Health Maintenance Organization Members Research Articles

The Association of Weight Reduction and Other Variables after Bariatric Surgery with the Likelihood of SARS-CoV-2 Infection.

Although obesity has been confirmed as a risk factor for SARS-CoV-2 infection and its severity, the role of post-bariatric surgery (BS) variables and the infection is unclear. We, therefore, aimed to study comprehensively the relationship between the extent of weight reduction after surgery and other demographic, clinical, and laboratory variables with the rates of SARS-CoV-2 infection. A population-based cross-sectional study was performed, utilizing advanced tracking methodologies on the computerized database of a nation-wide health maintenance organization (HMO). The study population included all HMO members aged ≥18 years that had been tested at least once for SARS-CoV-2 during the study period and underwent BS at least one year before their testing. Of the total 3038 individuals who underwent BS, 2697 (88.78%) were positive for SARS-CoV-2 infection and 341 (11.22%) were negative. Multivariate regression analysis demonstrated that the body mass index and the amount of weight reduction after the BS were not related to the likelihood of SARS-CoV-2 infection. Post-operative low socioeconomic status (SES) and vitamin D3 deficiency were associated with significant and independent increased rates of SARS-CoV-2 infection (odds ratio [OR] 1.56, 95% confidence interval [CI], 1.19-2.03, p < 0.001; and OR 1.55, 95% CI, 1.18-2.02, p < 0.001; respectively). Post-operative physical activity > 3 times/week was associated with a significant and independent reduced rate of SARS-CoV-2 infection (OR 0.51, 95% CI, 0.35-0.73, p < 0.001). Post-BS vitamin D3 deficiency, SES, and physical activity, but not the amount of weight reduction, were significantly associated with the rates of SARS-CoV-2 infection. Healthcare workers should be aware of these associations after BS and intervene accordingly.

The variability of diagnosed migraine epidemiology amongst different municipalities in southern Israel

BackgroundAppropriate and timely diagnosis is one of the most important milestones in effective migraine care and is affected by public awareness, access to medical care, health care systems, and physicians’ knowledge. We assessed the variability in migraine diagnosis rates in different communities under universal national health coverage in Israel.MethodsIn this population-based retrospective, observational, cohort study, adult (≥18 years) migraine patients were identified in the computerized database of the southern district of the Clalit Health Services Health Maintenance Organization (HMO) based on recorded diagnosis and/or purchase of specific anti-migraine acute medication (triptans). Migraine prevalence in 2018 was calculated in the entire study population and in different municipalities. We utilized a standardized (age and gender) mortality ratio (SMR) approach for comparison among the municipalities.ResultsIn 2018, a total of 29,938 migraine patients were identified out of 391,528 adult HMO members, with an overall prevalence (per 10,000) of migraine of 764.64 (7.65%), 1143.34 (11.43%) for women, and 374.97 (3.75%) for men. Among the municipalities, adjusted prevalence (per 10,000) ranged from 386.15 (3.86%) to 1320.60 (13.21%). The female-to-male ratio ranged from 1.8:1 to 5.1:1. Prevalence rates were positively associated with the socioeconomic status of the municipalities (Spearman rho = 0.472, P = 0.031).ConclusionsHigh variability in the prevalence of diagnosed migraine suggests underdiagnosis. Resources for awareness and educational programs should be directed to low diagnosed prevalence communities.Graphical

Migraine epidemiology and comorbidities in Southern Israel: a clinical database study in a universal health coverage setting

BackgroundUnderstanding migraine epidemiology and its burden is crucial for planning health policies and interventions at the local level as well as at the global level. National policies in Israel rely on global estimations and not on local data since local epidemiologic studies had not previously been performed. In this study, we evaluated the epidemiology of migraine in the southern district of Israel using the electronic medical records database of the largest Israeli health maintenance organization (HMO).MethodsIn this population-based, retrospective, observational cohort study, adult migraine patients were identified in the computerized database of the southern district of the Clalit Health Services HMO (total population, 0.75 million). Patients were identified based on recorded diagnosis (International Classification of Diseases, Ninth Revision) and/or claims for specific anti-migraine medication (triptans) between 2000 and 2018. A 1:2 age-, gender-, and primary care clinic–matched control group was used for evaluation of comorbidities.ResultsIn 2018, a total of 29,938 patients with migraine were identified out of 391,528 adult HMO members. Most of the patients were women (75.8%), and the mean ± standard deviation age at diagnosis was 36.94 ± 13.61 years. The overall prevalence of migraine (per 10,000) was 764.64 (7.65%), 1143.34 (11.43%) for women and 374.97 (3.75%) for men. The highest prevalence was observed in patients aged 50 to 60 years and 40 to 50 years (1143.98 [11.44%] and 1019.36 [10.19%], respectively), and the lowest prevalence was among patients aged 18 to 30 years and > 70 years (433.45 [4.33%] and 398.49 [3.98%], respectively).ConclusionsThis is the first large-scale epidemiologic study of migraine prevalence in Israel. Compared to international estimations, migraine appears to be underdiagnosed in the southern district of Israel.

Second Malignancies Among Older Patients with Classical Myeloproliferative Neoplasms Treated with Ruxolitinib

Introduction: Myeloproliferative neoplasms (MPN) are associated with an increased risk of clonal evolution to more aggressive myeloid disorders and the development of second malignancies (SM) including lymphoproliferative and solid tumors. The reasons for SM are unclear, but a therapy-related effect has been invoked. Ruxolitinib (RUX) is a guideline-recommended cytoreductive agent used in the US for myelofibrosis (MF) and polycythemia vera (PV) since 2011 and 2014, respectively. RUX has been linked to an increased risk of non-melanoma skin cancers (NMSC), but its influence on the development of other SM is debated. We aimed to evaluate the effect of RUX on the development of solid and lymphoid SM in a large, population-based cohort of patients (pts) with MPN. Methods: We conducted a retrospective cohort study of older adults with MPN including PV, essential thrombocythemia (ET) and MF in the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. Pts were required to 1) be diagnosed in 2012-2017, 2) be 66-99 years of age at diagnosis, 3) have continuous enrollment in Medicare Parts A and B from one year before MPN diagnosis through end of follow-up, and 4) have continuous Part D coverage from diagnosis to the end of follow-up. We excluded pts who were health maintenance organizations members, or treated with chlorambucil, busulfan or allogeneic stem cell transplant. We followed pts from MPN diagnosis to 12/31/2019, SM diagnosis, death or change of insurance status, whichever came first. RUX proportion of days covered (PDC) was calculated as the ratio of the number of days the patient was covered by RUX to the number of days from RUX initiation to 6 months before end of follow-up. Our outcome of interest was first SM, i.e., any new malignancy other than new myeloid malignancy and NMSC, diagnosed at least 6 months after cohort entry. We identified SM using SEER data for the years 2012-2017 and Medicare claims for the years 2018-2019. We categorized SM as solid or lymphoid. The cumulative incidence function (CIF) of SM was computed via a competing risk model. Death and development of a SM other than malignancy of interest (solid or lymphoid) were considered as competing events. Gray's test was utilized to assess difference across strata. The impact of RUX on the development of SM was assessed by multivariable competing risks models. The models adjusted for age at MPN diagnosis, sex, race, marital status, SEER region, Elixhauser comorbidity score, history of prior malignancy, disability status, state buy-in, census tract Yost index and hydroxyurea exposure. All statistical tests were two-sided and performed with SAS Version 9.4. Results: The study included 4019 pts (1556 PV, 1896 ET, 567 MF) with a median age at diagnosis of 77 (interquartile range [IQR]: 71-83) years. The median follow-up was 3.5 (IQR: 2.23- 4.98) years and 3.18 (IQR: 2.17- 4.75) years for 408 RUX users and 3611 non-users, respectively. Among RUX users, RUX was initiated after a median of 0.66 years since diagnosis. Pts received RUX for a median of 1.15 (IQR: 0.42-2.12) years with a median PDC of 94.6% (IQR: 71.3- 99.7%). Compared with those who did not receive RUX, RUX users were more likely to be younger, have MF and a history of prior malignancy. A total of 396 pts developed a SM including 306 solid SMs and 90 lymphoid SM. About 9% RUX users and 10% non-users developed a SM, resulting in a CIF of 17.8% (95% confidence interval [CI]: 10.1-27.4%) and 16.3% (95% CI: 13.9-18.9%), respectively (Gray's test, p=0.17; (Figure 1). The CIF of solid SM among RUX users was 11.8% (95% CI: 5.4-21.1%), and 13.0% among non-users (95% CI: 10.7-15.5%, p= 0.06); in lymphoid SM, CIF was 6.0 % (95% CI: 2.64-11.3%) among RUX users, and 3.3% (95% CI: 2.6- 4.2%) among non-users (p=0.52). In the multivariable model, the risk of any SM (hazard ratio [HR]=1.07, 95% CI: 0.73-1.58, p=0.72), solid (HR=0.97, 95% CI: 0.62-1.51, p=0.89) and lymphoid SM (HR=1.45, 95% CI: 0.66-3.20, p=0.35) did not differ by RUX use status. No difference in the risk of any SM was observed when evaluating the influence of RUX PDC (Figure 2) Similar findings were seen in MPN subgroups. Conclusions: In this large population-based study of older pts with MPN, the risk of solid and lymphoid SM was similar among RUX users and non-users. Our results suggest that the use of RUX does not increase the risk of SM in older pts with MPN. Acknowledgments: The study was supported by Frederick A. Deluca Foundation. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Adherence to smoking cessation guidelines (5As) by psychiatrists and primary care physicians for persons with serious mental illness

Smoking rates are three times higher among people with serious mental illness (PWSMI), yet, earlier studies showed that physician compliance with smoking cessation guidelines (5As) for PWSMI is low. Objectives: 1) Compare the 5A (Ask-Advise-Assess-Assist-Arrange) practice rates between psychiatrists and primary care physicians (PCPs) regarding smoking cessation for PWSMI. 2) Compare the 5A practice rates reported by physicians with rates reported by PWSMI. 3) Identify which specialty is perceived as primarily responsible for smoking cessation promotion for PWSMI. Methods: Telephone surveys were carried out in a large health maintenance organization (HMO) among all psychiatrists, a random sample of PCPs, and HMO members with serious mental illness who had registered/participated in a smoking cessation program. Physicians were asked how frequently they carried out each 5A practice, along with questions regarding role responsibility and interaction between the two clinical specialties. PWSMI were asked to report about each 5A practice by both PCP and treating psychiatrist. Results: Ask-Advise-Assess rates were higher than Assist-Arrange rates for both specialties. 83% of PCPs had satisfactory 5A practice scores compared to 46% of psychiatrists (X 2=23.9, p < 0.001). With the exception of Ask rates, physician rates for each 5A component were higher than those reported by PWSMI. PCPs were more likely to see smoking cessation promotion as their responsibility and did not always confer with the psychiatrist regarding referral and SCM prescription. Conclusions: Interventions focusing on promoting Assist-Arrange practices and better integration between the specialties are required.

A novel methodology to measure waiting times for community-based specialist care in a public healthcare system

BackgroundMonitoring waiting time (WT) in healthcare systems is essential, since long WT are associated with adverse health outcomes, reduced patient satisfaction and increased private financing. ObjectiveTo describe a methodology developed for routine national monitoring of WT for community-based non-urgent specialist appointments, in a public healthcare system. MethodsThe methodology is based on data from computerized appointment scheduling systems of all Health Maintenance Organizations (HMOs) in Israel. Data included first 50 available appointments for community-based specialists and actual number of visits. Five most frequent specialties: orthopedics, ophthalmology, gynecology, dermatology and otolaryngology, were included.WT offered to HMO members for non-urgent care was calculated for two scenarios: "specific" physician and "any" physician in the region. Distribution of offered WT was calculated separately for each specialty and geographical region, combined to create the nationwide distribution. ResultsThe methodology was tested on data extracted between December 2018-June 2019. Estimated national median WT for "specific" physician, ranged from 9 days (ophthalmology/gynecology) to 20 days (dermatology), with large variation between geographic regions. WT were 26–56 % shorter for "any" than for "specific" physician. ConclusionsThis novel method offers a solution for ongoing national WT measurement, using computerized scheduling systems. It integrates two scenarios for appointment scheduling and allows identification of differences between specialties and regions, setting the ground for interventions to strengthen public healthcare systems.

Pharmaceutical policies: effects of educational or regulatory policies targeting prescribers.

Pharmaceuticals make an important contribution to people's health. Medicines, however, are frequently not used appropriately. Improving the use of medicines can improve health outcomes and save resources. On the other hand, regulatory and educational policies may have unintended effects on health and costs. To assess the effects of pharmaceutical educational and regulatory policies targeting prescribers on medicine use, healthcare utilisation, health outcomes and costs (expenditures). We searched CENTRAL, MEDLINE, Embase, and two trial registries in March 2018 and several other databases between 2014 and 2018. We reviewed the reference lists of included studies and other relevant reviews, contacted authors of relevant reviews and studies to identify additional studies, and did a citation search for all included studies using ISI Web of Science (searched 05 January 2016). Randomised trials, non-randomised trials, interrupted time series studies, repeated measures studies and controlled before‒after studies of policies regulating who can prescribe medicines and other policies targeted at prescribers. We included in this category monitoring and enforcement of restrictions, generic prescribing, programmes to implement treatment guidelines, system-wide policies regarding monitoring medicine safety, and legislated or mandatory continuing education or quality improvement specifically targeted at prescribing. We defined 'policies' in this review as laws, rules, financial and administrative orders made by governments, non-governmental organisations or private insurers. We excluded interventions applied at the level of a single facility. For us to include a study, it had to include an objective measure of at least one of the following outcomes: medicine use, healthcare utilization, health outcomes, or costs. Two review authors independently reviewed abstracts and reference lists of relevant reports, assessed full-text studies for inclusion, extracted data, and assessed risk of bias and certainty of the evidence (GRADE). For all the steps in the above process we resolved disagreements by discussion. We identified two studies that met our selection criteria: a controlled interrupted time series study evaluating a regulatory policy involving the monitoring of prescribing of benzodiazepines; and a controlled before‒after study of an educational policing involving mailed educational materials on prescribing for physicians and Health Maintenance Organization (HMO) members as well as an intervention to regulate drug reimbursement. We are uncertain about the effects on medicine use of a regulatory policy involving the monitoring of prescribing with triplicate prescriptions, compared with no regulatory intervention (very low certainty evidence). We are also uncertain about the effects on medicine use, assessed through doctors' prescribing, and costs of an educational policy involving mailed educational materials on prescribing for physicians and HMO members, compared to no educational intervention or an intervention to regulate drug reimbursement (very low certainty evidence). Neither of the included studies measured healthcare utilization, health outcomes, or additional costs, if any, to patients. We are uncertain of the effects of educational or regulatory policies targeting prescribers due to very limited evidence of very low certainty. The impacts of these policies therefore need to be evaluated rigorously using appropriate study designs. Evaluations are needed across a range of settings, including low- and middle-income countries, and across different types of prescribers and medicines.

The Evolution of Health Insurer Costs in Massachusetts, 2010-12.

We analyze the evolution of health insurer costs in Massachusetts between 2010-2012, paying particular attention to changes in the composition of enrollees. This was a period in which Health Maintenance Organizations (HMOs) increasingly used physician cost control incentives but Preferred Provider Organizations (PPOs) did not. We show that cost growth and its components cannot be understood without accounting for (i) consumers' switching between plans, and (ii) differences in cost characteristics between new entrants and those leaving the market. New entrants are markedly less costly than those leaving (and their costs fall after their entering year), so cost growth of continuous enrollees in a plan is significantly higher than average per-member cost growth. Relatively high-cost HMO members switch to PPOs while low-cost PPO members switch to HMOs, so the impact of cost control incentives on HMO costs is likely different from their impact on market-wide insurer costs.

Comparing The Effects Of Reference Pricing And Centers-Of-Excellence Approaches To Value-Based Benefit Design.

Various health insurance benefit designs based on value-based purchasing have been promoted to steer patients to high-value providers, but little is known about the designs' relative effectiveness and underlying mechanisms. We compared the impact of two designs implemented by the California Public Employees' Retirement System on inpatient hospital total hip or knee replacement: a reference-based pricing design for preferred provider organizations (PPOs) and a centers-of-excellence design for health maintenance organizations (HMOs). Payment and utilization data for the procedures in the period 2008-13 were evaluated using pre-post and quasi-experimental designs at the system and health plan levels, adjusting for demographic characteristics, case-mix, and other confounders. We found that both designs prompted higher use of designated low-price high-quality facilities and reduced average replacement expenses per member at the plan and system levels. However, the designs used different routes: The reference-based pricing design reduced average replacement payments per case in PPOs by 26.7percent in the first year, compared to HMOs, but did not lower PPO members' utilization rates. In contrast, the centers-of-excellence design lowered HMO members' utilization rates by 29.2percent in the first year, compared to PPOs, but did not reduce HMO average replacement payments per case. The reference-based pricing design appears more suitable for reducing price variation, and the centers-of-excellence design for addressing variation in use.

The Evolution of Health Insurer Costs in Massachusetts, 2010-12

We analyze the evolution of health insurer costs in Massachusetts between 2010-2012, paying particular attention to changes in the composition of enrollees. This was a period in which Health Maintenance Organizations (HMOs) increasingly used physician cost control incentives but Preferred Provider Organizations (PPOs) did not. We show that cost growth and its components cannot be understood without accounting for (i) consumers’ switching between plans, and (ii) differences in cost characteristics between new entrants and those leaving the market. New entrants are markedly less costly than those leaving (and their costs fall after their entering year), so cost growth of continuing enrollees in a plan is significantly higher than average per-member cost growth. Relatively high-cost HMO members switch to PPOs while low-cost PPO members switch to HMOs, so the impact of cost control incentives on HMO costs is likely different from their impact on market-wide insurer costs.

Patient-Centered Medical Home Impact on Health Plan Members With Diabetes

To compare costs and utilization for patients with diabetes enrolled in patient-centered medical home (PCMH) practices and non-PCMH practices. Commercial Health Maintenance Organization members with diabetes who enrolled between 2008 and 2011 in 26 Pennsylvania-based PCMH practices that were recognized by the National Committee for Quality Assurance in 2009 were compared with similar patients in 97 non-PCMH primary care practices. A difference-in-differences longitudinal research design was used to analyze differences between both groups on per-member, per-month costs and utilization. The statistical models controlled for baseline practice and patient-level characteristics through 2-step propensity score matching. The regression analysis on program effect further controlled for within-practice variation. Sensitivity analyses were also conducted on patients with type 1 and type 2 diabetes separately, and a third analysis was limited to diabetic patients enrolled in practices within Philadelphia. Adoption of the PCMH reduced overall medical costs for diabetic patients by 21% in year 1. This reduction was driven largely by inpatient costs, which fell by 44%. Reductions in emergency department visits, outpatient costs, and specialist visits were also seen in subsequent years among patients enrolled in PCMH practices. Additional sensitivity analyses indicated that adoption of the PCMH model yielded similar results when analyzing patients with type 2 diabetes as well as for diabetic patients enrolled in PCMH practices located within the city of Philadelphia. The cost of care for patients with diabetes can be reduced by securing care at a PCMH practice. Immediate results were seen in reduction of inpatient costs, which indicate that these patients enrolled in PCMH practices were using less costly inpatient services.

Differential associations of oral estradiol and conjugated equine estrogen with hemostatic biomarkers

The risk of venous thrombosis (VT) associated with oral hormone therapy (HT) may differ by type of estrogen compound. To compare the thrombotic profile of women using oral conjugated equine estrogens (CEE) with that of women using oral estradiol (E2). In postmenopausal, female, health maintenance organization (HMO) members with no history of VT, we measured thrombin generation, levels of factor VII activity, antithrombin activity and total protein S antigen. Mean levels of hemostasis biomarkers were cross-sectionally compared by use and type of estrogen using multiple linear regressions. The type of estrogen used was determined primarily by the HMO formulary, which changed its preferred estrogen from CEE to E2 during the study period. The sample included 92 E2 users and 48 CEE users, with a mean age of 64.1 years and mean BMI of 29.1 kg m(-2) . Twenty-seven per cent of HT contained medroxyprogesterone acetate. Compared with E2 users, CEE users had greater thrombin generation peak values and endogenous thrombin potential, and lower total protein S (multivariate adjusted differences of 49.8 nm (95% CI, 21.0, 78.6), 175.0 nm × Min (95% CI, 54.4, 295.7) and -13.4% (95% CI, -19.8, -6.9), respectively). Factor VII and antithrombin levels were not different between E2 and CEE users. Results were similar in subgroups of users of unopposed HT, opposed HT, low-dose estrogen and standard dose estrogen. The hemostatic profile of women using CEE is more prothrombotic than that of women using E2. These findings provide further evidence for a different thrombotic risk for oral CEE and oral E2.

Epidemiology and comorbidity of severe mental illnesses in the community: findings from a computerized mental health registry in a large Israeli health organization

Maccabi Healthcare Services, a large health maintenance organization (HMO) operating in Israel, has recently constructed a computerized registry of patients with severe mental illnesses (SMI). In the present study, we aimed to use this registry to investigate the epidemiology of schizophrenia and bipolar affective disorder among adults, and to assess their comorbidity and mortality compared to the general population. In this historical cohort study, we investigated the age- and sex-specific prevalence and incidence rates of HMO members diagnosed with schizophrenia or bipolar affective disorder between 2003 and 2009. We compared their medical comorbidity and mortality to the general HMO population. A total of 8,848 and 5,732 patients were diagnosed with bipolar (crude prevalence rate of 5 per 1,000) and schizophrenia (3 per 1,000), respectively. The annual incidence rates were 4.2 and 2.4 per 1,000 for schizophrenia and bipolar disorder, respectively. On average, schizophrenic men were diagnosed 4-5 years earlier than schizophrenic women. Compared to the general population, schizophrenia and bipolar disorder patients had a 12- and 9-year shorter life expectancy, respectively. They were also more likely to be diagnosed with diabetes mellitus (odds ratio of 1.9 and 1.6, respectively). The current study demonstrates the potential use of automated medical databases to characterize the epidemiology of SMI in the community. The increased comorbidity and mortality among these patients has important implication for health authorities for prevention and delivery of health-care services.

State Policies and Language Access in California’s HMOs: Public Reporting and Regulation of HMOs’ Language Services

Describe the status of language access services for California's limited English proficient (LEP) health maintenance organization (HMO) members within the context of voluntary public reporting and anticipated state regulation. Descriptive analysis of longitudinal data provided by health plans. Retrospective, descriptive analysis of responses to voluntary annual/biennial surveys of commercial, Medicare, Medicaid, and Healthy Families HMOs, 2003-2008. From 2003 to 2008, during California's public reporting of HMO language services, the percentage of HMOs providing in-person interpretation free of charge to consumers increased to over 80% across all product lines. By 2008, the percentage of commercial HMO plans matching new LEP members to providers by language increased to 70%, while 79% provided telephone interpretation services in at least seven languages. Increasingly HMOs provide language access services for LEP Californians, perhaps resulting from public reporting and anticipated state regulation, although similar trends in other states cannot be ruled out.

Risk of Fractures Requiring Hospitalization After an Initial Prescription for Zolpidem, Alprazolam, Lorazepam, or Diazepam in Older Adults

To determine whether zolpidem is a safer alternative to benzodiazepines. Retrospective cohort study. Community based. Health maintenance organization members with an initial prescription for zolpidem (n=43,343), alprazolam (n=103,790), lorazepam (n=150,858), or diazepam (n=93,618). Zolpidem and benzodiazepine prescriptions were identified from pharmacy databases. Rates of nonvertebral fractures and hip fractures requiring hospitalization were compared before and after an initial prescription for each treatment, adjusting for confounders using doubly robust estimation. In patients aged 65 and older, the rates of nonvertebral fractures and dislocations were similar in the pre- treatment intervals. The rate ratios (RRs) for the 90-day posttreatment interval relative to the pretreatment interval were 2.55 (95% confidence interval (CI)=1.78-3.65; P<.001) for zolpidem, 1.14 (95% CI=0.80-1.64; P=.42) for alprazolam, 1.53 (95% CI=1.23-1.91; P< .001) for lorazepam, and 1.97 (95% CI=1.22-3.18; P=.01) for diazepam. The ratio of RRs (RRR)-the RR in the posttreatment period adjusted for the corresponding RR in the pretreatment period-were 2.23 (95% CI=1.36-3.66; P=.006) for zolpidem relative to alprazolam, 1.68 (95% CI=1.12-2.53; P=.02) for zolpidem relative to lorazepam, and 1.29 (95% CI=0.72-2.30; P=.32) for zolpidem relative to diazepam. The RRs decreased with time from the initial prescription (trend P<.001), as would be expected if the association is causal. In older adults, the risk of injury with zolpidem exceeded that with alprazolam and lorazepam and was similar to that with diazepam. If the associations are causal, then the high incidence of these fractures implies that these treatment induce a substantial number of fractures and consequential costs. Further study of the association is imperative.

Two-year Trends in Colorectal Cancer Screening After Switch to a High-deductible Health Plan

Recent health reform laws might accelerate high-deductible health plan (HDHP) growth. The impact of HDHPs on long-term colorectal cancer screening rates and low socioeconomic status (SES) members is unknown. We studied colorectal cancer screening rates among 1306 Health Maintenance Organization (HMO) members for 1 year before and 2 years after an employer-mandated switch to HDHPs, compared with 1306 propensity score-matched controls who remained in HMOs by employer choice. HDHP members had full coverage of fecal occult blood testing (FOBT) but colonoscopy, flexible sigmoidoscopy, and double-contrast barium enema were subject to $500 to $2000 annual deductibles. HMO members had full coverage of these tests. We used generalized estimating equations to adjust screening rates for member characteristics. We stratified analyses by SES. Overall colorectal cancer screening rates in the HDHP group relative to the control group trended down from baseline to the first and second follow-up years [ratios of change, 0.88, (95% confidence interval, 0.73 to 1.06) and 0.83, (0.69 to 1.00), respectively]. Low SES HDHP members experienced a statistically significant relative decrease in colonoscopy in both follow-up years [0.65, (0.48 to 0.88) and 0.59, (0.42 to 0.84), respectively] and a trend toward increased FOBT [1.26, (0.92 to 1.72) and 1.30, (0.95 to 1.77), respectively] to maintain stable overall colorectal cancer screening rates [1.01, (0.77 to 1.32) and 0.93, (0.71 to 1.22), respectively]. High SES members experienced less pronounced decrease in colonoscopy [0.89, (0.67 to 1.18) and 0.87, (0.62 to 1.21), respectively] but FOBT rates did not increase [0.83, (0.62 to 1.11 and 0.81), (0.60 to 1.11), respectively]. Switching to a HDHP was associated with a downward trend in overall colorectal cancer screening rates after 2 years. Low SES HDHP members maintained stable rates, but substituted FOBT for colonoscopy and other tests now more widely recommended. Further research should investigate whether such reduced adherence to screening guidelines adversely affects health outcomes.

P1-423 Assessment of influenza outbreaks using a private healthcare information system: an analysis of the 2009 H1N1 epidemic in Buenos Aires

IntroductionThis study aims to determine if the A/H1N1 influenza outbreak could have been earlier detected through changes in morbidity and mortality patterns analysed from a health information system (HIS).MethodsSpecific data...

Adverse childhood experiences and sleep disturbances in adults

Sleep disturbances are associated with an increased risk for many chronic diseases and unhealthy behaviors. A history of adverse childhood experiences (ACEs) is also associated with similar adult health outcomes. We studied the relationship between multiple ACEs and the likelihood of experiencing self-reported sleep disturbances in adulthood. We used data from the adverse childhood experiences (ACE) study, a retrospective cohort study of 17,337 adult health maintenance organization members in California who completed a survey about eight ACEs, which included childhood abuse and growing up with various forms of household dysfunction. The self-reported sleep disturbances measured included ever having trouble falling or staying asleep and feeling tired after a good night's sleep. We used an integer count of the number of ACEs (the ACE score) to assess the cumulative impact of these experiences on the likelihood of self-reported sleep disturbances. Thirty-three percent of the cohort reported trouble falling or staying asleep, while 24% reported feeling tired after sleeping. All eight ACE categories were associated with an increased likelihood of self-reported sleep disturbances (p<0.05). Compared to persons with an ACE score of 0, those with an ACE score ≥ 5 were 2.1 (95% CI: 1.8-2.4) times more likely to report trouble falling or staying asleep and 2.0 (95% CI: 1.7-2.3) times more likely to report feeling tired even after a good night's sleep. The trend for increasing odds for both types of self-reported sleep disturbance with increasing ACE scores was statistically significant (p<0.0001). Adverse childhood experiences were associated with self-reported sleep disturbances in adulthood, and the ACE score had a graded relationship to these sleep disturbances. A history of ACEs should be obtained for patients with self-reported sleep disturbances to coordinate services that ameliorate the long-term effects of these events.

Development and Psychometric Testing of the Colonoscopy Embarrassment Scale

Colorectal cancer, the third leading cause of cancer-related death in the United States, could largely be prevented if more people had polyps removed via colonoscopies. Embarrassment is one important barrier to colonoscopy, but little is known about embarrassment in this context, and there were no reliable and valid measures of this construct. The purpose of this study was to develop a reliable and valid instrument to measure colonoscopy-related embarrassment. Transtheoretical Model of Behavior Change and Health Belief Model provided the theoretical basis for this study. Participants were health maintenance organization members aged 50 to 65 years (N=234). Using a cross-sectional, descriptive research design, data were collected using a mailed survey. Internal consistency (Cronbach's α=.96) and construct validity of the 13-item instrument were demonstrated. This unidimensional scale shows promise as a valid and reliable instrument to measure colonoscopy-related embarrassment and to inform development of interventions to reduce embarrassment, leading to higher colonoscopy completion rates and lower mortality.

Patient Barriers to Mammography Identified During a Reminder Program

Background: Patient mammogram reminders are effective at increasing screening, but patient barriers remain. We evaluated patient characteristics and reported barriers for their association with mammogram completion after a reminder program. Methods: This retrospective cohort study used data from electronic records and a subgroup survey. Participants were female Kaiser Permanente Northwest health maintenance organization (HMO) members aged 50-69 who were 20 months past their last mammogram (index date) and had received a reminder intervention (n = 4708). A mailed survey was completed by 340 of 667 (50.2%) women who received it. The intervention was a "mammogram due soon" postcard 20 months after the last mammogram, followed by up to two automated phone calls and one live call for nonresponders. The outcome was mammogram completion at 10 months after index date. Results: Characteristics associated with lower mammogram completion rates were aged <60 (odds ratio [OR] 0.69, p < 0.0001), health plan membership <5 years (OR 0.81, p = 0.019), family income <$40,000/year (OR 0.77, p = 0.018), and obesity (OR 0.67, p < 0.0001). Obese women were more likely than nonobese women to report "too much pain" from mammograms (31.3% vs.18.8%, p < 0.01). Younger women were more likely to endorse that they were "too busy" (19.1% vs. 6.4%, p < 0.001) and had more worries about mammogram accuracy (2.5 vs. 2.3 on a 5-point scale, p < 0.05). Pain mediated the relationship between obesity and mammogram completion rates (indirect effect = -0.111, p = 0.008). Conclusions: Important barriers to mammogram completion remain even after an effective mammogram reminder system among insured patients. Tailored interventions are necessary to overcome these barriers.