RESUMEN

BACKGROUND: Classifying medication adherence is important for efficiently targeting adherence improvement interventions. The purpose of this study was to evaluate the use of a novel method, group-based trajectory models, for classifying patients by their long-term adherence. RESEARCH DESIGN: We identified patients who initiated a statin between June 1, 2006 and May 30, 2007 in prescription claims from CVS Caremark and evaluated adherence over the subsequent 15 months. We compared several adherence summary measures, including proportion of days covered (PDC) and trajectory models with 2-6 groups, with the observed adherence pattern, defined by monthly indicators of full adherence (defined as having ≥24 d covered of 30). We also compared the accuracy of adherence prediction based on patient characteristics when adherence was defined by either a trajectory model or PDC. RESULTS: In 264,789 statin initiators, the 6-group trajectory model summarized long-term adherence best (C=0.938), whereas PDC summarized less well (C=0.881). The accuracy of adherence predictions was similar whether adherence was classified by PDC or by trajectory model. CONCLUSIONS: Trajectory models summarized adherence patterns better than traditional approaches and were similarly predicted by covariates. Group-based trajectory models may facilitate targeting of interventions and may be useful to adjust for confounding by health-seeking behavior.

Asunto(s)

Inhibidores de Hidroximetilglutaril-CoA Reductasas/administración & dosificación , Cumplimiento de la Medicación/estadística & datos numéricos , Adulto , Factores de Edad , Anciano , Utilización de Medicamentos , Femenino , Humanos , Revisión de Utilización de Seguros/estadística & datos numéricos , Masculino , Medicare/estadística & datos numéricos , Persona de Mediana Edad , Características de la Residencia/estadística & datos numéricos , Factores Socioeconómicos , Estados Unidos

RESUMEN

OBJECTIVE: Six oral medication classes have been approved by the Food and Drug Administration for the treatment of type 2 diabetes. Although all of these agents effectively lower blood glucose, the evidence supporting their impact on other clinical events is variable. There also are substantial cost differences between agents. We aimed to evaluate temporal trends in the use of specific drugs for the initial management of type 2 diabetes and to estimate the economic consequences of non-recommended care. METHODS: We studied a cohort of 254,973 patients, aged 18 to 100 years, who were newly initiated on oral hypoglycemic monotherapy between January 1, 2006, and December 31, 2008, by using prescription claims data from a large pharmacy benefit manager. Linear regression models were used to assess whether medication initiation patterns changed over time. Multivariate logistic regression models were constructed to identify independent predictors of receiving initial therapy with metformin. We then measured the economic consequences of prescribing patterns by drug class for both patients and the insurer. RESULTS: Over the course of the study period, the proportion of patients initially treated with metformin increased from 51% to 65%, whereas those receiving sulfonylureas decreased from 26% to 18% (P<.001 for both). There was a significant decline in the use of thiazolidinediones (20.1%-8.3%, P<.001) and an increase in prescriptions for dipeptidyl peptidase-4 inhibitors (0.4%-7.3%, P<.001). Younger patients, women, and patients receiving drug benefits through Medicare were least likely to initiate treatment with metformin. Combined patient and insurer spending for patients who were initiated on alpha-glucosidase inhibitors, thiazolidinediones, meglitinides, or dipeptidyl peptidase-4 inhibitors was $677 over a 6-month period compared with $116 and $118 for patients initiated on metformin or a sulfonylurea, respectively, a cost difference of approximately $1120 annually per patient. CONCLUSION: Approximately 35% of patients initiating an oral hypoglycemic drug did not receive recommended initial therapy with metformin. These practice patterns also have substantial implications for health care spending.

Asunto(s)

Diabetes Mellitus Tipo 2/tratamiento farmacológico , Hipoglucemiantes/economía , Hipoglucemiantes/uso terapéutico , Pautas de la Práctica en Medicina/estadística & datos numéricos , Administración Oral , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Inhibidores de la Dipeptidil-Peptidasa IV/administración & dosificación , Inhibidores de la Dipeptidil-Peptidasa IV/economía , Inhibidores de la Dipeptidil-Peptidasa IV/uso terapéutico , Medicina Basada en la Evidencia , Femenino , Humanos , Hipoglucemiantes/administración & dosificación , Modelos Logísticos , Masculino , Metformina/administración & dosificación , Metformina/economía , Metformina/uso terapéutico , Persona de Mediana Edad , Calidad de la Atención de Salud , Compuestos de Sulfonilurea/administración & dosificación , Compuestos de Sulfonilurea/economía , Compuestos de Sulfonilurea/uso terapéutico , Tiazolidinedionas/administración & dosificación , Tiazolidinedionas/economía , Tiazolidinedionas/uso terapéutico , Estados Unidos , alfa-Glucosidasas/administración & dosificación , alfa-Glucosidasas/economía , alfa-Glucosidasas/uso terapéutico

RESUMEN

BACKGROUND: Patients with chronic disease often take many medications multiple times per day. Such regimen complexity is associated with medication nonadherence. Other factors, including the number of pharmacy visits patients make to pick up their prescriptions, may also undermine adherence. Our objective was to estimate the extent of prescribing and filling complexity in patients prescribed a cardiovascular medication and to evaluate its association with adherence. METHODS: The study population comprised individuals prescribed a statin (n = 1 827 395) or an angiotensin- converting enzyme inhibitor or renin angiotensin receptor blocker (ACEI/ARB) (n = 1 480 304) between June 1, 2006, and May 30, 2007. We estimated complexity by measuring the number of medications, prescribers, pharmacies, pharmacy visits, and refill consolidation (a measure of the number of visits per fill) during the 3 months from the first prescription. The number of daily doses was also measured in ACEI/ARB users. After this period, adherence was evaluated over the subsequent year. The relationship between complexity and adherence was assessed with multivariable linear regression. RESULTS: The statin cohort had a mean age of 63 years and were 49% male. On average, during the 3-month complexity assessment period, statin users filled 11.4 prescriptions for 6.3 different medications, had prescriptions written by 2 prescribers, and made 5.0 visits to the pharmacy. Results for ACEI/ARB users were similar. Greater prescribing and filling complexity was associated with lower levels of adherence. In adjusted models, patients with the least refill consolidation had adherence rates that were 8% lower over the subsequent year than patients with the greatest refill consolidation. CONCLUSION: Medication use and prescription filling for patients with cardiovascular disease is complex, and strategies to reduce this complexity may help improve medication adherence.

Asunto(s)

Fármacos Cardiovasculares/administración & dosificación , Enfermedades Cardiovasculares/tratamiento farmacológico , Cumplimiento de la Medicación , Polifarmacia , Pautas de la Práctica en Medicina , Antagonistas de Receptores de Angiotensina/administración & dosificación , Inhibidores de la Enzima Convertidora de Angiotensina/administración & dosificación , Enfermedad Crónica , Quimioterapia Combinada , Femenino , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/administración & dosificación , Masculino , Persona de Mediana Edad

RESUMEN

Immigration to the United States presents both challenges and opportunities that affect students' academic achievement. Using a 5-year longitudinal, mixed-methods approach, we identified varying academic trajectories of newcomer immigrant students from Central America, China, the Dominican Republic, Haiti, and Mexico. Latent class growth curve analysis revealed that although some newcomer students performed at high or improving levels over time, others showed diminishing performance. Multinomial logistic regressions identified significant group differences in academic trajectories, particularly between the high-achieving youth and the other groups. In keeping with ecological-developmental and stage-environment fit theories, School Characteristics (school segregation rate, school poverty rate, and student perceptions of school violence), Family Characteristics (maternal education, parental employment, and household structure), and Individual Characteristics (academic English proficiency, academic engagement, psychological symptoms, gender, and 2 age-related risk factors, number of school transitions and being overaged for grade placement) were associated with different trajectories of academic performance. A series of case studies triangulate many of the quantitative findings as well as illuminate patterns that were not detected in the quantitative data. Thus, the mixed-methods approach sheds light on the cumulative developmental challenges that immigrant students face as they adjust to their new educational settings.

Asunto(s)

Comparación Transcultural , Educación , Escolaridad , Emigrantes e Inmigrantes , Familia/etnología , Adolescente , Conducta del Adolescente/etnología , Conducta del Adolescente/psicología , Niño , China/etnología , República Dominicana/etnología , Evaluación Educacional , Familia/psicología , Femenino , Haití/etnología , Humanos , Estudios Longitudinales , Masculino , México/etnología , Modelos Psicológicos , Análisis de Regresión , Resiliencia Psicológica , Factores de Riesgo , Instituciones Académicas , Factores Sexuales , Medio Social , Apoyo Social , Factores Socioeconómicos , Estudiantes/psicología , Estados Unidos , Violencia

RESUMEN

PURPOSE: To explore whether the use of behavioral health services (BHS) among women with breast cancer is influenced by how insurance plans administer these services, we compared utilization of psychotherapy and psychotherapeutic medications among women with breast cancer who received BHS coverage through a carve-out versus integrated arrangement. PATIENTS AND METHODS: We analyzed insurance claims, enrollment data, and benefit design data from the MarketScan Commercial Claims & Encounters Research Database for the years 1998 to 2002 for women

Asunto(s)

Ansiolíticos/uso terapéutico , Antidepresivos/uso terapéutico , Neoplasias de la Mama/psicología , Neoplasias de la Mama/terapia , Seguro de Salud/economía , Psicoterapia , Adolescente , Adulto , Femenino , Humanos , Cobertura del Seguro , Persona de Mediana Edad , Estados Unidos

RESUMEN

BACKGROUND: The number, nature, and costs of serious adverse effects experienced by younger women receiving chemotherapy for breast cancer outside of clinical trials are unknown. METHODS: From a database of medical claims made by individuals with employer-provided health insurance between January 1998 and December 2002, we identified 12,239 women 63 years of age or younger with newly diagnosed breast cancer, of whom 4075 received chemotherapy during the 12 months after the initial breast cancer diagnosis and 8164 did not. Diagnostic codes for eight chemotherapy-related adverse effects were identified. Total hospitalizations for all causes, hospitalizations or emergency room visits for adverse effects that are typically related to chemotherapy, and health care expenditures were compared between the two groups of women. All statistical tests were two-sided. RESULTS: Women who received chemotherapy were more likely than those who did not to be hospitalized or to visit the emergency room for all causes (61% versus 42%; mean difference = 19%, 95% confidence interval [CI] = 16.7% to 21.3%, P<.001) and for chemotherapy-related serious adverse effects (16% versus 5%, mean difference = 11%, 95% CI = 9.6% to 12.4%, P<.001). The percentages of chemotherapy recipients who were hospitalized or visited the emergency room during the year after their breast cancer diagnosis were 8.4% for fever or infection; 5.5% for neutropenia or thrombocytopenia; 2.5% for dehydration or electrolyte disorders; 2.4% for nausea, emesis, or diarrhea; 2.2% for anemia; 2% for constitutional symptoms; 1.2% for deep venous thrombosis or pulmonary embolus; and 0.9% for malnutrition. Chemotherapy recipients incurred large incremental expenditures for chemotherapy-related serious adverse effects (1271 dollars per person per year) and ambulatory encounters (17,617 dollars per person per year). CONCLUSIONS: Chemotherapy-related serious adverse effects among younger, commercially insured women with breast cancer may be more common than reported by large clinical trials and lead to more patient suffering and health care expenditures than previously estimated.

Asunto(s)

Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Protocolos de Quimioterapia Combinada Antineoplásica/economía , Neoplasias de la Mama/tratamiento farmacológico , Adulto , Neoplasias de la Mama/economía , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Costos de la Atención en Salud , Humanos , Revisión de Utilización de Seguros , Modelos Logísticos , Persona de Mediana Edad , Oportunidad Relativa , Admisión del Paciente/estadística & datos numéricos , Estados Unidos

RESUMEN

A majority of employees can choose among health insurance plans of varying generosity. They may switch plans if prices, information, or their health status change. This paper analyzes switching behavior presumptively caused by changes in health status. We show that people who move to a less generous plan have lower medical spending prior to the switch than the average for the generous plan in which they started, while those who move to a more generous plan appear to anticipate higher spending, which they delay until after the switch. This transfer of costs from a less to a more generous plan increases the burden of adverse selection. Our data suggest that switching may be more important to the level of premiums than previously documented.

Asunto(s)

Planes de Asistencia Médica para Empleados/economía , Planes de Asistencia Médica para Empleados/estadística & datos numéricos , Servicios de Salud/economía , Servicios de Salud/estadística & datos numéricos , Estado de Salud , Adulto , Estudios de Cohortes , Femenino , Gastos en Salud , Humanos , Revisión de Utilización de Seguros , Masculino , Persona de Mediana Edad , Modelos Psicológicos

RESUMEN

Before the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, Medicare reimbursed physicians for chemotherapy drugs at rates that greatly exceeded physicians' costs for those drugs. We examined the effect of physician reimbursement on chemotherapy treatment of Medicare beneficiaries older than age sixty-five with metastatic lung, breast, colorectal, or other gastrointestinal cancers between 1995 and 1998 (9,357 patients). A physician's decision to administer chemotherapy to metastatic cancer patients was not measurably affected by higher reimbursement. Providers who were more generously reimbursed, however, prescribed more-costly chemotherapy regimens to metastatic breast, colorectal, and lung cancer patients.

Asunto(s)

Antineoplásicos/economía , Neoplasias de la Mama/tratamiento farmacológico , Neoplasias Colorrectales/tratamiento farmacológico , Utilización de Medicamentos/economía , Neoplasias Pulmonares/tratamiento farmacológico , Oncología Médica/economía , Medicare Part B/legislación & jurisprudencia , Pautas de la Práctica en Medicina/economía , Mecanismo de Reembolso , Anciano , Antineoplásicos/uso terapéutico , Neoplasias de la Mama/economía , Neoplasias Colorrectales/economía , Femenino , Humanos , Neoplasias Pulmonares/economía , Masculino , Metástasis de la Neoplasia/tratamiento farmacológico , Estadificación de Neoplasias , Pautas de la Práctica en Medicina/estadística & datos numéricos , Programa de VERF , Estados Unidos

RESUMEN

We evaluated peak plasma concentrations, trough concentrations, and the 24-hour area under the concentration curve (AUC(0-24 h)) during maintenance with sublingual (SL) liquid or tablet formulations in 57 opiate-dependent volunteers. Study participants were assigned randomly to one of three SL daily buprenorphine dose pairs and maintained for 2 weeks with the liquid formulation followed by 2 weeks with the corresponding tablet dose. Plasma samples were obtained after at least 10 days of maintenance with the liquid formulation and after at least 10 days of that with the tablet formulation. The bioequivalence of the tablet compared with the liquid doses ranged from 57% to 75% based on peak concentrations, from 102% to 108% based on trough concentrations, and from 66% to 86% based on 24-hour AUC, but there was a large intersubject and intrasubject variability in plasma concentrations, with greater variability following tablets than liquid. Measures of withdrawal symptoms or illicit opioid use were not associated with buprenorphine dose, formulation, or plasma buprenorphine levels.

Asunto(s)

Buprenorfina/administración & dosificación , Antagonistas de Narcóticos/administración & dosificación , Trastornos Relacionados con Opioides/rehabilitación , Administración Sublingual , Adulto , Buprenorfina/efectos adversos , Buprenorfina/farmacocinética , Femenino , Humanos , Masculino , Tasa de Depuración Metabólica , Persona de Mediana Edad , Antagonistas de Narcóticos/efectos adversos , Antagonistas de Narcóticos/farmacocinética , Trastornos Relacionados con Opioides/sangre , Soluciones Farmacéuticas , Síndrome de Abstinencia a Sustancias/sangre , Síndrome de Abstinencia a Sustancias/diagnóstico , Comprimidos , Resultado del Tratamiento

RESUMEN

OBJECTIVE: Physicians may prescribe buprenorphine for opioid agonist maintenance treatment outside of narcotic treatment programs, but treatment guidelines for patients with co-occurring cocaine and opioid dependence are not available. This study compares effects of buprenorphine and methadone and evaluates the efficacy of combining contingency management with maintenance treatment for patients with co-occurring cocaine and opioid dependence. METHOD: Subjects with cocaine and opioid dependence (N=162) were provided manual-guided counseling and randomly assigned in a double-blind design to receive daily sublingual buprenorphine (12-16 mg) or methadone (65-85 mg p.o.) and to contingency management or performance feedback. Contingency management subjects received monetary vouchers for opioid- and cocaine-negative urine tests, which were conducted three times a week; voucher value escalated during the first 12 weeks for consecutive drug-free tests and was reduced to a nominal value in weeks 13-24. Performance feedback subjects received slips of paper indicating the urine test results. The primary outcome measures were the maximum number of consecutive weeks abstinent from illicit opioids and cocaine and the proportion of drug-free tests. Analytic models included two-by-two analysis of variance and mixed-model repeated-measures analysis of variance. RESULTS: Methadone-treated subjects remained in treatment significantly longer and achieved significantly longer periods of sustained abstinence and a greater proportion drug-free tests, compared with subjects who received buprenorphine. Subjects receiving contingency management achieved significantly longer periods of abstinence and a greater proportion drug-free tests during the period of escalating voucher value, compared with those who received performance feedback, but there were no significant differences between groups in these variables during the entire 24-week study. CONCLUSIONS: Methadone may be superior to buprenorphine for maintenance treatment of patients with co-occurring cocaine and opioid dependence. Combining methadone or buprenorphine with contingency management may improve treatment outcome.

Asunto(s)

Analgésicos Opioides/uso terapéutico , Terapia Conductista/métodos , Buprenorfina/uso terapéutico , Trastornos Relacionados con Cocaína/rehabilitación , Metadona/uso terapéutico , Trastornos Relacionados con Opioides/rehabilitación , Adulto , Trastornos Relacionados con Cocaína/diagnóstico , Trastornos Relacionados con Cocaína/epidemiología , Terapia Combinada , Comorbilidad , Femenino , Humanos , Masculino , Trastornos Relacionados con Opioides/diagnóstico , Trastornos Relacionados con Opioides/epidemiología , Detección de Abuso de Sustancias/estadística & datos numéricos , Régimen de Recompensa , Resultado del Tratamiento

RESUMEN

This preliminary study evaluated the relationship between therapy process variables (mechanistic processes and interpersonal processes), and treatment outcome (i.e., retention and cocaine abstinence) among 16 cocaine-dependent pregnant or postpartum women treated with the Community Reinforcement Approach (CRA). Two new rating scales were developed for this purpose. The Mechanisms of Action Rating Scale (MARS) assesses five CRA mechanistic domains (Big Picture goals, functional analyses of behavior, nondrug-related activities, skills training, and homework). The Interpersonal Variables Rating Scale (IVRS) measures three nonspecific or interpersonal dimensions of psychotherapy (i.e., empathy, response to resistance, and therapeutic alliance). These rating scales were used to rate one, early treatment, videotaped CRA session for each subject. Results indicated that: 1) sessions with patients who achieved three or more consecutive weeks of cocaine abstinence were rated significantly higher on therapist empathy and positive responses to resistance, and total IVRS scores (all of which indicate positive interpersonal processes); and 2) Big Picture goals, positive therapeutic alliance, and total IVRS scores were significantly and positively correlated with number of consecutive weeks of cocaine-negative urine toxicology tests. Only MARS homework scores were significantly and positively associated with number of study weeks completed. Finally, the pattern of interrelationships among the MARS subdomains suggests the coherence of the multifaceted CRA treatment. The findings of this preliminary study suggest the importance of monitoring both mechanistic and interpersonal processes during CRA treatment of cocaine dependence.

Asunto(s)

Trastornos Relacionados con Cocaína/terapia , Relaciones Interpersonales , Refuerzo en Psicología , Alcoholismo/epidemiología , Trastornos Relacionados con Cocaína/epidemiología , Servicios Comunitarios de Salud Mental , Trastorno Depresivo Mayor/diagnóstico , Trastorno Depresivo Mayor/epidemiología , Manual Diagnóstico y Estadístico de los Trastornos Mentales , Femenino , Humanos , Resultado del Tratamiento

RESUMEN

Buprenorphine is an effective treatment for heroin dependence. The feasibility and potential efficacy of buprenorphine with brief counseling in primary care is unknown. We enrolled 14 heroin dependent patients in a 13-week clinical trial using thrice weekly buprenorphine along with brief counseling in the primary care center of an urban medical center. Primary outcomes included urine toxicology and treatment retention. Opioid-positive urine toxicology tests reduced over the 13-week period from 95 to 25% (p < 0.05). Eleven patients (79%) had greater than or equal to one week of opioid-free urine toxicologies. Nine patients (64%) had greater than or equal to three weeks of opioid-free urine toxicologies. Eleven patients (79%) were retained through the maintenance phase. We conclude that buprenorphine maintenance is feasible in a primary care setting.

Asunto(s)

Atención Ambulatoria , Buprenorfina/administración & dosificación , Dependencia de Heroína/rehabilitación , Población Urbana , Administración Sublingual , Adulto , Buprenorfina/efectos adversos , Terapia Combinada , Connecticut , Consejo , Relación Dosis-Respuesta a Droga , Esquema de Medicación , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Atención Primaria de Salud , Apoyo Social , Resultado del Tratamiento