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Adherence to beta-blocker therapy under drug cost-sharing in patients with and without acute myocardial infarction.

https://arctichealth.org/en/permalink/ahliterature162000
Source
Am J Manag Care. 2007 Aug;13(8):445-52
Publication Type
Article
Date
Aug-2007
Author
Sebastian Schneeweiss
Amanda R Patrick
Malcolm Maclure
Colin R Dormuth
Robert J Glynn
Author Affiliation
Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont St (Ste 3030), Boston, MA 02120, USA. schneeweiss@post.harvard.edu
Source
Am J Manag Care. 2007 Aug;13(8):445-52
Date
Aug-2007
Language
English
Publication Type
Article
Keywords
Acute Disease
Adrenergic beta-Antagonists - economics - therapeutic use
Aged
Aged, 80 and over
British Columbia
Case-Control Studies
Cohort Studies
Comorbidity
Cost Sharing
Deductibles and Coinsurance
Diabetes Complications
Female
Health Policy - trends
Humans
Male
Medical Record Linkage
Myocardial Infarction - drug therapy - economics
Patient Compliance - statistics & numerical data
Prescription Fees
Vascular Diseases
Abstract
To evaluate the effects of patient copayment and coinsurance policies on adherence to therapy with beta-adrenergic blocking agents (beta-blockers) and on the rate of initiation of beta-blocker therapy after acute myocardial infarction (MI) in a population-based natural experiment.
Three sequential cohorts included British Columbia residents age 66 years and older who initiated beta-blocker therapy during time intervals with full drug coverage (2001), a $10 or $25 copayment (2002), and 25% coinsurance (2003-2004). We used linked data on all prescription drug dispensings, physician services, and hospitalizations. Follow-up of each cohort was 9 months after the policy changes.
We measured the proportion of subjects in each cohort who were adherent to beta-blocker therapy over time, with adherence defined as having >80% of days covered. We also measured the proportion of patients initiating beta-blocker therapy after acute MI. Policy effects were evaluated using multivariable regression.
Adherence to beta-blocker therapy was marginally reduced as a consequence of the copayment policy (-1.3 percentage points, 95% confidence interval [CI] = -2.5 , -0.04) or the coinsurance policy (-0.8 percentage points, 95% CI = -2.0, 0.3). The proportion of patients initiating beta-blockers after hospitalization for acute MI remained steady at about 61% during the study period, similar to that observed in a control population of elderly Pennsylvania residents with full drug coverage.
Fixed patient copayment and coinsurance policies had little negative effect on adherence to relatively inexpensive beta-blocker therapy, or initiation of beta-blockers after acute MI.
Notes
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PubMed ID
17685825 View in PubMed
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Clinical and economic consequences of a reimbursement restriction of nebulised respiratory therapy in adults: direct comparison of randomised and observational evaluations.

https://arctichealth.org/en/permalink/ahliterature181384
Source
BMJ. 2004 Mar 6;328(7439):560
Publication Type
Article
Date
Mar-6-2004
Author
Sebastian Schneeweiss
Malcolm Maclure
Bruce Carleton
Robert J Glynn
Jerry Avorn
Author Affiliation
Brigham and Women's Hospital and Harvard Medical School, Division of Pharmacoepidemiology and Pharmacoeconomics, 1620 Tremont St (Suite 3030), Boston, MA 02120, USA. schneeweiss@post.harvard.edu
Source
BMJ. 2004 Mar 6;328(7439):560
Date
Mar-6-2004
Language
English
Publication Type
Article
Keywords
Administration, Inhalation
Adolescent
Adult
Aged
British Columbia
Bronchodilator Agents - administration & dosage - economics
Cluster analysis
Cohort Studies
Cost Savings
Drug Costs - statistics & numerical data
Health Expenditures
Health Policy - economics
Humans
Insurance, Health, Reimbursement
Insurance, Pharmaceutical Services - utilization
Medical Assistance - utilization
Middle Aged
Abstract
To compare the results of a randomised and an observational evaluation of the same policy that restricted reimbursement for nebulised respiratory medications in adult patients in a community setting.
Cluster randomised controlled trial and observational time series with historical controls.
Pharmacare, the government funded drug benefits plan for elderly people and patients receiving social assistance in British Columbia, Canada.
In the randomised controlled trial 104 clusters of medical practices, pair matched by geography and approximately by practice size, were randomised to the intervention group (449 patients affected by the policy on 1 March 1999), and the control group (offered a six month exemption, affecting 386 patients). The observational analysis included all Pharmacare beneficiaries (excluding the 386 exempt patients) who had used any nebulised drugs six months before the policy (4624 patients).
Pharmacare restricted reimbursement for nebulised bronchodilators, steroids, and cromoglycate to patients whose doctors applied for an individual patient's exemption, giving an appropriate clinical reason.
Number of contacts with doctors and services, emergency admissions to hospital, and utilisation of and expenditure for respiratory drugs in databases of British Columbia's Ministry of Health.
Contacts with doctors or emergency admissions to hospital did not increase in association with the restriction, regardless of the analytical approach. In the observational analysis, we found a reduction of C24 dollars per patient month in all nebulised drug use (95% confidence interval 19 to 29) and an increase of C3 dollars per patient month in all expenditure for inhalers (1.4 to 4.5). The randomised evaluation found savings of C8 dollars per patient month for nebulisers (P = 0.24) and no increase in spending on inhalers (P = 0.79). Correcting for 60% non-compliance by exempt doctors in a sensitivity analysis yielded similar results as the observational evaluation.
Observational as well as randomised analyses found moderate net savings and no increase in unintended healthcare outcomes after restricting reimbursement for nebulised respiratory drugs. Randomised policy trials are feasible and, if carefully implemented, likely to be concordant with observational evaluations.
Notes
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PubMed ID
14982865 View in PubMed
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Emergency hospital admissions after income-based deductibles and prescription copayments in older users of inhaled medications.

https://arctichealth.org/en/permalink/ahliterature156082
Source
Clin Ther. 2008;30 Spec No:1038-50
Publication Type
Article
Date
2008
Author
Colin R Dormuth
Malcolm Maclure
Robert J Glynn
Peter Neumann
Alan M Brookhart
Sebastian Schneeweiss
Author Affiliation
Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA. colin.dormuth@ti.ubc.ca
Source
Clin Ther. 2008;30 Spec No:1038-50
Date
2008
Language
English
Publication Type
Article
Keywords
Administration, Inhalation
Adrenergic beta-Agonists - economics - therapeutic use
Aged
Aged, 80 and over
Asthma - drug therapy
Canada
Cholinergic Antagonists - economics - therapeutic use
Cohort Studies
Deductibles and Coinsurance - economics
Drug Utilization
Emergency Service, Hospital - statistics & numerical data
Emphysema - drug therapy
Female
Glucocorticoids - economics - therapeutic use
Health Policy
Health Services - utilization
Humans
Insurance Claim Review
Lung Diseases - drug therapy
Male
Pulmonary Disease, Chronic Obstructive - drug therapy
State Health Plans - economics
Abstract
Rapid growth in prescription drug costs has compelled insurers to require increased patient cost-sharing.
The aim of this study was to compare the effects of 2 recent cost-sharing policies on emergency hospitalizations due to chronic obstructive pulmonary disease, asthma, or emphysema (CAE), and on physician visits.
We analyzed data from a large-scale natural experiment in British Columbia (BC), Canada. The cost-sharing policies were a fixed copayment policy (fixed copay policy) and an income-based deductible (IBD) policy with 25% coinsurance (IBD policy). Prescription, physician billing, and hospitalization records were obtained from the BC Ministry of Health. From the total population of BC residents > or = 65 years of age, we extracted data from all patients dispensed an inhaled corticosteroid, beta(2)-agonist, or anticholinergic from June 30, 1997, to April 30, 2004. Poisson regression was used to evaluate the impact of the policies in a cohort of patients receiving long-term inhaler treatment. An identically defined historical control group unaffected by the policy changes was used for comparison.
The study population included 37,320 users of long-term inhaled medications from the BC population of 576,000 persons > or = 65 years of age. During the IBD period but not the fixed copay period, emergency hospitalizations for CAE increased 41% (95% CI for adjusted rate ratio [RR], 1.24-1.60) in patients > or = 65 years of age. There was also a significant increase in physician visits of 3% (95% CI for adjusted RR, 1.01-1.05). No significant increases were observed during the fixed copay period. In a secondary analysis using a concurrent control group, we estimated a smaller but significant increase in emergency CAE hospitalizations of 29% (95% CI for adjusted RR, 1.09-1.52). This analysis also showed increases in physician visits (fixed copay period RR, 1.03 [95% CI for adjusted RR, 1.01-1.05]; IBD period RR, 1.07 [95% CI for adjusted RR, 1.05-1.08]).
The results suggest that the IBD policy was likely associated with an increased risk for emergency hospitalization and physician visits in these users of inhaled medications who were aged > or = 65 years.
Notes
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PubMed ID
18640478 View in PubMed
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The impact of cost sharing on antidepressant use among older adults in British Columbia.

https://arctichealth.org/en/permalink/ahliterature157979
Source
Psychiatr Serv. 2008 Apr;59(4):377-83
Publication Type
Article
Date
Apr-2008
Author
Philip S Wang
Amanda R Patrick
Colin R Dormuth
Jerry Avorn
Malcolm Maclure
Claire F Canning
Sebastian Schneeweiss
Author Affiliation
National Institute of Mental Health, Bethesda, MD 20892-9629, USA. wangphi@mail.nih.gov
Source
Psychiatr Serv. 2008 Apr;59(4):377-83
Date
Apr-2008
Language
English
Publication Type
Article
Keywords
Adrenergic Uptake Inhibitors - therapeutic use
Aged
Antidepressive Agents - therapeutic use
British Columbia - epidemiology
Cost Sharing - statistics & numerical data
Depressive Disorder - drug therapy - epidemiology
Drug Therapy - trends - utilization
Female
Health Policy
Humans
Imipramine - therapeutic use
Male
Middle Aged
Prevalence
Abstract
Antidepressant therapies are underused among older adults and could be further curtailed by patient cost-sharing requirements. The authors studied the effects of two sequential cost-sharing policies in a large, stable population of all British Columbia seniors: change from full prescription coverage to 10-25 dollars copayments (copay) in January 2002 and replacement with income-based deductibles and 25% coinsurance in May 2003.
PharmaNet data were used to calculate monthly dispensing of antidepressants (in imipramine-equivalent milligrams) among all British Columbia residents age 65 and older beginning January 1997 through December 2005. Monthly rates of starting and stopping antidepressants were calculated. Population-level patterns over time were plotted, and the effects of implementing cost-sharing policies on antidepressant use, initiation, and stopping were examined in segmented linear regression models.
Implementation of the copay policy was not associated with significant changes in level of antidepressant dispensing or the rate of dispensing growth. Subsequent implementation of the income-based deductible policy also did not lead to a significant change in dispensing level but led to a significant (p=.02) decrease in the rate of growth of antidepressant dispensing. The copay policy was associated with a significant (p=.01) drop in the frequency of antidepressant initiation among persons with depression. Income-based deductibles reduced the rate of increase in antidepressant initiation over time. Implementation of the copay and income-based deductible policies did not have significant effects on stopping rates.
Introducing new forms of medication cost sharing appears to have the potential to reduce some use and initiation of antidepressant therapy by seniors. The clinical consequences of such reduced use need to be clarified.
Notes
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PubMed ID
18378836 View in PubMed
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Quasi-experimental longitudinal designs to evaluate drug benefit policy changes with low policy compliance.

https://arctichealth.org/en/permalink/ahliterature188126
Source
J Clin Epidemiol. 2002 Aug;55(8):833-41
Publication Type
Article
Date
Aug-2002
Author
Sebastian Schneeweiss
Malcolm Maclure
Stephen B Soumerai
Alexander M Walker
Robert J Glynn
Author Affiliation
Divison of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 221 Longwood Ave (BLI-341), Boston, MA 02115, USA. schneeweiss@post.harvard.edu
Source
J Clin Epidemiol. 2002 Aug;55(8):833-41
Date
Aug-2002
Language
English
Publication Type
Article
Keywords
Attitude of Health Personnel
British Columbia
Drug Prescriptions - economics
Guideline Adherence
Health Expenditures
Health Policy - economics
Humans
Insurance, Pharmaceutical Services - economics
Longitudinal Studies
Patient compliance
Program Evaluation
Abstract
A causal relation between drug benefit policy change and the increase in adverse outcomes can be tested by comparing the experience of a group of patients affected by the policy vs. the (counterfactual) experience of the same patients if the policy had not been implemented. Because counterfactual experiences cannot be observed, it must be assumed that the counterfactual is correctly described by extrapolating from the same population's previous experience. The null hypothesis of no policy effect can be empirically tested using quasi-experimental longitudinal designs with repeated measures. If compliance to a policy is low, results may be biased towards the null, but a subgroup analysis of compliers may be biased by nonignorable treatment selection. Using the example of reference drug pricing in British Columbia we discuss assumptions for causal interpretations of such analyses, and provide supplementary analyses to assess and improve the validity of findings. Results from nonrandomized comparisons of subgroups defined by their compliance to a policy change should generally be interpreted cautiously, and several biases should be explored.
PubMed ID
12384199 View in PubMed
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Using policy simulation to predict drug plan expenditure when planning reimbursement changes.

https://arctichealth.org/en/permalink/ahliterature172368
Source
Pharmacoeconomics. 2005;23(10):1021-30
Publication Type
Article
Date
2005
Author
Colin R Dormuth
Sean Burnett
Sebastian Schneeweiss
Author Affiliation
Division of Pharmacoepidemiology and Pharmacoeconomics, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts 02120, USA. cdormuth@hsph.harvard.edu
Source
Pharmacoeconomics. 2005;23(10):1021-30
Date
2005
Language
English
Publication Type
Article
Keywords
Aged
British Columbia
Computer simulation
Decision Making
Economics, Pharmaceutical - statistics & numerical data - trends
Health Policy - economics
Humans
Income
Insurance, Pharmaceutical Services - economics - trends
Middle Aged
Abstract
Drug plan decision makers need accurate financial impact projections before the implementation of new drug policy initiatives. Tools for such projections need to have small margins of error and be based on methodology that is easy to communicate to stakeholders. Ad hoc methods typically used for financial impact projections by health plans are inadequate.
To present a flexible tool for projecting the financial impact of drug policy changes based on historical dispensing data and simulation, and explore its validity using a recent example of a complex drug policy change in British Columbia, Canada.
A policy simulator (SAS) program using a Web browser interface) was used to produce 3-year forecasts of expenditure (for the drug plan and for individual families) along with the number of patients who would pay more or less for their drugs (stratified by age and income level) for various proposed drug policies starting in 2003. Drug expenditure under each policy was simulated based on projections from prescription claim records of the British Columbia PharmaNet database of community pharmacy prescriptions from 1 January 2001 to 31 December 2001. The simulator selected a random 1% sample of British Columbia families (175,000 families) in the database. Once the new drug policy was selected and implemented, the accuracy of the predictions were tested by comparing the actual PharmaCare expenditure for the period 1 May 2003 to 31 March 2004 after implementation of the new drug policy with the final simulation made for this policy in February 2003, 2 months before the policy was implemented.
The policy simulation tool produced hundreds of variations for decision makers in the months before the final policy rules were decided upon. When compared with actual drug expenditure after policy implementation, it was found that the tool had predicted spending with
PubMed ID
16235975 View in PubMed
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