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Biomedical subjects

Bruce Stuart

Publications and source records attributed to Bruce Stuart.

17 recordsLinked to original sources
PubMed2006

Coverage and use of prescription drugs in nursing homes: implications for the medicare modernization act.

BACKGROUND: The Medicare Modernization Act will affect drug coverage for most nursing home residents in the United States. Understanding the impact of the MMA requires knowledge of the process by which drugs are prescribed to residents and the effect of coverage on medication use. OBJECTIVES: We sought to characterize sources of drug coverage for Medicare beneficiaries residing in nursing facilities and to provide empirical estimates of the relationship between coverage and use. RESEARCH DESIGN: We used bivariate and multivariate analyses to assess the relationship between coverage and drug use in a sample of nursing home residents drawn from the 2001 Medicare Current Beneficiary Survey augmented with monthly institutional drug administration data. SUBJECTS: A total of 789 residents with a mean nursing home stay of 8.7 months in 2001 were studied. MEASURES: We measured the proportions of residents with drug coverage from Medicaid, other sources, or none at all, and mean number of unique prescription drugs administered per resident per month by source of coverage. RESULTS: We found that 20% of the sample had no drug coverage, 56% had drug coverage under Medicaid, 9% had coverage from other sources, and for 15% drug coverage status could not be determined. There were no statistically significant differences in drug utilization by drug coverage status. CONCLUSIONS: When drug coverage becomes a Medicare benefit in 2006, it is unlikely to spur additional medication use among nursing home residents but may redirect utilization as a result of health plan formulary restrictions.

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PubMed2006

Application of regression-discontinuity analysis in pharmaceutical health services research.

OBJECTIVE: To demonstrate how a relatively underused design, regression-discontinuity (RD), can provide robust estimates of intervention effects when stronger designs are impossible to implement. DATA SOURCES/STUDY SETTING: Administrative claims from a Mid-Atlantic state Medicaid program were used to evaluate the effectiveness of an educational drug utilization review intervention. STUDY DESIGN: Quasi-experimental design. DATA COLLECTION/EXTRACTION METHODS: A drug utilization review study was conducted to evaluate a letter intervention to physicians treating Medicaid children with potentially excessive use of short-acting beta(2)-agonist inhalers (SAB). The outcome measure is change in seasonally-adjusted SAB use 5 months pre- and postintervention. To determine if the intervention reduced monthly SAB utilization, results from an RD analysis are compared to findings from a pretest-posttest design using repeated-measure ANOVA. PRINCIPAL FINDINGS: Both analyses indicated that the intervention significantly reduced SAB use among the high users. Average monthly SAB use declined by 0.9 canisters per month (p<.001) according to the repeated-measure ANOVA and by 0.2 canisters per month (p<.001) from RD analysis. CONCLUSIONS: Regression-discontinuity design is a useful quasi-experimental methodology that has significant advantages in internal validity compared to other pre-post designs when assessing interventions in which subjects' assignment is based on cutoff scores for a critical variable.

Bronchodilator Agents↗
PubMed2005

The quality of antipsychotic drug prescribing in nursing homes.

BACKGROUND: The prescribing of antipsychotic drugs has been increasing in nursing homes (NHs) since the availability of second-generation antipsychotic agents, also known as the atypicals, but there is little information on the appropriateness of such prescribing. METHODS: A retrospective analysis using the nationally representative data set of the Medicare Current Beneficiary Survey merged to Minimum Data Sets assessments, medication administration records, and Medicare claims. We identified a sample of 2.5 million Medicare beneficiaries in NHs during 2000-2001 (unweighted n = 1096) to assess prevalence of antipsychotic use, rates of adherence to NH prescribing guidelines, and changes in behavioral symptoms. RESULTS: Approximately 693 000 (unweighted n = 302), or 27.6%, of all Medicare beneficiaries in NHs received at least 1 prescription for antipsychotics during the study period: 20.3% received atypicals only; 3.7%, conventionals only; and 3.6%, both atypicals and conventionals. Less than half (41.8%) of treated residents received antipsychotic therapy in accordance with NH prescribing guidelines. One (23.4%) in 4 patients had no appropriate indication, 17.2% had daily doses exceeding recommended levels, and 17.6% had both inappropriate indications and high dosing. Patients receiving antipsychotic therapy within guidelines were no more likely to achieve stability or improvement in behavioral symptoms than were those taking antipsychotics outside the guidelines. CONCLUSIONS: This study detected the highest level of antipsychotic use in NHs in over a decade. Most atypicals were prescribed outside the prescribing guidelines and for doses and indications without strong clinical evidence. Failure to detect positive relationships between behavioral symptoms and antipsychotic therapy raises questions about the appropriateness of prescribing.

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PubMed2005

Potentially inappropriate prescribing before and after nursing home admission among patients with and without dementia.

OBJECTIVES: This study was designed to describe changes in the prevalence of potentially inappropriate medication prescribing before and after nursing home admission, and to compare prevalence among residents with and without dementia. This paper extends the research on inappropriate medication prescribing among residents entering a nursing home, with the added feature of comparison by dementia status. METHODS: This retrospective cohort study was conducted using data from 59 randomly selected nursing homes in Maryland. Dually eligible (Medicare/Medicaid) residents aged > or = 65 years who were admitted to one of these nursing homes from 1992 to 1995 were eligible for inclusion in the cohort. An expert panel of physicians determined dementia status at admission. Potentially inappropriate prescribing, as defined by the 1997 Beers criteria, was compared using Medicaid prescription claims for up to 12 months before and after admission to characterize monthly prescribing patterns. RESULTS: The study group included 546 dually eligible nursing home residents with > or = 1 paid prescription claim for the 12 months before or after their admission date. A total of 372 (68%) residents were white, 443 (81%) were unmarried, 408 (75%) were female, and 334 (61%) were diagnosed with dementia at admission. Before nursing home admission, the mean monthly prevalence of potentially inappropriate medications for residents with and without dementia was 20% and 23%, respectively. After admission, the mean monthly prevalence increased to 28% among residents without dementia and decreased to 19% among residents with dementia. After adjusting for the mean number of other prescriptions, sociodemographic factors, and number of comorbid conditions, residents with dementia were as likely as residents without dementia to receive a potentially inappropriate drug before admission (prevalence ratio, 0.97; 95% CI, 0.58-1.62). After admission, residents with dementia were 27% less likely than residents without dementia to receive a potentially inappropriate drug, although the difference did not reach statistical significance (prevalence ratio, 0.73; 95% CI, 0.53-1.01). CONCLUSIONS: Inappropriate medication prescribing was similar before nursing home admission among patients with and without dementia. After admission, the prevalence was lower among residents with dementia, but it did not reach statistical significance.

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PubMed2005

Medicare cost differences between nursing home patients admitted with and without dementia.

PURPOSE: Our objective in this study was to compare Medicare costs of treating older adults with and without dementia in nursing home settings. DESIGN AND METHODS: An expert panel established the dementia status of a stratified random sample of newly admitted residents in 59 Maryland nursing homes between 1992 and 1995. Medicare expenditures per-person month (PPM) were compared for 640 residents diagnosed with dementia and 636 with no dementia for 1 year preadmission and 2 years postadmission. Multivariate analysis with generalized estimating equations was used to identify the source of Medicare cost differentials between the two groups. RESULTS: Medicare expenditures peaked in the month immediately preceding admission and dropped to preadmission levels by the third month in a nursing home. Adjusted PPM costs postadmission for the dementia group as a whole were 79% (p < .001) of the Medicare costs of treating residents without dementia. For the subgroup of residents admitted without a Medicare qualified stay (MQS), those with dementia had Medicare costs of just 63% (p < .001) of those without dementia. Overall Medicare costs PPM were insignificantly different between the two groups admitted with a MQS. IMPLICATIONS: Whether nursing home residents are admitted with a MQS is the single most important factor in assessing treatment cost differentials between residents admitted with and without dementia. Failure to consider this factor may lead researchers and policy makers to misdirect their attention from the true source of the differential-dementia patients admitted without a qualifying stay.

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PubMed2005

Medicare beneficiaries and the impact of gaining prescription drug coverage on inpatient and physician spending.

OBJECTIVE: To assess whether gaining prescription drug coverage produces cost offsets in Medicare spending on inpatient and physician services. DATA SOURCE: Two-year panels constructed from 1995 to 2000 Medicare Current Beneficiary Survey, a dataset of Medicare claims and health care surveys from the Medicare population. STUDY DESIGN: We estimated a series of fixed-effects panel models to calculate adjusted changes in Medicare spending as drug coverage was acquired (Gainers) relative to the spending of beneficiaries who never had drug coverage (Nevers). Explanatory variables in the model include age, calendar year, income, and health status. PRINCIPAL FINDINGS: Assessments of inpatient and physician services spending provided no evidence of overt selection behavior prior to the acquisition of drug coverage (i.e., there were no preswitch spikes in Medicare spending for Gainers). After enrollment, the medical spending of Gainers resembled those of beneficiaries who never had drug coverage. Overall, the multivariate models showed no systematic postenrollment changes in either inpatient or physician spending that could be attributed to the acquisition of drug coverage. CONCLUSIONS: We found no consistent evidence that drug coverage either increases or reduces spending for hospital and physician services. This does not necessarily mean that drug therapy does not substitute for or complement other medical treatments, but rather that neither effect predominates across the Medicare population as a whole.

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PubMed2004

Impact of prescription coverage on hospital and physician costs: a case study of medicare beneficiaries with chronic obstructive pulmonary disease.

BACKGROUND: It is widely believed that appropriate use of prescription medicines can reduce avoidable hospitalizations and more expensive nonpharmacologic therapies, but identifying such cost offsets in operational programs is elusive. Any possible impact would be most apparent in patients with medication-sensitive disease conditions, such as chronic obstructive pulmonary disease (COPD). OBJECTIVE: The goals of this study were to develop an observational study design appropriate for estimating potential cost savings in the US Medicare budget as a result of extending drug coverage to persons with particular chronic diseases and to apply these study methods, in an exploratory analysis, to a sample of Medicare beneficiaries with COPD. METHODS: Spending for drugs, hospitalizations, and physician services was compared for COPD patients with and without prescription coverage using data from the 1999 and 2000 US Medicare Current Beneficiary Survey. To control for channeling bias, multivariate matching on observable variables was combined with tests for missing variable bias. The matching algorithm used propensity score weighting to ensure comparability between the 2 groups on all observed characteristics at baseline. RESULTS: Our sample comprised 462 beneficiaries with prevalent COPD in the year 2000: 384 (83.1%) had prescription coverage the entire year and 78 (16.9%) had no coverage. After adjustment, drug coverage was associated with 61% higher spending on medications and 29% lower spending on physician services (both, P < 0.05). Hospital costs appeared slightly lower for those with drug benefits, but the difference was not statistically significant. No statistically significant effects were found for services specific to COPD. However, effect sizes were large even for nonsignificant findings. CONCLUSIONS: Although this analysis did not establish a strong causal link between drug benefits and lower costs, 11 of our 12 comparisons had signs consistent with the cost-offset hypothesis.

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PubMed2004

Navigating the new Medicare drug benefit.

BACKGROUND: Medicare beneficiaries have had to wait 40 years for an outpatient prescription drug benefit. On December 8, 2003, President Bush signed into law the Medicare Prescription Drug, Improvement and Modernization Act of 2003 that will provide at least limited drug coverage to all beneficiaries who sign up for it. OBJECTIVE: The aim of this commentary is to provide a basic appreciation of the mechanics of the new drug benefit and an analysis of why it looks the way it does. CONCLUSIONS: A combination of ideology and spending constraints led Congress to develop a benefit package that while generous for low-income beneficiaries with limited assets, has significant gaps in coverage for everyone else. After a transitional program of discount cards that will carry them through 2005, beneficiaries will have to choose their source of prescription benefits from private stand-alone drug plans, managed care organizations, or (if available to them) employer-sponsored plans. The structure of the benefit is a radical departure from the way other Medicare benefits are provided and paid for, and raises a number of important questions. Will sufficient numbers of risk-bearing private drug plans enroll in the program for competition to work? Will employers maintain retiree drug coverage? Will the new program stop the slide in Medicare managed care? How will beneficiaries react when the law is explained in ways they truly understand? The answers to these questions will help determine the success or failure of drug coverage under Medicare.

Drug Costs↗
PubMed2003

Trends in the prescription of inappropriate drugs for the elderly between 1995 and 1999.

BACKGROUND: Using criteria developed by Beers et al between 1991 and 1997, previous studies have reported high levels of inappropriate drug prescribing for community-dwelling elderly patients (age>or=65 years). However, it is not known whether the Beers criteria have had a beneficial effect on prescribing practices. OBJECTIVES: The aims of this study were to compare the prevalence of potentially inappropriate drug use (based on the Beers list) among older Americans between 1995 and 1999; to determine whether any decreases in such use were more likely to be the result of improved adherence to guidelines or of replacement of older medications by newer drugs; and to examine individual characteristics that place elderly patients at increased risk for inappropriate drug use. METHODS: This was a panel study involving nationally representative samples of community-dwelling elderly persons from the 1995 and 1999 Medicare Current Beneficiary Surveys (MCBS). For comparison, data were analyzed from samples of disabled Medicare beneficiaries aged <65 years for the same periods. The samples were assessed for the use of 36 individual drugs, drug classes, and combinations carrying a risk for adverse out comes in the elderly based on the 1997 Beers criteria for drugs to be avoided in this population. RESULTS: The study samples contained 7628 community-dwelling elderly persons from the 1995 MCBS and 8902 from the 1999 MCBS, and 1863 and 1851 disabled Medicare beneficiaries aged <65 years for the respective survey years. The proportion of elderly patients taking >or=1 drug on the Beers list declined from 24.8% in 1995 to 21.3% in 1999 (P<0.05). There was a nonsignificant increase in the proportion of disabled Medicare beneficiaries taking >or=1 drug on the Beers list from 31.1% in 1995 to 31.5% in 1999. CONCLUSIONS: There was a significant decline in the use of potentially inappropriate drugs by elderly patients between 1995 and 1999, particularly in the use of those drugs linked to the most severe outcomes. However, approximately 7 million elderly patients still received potentially inappropriate drugs in 1999, underscoring the continued need for effective interventions to improve prescribing for this vulnerable population.

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PubMed2003

How robust are health plan quality indicators to data loss? A Monte Carlo simulation study of pediatric asthma treatment.

OBJECTIVES: (1) To test the robustness of a health plan quality indicator (QI) for persistent asthma to various forms of data loss and (2) to assess the implications of the findings for other health plan quality measures. DATA SOURCES/STUDY SETTINGS: Maryland Medicaid fee-for-service (FFS) claims. Children with asthma (n = 5,804) were selected from Medicaid enrollment records and medical and pharmacy FFS claims filed between June 1996 and December 1997. STUDY DESIGN: A variant of a HEDIS measure for treatment of persistent asthma (the percent of asthma patients filling two or more rescue medications who also filled a controller medication) was selected to test the robustness of proportion-based QIs to loss of data. Data loss was simulated through a series of Monte Carlo experiments. DATA COLLECTION/EXTRACTION METHODS: Merged FFS medical and prescription claims. PRINCIPAL FINDINGS: The asthma QI measure was highly robust to systematic and random data loss. The measure declined by less than 2 percent in the presence of up to a 35 percent data loss. Redundancy in the numerator of the QI significantly increased the robustness of the measure to data loss. CONCLUSIONS: A HEDIS-related QI measure for persistent asthma is robust to data loss. The findings suggest that other proportion-based quality indicators, particularly those in which plan members have multiple opportunities to meet the numerator criterion, are likely to reflect true levels of health plan quality in the face of incomplete data capture.

Adolescent↗
PubMed2002

Medication decisions--right and wrong.

This paper reviews the recent literature on problems associated with prescription drug use in older adults. The authors address four major issues: Why giving patients the wrong drug is so common; how taking the wrong amount is an even larger problem; why good drugs may be wrong for particular patients; and how high out-of-pocket spending and inadequate insurance coverage may disrupt otherwise sound drug regimens. The organizing theme of this review is the right drug for the right patient, taken in the right way at the right price. Despite significant gaps in the research record the evidence leaves no doubt that elderly individuals are at significant risk for inappropriate medication use. The paper concludes with an agenda for future studies: the need to validate standards for geriatric drug use, assess inappropriate drug use at the national level, establish population-based risk factors, and target research to the most significant adverse outcomes.

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Financial consequences of rural hospital long-term care strategies.

Data for 540 rural hospitals from 1982 to 1997 were analyzed to determine whether adoption of long-term-care (LTC) strategies improved hospital financial performance. Adoption of external and internal LTC strategies (other than swing-beds) was generally, but not unambiguously, associated with higher profits, increased occupancy, and/or lower costs.

Bed Conversion↗
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Riding the rollercoaster: the ups and downs in out-of-pocket spending under the standard Medicare drug benefit.

This study projects how much Medicare beneficiaries who sign up for the standard Part D drug benefit in 2006 will pay in quarterly out-of-pocket payments through 2008. In the first year we estimate that about 38 percent of enrollees will hit the benefit's no-coverage zone, known as the "doughnut hole," and that 14 percent will exceed the catastrophic threshold. Because drug spending is highly persistent over time, beneficiaries who experience the biggest gaps in coverage are likely to do so year after year, with potentially serious financial consequences.

Actuarial Analysis↗
PubMedDate not supplied

Employer-sponsored health insurance and prescription drug coverage for new retirees: dramatic declines in five years.

Employer-sponsored health insurance is often described as the most reliable private source of Medicare supplementation, particularly for prescription drug benefits. This study's findings show that employer coverage is becoming an increasingly less dependable source of coverage for new retirees, and the problem is likely to get worse. We found that the proportion of Medicare beneficiaries ages 65-69 with employer coverage declined from 46 percent in 1996 to 39 percent in 2000. The proportion with drug coverage from an employer declined from 40 percent in 1996 to 35 percent in 2000. Losses among males, the group most affected, would have been even greater had it not been for a slight increase in benefits from spouses' policies.

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PubMedDate not supplied

The impact of drug coverage on COX-2 inhibitor use in Medicare.

Passage of the Medicare drug benefit legislation has renewed attention to the relationship between drug coverage and medication use. This study assesses the impact of drug coverage on COX-2 inhibitor use among elderly people with osteoarthritis, taking into account risk for adverse gastrointestinal events. COX-2 use among aged beneficiaries with the most generous coverage was twice that of those with no third-party coverage. COX-2 use also increased with increasing gastrointestinal risk. However, this risk differential in COX-2 use disappears among those with the most generous coverage. Potential overuse of costly medications should be addressed as the Medicare drug benefit is being phased in.

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Assessing the impact of coverage gaps in the Medicare Part D drug benefit.

The new Medicare Part D drug benefit contains major coverage gaps for people who spend moderate to high amounts on prescription drugs who qualify only for the standard coverage. To help policymakers understand the impact such gaps will have on those affected, we studied a representative sample of Medicare beneficiaries with naturally occurring prescription benefit gaps between 1998 and 2000 using data from the Medicare Current Beneficiary Survey. Our findings suggest that discontinuities in drug benefits result in sizable reductions in medication use and spending, which is magnified in people with common chronic illnesses.

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