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In regions experiencing aquifer depletion, planning for groundwater sustainability requires both accurate accounting of current groundwater budgets and an assessment of future conditions, with changes in recharge and pumping. Hydrologic variability, climate change effects on water flows, changing water infrastructure operations, and inherent uncertainties in modeling, challenge the plans to achieve groundwater sustainability. This paper examines the importance, magnitude, and policy implications of uncertainties in groundwater overdraft estimation for water management in California. We review water balance estimates from two regional-scale groundwater models—C2VSim and CVHM—for sub-regions within California's Central Valley, and examine the variability and uncertainty in historical and future estimates of groundwater overdraft. Assuming reductions in agricultural water use for sub-regions with overdraft, we estimate the probabilities of ending groundwater overdraft for different periods. We also obtain the economic costs associated with these reductions in agricultural production. Results from both groundwater models show significant inter-annual variability in flows affecting groundwater storage, and our model comparison highlights the uncertainty in water budget estimates for Central Valley sub-regions given the differences between models. The analysis of the probabilities of achieving sustainability at the sub-regional scale show that the average overdraft rate is important and that greater variance in annual groundwater storage increases uncertainties in ending overdraft, especially for shorter periods. Greater reductions in annual net water increases the reliability of achieving groundwater sustainability, but rising rapidly agricultural economic losses. Setting management thresholds below groundwater levels can ease meeting sustainability criteria, but also can introduce a false pathway to sustainability. Finally, we discuss policy implications for the design of local groundwater sustainability plans and state assessment and regulation of local plans. • Many regions in California's Central Valley use groundwater unsustainably. • Uncertainty in models and future hydrology challenge groundwater sustainability. • Comparison of models shows significant uncertainty in estimates for water budgets. • Less water use increases sustainable paths but also agricultural economic losses. • Consideration of uncertainty and costs is essential for planning for sustainability. [ABSTRACT FROM AUTHOR]

In a northern California population of older women who were treated with oral bisphosphonate drugs, the incidence of atypical femur fracture, a rare complication of treatment, increased with longer duration of bisphosphonate exposure. These findings align with those previously reported in an independent southern California population., Introduction: The age-adjusted incidence of atypical femur fracture (AFF) reported in southern California increased with bisphosphonate (BP) exposure, ranging up to 113 per 100,000 person-years for 8-10-year exposure. This study examines the incidence of AFF in a northern California population., Methods: Women age 45-89 years who initiated oral BP during 2002-2014 in Kaiser Permanente Northern California were followed for AFF outcome, defined by a primarily transverse diaphyseal femur fracture through both cortices, with focal periosteal/endosteal hypertrophy, minimal trauma, and minimal/no comminution. Total BP exposure was determined from dispensed prescriptions. The incidence of AFF, calculated for 2-year BP categories ranging from < 2 to > 10 years, was age-adjusted using the 2000 US Census., Results: Among 94,542 women, 107 experienced an AFF during or < 1 year after BP cessation (mean exposure 6.6 ± 3.0 years and total days' supply 5.7 ± 2.8 years at AFF). A strong relationship between AFF incidence and increasing BP exposure was seen, more than doubling for each 2-year category until 8-10 years. Among women with 2- to < 4-year BP, the crude and age-adjusted incidence was 18 and 9 per 100,000 person-years but increased over 2- and 5-fold for women with 4- to < 6- and 6- to < 8-year BP, respectively. For those receiving ≥ 8-year BP, the crude and age-adjusted incidence peaked at 196 and 112 per 100,000 person-years exposure., Conclusion: Incidence of AFF increases markedly after 4-6 years of BP. These trends align with southern California and confirm a strong BP duration-related risk of this rare but serious event.

Unlabelled: Contemporary femur fracture rates were examined in northern California women and compared by race/ethnicity. During 2006-2012, hip fracture rates declined, but diaphyseal fracture rates increased, especially in Asians. Women with diaphyseal fracture were younger and more likely to be bisphosphonate-treated. These disparities in femur fracture should be further examined., Introduction: The epidemiology of diaphyseal femur fracture differs from proximal femur (hip) fracture, although few studies have examined demographic variations in the current era. This study examines contemporary differences in low-energy femur fracture by race/ethnicity in a large, diverse integrated health-care delivery system., Methods: The incidence of hip and diaphyseal fracture in northern California women aged ≥50 years old during 2006-2012 was examined. Hip (femoral neck and pertrochanteric) fractures were classified by hospital diagnosis codes, while diaphyseal (subtrochanteric and femoral shaft) fractures were further adjudicated based on radiologic findings. Demographic and clinical data were obtained from health plan databases. Fracture incidence was examined over time and by race/ethnicity., Results: There were 10,648 (97.3 %) hip and 300 (2.7 %) diaphyseal fractures among 10,493 women. The age-adjusted incidence of hip fracture fell from 281 to 240 per 100,000 women and was highest for white women. However, diaphyseal fracture rates increased over time, with a significant upward trend in Asians (9 to 27 per 100,000) who also had the highest rate of diaphyseal fracture. Women with diaphyseal fracture were younger than women with hip fracture, more likely to be of Asian race and to have received bisphosphonate drugs. Women with longer bisphosphonate treatment duration were also more likely to have a diaphyseal fracture, especially younger Asian women., Conclusion: During 2006 to 2012, hip fracture rates declined, but diaphyseal fracture rates increased, particularly among Asian women. The association of diaphyseal fracture and bisphosphonate therapy should be further investigated with examination of fracture pattern.

Context: Medicare Part D drug benefits include substantial cost sharing., Objective: To determine beneficiaries' knowledge of benefits and cost responses., Design, Setting, and Participants: Telephone interviews were conducted in 2007 in a stratified random sample of community-dwelling Kaiser Permanente-Northern California Medicare Advantage beneficiaries aged 65 years or older, with a gap in coverage if they exceeded $2250 in drug costs (N = 1040; 74.9% response rate). Half were selected to have reached the gap in 2006. In the source population of Medicare Advantage Prescription Drug plan beneficiaries, 8% entered the coverage gap in 2006. Models were adjusted for individual characteristics and weighted for sampling proportions., Main Outcome Measures: Knowledge of cost sharing including awareness of the coverage gap, gap start and end amounts, and drug cost sharing before, during, and after the gap. Cost-related responses including cost-coping behaviors (eg, switching to lower-cost medications), reduced adherence (eg, not refilling prescriptions), and financial burden (eg, going without necessities)., Results: An estimated 40% (95% confidence interval [CI], 35%-45%) of beneficiaries were aware that their drug plan in 2006 included a coverage gap; knowledge of the gap was greater among individuals who reached the gap during the year. Approximately 36% (95% CI, 32%-41%) of beneficiaries reported at least 1 of the following responses to drug costs: cost-coping behavior (26%), reduced adherence (15%), or experiencing financial burden (7%). In multivariate analyses, beneficiaries with lower household income more frequently reported cost responses (difference of 14.5 percentage points for < $40,000/y vs > or = $40,000/y [95% CI, 3.6-25.4 percentage points]). Compared with beneficiaries who were unaware of having a coverage gap, those who were aware more frequently reported any cost response (difference of 11.3 percentage points [95% CI, 0.8-21.9 percentage points]), but had fewer reports of borrowing money or going without necessities (difference of 5.5 percentage points [95% CI, 1.1-10.0 percentage points])., Conclusions: Beneficiaries in this Medicare Advantage plan have limited knowledge of Part D cost sharing and often report behavioral responses to drug costs. Limited knowledge is associated with fewer reports of cost responses overall, but more reports of financial burden.

Background: Generic-only pharmacy benefits may present more of a burden to patients with chronic disease conditions such as chronic obstructive pulmonary disease (COPD), where generic drug therapy choices are more limited., Objective: To evaluate the strategies that elderly patients with COPD use to manage their out-of-pocket (OOP) prescription expenses in a generic-only pharmacy benefit compared with similar patients with a single-tier copayment or a 2-tier pharmacy benefit with coverage of brand formulary drugs., Methods: Surveys were mailed to a sample of 3,000 Kaiser Permanente (California) patients (aged > or = 65 years) who had a diagnosis for COPD and received at least 1 prescription for a COPD-related medication during 2003. The sample was stratified by type of pharmacy benefit: generic-only, single copayment tier, and 2 copayment tiers. The survey contained questions about strategies used to reduce OOP prescription expenses, such as stop taking a prescribed medication, purchase prescriptions out of the country, or discuss OOP prescription expenses with a physician. The likelihood of using specific strategies to reduce OOP prescription expenses was modeled using logistic regression. Covariates included social support, quality of life, smoking status, socioeconomic status, total prescription costs, and demographics., Results: A total of 1,624 surveys were returned, for a 54% response rate. Results from logistic regressions indicate that COPD patients with a generic-only benefit are significantly more likely to report that they discussed their OOP costs with their physician (odds ratio [OR]=9.02; 95% confidence interval [CI], 6.15- 13.22), purchased their medications from another country (OR=6.70; 95% CI, 3.17-14.16) and reduced spending on food and clothing (OR=4.06; 95% CI, 2.70-6.12). They are also more likely to report that they had taken less than the prescribed amount of a regular medication (OR=1.70; 95% CI, 1.25-2.31) and that they stopped taking one or more of their regular medications (OR=1.77; CI, 1.27-2.47). Patients with low annual household incomes (<25,000 US dollars) were significantly more likely to discuss their OOP costs with their physician (OR=1.47; 95% CI, 1.08-2.00 ) and to reduce spending on food and clothing (OR=1.97; 95% CI, 1.42-2.73) than those with higher incomes. Approximately 15% of COPD patients obtained drug samples from their physicians as a method to reduce OOP costs, and there was no difference among the 3 groups in the prevalence of this cost management strategy. Overall, patients in the generic-only pharmacy benefit used an average of 3 methods to reduce OOP pharmacy costs compared with approximately 1.5 cost reduction methods used by patients in single-tier and 2-tier copayment designs who had coverage of formulary brand as well as generic drugs., Conclusion: Elderly patients with COPD and a generic-drug-only pharmacy benefit are more likely to report using a variety of strategies to reduce their OOP costs compared with similar patients with single-tier copayment or 2-tier copayment pharmacy benefits. The most common strategy was discussing OOP costs with their physician, and use of this strategy was inversely related to household income. There was no difference in the proportion of COPD patients among the 3 pharmacy benefit groups that used drug samples from their physicians as a means to reduce OOP costs.

Objectives: Many health maintenance organizations (HMOs) have selected 1 or 2 selective serotonin reuptake inhibitors (SSRIs) as their preferred drug for treating depression. This study investigated the effect of "single-drug" formulary restrictions on the likelihood of drug therapy completion for new patients, controlling for initial SSRIs used and other factors., Methods: Prescription drug and medical record data for 187 patients who were newly prescribed SSRIs were retrieved from a single California group practice consisting of 22 board-certified primary care physicians. The group practice contracted with 2 independent practice association-model HMOs with different SSRI formulary restrictions. A multivariate analysis of drug therapy completion was conducted and 2 sensitivity analyses were performed. Completed therapy was based on the patient having achieved 6 months of uninterrupted therapy at a minimum therapeutic dose., Results: Patients from the HMO with a single preferred SSRI (paroxetine) were 80% less likely to complete therapy than were patients from the HMO with 2 preferred SSRIs (fluoxetine and paroxetine) (odds ratio [OR] = 0.200, 95% confidence interval [CI] = 0.083-0.430). This formulary effect was independent of the initial drug used to treat the patient. Drug selection was also found to affect completion rates. Patients treated with sertraline were significantly less likely to complete therapy than were patients treated with fluoxetine (OR = 0.319, 95% CI = 0.105-0.968). Similar results were found for patients taking paroxetine relative to fluoxetine (OR = 0.357, 95% CI = 0.149-0.853)., Conclusion: These results suggest that the use of single-product formularies may have unintended consequences on patient completion rates, independent of whether or not the most effective product is selected for preferred formulary status.