Pooled Cross-sectional Study Research Articles

PCN197 - Cost-Related Medication Nonadherence Among Elderly Medicare Cancer Survivors Using Erythropoiesis-Stimulating Agents

Use of erythropoiesis-stimulating agents (ESAs) poses a significant economic burden to elderly Medicare cancer survivors. The burden of high drug expense, especially for the elderly, is one of the major reasons to not adhere to prescription regimens. The objectives of this study were to 1) provide national estimates on the prevalence of cost-related medication nonadherence (CRN), 2) to examine the association between ESA use and CRN, and 3) identify predictors of CRN among elderly Medicare cancer survivors using ESAs. This study was a pooled cross-sectional study of the Medicare Current Beneficiary Survey from 2006 to 2011. ESA users were defined as having at least one prescription of darbepoetin or epoetin in Medicare Part B or D. Self-reported CRN was the main outcome and was measured based on responses to four survey questions: taking smaller doses of prescriptions, skipping doses to make prescriptions last longer, delaying obtaining prescriptions because of cost, and not obtaining prescriptions because cost too much. Weighted logistic regression was conducted to identify predicators of CRN. ESA users had higher prevalence of CRN (9.82% vs. 6.98%, P=0.0307), compared to ESA non-users. ESA use was associated with CRN (OR: 1.46, 95% CI: 1.03-2.07). Among elderly Medicare cancer survivors using ESAs, predictors of CRN included high out-of-pocket (OOP) costs of ESAs ($100 to $500 per year, OR: 4.37, 95% CI: 1.17-16.30; $500 to $1,000 per year, OR: 17.39, 95% CI: 5.10-59.31; and >$1,000 per year, OR: 14.30, 95% CI: 4.04-50.55), disability status (OR: 2.47, 95% CI: 1.14-5.36), and without low-income subsidy (OR: 5.13, 95% CI: 1.60-16.42). Centers for Medicare and Medicaid Services and healthcare providers should adopt new strategies for better access to prescribed regimens for patients with risks of nonadherence due to high OOP medical and prescription drug costs.

The impact of dementia on antidiabetic drug use in Medicare beneficiaries with diabetes: findings post-Medicare part D.

The objectives of the study were to measure the utilization rates of antidiabetic drugs in diabetic patients with dementia and to assess the impact of dementia on antidiabetic drug use. This study was a pooled cross-sectional study of the Medicare Current Beneficiaries Survey from 2006 to 2010. Lower utilizations of biguanides, DPP-4 inhibitors and thiazolidinediones were observed in dementia patients. The likelihood of using antidiabetic drugs was about 30% (odds ratio: 0.69; 95% CI: 0.56-0.84) lower in dementia patients and 40% (odds ratio: 0.61; 95% CI: 0.44-0.84) lower in patients with Alzheimer's disease. Healthcare providers should be aware of underuse of antidiabetic drugs in patients with dementia.

Paleolithic and Mediterranean Diet Pattern Scores Are Inversely Associated with Biomarkers of Inflammation and Oxidative Balance in Adults

Background:Chronic inflammation and oxidative balance are associated with poor diet quality and risk of cancer and other chronic diseases. A diet–inflammation/oxidative balance association may relate to evolutionary discordance.Objective:We investigated associations between 2 diet pattern scores, the Paleolithic and the Mediterranean, and circulating concentrations of 2 related biomarkers, high-sensitivity C-reactive protein (hsCRP), an acute inflammatory protein, and F2-isoprostane, a reliable marker of in vivo lipid peroxidation.Methods:In a pooled cross-sectional study of 30- to 74-y-old men and women in an elective outpatient colonoscopy population (n = 646), we created diet scores from responses on Willett food-frequency questionnaires and measured plasma hsCRP and F2-isoprostane concentrations by ELISA and gas chromatography–mass spectrometry, respectively. Both diet scores were calculated and categorized into quintiles, and their associations with biomarker concentrations were estimated with the use of general linear models to calculate and compare adjusted geometric means, and via unconditional ordinal logistic regression.Results:There were statistically significant trends for decreasing geometric mean plasma hsCRP and F2-isoprostane concentrations with increasing quintiles of the Paleolithic and Mediterranean diet scores. The multivariable-adjusted ORs comparing those in the highest with those in the lowest quintiles of the Paleolithic and Mediterranean diet scores were 0.61 (95% CI: 0.36, 1.05; P-trend = 0.06) and 0.71 (95% CI: 0.42, 1.20; P-trend = 0.01), respectively, for a higher hsCRP concentration, and 0.51 (95% CI: 0.27, 0.95; P-trend 0.01) and 0.39 (95% CI: 0.21, 0.73; P-trend = 0.01), respectively, for a higher F2-isoprostane concentration.Conclusion: These findings suggest that diets that are more Paleolithic- or Mediterranean-like may be associated with lower levels of systemic inflammation and oxidative stress in humans.

Dihydrofolate reductase 19-bp deletion polymorphism modifies the association of folate status with memory in a cross-sectional multi-ethnic study of adults

Folate status has been positively associated with cognitive function in many studies; however, some studies have observed associations of poor cognitive outcomes with high folate. In search of an explanation, we hypothesized that the association of folate with cognition would be modified by the interaction of high-folate status with a common 19-bp deletion polymorphism in the dihydrofolate reductase (DHFR) gene. To our knowledge, the cognitive effects of this gene have not been studied previously. We examined the association between cognitive outcomes with the 19-bp deletion DHFR polymorphism, folate status, and their interaction with high or normal plasma folate. This was a pooled cross-sectional study of the following 2 Boston-based cohorts of community living adults: the Boston Puerto Rican Health Study and the Nutrition, Aging, and Memory in Elders study. Individuals were genotyped for the DHFR 19-bp deletion genotype, and plasma folate status was determined. Cognitive outcomes included the Mini-Mental State Examination, Center for Epidemiologic Studies Depression Scale, and factor scores for the domains of memory, executive function, and attention from a set of cognitive tests. The prevalence of the homozygous deletion (del/del) genotype was 23%. In a multivariable analysis, high folate status (>17.8 ng/mL) was associated with better memory scores than was normal-folate status (fourth-fifth quintiles compared with first-third quintiles: β ± SE = -0.22 ± 0.06, P < 0.01). Carriers of the DHFR del/del genotype had worse memory scores (β ± SE = -0.24 ± 0.10, P < 0.05) and worse executive scores (β = -0.19, P < 0.05) than did those with the del/ins and ins/ins genotypes. Finally, we observed an interaction such that carriers of the del/del genotype with high folate had significantly worse memory scores than those of both noncarriers with high-folate and del/del carriers with normal-folate (β-interaction = 0.26 ± 0.13, P < 0.05). This study identifies a putative gene-nutrient interaction that, if confirmed, would predict that a sizable minority carrying the del/del genotype might not benefit from high-folate status and could see a worsening of memory. An understanding of how genetic variation affects responses to high-folate exposure will help weigh risks and benefits of folate supplementation for individuals and public health.

Do hospitals that do the right thing have more satisfied patients?

Hospital incentive payments are increasingly becoming tied to quality. However, the U.S. health care system continues to face rising health care costs and scarce workforce resources, making improving quality a challenge. Patient satisfaction and process quality are two areas of quality tied to reimbursement. Both are associated with positive health outcomes, but little is known about the relationship between the two. The purpose of this study is to determine if there is an association between process quality and patient satisfaction in a representative sample of U.S. hospitals. We utilize a pooled cross-sectional study design with year fixed effects from 2009 to 2011. We linked the Hospital Compare data set and the American Hospital Association Annual Survey of Hospitals (AHA) data set. We use a method prescribed by the Joint Commission to determine hospital-level process quality in three areas: heart failure, acute myocardial infarction, and pneumonia treatment. We then use regression models to measure the relationship between process quality and two measures of overall hospital patient satisfaction. After we control for hospital-level characteristics and year, we find that patient satisfaction is positively associated with all three areas of hospital process quality (p < .01). For example, acute myocardial infarction process quality was positively associated with whether patients "would definitely recommend the hospital" (B = 0.75, p < .01). Process quality areas were moderately and positively correlated (p < .01), and on average, patient satisfaction scores have increased over time (p < .01). Our findings of an association between process quality and patient satisfaction suggest that focusing on process quality does not have negative implications for patient satisfaction. As performance in different process quality areas is only moderately correlated, managers should continually monitor all areas. The trend of increased patient satisfaction over time, perhaps because of industry pressures, should be investigated further.

Differences in proxy-reported and patient-reported outcomes: assessing health and functional status among medicare beneficiaries.

BackgroundProxy responses are very common when surveys are conducted among the elderly or disabled population. Outcomes reported by proxy may be systematically different from those obtained from patients directly. The objective of the study is to examine the presence, direction, and magnitude of possible differences between proxy-reported and patient-reported outcomes in health and functional status measures among Medicare beneficiaries.MethodsThis study is a pooled cross-sectional study of a nationally representative sample of community-dwelling Medicare beneficiaries from 2006 to 2011. Survey respondents can respond to the Medicare Current Beneficiary Survey either by themselves or via proxies. Health and functional status was assessed across five domains: physical, affective, cognitive, social, and sensory status. Propensity score matching was used to get matched pairs of patient-reports and proxy-reports.ResultsAfter applying the propensity score matching, the study identified 7,780 person-years of patient-reports paired with 7,780 person-years of proxy-reports. Except for the sensory limitation, differences between proxy-reported and patient-reported outcomes were present in physical, affective, cognitive, and social limitations. Compared to patient-reports, a question regarding survey respondents’ difficulties in managing money was associated with the largest proxy response bias (relative risk, RR = 3.83). With few exceptions, the presence, direction, and magnitude of differences between proxy-reported and patient-reported outcomes did not vary much in the subgroup analysis.ConclusionsWhen there is a difference between proxy-reported and patient-reported outcomes, proxies tended to report more health and functional limitations among the elderly and disabled population. The extent of proxy response bias depended on the domain being tested and the nature of the question being asked. Researchers should accept proxy reports for sensory status and objective, observable, or easy questions. For physical, affective, cognitive, or social status and private, unobservable, or complex questions, proxy-reported outcomes should be used with caution when patient-reported outcomes are not available.

Implementation of the American Diabetes Association's Standards of Medical Care post-Medicare Part D: The case of statin utilization in the elderly with diabetes.

The American Diabetes Association's (ADA's) Standards of Medical Care in Diabetes for statin use have changed to be driven by risk status rather than low-density lipoprotein cholesterol level. The objectives of this study were to 1) examine how statins were used by risk status in elderly diabetics for whom they are recommended by the ADA's Standards with high levels of evidence, and 2) identify potential predictors of statin non-use using data containing Medicare Part D information in understanding how to further align patient care with the ADA's Standards. This study was a pooled cross-sectional study of the Medicare Current Beneficiaries Survey from 2006 to 2010. Sampling weights were applied to generate national estimates. Weighted logistic regression was performed to identify potential predicators of statin non-use. Between 2006 and 2010, 53.96%, 52.14%, 52.28%, 57.74%, and 59.81% of eligible diabetics used statins, respectively. About 70% of the patients with overt cardiovascular disease (CVD) took statins while only about 50% of those with CVD risk factors used statins in 2010. Compared to those with overt CVD, patients with CVD risk factors were less likely to take statins (OR: 0.56; 95% CI: 0.48-0.64). Other non-use predictors included: non-Hispanic Black, non-metropolitan areas, and comorbidities. Implementation of the ADA's statin recommendations increased over the study period. Statin use differed significantly by patients' risk status. Future ADA's Standards focusing on how to improve utilization of statins for individuals with different risk status, particularly those with CVD risk factors but without overt CVD, are warranted.

PCV93 - Implementation Of The American Diabetes Association’s Standards Of Medical Care: The Case Of Statin Utilization In The Elderly With Diabetes

Since 2005, the American Diabetes Association’s (ADA’s) Standards of Medical Care in Diabetes have recommended that elderly diabetic patients with overt cardiovascular disease (CVD) or CVD risk factors should take statins to manage lipid levels. The objectives of this study were to 1) provide national estimates of statin utilization, and 2) identify predictors of statin use in elderly Medicare beneficiaries with diabetes to whom the ADA’s Standards of Medical Care apply. This study was a pooled cross-sectional study of the Medicare Current Beneficiaries Survey (MCBS) from 2006 to 2010. Sampling weights were applied to generate national estimates. Weighted logistic regression was performed to identify predicators of statin use. Among 8,539 person-years of elderly diabetic patients, 8,115 (94.69%, weighted percentage) were eligible for statin therapy according to the ADA’s Standards of Medical Care. In 2006, 2007, 2008, 2009, and 2010, 55.27%, 53.30%, 53.23%, 57.86%, and 60.70% of eligible diabetics used statins, respectively. Predictors of non-use of statin included: being non-Hispanic black (odds ratio [OR]: 0.69; 95% confidence interval [CI]: 0.56-0.84), living in non-metropolitan areas (OR: 0.78; 95% CI: 0.69-0.88), being underweight, with a body mass index of 18.5 or under, (OR: 0.27; 95% CI: 0.13-0.54), having one or more comorbidities in addition to CVD (OR: 0.81; 95% CI: 0.68-0.95), and having CVD risk factors (OR: 0.59; 95% CI: 0.51-0.67). A 10% increase in statin use was observed among diabetic patients who satisfied ADA’s criteria for statin use between 2006 and 2010. Still, approximately 40% of eligible individuals with diabetes were not taking statins in 2010. For elderly Medicare beneficiaries with diabetes, healthcare providers should be aware of patient factors associated with statin non-use and provide interventions to improve prescribing patterns and patient adherence.

Rising labor costs, earnings management, and financial performance of health care providers around the world.

Amid increasing interest in how government regulation and market competition affect the cost and financial sustainability in health care sector, it remains unclear whether health care providers behave similarly to their counterparts in other industries. The goal of this chapter is to study the degree to which health care providers manipulate accruals in periods of financial difficulties caused, in part, by the rising costs of labor. We collected the financial information of health care provider in 43 countries from 1984 to 2013 and conducted a pooled cross-sectional study with country and year fixed-effects. The empirical evidence shows that health care providers with higher wage costs are more likely to smooth their earnings in order to maintain financial sustainability. The finding of this study not only informs regulators that earnings management is pervasive in health care organizations around the world, but also contributes to the studies of financial booktax reporting alignment, given the existing empirical evidence linking earnings management to corporate tax avoidance in this very sector.

Correlates of unprotected anal intercourse: the influence of anal sex position among men who have sex with men in Beijing, china.

Understanding barriers to consistent condom use among men who have sex with men (MSM) requires consideration of the context in which risk behaviors occur. Anal sex position is one such context. This pooled cross-sectional study used survey data from 1,230 MSM and their 2,618 reported male sexual partnerships. Overall, nearly half of the participants engaged in unprotected anal intercourse (UAI) with at least one of upto three partners in the past 6months. "Insertive" men engaged in less UAI (39%) than "receptive" (53%) or "versatile" (51%) men. Regardless of sexual position, UAI was associated with cohabiting with a male or female partner and perceiving great or moderate risk of HIV from male contact at the individual level, and steady (vs. casual) partnership at the dyad level. However, early MSM anal sex debut, high number of male partners, alcohol use, receiving and buying condoms, HIV testing, and MSM sex-seeking venues were found to be only statistically significantly correlated with UAI among some but not all sexual positions, implying that interventions to increase condom use should take into account how anal sex position may influence willingness and ability to engage in safer sex. Dyad level data appear to provide additional insight into the influence of sexual positions, and should be used to complement individual data for future intervention designs.

Dental caries among children visiting a mobile dental clinic in South Central Kentucky: a pooled cross-sectional study

BackgroundDental caries is one of the most common chronic childhood diseases affecting a large portion of children in the United States. The prevalence of childhood dental caries in Kentucky is among the highest in the nation. The purposes of this study are to (1) compare sociodemographic differences between caries and no caries groups and (2) investigate factors associated with untreated dental caries among children who visited a mobile dental clinic in South Central Kentucky.MethodsStudy subjects were children aged 6 to 15 years who participated in the school-based dental sealant program through the mobile dental clinic operated by the Institute for Rural Health at Western Kentucky University between September 2006 and May 2011 (n = 2,453). Descriptive statistics were calculated for sociodemographic factors (age, gender, race/ethnicity, insurance status, and urban versus rural residential location) and caries status. We used chi-square tests to compare sociodemographic differences of children stratified by caries and no caries status as well as three levels of caries severity. We developed a logistic regression model to investigate factors associated with untreated dental caries while controlling for sociodemographic characteristics.ResultsThe proportion of children having untreated dental caries was 49.7% and the mean number of untreated dental caries was 2.0. The proportion of untreated dental caries was higher in older children, children with no insurance and living in rural residential locations, and caries severity was also higher in these groups. Odds ratio indicated that older ages, not having private insurance (having only public, government-sponsored insurance or no insurance at all) and rural residential location were associated with having untreated dental caries after controlling for sociodemographic characteristics of children.ConclusionsUntreated dental caries was more likely to be present in older children living in rural areas without insurance. Health interventionists may use this information and target rural children without having proper insurance in order to reduce geographic disparities in untreated dental caries in South Central Kentucky.

The importance of the political and the social in explaining mortality differentials among the countries of the OECD, 1950-1998.

This article analyzes (within the conceptual frame defined in the previous article) the impact of political variables such as time of government by political parties (social democratic, Christian democratic or conservative, liberal, and ex-dictatorial that have governed the OECD countries during the 1950-1998 period) and their electoral support on (1) redistributional policies in the labor market and in the welfare state; (2) the income inequalities measured by Theil and Gini indexes; and (3) health indicators, such as infant mortality and life expectancy. This analysis is carried out statistically by a bivariate and a multivariate analysis (a pooled cross-sectional study). Both analyses show that political variables play an important role in defining how public and social policies determine the levels of inequalities and affect the level of infant mortality. In general, political parties more committed to redistributional policies, such as social democratic parties, are the most successful in reducing inequalities and improving infant mortality. Less evidence exists, however, on effects on life expectancy. The article also quantifies statistically the relationship between the political and the policy variables and between these variables and the dependent variables--that is, the health indicators.