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BACKGROUND: Although studies have documented hospital and surgical service geographic variability, prescription use geographic variability is largely unknown. Opiate pain medications are widely used, particularly because the promulgation of clinical guidelines promoting aggressive pain treatment. This study describes temporal and interstate variability in aggregate prescription opiate medication use within U.S. Medicaid programs. METHODS: A dataset of 49 states' fee-for-service (FFS) Medicaid prescription drug dispensing records from 1996 to 2002 was compiled and used to quantify medication dispensing examining all opiates, controlled release oxycodone, and methadone. The defined daily dose (DDD) per 1000 FFS Medicaid adult enrollees per day was calculated for all opiate medication categories. A market basket of nonpain prescription medications was constructed for comparison. Rates, trends, and the coefficient of variation were determined overall, by year and for each state. RESULTS: From 1996 to 2002, overall use of opiate pain medications increased 309%. The market basket use increased 170%. Total opiate dispensing varied widely from state to state, with a range of 6.9 to 44.1 DDD/1000/d in 1996, and 7.1 to 165.0 DDD/1000/d (a 23-fold difference) in 2002. The coefficient of variation was 49.6 in 2002. Controlled release oxycodone and methadone had a greater rate of increase compared with all opiates. CONCLUSIONS: The dispensing of opiate medications in Medicaid programs increased at almost twice the rate of nonpain-related medications during the 7-year study period. Large, unexplained geographic variation in aggregate use exists. The impact of Medicaid cost-containment strategies on utilization and outcomes should be investigated. [ABSTRACT FROM AUTHOR]

BACKGROUND: Insurance coverage of patient self-management devices like self-monitoring blood glucose (SMBG) equipment may help to reduce race-related barriers to effective care. OBJECTIVES: We examined whether providing free home glucose monitors had greater impacts on self-monitoring among black versus white patients with diabetes. RESEARCH DESIGN: Using electronic medical record data (1992-1996), we used longitudinal survival analysis to examine racial differences in rates of initiation of SMBG after coverage and rates of discontinuation of SMBG 18 months after initiation. We used piecewise Cox models to compare relative rates of SMBG initiation between black and white patients before and after the policy. SUBJECTS: The study cohort included 2275 continuously enrolled adult patients with diabetes in a large, staff model HMO. Multivariate models were restricted to patients using oral therapy. RESULTS: Controlling for time-dependent and fixed effects, black patients were as likely to initiate SMBG as white patients before the policy (hazard ratio 1.14; 95% confidence interval 0.86-1.50) but more likely after the policy (hazard ratio 1.33; 95% confidence interval 1.01-1.76). Among postpolicy SMBG initiators, black patients were consistently at higher risk of SMBG discontinuation than white patients over time (P < 0.05). By the end of follow-up, discontinuation rates were 78% among black patients and 64% among white patients. CONCLUSIONS: The policy is effective in triggering additional diabetes patients to self-manage, particularly black patients. However, persistence after initiation of monitoring is short-lived. Although our results show the potential of such policies to narrow racial gaps in self-management among racial minority groups, further interventions may be needed to promote long-term adherence. [ABSTRACT FROM AUTHOR]

BACKGROUND: State Medicaid programs introduce many types of prescribing restrictions to manage pharmaceutical use and expenditure. Little is known about the differential effect of implementing prior authorization (PA) policies at market entry versus waiting until several years later when prescribing behavior may already be established. OBJECTIVES: We sought to examine the impact on overall use of Cox II inhibitors of PA policies implemented at market entry versus at least 2 years after market entry. RESEARCH DESIGN: We quantified Cox II inhibitor and nonselective nonsteroidal anti-inflammatory drug (NSAID) utilization for state Medicaid programs from January 1996 to September 2003. We used generalized estimating equations, Tukey's studentized range test and segmented linear regression on state Medicaid programs to determine the significance of changes in medication use. MEASURES: The primary end point was the number of defined daily doses (DDD) per 1000 population per day. RESULTS: Six states implementing prescribing restrictions for Cox II inhibitors at market entry had the lowest rates of uptake, averaging 10.9 DDD/1000/d. Twelve states adopting restrictions more than 2 years after market entry experienced declines in use from 23.0 DDD/1000/d before to 13.9 DDD/1000/d after the restrictions (P < 0.01). The 17 states that had never restricted access had the highest utilization, averaging 29.0 DDD/1000/d. CONCLUSION: Implementing prescribing restrictions at market entry of Cox II inhibitors was effective in restricting uptake. Despite the difficulty in changing well-established prescribing patterns, utilization in states implementing policies 2 years after market entry approached that of the early adopting states within 1 year. Clinical outcomes of such policies remain unknown. [ABSTRACT FROM AUTHOR]

Objective: To compare the risk of incident cardiovascular disease (CVD) events following sleeve gastrectomy (SG) and Roux en Y gastric bypass (RYGB)., Summary Background Data: Bariatric surgery is associated with reduced CVD risk but the differential effect of contemporary bariatric procedures is unclear., Methods: We used insurance claims to conduct a retrospective cohort study of CVD outcomes for patients who underwent RYGB versus SG between 2010 and 2021. Patients were followed for up to 5 years for a primary composite major adverse cardiovascular event (MACE) outcome as well as individual outcomes including myocardial infarction, stroke, heart failure, and arrhythmia. We compared cumulative risks of CVD events using multivariable Cox proportional hazards modeling, in overall cohorts and in sub-cohorts of older adults and those with type 2 diabetes (T2D) or pre-existing CVD and elevated morbidity., Results: Matched, weighted cohorts of 13,545 SG and RYGB patients were observed for an average of 2.5 years after surgery, with 26.2% not lost to follow-up by the end of 5 years. There was no difference in MACE risk between procedures (aHR 1.01 for RYGB vs. SG [95% CI 0.90, 1.12]) in the overall cohort or among the subgroup of older adults (aHR 0.97 for RYGB vs. SG [95% CI 0.85, 1.10]). Patients with T2D experienced lower risk of MACE following RYGB compared to SG (aHR 0.78 [95% CI 0.66, 0.92]), as did those with pre-existing CVD or elevated morbidity prior to surgery (aHR 0.81 [95% CI 0.70, 0.93])., Conclusions: These findings further support the preferential use of RYGB over SG for patients with T2D or who have pre-existing CVD. However, among other groups of patients, including older adults, we did not observe a relative benefit of RYGB during the time horizon in this study., Competing Interests: Conflicts of Interest and Source of Funding: The authors have no conflicts of interest to disclose. This research was supported through a grant from NIH / NIDDK (R01DK112750; Lewis PI)., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To compare acute care utilization and costs following sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB)., Summary Background Data: Comparing postbariatric emergency department (ED) and inpatient care use patterns could assist with procedure choice and provide insights about complication risk., Methods: We used a national insurance claims database to identify adults undergoing SG and RYGB between 2008 and 2016. Patients were matched on age, sex, calendar-time, diabetes, and baseline acute care use. We used adjusted Cox proportional hazards to compare acute care utilization and 2-part logistic regression models to compare annual associated costs (odds of any cost, and odds of high costs, defined as ≥80th percentile), between SG and RYGB, overall and within several clinical categories., Results: The matched cohort included 4263 SG and 4520 RYGB patients. Up to 4 years after surgery, SG patients had slightly lower risk of ED visits [adjusted hazard ratio (aHR): 0.90; 95% confidence interval (CI): 0.85,0.96] and inpatient stays (aHR: 0.80; 95% CI: 0.73,0.88), especially for events associated with digestive-system diagnoses (ED aHR: 0.68; 95% CI: 0.62,0.75; inpatient aHR: 0.61; 95% CI: 0.53,0.72). SG patients also had lower odds of high ED and high total acute costs (eg, year-1 acute costs adjusted odds ratio (aOR) 0.77; 95% CI: 0.66,0.90) in early follow-up. However, observed cost differences decreased by years 3 and 4 (eg, year-4 acute care costs aOR 1.10; 95% CI: 0.92,1.31)., Conclusions: SG may have fewer complications requiring emergency care and hospitalization, especially as related to digestive system disease. However, any acute care cost advantages of SG may wane over time., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Alarming increasing trends in physician workload have attracted much attention in recent years. Heavy workload may compromise the quality of medication use. Previous studies have identified a series of factors contributing to inappropriate prescribing; however, there is no demonstrated evidence supporting an association between workload and the appropriateness of physicians' prescriptions in China. This study aimed to investigate the relationship between physician workload and prescription quality in a tertiary hospital in Beijing, China., Methods: Our study was a single-center, retrospective study, with all outpatient electronic health records extracted from hospital information system of a tertiary hospital in Beijing from July 1 to November 30, 2015. We used outpatient volume in each 5-hour shift as the measure of physician workload. The evaluation of prescribing quality was based on the Rational Drug Use System. Generalized linear models with a γ distribution and a log link were used to explore factors associated with inappropriate prescribing, and we undertook a series of robustness tests with respect to different exclusion criteria., Results: A total of 457,784 prescriptions from 502 physicians were included in the study. Physicians had an average workload of 34.3 (±19.8) patients per shift, and the mean rate of inappropriate prescribing per shift was 14.1% (±14.6%). Higher rates of inappropriate prescribing were associated with heavier workloads (P < 0.001). Physicians who worked in the afternoon, chief physicians, those working in surgical department, males, and those with more than 20-year experience had higher rates of inappropriate prescribing with increasing workload., Conclusions: Heavier workload was associated with higher risk of prescribing inappropriately. It requires great efforts to determine optimal physician workloads and mitigate the potential adverse effects on the prescription quality., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The aim of the study was to compare diabetes outcomes following vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB)., Background: There are few comparative studies on diabetes outcomes after VSG and RYGB., Methods: We used a US-wide commercial insurance claims database to identify adults with diabetes undergoing VSG or RYGB in 2010 to 2016. We matched patients on baseline insulin use, total diabetes medication burden, age, presence of diabetes complications, and follow-up duration, and used adjusted Cox proportional hazards models to compare diabetes medication discontinuation between procedures. We used difference-in-differences analyses to compare changes in medication use intensity up to 2 years after surgery., Results: The matched cohort included 1111 VSG and 922 RYGB patients: 16% were younger than 40 years, 11% were 60 years or older, 67% were women, 67% had a body mass index of 40 kg/m2 or higher, and 23% were on insulin at the time of surgery. Thirteen percent were lost to follow-up at 1 year, and 30% at 2 years after surgery. Patients with VSG were less likely than matched RYGB patients to discontinue all diabetes medications (hazard ratio 0.80, 95% confidence interval 0.72-0.88). Although both groups had substantial decreases in medication use after surgery, RYGB patients had an 86% (32%, 140%) lower total diabetes medication dose than VSG by the second half of postoperative year 2., Conclusions: In a large claims-based, nationwide cohort of bariatric patients with diabetes, those undergoing RYGB were more likely to come off all medications than those undergoing VSG. Patients with diabetes should consider this potential benefit of RYGB when making informed decisions about obesity treatments., Competing Interests: The authors report no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Unaffordability of medications is a barrier to effective treatment. Cost-related nonadherence (CRN) is a crucial, widely used measure of medications access., Objectives: Our study examines the current national prevalence of and risk factors for CRN (eg, not filling, skipping or reducing doses) and companion measures in the US Medicare population., Research Design: Survey-weighted analyses included logistic regression and trends 2006-2016., Subjects: Main analyses used the 2016 Medicare Current Beneficiary Survey. Our study sample of 12,625 represented 56 million community-dwelling beneficiaries., Measures: Additional outcome measures were spending less on other necessities in order to pay for medicines and use of drug cost reduction strategies such as requesting generics., Results: In 2016, 34.5% of enrollees under 65 years with disability and 14.4% of those 65 years and older did not take their medications as prescribed due to high costs; 19.4% and 4.7%, respectively, experienced going without other essentials to pay for medicines. Near-poor older beneficiaries with incomes $15-25K had 50% higher odds of CRN (vs. >$50K), but beneficiaries with incomes <$15K, more likely to be eligible for the Part D Low-Income Subsidy, did not have significantly higher risk. Three indicators of worse health (general health status, functional limits, and count of conditions) were all independently associated with higher risk of CRN., Conclusions: Changes in the risk profile for CRN since Part D reflect the effectiveness of targeted policies. The persistent prevalence of CRN and associated risks for sicker people in Medicare demonstrate the consequences of high cost-sharing for prescription fills.

Background: High deductible health plans linked to Health Savings Accounts (HSA-HDHPs) must include all care under the deductible except for select preventive services. Some employers and insurers have adopted Preventive Drug Lists (PDLs) that exempt specific classes of medications from deductibles., Objective: The objective of this study was to examine the association between shifts to PDL coverage and medication utilization among patients with diabetes in HSA-HDHPs., Research Design: A natural experiment comparing pre-post changes in monthly and annual outcomes in matched study groups., Subjects: The intervention group included 1744 commercially-insured HSA-HDHP patients with diabetes age 12-64 years switched by employers to PDL coverage; the control group included 3349 propensity-matched HSA-HDHP patients whose employers offered no PDL., Measures: Outcomes were out-of-pocket (OOP) costs for medications and the number of pharmacy fills converted to 30-day equivalents., Results: Transition to the PDL was associated with a relative pre-post decrease of $612 (-35%, P<0.001) per member OOP medication expenditures; OOP reductions were higher for key classes of antidiabetic and cardiovascular medicines listed on the PDL; the policy did not affect unlisted classes. The PDL group experienced relative increases in medication use of 6.0 30-day fills per person during the year (+11.2%, P<0.001); the increase was more than twice as large for lower-income (+6.6 fills, +12.6%, P<0.001) than higher-income (+3.0 fills, +5.1%, P=0.024) patients., Conclusion: Transition to a PDL which covers important classes of medication to manage diabetes and cardiovascular conditions is associated with substantial annual OOP cost savings for patients with diabetes and increased utilization of important classes of medications, especially for lower-income patients.

Background: Providers need timely, clinically meaningful, and actionable information to improve quality of care. Payers may play an important role in providing such information in ambulatory care settings. We sought to learn about providers' use and perceptions of quality reports from insurers., Methods: We employed a mixed-methods study design. We analyzed the performance of 118 provider groups on 21 HEDIS measures included in one New England insurer's quality reporting program and evaluated how a subset of provider groups (n = 55) accessed the reports. We also conducted 14 semistructured interviews with providers and administrators to assess their perspectives about quality reports from insurers in general., Results: Performance on quality measures varied greatly across provider groups and by metric. Only 20% of provider groups accessed the quality reports during the study period. While providers reported that payer information on quality has the potential to be useful, respondents suggested important reasons why insurer quality reports were not widely accessed, including information overload, conflicts with other sources of information, and the significant provider effort required to make the reports actionable., Conclusions: Payer-provider collaborations are needed to improve the usefulness of payers' quality measurement reports, and coordination among payers is needed to streamline reported measures.

Objective: To assess patterns and predictors of postpartum diabetes screening in a commercially insured, geographically and sociodemographically diverse sample of women with gestational diabetes mellitus., Methods: Using commercial insurance claims (2000-2012) from all 50 states, we conducted a retrospective cohort study in 447,556 women with at least one delivery and continuous enrollment 1 year before and after delivery. We identified women with a gestational diabetes mellitus pregnancy and examined postpartum diabetes screening type and timing and performed logistic regression to identify screening predictors., Results: Gestational diabetes mellitus was diagnosed in 32,253 (7.2%) women during the study timeframe. Three fourths received no screening within 1 year postpartum. Rates of recommended 75-g oral glucose tolerance testing within 6-12 weeks were low but increased over time (27 [2%] in 2001 compared with 249 [7%] in 2011, adjusted odds ratio [OR] 3.1, 95% confidence interval [CI] 2.0-47). Among women screened, those in the Northeast (19%) and South (18%) were least likely to receive a 75-g oral glucose tolerance test within 0-12 weeks (adjusted OR 0.4 for each, CI 0.4-0.5) compared with the West (36%). Asian women were most likely to receive any screening (18%; adjusted OR 1.5, CI 1.3-1.6) compared with white women (12%). Black women were most likely to receive hemoglobin A1c (21%; adjusted OR 2.0, CI 1.3-3.2) compared with white women (11%). Antepartum antiglycemic medication (21%; adjusted OR 2.1, CI 2.0-2.3) or visit to a nutritionist-diabetes educator (19%; adjusted OR 1.6, CI 1.4-1.7) or endocrinologist (23%; adjusted OR 1.7, CI 1.6-1.9) predicted screening within 12 weeks postpartum., Conclusion: Postpartum diabetes screening remains widely underused among commercially insured women with gestational diabetes mellitus. Differences in screening by geography, race, and antepartum care can inform health system and public health interventions to increase diabetes detection in this high-risk population.

Background: Little is known about the effect of the Affordable Care Act's (ACA) elimination of out-of-pocket costs for preventive services. This policy likely reduced out-of-pocket colonoscopy costs most for high-deductible health plan (HDHP) members., Objectives: Determine the ACA's impact on colorectal cancer screening among HDHP members., Research Design: Pre-post with comparison group, constructed before and after the ACA., Subjects: We studied 2003-2012 administrative claims data of a large national health insurer. HDHP members had 1 year of low-deductible (≤$500) plan enrollment followed by 1 year of HDHP (≥$1000) enrollment after an employer-mandated switch; HDHP enrollment occurred fully after the ACA for 21,605 members and fully before the ACA for 106,609 members. We propensity score-matched contemporaneous low-deductible (≤$500) control group members to both the before-ACA and after-ACA HDHP groups. We examined the 1-year impact of the HDHP switch separately in the before-ACA and after-ACA study cohorts, then compared these changes to estimate ACA effects., Measures: Overall colorectal cancer screening, colonoscopy, and fecal-occult blood testing annual rates., Results: Before the ACA, colorectal cancer screening tests declined by 37/10,000 (-71, -4) among HDHP members versus controls; after the ACA, HDHP members experienced a nonsignificant increase in screening [+52/10,000 (-19,124)]. Corresponding changes in colonoscopy were -55/10,000 (-81, -29) before and +20/10,000 (-38, 78) after the ACA. Thus, the ACA was associated with increased colorectal cancer screening rates [+89/10,000 (11, 168); relative: +9.1% (0.5-17.8)] and screening colonoscopies [+75/10,000 (12-139); relative: +16.4% (2.5-30.3)] among HDHP members., Conclusion: The ACA was associated with improved colorectal cancer screening among HDHP members.

Context: Prior research suggests that mammography declined from 2000 to 2005 and that socioeconomic disparities remained wide., Objective: To assess national trends and disparities in mammography among commercially insured women from 2001 to 2010., Design, Setting, Participants: This study used a longitudinal time series design to examine mammography rates among 5.4 million US women aged 40 to 64 years from 2001 to 2010. Adjusted annual rates stratified by age group (40-49 years/50-64 years) and neighborhood-level socioeconomic characteristics including poverty and race/ethnicity were plotted. Mammography disparities were defined as the absolute percentage difference in adjusted screening rates between population subgroups in a given year. Trends in 2001-2010 screening rates and socioeconomic disparities were fitted as annual percentage changes (APCs) using join point analysis, which can determine changes in trends., Main Outcome Measure: Annual and biennial mammogram., Results: Adjusted annual mammography rates among women aged 40 to 49 years increased from 38.5% to 45.5% (0.78% APC, P < .001) over the decade. Among women aged 50 to 64 years, 2001-2004 rates decreased from 49.7% to 47.4% (-0.78% APC, P = .035) and then increased to 51.8% by 2010 (APC of 0.80%, P < .001). Women aged 40 to 49 years had an unchanged high-low neighborhood poverty screening disparity of 11.0% over the decade (APC -0.05%, P = .508). The estimated white-black disparity decreased from 9.6% to 7.7% from 2001 to 2010 (-0.21% APC, P = .042). The white-Hispanic disparity decreased from 9.6% to 6.2% between 2001 and 2003 (APC -1.69%, P = .143) and then to 5.3% by 2010 (APC -0.14%, P = .343). Among women aged 50 to 64 years, estimated high-low poverty and white-black disparities declined (11.0%-9.5% [-0.16% APC, P = .026] and 8.6%-6.3% [-0.26% APC, P = .008], respectively) while the white-Hispanic disparity decreased from 14.9% to 5.4% between 2001 and 2003 (-4.77% APC, P = .023) and was 6.5% by 2010., Conclusions: Mammography increased among women aged 40 to 49 years from 2001 to 2010 and after 2004 among women aged 50 to 64 years. Women from black and Hispanic neighborhoods experienced reduced disparities, but disparities by poverty level changed little.

Background: Disabled Americans who qualify for Medicare coverage typically have multiple chronic conditions, are highly dependent on effective drug therapy, and have limited financial resources, putting them at risk for cost-related medication nonadherence (CRN). Since 2006, the Part D benefit has helped Medicare beneficiaries afford medications., Objective: To investigate recent national trends in medication affordability among this vulnerable population, stratified by morbidity burden., Design and Subjects: We estimated annual rates of medication affordability among nonelderly disabled participants in a nationally representative survey (2006-2011, n=14,091 person-years) using multivariate logistic regression analyses., Measure: Survey-reported CRN and spending less on other basic needs to afford medicines., Results: In the 6 years following Part D implementation, the proportion of disabled Medicare beneficiaries reporting CRN ranged from 31.6% to 35.6%, while the reported prevalence of spending less on other basic needs to afford medicines ranged from 17.7% to 21.8%. Across study years, those with multiple chronic conditions had consistently worse affordability problems. In 2011, the prevalence of CRN was 37.3% among disabled beneficiaries with ≥ 3 morbidities as compared with 28.1% among those with fewer morbidities; for spending less on basic needs, the prevalence was 25.4% versus 15.7%, respectively. There were no statistically detectable changes in either measure when comparing 2011 with 2007., Conclusions: Disabled Medicare beneficiaries continue to struggle to afford prescription medications. There is an urgent need for focused policy attention on this vulnerable population, which has inadequate financial access to drug treatments, despite having drug coverage under Medicare Part D.

Background: The use of lipid-lowering agents is suboptimal among dual enrollees, particularly blacks., Objectives: To determine whether the removal of restrictive drug caps under Medicare Part D reduced racial differences among dual enrollees with diabetes., Research Design: An interrupted time series with comparison series design (ITS) cohort study., Subjects: A total of 8895 black and white diabetes patients aged 18 years and older drawn from a nationally representative sample of fee-for-service dual enrollees (January 2004-December 2007) in states with and without drug caps before Part D., Measures: We examined the monthly (1) proportion of patients with any use of lipid-lowering therapies; and (2) intensity of use. Stratification measures included age (less than 65, 65 y and older), race (white vs. black), and sex., Results: At baseline, lipid-lowering drug use was higher in no drug cap states (drug cap: 54.0% vs. nondrug cap: 66.8%) and among whites versus blacks (drug cap: 58.5% vs. 44.9%, no drug cap: 68.4% vs. 61.9%). In strict drug cap states only, Part D was associated with an increase in the proportion with any use [nonelderly: +0.07 absolute percentage points (95% confidence interval, 0.06-0.09), P<0.001; elderly: +0.08 (0.06-0.10), P<0.001] regardless of race. However, we found no evidence of a change in the white-black gap in the proportion of users despite the removal of a significant financial barrier., Conclusions: Medicare Part D was associated with increased use of lipid-lowering drugs, but racial gaps persisted. Understanding non-coverage-related barriers is critical in maximizing the potential benefits of coverage expansions for disparities reduction.

Background: By shifting a greater share of out-of-pocket medical costs to consumers, high-deductible health plans (HDHP) might discourage use of essential outpatient services., Objective: The objective of the study was to examine the impact of an HDHP on outpatient visits and associated laboratory and radiology tests., Research Design/subjects: We used a pre-post with comparison group study design to examine the differential change in outpatient service utilization among 7953 adults who were switched from a traditional Health Maintenance Organization plan to an HDHP compared with 7953 adults remaining in traditional plans. HDHP members had full coverage of preventive laboratory tests and modest copayments for outpatient visits, similar to controls, but faced full cost sharing under the deductible for radiology tests and laboratory tests not classified as preventive., Results: Compared with controls, the HDHP group experienced moderate relative decreases in overall office visits (incidence rate ratios = 0.91, or a 9% relative reduction; 95% confidence interval: 0.88, 0.94) and visits for higher-priority (0.91; 0.85, 0.97) and lower-priority (0.89; 0.81, 0.99) chronic conditions. There were no significant differences in changes in visit rates for acute higher-priority or lower-priority conditions (both 0.93; 0.86, 1.01) or preventive laboratory tests (0.97; 0.93, 1.02). HDHP members showed moderate relative reductions in the use of general laboratory tests (0.91; 0.86, 0.97) but not radiology tests (0.97; 0.91, 1.03)., Conclusions: Chronic outpatient visits declined among HDHP members, although preventive laboratory tests and acute visits remained unchanged. HDHP patients with chronic illnesses who have more contact with the health care system might be more likely to reduce utilization because of increased exposure to costs associated with ambulatory visits.

Background: Although several national studies have attempted to measure medication nonadherence due to cost in cross-sectional studies of the elderly and disabled, little information exists on the psychometric properties of these measures over time., Objectives: Examine the test-retest reliability of several recently published measures of cost-related medication nonadherence, among elderly community., Methods: We developed a questionnaire and tested the reliability of measures of cost-related medication nonadherence and general cost-reduction strategies in a sample of 185 elderly in eastern Massachusetts surveyed twice (1-2 months apart). General and medicine-specific cost-related nonadherence measures included: failure to fill or delayed refilling of a prescription due to its cost, skipping doses, or taking smaller doses to make a medicine last longer. We also tested the reliability of reported drug cost-reduction strategies, such as: using generic drugs; purchasing prescriptions via mail/internet or from outside the United States; receiving prescription samples from a doctor; and spending less on food, heat, or other basic needs to afford medicines. We used the McNemar test, a matched pair chi analysis, and Kappa statistics to examine the association of responses within patients between identical items asked at 2 points in time., Results: Kappa statistics for test-retest reliability ranged from 0.6 to 0.9 for all but one measure of cost-related nonadherence, and McNemar test statistics indicated no systematic change in the measures over time., Conclusions: The estimated test-retest reliability of the measures of cost-related medication nonadherence were generally high. The measures have been integrated into the nationally representative Medicare Current Beneficiary Survey (MCBS), an ongoing national panel survey of Medicare beneficiaries, which will allow researchers and policymakers to identify changes in cost-related nonadherence among disabled and elderly Medicare beneficiaries.