In This Issue of Archives of Internal Medicine FREE

Prior authorization is a popular but understudied strategy for reducing medication costs in Medicaid and Medicare Part D prescription drug programs. We evaluated the impact of a prior authorization policy in Michigan Medicaid on antidepressant use and health outcomes among dual Medicaid and Medicare enrollees with disabilities. Prior authorization was associated with increased use of preferred agents with no evidence of disruptions in therapy or adverse health events among new users. However, lower rates of treatment initiation and short-term switching among patients already receiving therapy were also observed, suggesting problems in policy implementation.

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Jiao et al created a “healthy lifestyle” score, incorporating smoking, alcohol use, dietary quality, body weight, and physical activity, and examined it in relation to incident pancreatic cancer in a large US cohort. The higher score indicated a healthier lifestyle. Compared with the lowest score (0 points), the highest score (5 points) was associated with a 58% reduction in risk of developing pancreatic cancer (relative risk, 0.42; 95% confidence interval, 0.26-0.66). Not having the highest score explained 27% of pancreatic cancer cases in their population. These data suggest that one's risk of developing pancreatic cancer can be substantially reduced if one has a comprehensive behavioral profile reflecting factors including not smoking, alcohol use according to the US recommendation, a Mediterranean diet pattern, normal weight, and regular physical activity.

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Solomon et al conducted a retrospective cohort study of older adults with employer-provided drug coverage from 1997 to 2002 and measured the time until initiation of medical therapy for 17 183 patients with newly diagnosed hypertension, diabetes, or hypercholesterolemia. Their results suggest that higher copayments were associated with delayed initiation of therapy. In survival models, doubling copayments resulted in large reductions in the predicted proportion of patients initiating pharmacotherapy at 1 and 5 years after diagnosis (for hypertension, 54.8% vs 39.9% at 1 year and 81.6% vs 66.2% at 5 years [P < .001]; for hypercholesterolemia, 40.2% vs 31.1% at 1 year and 64.3% vs 53.8% at 5 years [P < .002]; and for diabetes, 45.8% vs 40.0% at 1 year and 69.3% vs 62.9% at 5 years [P < .04]). Interestingly, patients' rate of initiation and sensitivity to copayments strongly depended on their prior experience with prescription drugs.

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Schnipper et al conducted a cluster-randomized controlled trial on general medicine units at 2 academic medical centers to study the effects of medication reconciliation on unintentional medication discrepancies that had potential for patient harm. The intervention consisted of a computerized medication reconciliation tool and process redesign involving physicians, nurses, and pharmacists. Patients on teams assigned to the intervention arm had an adjusted 28% relative risk reduction in the number of potentially harmful medication discrepancies at admission or discharge (from 1.44 to 1.05 per patient). Benefits were greater in patients at higher risk for discrepancies based on a risk score derived from patients in the control arm. There was also a trend toward greater benefit in 1 of the 2 hospitals where there was better integration of the computerized tool with the order entry system at discharge and where nurses may have played a more active role in verifying medication histories taken by physicians.

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Mozaffarian et al prospectively investigated how lifestyle risk factors, assessed in combination, relate to new-onset diabetes in a broad and relatively unselected population of 4883 older adults. During 10 years of follow-up, the authors identified 337 new cases of drug-treated diabetes. In multivariable analyses, each lifestyle factor was independently associated with incident diabetes mellitus, with 35% lower risk (relative risk [RR], 0.65) for each 1 additional lifestyle factor in the low-risk group. Individuals with physical activity, diet, smoking, and alcohol habits all in the low-risk group had an 82% lower diabetes risk (RR, 0.18) compared with all others. Adding absence of adiposity to the other 4 low-risk lifestyle factors, an 89% lower diabetes risk was present (RR, 0.11). Overall, 9 of 10 new diabetes cases appeared attributable to these 5 lifestyle factors.

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