Longitudinal patterns of antidepressant prescribing in primary care in the UK: comparison with treatment guidelines

The objective of this study was to determine whether patients beginning therapy on the most common tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) differed in their likelihood of having antidepressant treatment that was consistent with recommended treatment guidelines in the UK. An analytical file constructed from a large general practitioner medical records database (DIN-LINK) from the UK for the years 1992-97 was constructed. A total of 16 204 patients with a new episode of antidepressant therapy who initiated therapy on one of the most often prescribed TCAs (amitriptyline, dothiepin, imipramine and lofepramine) or SSRIs (fluoxetine, paroxetine and sertraline) were analysed. A dichotomous measure was defined to indicate whether subjects were prescribed at least 120 days of antidepressant therapy at an adequate average daily dose within the first 6 months after initiation of therapy. Only 6.0% of patients initiating therapy on aTCA and 32.9% of patients initiating therapy on a SSRI were prescribed antidepressant treatment that was consistent with treatment guidelines. After controlling for observable characteristics, patients who initiated therapy on a SSRI were much more likely (odds ratio=7.473, p<0.001) to have a prescribed average daily dose and duration consistent with recommended treatment guidelines within the first 6 months of initiating therapy than were patients who initiated therapy on a TCA. These findings suggest that initial antidepressant selection is an important determinant of whether the subsequent course of treatment is consistent with current national guidelines for the treatment of depression in the UK.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/68732/2/10.1177_026988119901300204.pd

A More Generalizable Method to Evaluate Changes in Health Care Costs with Changes in Health Risks Among Employers of All Sizes

The objective of this study was to estimate the association between changes in health care expenditures relative to changes in health risk status for employers of all sizes. Repeat health risk assessments (HRAs) were obtained from 50,005 employees and spouses with 2 years of health plan enrollment, and from 37,559 employees and spouses with 3 years of enrollment in employer-sponsored medical coverage. Changes in health care expenditures were measured from the year before completion of the first HRA to the years before and after the completion of the second HRA. Propensity score weighting was used to adjust for those who did not repeat the HRA so results could be extrapolated to the larger population. Propensity score weighted multiple regression analyses were used to estimate the relationship between changes in health care expenditures with changes in risk status for 9 risk categories. Significantly higher health care expenditures were associated with those who moved from low risk to medium or high risk, compared to those who remained low risk. Expenditure reductions estimated for those who improved their health status from high risk to medium or low risk were not statistically significant. This study is unique because of its large sample size, its use of data from a wide range of employer sizes, and its efforts to extend generalizability to those who did not complete both HRAs. These results demonstrate that the potential for short-term health care savings may be greater for programs that help maintain low risk than for programs focused on risk reduction. (Population Health Management 2014;17:297?305)Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140183/1/pop.2013.0103.pd

Disparities in Major Joint Replacement Surgery among Adults with Medicare Supplement Insurance

The objective of this study was to determine if disparities in hip and knee replacement surgery exist among osteoarthritis patients with AARP-branded Medicare supplement plan (ie, Medigap) coverage provided by UnitedHealthcare. Patients were selected into the study if they had 1 or more medical claims with a diagnosis of osteoarthritis from July 1, 2006 to June 30, 2007. Logistic regression analyses tested for age-, sex-, race-, or income-related differences in the likelihood of receiving a hip or knee replacement surgery. The regression models controlled for socioeconomics, health status, type of supplement plan, and residential location. Of the 2.2 million Medigap insureds eligible for this study, 529,652 (24%) had osteoarthritis. Of these, 32,527 (6.1%) received a hip or knee replacement. Males were 6% (P-<-0.001) more likely than females to have a replacement surgery. Patients living in minority or lower income neighborhoods were less likely to receive a hip or knee replacement. Supplement plan type was not a strong predictor of the likelihood of hip or knee replacement. Disparities were much greater by comorbid condition and residential location. Disparities in hip and knee replacement surgery existed by age, sex, race, and income levels. Larger disparities were found by residential location and comorbid condition. Interventions are being considered to address these disparities. (Population Health Management 2011;14:231-238)Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90479/1/pop-2E2010-2E0042.pd

Evaluation of a High-Risk Case Management Pilot Program for Medicare Beneficiaries with Medigap Coverage

The objective was to evaluate the 3-year experience of a high-risk case management (HRCM) pilot program for adults with an AARP Medicare Supplement (Medigap) Insurance Plan. Participants were provided in-person visits as well as telephonic and mailed services to improve care coordination from December 1, 2008, to December 31, 2011. Included were adults who had an AARP Medigap Insurance Plan, resided in 1 of 5 pilot states, and had a Hierarchical Condition Category score>3.74, or were referred into the program. Propensity score weighting was used to adjust for case-mix differences among 2015 participants and 7626 qualified but nonparticipating individuals. Participants were in the program an average of 15.4 months. After weighting, multiple regression analyses were used to estimate differences in quality of care and health care expenditures between participants and nonparticipants. Increased duration in the program was associated with fewer hospital readmissions. Additionally, participants were significantly more likely to have recurring office visits and recommended laboratory tests. The program demonstrated $7.7 million in savings over the 3 years, resulting in a return on investment of$1.40 saved for every dollar spent on the program. Savings increased each year from 2009 to 2011 and with longer length of engagement. The majority of savings were realized by the federal Medicare program. This study focused on quality of care and savings for an HRCM program designed solely for Medicare members with Medicare Supplement coverage. This program had a favorable impact on quality of care and demonstrated savings over a 3-year period. (Population Health Management 2015;18:93?103)Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140185/1/pop.2014.0035.pd

Value of Laboratory Tests in Employer-Sponsored Health Risk Assessments for Newly Identifying Health Conditions: Analysis of 52,270 Participants

Employer-sponsored health risk assessments (HRA) may include laboratory tests to provide evidence of disease and disease risks for common medical conditions. We evaluated the ability of HRA-laboratory testing to provide new disease-risk information to participants.We performed a cross-sectional analysis of HRA-laboratory results for participating adult employees and their eligible spouses or their domestic partners, focusing on three common health conditions: hyperlipidemia, diabetes mellitus, and chronic kidney disease. HRA with laboratory results of 52,270 first-time participants were analyzed. Nearly all participants had access to health insurance coverage. Twenty-four percent (12,392) self-reported one or more of these medical conditions: 21.1% (11,017) self-identified as having hyperlipidemia, 4.7% (2,479) self-identified as having diabetes, and 0.7% (352) self-identified as having chronic kidney disease. Overall, 36% (n = 18,540) of participants had laboratory evidence of at least one medical condition newly identified: 30.7% (16,032) had laboratory evidence of hyperlipidemia identified, 1.9% (984) had laboratory evidence of diabetes identified, and 5.5% (2,866) had laboratory evidence of chronic kidney disease identified. Of all participants with evidence of hyperlipidemia 59% (16,030 of 27,047), were newly identified through the HRA. Among those with evidence of diabetes 28% (984 of 3,463) were newly identified. The highest rate of newly identified disease risk was for chronic kidney disease: 89% (2,866 of 3,218) of participants with evidence of this condition had not self-reported it. Men (39%) were more likely than women (33%) to have at least one newly identified condition (p<0.0001). Among men, lower levels of educational achievement were associated with modestly higher rates of newly identified disease risk (p<0.0001); the association with educational achievement among women was unclear. Even among the youngest age range (20 to 29 year olds), nearly 1 in 4 participants (24%) had a newly identified risk for disease.These results support the important role of employer-sponsored laboratory testing as an integral element of HRA for identifying evidence of previously undiagnosed common medical conditions in individuals of all working age ranges, regardless of educational level and gender

What Can a Pilot Congestive Heart Failure Disease Management Program Tell Us about Likely Return on Investment?: A Case Study from a Program Offered to Federal Employees

In 1999, the Blue Cross and Blue Shield Federal Employee Program (FEP) implemented a pilot disease management program to manage congestive heart failure (CHF) among members. The purpose of this project was to estimate the financial return on investment in the pilot CHF program, prior to a full program rollout. A cohort of 457 participants from the state of Maryland was matched to a cohort of 803 nonparticipants from a neighboring state where the CHF program was not offered. Each cohort was followed for 12 months before the program began and 12 months afterward. The outcome measures of primary interest were the differences over time in medical care expenditures paid by FEP and by all payers. Independent variables included indicators of program participation, type of heart disease, comorbidity measures, and demographics. From the perspective of the funding organization (FEP), the estimated return on investment for the pilot CHF disease management program was a savings of $1.08 in medical expenditure for every dollar spent on the program. Adding savings to other payers as well, the return on investment was a savings of$1.15 in medical expenditures per dollar spent on the program. The amount of savings depended upon CHF risk levels. The value of a pilot initiative and evaluation is that lessons for larger-scale efforts can be learned prior to full-scale rollout. (Disease Management 2005;8:346-360)Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63402/1/dis.2005.8.346.pd

Preliminary examination of the efficacy and safety of a standardized chamomile extract for chronic primary insomnia: A randomized placebo-controlled pilot study

<p>Abstract</p> <p>Background</p> <p>Despite being the most commonly used herbal for sleep disorders, chamomile's (<it>Matricaria recutita</it>) efficacy and safety for treating chronic primary insomnia is unknown. We examined the preliminary efficacy and safety of chamomile for improving subjective sleep and daytime symptoms in patients with chronic insomnia.</p> <p>Methods</p> <p>We performed a randomized, double-blind, placebo-controlled pilot trial in 34 patients aged 18-65 years with DSM-IV primary insomnia for ≥ 6-months. Patients were randomized to 270 mg of chamomile twice daily or placebo for 28-days. The primary outcomes were sleep diary measures. Secondary outcomes included daytime symptoms, safety assessments, and effect size of these measures.</p> <p>Results</p> <p>There were no significant differences between groups in changes in sleep diary measures, including total sleep time (TST), sleep efficiency, sleep latency, wake after sleep onset (WASO), sleep quality, and number of awakenings. Chamomile did show modest advantage on daytime functioning, although these did not reach statistical significance. Effect sizes were generally small to moderate (Cohen's <it>d </it>≤ 0.20 to < 0.60) with sleep latency, night time awakenings, and Fatigue Severity Scale (FSS), having moderate effect sizes in favor of chamomile. However, TST demonstrated a moderate effect size in favor of placebo. There were no differences in adverse events reported by the chamomile group compared to placebo.</p> <p>Conclusion</p> <p>Chamomile could provide modest benefits of daytime functioning and mixed benefits on sleep diary measures relative to placebo in adults with chronic primary insomnia. However, further studies in select insomnia patients would be needed to investigate these conclusions.</p> <p>Trial Registration</p> <p>ClinicalTrials.gov Identifier <a href="http://www.clinicaltrials.gov/ct2/show/NCT01286324">NCT01286324</a></p

Assessment of possible impact of a health promotion program in Korea from health risk trends in a longitudinally observed cohort

BACKGROUND: Longitudinally observed cohort data can be utilized to assess the potential for health promotion and healthcare planning by comparing the estimated risk factor trends of non-intervened with that of intervened. The paper seeks (1) to estimate a natural transition (patterns of movement between states) of health risk state from a Korean cohort data using a Markov model, (2) to derive an effective and necessary health promotion strategy for the population, and (3) to project a possible impact of an intervention program on health status. METHODS: The observed transition of health risk states in a Korean employee cohort was utilized to estimate the natural flow of aggregated health risk states from eight health risk measures using Markov chain models. In addition, a reinforced transition was simulated, given that a health promotion program was implemented for the cohort, to project a possible impact on improvement of health status. An intervened risk transition was obtained based on age, gender, and baseline risk state, adjusted to match with the Korean cohort, from a simulated random sample of a US employee population, where a health intervention was in place. RESULTS: The estimated natural flow (non-intervened), following Markov chain order 2, showed a decrease in low risk state by 3.1 percentage points in the Korean population while the simulated reinforced transition (intervened) projected an increase in low risk state by 7.5 percentage points. Estimated transitions of risk states demonstrated the necessity of not only the risk reduction but also low risk maintenance. CONCLUSIONS: The frame work of Markov chain efficiently estimated the trend, and captured the tendency in the natural flow. Given only a minimally intense health promotion program, potential risk reduction and low risk maintenance was projected