BENEFICIARIES WITH CANCER. L.R. Shugarman 1 , C. Bird 1 , J. Lynn 1 ; 1 RAND, Santa Monica, CA PURPOSE: Medical care at the end of life is quite costly; over one quarter of Medicare payments support care of beneficiaries who will die within a year. The aggregate costs and utilization patterns of men and women facing death may not be the same due to differences in their age, preferences, and cultural stereotypes. We analyzed Medicare services utilization and payments for men and women dying of cancer to determine whether differences occur within 5year age strata. We selected cancer because of its clear diagnosis, generally accepted standards of care and limited treatment options for which we do not expect gender differences. METHODS: We analyzed 1993 through 1998 Medicare claims and eligibility data for an overall 0.1% random sample (a 2% sample of an initial 5% sample) of beneficiaries who: were age 65 and over with a diagnosis of cancer but without a diagnosis of end stage renal disease, died in the target time interval and had one year of continuous data before death. Beneficiaries were identified as having a cancer diagnosis if cancer accounted for the plurality of physician spending in the year of death. Age strata were based on the beneficiary's age at death. RESULTS: Across all age strata, women were more likely to use skilled nursing facility care than men (35% vs. 27%, p < .10) and hospice care (42% vs. 37%, p < .10). With the exception of 80 ± 84 year-olds, Medicare total reimbursements for hospitalizations were higher for women than for men ($18,531 vs. $17,166, p < .05, overall) . The beneficiary's responsibility for Medicare costs (e.g., deductibles and co-payments) was higher for men aged 65 ± 69 ($5,188 vs. $4,863, p < .10) and for women in the 70 ± 74 age stratum ($5,163 vs. $4,403, p < .05) and in the 75 ± 79 age stratum ($4,501 vs. $4,298, p < .10). CONCLUSION: Observed gender differences in aggregate spending and utilization are attenuated by age stratification. The persisting differences in use of skilled nursing facilities and hospice and higher hospital costs represent both differences in care and coverage under Medicare. These findings require more study, such as analyses stratified by other primary diseases, type of cancer, and type of service. Our data support the contention that social setting, cultural setting, and patient preferences may combine to create modest but persistent differences in treatment patterns by gender. PURPOSE: Although cervical cancer deaths account for fewer than one percent of cancer deaths among women aged 65 and older, most elderly women report continuing to undergo periodic Pap smear screening. We sought to describe the burden of downstream testing following Pap smears in elderly women who undergo screening. METHODS: Using three years of Medicare Part B 5% Files (1995 ± 1997), we identified women over age 65 who underwent Pap smear screening during a 16-month period in 1996 and 1997. In order to exclude women undergoing follow-up Pap smears or surveillance smears (women with a previous procedure or diagnosis suggestive of cervical dysplasia or malignancy), we required a one-year observation period without such testing prior to the screening Pap smear for each woman. We measured downstream events including subsequent Pap smears, colposcopies, and other diagnostic and therapeutic surgical procedures (e.g. conization) during the 8 months following the screening Pap smear. RESULTS: In 1996, almost two and a half million female Medicare beneficiaries over age 65 underwent Pap smear screening. For every 100,000 women screened, 3020 had at least one additional Pap smear, 669 underwent colposcopy, and 183 had other surgical procedures during the eight-month period following the screening Pap smear. Rates of downstream interventions were similar for women aged 66 ± 75 and 76 ± 85, and declined only modestly in women age 86 and older. Overall, for every 100,000 women screened, 3497 experienced downstream interventions within 8 months of the initial Pap smear. For comparison, according to population-based surveillance data (SEER,1996) , 16 women per 100,000 aged 65 and older are diagnosed with cervical cancer each year, while nine are expected to die from the disease. CONCLUSION: Relative to the small number of expected cases of cervical cancer, women aged 65 and older continue to be screened in large numbers and undergo substantial follow-up testing in response to abnormal Pap smear results. Whether this testing reduces the subsequent risk of death from cervical cancer is unknown. There are no data, however, regarding the frequency at which women actually undergo screening. We sought to describe the frequency of cervical cancer screening in the United States. METHODS: We used the 1998 Behavioral Risk Factor Surveillance System of the Centers for Disease Control and Prevention (CDC), a cross-sectional population-based telephone survey conducted annually on a random sample of civilian non-institutionalized adults. We focused on female respondents aged 18 and older (n=86,715). For women who reported ever having had a Pap smear, we estimated screening intervals based on the timing of a woman's most recent Pap smear. We assumed that each woman either was not being regularly screening, or was being screened at one of three discrete screening intervals (every year, every 2 years, or every 3 years). RESULTS: The vast majority (93%) of American women report having had at least one Pap smear in their lifetime. Among women who have not had a hysterectomy and who have been screened at least once, 90% report having had a Pap smear within the past three years. Based on the reported time since the last Pap smear, we estimate that 59% of women undergo Pap smear screening annually, 18% have a two-year screening interval, 13% are screened every three years, and 10% are not being screened regularly. Even the very elderly report regular screening Ð an estimated 34% percent of women aged 75 ± 84 and 18% of women aged 85 and older undergo annual Pap smear screening. Extrapolating these data to the country as a whole, more than 45 million American women undergo Pap smear screening annually. CONCLUSION: The majority of American women are being screened for cervical cancer too frequently. Lengthening the screening interval would not only reduce the number of pelvic exams, but would also reduce follow-up testing for abnormal smears and the volume of specimens that cytotechnologists are required to read. We performed a study to determine the utility of routine screening of transaminase and CPK values in patients taking statin medications. METHODS: We performed a retrospective on-line medical record review of the primary care practice at Beth Israel Deaconess Medical Center. A computerized search identified all patients at our institution with a statin on their medication list, as well as their ALT, AST and CPK values for 1998. Patients were separated into four categories based on which laboratory data had been measured during the year: CPK only, transaminase only, both CPK and transaminase or neither. From each of these four categories, 45 patient records were randomly selected for review to verify that they were followed at this primary care practice and were on a statin. The random samples were used to identify the rate of physician monitoring of transaminase and CPK values within this practice. We reviewed the on-line medical records of all patients within this practice on statins who had significantly abnormal test results (defined in prior trials of statin therapy as greater than 3x the upper limit of normal for transaminases and greater than 10x the upper limit of normal for CPK) to determine the relationship to statin therapy and outcome. RESULTS: 4556 patients at our institution had a statin on their medication list. Of the 180 random charts reviewed, 26% (corresponding to 1189 of the total cohort) were receiving care from this primary care practice and were taking a statin. Among the patients whose charts were reviewed, 53% were female with a mean age of 61 years. These data also demonstrated that physicians within our practice monitored serum transaminase values (defined as measurement of either AST or ALT during 1998, or within six months of starting a statin) in 84% of patients; physicians monitored CPK values in 54% of patients. 29% of the patients within this practice were on a dose greater than the recommended starting dosage. Of all the patients in this practice who had been monitored, 12 (1.2%) had a significant elevation of AST or ALT and 6 (0.9%) had a significant elevation of CPK. However, after a detailed chart review, none of these abnormalities were attributable to statins. CONCLUSION: In this study of statin use in a primary care practice, no cases of significantly abnormal transaminase or CPK values attributable to statins were discovered through routine monitoring. This questions the necessity of routine measurement of transaminase and CPK in all patients taking statin medications. and had no risk of zoster during that time. Thereafter, vaccinated patients had half the usual zoster and postherpetic neuralgia (PHN) incidence rates (or post-boost effect=50%). Agespecific zoster incidence was that of Rochester, Minn. Half the zoster patients received antiviral therapy; 20 ± 40% of all zoster patients developed PHN, depending on their age. Multiple sensitivity analyses were performed. RESULTS: In the baseline analysis, vaccination gained 0.0004 QALY compared to no vaccination at a cost of $51.13 or $143,000/QALY gained. Vaccination is least expensive at age 66, costing $129,000/QALY gained. In 60-year-olds, costs/QALY gained is greater than $50,000 with wide variation of: immunologic boosting duration, post-boost effect, PHN probability or duration, herpes zoster duration or utility, or antiviral therapy or hospitalization parameters. Vaccinating 60-year-olds costs $103,000 or $61,500 per QALY when lifetime zoster risk (baseline 11.0%) increased to 1 in 7 (14.3%) or 1 in 5 (20%) respectively. If lifetime zoster risk is 20%, costs/QALY gained are less than $50,000 if post-boost effect is < 38%, median PHN duration is > 114 days (baseline 90), average PHN utility is < 0.76 (where 0=death and 1=perfect health), or vaccination cost < $54.21 (baseline $61.96, including $5 administration cost). CONCLUSION: Varicella vaccination of 60-year-olds is expensive compared to many accepted medical interventions in a model biased toward its use. Results are most sensitive to the lifetime risk of zoster, which varies significantly in different populations. 1994) is a valid and reliable assessment tool designed to enable rapid determination of current or past psychiatric disorders in primary care patients. The current analyses were conducted to assess whether or not smokers with current psychiatric diagnoses, as determined with the PRIME-MD, are at higher risk for early relapse to smoking after quitting. METHODS: The PRIME-MD was administered as part of the study screening procedures in an NIH-funded smoking cessation clinical trial that enrolled 677 smokers. Brief individual smoking cessation counseling was provided prior to quitting and on the quit day; nicotine patches were dispensed on the quit day. The outcome measure in the current analyses was biochemically-verified smoking status at one week post-cessation. PRIME-MD diagnoses included major depressive disorder (MDD), panic disorder (PD), generalized anxiety disorder (GAD), and probable alcohol abuse/dependence. RESULTS: A total of 182 smokers (27%) were diagnosed with at least one of the four disorders and 30 smokers had two or more diagnoses. 63% of the participants without any current diagnoses were abstinent at one week compared to 20% of participants with MDD (n=133), 5% with GAD (n=20), and 0% with PD (n=3). No statistically significant increase in risk of relapse was observed for 62 participants with alcohol abuse/dependence (50% abstinence rate). Only 7% of participants with two or more disorders were abstinent at one week post-quit. CONCLUSION: Smokers with current mood and anxiety disorders appear to be at significant risk for early relapse to smoking. The PRIME-MD can provide rapid assessment of these psychiatric diagnoses that are commonly seen in the primary care setting. Identification of smokers with significant depression and anxiety can aid in the development of smoking cessation treatment plans (e.g., including an anti-depressant such as bupropion SR for depressed patients) and can focus attention on the importance of aggressive relapse prevention in these individuals. Russian language interpreters who administered the survey to adults with a valid phone number, using a list provided by the resettlement agency. We report comparisons with the 1999 Behavioral Risk Factor and Surveillance System (BRFSS) data (www.cdc.gov). RESULTS: Of 426 available adults, completed interviews were obtained in 56% (n=241), with mean age 54.2 yrs (18 ± 94), 54% women, and subjects had resided in the county a mean of 7.5 yrs (1 ± 29) . 91% had some type of health care coverage 91% (n=220), comparable to reports for BRFSS. Self-rated health was rated poor/fair by 60% (n=241), compared with responses on the 1999 BRFSS of 13.1% National and 21.6% Kentucky. Preventive measures shown in Table [ To elucidate the impact of the individual and combined components of a physician's preventive``medical message'' on people's intention to adopt more healthy behaviors. The specific risk used in this study was that of developing manifestations of coronary artery disease. METHODS: 86 young people (ages 20 ± 30) and 64 older people (ages 60 ± 80) in France indicated their degree of intention to adopt a healthy behavior in response to a series of 64 hypothetical messages from their physician about their risk of developing a cardiac event. The messages were all possible combinations of 4 components: the type of cardiac event (angina or a heart attack), the probability of developing it (5, 10, 15, or 20%), the time frame (within 5, 10, 15, or 20 years), and the degree of the patient's control over developing it (``given your family history, it is probable that you could not do much to reduce this risk'' or``the reduction of this risk depends entirely on your behavior''). They were asked about adopting 1 of 3 behaviors: à`m edical treatment,'' a strict dietary regimen, or regular exercise. The results were examined graphically and by ANOVA. RESULTS: All components had a significant effect on the intention to change behavior, but these effects varied according to age. The young people were influenced most by the degree of controllability, the probability, and the nature of the cardiac event; the older people by the time horizon. Even without a promise of controllability, participants were inclined to adopt protective behavior. An increase in probability had less added effect as the probability got larger; nonetheless, the level of intent to change behavior associated with a large probability over a long time (e.g., 20% over 20 years) was higher than that associated with a smaller probability over a short time frame (e.g., 5% over 5 years). The type of protective action had no effect on intention. CONCLUSION: The preventive medical message should include the type of event, the probability of developing it, the time frame, and the degree to which the patient can prevent it. The physician should stress the time frame in talking with older people and the other factors with young people. TREATMENT, 1987 TO 1998 . R.S. Stafford 1 , E. Macdonald 1 , S. Finkelstein 2 ; 1 Massachusetts General Hospital, Boston, MA; 2 Massachusetts Institute of Technology, Cambridge, MA PURPOSE: Physicians' approach to the treatment of depression has changed drastically in the last 15 years with the availability of selective serotonin reuptake inhibitors (SSRIs) in 1988. We sought to closely examine trends in antidepressant use, as well as assess broader changes in treatment patterns. METHODS: Using data available from the National Disease and Therapeutic Index (NDTI), a physician survey conducted by IMS Health, we examined trends in antidepressant prescribing from 1987 ± 98. NDTI provides nationally representative diagnostic and prescribing information on patients treated by U.S. office-based physicians. We selected visits by patients reported to have depression. Annual sample sizes varied from 3,901 visits in 1987 to 6,639 in 1998. We examined annual prescribing data to measure: 1) the frequency of visits where depression was noted and 2) the likelihood of specific medications being reported as treatment. RESULTS: The NDTI data show a dramatic shift in the treatment of depression between 1987 and 1998. In 1987, tricyclic antidepressants (TCAs) were the predominant drug class prescribed to patients with depression (47% of patients). Among individual antidepressants, the most common were amitriptyline (14%), trazadone (12%), doxepin (8%), and desipramine (6%). In 1989, a year after its introduction, fluoxetine was prescribed to 21% of patients with depression. Despite the introduction and growing use of other SSRIs in the 1990s, fluoxetine has maintained a constant share of patients at around 25%. The introduction of sertraline in 1992, paroxetine in 1993 and more recent SSRIs led aggregate SSRI use to grow to 38% in 1992 38% in , 56% in 1994 38% in , 60% in 1996 38% in and 75% in 1998 38% in . In 1998 , sertraline (21%), paroxetine (17%) and bupropion (6%) were the leading antidepressants. TCAs accounted for only 8% of depression patients in 1998. The prescribing of non-TCA, non-SSRI antidepressants decreased from 13% (chiefly trazadone) in 1987 to 10% (chiefly buproprion) in 1998. The use of benzodiazepines in depression declined from 11% of patients in 1987 to 3% in 1998. The rate of patients with reported depression not receiving an antidepressant decreased from 30% in 1987 to 9% in 1998. The estimated national number of physician visits by patients with depression increased from 14.4 million visits in 1987 to 22.5 million in 1998. CONCLUSION: The increasing therapeutic dominance of SSRIs has been pivotal to changes in depression treatment. Perhaps because of their effectiveness and side-effect profile, increasing SSRI use also may have contributed to the declining use of benzodiazepines, increased aggregate antidepressant treatment rates, and the increasing frequency of physician visits where depression was reported.