Multimorbidity, Management of COPD and Health Outcomes among Medicaid Beneficiaries

Chronic Obstructive Pulmonary Disease (COPD) is characterized by persistent and progressive airflow limitation caused due to chronic inflammation in the lungs. Approximately 15 million adults in the United States (U.S.) are estimated to be diagnosed with COPD and an equal number may have undiagnosed COPD. Challenges to COPD management include high prevalence of inflammation-related multimorbidity among individuals with COPD. The association between multimorbidity, existing COPD management and role of novel therapies with anti-inflammatory properties (e.g. statins) in improving COPD-specific outcomes is not well researched. Therefore, the purpose of this study was to use real-world observational data to provide a comprehensive understanding of the relationship between multimorbidity and COPD management as well as assess the effectiveness and safety of statins in terms of COPD management. The specific aims of three studies were to: (1) examine the association between inflammation-related multimorbidity and COPD management in terms of COPD medication receipt, long-acting bronchodilators persistence and COPD-specific outcomes; (2) assess the effectiveness of novel statin therapy in improving COPD-specific outcomes; (3) evaluate the safety of statins and other commonly used medications (antidepressants and inhaled corticosteroids) in terms of new-onset diabetes. This study used a retrospective longitudinal dynamic cohort design using data extracted from multiple years (2005-2008) of Medicaid Analytic eXtract (MAX) files to identify Medicaid beneficiaries with newly diagnosed COPD (n = 19,060). Findings from the first study documented very high prevalence of inflammation-related multimorbidity and indicated that it was significantly associated with reduced COPD-medication utilization and decreased persistence on long-bronchodilators. Our study findings suggest that COPD medication management may be poor due to competing demands arising from the presence of inflammation-related multimorbidity. The results from the study on effectiveness of statins revealed that any statin use improved COPD-specific outcomes compared to no statin use. A closer examination of the data revealed that only those with long-term statin use had better outcomes as compared to those with no statin use. We also found that beneficiaries with inflammation-related multimorbidity and statin use had better COPD-specific outcomes compared to those with multimorbidity and no statin use. From the third study, we found that association between statin use and risk of new-onset diabetes was no longer significant in analyses that controlled for selection bias in unobserved characteristics. Collectively, these findings indicate poor COPD management among those with multimorbidity and emphasize the need for novel therapies to effectively manage COPD. In this context, the current study underscores the advantage of statins in improving COPD-specific clinical and economic outcomes. This study indicate the need of randomized clinical trials and long-term observational studies to establish the efficacy, effectiveness, and safety of novel therapeutic agents in management of COPD

Association Between Statin Medications and COPD-Specific Outcomes: A Real-World Observational Study

Background Disease-modifying drugs are not yet available for the management of chronic obstructive pulmonary disease (COPD). HMG-CoA reductase inhibitors (statins) have anti-inflammatory properties and are therefore being considered for use in the management of COPD. Objective Our objective was to examine the association between statin use and COPD-specific outcomes in a realworld setting. Methods This was a retrospective longitudinal dynamic cohort study that used Medicaid claims data from multiple years (2005–2008) to identify patients with newly diagnosed COPD. Statin therapy was determined from the prescription drug file using National Drug Codes (NDCs). COPD-specific outcomes such as hospitalizations and emergency room and outpatient visits were identified based on a primary diagnosis of COPD. Multivariable logistic regressions with inverse probability treatment weights (IPTWs) were used to examine the relationship between statin therapy and COPD-specific outcomes. Results The study included 19,060 Medicaid beneficiaries with newly diagnosed COPD, 30.3% of whom received statins during the baseline period. Adults who received statins had significantly lower rates of COPDspecific hospitalizations (4.7 vs. 5.2%; p \ 0.05), emergency room visits (13.4 vs. 15.4%; p \ 0.001), and outpatient visits (41.4 vs. 44.7%; p \ 0.001) than those who did not receive statin therapy. Even after adjusting for observed selection bias with IPTWs, adults receiving statins were less likely to have COPD-specific hospitalizations [adjusted odds ratio (AOR) 0.76; 95% confidence interval (CI) 0.66–0.87], emergency room visits (AOR 0.81; 95% CI 0.75–0.89), and outpatient visits (AOR 0.86; 95% CI 0.80–0.91) than those not receiving statins. Conclusions Findings from this study suggest statins have beneficial effects in patients with newly diagnosed COPD and warrant further clinical trial investigation

Explaining the increased health care expenditures associated with gastroesophageal reflux disease among elderly Medicare beneficiaries with chronic obstructive pulmonary disease: a cost-decomposition analysis

Objective: To estimate excess health care expenditures associated with gastroesophageal reflux disease (GERD) among elderly individuals with chronic obstructive pulmonary disease (COPD) and examine the contribution of predisposing characteristics, enabling resources, need variables, personal health care practices, and external environment factors to the excess expenditures, using the Blinder-Oaxaca linear decomposition technique.Methods: This study utilized a cross-sectional, retrospective study design, using data from multiple years (2006-2009) of the Medicare Current Beneficiary Survey linked with fee-for-service Medicare claims. Presence of COPD and GERD was identified using diagnoses codes. Health care expenditures consisted of inpatient, outpatient, prescription drugs, dental, medical provider, and other services. For the analysis, t-tests were used to examine unadjusted subgroup differences in average health care expenditures by the presence of GERD. Ordinary least squares regressions on log-transformed health care expenditures were conducted to estimate the excess health care expenditures associated with GERD. The Blinder-Oaxaca linear decomposition technique was used to determine the contribution of predisposing characteristics, enabling resources, need variables, personal health care practices, and external environment factors, to excess health care expenditures associated with GERD.Results: Among elderly Medicare beneficiaries with COPD, 29.3% had co-occurring GERD. Elderly Medicare beneficiaries with COPD/GERD had 1.5 times higher ($36,793 vs$24,722 [P\u3c0.001]) expenditures than did those with COPD/no GERD. Ordinary least squares regression revealed that individuals with COPD/GERD had 36.3% (P\u3c0.001) higher expenditures than did those with COPD/no GERD. Overall, 30.9% to 43.6% of the differences in average health care expenditures were explained by differences in predisposing characteristics, enabling resources, need variables, personal health care practices, and external environment factors between the two groups. Need factors explained up to 41% of the differences in average health care expenditures between the two groups.Conclusion: Among elderly Medicare beneficiaries with COPD, the presence of GERD was associated with higher expenditures. Need factors primarily contributed to the differences in average health care expenditures, suggesting that the comanagement of chronic conditions may reduce excess health care expenditures associated with GERD

Inhaled anticholinergic use and all-cause mortality among elderly Medicare beneficiaries with chronic obstructive pulmonary disease

Background: The purpose of this study was to examine the association between use of inhaled anticholinergics and all-cause mortality among elderly individuals with chronic obstructive pulmonary disease (COPD), after controlling for demographic, socioeconomic, health, functional status, smoking, and obesity.Methods: We used a retrospective longitudinal panel data design. Data were extracted for multiple years (2002–2009) of the Medicare Current Beneficiary Survey (MCBS) linked with fee-for-service Medicare claims. Generic and brand names of inhaled anticholinergics were used to identify inhaled anticholinergic utilization from the self-reported prescription medication files. All-cause mortality was assessed using the vital status variable. Unadjusted group differences in mortality rates were tested using the chi-square statistic. Multivariable logistic regressions with independent variables entered in separate blocks were used to analyze the association between inhaled anticholinergic use and all-cause mortality. All analyses accounted for the complex design of the MCBS.Results: Overall, 19.4% of the elderly Medicare beneficiaries used inhaled anticholinergics. Inhaled anticholinergic use was significantly higher (28.5%) among those who reported poor health compared with those reporting excellent or very good health (12.7%). Bivariate analyses indicated that inhaled anticholinergic use was associated with significantly higher rates of all-cause mortality (18.7%) compared with nonusers (13.6%). However, multivariate analyses controlling for risk factors did not suggest an increased likelihood of all-cause mortality (adjusted odds ratio 1.26, 95% confidence interval 0.95–1.67).Conclusion: Use of inhaled anticholinergics among elderly individuals with COPD is potentially safe in terms of all-cause mortality when we adjust for baseline risk factors

Concomitant Medication Use and New-Onset Diabetes Among Medicaid Beneficiaries with Chronic Obstructive Pulmonary Disease

Use of multiple prescription medications is common among individuals with chronic obstructive pulmonary disease (COPD) because of coexisting inflammatory-related conditions. Specifically, the use of antidepressants, inhaled corticosteroids (ICSs), and statins may place individuals with COPD at high risk for new-onset diabetes. The objective was to examine the relationship between the use of antidepressants, ICSs, and statins and new-onset diabetes among Medicaid beneficiaries with COPD. This study used a retrospective longitudinal cohort design using multiple years (2005–2008) of Medicaid claims for beneficiaries with newly diagnosed COPD (n = 15,287), who were diabetes free at baseline. National Drug Codes were used to determine the receipt of antidepressants, ICSs, and statins, and International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to define new-onset diabetes (250.x2). Multivariable logistic regression was used to examine the adjusted relationship between medication use and new-onset diabetes. Overall, 6.3% of the study population was diagnosed with new-onset diabetes. After controlling for baseline characteristics, individuals using ICSs (adjusted odds ratio [AOR]: 1.23; 95% confidence interval [CI]: 1.07, 1.47) or statins (AOR: 1.48; 95% CI: 1.27, 1.72) had a greater risk of new-onset diabetes compared to those not given ICSs, statins, or antidepressants. Analyses using combined medication categories revealed that adults using statins in combination with both antidepressants and ICSs, or when combined with ICS, were more likely to have new-onset diabetes. These findings indicate that multiple medication use (ICSs and statins) was associated with increased rates of new-onset diabetes. Further research is warranted to understand this association

Multimorbidity and COPD Medication Receipt Among Medicaid Beneficiaries With Newly Diagnosed COPD

BACKGROUND: Multimorbidity is highly prevalent among patients with COPD. The association between multimorbidity and COPD medication management is not well researched. The aim of this study was to examine the association between multimorbidity and COPD medication receipt among Medicaid beneficiaries with newly diagnosed COPD. METHODS: A retrospective longitudinal dynamic cohort design was used, and data were extracted from Medicaid Analytic eXtract files from 2005 to 2008. Medicaid beneficiaries with newly diagnosed COPD (N 19,060) were identified using the International Classification of Diseases, 9th Revision, Clinical Modification, for COPD. This code (for commonly co-occurring conditions with COPD) was used to create a multimorbidity variable. These conditions included anxiety, arthritis, bipolar disorder, cardiovascular diseases, depression, diabetes, hypertension, hyperlipidemia osteoporosis, and schizophrenia. Medicaid beneficiaries with newly diagnosed COPD were categorized as: (1) physical multimorbidity only, (2) psychiatric multimorbidity only, (3) both physical and psychiatric multimorbidity, and (4) no multimorbidity. Receipt of COPD medications (short- or long-acting bronchodilators, inhaled corticosteroids) was identified using National Drug Codes. Bivariate relationships between multimorbidity and COPD medication receipt were tested using the chi-square test of independence. The associations between multimorbidity and COPD medication receipt were analyzed with logistic and multinomial logistic regression analyses. RESULTS: Among Medicaid beneficiaries with newly diagnosed COPD, 81.9% had at least one co-occurring chronic condition. After controlling for subject characteristics, adults with multimorbidity were less likely to receive COPD medications compared with those without any inflammation-related multimorbidity. For example, those with physical multimorbidity were less likely to receive short-acting bronchodilators (adjusted odds ratio [OR] 0.76, 95% CI 0.69 – 0.83), long-acting bronchodilators (adjusted OR 0.84, 95% CI 0.76 – 0.92), and inhaled corticosteroids (adjusted OR 0.75, 95% CI 0.68 – 0.82) compared with those with no inflammation-related multimorbidity.CONCLUSIONS: The prevalence of multimorbidity is very high among Medicaid beneficiaries with newly diagnosed COPD. Our findings indicate poor COPD medication management among those with multimorbidit

A real-world study of the effect of timing of insulin initiation on outcomes in older medicare beneficiaries with type 2 diabetes mellitus

OBJECTIVES—To compare clinical and economic outcomes of early insulin initiation with those of delayed initiation in older adults with type 2 diabetes mellitus (T2DM). DESIGN—Retrospective cohort study. SETTING—Humana Medicare Advantage health insurance plan. PARTICIPANTS—Older (≥65) Medicare beneficiaries with T2DM. MEASUREMENTS—Subjects were grouped according to number of classes of oral antidiabetes drugs (OADs) they had taken before initiation of insulin: one (early insulin initiators), two, or three or more (delayed insulin initiators). One-year follow-up outcomes included change in glycosylated hemoglobin (HbA1c), percentage of older adults with HbA1c less than 8.0%, hypoglycemic events, and total healthcare costs. RESULTS—Overall, 14,669 individuals were included in the analysis. Baseline and 1-year follow-up HbA1c levels were available for 4,028 (27.5%) individuals. Insulin was initiated early in 32% and delayed in 20%. At follow-up, unadjusted reduction in HbA1c was 0.9 ± 3.7% for thegroup with one OAD, 0.7 ± 2.4% for those with two, and 0.5 ± 3.6% for those with three or more. Early insulin initiation was associated with significantly greater reduction in HbA1c (0.4%; adjusted P \u3c.001), 30% greater likelihood of achieving HbA1c less than 8.0% (adjusted odds ratio = 1.30, 95% confidence interval = 1.18–1.43), and no significant differences in total costs or hypoglycemia events (11.5% of early initiators vs 10.2% of delayed initiators; P = .32). CONCLUSION—This study suggests beneficial effects of early insulin initiation in older adults with T2DM who do not have adequate glycemic control, without increasing the risk of hypoglycemia or greater total direct healthcare costs

Multimorbidity, Mental Illness, and Quality of Care: Preventable Hospitalizations among Medicare Beneficiaries

Background. Individuals with multimorbidity are vulnerable to poor quality of care due to issues related to care coordination. Ambulatory care sensitive hospitalizations (ACSHs) are widely accepted quality indicators because they can be avoided by timely, appropriate, and high-quality outpatient care. Objective. To examine the association between multimorbidity, mental illness, and ACSH. Study Design. We used a longitudinal panel design with data from multiple years (2000–2005) of Medicare Current Beneficiary Survey. Individuals were categorized into three groups: (1) multimorbidity with mental illness (MM/MI); (2) MM/no MI; (3) no MM. Multivariable logistic regressions were used to analyze the association between multimorbidity and ACSH. Results. Any ACSH rates varied from 10.8% in MM/MI group to 8.8% in MM/No MI group. Likelihood of any ACSH was higher among beneficiaries with MM/MI (AOR = 1.62; 95% CI = 1.14, 2.30) and MM (AOR = 1.54; 95% CI = 1.12, 2.11) compared to beneficiaries without multimorbidity. There was no statistically significant difference in likelihood of ACSH between MM/MI and MM/No MI groups. Conclusion. Multimorbidity (with or without MI) had an independent and significant association with any ACSH. However, presence of mental illness alone was not associated with poor quality of care as measured by ACSH