Adams Alyce S, Soumerai Stephen B, Zhang Fang, Gilden Daniel, Burns Marguerite, Huskamp Haiden A, Trinacty Connie, Alegria Margarita, LeCates Robert F, Griggs Jennifer J, Ross-Degnan Dennis, Madden Jeanne M
Division of Research, Kaiser Permanente, Oakland, California.
Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts.
Clin Ther. 2015 Mar 1;37(3):597-609. doi: 10.1016/j.clinthera.2014.12.011. Epub 2015 Jan 22.
Black patients with diabetes are at greater risk of underuse of antidepressants even when they have equal access to health insurance. This study aimed to evaluate the impact of removing a significant financial barrier to prescription medications (drug caps) on existing black-white disparities in antidepressant treatment rates among patients with diabetes and comorbid depression.
We used an interrupted time series with comparison series design and a 5% representative sample of all fee-for-service Medicare and Medicaid dual enrollees to evaluate the removal of drug caps on monthly antidepressant treatment rates. We evaluated the impact of drug cap removal on racial gaps in treatment by modeling the month-to-month white-black difference in use within age strata (younger than 65 years of age or 65 years of age or older). We compared adult dual enrollees with diabetes and comorbid depression living in states with strict drug caps (n = 221) and those without drug caps (n = 1133) before the policy change. Our primary outcome measures were the proportion of patients with any antidepressant use per month and the mean standardized monthly doses (SMDs) of antidepressants per month.
The removal of drug caps in strict drug cap states was associated with a sudden increase in the proportion of patients treated for depression (4 percentage points; 95% CI, 0.03-0.05, P < 0.0001) and in the intensity of antidepressant use (SMD: 0.05; 95% CI, 0.03-0.07, P < 0.001). Although antidepressant treatment rates increased for both white and black patients, the white-black treatment gap increased immediately after Part D (0.04 percentage points; 95% CI, 0.01-0.08) and grew over time (0.04 percentage points per month; 95% CI, 0.002-0.01; P < 0.001).
Policies that remove financial barriers to medications may increase depression treatment rates among patients with diabetes overall while exacerbating treatment disparities. Tailored outreach may be needed to address nonfinancial barriers to mental health services use among black patients with diabetes.
患有糖尿病的黑人患者即使有同等的医疗保险机会，使用抗抑郁药的比例也更低。本研究旨在评估消除处方药的重大经济障碍（药物上限）对糖尿病合并抑郁症患者抗抑郁治疗率中现有的黑白差异的影响。
我们采用了带有对照序列设计的中断时间序列，并使用了所有按服务收费的医疗保险和医疗补助双重参保者的5%代表性样本，以评估取消药物上限对每月抗抑郁治疗率的影响。我们通过对年龄层（65岁以下或65岁及以上）内使用情况的逐月黑白差异进行建模，评估取消药物上限对治疗种族差距的影响。我们比较了政策变化前居住在有严格药物上限的州（n = 221）和没有药物上限的州（n = 1133）的患有糖尿病和合并抑郁症的成年双重参保者。我们的主要结局指标是每月使用任何抗抑郁药的患者比例以及每月抗抑郁药的平均标准化月剂量（SMD）。
在有严格药物上限的州取消药物上限与抑郁症治疗患者比例的突然增加（4个百分点；95% CI，0.03 - 0.05，P < 0.0001）以及抗抑郁药使用强度的增加（SMD：0.05；95% CI，0.03 - 0.07，P < 0.001）相关。尽管白人和黑人患者的抗抑郁治疗率均有所提高，但在D部分之后，黑白治疗差距立即增加（0.04个百分点；95% CI，0.01 - 0.08），并随时间增长（每月0.04个百分点；95% CI，0.002 - 0.01；P < 0.001）。
消除药物经济障碍的政策可能会提高糖尿病患者总体的抑郁症治疗率，同时加剧治疗差异。可能需要针对性的宣传推广来解决患有糖尿病的黑人患者使用心理健康服务的非经济障碍。
