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Journal: Medical care


It is important to understand the magnitude and distribution of the economic burden of prescription opioid overdose, abuse, and dependence to inform clinical practice, research, and other decision makers. Decision makers choosing approaches to address this epidemic need cost information to evaluate the cost effectiveness of their choices.

Concepts: Clinical trial, United States, Economics, Poverty in the United States, Decision theory, Decision making software, Choice, Choice architecture



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.

Concepts: Scientific method, Prediction, Futurology, Future, Prophecy, Hypothesis, Divination, CVS Caremark


BACKGROUND:: Academic medical institutions have instituted conflict of interest (COI) policies in response to concerns about pharmaceutical industry influence. OBJECTIVE:: To determine whether exposure to COI policies during psychiatry residency training affects psychiatrists' antidepressant prescribing patterns after graduation. RESEARCH DESIGN:: We used 2009 physician-level national administrative prescribing data from IMS Health for 1652 psychiatrists from 162 residency programs. We used difference-in-differences estimation to compare antidepressant prescribing based on graduation before (2001) or after (2008) COI policy adoption across residency program groups with maximally, moderately, and minimally restrictive COI policies. The primary outcomes were shares of psychiatrists' prescribing of heavily promoted, brand reformulated, and brand antidepressants. RESULTS:: Rates of prescribing heavily promoted, brand reformulated, and brand antidepressants in 2009 were lower among post-COI graduates than pre-COI graduates at all levels of COI restrictiveness. However, differences between pre-COI and post-COI graduates' prescribing of heavily promoted medications were larger for maximally restrictive programs than both minimally restrictive programs [-4.3 percentage points; 95% confidence interval (CI), -7.0, -1.6] and moderately restrictive programs (-3.6 percentage points; 95% CI, -6.2, -1.1). The difference in prescribing reformulations was larger for maximally restrictive programs than minimally restrictive programs (-3.0 percentage points; 95% CI, -5.3, -0.7). Results were consistent for prescribing of brand drugs. CONCLUSIONS:: This study provides the first empirical evidence of the effects of COI policies. Our results suggest that COI policies can help inoculate physicians against persuasive aspects of pharmaceutical promotion. Further research should assess whether these policies affect other drug classes and physician specialties similarly.

Concepts: Pharmacology, Medicine, Physician, Pharmaceutical industry, Medical school, Psychiatric medication, Internal medicine, IMS Health


Adoption and implementation of electronic health records (EHRs) has not been without challenges as it infuses technology into what has been a historically manual process of recording patient information. In an effort to identify these challenges, the Office of the National Coordinator for Health Information Technology leveraged the Regional Extension Center population of over 140,000 providers to develop a structured way to track challenges to EHR adoption and Meaningful Use (MU).

Concepts: Electronic health record, Electronic medical record, Health informatics, Medical informatics, VistA, Personal health record, Gramophone record, Health information management


Legal in some European countries and US states, physician-assisted suicide and voluntary active euthanasia remain under debate in these and other countries.

Concepts: Medical ethics, Death, Homicide, Euthanasia, Assisted suicide


BACKGROUND:: Oral antineoplastic drugs, not generally covered by Medicare Part B, have assumed an increasingly important role in cancer treatment. OBJECTIVE:: We examined use and spending on infused/injected (Part B covered) and non-Part B antineoplastic agents in a Medicare beneficiary population with cancer, and the effect of supplemental insurance. RESEARCH DESIGN:: This retrospective, observational study used pooled 1997-2007 data from the Medicare Current Beneficiary Survey, linked to Medicare claims. Logistic regression models identified factors associated with antineoplastic use. Generalized linear models were used to estimate spending among antineoplastic users. Population studied: A total of 1836 Medicare beneficiaries with newly diagnosed cancer were selected based on the presence of claims-based diagnoses after a 12-month washout period. RESULTS:: Five hundred fifty-nine (31.0%) Medicare beneficiaries received antineoplastic therapy; 395 (21.3%) used Part B, 253 (14.6%) used non-Part B antineoplastics. Spending per user was $7841 (any), $10,364 (Part B), and $1535 for non-Part B antineoplastics. Supplemental insurance was associated with antineoplastic use. Primary cancer site and age were key predictors of spending among users. Spending on non-Part B antineoplastics increased during 2006-2007 relative to 2004-2005 but time trends were not significant in multivariate analysis. CONCLUSIONS:: Antineoplastic therapy use by Medicare beneficiaries is sensitive to the presence but not type of supplemental insurance. Non-Part B therapy was used by a relatively large proportion of beneficiaries with cancer receiving therapy, although spending was less than for Part B therapy. Monitoring the role of supplemental insurance, and particularly the role of Medicare Part D is a critical area for ongoing research.

Concepts: Regression analysis, Medicare, Medicare Part D, Medicare Prescription Drug, Improvement, and Modernization Act, Antineoplastic


: Hospital care for ambulatory care sensitive conditions (ACSC) is potentially avoidable and often viewed as an indicator of suboptimal primary care. However, potentially preventable encounters with the health care system also occur in emergency department (ED) settings. We examined ED visits to identify subpopulations with disproportionate use of EDs for ACSC care.

Concepts: Health care, Health economics, Medicine, Health insurance, Health disparities, Hospital, Urgent care, Trauma center


Transgender individuals, or those who cross or transcend sex categories, commonly experience stigma and discrimination. Anecdotal evidence indicates that this transphobia manifests in health care settings, but few studies address the forms of mistreatment experienced in this context. This study was designed to explore transgender patients' experiences with health care. This brief report focuses on their negative experiences.

Concepts: Health care, Health care provider, Illness, Experience, Philosophy of science, Evidence, Scientific evidence, Anecdotal evidence


: To examine the prevalence of obesity and its relationship with pressure ulcers among nursing home (NH) populations, and whether such relationship varies with certified nursing assistant (CNA) level in NHs. DATA AND STUDY POPULATION:: The 1999-2009 nationwide Minimum Data Sets were linked with Online Survey of Certification and Reporting records. We identified newly admitted NH residents who became long-stayers and followed them up to 1 year.

Concepts: Population, Certification, Nursing, Nursing home, Healthcare occupations, Certified Nursing Assistant, Nursing assistant skills, Personal Support Worker