Tami L. Mark

Developed for clinical use in oncology settings, the Patient Assessment, Care & Education (PACE) System™ is a computer technology tool designed to address the under-identification and treatment of chemotherapy-related symptoms. This system includes general core questions together with the Patient Care Monitor™ (PCM), a validated questionnaire that assesses patient-reported problems, six symptom burden indices, and one global quality of life index. The system automatically scores the PCM and generates a written report. The objective of this study was to assess the manner in which clinicians use this system and identify the benefits and challenges that oncology clinics may face when adopting this system. The study was part of a larger evaluation of the system that included standardized surveys and chart review. Sixteen providers (physicians, nurses, and physician assistants) at 13 community oncology clinics participated in a 30-minute interview. Responses were coded according to common phrases or concepts. Clinicians indicated that they use the system mainly for symptom assessment or review of systems. The most common benefits identified included the improved ability to identify under-reported symptoms, enhanced communication with patients; increased efficiency; and its ability to highlight patients' most bothersome symptoms. Challenges included patient burden from the frequent need to answer the questionnaires, issues with the wording and formatting of the screening questionnaire, and technical difficulties. In sum, these interviews suggest that electronic symptom assessments offer potential advantages in terms improving the integration of routine assessment of patients' symptoms and health-related quality of life into the daily flow of an oncology clinic. The approach should receive additional research and development attention.

Sustained treatment with a cholinesterase inhibitor (ChEI) is used in the management of the symptoms of Alzheimer's disease (AD). However, the characteristic declines in learning and memory seen in AD may erode the patient's ability to adhere to medication regimens with or without caregiver support. To examine differences by type of ChEI in (1) monthly prevalence of use, (2) nonpersistence, (3) switching from the index drug to another ChEI, (4) number of days on therapy, (5) medication possession ratio (MPR), and (6) an estimate of the relationship of these characteristics to total annual health care expenditures. Data were from the MarketScan Medicare Supplemental and Coordination of Benefits 2001-2003 database, which comprised 1.47 million Medicare beneficiaries during this 3-year time period. Inclusion criteria were: (1) aged 65 years or older; (2) at least 1 claim with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 331.0 for AD in any of 15 diagnosis fields on outpatient claims or any of 2 diagnosis fields on inpatient claims at any time during 18 months of observation; (3) at least 1 pharmacy claim for donepezil, galantamine, or rivastigmine preceded by a 6-month period without a ChEI claim; and (4) at least 12 months of follow-up data, for a minimum 18 months continuous enrollment. Multivariate analyses, including logistic regression and exponential conditional mean models, tested for cohort differences in ChEI utilization, controlling for demographics, region of the country, type of insurer, and the Charlson Comorbidity Index (comorbid diagnoses). Using exponential conditional mean models, we also examined the relationship between utilization characteristics and all-cause (i.e., not specific to AD) health care expenditures for a 12-month period, including inpatient and outpatient (physician) care, laboratory and radiology services, emergency room (ER) use, prescription drugs, and long-term care services (e.g., nursing home care, home health visits) paid by Medicare or private insurance, but excluding long-term care services paid by Medicaid. Expenditure was defined as allowed charge (i.e., the total payment received by the service provider including plan and patient paid amounts.) More than 70% of the patients who received ChEI therapy and who otherwise met the inclusion criteria were excluded from this study due to the absence of at least 1 claim with a diagnosis for AD. Of the 3,177 patients included in the study, the index ChEI was donepezil for 62.8% of the patients (n=1,994); 17.2% received galantamine (n=546) and 20.1% received rivastigmine (n=637). The total number of days of index therapy dispensed was greater for those starting on donepezil (mean [median, SD] days=226 [263, 115]) compared with rivastigmine (206 [233, 120], P<0.001), but was not significantly different compared with galantamine (216 [250, 119], P=0.085). Monthly prevalence of use was similar for the 3 drugs until month 5 when a smaller proportion of rivastigmine patients had index medication on hand (65.9%) compared with 72.1% of donepezil patients (P=0.003) and 72.7% of galantamine patients (P=0.012). At 12 months, the likelihood of receiving the index ChEI was higher for donepezil (61.1%) than for either rivastigmine (50.1%, P<0.001) or galantamine (56.4%, P=0.048) and was higher for galantamine than for rivastigmine (P=0.030). The rate of switching for donepezil patients was significantly lower (14.5%) than the switch rate for rivastigmine patients (21.5%, P<0.001) and was similar to the switch rate for galantamine patients (15.0%, P=0.781 for donepezil vs. galantamine; P=0.004 for galantamine vs. rivastigmine). Rates of nonpersistence, measured as having at least 1 gap in therapy of 30 days or more during the 1-year follow-up, were 63.5% for donepezil, 63.7% for galantamine (P=0.933 for donepezil vs. galantamine), and 68.0% for rivastigmine (P=0.042 for donepezil vs. rivastigmine). MPRs and total days supply of any ChEI did not significantly differ among the 3 drugs. Results of multivariate models showed that, controlling for index ChEI drug, each additional month of ChEI treatment was associated with a reduction of 1% in total all-cause health care costs. The mean (SD) total all-cause 1-year health care costs for patients initiated on the 3 ChEIs were not significantly different: $12,112 ($16,437) for donepezil, $12,137 ($19,154) for galantamine (P=0.978), and $12,853 ($14,543) for rivastigmine (P=0.278). During the first year following initiation of ChEI therapy, patients initiated on donepezil had a greater days supply of the index medication than did patients initiated on rivastigmine. At 12 months following treatment initiation, the proportion of patients in therapy was higher for donepezil than for either rivastigmine or galantamine and was higher for galantamine than for rivastigmine. Patients treated with either donepezil or galantamine were less likely to switch from the index drug to another ChEI than were patients treated with rivastigmine. All-cause 1-year health care costs for patients initiated on the 3 ChEIs were not significantly different.

This article presents national estimates of mental health and substance abuse (MHSA) spending in 2003 by age groups. Overall, $121 billion was spent on MHSA treatment across all age groups in 2003. Of the total $100 billion spent on MH treatment, about 17% was spent on children and adolescents, 68% on young and mid-age adults, and 15% on older adults. MH spending per capita by age was $232 per youth, $376 per young and mid-age adult, and $419 per older adult. Of the total $21 billion spent on SA treatment, about 9% was spent on children and adolescents, 86% on adults ages 18 through 64, and 5% on older adults age 65 and older. SA spending per capita by age was $26 per youth, $98 per mid-age adult, and $28 per older adult.

The aim of the study was to evaluate The Patient Assessment, Care and Education (PACE) System™—an electronic patient symptom screening and reporting system for oncology. Specifically, the study determined provider and patient opinions of The PACE System™ and documented evidence as to whether symptom assessment rates increased after this system was implemented. Ninety-two providers (i.e., physicians, nurse practitioners, and physician assistants) at 16 community oncology clinics were surveyed about their experiences with The PACE System™. In addition, 100 patients at two community oncology clinics were surveyed about their perceptions of The PACE System™. Finally, at two oncology clinics, 100 patient charts were abstracted in the year before implementation of The PACE System™, and 100 patient charts were abstracted in the year after its implementation to evaluate changes in symptom assessment rates. Providers seemed to value the system. In particular, they reported that the screening and reporting system helped them to identify, track, and document the patients’ most important symptoms. The patient survey indicated that the majority of patients at the two sites found the system easy to use and generally helpful and would recommend it to others. The chart review indicated that assessment rates for depression, fatigue, and pain increased after The PACE System™ was implemented. The PACE System™ appears to be a promising approach to addressing the widespread problem of under-identification and under-treatment of symptoms in patients receiving cancer treatment.

Since 1987, public and private investment in substance abuse (SA) treatment has not kept pace with other health spending. SA treatment spending in the United States grew from $9.3 billion in 1986 to $20.7 billion in 2003. The average annual total growth rate was 4.8 percent. In comparison, total U.S. health care spending grew by 8.0 percent. As a result of the slower growth of SA spending compared to that for all health care, SA spending fell as a share of all health spending from 2.1 percent in 1986 to 1.3 percent in 2003.

The goal of this study was to examine prescription fill patterns of lipid-lowering agents among Medicare/ Medicaid dual-eligible patients by ethnicity. Study data were obtained from the Thomson Medstat MarketScan Medicaid claims database. Medicare/Medicaid beneficiaries who filled prescriptions for lipid-lowering agents during 2003 were included in the study. Logistic regression models estimated the probability that beneficiaries, by ethnicity, switched to a different lipid-lowering medication, augmented therapy with another lipid-lowering agent, or titrated the dosage of the drug upward over the course of the year. The models revealed that African Americans were less likely to switch lipid-lowering agents (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.60-0.78), augment lipid-lowering agents (OR, 0.53; 95% CI, 0.43-0.66), or titrate upward (OR, 0.75; 95% CI, 0.67-0.84) than whites. These results suggest that African Americans may be receiving less aggressive treatment than other patients, which in turn may explain why many studies find that African Americans are less likely to reach lipid goals. These treatment disparities merit further study, because they may impact dual-eligible patients moving into Medicare Part D plans.

To examine the effects of statin cost-sharing (ie, copayments, coinsurance) on adherence to statin medications and the impact of adherence on healthcare utilization and spending. Retrospective, observational study of statin users receiving health benefits or supplemental coverage from employer-sponsored health plans. Medical and pharmacy claims were selected from the Medstat MarketScan database for patients who were continuously enrolled from 2000 through 2003. Two-stage residual inclusion models were estimated. The first stage modeled adherence to statins, which was derived from the medication possession ratio, and represented the percentage of days on therapy in an 18-month time frame, July 2001 through December 2002. In the second stage, generalized linear models were used to estimate 2003 utilization and expenditures. Separate estimates were produced for new statin users (n = 24 113) and continuing statin users (n = 93 253). Lower statin copayments were associated with higher levels of statin adherence. In percentage terms, when holding all other variables at their mean value, a $10 increase in copayment resulted in a 1.8 percentage point reduction in the probability of adherence for new users and a 3 percentage point reduction in the probability of adherence for continuing users. For continuing users adherent to statins, total costs did not change, but fewer negative events (emergency department visits, hospitalizations, and coronary heart disease-related hospitalizations) occurred. Policy makers and plan managers should consider interventions that improve adherence to statins, such as lower copayments.