In This Issue:
- Drug Reactions Among the Elderly
- SSI for Homeless Individuals
- Childhoold Vaccine Supply
- Health Care in the U.S.
INTERVENTIONS TO REDUCE DRUG-RELATED REACTIONS AMONG COMMUNITY-RESIDENT ELDERLY MEDICARE AND MEDICAID PATIENTS
Adverse drug reactions (ADRs), or the unintentional, harmful results of drug therapy, are a pervasive problem among elderly people who reside in the community, according to articles published in the Journal of the American Medical Association and elsewhere in the 1980s. Although most ADRs are mild and reversible, past research indicates that one in five elderly people will experience an ADR at some time, that 10 percent to 15 percent of geriatric hospital admissions are caused by ADRs, and that the costs of treatment for ADRs among the aged are an estimated $4 billion to $20 billion annually.
The report, Interventions to Reduce Drug-Related Reactions among Community-Resident Elderly Medicare and Medicaid Patients, examines various strategies that appear promising in achieving cost-effective reductions of ADRs among this population, with special emphasis on those actions that could reduce the Medicare costs associated with ADRs. The study provides background information on the government regulation of drugs, describes factors that are linked to the occurrence of ADRs, and lists the strengths and weaknesses of several ADR-reduction interventions.
Many factors affect the incidence of ADRs, including physicians' knowledge of patients' medical histories and of the side effects of certain drugs, patients' characteristics and compliance with prescribed drug regimens, and interactions between physicians and patients. Two factors that are particularly likely to cause ADRs are polypharmacy, or the simultaneous use of two or more medications, and the use of specific drugs that repeatedly have been implicated in ADRs among the elderly. Four classes of interventions appear promising in reducing elderly patients' incidence of ADRs. These strategies include improving patient monitoring, educating patients and their caregivers about medications, increasing scientific knowledge of the ways drugs affect the elderly, and enhancing health professionals' knowledge about the risks of ADRs.
Accordingly, the report outlines a range of actions that could be taken to reduce ADRs among the elderly. These approaches include investigating the costs and feasibility of using patient-maintained medication records and funding a major demonstration that would determine the cost-effectiveness of pharmacist consultations, periodic medication reviews, and educational efforts for patients and families. Additionally, the study advises including more elderly people in clinical trials; encouraging professional associations and medical education programs to increase their emphasis on ADRs; and convening a national symposium on polypharmacy and adverse drug events. Since no one strategy will effectively reduce the incidence of ADRs, a multifaceted approach involving federal and state agencies, health care providers, and patients themselves will be needed.
This study was conducted by Mathematica Policy Research under contract to the Health Care Financing Administration. The study's project officer, Ronald Deacon, can be reached on 410-966-6622. Copies of the executive summary, #4477, are available from PIC.
SUPPLEMENTAL SECURITY INCOME FOR HOMELESS INDIVIDUALS
Although few national data are available, research indicates that one-third of the estimated 600,000 homeless Americans are mentally ill, that 40 percent have alcohol problems, and that an additional 10 percent abuse other types of drugs. One way HHS has responded to the needs of the homeless has been to provide services under mainstream programs such as Supplemental Security Income (SSI), which targets individuals who are aged, blind, or disabled and have little or no resources and income.
The report, Supplemental Security Income for Homeless Individuals, analyzes the role SSI has played in alleviating homelessness, describes the difficulties encountered in serving this population, and recommends steps that Social Security Administration (SSA) field offices can take to improve access to SSI among the homeless.
Extensive literature reviews and interviews with SSA staff and other respondents from 10 states indicate that there is disagreement about the role SSI can play as a long-term solution to homelessness; however, the program may be influential in providing the homeless with income support, primary care, substance abuse services, and mental health care.
There are no reliable data on the number of homeless who are eligible for or actually receiving SSI, but a number of obstacles impede access to services. Homeless people have a transient lifestyle, making it difficult for district offices to contact them for more information, they may lack documentation to prove their eligibility for benefits, and their dysfunctional mental state may cause them to distrust the system or be unwilling to cooperate. Respondents are, however, working to increase access to SSI. Most of the SSA offices contacted for this report either had implemented programs specifically for the homeless or were making special efforts to facilitate the receipt of SSI benefits. Some of the initiatives already in place include taking applications at facilities that serve the homeless, establishing ties or networks with service providers, or designating staff members to coordinate services for the homeless. Despite these efforts, some providers still are unaware of SSA outreach activities.
Because these findings suggest that the homeless need help in overcoming obstacles to the receipt of SSI benefits, the report recommends that SSA staff work with other agencies to enhance or better coordinate their efforts. The study further advises that SSA collect data, in eight to 10 sites with a high incidence of homelessness, on the number of homeless who apply for SSI, the number approved for benefits, and the number and explanations for those denied benefits. These data would provide more reliable information on the numbers of the homeless, their characteristics, and their utilization of services, which would in turn allow SSA to target services more effectively.
In its response, SSA states that collaboration with other agencies is a key component of its outreach strategy for the homeless and that it strongly supports this recommendation. The agency does not agree with the recommendation to develop a national method for data collection because it believes that implementing such a system would be overly burdensome on SSA resources without obtaining useful information. The Office of Inspector General, however, emphasizes that collecting these data would provide much-needed, very basic information on homeless people applying for SSI benefits.
An additional source of information on this population is in the planning stages. The Census Bureau is preparing to pretest a national survey for 1994 that will estimate the number and characteristics of homeless people as well as services and benefits, such as SSI, that they receive.
The inspection was conducted by the Office of Evaluation and Inspections, Office of Inspector General. Copies of the final report, #4371, are available from PIC.
OPTIONS FOR ASSURING AN ADEQUATE VACCINE SUPPLY>
The nation relies upon pharmaceutical manufacturers for the production and supply of vaccines used in immunization programs. This dependency has created concern among some vaccine authorities, particularly in government, because during the past few decades the number of American pharmaceutical companies producing vaccines has declined substantially. As a result, the National Vaccine Advisory Committee requested that the National Vaccine Program Office frame the issues and concerns surrounding the supply of childhood vaccines and present options for addressing supply problems.
The report resulting from that request, Options for Assuring an Adequate Supply of Childhood Vaccine, examines issues regarding the U.S. supply of childhood vaccines, outlines strategies that could be used to ensure an adequate supply, and describes areas in which further research is needed. The study also assesses the roles of the public and private sectors in supporting research and development; reviews incentives for foreign vaccine manufacturers to enter the U.S. market; and discusses the effects of scientific advances on research, development, production, storage, and transport of vaccine. The report was compiled by means of interviews with staff of federal agencies, state health departments, and vaccine manufacturers.
The exact reasons for the decline in the number of commercial vaccine manufacturers are not clear, although possible contributing factors include the public need for a given vaccine and the extent to which this need is being met by other manufacturers, the manufacturer's ability to establish adequate selling prices for vaccine products, and the availability of company personnel and facilities needed to engage in vaccine research. Other factors that may have influenced this decline include the cost and complexity of complying with federal regulations concerning vaccine safety and efficacy, the manufacturer's ability to predict potential costs of liability for harm produced through the use of vaccines, and the availability of government financing for vaccine research and development and possibly, production.
Most respondents in the study agreed that the federally funded vaccine stockpile, which requires manufacturers to keep a six-month supply of mandated childhood vaccines, is an acceptable amount of reserve vaccine; however, several strategies might help the National Vaccine Program better ensure an adequate supply. These strategies include (1) expanding the Centers for Disease Control's (CDC's) contracting authority and its distribution of vaccines through state health departments; (2) enabling CDC to contract with multiple vaccine manufacturers, rather than only the lowest bidder; (3) increasing government production of vaccines at the state and/or national level; (4) developing contingency plans in case a sole vaccine supplier should leave the U.S. market; and (5) providing incentives for existing suppliers to remain in the U.S. vaccine market and for new suppliers to enter it.
Finally, the report reviews issues that require further research and outlines an evaluation plan that could provide additional information on ways to improve the efficiency of vaccine distribution.
The study was conducted by Abt Associates, Inc., under contract to the National Vaccine Program Office, Public Health Service. The study's project officer, Dr. Chester Robinson, can be reached on 301-443-6683. Copies of the final report, #4484, are available from PIC.
THE FUTURE ENVIRONMENT FOR HEALTH AND HEALTH CARE IN THE UNITED STATES
For nearly 25 years health care spending has continued to soar, despite cost-containment initiatives such as the Medicare Prospective Payment System and managed care strategies. By the year 2000, Americans will spend an estimated 16 percent of the gross national product (GNP) on health care, and if these trends continue, the figure will reach 25 percent to 30 percent of GNP by 2030.
The report, The Future Environment for Health and Health Care in the United States, examines the causes of America's apparent health care crisis, describes misguided criticisms of our health care system, reviews the factors that affect the supply of and demand for health care, and analyzes public policies that may contain health expenditures in the years to come.
A number of factors have contributed to the health care crisis. First, as incomes have risen, Americans have been able to spend more on services they once could not afford, among them health care. Second, the availability of insurance coverage has reduced consumers' incentives to find cost-effective providers. Third, the aging of the population, which may be accompanied by the need for greater levels of service and/or long-term care, has serious implications for the health care system. Finally, Americans have become accustomed to increases in the average life span and have developed high expectations about the capabilities of our health care system; however, these achievements have come about through the application of costly technological innovations.
The study also finds that accomplishing health care reform will require a modification of the current supply of and demand for health care. Americans must begin rethinking our conception of health and our understanding of the appropriate ends of medicine. Additionally, policymakers must place greater emphasis on productivity by conducting research on the effectiveness of medical procedures; disseminating the results to consumers and insurers; expanding the market share of health maintenance organization (HMO)-style financing systems, which encourage providers to practice efficiently; and focusing on quality services for the elderly outside of high-cost environments.
The study was conducted by the Hudson Institute under contract to the Office of the Assistant Secretary for Planning and Evaluation. The study's project officer, Nancy DeLew, can be reached on 202-690-5874. Copies of the executive summary, #4428, are available from PIC.
Recently Acquired Reports
- Hispanic Access to Health Care: Significant Gaps Exist
- Social Security: Racial Difference in Disability Decisions Warrants Further Investigation
- Use of Emergency Rooms by Medicaid Recipients
- Medicaid and Homeless Individuals
SERVICES AVAILABLE FROM THE PIC
The Policy Information Center (PIC) is a centralized source of information on in-process, completed, and on-going evaluations; short-term evaluative research and; policy-oriented projects conducted by HHS as well as other Federal departments and agencies. The PIC on-line database provides project descriptions of these studies. It is available on-line at: http://aspe.hhs.gov/PIC/. Inquiries regarding PIC services should be directed to Carolyn Solomon, Technical Information Specialist, at 202-690-5694. Or E-mail PIC at: webmaster.aspe@hhs.gov