Why most interventions to improve physician prescribing do not seem to work.
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Biomedical subjects
Stephen B Soumerai
Publications and source records attributed to Stephen B Soumerai.
Barriers to self-monitoring of blood glucose among adults with diabetes in an HMO: a cross sectional study.
BACKGROUND: Recent studies suggest that patients at greatest risk for diabetes complications are least likely to self-monitor blood glucose. However, these studies rely on self-reports of monitoring, an unreliable measure of actual behavior. The purpose of the current study was to examine the relationship between patient characteristics and self-monitoring in a large health maintenance organization (HMO) using test strips as objective measures of self-monitoring practice. METHODS: This cross-sectional study included 4,565 continuously enrolled adult managed care patients in eastern Massachusetts with diabetes. Any self-monitoring was defined as filling at least one prescription for self-monitoring test strips during the study period (10/1/92-9/30/93). Regular SMBG among test strip users was defined as testing an average of once per day for those using insulin and every other day for those using oral sulfonylureas only. Measures of health status, demographic data, and neighborhood socioeconomic status were obtained from automated medical records and 1990 census tract data. RESULTS: In multivariate analyses, lower neighborhood socioeconomic status, older age, fewer HbA1c tests, and fewer physician visits were associated with lower rates of self-monitoring. Obesity and fewer comorbidities were also associated with lower rates of self-monitoring among insulin-managed patients, while black race and high glycemic level (HbA1c>10) were associated with less frequent monitoring. For patients taking oral sulfonylureas, higher dose of diabetes medications was associated with initiation of self-monitoring and HbA1c lab testing was associated with more frequent testing. CONCLUSIONS: Managed care organizations may face the greatest challenges in changing the self-monitoring behavior of patients at greatest risk for poor health outcomes (i.e., the elderly, minorities, and people living in low socioeconomic status neighborhoods).
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Physician gender and changes in drug prescribing after the implementation of reference pricing in British Columbia.
BACKGROUND: Gender-specific attitudes and communication styles are known to influence both the content and outcome of medical visits. Therefore, gender-specific differences in response to cost containment may also occur. OBJECTIVE: The purpose of this study was to assess the effect of physician gender on changes in prescribing patterns of angiotensin-converting enzyme (ACE) inhibitors after the implementation of reference pricing for prescription drugs in British Columbia, Canada. METHODS: Reference pricing is a cost-sharing policy by which use of high-priced medication requires out-of-pocket payment of the price difference between the cost-sharing drug and a lower-cost drug within the same class. In British Columbia, reference pricing for ACE inhibitors was introduced on January 1, 1997. Analysis was carried out on linked pharmacy and medical service claims data on 927 female and 2922 male physicians treating 47,680 Pharmacare Plan A enrollees who were aged >-65 years and were prescribed a high-priced ACE inhibitors before the implementation of reference pricing. RESULTS: Female physicians (24.1% of all physicians) were younger, treated more female patients, had patients with fewer chronic illnesses, and worked more often as general practitioners than did male physicians. The patients of female physicians were more likely to receive a written physician-requested exemption from copayment, according to a multivariate logistic regression analysis (odds ratio [OR], 1.25; 95% CI, 1.04-1.50). Data suggested that patients of female physicians were more likely to stop antihypertensive drug therapy (OR, 1.43; 95% CI, 0.96-2.13); however, this was independent of the new copayment policy. CONCLUSIONS: The results provide empirical evidence that physician gender is associated with slightly different patient management strategies regarding physician-requested exemptions after the start of a new drug cost-sharing policy. However, these differences are unlikely to have meaningful clinical or economic consequences.
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Lack of relationship between long-term use of benzodiazepines and escalation to high dosages.
OBJECTIVE: The objective of this study was to determine whether long-term benzodiazepine use is associated with dose escalation. METHODS: The authors examined changes in dose and the frequency of dose escalation among new and continuing (at least two years) recipients of benzodiazepines identified from a database containing drug-dispensing and health care use data for all New Jersey Medicaid patients for 39 months. Independent variables included age; Medicaid eligibility category; gender; race or ethnicity; neighborhood socioeconomic variables; chronic illnesses, such as schizophrenia, bipolar illness, panic disorder, and seizure disorder; and predominant benzodiazepine received. Logistic regression analyses were conducted to determine the association between the independent variables and escalation to a high dosage (at least 20 diazepam milligram equivalents [DMEs] per day for elderly patients and at least 40 DMEs per day for younger patients). RESULTS: A total of 2,440 patients were identified, comprising 460 new and 1,980 continuing recipients. Seventy-one percent of continuing recipients had a permanent disability. Among all groups of continuing recipients, the median daily dosage remained constant at 10 DMEs during two years of continuous use. No clinically or statistically significant changes in dosage were observed over time. The incidence of escalation to a high dosage was 1.6 percent. Subgroups with a higher risk of dose escalation included antidepressant recipients and patients who filled duplicate prescriptions for benzodiazepines at different pharmacies within seven days. Elderly and disabled persons had a lower risk of dose escalation than younger patients. CONCLUSION: The results of this study did not support the hypothesis that long-term use of benzodiazepines frequently results in notable dose escalation.
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Effects on breastfeeding of changes in maternity length-of-stay policy in a large health maintenance organization.
OBJECTIVE: The purpose of this study was to evaluate the effects on breastfeeding rates of a private-sector early discharge program and a subsequent government mandate guaranteeing 48 hours of hospital coverage. METHODS: Interrupted time-series analyses were conducted on retrospective data from the automated medical records of a large health maintenance organization in eastern Massachusetts. A population of 20 366 mother-infant pairs with normal vaginal deliveries between October 1990 and March 1998 was identified. This study period spanned the 2 interventions of interest: 1) the introduction of a new health maintenance organization protocol of 1 postpartum overnight hospitalization followed by a nurse home visit for normal vaginal deliveries, then 2) Massachusetts state minimum coverage legislation. Breastfeeding initiation and breastfeeding continuation among initiators (exclusive or with supplements) into the third month of life were determined through a text search of the first 90 days of infants' automated medical records. RESULTS: Both policies had dramatic impacts on length of stay (LOS); postpartum LOS <2 nights rose from 29% of pairs to 65% when the early discharge program was implemented, then fell to 15% after the state mandate. Breastfeeding initiation, however, rose gradually from 71% in the fourth quarter of 1990 to 82% in the first quarter of 1998, with no changes after the interventions. Continuation of breastfeeding among those who initiated remained constant at 73%. Younger maternal age, primiparity, low socioeconomic status, and nonwhite race all were found to be risk factors for lower rates of breastfeeding (either initiation or continuation), but there was no evidence of a decline in breastfeeding associated with shorter LOS among these vulnerable groups. CONCLUSIONS: Early postpartum discharge with outpatient breastfeeding support and a home visitor program has no adverse effects on initiation or continuation of breastfeeding.
Breast Feeding↗
Effects of a law against early postpartum discharge on newborn follow-up, adverse events, and HMO expenditures.
BACKGROUND: Concern about harm to newborns from early postpartum discharges led to laws establishing minimum hospital stays in the mid-1990s. We evaluated the effects of an early-discharge protocol (a hospital stay of one postpartum night plus a home visit) in a health maintenance organization (HMO) and a subsequent state law guaranteeing a 48-hour hospital stay. METHODS: Using interrupted-time-series analysis and data on 20,366 mother-infant pairs with normal vaginal deliveries, we measured changes in length of stay, newborn examinations on the third or fourth day of life, and office visits, emergency department visits, and hospital readmissions for newborns. We also examined expenditures for hospitalizations and home-based care. RESULTS: The early-discharge program increased the rate of stays of less than two nights from 29.0 percent to 65.6 percent (P<0.001). The rate declined to 13.7 percent after the state mandate (P<0.001). The rate of newborn examinations on the third or fourth day of life increased from 24.5 percent to 64.4 percent with the program (P<0.001), then dropped to 53.0 percent after the mandate (P<0.001)--changes that primarily reflected changes in the rate of home visits. The rate of nonurgent visits to a health center increased from 33.4 percent to 44.7 percent (P<0.001) after the reduced-stay program was implemented. There were no significant changes in the rate of emergency department visits (quarterly mean, 1.1 percent) or rehospitalizations (quarterly mean, 1.5 percent). Results were similar for a vulnerable subgroup with lower incomes, younger maternal age, a lower level of education, or some combination of these characteristics. Average HMO expenditures on hospital and home-based services decreased by $90 per delivery with the early-discharge program and increased by $100 after the mandate. CONCLUSIONS: Neither policy appears to have affected the health outcomes of newborns. After the mandate, newborns were less likely to be examined as recommended on day 3 or 4. Because of changes in hospital prices, the two policies had minimal effects on HMO expenditures for hospital and home-based services.
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Reference drug pricing.
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Costs and Cost Analysis↗
Impact of reference-based pricing for angiotensin-converting enzyme inhibitors on drug utilization.
BACKGROUND: Increasing copayments for higher-priced prescription medications has been suggested as a means to help finance drug coverage for elderly patients, but evaluations of the impact of such policies are rare. The objective of this study was to analyze the effect of reference-based pricing of angiotensin-converting enzyme (ACE) inhibitors on drug utilization, cost savings and potential substitution with other medication classes. METHODS: We analyzed 36 months of claims data from British Columbia for 2 years before and 1 year after implementation of reference-based pricing (in January 1997). The 119,074 patients were community-living Pharmacare beneficiaries 65 years of age or older who used ACE inhibitors during the study period. The main outcomes were changes over time in use of ACE inhibitors, use of antihypertensive drugs and expenditures for antihypertensive drugs, as well as predictors of medication switching related to reference-based pricing. RESULTS: We observed a sharp decline (29%) in the use of higher-priced cost-shared ACE inhibitors immediately after implementation of the policy (p < 0.001). After a transition period, the post-implementation utilization rate for all ACE inhibitors was 11% lower than projected from pre-implementation data. However, overall utilization of antihypertensives was unchanged (p = 0.40). The policy saved $6.7 million in pharmaceutical expenditures during its first 12 months. Patients with heart failure or diabetes mellitus who were taking a cost-shared ACE inhibitor were more likely to remain on the same medication after implementation of reference-based pricing (OR 1.12 [95% confidence interval, CI, 1.06-1.19] and 1.28 [95% CI 1.20-1.36] respectively). Patients with low-income status were more likely than those with high-income status to stop all antihypertensive therapy (OR 1.65 [95% CI 1.43-1.89]), which reflects a general trend toward discontinuation of therapy among these patients even before implementation of reference-based pricing. INTERPRETATION: Reference-based pricing in British Columbia achieved a sustained reduction in drug expenditures, and no changes in overall use of antihypertensive therapy were observed. Further research is needed on the overall health and economic effects of such policies.
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Outcomes of reference pricing for angiotensin-converting-enzyme inhibitors.
BACKGROUND: In January 1997, reference pricing for angiotensin-converting-enzyme (ACE) inhibitors for patients 65 years of age or older was introduced in British Columbia, Canada. For medications within a specific class, insurance covers the cost up to the reference price, and patients pay the extra cost of more expensive medications. Although reference pricing may reduce the costs of prescription drugs, there is concern that patients may switch to less effective medications or stop treatment. METHODS: We analyzed data from the Ministry of Health on all 37,362 residents of British Columbia who were 65 or older and were enrolled in the provincial health insurance program, received ACE inhibitors priced higher than the reference price of $27 a month in 1996, and were potentially affected by the new policy. We identified 5353 residents who switched to an ACE inhibitor not subject to cost sharing during the first six months and compared them with 27,938 residents who received only ACE inhibitors subject to cost sharing. RESULTS: Reference pricing for ACE inhibitors was not associated with changes in the rates of visits to physicians, hospitalizations, admissions to long-term care facilities, or mortality. The probability of stopping antihypertensive therapy decreased as compared with the probability before the change in policy (relative risk, 0.76; 95 percent confidence interval, 0.65 to 0.89). Eighteen percent of patients who had been prescribed ACE inhibitors subject to cost sharing switched to lower-priced alternatives. As compared with patients who did not switch, those who did had a moderate transitory increase in the rates of visits to physicians (rate ratio, 1.11; 95 percent confidence interval, 1.07 to 1.15) and hospital admissions through the emergency room (rate ratio, 1.19; 95 percent confidence interval, 0.99 to 1.42) during the two months after switching, but not subsequently. CONCLUSIONS: We found little evidence that when reference pricing for ACE inhibitors was introduced in British Columbia, patients stopped treatment for hypertension or that health care utilization and costs increased.
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Effectiveness of thrombolytic therapy for acute myocardial infarction in the elderly: cause for concern in the old-old.
BACKGROUND: National guidelines have encouraged increased use of thrombolytic therapy for elderly patients with acute myocardial infarction (AMI). However, evidence supporting thrombolytic therapy in patients 75 years and older is lacking. In a retrospective cohort study of 2659 elderly AMI patients, we determined the association between thrombolytic use and in-hospital mortality by age and among patients with or without absolute or relative contraindications to thrombolytic treatment. METHODS: We abstracted the medical records of 2659 elderly patients admitted with AMI at 37 Minnesota community hospitals between 1992 and 1996. The main outcome measure was in-hospital mortality, controlling for demographic, clinical, comorbidity, and severity-of-illness variables. RESULTS: Sixty-three percent of 719 eligible patients received thrombolytic therapy. Twenty-seven percent of thrombolytic recipients had absolute contraindications to treatment. Patients receiving thrombolytic agents had fewer and less severe comorbidities than those not receiving thrombolytic therapy. There was a 4% increase in the odds of death for every 1-year increase in age for all thrombolytic recipients vs nonrecipients (odds ratio [OR], 1.04 per year; 95% confidence interval [CI], 1.01-1.08; P =.03). Among patients with 1 or more contraindication, the OR for death associated with thrombolytic use was 1.57 (95% CI, 1.03-2.40; P =.04). The adjusted odds of death among eligible thrombolytic recipients (vs nonrecipients) increased significantly with age (OR, 1.08 per year; 95% CI, 1.02-1.14; P =.008). Among eligible patients aged 80 to 90 years, the predicted odds of death among thrombolytic recipients vs nonrecipients was 1.4. Among eligible patients younger than 80 years, thrombolytic use was associated with reduced mortality. CONCLUSIONS: Our findings suggest the need for more research on the effectiveness of thrombolytic therapy for AMI patients 75 years and older and for more careful selection of elderly patients for this treatment.
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Quasi-experimental longitudinal designs to evaluate drug benefit policy changes with low policy compliance.
A causal relation between drug benefit policy change and the increase in adverse outcomes can be tested by comparing the experience of a group of patients affected by the policy vs. the (counterfactual) experience of the same patients if the policy had not been implemented. Because counterfactual experiences cannot be observed, it must be assumed that the counterfactual is correctly described by extrapolating from the same population's previous experience. The null hypothesis of no policy effect can be empirically tested using quasi-experimental longitudinal designs with repeated measures. If compliance to a policy is low, results may be biased towards the null, but a subgroup analysis of compliers may be biased by nonignorable treatment selection. Using the example of reference drug pricing in British Columbia we discuss assumptions for causal interpretations of such analyses, and provide supplementary analyses to assess and improve the validity of findings. Results from nonrandomized comparisons of subgroups defined by their compliance to a policy change should generally be interpreted cautiously, and several biases should be explored.
Attitude of Health Personnel↗
Prescription duration after drug copay changes in older people: methodological aspects.
OBJECTIVES: Impact assessment of drug benefits policies is a growing field of research that is increasingly relevant to health care planning for older people. Some cost-containment policies are thought to increase noncompliance. This paper examines mechanisms that can produce spurious reductions in drug utilization measures after drug policy changes when relying on pharmacy dispensing data. Reference pricing, a copayment for expensive medications above a fixed limit, for angiotensin-converting enzyme(ACE) inhibitors in older British Columbia residents, is used as a case example. DESIGN: Time series of 36 months of individual claims data. Longitudinal data analysis, adjusting for autoregressive data. SETTING: Pharmacare, the drug benefits program covering all patients aged 65 and older in the province of British Columbia, Canada. PARTICIPANTS: All noninstitutionalized Pharmacare beneficiaries aged 65 and older who used ACE inhibitors between 1995 and 1997 (N = 119,074). INTERVENTION: The introduction of reference drug pricing for ACE inhibitors for patients aged 65 and older. MEASUREMENTS: Timing and quantity of drug use from a claims database. RESULTS: We observed a transitional sharp decline of 110% t a standard error of 30% (P = .02) in the overall utilization rate of all ACE inhibitors after the policy implementation; five months later, utilization rates had increased, but remained under the predicted prepolicy trend. Coinciding with the sharp decrease, we observed a reduction in prescription duration by 31% in patients switching to no-cost drugs. This reduction may be attributed to increased monitoring for intolerance or treatment failure in switchers, which in turn led to a spurious reduction in total drug utilization. We ruled out the extension of medication use over the prescribed duration through reduced daily doses (prescription stretching) by a quantity-adjusted analysis of prescription duration. CONCLUSION: The analysis of prescription duration after drug policy interventions may provide alternative explanations to apparent short-term reductions in drug utilization and adds important insights to time trend analyses of drug utilization data in the evaluation of drug benefit policy changes.
Age Factors↗
Impact of a health maintenance organization hospitalist system in academic pediatrics.
OBJECTIVE: Hospitalist systems decrease length of stay (LOS) and cost for hospitalized adults. Whether hospitalist systems decrease LOS and cost for hospitalized children has not been conclusively established. We wanted to determine whether a health maintenance organization's (HMO's) implementation of a pediatric hospitalist system affected LOS, costs, mortality, readmission rate, follow-up rate, and parents' ratings of care. DESIGN: Interrupted time-series study of general pediatric patients admitted to a freestanding pediatric teaching hospital from 1993 to 1998. The intervention group consisted of all patients admitted to a staff model not-for-profit HMO that began using hospitalists in October 1996. Patients in other HMOs and traditional insurance groups were studied for comparison. The main outcomes were mean LOS and inflation-adjusted costs. Other outcomes included parents' ratings of care and mortality, readmission, and follow-up rates. RESULTS: Immediately after the introduction of the hospitalist system, mean LOS for staff model not-for-profit HMO fell 12% (0.3 days), and mean cost of hospitalization decreased 16% ($217) compared with prehospitalist levels. Parental ratings of care, initially somewhat low, improved substantially. Seven-day follow-up rates, mortality, and readmission rates did not change. Comparison groups experienced no concurrent improvements in LOS, cost, parental ratings, mortality, or readmission rates. CONCLUSIONS: A pediatric hospitalist system within a staff-model HMO significantly improved LOS, cost, and parental ratings of care without affecting rates of posthospitalization follow-up. Additional studies are needed both to measure broader aspects of quality and to assess the impact of such a program on patients being cared for through other types of delivery and insurance systems.
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