OBJECTIVES: This study seeks to further characterize the role of exercise testing in the elderly for prognosis and diagnosis of coronary artery disease. BACKGROUND: Recent exercise testing guidelines have recognized that statements regarding the elderly do not have an adequate evidence-based quality because the studies they are based on have limitations in sample size and design. The Duke Treadmill Score has been recommended for risk stratification, but recent evidence has suggested that it does not function in the elderly.

METHODS: The study population consisted of male veterans (1872 patients >or=65 years; 3798 patients <65 years) who underwent routine clinical exercise testing with a mean follow-up of six years. A subset who underwent coronary angiography as clinically indicated (elderly, n = 405; younger, n= 809) were included. The primary outcome for all subjects was cardiovascular mortality with coronary angiographic findings as the outcome in those selected for angiography.

RESULTS: In survival analysis, exercise-induced ST depression was prognostic in both age groups only when cardiovascular death was considered as the end point. Peak metabolic equivalents were the most significant predictor for both age groups only when all-cause death was considered as the end point. New age-specific prognostic scores were developed and found to be predictive for cardiovascular mortality in the elderly. Moreover, in the angiographic subset of the elderly, a specific diagnostic score provided significantly better discrimination than exercise ST measurements alone. For any new score, there is a need for validation in another elderly population.

CONCLUSIONS: The mortality end point affected the choice of prognostic variables. This study demonstrates that exercise test scores can be helpful for the diagnosis and prognosis of coronary disease in the elderly.

BACKGROUND: Chronically ill patients often experience difficulty paying for their medications and, as a result, use less than prescribed.

OBJECTIVES: The objectives of this study were to determine the relationship between patients with diabetes' health insurance coverage and cost-related medication underuse, the association between cost-related underuse and health outcomes, and the role of comorbidity in this process.

RESEARCH DESIGN: We used a patient survey with linkage to insurance information and hemoglobin A1C (A1C) test results.

PATIENTS: We studied 766 adults with diabetes recruited from 3 Veterans Affairs (VA), 1 county, and 1 university healthcare system.

MAIN OUTCOMES: Main outcomes consisted of self-reported medication underuse as a result of cost, A1C levels, symptom burden, and Medical Outcomes Study 12-Item Short-Form physical and mental functioning scores.

RESULTS: Fewer VA patients reported cost-related medication underuse (9%) than patients with private insurance (18%), Medicare (25%), Medicaid (31%), or no health insurance (40%; P <0.0001). Underuse was substantially more common among patients with multiple comorbid chronic illnesses, except those who used VA care. The risk of cost-related underuse for patients with 3+ comorbidities was 2.8 times as high among privately insured patients as VA patients (95% confidence interval, 1.2-6.5), and 4.3 to 8.3 times as high among patients with Medicare, Medicaid, or no insurance. Individuals reporting cost-related medication underuse had A1C levels that were substantially higher than other patients (P <0.0001), more symptoms, and poorer physical and mental functioning (all P <0.05).

CONCLUSIONS: Many patients with diabetes use less of their medication than prescribed because of the cost, and those reporting cost-related adherence problems have poorer health. Cost-related adherence problems are especially common among patients with diabetes with comorbid diseases, although the VA's drug coverage may protect patients from this increased risk.

OBJECTIVE: To identify problems faced by older adults with diabetes due to out-of-pocket medication costs. RESEARCH DESIGN AND METHODS: In this cross-sectional national survey of 875 adults with diabetes treated with hypoglycemic medication, respondents reported whether they had underused prescription medications due to cost pressures or had experienced other financial problems associated with medication costs such as forgoing basic necessities. Respondents also described their interactions with clinicians about medication costs. RESULTS: A total of 19% of respondents reported cutting back on medication use in the prior year due to cost, 11% reported cutting back on their diabetes medications, and 7% reported cutting back on their diabetes medications at least once per month. Moreover, 28% reported forgoing food or other essentials to pay medication costs, 14% increased their credit card debt, and 10% borrowed money from family or friends to pay for their prescriptions. Medication cost problems were especially common among respondents who were younger, had higher monthly out-of-pocket costs, and had no prescription drug coverage. In general, few respondents, including those reporting medication cost problems, reported that their health care providers had given them information or other assistance to address medication cost pressures. CONCLUSIONS: Out-of-pocket medication costs pose a significant burden to many adults with diabetes and contribute to decreased treatment adherence. Clinicians should actively identify patients with diabetes who are facing medication cost pressures and assist them by modifying their medication regimens, helping them understand the importance of each prescribed medication, providing information on sources of low-cost drugs, and linking patients with coverage programs.

OBJECTIVE: To examine the effects of market-level managed care activity on the treatment, cost, and outcomes of care for Medicare fee-for-service acute myocardial infarction (AMI) patients.

DATA SOURCES/STUDY SETTING: Patients from the Cooperative Cardiovascular Project (CCP), a sample of Medicare beneficiaries discharged from nonfederal acute-care hospitals with a primary discharge diagnosis of AMI from January 1994 to February 1996.

STUDY DESIGN: We estimated models of patient treatment, costs, and outcomes using ordinary least squares and logistic regression. The independent variables of primary interest were market-area managed care penetration and competition. The models included controls for patient, hospital, and other market area characteristics.

DATA COLLECTION/EXTRACTION METHODS: We merged the CCP data with Medicare claims and other data sources. The study sample included CCP patients aged 65 and older who were admitted during 1994 and 1995 with a confirmed AMI to a nonrural hospital.

PRINCIPAL FINDINGS: Rates of revascularization and cardiac catheterization for Medicare fee-for-service patients with AMI are lower in high-HMO penetration markets than in low-penetration ones. Patients admitted in high-HMO-competition markets, in contrast, are more likely to receive cardiac catheterization for treatment of their AMI and had higher treatment costs than those admitted in low-competition markets.

CONCLUSIONS: The level of managed care activity in the health care market affects the process of care for Medicare fee-for-service AMI patients. Spillovers from managed care activity to patients with other types of insurance are more likely when managed care organizations have greater market power.

OBJECTIVE: To investigate the relative impact of physician groups and health plans on quality of care measures. DESIGN: Secondary data analysis of receipt of preventive care services included in the Health Plan Employer Data and Information Set (HEDIS) among 10 758 patients representing 21 health maintenance organizations and 22 large provider groups in the San Francisco and Los Angeles, California, areas in 1997. Each patient was eligible for (at least) one of six HEDIS-measured services. Data identify whether or not the service was provided, the patient's health plan, and the provider group responsible for the care. We used logistic regression to examine variations across plans in HEDIS rates, and whether variations persist after controls for provider groups are included.

SETTING: Patients from 21 health maintenance organizations serving San Francisco and Los Angeles, California, in 1997.

MAIN OUTCOME MEASURES: Breast cancer screening, childhood immunizations, cervical cancer screening, diabetic retinal exam, prenatal care in the first trimester, and check-ups after delivery among patients for whom these services are appropriate.

RESULTS: There are statistically significant differences across health plans in utilization rates for the six services examined. These differences are not substantially affected when we control for the provider group that cared for the patient. That is, controlling for provider group does not explain variations across plans, consistent with the view that health plans have an impact on HEDIS quality measures independent of the providers that they contract with.

CONCLUSIONS: There are activities that plans can undertake which influence their HEDIS scores. On the face of it, these results suggest that plans can independently improve quality, in contrast to hypotheses that plans would be "too far" from patients to have an influence. Continued attention to collecting plan-level data is warranted. Further work should address other possible sources of variations in HEDIS scores, such as variability in the quality of plan administrative databases.

Using data from a survey of deaths of children less than 5 years old conducted in 1997 in a county in Shaanxi Province, China, this paper examines gender differences in child survival in contemporary rural China. First, excess female child mortality in the county in 1994-96 is described, followed by an analysis of the mechanisms whereby the excess mortality takes place, and the underlying social, economic and cultural factors behind it. Excess female child mortality in this county is probably caused primarily by discrimination against girls in curative health care rather than in preventive health care or food and nutrition. Although discrimination occurs in all kinds of families and communities, discrimination itself is highly selective, and is primarily against girls with some specific characteristics. It is argued that the excess mortality of girls is caused fundamentally by the strong son preference in traditional Chinese culture, but exacerbated by the government-guided family planning programme and regulations. This suggests that it is crucial to raise the status of girls within the family and community so as to mitigate the pressures to discriminate against girls in China's low fertility regime. Finally, the possible policy options to improve female child survival in contemporary rural China are discussed.

Variability in demand for hospital services may have important effects on hospital costs, but this has been difficult to examine because data on within-year variations in hospital use have not been available for large samples of hospitals. We measure daily occupancy in California hospitals and examine variation in hospital utilization at the daily level. We find substantial day-to-day variation in hospital utilization, and noticeable differences between hospitals in the amount of day-to-day variation in utilization. We examine the impact of variation on hospital costs, showing that increases in variance are associated with increases in hospital expenditures, but that the effects are qualitatively modest

This issue of CHP/PCOR's quarterly newsletter covers news and developments at the centers for the fall quarter 2003.

The issue features articles about a handful of health policy talks sponsored by the centers in the fall quarter; a novel "interactive textbook" on clinical symptom research; the recent arrival from China of the second fellow for CHP/PCOR's China-U.S. Health and Aging Research Training Program; a roundup of the 25th annual conference of the Society for Medical Decision Making; and a summary of last quarter's media coverage highlighting the centers' research work.

This paper investigates trends in disability in the U.S. population, particularly among people under age fifty. Even as the elderly have become less disabled, reported disability has risen for younger Americans, especially those ages 30-49. We suggest some possible explanations for rising disability levels, such as obesity, technological advances in medicine, and changing disability insurance laws. Obesity and its attendant disorders seem particularly associated with these trends, although the data are not definitive. Whatever its sources, rising disability among the young could have adverse consequences for public programs such as disability insurance, Medicare, and Medicaid.