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Background: Prior studies of the Medicare Part D coverage gap are limited in generalizability and scope. Objective: To determine the effect of the coverage gap on drugs used for asymptomatic (antihypertensive and lipid-lowering drugs) and symptomatic (pain relievers, acid suppressants, and antidepressants) conditions in elderly patients with hypertension and hyperlipidemia. Design: Quasi-experimental study using pre-post design and contemporaneous control group. Setting: Medicare claims files from 2005 and 2006 for 5% random sample of Medicare beneficiaries. Patients: Part D plan enrollees with hypertension or hyperlipidemia aged 65 years or older who had no coverage, generic-only coverage, or both brand-name and generic coverage during the gap in 2006. Patients who were fully eligible for the low-income subsidy served as the control group. Measurements: Monthly 30-day supply prescriptions available, medication adherence, and continuous medication gaps of 30 days or more for antihypertensive or lipid-lowering drugs; monthly 30-day supply prescriptions available for pain relievers, acid suppressants, or antidepressants before and after coverage gap entry. Results: Patients with no gap coverage had a decrease in monthly antihypertensive and lipid-lowering drug prescriptions during the coverage gap. Nonadherence also increased in this group (antihypertensives: odds ratio [OR], 1.60 [95% CI, 1.50 to 1.71]; lipid-lowering drugs: OR, 1.59 [CI, 1.50 to 1.68]). The proportion of patients with no gap coverage who had continuous medication gaps in lipid-lowering medication use and antihypertensive use increased by an absolute 7.3% (OR, 1.38 [CI, 1.29 to 1.46]) and 3.2% (OR, 1.35 [CI, 1.25 to 1.45]), respectively, because of the coverage gap. Decreases in use were smaller for pain relievers and antidepressants and larger for acid suppressants in patients with no gap coverage. Patients with generic-only coverage had decreased use of cardiovascular medications but no change in use of drugs for symptomatic conditions. No measures changed in the brand-name and generic coverage groups. Results of sensitivity analyses were consistent with the main findings. Limitation: Because this study was nonrandomized, unobserved differences may still exist between study groups. Conclusion: The Part D coverage gap was associated with decreased use of medications for hypertension and hyperlipidemia in patients with no gap coverage and generic-only gap coverage. The proposed phasing out of the gap by 2020 will benefit such patients; however, use of low-value medications may also increase. Primary Funding Source: Penn-Pfizer Alliance and American Heart Association. [ABSTRACT FROM AUTHOR]

Gray SW, Hornik RC, Schwartz JS, Armstrong K. The impact of risk information exposure on women's beliefs about direct-to-consumer genetic testing for BRCA mutations. Despite an increase in direct-to-consumer (DTC) genetic testing, little is known about how variations in website content might alter consumer behavior. We evaluated the impact of risk information provision on women's attitudes about DTC BRCA testing. We conducted a randomized experiment; women viewed a 'mock' BRCA testing website without [control group (CG)] or with information on the potential risks of DTC testing [RG; framed two ways: unattributed risk (UR) information and risk information presented by experts (ER)]. Seven hundred and sixty-seven women participated; mean age was 37 years, mean education was 15 years, and 79% of subjects were white. Women in the RG had less positive beliefs about DTC testing (mean RG = 23.8,CG = 25.2;p = 0.001), lower intentions to get tested (RG = 2.8,CG = 3.1;p = 0.03), were more likely to prefer clinic-based testing (RG = 5.1,CG = 4.8;p = 0.03) and to report that they had seen enough risk information (RG = 5.3,CG = 4.7;p < 0.001). UR and ER exposure produced similar effects. Effects did not differ for women with or without a personal/family history of breast/ovarian cancer. Exposing women to the potential risks of DTC BRCA testing altered their beliefs, preferences, and intentions. Risk messages appear to be salient to women irrespective of their chance of having a BRCA mutation. [ABSTRACT FROM AUTHOR]

Objective: Examine how patient-clinician information engagement (PCIE) may operate through feeling informed to influence patients' treatment decision satisfaction (TDS).Methods: Randomly drawn sample (N=2013) from Pennsylvania Cancer Registry, comprised of breast, prostate and colon cancer patients completed mail surveys in the Fall of 2006 (response rate=64%) and Fall of 2007. Of 2013 baseline respondents, 85% agreed to participate in follow-up survey (N=1703). Of those who agreed, 76% (N=1293) completed follow-up surveys. The sample was split between males and females. The majority of participants were White, over the age of 50, married, and with a high school degree. Most reported having been diagnosed with in situ and local cancer.Results: PCIE was related to concurrent TDS (beta=.06) and feeling informed (beta=.15), after confounder adjustments. A mediation analysis was consistent with PCIE affecting TDS through feeling informed. Baseline PCIE predicted feeling informed (beta=.04) measured 1 year later, after adjustments for baseline feeling informed and other confounders. Feeling informed was related to concurrent TDS (beta=.35) after confounder adjustment and follow-up TDS (beta=.13) after baseline TDS and confounder adjustment.Conclusion: Results suggest PCIE affects TDS in part through patients' feeling informed.Practice Implications: PCIE may be important in determining patients' level of feeling informed and TDS. [ABSTRACT FROM AUTHOR]

BACKGROUND: Little is known about the effect of guidelines that recommend shared decision making on physician practice patterns. The objective of this study was to determine the association between physicians' perceived effect of guidelines on clinical practice and self-reported prostate-specific antigen (PSA) screening patterns. METHODS: This was a cross-sectional study using a nationally representative sample of 3914 primary care physicians participating in the 1998-1999 Community Tracking Study Physician Survey. Responses to a case vignette that asked physicians what proportion of asymptomatic 60-year-old white men they would screen with a PSA were divided into 3 distinct groups: consistent PSA screeners (screen all), variable screeners (screen 1%- 99%), and consistent nonscreeners (screen none). Logistic regression was used to determine the association between PSA screening patterns and physician-reported effect of guidelines (no effect v. any magnitude effect). RESULTS: Only 27% of physicians were variable PSA screeners; the rest were consistent screeners (60%) and consistent nonscreeners (13%). Only 8% of physicians perceived guidelines to have no effect on their practice. After adjustment for demographic and practice characteristics, variable screeners were more likely to report any magnitude effect of guidelines on their practice when compared with physicians in the other 2 groups (adjusted odds ratio= 1.73; 95% confidence interval=1:25-2:38;P=0:001). CONCLUSIONS: Physicians who perceive an effect of guidelines on their practice are almost twice as likely to exhibit screening PSA practice variability, whereas physicians who do not perceive an effect of guidelines on their practice are more likely to be consistent PSA screeners or consistent PSA nonscreeners. [ABSTRACT FROM AUTHOR]

Reducing risk factors for patients with vascular disease can reduce the subsequent incidence of cerebro-cardiovascular disease. While physicians have had extensive training in the importance of atherosclerotic vascular disease risk factor modification, evidence suggests that they systematically miss opportunities for clinical prevention during routine practice. The aim of this study was to identify whether physicians felt confident in their knowledge and effectiveness regarding counseling patients to reduce cardiovascular risk and to determine barriers to prevention interventions in the office setting. Surveys were mailed to 509 physicians affiliated with an academic community hospital. Nonrespondents were sent reminders and a second survey. Comparisons were made using chi-square analysis. Two hundred and five surveys were returned (40.3%). Thirty-six percent of physicians felt knowledgeable about weight management techniques, compared to 3% who were confident that they succeeded in their practice (p < 0.001). Similar patterns were found for Tobacco Cessation (62% versus 14%, p = 0.001), Alcohol Reduction (46% versus 7%, p < 0.001), Stress Management (35% versus 5%, p < 0.001), Exercise (53% versus 10%, p < 0.001), Nutrition (36% versus 8%, p < 0.001), Diabetes Management (48% versus 23%, p < 0.001), Blood Pressure Management (57% versus 43%, p < 0.001) and Lipid Management (59% versus 38%, p < 0.001). We identified a significant gap between physician confidence in their knowledge about risk factors and their effectiveness at providing counseling and obtaining results in their office. Most physicians felt that the routine office follow-up visit was an ineffective method for instituting vascular risk factor reduction. Alternate settings for risk factor reduction may be needed for improving atherosclerosis prevention. [ABSTRACT FROM AUTHOR]

Study Objective: We determined the additional cost of an extended emergency department (ED) length of stay for chest pain patients awaiting non-ICU, monitored (telemetry) beds.Methods: This was a prospective cohort study of all ED chest pain patients aged 24 years or older and admitted to a telemetry bed in an urban university hospital during a 12-month period. Structured ED data collection included demographics, chest pain presentation, medical history, and laboratory test and ECG results. Hospital course was monitored daily, followed by a 30-day telephone follow-up. Risk severity scores (Goldman, Acute Cardiac Ischemia-Time-Insensitive Predictive Instrument, and Charlson) were calculated. Hospital charges, real costs, and revenues were obtained at discharge and 2 years later. The main outcome measure was risk-adjusted additional cost to the hospital of a delayed ED admission. Clinical outcome was a secondary measure.Results: Of the 817 patients with chest pain presenting to the ED during the study period, there were 904 hospitalizations. Of these, 825 patients waited more than 3 hours for their bed (91%). There were 21 patient visits with a final diagnosis of acute myocardial infarction. ED length of stay was not associated with total hospital length of stay (r =0.01), hospital costs, or hospital or professional charges, revenues, or collection rates. The annual opportunity cost in lost hospital revenue for chest pain patients was 168,300 US dollars (204 US dollars per patient waiting >3 hours for a hospital bed).Conclusion: Extended ED length of stay demonstrated no association with total hospital costs or revenues or total hospital length of stay but imposed substantial ED opportunity costs, with decreased potential revenue. Interventions that reduce ED delays in hospital admissions have the potential to significantly increase hospital revenues. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To examine the effectiveness of a transitional care intervention delivered by advanced practice nurses (APNs) to elders hospitalized with heart failure. DESIGN: Randomized, controlled trial with follow-up through 52 weeks postindex hospital discharge. SETTING: Six Philadelphia academic and community hospitals. PARTICIPANTS: Two hundred thirty-nine eligible patients were aged 65 and older and hospitalized with heart failure. INTERVENTION: A 3-month APN-directed discharge planning and home follow-up protocol. MEASUREMENTS: Time to first rehospitalization or death, number of rehospitalizations, quality of life, functional status, costs, and satisfaction with care. RESULTS: Mean age of patients (control n=121; intervention n=118) enrolled was 76; 43% were male, and 36% were African American. Time to first readmission or death was longer in intervention patients (log rank chi(2)=5.0, P=.026; Cox regression incidence density ratio=1.65, 95% confidence interval=1.13-2.40). At 52 weeks, intervention group patients had fewer readmissions (104 vs 162, P=.047) and lower mean total costs ($7,636 vs $12,481, P=.002). For intervention patients, only short-term improvements were demonstrated in overall quality of life (12 weeks, P<.05), physical dimension of quality of life (2 weeks, P<.01; 12 weeks, P<.05) and patient satisfaction (assessed at 2 and 6 weeks, P<.001). CONCLUSION: A comprehensive transitional care intervention for elders hospitalized with heart failure increased the length of time between hospital discharge and readmission or death, reduced total number of rehospitalizations, and decreased healthcare costs, thus demonstrating great promise for improving clinical and economic outcomes. [ABSTRACT FROM AUTHOR]

Context: Comprehensive discharge planning by advanced practice nurses has demonstrated short-term reductions in readmissions of elderly patients, but the benefits of more intensive follow-up of hospitalized elders at risk for poor outcomes after discharge has not been studied.Objective: To examine the effectiveness of an advanced practice nurse-centered discharge planning and home follow-up intervention for elders at risk for hospital readmissions.Design: Randomized clinical trial with follow-up at 2, 6, 12, and 24 weeks after index hospital discharge.Setting: Two urban, academically affiliated hospitals in Philadelphia, Pa.Participants: Eligible patients were 65 years or older, hospitalized between August 1992 and March 1996, and had 1 of several medical and surgical reasons for admission.Intervention: Intervention group patients received a comprehensive discharge planning and home follow-up protocol designed specifically for elders at risk for poor outcomes after discharge and implemented by advanced practice nurses.Main Outcome Measures: Readmissions, time to first readmission, acute care visits after discharge, costs, functional status, depression, and patient satisfaction.Results: A total of 363 patients (186 in the control group and 177 in the intervention group) were enrolled in the study; 70% of intervention and 74% of control subjects completed the trial. Mean age of sample was 75 years; 50% were men and 45% were black. By week 24 after the index hospital discharge, control group patients were more likely than intervention group patients to be readmitted at least once (37.1 % vs 20.3 %; P<.001). Fewer intervention group patients had multiple readmissions (6.2% vs 14.5%; P = .01) and the intervention group had fewer hospital days per patient (1.53 vs 4.09 days; P<.001). Time to first readmission was increased in the intervention group (P<.001). At 24 weeks after discharge, total Medicare reimbursements for health services were about $1.2 million in the control group vs about $0.6 million in the intervention group (P<.001). There were no significant group differences in post-discharge acute care visits, functional status, depression, or patient satisfaction.Conclusions: An advanced practice nurse-centered discharge planning and home care intervention for at-risk hospitalized elders reduced readmissions, lengthened the time between discharge and readmission, and decreased the costs of providing health care. Thus, the intervention demonstrated great potential in promoting positive outcomes for hospitalized elders at high risk for rehospitalization while reducing costs. [ABSTRACT FROM AUTHOR]

A decision analytic model was used to examine alternative strategies to screen donated blood for human immunodeficiency virus (HIV) using data from the literature and from 1987 blood-screening programs in areas with high and low prevalence of HIV. Sensitivity analyses incorporated uncertainties about HIV infection and test performance. Current screening strategies are estimated to allow 20.5 infected units per million donated units to be transfused at a cost of $16,850 per HIV-positive unit detected in high-prevalence areas and 4.7 infected units per million donated units to be transfused at a cost of $32,275 per HIV-positive unit detected in low prevalence areas, with nine false-positive notifications of uninfected patients per million units screened and 14.9 discarded, noninfected units per HIV-positive unit in low-prevalence areas. Testing donated blood for HIV can be improved by individualizing screening strategies for areas with different prevalences of HIV. Efforts to further reduce transfusion-associated HIV should focus on improved test performance in early stages of infection, reduction of unnecessary transfusions, donor recruitment in lower-risk groups, and public health measures to reduce HIV infection among the general population. [ABSTRACT FROM AUTHOR]

Objective: To determine whether hospital rankings based on complication rates provide the same information as hospital rankings based on mortality rates.Design: A retrospective study of in-hospital death, complication, and death following complication (failure to rescue). Hospitals were ranked using residuals based on the difference between the observed and the expected number of events (from logistic regression models); rankings were compared using Spearman rank correlations.Setting: Hospitals performing coronary artery bypass graft (CABG) surgery in the 1991 and 1992 MedisGroups National Comparative Data Bases. PATIENTS AND DATA SETS: Record abstraction data for 16,673 patients who underwent CABG procedures at 57 hospitals, linked with data from the 1991 American Hospital Association Annual Survey.Results: After adjusting for patient admission severity of illness, there were low correlations between hospital rankings based on death or failure to rescue and those rankings based on complication (death vs complication, r = 0.07, P = .58; failure to rescue vs complication, r = -0.22, P = .11). In addition, many hospital characteristics that are generally associated with a higher quality of care were associated with higher complication rates but with expected or lower-than-expected mortality rates.Conclusions: Hospital rankings based on complication rates provide different information than those based on mortality rates. Until more is known about these differences, complication rates should not be used to judge hospital quality of care in CABG surgery. [ABSTRACT FROM AUTHOR]

Objective: To compare the appropriateness of use of coronary artery bypass graft (CABG) surgery in Academic Medical Center Consortium hospitals as judged 1) according to criteria developed by an expert panel, 2) according to revisions of those criteria made by cardiac surgeons from the Academic Medical Center Consortium, and 3) by review of cases by the surgeons responsible for those cases.Design: Retrospective, randomized medical record review.Setting: 12 Academic Medical Center Consortium hospitals.Patients: Random sample of 1156 patients who had had isolated CABG surgery in 1990.Main Outcome Measures: 1) Percentage of patients with indications for which CABG surgery was classified as appropriate, Inappropriate, or of uncertain appropriateness and 2) percentage of cases in which CABG surgery was judged inappropriate or uncertain for which ratings changed after local case review.Results: Data were retrieved from medical records by trained abstractors using an explicit data collection instrument. Cases in which CABG surgery was judged to be inappropriate or uncertain were individually reviewed by the responsible surgeons. According to the expert panel ratings, 83% of the CABG operations (95% CI, 81% to 85%) were necessary, 9% (CI, 8% to 10%) were appropriate, 7% (CI, 5% to 8%) were uncertain, and 1.6% (CI, 0.6% to 2.5%) were inappropriate. These rates are almost identical to those found in a previous study that was done in New York State and that used the same criteria (in that study, 91% of operations were classified as necessary or appropriate, 7% were classified as uncertain, and 2.4% were classified as inappropriate). Rates of inappropriate procedures varied from 0% to 5% among the 12 member hospitals (P = 0.02). The Academic Medical Center Consortium cardiac surgeons revised 568 (24%) of the indications used by the expert panel. However, because those revisions altered the appropriateness ratings in both directions and affected only 50 cases (4%), the net effect of the revisions was slight: The rate of inappropriate CABG surgery increased from 1.6% to 1.9%. Local review found that data collection errors had caused erroneous ratings in 12.5% of 64 cases in which surgery had been classified as inappropriate or uncertain.Conclusions: The Academic Medical Center Consortium hospitals had low rates of inappropriate and uncertain use of CABG surgery, regardless of the criteria used for assessment. Even though surgeons from the Consortium revised the appropriateness ratings extensively, their revisions had a negligible effect on the overall assessment of appropriateness. However, because of potential data collection errors, appropriateness criteria should be used for individual case audits only if supplemented by subsequent physician review. [ABSTRACT FROM AUTHOR]

Objective: To compare the economic consequences of doxycycline therapy with those of azithromycin therapy for women with uncomplicated cervical chlamydial infections.Design: Decision analysis in which the health outcomes, costs, and cost-effectiveness of two provider-administered treatment strategies for women with uncomplicated cervical chlamydial infections were compared: 1) initial therapy with doxycycline, 100 mg orally twice daily for 7 days (estimated cost, $5.51) and 2) initial therapy with azithromycin, 1 g orally administered as a single dose (estimated cost, $18.75).Results: Under baseline assumptions, the azithromycin strategy incurred fewer major and minor complications and was less expensive overall than the doxycycline strategy despite a higher initial cost for acquiring antibiotic agents. In univariate sensitivity analyses, the azithromycin strategy prevented more major complications but was more expensive than the doxycycline strategy when doxycycline effectiveness was greater than 0.93. In a multivariate sensitivity analysis combining 11 parameter estimates selected so that the cost-effectiveness of the doxycycline strategy would be maximized relative to that of the azithromycin strategy, the azithromycin strategy resulted in fewer complications but was more costly. The incremental cost-effectiveness was $521 per additional major complication prevented. However, if the difference in the cost of azithromycin and doxycycline decreased to $9.80, the azithromycin strategy was less expensive and more effective, even under these extreme conditions.Conclusions: On the basis of the best available data as derived from the literature and experts, the azithromycin strategy was more cost-effective than the doxycycline strategy for women with uncomplicated cervical chlamydial infections. Despite the dominance of the azithromycin strategy over the doxycycline strategy, the adoption of the azithromycin strategy may be limited by the practical financial constraints of our currently fragmented health care system, in which the costs and benefits of preventing chlamydia sequelae are often incurred by different components of the system. [ABSTRACT FROM AUTHOR]