LDL tests, and eye exams, with effects being smallest for HbA1c tests. The effects of other co-morbidities on diabetes monitoring in patients with dementia varied by the nature of the co-morbidity and the specific test.
Dementia reduces the likelihood that diabetes patients received recommended annual monitoring for diabetes. More research is needed to understand reasons for reduced monitoring in this patient subgroup and how this impacts patient functioning, adverse events, and quality of life.
diabetes; dementia; guideline adherence; care quality; Medicare
Objective. To develop, implement, and assess the effectiveness of an online medication therapy management (MTM) program to train pharmacists and pharmacy students in providing MTM services for patients with diabetes and to increase their intent to perform these services.
Design. An online program was created using an Internet-based learning platform to simulate 4 MTM meetings between a pharmacist and a virtual patient diagnosed with diabetes.
Assessment. Eighty students and 42 pharmacists completed the program. After completing the program, scores on post-intervention assessments showed significant improvement in 2 areas: control over performing MTM, and knowledge of how to perform MTM. Students had a significantly less-positive attitude about MTM and a decline in their perception of the social expectation that MTM is part of the practice of pharmacy, while pharmacists’ attitudes did not change significantly in these areas.
Conclusion. This online program using a virtual patient improved both participants’ belief that they have control over performing MTM, and their knowledge of how to perform MTM for diabetic patients, which may increase the likelihood that pharmacists and pharmacy students will perform MTM in the future.
medication therapy management; diabetes; pharmacist; virtual patient; simulation; pharmacy student
The patient-centered medical home (PCMH) concept has recently garnered national attention as a means of improving the quality of primary care. Preventive services are one area where the PCMH is hoped to achieve gains, though there has been limited exploration of PCMH characteristics that can assist with practice redesign.
To examine whether first-contact access characteristics of a medical home (e.g., availability of appointments or advice by telephone) confer additional benefit in the receipt of preventive services for individuals already in a longitudinal relationship with a usual primary care physician at a site of care.
Secondary analysis examining data from 5,507 insured adults with a usual physician who participated in the 2003–2006 round of the Wisconsin Longitudinal Survey. Using logistic regression, we calculated the odds of receiving each preventive service, comparing individuals who had first-contact access to those without first-contact access.
Eighteen percent of the sample received care with first-contact access. In multivariable analyses, after adjustment, individuals who had first-contact access had higher odds of having received a prostate exam (OR 1.62; 95% CI 1.20–2.18), a flu shot (OR 1.36; 95% CI 1.01–1.82) and a cholesterol test (OR 1.36; 95% CI 1.01–1.82) in the past year. There was no significant difference in receipt of mammograms (OR 1.23; 95% CI 0.94–1.61).
In the primary care home, first-contact accessibility adds benefit beyond continuity of care with a physician in improving receipt of preventive services. Amid increasing primary care demands and finite resources to translate the PCMH into clinic settings there is need for further studies of the interplay between specific PCMH principles and how they perform in practice.
patient-centered medical home; preventive medicine; access to care; continuity of care; primary care; quality improvement
We examined trends and patient characteristics for non-traumatic dental condition (NTDC) visits to emergency departments (EDs), and compared them to other ED visit types, specifically non-dental ambulatory care sensitive conditions (non-dental ACSCs) and non-ambulatory care sensitive conditions (non-ACSCs) in the United States.
We analyzed data from the National Hospital Ambulatory Medical Care survey (NHAMCS) for 1997 to 2007. We performed descriptive statistics and used a multivariate multinomial logistic regression to examine the odds of one of the three visit types occurring at an ED. All analyses were adjusted for the survey design.
NTDC visits accounted for 1.4% of all ED visits with a 4% annual rate of increase (from 1.0% in 1997 to 1.7% in 2007). Self-pay patients (32%) and Medicaid enrollees (27%) were over-represented among NTDC visits compared to non-dental ACSC and non-ACSC visits (P < 0.0001). Females consistently accounted for over 50% of all types of ED visits examined. Compared to whites, Hispanics had significantly lower odds of an NDTC visit versus other visit types (P < 0.0001). Blacks had significantly lower odds of making NDTC visits when compared to non-dental ACSC visits only (P < 0.0001). Compared to private insurance enrollees, Medicaid and self-pay patients had 2–3 times the odds of making NTDC visits compared to other visit types.
Nationally, NTDC visits to emergency departments increased over time. Medicaid and self-pay patients had significantly higher odds of making NDTC visits.
emergency service; dental disease; adults; dental utilization
This study examined multiple dimensions of healthcare access in order to develop a typology of perceived barriers to healthcare access in community-dwelling elderly. Secondary aims were to define distinct classes of older adults with similar perceived healthcare access barriers and to examine predictors of class membership to identify risk factors for poor healthcare access.
A sample of 5,465 community-dwelling elderly was drawn from the 2004 wave of the Wisconsin Longitudinal Study. Perceived barriers to healthcare access were measured using items from the Group Health Association of America Consumer Satisfaction Survey. We used latent class analysis to assess the constellation of items measuring perceived barriers in access and multinomial logistic regression to estimate how risk factors affected the probability of membership in the latent barrier classes.
Latent class analysis identified four classes of older adults. Class 1 (75% of sample) consisted of individuals with an overall low level of risk for perceived access problems (No Barriers). Class 2 (5%) perceived problems with the availability/accessibility of healthcare providers such as specialists or mental health providers (Availability/Accessibility Barriers). Class 3 (18%) perceived problems with how well their providers' operations arise organized to accommodate their needs and preferences (Accommodation Barriers). Class 4 (2%) perceived problems with all dimension of access (Severe Barriers). Results also revealed that healthcare affordability is a problem shared by members of all three barrier groups, suggesting that older adults with perceived barriers tend to face multiple, co-occurring problems. Compared to those classified into the No Barriers group, those in the Severe Barrier class were more likely to live in a rural county, have no health insurance, have depressive symptomatology, and speech limitations. Those classified into the Availability/Accessibility Barriers group were more likely to live in rural and micropolitan counties, have depressive symptomatology, more chronic conditions, and hearing limitations. Those in the Accommodation group were more likely to have depressive symptomatology and cognitive limitations.
The current study identified a typology of perceived barriers in healthcare access in older adults. The identified risk factors for membership in perceived barrier classes could potentially assist healthcare organizations and providers with targeting polices and interventions designed to improve access in their most vulnerable older adult populations, particularly those in rural areas, with functional disabilities, or in poor mental health.
Objective. To measure the impact of medication therapy management (MTM) learning activities on students’ confidence and intention to provide MTM using the Theory of Planned Behavior.
Design. An MTM curriculum combining lecture instruction and active-learning strategies was incorporated into a required pharmacotherapy laboratory course.
Assessment. A validated survey instrument was developed to evaluate student confidence and intent to engage in MTM services using the domains comprising the Theory of Planned Behavior. Confidence scores improved significantly from baseline for all items (p < 0.00), including identification of billable services, documentation, and electronic billing. Mean scores improved significantly for all Theory of Planned Behavior items within the constructs of perceived behavioral control and subjective norms (p < 0.05). At baseline, 42% of students agreed or strongly agreed that they had knowledge and skills to provide MTM. This percentage increased to 82% following completion of the laboratory activities.
Conclusion. Implementation of simulated MTM activities in a pharmacotherapy laboratory significantly increased knowledge scores, confidence measures, and scores on Theory of Planned Behavior constructs related to perceived behavioral control and subjective norms. Despite these improvements, intention to engage in future MTM services remained unchanged.
medication therapy management; active learning; theory of planned behavior; laboratory course; student confidence; intention
Measuring community pharmacists’ self-efficacy in performing medication therapy management (MTM) services can be useful for tailoring interventions and predicting participation.
To identify relevant survey constructs related to the Wisconsin Pharmacy Quality Collaborative (WPQC) MTM program and to evaluate scale validity.
The 31-item MTM Self-efficacy Scale was developed using previous research, identifying critical program components, and beta-testing. After administration to pharmacists in the 53 WPQC pilot sites, summary statistics and exploratory factor analysis (EFA) were conducted. Parallel analysis was used to determine the optimal number of factors. Internal consistency reliabilities were calculated.
Baseline participation rate was 94% (N=76). The 11-point scale (0–10) item means ranged from 2.83±3.05 to 7.82±2.19. Parallel analysis produced a 3-factor solution, accounting for 56% of the variance. Low factor loadings or unacceptably high cross-loadings resulted in 17 item deletions. The final EFA on the remaining 14 items retained the original 3-factor solution and increased the proportion of explained variance (72%). The factors relate to MTM tasks (alpha = 0.92), personal interactions (alpha = 0.86), and goal setting (alpha = 0.84). Overall Cronbach’s alpha = 0.90.
Constructs for measuring self-efficacy were identified that may aid in future research predicting whether pharmacists engage in and persist in providing MTM services.
Self-efficacy; Medication therapy management; Community pharmacy; Scale validation; Research methods
Sex and age may exert a combined influence on receipt of preventive services with differences due to number of ambulatory care visits.
We used nationally representative data to determine weighted percentages and adjusted odds ratios of men and women stratified by age group who received selected preventive services. The presence of interaction between sex and age group was tested using adjusted models and retested after adding number of visits.
Men were less likely than women to have received blood pressure screening (aOR 0.44;0.40–0.50), cholesterol screening (aOR 0.72;0.65–0.79), tobacco cessation counseling (aOR 0.66;0.55–0.78), and checkups (aOR 0.53;0.49–0.57). In younger age groups, men were particularly less likely than women to have received these services. In adjusted models, this observed interaction between sex and age group persisted only for blood pressure measurement (p = .016) and routine checkups (p < .001). When adjusting for number of visits, the interaction of age on receipt of blood pressure checks was mitigated but men were still overall less likely to receive the service.
Men are significantly less likely than women to receive certain preventive services, and younger men even more so. Some of this discrepancy is secondary to a difference in number of ambulatory care visits.
To assess the feasibility, acceptability, and preliminary impact of a telepharmacy intervention in an underserved, rural asthma patient population.
Subjects and Methods:
Patients with asthma were randomized to receive either standard care or telephone consultations from pharmacists regarding asthma self-management over a 3-month period. Qualitative interviews were conducted to identify participants' attitudes/opinions regarding the intervention. Baseline and follow-up surveys assessed asthma control, patient activation, and medication utilization.
Ninety-eight adults were recruited (78% accrual); 83 completed the study (15% dropout). Participants reported positive opinions and believed the intervention improved their asthma self-management. The intervention group had significantly higher patient activation compared with the control (p<0.05). There were no significant between-group differences regarding asthma control. However, within-group analyses of the intervention group showed an improvement in asthma control (p<0.01) and medication adherence (p<0.01). No within-group differences were found for the control group.
This telepharmacy intervention is feasible and showed indicators of effectiveness, suggesting the design is well suited for a robust study to evaluate its impact in uncontrolled asthma patients. Pharmacists helping patients manage asthma through telecommunications may resolve access barriers and improve care.
patient–pharmacist communication; asthma; telepharmacy; intervention; rural; underserved