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BACKGROUND: Copayments (copays) for prescription drugs are a common policy among state Medicaid programs. Research exploring the effects of copays on pharmacy and health care utilization in Medicaid patients is limited, especially among patients with chronic disease. OBJECTIVES: The goal of this research was to quantify the impact of a copay policy for prescription drugs on medication and health services utilization overall and among subjects with several common chronic diseases enrolled in a state Medicaid program. RESEARCH DESIGN: Using aggregated pharmacy claims, segmented linear regression models were used to evaluate changes in overall and disease-specific pharmacy utilization after implementation of a copay policy. Trends in emergency department encounters, office visits, and hospitalizations were used to evaluate the impact of this policy on unintended consequences. Utilization among cohorts of patients with several chronic conditions were analyzed to determine if a differential response existed by drug indication. RESULTS: After copay implementation, utilization of prescription drugs declined significantly by 17.2% (P < 0.0001). This pattern was observed at varying degrees for all drug classes investigated. Rates of emergency department encounters, office visits, or hospitalizations did not increase after the policy was introduced. Subjects with diabetes, respiratory disease, and schizophrenia immediately reduced their use of nonindicated drugs significantly more than drugs indicated for their condition. CONCLUSIONS: Among Medicaid recipients, nominal copays are associated with significant reductions in use of clinically important drug classes. However, patients with chronic disease exhibited a differential response depending on the disease indication of the drug class.

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OBJECTIVE: Fecal incontinence is an embarrassing and disabling condition of which the epidemiology is poorly understood. Our goal is to estimate the incidence of fecal incontinence after childbirth. METHODS: A population-based survey was mailed to all women who delivered a liveborn infant in the state of Oregon between April 2002 and September 2002. The survey estimated the incidence of fecal incontinence. Surveys were to be completed within 3-6 months postpartum. Women were considered to have fecal incontinence based upon the National Institute of Child Health and Human Development definition of fecal incontinence: recurring episodes of involuntary loss of stool or flatus. RESULTS: Surveys were mailed to 21,824 eligible postpartum women. A total of 8,774 women responded (40%) to the survey, 2,569 (29%) of whom reported experiencing fecal incontinence since delivery. Almost half (46%) of all women with postpartum fecal incontinence reported incontinence of stool, and 38% reported exclusively incontinence of flatus. Approximately 46% reported onset of incontinence after delivery of their first child. Higher body mass index, longer pushing, forceps-assisted delivery, third- or fourth-degree laceration, and smoking were associated with severe fecal incontinence. CONCLUSION: In this population-based study, more than one in four women reported fecal incontinence within 6 months of childbirth, with almost half reporting onset of symptoms after delivery of their first child. Four in 10 women reported loss of flatus or stool during intercourse. Given the burden of this condition, both in number and social impact coupled with the hesitancy of women to want to initiate this conversation, providers should ask women about symptoms of fecal incontinence during postpartum examinations. Additionally, these data suggest that there may be a benefit to extending postpartum follow-up visits beyond the typical 6-8 weeks to provide surveillance for potential incontinence. LEVEL OF EVIDENCE: II.

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This roundtable examines the role of health services research from the perspective of the state legislature. Four research and policy experts-each of whom is a current or former legislator-explore how research can be translated effectively into state health policy, and how researchers and legislators can communicate clearly with one another and engage in productive collaborations.

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A broad array of agencies, institutions, and individuals interact with community-based substance abuse treatment programs, providing resources or services and asserting demands and expectations in return. These relationships shape the environment in which treatment and community-based research take place, and themselves raise issues worthy of research attention. This article enumerates the stakeholders in one well-established program and describes the scope of the program's efforts to accommodate these stakeholders, along with some of the complications and difficulties programs confront in their attempts to satisfy stakeholders, especially when their demands are unrealistic or their interests conflict. The article concludes by identifying research areas that could facilitate these relationships, enhancing their benefits for patients.

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Prevention of cardiovascular disease must begin in childhood, preferably before risk factors develop. Elevated low-density lipoprotein cholesterol levels in children are likely to track over time and become high-risk levels in adults. The Dietary Intervention Study in Children (DISC) was a multicenter, collaborative randomized trial in pre-adolescent children designed to test the efficacy and safety of a dietary intervention to lower saturated fat and cholesterol intake among growing children with elevated low-density lipoprotein cholesterol. Numerous DISC results, which include findings on lipids-lipoproteins, genetics, and nutrient adequacy, as well as descriptions of the behavioral intervention strategies, have been reported. A summary of practical findings and their potential clinical applications have not previously been published. Highlights of key lessons learned from DISC and translational applications of potential interest to nurses and other health care providers are presented.

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We conducted a systematic review of the literature to evaluate the efficacy of telemedicine for making diagnostic and management decisions in three classes of application: office/hospital-based, store-and-forward, and home-based telemedicine. We searched the MEDLINE, EMBASE, CINAHL and HealthSTAR databases and printed resources, and interviewed investigators in the field. We excluded studies where the service did not historically require face-to-face encounters (e.g. radiology or pathology diagnosis). A total of 58 articles met the inclusion criteria. The articles were summarized and graded for the quality and direction of the evidence. There were very few high-quality studies. The strongest evidence for the efficacy of telemedicine for diagnostic and management decisions came from the specialties of psychiatry and dermatology. There was also reasonable evidence that general medical history and physical examinations performed via telemedicine had relatively good sensitivity and specificity. Other specialties in which some evidence for efficacy existed were cardiology and certain areas of ophthalmology. Despite the widespread use of telemedicine in most major medical specialties, there is strong evidence in only a few of them that the diagnostic and management decisions provided by telemedicine are comparable to face-to-face care.

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OBJECTIVE: Potential risk factors and visual performance measures were evaluated for relationship to self-report of clinical visual symptoms after the refractive procedure for placement of Intacs microthin prescription inserts for myopia. DESIGN: Retrospective nonrandomized comparative study. PARTICIPANTS/INTERVENTION: Patients were participants in the U.S. Food and Drug Administration phase III KeraVision prospective clinical trials. MAIN OUTCOME MEASURES: Study participants (n = 263) were retrospectively classified into one of three outcome groups on the basis of postoperative self-reported visual symptoms and/or request for Intacs inserts removal through month 24. Differences between outcome groups in visual acuity, refractive error, corneal geometry, corneal topography, type of preoperative corrective lens wear, and demographic variables were evaluated with multivariate logistic regression. RESULTS: Clinical trial participants who had preoperative mean keratometry >45 diopters (D) (adjusted odds ratio [OR], 0.43; 95% confidence interval [CI], 0.21, 0.85, P = 0.02), manifest refractive astigmatism of 0.75 D or 1.00 D (adjusted OR, 0.52; 95% CI, 0.25, 1.08, P = 0.08), measured uncorrected visual acuity > or =2 lines better than that predicted by their respective cycloplegic refractive error (adjusted OR, 0.39; 95% CI, 0.14, 1.12, P = 0.08) and/or had worn soft contact lenses (adjusted OR, 0.58; 95% CI, 0.32, 1.04, P = 0.07) tended to be less likely to report postoperative clinical visual symptoms with Intacs inserts. Risk of clinical visual symptoms and request for Intacs inserts removal approximately doubled for each 0.50 D of additional postoperative defocus equivalent (crude OR, 1.86; 95% CI, 1.39, 2.48, P = 0.00). Controlling for postoperative defocus and important preoperative risk factors, subjects who reported significant clinical visual symptoms were more likely to have had preoperative uncorrected visual acuity that was worse than that predicted by their respective cycloplegic refractive error (adjusted OR, 1.84; 95% CI, 0.98, 3.42, P = 0.06). Risk of reporting clinical visual symptoms was increased with mesopic pupil diameter > or =6.5 mm (adjusted OR, 1.76; 95% CI, 0.96, 3.24, P = 0.07). Within the group of patients who reported postoperative clinical visual symptoms, 71 of 122 (58%) had ceased reporting them by month 24. CONCLUSIONS: Adjusting for important risk factors simultaneously, this study suggested that certain preoperative characteristics may increase or decrease the likelihood, depending on the characteristic, of refractive surgery candidates to report significant clinical visual symptoms with Intacs inserts.

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In 1996, the eight-million member Kaiser Permanente HMO adopted a vision statement that said by 2005 it would expand its services to include home- and community-based services for its members with disabilities. It funded a 3-year, 32-site demonstration that showed that it was feasible to link HMO services with existing home-and community-based (HCB) services and that members appreciated the improved coordination and access. This private-sector project showed that devolution can produce innovative and feasible models of care, but it also showed that without federal financial and regulatory support, such models are unlikely to take hold if they are focused on "unprofitable" populations, for example, those who are chronically ill, poor, and/or disabled.

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