human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: This paper examines changes in drug utilization following Taiwan 's newly implemented National Health Insurance ( NHI ) outpatient prescription drug cost-sharing program for persons over 65 years old . The study is a hospital outpatient prescription level analysis that adopts a pretest-posttest control group experiment design . Selected measures of outpatient prescription drug utilization are examined for cost-sharing and non cost-sharing groups in cost-sharing periods and pre cost-sharing periods . Additional analyses were conducted comparing older patients with and without chronic diseases and differences for essential and non-essential drugs . Patients over age 65 were drawn from 21 hospitals in the Taipei area using a stratified r and om sampling method . This paper yields several interesting findings . First , average prescription cost and prescription period increased for both the cost-sharing and non cost-sharing groups . However , the rate of increase was significantly less in the cost-sharing group when compared with the non cost-sharing group . Second , the elderly with non-chronic diseases were more sensitive ( i.e. , reducing drug utilization ) to the drug cost-sharing program when compared with those with chronic diseases . Third , for the elderly with non-chronic diseases average drug cost per prescription experienced a smaller decrease in essential drugs but a moderate increase in non-essential drugs for the cost-sharing group . By contrast , for the non cost-sharing group , average drug cost per prescription increased sharply in non-essential drugs as well as essential drugs . Finally , there was a significant increase in the number of prescriptions as well as drug costs above the upper bound of the cost-sharing schedule . The  outpatient drug cost-sharing program  implemented by the NHI in Taiwan did not reverse the trend of prescription drug cost increases in hospitals . The significant increase in the number of prescriptions above the upper bound of the cost-sharing schedule implies that the NHI should increase the upper bound . Further analysis needs to evaluate any adverse clinical impact for older patients result ing from policy changes CONTEXT Rising costs of medications and inequities in access have sparked calls for drug policy reform in the United States and Canada . Control of drug expenditures by prescription cost-sharing for elderly persons and poor persons is a contentious issue because little is known about the health impact in these subgroups . OBJECTIVES To determine ( 1 ) the impact of introducing prescription drug cost-sharing on use of essential and less essential drugs among elderly persons and welfare recipients and ( 2 ) rates of emergency department ( ED ) visits and serious adverse events associated with reductions in drug use before and after policy implementation . DESIGN AND SETTING Interrupted time-series analysis of data from 32 months before and 17 months after introduction of a prescription coinsurance and deductible cost-sharing policy in Quebec in 1996 . Separate 10-month prepolicy control and postpolicy cohort studies were conducted to estimate the impact of the drug reform on adverse events . PARTICIPANTS A r and om sample of 93 950 elderly persons and 55 333 adult welfare medication recipients . MAIN OUTCOME MEASURES Mean daily number of essential and less essential drugs used per month , ED visits , and serious adverse events ( hospitalization , nursing home admission , and mortality ) before and after policy introduction . RESULTS After cost-sharing was introduced , use of essential drugs decreased by 9.12 % ( 95 % confidence interval [ CI ] , 8.7%-9.6 % ) in elderly persons and by 14.42 % ( 95 % CI , 13.3%-15.6 % ) in welfare recipients ; use of less essential drugs decreased by 15.14 % ( 95 % CI , 14.4%-15.9 % ) and 22.39 % ( 95 % CI , 20.9%-23.9 % ) , respectively . The rate ( per 10 000 person-months ) of serious adverse events associated with reductions in use of essential drugs increased from 5.8 in the prepolicy control cohort to 12.6 in the postpolicy cohort in elderly persons ( a net increase of 6.8 [ 95 % CI , 5.6 - 8.0 ] ) and from 14.7 to 27.6 in welfare recipients ( a net increase of 12.9 [ 95 % CI , 10.2 - 15.5 ] ) . Emergency department visit rates related to reductions in the use of essential drugs also increased by 14.2 ( 95 % CI , 8.5 - 19.9 ) per 10 000 person-months in elderly persons ( prepolicy control cohort , 32.9 ; postpolicy cohort , 47.1 ) and by 54.2 ( 95 % CI , 33.5 - 74.8 ) among welfare recipients ( prepolicy control cohort , 69.6 ; postpolicy cohort , 123.8 ) . These increases were primarily due to an increase in the proportion of recipients who reduced their use of essential drugs . Reductions in the use of less essential drugs were not associated with an increase in risk of adverse events or ED visits . CONCLUSIONS In our study , increased cost-sharing for prescription drugs in elderly persons and welfare recipients was followed by reductions in use of essential drugs and a higher rate of serious adverse events and ED visits associated with these reductions Abstract Objective To compare the results of a r and omised and an observational evaluation of the same policy that restricted reimbursement for nebulised respiratory medications in adult patients in a community setting . Design s Cluster r and omised controlled trial and observational time series with historical controls . Setting Pharmacare , the government funded drug benefits plan for elderly people and patients receiving social assistance in British Columbia , Canada . Participants In the r and omised controlled trial 104 clusters of medical practice s , pair matched by geography and approximately by practice size , were r and omised to the intervention group ( 449 patients affected by the policy on 1 March 1999 ) , and the control group ( offered a six month exemption , affecting 386 patients ) . The observational analysis included all Pharmacare beneficiaries ( excluding the 386 exempt patients ) who had used any nebulised drugs six months before the policy ( 4624 patients ) . Intervention Pharmacare restricted reimbursement for nebulised bronchodilators , steroids , and cromoglycate to patients whose doctors applied for an individual patient 's exemption , giving an appropriate clinical reason . Main outcome measures Number of contacts with doctors and services , emergency admissions to hospital , and utilisation of and expenditure for respiratory drugs in data bases of British Columbia 's Ministry of Health . Results Contacts with doctors or emergency admissions to hospital did not increase in association with the restriction , regardless of the analytical approach . In the observational analysis , we found a reduction of $ C24 per patient month in all nebulised drug use ( 95 % confidence interval 19 to 29 ) and an increase of $ C3 per patient month in all expenditure for inhalers ( 1.4 to 4.5 ) . The r and omised evaluation found savings of $ C8 per patient month for nebulisers ( P = 0.24 ) and no increase in spending on inhalers ( P = 0.79 ) . Correcting for 60 % non-compliance by exempt doctors in a sensitivity analysis yielded similar results as the observational evaluation . Conclusions Observational as well as r and omised analyses found moderate net savings and no increase in unintended healthcare outcomes after restricting reimbursement for nebulised respiratory drugs . R and omised policy trials are feasible and , if carefully implemented , likely to be concordant with observational evaluations BACKGROUND Medication nonadherence is a major public health problem , especially for patients with coronary artery disease . The cost of prescription drugs is a central reason for nonadherence , even for patients with drug insurance . Removing patient out-of-pocket drug costs may increase adherence , improve clinical outcomes , and even reduce overall health costs for high-risk patients . The existing data are inadequate to assess whether this strategy is effective . TRIAL DESIGN The Post-Myocardial Infa rct ion Free Rx and Economic Evaluation ( Post-MI FREEE ) trial aims to evaluate the effect of providing full prescription drug coverage ( ie , no copays , coinsurance , or deductibles ) for statins , beta-blockers , angiotensin-converting enzyme inhibitors , and angiotensin II receptor blockers to patients after being recently discharged from the hospital . Potentially eligible patients will be those individuals who receive their health and pharmacy benefits through Aetna , Inc. Patients enrolled in a Health Savings Account plan , who are > or = 65 years of age , whose plan sponsor ( ie , the employer , union , government , or association that sponsors the particular benefits package ) has opted out of participating in the study , and who do not receive both medical services and pharmacy coverage through Aetna will be excluded . The plan sponsor of each eligible patient will be block r and omized to either full drug coverage or current levels of pharmacy benefit , and all subsequently eligible patients of that same plan sponsor will be assigned to the same benefits group . The primary outcome of the trial is a composite clinical outcome of readmission for acute MI , unstable angina , stroke , congestive heart failure , revascularization , or inhospital cardiovascular death . Secondary outcomes include medication adherence and health care costs . All patients will be followed up for a minimum of 1 year . CONCLUSION The Post-MI FREEE trial will be the first r and omized study to evaluate the impact of reducing cost-sharing for essential cardiac medications in high-risk patients on clinical and economic outcomes OBJECTIVE To evaluate the impact of the final Centers for Medicare & Medicaid Services ' ( CMS ) " short-fill " rule regarding the appropriate dispensing of prescription drugs in long-term care facilities . DESIGN A prospect i ve study to determine rates of unconsumed medication and the net-cost impact on Medicare Part D prescription drug plans based on the proposed and final CMS rule and other scenarios under consideration by CMS . SETTING Four hundred twenty-five long-term care facilities in six states . PATIENTS Residents covered by Medicare Part D. MAIN OUTCOME MEASURES Rates of unconsumed medication , average dispensing fees , potential reduction in unconsumed medication , incremental fills , incremental dispensing fees , net cost or savings to Medicare Part D plans , and percentage increase in fills . RESULTS Total estimates of the cost of unconsumed medication charged to Medicare Part D plans for residents in long-term care facilities are $ 87 million for br and products and $ 39 million for generics annually . Based on current dispensing fees , it is likely that implementation of the final rule will result in incremental costs to CMS plans in the range of $ 30 million annually . The number of Medicare Part D prescription fills will increase by about 20 % . A seven-day fill requirement on br and products would raise incremental costs to more than $ 150 million annually , and inclusion of generic products in a seven-day fill requirement would result in incremental costs in the range of $ 850 million annually . CONCLUSION The final CMS rule on short-fills is unlikely to result in savings to Medicare Part D plans . Shorter fill times and inclusion of generic products would significantly raise costs to these plans OBJECTIVE To examine the effect of Part D on 65 - 78-year-old noninstitutionalized dual eligibles ' prescription utilization and expenditures .  DATA SOURCE R and om sample of unique pharmacy customers of a national retail pharmacy chain who filled at least one prescription during both 2005 and 2006 . For each subject , we obtained cl aims data for every prescription filled between January 1 , 2005 , and April 31 , 2007 . STUDY DESIGN Generalized estimating equations were used to examine the experience of a " treatment " group  ( dual eligibles between 65 and 78 years on January 1 , 2005 ) with that of a " control " group  ( near-elderly patients with Medicaid coverage between 60 and 63 years on January 1 , 2005 ) during the first 18 months after Part D implementation . PRINCIPAL FINDINGS Expenditures for the treatment and control groups tracked each other closely in the pre-Part D period . Immediately following the implementation of Part D , expenditures for both groups decreased and then leveled off . There were no significant changes in trends in the dual eligibles ' out-of-pocket expenditures , total monthly expenditures , pill-days , or total number of prescriptions due to Part D. CONCLUSIONS We find no evidence that Part D adversely affected pharmaceutical utilization or out-of-pocket expenditures of dual eligibles during the transition period , nor during the 16 months subsequent to Part D implementation Objectives : In February 2002 , the Department of Veterans Affairs ( VA ) raised medication copayments from $ 2 to $ 7 per 30-day supply of medication for certain veteran groups . We examined the impact of the copayment increase on medication acquisition from VA . Methods : This was a retrospective cohort study using data from national VA data bases from February 2001 through February 2003 . We took a r and om sample of over 5 % of male VA users in 2001 . Of 149,107 veterans sample d , 19,504 ( 13 % ) had copayments for no drugs , 101,410 ( 68 % ) had copayments for some drugs , and 28,193 ( 19 % ) had  copayments for all drugs . We used multivariable count models to examine changes in the number of 30-day medication supplies after the increase . Results : After the copayment increase , veterans subject to copayments for all drugs received 8 % fewer 30-day supplies of medication annually relative to veterans with no cop 
    Output:
    
agent
Increasing the amount of money that people pay for medicines may reduce insurers ' medicine expenditures and may reduce patients ' medicine use .
These types of interventions may lead to small decreases in or uncertain effects on healthcare utilisation .
Cap and co-payment polices may reduce the use of medicines and reduce medicine expenditures for health insurers .
However , they may also reduce the use of life-sustaining medicines or medicines that are important in treating chronic , including symptomatic , conditions and , consequently , could increase the use of healthcare services .
Fixed co-payment with a ceiling and tiered fixed co-payment may be less likely to reduce the use of essential medicines or to increase the use of healthcare services
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: This paper examines changes in drug utilization following Taiwan 's newly implemented National Health Insurance ( NHI ) outpatient prescription drug cost-sharing program for persons over 65 years old . The study is a hospital outpatient prescription level analysis that adopts a pretest-posttest control group experiment design . Selected measures of outpatient prescription drug utilization are examined for cost-sharing and non cost-sharing groups in cost-sharing periods and pre cost-sharing periods . Additional analyses were conducted comparing older patients with and without chronic diseases and differences for essential and non-essential drugs . Patients over age 65 were drawn from 21 hospitals in the Taipei area using a stratified r and om sampling method . This paper yields several interesting findings . First , average prescription cost and prescription period increased for both the cost-sharing and non cost-sharing groups . However , the rate of increase was significantly less in the cost-sharing group when compared with the non cost-sharing group . Second , the elderly with non-chronic diseases were more sensitive ( i.e. , reducing drug utilization ) to the drug cost-sharing program when compared with those with chronic diseases . Third , for the elderly with non-chronic diseases average drug cost per prescription experienced a smaller decrease in essential drugs but a moderate increase in non-essential drugs for the cost-sharing group . By contrast , for the non cost-sharing group , average drug cost per prescription increased sharply in non-essential drugs as well as essential drugs . Finally , there was a significant increase in the number of prescriptions as well as drug costs above the upper bound of the cost-sharing schedule . The  outpatient drug cost-sharing program  implemented by the NHI in Taiwan did not reverse the trend of prescription drug cost increases in hospitals . The significant increase in the number of prescriptions above the upper bound of the cost-sharing schedule implies that the NHI should increase the upper bound . Further analysis needs to evaluate any adverse clinical impact for older patients result ing from policy changes CONTEXT Rising costs of medications and inequities in access have sparked calls for drug policy reform in the United States and Canada . Control of drug expenditures by prescription cost-sharing for elderly persons and poor persons is a contentious issue because little is known about the health impact in these subgroups . OBJECTIVES To determine ( 1 ) the impact of introducing prescription drug cost-sharing on use of essential and less essential drugs among elderly persons and welfare recipients and ( 2 ) rates of emergency department ( ED ) visits and serious adverse events associated with reductions in drug use before and after policy implementation . DESIGN AND SETTING Interrupted time-series analysis of data from 32 months before and 17 months after introduction of a prescription coinsurance and deductible cost-sharing policy in Quebec in 1996 . Separate 10-month prepolicy control and postpolicy cohort studies were conducted to estimate the impact of the drug reform on adverse events . PARTICIPANTS A r and om sample of 93 950 elderly persons and 55 333 adult welfare medication recipients . MAIN OUTCOME MEASURES Mean daily number of essential and less essential drugs used per month , ED visits , and serious adverse events ( hospitalization , nursing home admission , and mortality ) before and after policy introduction . RESULTS After cost-sharing was introduced , use of essential drugs decreased by 9.12 % ( 95 % confidence interval [ CI ] , 8.7%-9.6 % ) in elderly persons and by 14.42 % ( 95 % CI , 13.3%-15.6 % ) in welfare recipients ; use of less essential drugs decreased by 15.14 % ( 95 % CI , 14.4%-15.9 % ) and 22.39 % ( 95 % CI , 20.9%-23.9 % ) , respectively . The rate ( per 10 000 person-months ) of serious adverse events associated with reductions in use of essential drugs increased from 5.8 in the prepolicy control cohort to 12.6 in the postpolicy cohort in elderly persons ( a net increase of 6.8 [ 95 % CI , 5.6 - 8.0 ] ) and from 14.7 to 27.6 in welfare recipients ( a net increase of 12.9 [ 95 % CI , 10.2 - 15.5 ] ) . Emergency department visit rates related to reductions in the use of essential drugs also increased by 14.2 ( 95 % CI , 8.5 - 19.9 ) per 10 000 person-months in elderly persons ( prepolicy control cohort , 32.9 ; postpolicy cohort , 47.1 ) and by 54.2 ( 95 % CI , 33.5 - 74.8 ) among welfare recipients ( prepolicy control cohort , 69.6 ; postpolicy cohort , 123.8 ) . These increases were primarily due to an increase in the proportion of recipients who reduced their use of essential drugs . Reductions in the use of less essential drugs were not associated with an increase in risk of adverse events or ED visits . CONCLUSIONS In our study , increased cost-sharing for prescription drugs in elderly persons and welfare recipients was followed by reductions in use of essential drugs and a higher rate of serious adverse events and ED visits associated with these reductions Abstract Objective To compare the results of a r and omised and an observational evaluation of the same policy that restricted reimbursement for nebulised respiratory medications in adult patients in a community setting . Design s Cluster r and omised controlled trial and observational time series with historical controls . Setting Pharmacare , the government funded drug benefits plan for elderly people and patients receiving social assistance in British Columbia , Canada . Participants In the r and omised controlled trial 104 clusters of medical practice s , pair matched by geography and approximately by practice size , were r and omised to the intervention group ( 449 patients affected by the policy on 1 March 1999 ) , and the control group ( offered a six month exemption , affecting 386 patients ) . The observational analysis included all Pharmacare beneficiaries ( excluding the 386 exempt patients ) who had used any nebulised drugs six months before the policy ( 4624 patients ) . Intervention Pharmacare restricted reimbursement for nebulised bronchodilators , steroids , and cromoglycate to patients whose doctors applied for an individual patient 's exemption , giving an appropriate clinical reason . Main outcome measures Number of contacts with doctors and services , emergency admissions to hospital , and utilisation of and expenditure for respiratory drugs in data bases of British Columbia 's Ministry of Health . Results Contacts with doctors or emergency admissions to hospital did not increase in association with the restriction , regardless of the analytical approach . In the observational analysis , we found a reduction of $ C24 per patient month in all nebulised drug use ( 95 % confidence interval 19 to 29 ) and an increase of $ C3 per patient month in all expenditure for inhalers ( 1.4 to 4.5 ) . The r and omised evaluation found savings of $ C8 per patient month for nebulisers ( P = 0.24 ) and no increase in spending on inhalers ( P = 0.79 ) . Correcting for 60 % non-compliance by exempt doctors in a sensitivity analysis yielded similar results as the observational evaluation . Conclusions Observational as well as r and omised analyses found moderate net savings and no increase in unintended healthcare outcomes after restricting reimbursement for nebulised respiratory drugs . R and omised policy trials are feasible and , if carefully implemented , likely to be concordant with observational evaluations BACKGROUND Medication nonadherence is a major public health problem , especially for patients with coronary artery disease . The cost of prescription drugs is a central reason for nonadherence , even for patients with drug insurance . Removing patient out-of-pocket drug costs may increase adherence , improve clinical outcomes , and even reduce overall health costs for high-risk patients . The existing data are inadequate to assess whether this strategy is effective . TRIAL DESIGN The Post-Myocardial Infa rct ion Free Rx and Economic Evaluation ( Post-MI FREEE ) trial aims to evaluate the effect of providing full prescription drug coverage ( ie , no copays , coinsurance , or deductibles ) for statins , beta-blockers , angiotensin-converting enzyme inhibitors , and angiotensin II receptor blockers to patients after being recently discharged from the hospital . Potentially eligible patients will be those individuals who receive their health and pharmacy benefits through Aetna , Inc. Patients enrolled in a Health Savings Account plan , who are > or = 65 years of age , whose plan sponsor ( ie , the employer , union , government , or association that sponsors the particular benefits package ) has opted out of participating in the study , and who do not receive both medical services and pharmacy coverage through Aetna will be excluded . The plan sponsor of each eligible patient will be block r and omized to either full drug coverage or current levels of pharmacy benefit , and all subsequently eligible patients of that same plan sponsor will be assigned to the same benefits group . The primary outcome of the trial is a composite clinical outcome of readmission for acute MI , unstable angina , stroke , congestive heart failure , revascularization , or inhospital cardiovascular death . Secondary outcomes include medication adherence and health care costs . All patients will be followed up for a minimum of 1 year . CONCLUSION The Post-MI FREEE trial will be the first r and omized study to evaluate the impact of reducing cost-sharing for essential cardiac medications in high-risk patients on clinical and economic outcomes OBJECTIVE To evaluate the impact of the final Centers for Medicare & Medicaid Services ' ( CMS ) " short-fill " rule regarding the appropriate dispensing of prescription drugs in long-term care facilities . DESIGN A prospect i ve study to determine rates of unconsumed medication and the net-cost impact on Medicare Part D prescription drug plans based on the proposed and final CMS rule and other scenarios under consideration by CMS . SETTING Four hundred twenty-five long-term care facilities in six states . PATIENTS Residents covered by Medicare Part D. MAIN OUTCOME MEASURES Rates of unconsumed medication , average dispensing fees , potential reduction in unconsumed medication , incremental fills , incremental dispensing fees , net cost or savings to Medicare Part D plans , and percentage increase in fills . RESULTS Total estimates of the cost of unconsumed medication charged to Medicare Part D plans for residents in long-term care facilities are $ 87 million for br and products and $ 39 million for generics annually . Based on current dispensing fees , it is likely that implementation of the final rule will result in incremental costs to CMS plans in the range of $ 30 million annually . The number of Medicare Part D prescription fills will increase by about 20 % . A seven-day fill requirement on br and products would raise incremental costs to more than $ 150 million annually , and inclusion of generic products in a seven-day fill requirement would result in incremental costs in the range of $ 850 million annually . CONCLUSION The final CMS rule on short-fills is unlikely to result in savings to Medicare Part D plans . Shorter fill times and inclusion of generic products would significantly raise costs to these plans OBJECTIVE To examine the effect of Part D on 65 - 78-year-old noninstitutionalized dual eligibles ' prescription utilization and expenditures .  DATA SOURCE R and om sample of unique pharmacy customers of a national retail pharmacy chain who filled at least one prescription during both 2005 and 2006 . For each subject , we obtained cl aims data for every prescription filled between January 1 , 2005 , and April 31 , 2007 . STUDY DESIGN Generalized estimating equations were used to examine the experience of a " treatment " group  ( dual eligibles between 65 and 78 years on January 1 , 2005 ) with that of a " control " group  ( near-elderly patients with Medicaid coverage between 60 and 63 years on January 1 , 2005 ) during the first 18 months after Part D implementation . PRINCIPAL FINDINGS Expenditures for the treatment and control groups tracked each other closely in the pre-Part D period . Immediately following the implementation of Part D , expenditures for both groups decreased and then leveled off . There were no significant changes in trends in the dual eligibles ' out-of-pocket expenditures , total monthly expenditures , pill-days , or total number of prescriptions due to Part D. CONCLUSIONS We find no evidence that Part D adversely affected pharmaceutical utilization or out-of-pocket expenditures of dual eligibles during the transition period , nor during the 16 months subsequent to Part D implementation Objectives : In February 2002 , the Department of Veterans Affairs ( VA ) raised medication copayments from $ 2 to $ 7 per 30-day supply of medication for certain veteran groups . We examined the impact of the copayment increase on medication acquisition from VA . Methods : This was a retrospective cohort study using data from national VA data bases from February 2001 through February 2003 . We took a r and om sample of over 5 % of male VA users in 2001 . Of 149,107 veterans sample d , 19,504 ( 13 % ) had copayments for no drugs , 101,410 ( 68 % ) had copayments for some drugs , and 28,193 ( 19 % ) had  copayments for all drugs . We used multivariable count models to examine changes in the number of 30-day medication supplies after the increase . Results : After the copayment increase , veterans subject to copayments for all drugs received 8 % fewer 30-day supplies of medication annually relative to veterans with no cop 
    Output:
    