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Biomedical subjects

Arnold M Epstein

Publications and source records attributed to Arnold M Epstein.

At least 37 records · Page 2Linked to original sources
PubMed2004

Physicians' beliefs about racial differences in referral for renal transplantation.

BACKGROUND: Black patients with end-stage renal disease are much less likely than white patients to undergo renal transplantation, but previous research has shown that black patients are only slightly less likely to desire this procedure. A better understanding of physicians' views about racial differences in access to transplantation may help reduce disparities in care. METHODS: We surveyed 278 nephrologists in 4 US regions about quality of life and survival for black and white patients undergoing renal transplantation and reasons for racial differences in access to transplantation. We also surveyed 606 of their patients about their care. RESULTS: Physicians were less likely to believe transplantation improves survival for blacks than whites (69% versus 81%; P = 0.001), but similarly likely to believe it improves quality of life (84% versus 86%). Factors commonly cited by physicians as important reasons why blacks are less likely than whites to be evaluated for transplantation included patients' preferences (66%), availability of living donors (66%), failure to complete evaluations (53%), and comorbid illnesses (52%). Fewer physicians perceived patient-physician communication and trust (38%) or physician bias (12%) as important reasons. Black patients were less likely than white patients to report receiving some or a lot of information about transplantation (55% versus 74%; P = 0.006) when their physicians did not view patient-physician communication and trust as an important reason for racial differences in care. CONCLUSION: Nephrologists' views about the benefits of renal transplantation and reasons for racial differences in access to this procedure may affect how they present this treatment option to black and white patients.

Adult↗
PubMed2004

Effects of pharmaceutical promotion on adherence to the treatment guidelines for depression.

OBJECTIVES: We sought to examine the impact of direct-to-consumer advertising (DTCA) and pharmaceutical promotion to physicians on the likelihood that (1) an individual diagnosed with depression received antidepressant medication and that (2) antidepressant medication was used for the appropriate duration. RESEARCH DESIGN AND SUBJECTS: A quasiexperimental design was used to examine treatment patterns of 30,621 depressed individuals whose insurance claims were included in the MarketScan database from 1997 through 2000. The main explanatory variables were spending on DTCA, detailing to physicians, and free samples for 6 antidepressant medications. RESULTS: Individuals diagnosed with depression during periods when class-level antidepressant DTCA spending was highest (cumulative spending more than US 18.5 million dollars) had 32% higher relative odds of initiating medication therapy compared with those diagnosed during periods when DTCA spending was lowest (P < 0.0001). Free samples of medications dispensed to physicians had no effect on odds of initiating antidepressant use. Class-level DTCA spending on antidepressants had a small positive effect on the duration of antidepressant use, whereas DTCA spending for the specific medication taken by an individual had no effect on treatment duration. Detailing spending at the class or product level had no significant effect on duration of treatment with an antidepressant medication. CONCLUSIONS: Our results suggest that DTCA of antidepressants was associated with an increase in the number of people diagnosed with depression who initiated medication therapy. DTCA was associated with a small increase in the number of individuals treated with antidepressants who received the appropriate duration of therapy. Promotion to physicians was not associated with either the initiation of treatment with an antidepressant or with the duration of therapy.

Adolescent↗
PubMed2003

The effect of incentive-based formularies on prescription-drug utilization and spending.

BACKGROUND: Many employers and health plans have adopted incentive-based formularies in an attempt to control prescription-drug costs. METHODS: We used claims data to compare the utilization of and spending on drugs in two employer-sponsored health plans that implemented changes in formulary administration with those in comparison groups of enrollees covered by the same insurers. One plan simultaneously switched from a one-tier to a three-tier formulary and increased all enrollee copayments for medications. The second switched from a two-tier to a three-tier formulary, changing only the copayments for tier-3 drugs. We examined the utilization of angiotensin-converting-enzyme (ACE) inhibitors, proton-pump inhibitors, and 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins). RESULTS: Enrollees covered by the employer that implemented more dramatic changes experienced slower growth than the comparison group in the probability of the use of a drug and a major shift in spending from the plan to the enrollee. Among the enrollees who were initially taking tier-3 statins, more enrollees in the intervention group than in the comparison group switched to tier-1 or tier-2 medications (49 percent vs. 17 percent, P<0.001) or stopped taking statins entirely (21 percent vs. 11 percent, P=0.04). Patterns were similar for ACE inhibitors and proton-pump inhibitors. The enrollees covered by the employer that implemented more moderate changes were more likely than the comparison enrollees to switch to tier-1 or tier-2 medications but not to stop taking a given class of medications altogether. CONCLUSIONS: Different changes in formulary administration may have dramatically different effects on utilization and spending and may in some instances lead enrollees to discontinue therapy. The associated changes in copayments can substantially alter out-of-pocket spending by enrollees, the continuation of the use of medications, and possibly the quality of care.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed2003

Adherence to practice guidelines: the role of specialty society guidelines.

BACKGROUND: Physician adherence to guidelines is often poor, but the reasons have not been completely studied. We investigated whether physician adherence to guidelines for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) varied by source, development methods, or the extent of their evidence-base. METHODS AND RESULTS: We assessed adherence to guidelines developed by the American College of Cardiology/American Heart Association (ACC/AHA) for PTCA (1988 and 1993) and for CABG (1990) and guidelines developed by RAND for PTCA and CABG in 1990. We randomly sampled patients on Medicare who were undergoing coronary angiography in 5 states in 1991 and 1992, extracting clinical and laboratory data from medical records and using computer programs to classify the appropriateness of each procedure. A total of 543 PTCA and 676 CABG procedures were studied. By use of the 1988 ACC/AHA guidelines, 30% of PTCAs were rated class III (inappropriate), whereas 24% were class III by use of the 1993 guidelines. Only 1.5% of CABG procedures were class III with ACC/AHA guidelines. By use of RAND guidelines, 12% of PTCA and 9% of CABG procedures were classified as inappropriate. CONCLUSIONS: Adherence to guidelines is higher when the recommendations are supported by evidence from randomized clinical trials (CABG). The credibility of the source and familiarity with the guidelines do not ensure compliance. When evidence is lacking, as with PTCA at the time of this study, guideline recommendations may lag behind appropriate changes in clinical practice. More frequent revisions coupled with on-line access have the potential to make guidelines more useful.

Aged↗
PubMed2003

Race and gender disparities in rates of cardiac revascularization: do they reflect appropriate use of procedures or problems in quality of care?

BACKGROUND: Numerous studies have documented substantial differences by race and gender in the use of coronary artery bypass graft surgery and percutaneous coronary angioplasty. However, few studies have examined whether these differences reflect problems in quality of care. METHOD: We selected a random sample stratified by gender, race, and income of 5026 Medicare beneficiaries aged 65 to 75 who underwent inpatient coronary angiography during 1991 to 1992 in 1 of 5 states. We compared the frequency of 2 problems in quality by race and gender: underuse or the failure to receive a clinically indicated revascularization procedure and receipt of revascularization when it was not clinically indicated. We used 2 independent sets of criteria developed by the RAND Corporation and the American College of Cardiology/American Hospital Association (ACC/AHA). We also examined survival of the cohort through March 31, 1994. RESULTS: Revascularization procedures were clinically indicated more frequently among whites than blacks and among men than women. Failure to receive revascularization when it was indicated was more common among blacks than among whites (40% vs. 23-24%, depending on the criteria, both P<0.001) but similar among men and women (25% vs. 22-24%, P>0.05). Racial disparities remained similar after adjusting for patient and hospital characteristics. Among patients rated inappropriate, use of procedures was greater for whites than blacks using RAND criteria (10.5% vs. 5.8%, P<0.01) and greater for men than for women (14.2% vs. 5.3% by RAND criteria, P=0.001; 8.2% vs. 4.0%% by ACC/AHA criteria, P=0.04). After multivariate adjustment, the disparities for race and gender remained similar and were statistically significant using RAND criteria. Mortality rates tended to validate our appropriateness criteria for underuse. CONCLUSIONS: Racial differences in procedure use reflect higher rates of clinical appropriateness among whites, greater underuse among blacks, and more frequent revascularization when it was not clinically indicated among whites. Underuse is associated with higher mortality. In contrast, men had higher rates of clinical appropriateness and were more likely to receive revascularization when it was not clinically indicated. There was no evidence of greater underuse among women.

Black or African American↗
PubMed2002

Racial disparities in the quality of care for enrollees in medicare managed care.

CONTEXT: Substantial racial disparities in the use of some health services exist; however, much less is known about racial disparities in the quality of care. OBJECTIVE: To assess racial disparities in the quality of care for enrollees in Medicare managed care health plans. DESIGN AND SETTING: Observational study, using the 1998 Health Plan Employer Data and Information Set (HEDIS), which summarized performance in calendar year 1997 for 4 measures of quality of care (breast cancer screening, eye examinations for patients with diabetes, beta-blocker use after myocardial infarction, and follow-up after hospitalization for mental illness). PARTICIPANTS: A total of 305 574 (7.7%) beneficiaries who were enrolled in Medicare managed care health plans had data for at least 1 of the 4 HEDIS measures and were aged 65 years or older. MAIN OUTCOME MEASURES: Rates of breast cancer screening, eye examinations for patients with diabetes, beta-blocker use after myocardial infarction, and follow-up after hospitalization for mental illness. RESULTS: Blacks were less likely than whites to receive breast cancer screening (62.9% vs 70.9%; P<.001), eye examinations for patients with diabetes (43.6% vs 50.4%; P =.02), beta-blocker medication after myocardial infarction (64.1% vs 73.8%; P<.005), and follow-up after hospitalization for mental illness (33.2 vs 54.0%; P<.001). After adjustment for potential confounding factors, racial disparities were still statistically significant for eye examinations for patients with diabetes, beta-blocker use after myocardial infarction, and follow-up after hospitalization for mental illness. CONCLUSION: Among Medicare beneficiaries enrolled in managed care health plans, blacks received poorer quality of care than whites.

Adrenergic beta-Antagonists↗
PubMed2002

Promotion of prescription drugs to consumers.

BACKGROUND: Spending on prescription drugs is the fastest growing component of the health care budget. There is public concern about the possibility that direct-to-consumer advertising of prescription drugs will result in inappropriate prescribing and higher costs of care. Guidelines issued in 1997 by the Food and Drug Administration (FDA) regarding advertising to consumers through electronic media are considered by some to be responsible for unleashing a flood of direct-to-consumer advertising. METHODS: Using data on spending for promotional purposes and sales of prescription drugs, we examined industrywide trends for various types of promotion. We also tracked the relation between promotional efforts and sales over time. Finally, we documented the variation in direct-to-consumer advertising among and within five therapeutic classes of drugs and compared the variation in the intensity of such advertising with variation in the intensity of promotion to health care professionals. RESULTS: Annual spending on direct-to-consumer advertising for prescription drugs tripled between 1996 and 2000, when it reached nearly $2.5 billion. Despite this increase, such advertising accounts for only 15 percent of the money spent on drug promotion and is highly concentrated on a subgroup of products. Within a therapeutic class, there is marked variation in the intensity of direct-to-consumer advertising, and the amount of such advertising for specific products fluctuates over time. The initial surge in direct-to-consumer advertising preceded the 1997 FDA guidelines that clarified the rules for electronic direct-to-consumer advertising, and thus the 1997 guidelines may not have been the most important reason for the overall increase. CONCLUSIONS: Although the use of direct-to-consumer advertising has grown disproportionately to other forms of promotion, it continues to account for a small proportion of total promotional efforts. Nevertheless, physicians must assist patients in evaluating health-related information obtained through direct advertising.

Advertising↗
PubMed2002

The evolution of quality management in state Medicaid agencies: a national survey of states with comprehensive managed care programs.

BACKGROUND: Concern has been expressed about whether managed care health plans can successfully meet the special needs of Medicaid beneficiaries. A 1996 survey indicated that state Medicaid agencies had just begun conducting quality oversight and management. Since then the federal government has released guidelines under the Quality improvement System for Managed Care (QISMC) program to assist states with quality management of managed care programs. In 1999 a follow-up telephone survey was conducted with representatives from 45 states to describe the current state of and changes in quality management activities by state Medicaid agencies for Medicaid beneficiaries enrolled in managed care. RESULTS: The 45 states represented a 50% increase between 1995 and 1999. The number of states enrolling the disabled had doubled (from 15 to 30). Most states collecting data on satisfaction and childhood immunizations fed it back to health plans, although feedback of other measures of access and quality occurred less frequently and fewer states provided information to beneficiaries choosing health plans. Fewer than 25% of states reported having even one health plan demonstrate improvement in individual measures of access and quality except for prenatal care (28%) and childhood immunizations (33%). Fewer than half of the states included contractual penalties in their contracts with health plans, and very few (three or fewer per penalty) had over invoked such penalties. CONCLUSIONS: State Medicaid agencies continue to adapt to their new roles as value-based purchasers of health care. Although increasing numbers of states collect data on satisfaction, access, and quality of care, few states have been able to document improved performance in the health plans they oversee.

Feedback↗
PubMed2002

National Committee on Quality Assurance health-plan accreditation: predictors, correlates of performance, and market impact.

CONTEXT: Accreditation of health care organizations has traditionally been considered a building block of quality assurance. However, the differences between accredited and nonaccredited health plans and the impact of accreditation on plan enrollment are not well understood. OBJECTIVES: To determine the characteristics of plans that have submitted to accreditation review, the performance of accredited plans on quality indicators and the impact of accreditation on enrollment. DESIGN: The databases containing 1996 data on health plans' National Committee on Quality Assurance (NCQA) accreditation status, organizational characteristics, Health Plan Employer Data and Information Set (HEDIS) scores, and patient-reported quality and satisfaction scores were linked to compare accredited health plans to nonaccredited plans. We also combined longitudinal data sets (1993-1998) on accreditation and health plan enrollment. MAIN OUTCOME MEASURES: Mean performance of accredited and nonaccredited plans on HEDIS measures and patient-reported measures of quality; health plan enrollment changes. RESULTS: Accredited plans have higher HEDIS scores but similar or lower performance on patient-reported measures of health plan quality and satisfaction. Furthermore, a substantial number of the plans in the bottom decile of quality performance were accredited suggesting that accreditation does not ensure high quality care. Receipt of accreditation has been associated with increased enrollment in the early years of the accreditation program; however, plans denied NCQA accreditation do not appear to suffer enrollment losses. CONCLUSION: NCQA accreditation is positively associated with some measures of quality but does not assure a minimal level of performance. Efforts now underway to incorporate plan performance on HEDIS into criteria for accreditation seem warranted.

Accreditation↗
PubMedDate not supplied

Transmission of financial incentives to physicians by intermediary organizations in California.

Many U.S. physicians participate in provider-sponsored organizations that act as their intermediaries in contracting with managed care plans, particularly where capitation contracts are used. Examining a survey of 153 intermediary entities in California, we trace the cascade of financial incentives from health plans through physician organizations to primary care physicians. Although the physician organizations received the vast majority (84 percent) of their revenues through capitation contracts, most of the financial risk related to utilization and costs was retained at the group level. Capitation of primary care physicians was common in independent practice associations (IPAs), but payments typically were restricted to primary care services. Thirteen percent of medical groups and 19 percent of IPAs provided bonuses or withholds based on utilization or cost performance, which averaged 10 percent of base compensation.

California↗
PubMedDate not supplied

The impact of a national prescription drug formulary on prices, market share, and spending: lessons for Medicare?

Several recent bills in Congress to add a Medicare prescription drug benefit would allow the use of formularies to control costs. However, there is little empirical evidence of the impact of formularies among elderly and disabled populations. We assess the effect of a closed formulary implemented by the Veterans Health Administration (VHA) in 1997 on drug prices, market share, and drug spending. We find that the VHA National Formulary was effective at shifting prescribing behavior toward the selected drugs, achieving sizable price reductions from manufacturers, and greatly decreasing drug spending.

Aged↗
PubMedDate not supplied

The evolution of quality management in Medicaid managed care.

Since the early 1990s almost all states have moved some or all of their Medicaid beneficiaries to Medicaid managed care (MMC). Critics have worried about quality since MMC's inception. Proponents argued that state Medicaid agencies, as large-scale purchasers of care, would pursue "value-based purchasing" and other strategies to stimulate quality improvements. In this paper we extend and update previous evaluations of the use of managed care for the Medicaid population, the extent to which beneficiaries receive care from Medicaid only and from commercial health plans, and the quality management programs that state Medicaid agencies supported during 2001.

Health Services Research↗
PubMedDate not supplied

Quality oversight in medicaid primary care case management programs.

As health maintenance organizations (HMOs) have curtailed participation in Medicaid, enrollment in primary care case management (PCCM) programs has grown. To examine state Medicaid agencies' monitoring of PCCM and HMO programs, we surveyed Medicaid agency directors of forty-six states and the District of Columbia. Agencies were less likely to collect performance data in PCCM programs than in HMO programs. Few PCCM programs reported performance results for the public or providers. Reporting states tended to emphasize utilization results over quality-measure results. Despite growing enrollment, PCCM programs appear less likely to use the quality-oversight strategies employed by Medicaid health plans.

Case Management↗
PubMedDate not supplied

The predictive accuracy of the New York State coronary artery bypass surgery report-card system.

We examined the impact of New York State's public reporting system for coronary artery bypass surgery fifteen years after its launch. We found that users who picked a top-performing hospital or surgeon from the latest available report had approximately half the chance of dying as did those who picked a hospital or surgeon from the bottom quartile. Nevertheless, performance was not associated with a subsequent change in market share. Surgeons with the highest mortality rates were much more likely than other surgeons to retire or leave practice after the release of each report card.

Adult↗