Population-based persistency rates for topical glaucoma medications measured with pharmacy claims data.
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BACKGROUND: Persistency with drug therapy reflects a number of factors, including patient tolerability of adverse events resulting from therapy and clinician satisfaction with the medication's effectiveness in reducing intraocular pressure. OBJECTIVE: This study assesses persistency with topical glaucoma medications administered as initial therapy by evaluating rates of discontinuation and change in therapy. METHODS: A retrospective cohort study was conducted using pharmacy claims data from 3 geographically diverse healthcare plans. Newly treated glaucoma patients younger than 65 years of age were selected based on an initial glaucoma medication fill during a 12-month period. Patients were followed for persistency, defined as discontinuation or change (switch or add-on) of initial glaucoma therapy; discontinuation of therapy was also evaluated as a separate end point. RESULTS: In all, 1330 patients (followed for 1126 person-years) met the eligibility criteria. Compared with latanoprost users, patients initiated on other topical monotherapies were more likely to discontinue or change therapy, and patients initiated on other topical monotherapies were more likely than latanoprost users to discontinue therapy. CONCLUSION: Population-based data indicate that latanoprost offers superior persistency compared to agents from other popular classes of topical ocular hypotensives. (+info)
Cost of heart failure among hypertensive users of nonspecific NSAIDs and COX-2-specific inhibitors.
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OBJECTIVE: To determine the costs of heart failure in hypertensive patients receiving celecoxib, rofecoxib, and nonspecific nonsteroidal anti-inflammatory drugs (NSAIDs) in clinical practice. METHODS: Stable hypertensive patients without a history of heart failure and newly treated with celecoxib, rofecoxib, ibuprofen, naproxen, or diclofenac between January 1, 1999, and September 30, 2000, were identified from the LifeLink Integrated Claims Solutions employer database. The incidence rate of inpatient and outpatient heart failure claims was determined based on patients' time of exposure to study drugs after adjusting for confounding factors. The heart failure costs of managing inpatient and outpatient events were estimated as the total healthcare costs for patients with heart failure claims minus the total healthcare costs among matched control groups without heart failure claims. Healthcare costs were computed for the 0 to 30 days and 31 to 90 days following the initial outpatient or inpatient claim. Finally, the excess incidence rate of patients with inpatient and outpatient heart failure claims, relative to celecoxib, were multiplied by the heart failure cost of an inpatient and outpatient event to determine the incremental costs of heart failure associated with each of the study drugs relative to celecoxib. RESULTS: Among 50 940 patients, 707 patients had outpatient heart failure claims and 229 patients had inpatient heart failure claims. In this study, rofecoxib-treated patients were 26% more likely to have an outpatient claim (rate ratio [RR] = 1.26; 95% confidence interval [CI], 1.06-1.48; P= .007) and 52% more likely to have an inpatient claim (RR = 1.52; 95% Cl, 1.15-2.02; P = .003) for heart failure than celecoxib-treated patients. The adjusted RR of heart failure claims was similar between celecoxib and NSAIDs. The average cost of outpatient heart failure was $1054 within 30 days and $221 for the period 31 to 90 days after the initial claim (total 90-day cost of $1275). The cost for a patient with inpatient heart failure was $5966 during the hospitalization. The 90-day posthospitalization heart failure cost was $245 (total 90-day cost of $6,211 for hospitalization and follow-up). The total heart failure-related incremental cost per patient per day of use was $0.15 for rofecoxib and $0.04 for nonspecific NSAIDs relative to celecoxib. CONCLUSION: The additional heart failure costs associated with the use of rofecoxib significantly add to its cost in patients with stable hypertension, relative to celecoxib and nonspecific NSAIDs. The higher heart failure costs of rofecoxib were attributable to the higher incidence of patients with inpatient and outpatient heart failure claims relative to celecoxib and nonspecific NSAID populations being compared. (+info)
Health care provider quality improvement organization Medicare data-sharing: a diabetes quality improvement initiative.
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BACKGROUND: This paper describes a collaborative Medicare claims data linkage and sharing effort between the Baylor Health Care System (BHCS) and Texas Medical Foundation (TMF, the Texas Quality Improvement Organization) designed to assess the effect of three quality improvement interventions on care delivered to elderly patients with diabetes. The randomized controlled trial is being conducted among a network of primary care physician practices owned by BHCS and focuses on measures of care process and outcome. METHODS: Cohort definition and baseline measurement took place between January 1 and December 31, 2000. BHCS administrative data and TMF-supplied Medicare enrollment data were used to define the January 1, 2001 prevalence cohort of Medicare diabetic beneficiaries meeting study inclusion criteria. A total of 22 practices (with 92 physicians and 2,158 patients) were randomized to one of three interventions, each of which involved performance measurement feedback on three claims-based measures of care process. Physician profiles, generated by TMF using Medicare utilization files, were reported to study physicians via academic detailing sessions with a BHCS physician educator. RESULTS: The January 1 - December 31, 2000 baseline Medicare claims for the January 1, 2001 prevalence cohort were provided to HTPN by TMF in October 2001, representing a ten-month lag in the ability of Quality Improvement Organizations to provide Part B data relative to a specific episode of care time frame. Overall baseline rates for the claims-based process measures were: annual HbA1c testing (86.1%), annual eye examination (60.8%), and annual lipid profile (72.5%). As anticipated, medical-record based rates of annual eye examination were significantly underrepresented. Agreement between claims-based and medical record-based measures was very close for annual HbA1c and annual lipid profile. CONCLUSIONS: The use of Medicare claims data, through collaboration with a QIO, can help health care providers overcome a significant barrier associated with quality improvement initiatives. Limitations associated with the use of Medicare claims can impact implementation of intervention strategies, but do not prevent them from being a practical tool for improving care. (+info)
Improving the process through which health plans and providers exchange performance-related mammography data.
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The ability of health plans to bring about quality improvement is limited by the fact that physician networks are highly differentiated, with physician groups participating in many plans and plans contracting with many physician groups. The primary purpose of our study was to investigate the problems in the current system of quality monitoring by managed-care organizations (MCOs) at a large integrated health care delivery system (Montefiore Medical Center) and to develop ways of addressing these problems through collaboration among MCOs. The project began by mapping the current system for collecting, reporting, and using performance data to improve performance, using breast cancer screening as an example. We found that neither health plans nor providers were satisfied with the current system. From the perspective of the health plans, the current quality monitoring was costly and, more important, was not yielding appreciable increases in screening rates. From the providers' perspective, multiple health plan requests for chart pulls and other data collection activities cost them substantial amounts of time and money and generated multiple mailings of educational materials and reports, but rarely supplied meaningful information about their performance. From the perspective of the hospital, the current procedure of reporting from MCO to provider or center bypassed the institution's own quality monitoring and management structure and thus limited the institution's ability to assist in quality improvement. This study clearly showed the importance of collaboration among plans at a given provider site. Specifically, it pointed to the need for provider-oriented reporting of data, rather than plan-oriented reporting, to give physicians numbers that they believe. It also showed the need to engage the institution's own quality-management system to assist in bringing about improvements. (+info)
Using Medicare data to estimate the prevalence of breast cancer screening in older women: comparison of different methods to identify screening mammograms.
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OBJECTIVES: To compare different methods for defining screening mammograms with Medicare claims and their impact on estimates of breast cancer screening rates. METHODS: Medicare outpatient facility and physician claims for 61,962 women in 1993 and 59,652 women in 1998 were reviewed for evidence of receipt of screening mammography. We compared the estimates of screening mammography use derived from CPT (Current Procedure Terminology) codes to categorize mammograms as screening or diagnostic versus using an algorithm that uses CPT codes plus breast-related diagnoses in the prior two years. We also compared estimates obtained from review of physician claims alone, facility claims alone, or the combination of the two sources of claims. RESULTS: Use of physician claims alone produced estimates of screening rates similar to rates calculated from use of both physician and outpatient (facility) claims. In 1993, the CPT code for screening mammography underestimated the rate of screening compared to estimates generated by using the algorithm (8.3 percent versus 18.0 percent prevalence, p<0.001). By 1998, the screening prevalence rate generated from using the CPT code for screening mammography more closely approximated the rate generated by the algorithm (23.0 percent versus 25.1 percent). By all methods of estimating screening mammography with Medicare claims, its prevalence increased substantially between 1993 and 1998. CONCLUSION: Providers increased their use of the screening mammography code in their charges to Medicare during the 1990s. This has improved the claims' ability to distinguish screening from diagnostic mammograms, but screening rates computed with claims continue to fall below those generated from self-reports of mammography use among general populations of older women. (+info)
Patient reports of coverage denial: association with ratings of health plan quality and trust in physician.
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OBJECTIVE: To evaluate whether HMO patients' reports of denial of coverage were associated with their ratings of health plan quality and trust in their physician. STUDY DESIGN: Cross-sectional survey. PATIENTS AND METHODS: Within a mixed-model HMO, we surveyed 2000 adult patients who had seen a clinician at least once during the previous year. RESULTS: Of the 2000 patients, 921 (46%) responded. Denial of coverage within the previous 12 months was reported by 64 (7%) patients. Among the denials, 42% were for specialist referral, 32% were for tests or treatments, 18% were for a certain length of hospital stay, and 8% were for a hospital admission. Patients scoring in the lowest quartile on physical functioning were more than twice as likely as other patients to report denial of coverage (12.2% vs 5.1%, P = .001). In multivariable analyses, poor physical functioning remained the only significant independent variable associated with reporting denial of coverage (odds ratio = 3.0; 95% confidence interval, 2.4, 3.6). More than half (53%) of patients reporting denial of coverage said that they had considered leaving the health plan because of concerns about quality of care. These patients also were less likely to express high trust in their primary care physician (64% vs 78%, P < .001). CONCLUSIONS: Patients with poor physical functioning were more likely to report denial of coverage. Perceived denial of coverage was associated with lower ratings of health plan quality and with significantly less trust in patients' own primary care physicians. (+info)
Medicare program; improvement to the Medicare+Choice appeal and grievance procedures. Final rule with comment period.
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This final rule with comment period responds to comments on the January 24, 2001, proposed rule regarding improvements to the Medicare+Choice (M+C) appeal and grievance procedures. It establishes new notice and appeal procedures for enrollees when an M+C organization decides to terminate coverage of provider services. The January 24, 2001 proposed rule was published as a required element of an agreement entered into between the parties in Grijalva v. Shalala, civ. 93-711 (U.S.D.C. Az.), to settle a class action lawsuit. This rule also specifies a Medicare-participating hospital's responsibility for issuing discharge or termination notices under both the original Medicare and M+C programs, amends the Medicare provider agreement regulations with regard to beneficiary notification requirements, and amends M+C enrollee grievance procedures. (+info)
A prediction model for targeting low-cost, high-risk members of managed care organizations.
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OBJECTIVE: To describe the development and validation of a predictive model designed to identify and target HMO members who are likely to incur high costs. STUDY DESIGN: Split-sample multivariate regression analysis. PATIENTS AND METHODS: We studied enrollees in a 350000-member HMO with > or = 1 claim in 1998 and 1999. The prediction model uses a combination of clinical and behavioral vaiables and 1998 and 1999 claims data. The prediction model was applied and used to rank low-cost patients (1998 cost < dollars 2000) according to their estimated probability of incurring costs > or = dollars 2000 in 1999. For prospective testing, we applied our models to data that are not available in advance. The same prediction model was applied to rank a different set of low-cost patients (1999 cost < dollars 2000) according to estimated probability of incurring costs > or = dollars 2000 in 2000. Because the predictions were used for disease management purposes, the outcomes of a randomly selected control group not intervened on for the disease management program was analyzed. The predictive accuracy of the model was tested by comparing the percentages of "targeted" vs all low-cost patients who incurred high costs in the subsequent year. RESULTS: Of the low-cost, top-ranked 1998 patients, 47.8% incurred high (> or = dollars 2000) medical expenses in 1999 vs 14.2% of randomly selected patients who were low cost in 1998. Of the top-ranked 1999 patients, 39.7% incurred high costs in 2000 vs 12.2% of the randomly selected low-ranked patients. CONCLUSIONS: The prediction model successfully identifies low-cost, high-risk patients who are likely to incur high costs in the next 12 months. (+info)