Large Managed Care Organization Research Articles

Mo1966 Colorectal Cancer Screening Among Asian Subgroups in a Large Managed Care Organization

Background: Colorectal Cancer (CRC) is the second leading cause of cancer death in the US. CRC screening allows for early detection of CRC or its precursors, and leads to a decrease in CRC incidence and mortality. National guidelines recommend screening with several modalities including an annual fecal immunochemical test (FIT) or fecal occult blood test (FOBT), a colonoscopy every 10 years, or a flexible sigmoidoscopy every 5 years for individuals ages 50-75. Although national rates in CRC screening have improved from 52.3% to 60%; screening rates among Asian Americans are 11% lower compared with whites. Differences among Asian subgroups is unknown. Methods: Electronic clinical data were used to characterize CRC screening status as of December 31, 2012 for Asians, overall and in subgroups, compared with non-Hispanic whites (NHWs) who were members of Kaiser Permanente Southern California. Asian subgroups were classified as Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, and Other Asian. To be eligible for these analyses, patients had to be ages 50-89 as of January 1, 2010 and enrolled in the health plan for a minimum of 3 years. The primary outcome, receipt of CRC screening, was defined as having a colonoscopy in the prior 10 years, sigmoidoscopy in the prior 5 years, or FIT/FOBT in the year before December 31, 2012. A secondary outcome was the distribution of screening modalities across Asian subgroups. Log-binomial regression analyses were used to estimate differences in screening patterns controlling for age and sex. Results: Among the 408,242 eligible patients, 11.6% were Asian (Table 1). Compared with NHWs, Asians had a higher proportion of females (53% v. 47%), were younger, and lived in neighborhoods with higher education. A higher percentage of Asians had received CRC screening than NHWs (76% v. 71%). Filipinos, who comprised nearly half of the Asian patients, had a similar percentage screened as NWHs, while Chinese, Korean, Vietnamese, and other Asians had slightly higher proportions screened (Table 1). Compared with NWHs, Asian Indians, Filipinos, Vietnamese, and other Asians were more often screened with FIT/FOBT; all subgroups except Filipino were more often screened with colonoscopy; and all subgroups except Asian Indians and Japanese patients were more often screened with flexible sigmoidoscopy (Table 2). Conclusions: In contrast to national data, in a large managed-care setting, Asians overall had higher CRC screening rates than NHWs. Compared to NHWs, the magnitude of differences in screening varied by Asian subgroup and type of screening modality. Table 1: Population breakdown by Race/Ethnicity

High-risk case identification for use in comprehensive complex care management.

The current study aimed to develop a patient selection process for muiltimorbid care management that balances the needs to accurately identify patients who are at risk for future high costs and assures that those selected can clinically benefit from proactive care management. Six physicians were surveyed on characteristics of their current (2012) patients to elicit clinical considerations for high-risk patient identification. Data from 2010-2011 were extracted from Clalit Health Services' (Israel's largest managed care organization) comprehensive database to derive the Adjusted Clinical Groups (ACG) predictive model risk scores for risk of future high costs. Model discriminatory power was assessed using the c-statistic and positive predictive value (PPV), before and after application of the clinical exclusion criteria. Inclusion criteria were refined based on physician input from a survey on 375 patients. Recommended reasons for exclusion: active cancer, schizophrenia, dialysis, residence in nursing homes or long-term care facilities, and age 95 years or older. The high-risk group included 5341 patients (mean 50 patients per physician). The c-statistic of the ACG model before and after exclusions applied was 0.80 and 0.75, respectively. After exclusion, the PPV for the 6% highest risk patients was 40%. High-risk patients' age, number of chronic conditions, and utilization were substantially higher than those of all other patients. This study shows that a validated predictive modeling tool provides acceptable discriminatory power for selecting multimorbid patients for participation in proactive care management, even after some of the highest risk patients are excluded because of priori clinical considerations.

History of chronic comorbidity and risk of chemotherapy-induced febrile neutropenia in cancer patients not receiving G-CSF prophylaxis.

Chemotherapy-induced febrile neutropenia (FN) is a clinically important complication that affects patient outcome by delaying chemotherapy doses or reducing dose intensity. Risk of FN depends on chemotherapy- and patient-level factors. We sought to determine the effects of chronic comorbidities on risk of FN. We conducted a cohort study to examine the association between a variety of chronic comorbidities and risk of FN in patients diagnosed with six types of cancer (non-Hodgkin lymphoma and breast, colorectal, lung, ovary, and gastric cancer) from 2000 to 2009 who were treated with chemotherapy at Kaiser Permanente Southern California, a large managed care organization. We excluded those patients who received primary prophylactic granulocyte colony-stimulating factor. History of comorbidities and FN events were identified using electronic medical records. Cox models adjusting for propensity score, stratified by cancer type, were used to determine the association between comorbid conditions and FN. Models that additionally adjusted for cancer stage, baseline neutrophil count, chemotherapy regimen, and dose reduction were also evaluated. A total of 19 160 patients with mean age of 60 years were included; 963 (5.0%) developed FN in the first chemotherapy cycle. Chronic obstructive pulmonary disease [hazard ratio (HR) = 1.30 (1.07-1.57)], congestive heart failure [HR = 1.43 (1.00-1.98)], HIV infection [HR = 3.40 (1.90-5.63)], autoimmune disease [HR = 2.01 (1.10-3.33)], peptic ulcer disease [HR = 1.57 (1.05-2.26)], renal disease [HR = 1.60 (1.21-2.09)], and thyroid disorder [HR = 1.32 (1.06-1.64)] were all associated with a significantly increased FN risk. These results provide evidence that history of several chronic comorbidities increases risk of FN, which should be considered when managing patients during chemotherapy.

MP6-05 THE IMPACT OF SOCIO-DEMOGRAPHIC FACTORS ON ACTIVE SURVEILLANCE CHOICE IN MEN WITH LOW-RISK PROSTATE CANCER

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness I1 Apr 2014MP6-05 THE IMPACT OF SOCIO-DEMOGRAPHIC FACTORS ON ACTIVE SURVEILLANCE CHOICE IN MEN WITH LOW-RISK PROSTATE CANCER Brian Kim, Madhur Merchant, Jeff Slezak, Kimberly Porter, Joy Gelfond, Steven J. Jacobsen, and Gary W. Chien Brian KimBrian Kim More articles by this author , Madhur MerchantMadhur Merchant More articles by this author , Jeff SlezakJeff Slezak More articles by this author , Kimberly PorterKimberly Porter More articles by this author , Joy GelfondJoy Gelfond More articles by this author , Steven J. JacobsenSteven J. Jacobsen More articles by this author , and Gary W. ChienGary W. Chien More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.239AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The decision to undergo active surveillance (AS) in men with low-risk prostate cancer is multi-factorial. Previous studies have shown disparities in utilization and choice of prostate cancer care in different socio-demographic groups. This has partly been attributed to unequal access to the level of healthcare. The purpose of this study was to evaluate whether select patient socio-demographic characteristics influence the selection of AS versus immediate treatment when all subjects within our large managed-care organization have equal access to healthcare. METHODS Men with low-risk prostate cancer were enrolled between March 2011 and October 2013 at 13 Kaiser Permanente Southern California medical centers. Men were considered to be on AS if they had cT1-T2a stage prostate cancer, prostate-specific antigen (PSA) <10 ng/ml, a prostate biopsy revealing Gleason grade ≤6, fewer than 3 biopsy cores positive, ≤50% cancer in any core, and had not undergone immediate therapy within six months of their diagnosis. Patients in the AS cohort were then compared to men who received immediate treatment (surgery, radiation, other) with respect to all obtainable socio-demographic factors using the Wilcoxon Rank-Sum and Chi-squared tests. RESULTS Of the 4754 total patients with newly diagnosed prostate cancer, 681 men satisfied our inclusion criteria and were enrolled in the study; 414 (60.8%) of whom chose AS and 267 (39.2%) who had immediate treatment. Patients on AS were significantly older (62.8 vs. 60.5 years, p<0.0003). Univariate analysis revealed that Caucasian men were more likely to choose AS, whereas Black and Hispanic men were more likely to undergo immediate therapy (p<0.0035). In addition, primarily English-speaking patients, and those living in regions with higher income and education levels were more likely to choose AS (p<0.05). After multivariate adjusted analysis however, differences in ethnicity, language, income, and education levels were no longer observed between cohorts. CONCLUSIONS There were no socio-demographic factors, apart from age, that influenced the choice of AS versus immediate therapy in men with low-risk prostate cancer. Patients within ethnic minorities and lower socio-economic groups appeared to receive equal access to care and treatment counseling. This illustrates a potential benefit of comprehensive health organizations, in which the delivery-of-care is almost exclusively patient-centered. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e57-e58 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Brian Kim More articles by this author Madhur Merchant More articles by this author Jeff Slezak More articles by this author Kimberly Porter More articles by this author Joy Gelfond More articles by this author Steven J. Jacobsen More articles by this author Gary W. Chien More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Hepatitis B Testing and Vaccination Among Adults With Sexually Transmitted Infections in a Large Managed Care Organization

Data on viral hepatitis B (HBV) testing and vaccination in primary care settings among persons at sexual risk for HBV infection have been sparse. We examined rates and factors associated with HBV serologic testing and vaccination rates in adults infected with sexually transmitted infections. We conducted a retrospective cohort study of adults diagnosed with chlamydia, gonorrhea, or syphilis in Kaiser Permanente Southern California in 2008-2011. The vaccine series initiation was examined in subjects who were tested susceptible. The 90-day hepatitis B surface antigen (HBsAg) testing rate was 28.1% in 15 357 adults. Testing rates increased through the study period. Only 8.8% of patients received both HBsAg and hepatitis B surface antibody tests to determine prior exposure and susceptibility to HBV. Among those who were tested susceptible, 116 (10.6%) subjects initiated the vaccine series. In multivariable logistic regression analysis, the odds of receiving testing was inversely associated with female sex, black race, other/unknown race, or having prespecified chronic comorbidities. In survival analysis, adults aged 25-34 years and ≥55 years were more likely to initiate hepatitis B vaccine series compared with those aged 18-24 years. There are missed opportunities in HBV testing and vaccination in primary care. Implementation of provider decision-making support tools in the electronic medical record system may potentially improve hepatitis B testing and vaccination rates.

Abstracts from the Society for Acupuncture Research 2013 International ConferenceImpact of Acupuncture Research on 21st Century HealthcareApril 18–21, 2013The Michigan LeagueAnn Arbor, MI

Abstracts from the Society for Acupuncture Research 2013 International ConferenceImpact of Acupuncture Research on 21^st Century Healthcare<i>April 18–21, 2013</i><i>The Michigan League</i><i>Ann Arbor, MI</i>

The Accuracy and Trends of Smoking History Documentation in Electronic Medical Records in a Large Managed Care Organization

The accuracy of smoking history documentation in the electronic medical records was examined at a large managed care organization among 36,494 male members who self-reported smoking history in mailed surveys. The sensitivity of electronic smoking history documentation for ever-smoking status was 0.19 in years 2003–2005 (using ICD-9/CPT code only), 0.80 in 2006–2008 and 0.84 in 2009–2010 (combination of ICD-9/CPT codes and risk factor module used after 2006). The positive predictive value was 0.96, 0.90, and 0.95 in these periods, respectively. Among self-reported ever-smokers, increased healthcare utilization and smoking intensity/duration were associated with higher likelihood of having electronic smoking history documentation, while Asian race and Spanish language preference were associated with lower likelihood. These data suggest that enhanced efforts may be needed to screen for and document smoking among racial/ethnic minorities.

Chronic comorbid conditions associated with risk of febrile neutropenia in breast cancer patients treated with chemotherapy

Chemotherapy-induced febrile neutropenia (FN) is associated with increased patient mortality and health care costs. Comorbid conditions such as liver and renal dysfunction have been linked to increased risk of FN. However, the effects of other chronic comorbid conditions on risk of FN have not been well studied. To examine the association between chronic comorbid conditions and FN in breast cancer patients, we identified incident breast cancer patients from 2000 to 2009 treated with chemotherapy at Kaiser Permanente Southern California, a large managed care organization. Patients who received primary prophylactic granulocyte colony-stimulating factor (G-CSF) were excluded. We assessed history of comorbid conditions prior to cancer diagnosis using ICD-9 codes and disease registries. FN events were identified in the first chemotherapy cycle using a combination of ICD-9 codes and hospital discharge diagnoses. For each comorbid condition, propensity scores that included patient characteristics and other predisposing comorbid conditions were calculated and adjusted for in Cox models to determine associations between that comorbid condition and FN. We also evaluated secondary models that additionally adjusted for cancer stage, baseline absolute neutrophil count (ANC), chemotherapy regimen, and dose reductions. A total of 7,127 breast cancer patients were included; median age was 55years, and the majority had localized (47%) or regional (49%) disease at diagnosis. In the first chemotherapy cycle, 335 (4.7%) patients developed FN. Congestive heart failure (HR=3.0; 95% CI: 1.3-5.9), osteoarthritis (HR=2.0; 95% CI: 1.4-2.8), previous cancer (HR=3.4; 95% CI: 1.2-7.5), and thyroid disorder (HR=1.6; 95% CI: 1.1-2.3) were associated with increased risk of FN. These estimates were similar to those from secondary models that also adjusted for additional cancer and treatment-related covariates. Our findings suggest that several chronic comorbid conditions may be associated with risk of FN. This information, if confirmed by others, may aid clinical decision making with respect to use of prophylactic G-CSF during chemotherapy treatment.

Association Between Antihypertensive Medication Adherence and Visit‐to‐Visit Variability of Blood Pressure

It has been hypothesized that high visit-to-visit variability (VVV) of systolic blood pressure (SBP) may be the result of poor antihypertensive medication adherence. The authors studied this association using data from 1391 individuals taking antihypertensive medication selected from a large managed care organization. The 8-item Morisky Medication Adherence Scale, administered during 3 annual surveys, captured self-report adherence, with scores<6, 6 to <8, and 8 representing low, medium. and high adherence, respectively. The mean (standard deviation [SD]) for SD of SBP across study visits was 12.9 (4.4), 13.5 (4.8), and 14.1 (4.5) mm Hg in participants with high, medium, and low self-reported adherence, respectively. After multivariable adjustment and compared with those with high self-report adherence, SD of SBP was 0.60 (95% confidence interval, 0.13-1.07) and 1.08 (95% confidence interval, 0.29-1.87) mm Hg higher among participants with medium and low self-report adherence, respectively. Results were consistent when pharmacy fill was used to define adherence. These data suggest that low antihypertensive medication adherence explains only a small proportion of VVV of SBP.

Chronic Comorbidities and Chemotherapy-Induced Febrile Neutropenia in Patients with Non-Hodgkin Lymphoma

AbstractAbstract 3671 Background:Chemotherapy induced febrile neutropenia (FN) is a clinically important adverse event as it can impact patient survival by delaying or reducing chemotherapy dose administered. Clinical guidelines recommend granulocyte-colony stimulating factors (G-CSF) be used in cancer patients when febrile neutropenia (FN) risk is >20%. Although the myelotoxicity of the chemotherapy regimen is a key determinant of FN risk, it is now recognized that patient characteristics may increase this risk further. We conducted a retrospective cohort study to evaluate the association of chronic comorbidities to FN in patients with non-Hodgkin lymphoma (NHL). Methods:Incident NHL cases diagnosed between 2000–2009 who received chemotherapy within 12 months of cancer diagnosis were identified from Kaiser Permanente Southern California, a large managed care organization. Those who had prophylactic G-CSFs, dose-dense chemotherapy or bone marrow transplant were excluded. Comorbidities of interest included cardiovascular, liver, renal, metabolic and autoimmune disorders, anemia, previous cancer and HIV infection. History of comorbidity of interest were assessed in the 12 months prior to NHL diagnosis, and identified by ICD-9 codes or disease registries. FN was assessed only in the first chemotherapy cycle, and identified by absolute neutrophil count (ANC), ICD-9 codes for neutropenia and fever, or hospitalization with bacterial/fungal infection. Patients were followed from their first chemotherapy treatment to the start of the second cycle, death or day 28, whichever came first. Logistic regression was used to estimate the propensity score for each comorbidity; these propensity scores included patient characteristics and other comorbidities as covariates. Each comorbidity and propensity score were included in Cox models to determine associations between comorbidities and FN. We also evaluated models that additionally adjusted for cancer stage, baseline ANC, chemotherapy regimen, dose reduction, and radiation treatment prior to chemotherapy. Results:A total of 2,480 NHL patients who received chemotherapy were included. The mean age was 63.3 years. Fifty-five percent of the cases were male, and the majority of the cases were of white race (65.6%). Sixty percent of the cases received CHOP or R-CHOP. There were 236 (9.5%) patients that had FN in the first chemotherapy cycle. Anemia [adjusted hazard ratio adjusted (HR) =1.6, 95% CI, 1.2–2.2], HIV infection [HR=3.0, 95% CI 1.6–5.3], AIDS [HR=2.4, 95% CI 1.2–4.6], and rheumatoid diseases [HR=2.1, 95% CI 1.2–3.6] were all associated with a statistically significantly increased FN risk (Table 1). In addition, peptic ulcer disease, renal disease and connective tissue disease were also associated with risk of FN, although these associations were not statistically significant. HR estimates did not change materially after also adjusting for cancer stage, ANC, chemotherapy regimen, dose reduction and radiation therapy prior to chemotherapy in the Cox model. Conclusions:Our findings suggest that several chronic comorbidities may be associated with increased FN risk in the first chemotherapy cycle among NHL patients not already receiving prophylactic G-CSFs. This information, if confirmed by others, may aid clinical decision making with respect to use of prophylactic G-CSF use during chemotherapy treatment.Table 1Adjusted hazard ratio (HR) of comorbidities associated with febrile neutropenia in NHL patientsFNComorbid condition of interestHR95% CIAIDS2.431.154.62Anemia1.631.212.19Congestive heart failure1.050.501.99COPD/Emphysema1.190.781.76Connective tissue disease1.640.862.83Cerebrovascular disease0.730.281.53Diabetes1.230.881.69Diabetes with end organ damage1.210.761.86Diabetes with treatment1.350.931.93HIV infection2.961.565.27Hypertension1.070.801.45Hypertension with treatment1.060.781.45Liver disease1.360.622.59Myocardial infarction1.210.582.25Osteoarthritis0.960.621.42Peripheral vascular disease0.980.421.97Previous cancer0.710.122.27Rheumatoid disease2.141.153.62Rheumatoid disease with treatment2.120.904.19Thrombosis0.860.212.25Thyroid disorder1.440.942.14Peptic ulcer disease1.950.923.61Renal Disease1.600.972.53 Disclosures:Chao:Amgen,Inc: Research Funding. Page:Amgen, Inc: Employment, Shareholder Other. Rodriguez:Amgen, Inc: Research Funding. Yang:Amgen, Inc: Research Funding. Huynh:Amgen, Inc: Research Funding. Chia:Amgen, Inc: Employment, Shareholder Other.

Sexual Activity–Related Outcomes After Human Papillomavirus Vaccination of 11- to 12-Year-Olds

Previous surveys on hypothesized sexual activity changes after human papillomavirus (HPV) vaccination may be subject to self-response biases. To date, no studies measured clinical markers of sexual activity after HPV vaccination. This study evaluated sexual activity-related clinical outcomes after adolescent vaccination. We conducted a retrospective cohort study utilizing longitudinal electronic data from a large managed care organization. Girls enrolled in the managed care organization, aged 11 through 12 years between July 2006 and December 2007, were classified by adolescent vaccine (HPV; tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed; quadrivalent meningococcal conjugate) receipt. Outcomes (pregnancy/sexually transmitted infection testing or diagnosis; contraceptive counseling) were assessed through December 31, 2010, providing up to 3 years of follow-up. Incidence rate ratios comparing vaccination categories were estimated with multivariate Poisson regression, adjusting for health care-seeking behavior and demographic characteristics. The cohort included 1398 girls (493 HPV vaccine-exposed; 905 HPV vaccine-unexposed). Risk of the composite outcome (any pregnancy/sexually transmitted infection testing or diagnosis or contraceptive counseling) was not significantly elevated in HPV vaccine-exposed girls relative to HPV vaccine-unexposed girls (adjusted incidence rate ratio: 1.29, 95% confidence interval [CI]: 0.92 to 1.80; incidence rate difference: 1.6/100 person-years; 95% CI: -0.03 to 3.24). Incidence rate difference for Chlamydia infection (0.06/100 person-years [95% CI: -0.30 to 0.18]) and pregnancy diagnoses (0.07/100 person-years [95% CI: -0.20 to 0.35]), indicating little clinically meaningful absolute risk differences. HPV vaccination in the recommended ages was not associated with increased sexual activity-related outcome rates.

LARGE DATA SETS IN PRIMARY CARE RESEARCH

With the widespread adoption of electronic health records (EHRs), researchers have growing access to large data sets that are being used for quality improvement, comparative effectiveness research, and public health policy decision making. In the recent past, large managed care organizations had

Factors Associated with the Type of Psychotropic Medications Purchased for Common Mental Disorders in the Largest Managed Care Organization in Israel

To evaluate patient and physician characteristics associated with the type of psychotropic medications (anti-anxiety, antidepressant, or both) purchased. The Clalit Health Care Services is the largest managed care health fund in Israel, a country that employs a universal healthcare system. We randomly sampled 30,000 primary care patients over the age of 22 as of January, 2006. Overall, 2,217 purchased either antidepressant or antianxiety medications at least once during the year 2006 and had no prior purchases during the last quarter of 2005. The majority (1,518; 68.4%) purchased only anti-anxiety medications and as many as 264 (12%) purchased both anti-anxiety and antidepressant medications. The remaining 435 (19.6%) patients purchased only antidepressant medications. Physician level characteristics explained only a small portion of the variance and, thus, were not included in further analysis. Several patient level characteristics, including age, somatic, and psychiatric diagnosis were associated with the purchase of different types of medications. Contrary to clinical guidelines, the purchase of anti-anxiety medications is more prevalent than the purchase of antidepressant medications. In a managed care setting, patient characteristics have a greater role in determining purchasing patterns than provider characteristics; potentially, because of the managed care characteristics that actively guide the care provided to patients.

FDA safety alerts: Getting the response right!

The Food and Drug Administration (FDA) has issued more than 350 safety alerts for drugs and biological products, since January 2008. Approximately 12% (40) of these alerts were regarding medications indicated for the treatment of neurologic or psychiatric disorders. FDA safety alerts are intended to improve patient safety by providing the medical community with timely new safety data and actionable information that may impact treatment choices by both healthcare providers and patients. Communication of the safety alert to health care professionals also generally provides a summary of the data that serves as the basis for the alert, although often unpublished and not accessible for in depth review by decision makers. Health care providers and institutions are expected to orchestrate a response to these alerts that is in the best interest of delivering safe care to patients. Responses may range from dissemination of new information, policy development, or changes in selection or use of a drug or medication class. As mental health care delivery systems vary widely in size, patient population, infrastructure and financing, and resources (personnel and technology), responses to safety alerts may also vary to same degree. We were interested in identifying commonalities for failures and successes, in the experiences of clinical pharmacy specialists in mental health settings responding to safety alerts.

P02.144. Evaluation of health outcomes for members of a managed care organization referred for acupuncture

Purpose A community health center and clinic specializing in acupuncture partnered with a large managed care organization to determine whether acupuncture treatment might influence clinical outcomes and costs of care. Members of the managed care organization were referred through their physicians to receive up to 20 treatments for any of the following conditions: pain, headache, menstrual or menopausal symptoms, and carpal tunnel syndrome. Although the project is ongoing, results of the first 4 years of the project will be presented.

CV3 Comparative Effectiveness of Statins in a Large Managed Care Organization: Cardiovascular Event Rate and Total Health Care Cost

CV3 Comparative Effectiveness of Statins in a Large Managed Care Organization: Cardiovascular Event Rate and Total Health Care Cost

Hypertension Control Among Newly Treated Patients Before and After Publication of the Main ALLHAT Results and JNC 7 Guidelines

Medication prescribing practice changed following the publications of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) in 2002 and the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) in 2003. Few data are available on changes in hypertension control rates for patients initiating antihypertensive treatment before and after these publications. The authors compared systolic and diastolic blood pressure (SBP and DBP) levels and hypertension control (SBP <140 mm Hg and DBP <90 mm Hg) rates in patients initiating antihypertensive treatment in a large managed care organization during 2 time periods: July 1, 2001, to June 30, 2002 (n=322); and July 1, 2003, to June 30, 2004 (n=323). The blood pressure reduction associated with antihypertensive medication initiation was similar in 2001-2002 and 2003-2004 (-11.9 and -10.5 mm Hg, respectively, P=.251 for SBP; -6.9 and -5.9 mm Hg, respectively, P=.160 for DBP). The mean SBP and DBP prior to treatment were significantly lower in 2003-2004 vs 2001-2002 (145.4 vs 151.3 mm Hg, P<.001 for SBP; 87.6 vs 90.1 mm Hg, P<.002 for DBP). Hypertension control rates increased from 38.0% to 50.2% (P=.005) from 2001-2002 to 2003-2004. Lower pretreatment SBP and DBP explained hypertension control improvement over time. In this real-world clinic population, antihypertensive treatment was initiated at lower blood pressure levels following publication of ALLHAT and JNC 7, resulting in substantial improvements in hypertension control rates.

Perception of Direct‐To‐Consumer Genetic Testing and Direct‐To‐Consumer Advertising of Genetic Tests among Members of a Large Managed Care Organization

This small qualitative study was designed to determine possible attitudes toward and understanding of direct-to-consumer (DTC) genetic testing among members of a large managed care organization, and whether differences might exist between population groups. Ten focus groups were conducted by population type (high risk, White, African American, Hispanic/Latino) to determine knowledge, attitudes and beliefs about DTC genetics. Focus group transcripts were coded for attitudes toward and framing of the issue. Study results found participants were negative towards DTC genetic testing but they also found some aspects useful. Participants framed the issue mainly in terms of disease prevention and uncertainty of reaction to results, with some variation between population types. The concept of an "Informed Consumer," or process to seek information when the issue becomes personally relevant, emerged. This concept suggests that individuals may seek additional assistance to make personally-appropriate choices when faced with a DTC advertisement or genetic test.

Reported Adverse Events in Young Women Following Quadrivalent Human Papillomavirus Vaccination

To assess and describe young women's experiences with their first dose of quadrivalent human papillomavirus vaccine (HPV4) (Gardasil®) in a large managed care organization. We collected survey and electronic medical record (EMR) data for 899 young women aged 11-26 receiving their first HPV4 injection from February through September 2008. Survey items included questions about adverse events, interactions with healthcare providers, and knowledge and attitudes toward HPV disease and HPV4. Six hundred ninety-six (78%) participants reported pain at the injection site. Other common reactions included injection site bruising or discoloration (n=155, 17%) or swelling (n=127, 14%) and presyncope or syncope (n=134, 15%). Overall, preteens and teens were more likely than adult participants to report vaccine adverse events. Most respondents, particularly in the adult age group, reported that their healthcare provider reviewed important information about HPV infection and about the risks and benefits of receiving the vaccine. Knowledge and attitudes about HPV and HPV4 also varied by age, with older women generally exhibiting more accurate knowledge about HPV and perceived susceptibility to cervical cancer. There were significant age differences in young women's experiences with their first HPV4 injection. These findings highlight the importance of age-appropriate education and provider communications about HPV disease and vaccination.

Analysis of the comparative effectiveness of 3 oral bisphosphonates in a large managed care organization: adherence, fracture rates, and all-cause cost.

Despite widespread availability and use of oral bisphosphonates, fracture rates and associated medical costs are still high. Differences in fracture risk among these agents, if any, have not been quantified due to the lack of high-quality, head-to-head, randomized, controlled trials assessing this outcome. Randomized, placebo-controlled trials have shown that alendronate and risedronate reduce rates of both vertebral and nonvertebral fractures, whereas only reduction in vertebral fractures has been found for ibandronate. To determine if there were any differences among 3 oral bisphosphonates in adherence, total cost of care, and effectiveness in reducing fracture rates in a large managed care population. Administrative, longitudinal pharmacy and medical claims data were obtained from 14 geographically diverse health plans in the United States covering approximately 14 million members. Sampled members had at least 1 pharmacy claim for alendronate, risedronate, or ibandronate during the intake period (January 1, 2005, through October 31, 2007). The date of the first pharmacy claim for osteoporosis medications within the intake period was the index date. Members were followed for either 12, 24, or 36 months, depending on length of continuous health plan eligibility. Medication possession ratio (MPR) was measured using a total days supply that was calculated by multiplying the total quantity dispensed by the suggested days supply per unit of dispensing based on manufacturer-recommended dosing. For members who switched bisphosphonate strengths or medications, the estimated days supply was summed for all osteoporosis medications during the follow-up, including overlapping days supply. Outcomes included (a) the first incident fracture and percentages of members with at least 1 fracture after 6 months post-index; (b) the number of days from index to the first incident fracture, measured as time to event in Cox proportional hazards regression analysis; and (c) total all-cause health care costs (health plan allowed amount including member cost share). A total of 45,939 members were included (n = 24,909 alendronate, n = 13,834 risedronate, n = 7,196 ibandronate). In the 12-month analysis, MPRs were comparable (means = 0.57-0.58) for the 3 medications. After 24 months, MPRs had dropped for all medications, but those of both alendronate (mean = 0.50, 95% CI = 0.49-0.50) and risedronate (mean = 0.50, 95% CI = 0.49-0.51) were slightly higher than that of ibandronate (mean = 0.47, 95% CI = 0.46-0.48). At 36 months, again the MPRs had dropped for all 3 medications (means = 0.44-0.47) but were similar. There were no statistically significant differences among agents in the percentages of subjects with at least 1 fracture at 12, 24, or 36 months (36-month rates: alendronate 4.41%, risedronate 4.38%, ibandronate 6.28%, P = 0.102). The numbers of subjects with fracture(s) per month of follow-up were 0.0020 for alendronate, 0.0021 for risedronate, and 0.0022 for ibandronate (P = 0.087 overall). However, after adjusting for member characteristics, alendronate users had a 12% lower risk of experiencing any incident fracture than ibandronate users (hazard ratio = 0.88, 95% CI = 0.78-0.99, P = 0.034) within the follow-up period. In the first 12 post-index months, ibandronate users had higher mean [SD] unadjusted total all-cause health care costs ($7,464 [$15,975]) compared with alendronate ($7,233 [$16,671]) and risedronate ($ 6,983 [$16,870], P less than 0.001 for both comparisons), differences of approximately $19 per month and $40 per month, respectively. The results of the unadjusted 24-month analysis were similar, but there were no significant cost differences at 36 months. Total cost differences for the 3 medication groups were nonsignificant at 12, 24, and 36 months after adjusting for member characteristics. This retrospective analysis of an administrative claims database in a large managed care population showed similar rates of adherence and total adjusted all-cause health care costs for alendronate, risedronate, and ibandronate. Absolute unadjusted rates of fracture were small and did not significantly differ among agents, but after controlling for differences in member characteristics, the risk of fracture was 12% lower for alendronate users than for ibandronate users.