OBJECTIVE -Clinical inertia has been identified as a critical barrier to glycemic control in type 2 diabetes. We assessed the relationship between patients' initial medication adherence and subsequent regimen intensification among patients with persistently elevated A1C levels.RESEARCH DESIGN AND METHODS -We analyzed an inception cohort of 2,065 insured patients with type 2 diabetes who were newly started on hypoglycemic therapy and were followed for at least 3 years between 1992 and 2001. Medication adherence was assessed by taking the ratio of medication days dispensed (from pharmacy records) to medication days prescribed (as documented in the medical record) for the first prescribed hypoglycemic drug. Adherence was measured for the period between medication initiation and the next elevated A1C result measured at least 3 months later; intensification was defined as a dose increase or the addition of a second hypoglycemic agent.RESULTS -Patients were aged (mean Ϯ SD) 55.4 Ϯ 12.2 years; 53% were men, and 19% were black. Baseline medication adherence was 79.8 Ϯ 19.3%. Patients in the lowest quartile of adherence were significantly less likely to have their regimens increased within 12 months of their first elevated A1C compared with patients in the highest quartile (27 vs. 37%, respectively, with increased regimens if A1C is elevated, P Ͻ 0.001). In multivariate models adjusting for patient demographic and treatment factors, patients in the highest adherence quartile had 53% greater odds of medication intensification after an elevated A1C (95% CI 1.11-1.93, P ϭ 0.01). CONCLUSIONS

Objective-The goal of this study was to characterize racial-ethnic differences in mental health care utilization associated with postpartum depression in a multiethnic cohort of Medicaid recipients.Methods-In a retrospective cohort study, administrative claims data from New Jersey's Medicaid program were obtained for 29,601 women (13,001 whites, 13,416 blacks, and 3,184 Latinas) who delivered babies between July 2004 and October 2007. Racial-ethnic differences were estimated with logistic regression for initiation of antidepressant medication or outpatient mental health visits within six months of delivery, follow-up (a prescription refill or second visit), and continued mental health care (at least three visits or three filled antidepressant prescriptions within 120 days).Results-Nine percent (N=1,120) of white women initiated postpartum mental health care, compared with 4% (N=568) of black women and 5% (N=162) of Latinas. With analyses controlling for clinical factors, the odds of initiating treatment after delivery were significantly (p<.001) lower for blacks (adjusted odds ratio [AOR]=.43) and Latinas (AOR=.59) compared with whites. Among those who initiated treatment, blacks and Latinas were less likely than whites to receive follow-up treatment (blacks, AOR=.66, p<.001; Latinas, AOR=.67, p<.05) or continued care (blacks, AOR=.81, marginal difference at p<.10; Latinas, AOR=.67, p<.05). Among those who initiated antidepressant treatment, black women and Latinas were less likely than whites to refill a prescription.Conclusions-There were significant racial-ethnic differences in depression-related mental health care after delivery. Suboptimal treatment was prevalent among all low-income women in the study. However, racial and ethnic disparities in the initiation and continuation of postpartum depression care were particularly troubling and warrant clinical and policy attention.Postpartum depression is a serious and debilitating illness that affects appproximately 10%-20% of women who give birth (1). Available evidence suggests that rates of postpartum disclosures The authors report no competing interests. NIH Public Access NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript depression do not differ by race and ethnicity, but it does not conclusively demonstrate equal rates of illness across groups. Studies in which low-income mothers were systematically screened for clinical criteria indicate that rates of depression during the postpartum period are similar among Latinas, black women, and white women-8% for major depressive disorder and 23% for all depressive disorders in the first three months after delivery (2,3). Effective screening tools and treatment strategies for combating postpartum depression have been developed (4,5). However, detection and treatment rates for this condition are low (6-8), particularly among high-risk women (9). Untreated postpartum depression can have severe impacts on the health and well-being of the affected woman and her family, including long-term ...

OBJECTIVE -The purpose of this study was to examine medication adherence and other self-management practices as potential determinants of higher glycemic risk among black relative to white patients.RESEARCH DESIGN AND METHODS -We used a retrospective, longitudinal repeated-measures design to model the contribution of medication adherence to black-white differences in A1C among type 2 diabetic patients at a large multispecialty group practice. We identified 1,806 adult (aged Ն18 at diagnosis) patients (467 black and 1,339 white) with newly initiated oral hypoglycemic therapy between 1 December 1994 and 31 December 2000. Race was identified using an electronic medical record and patient self-report. Baseline was defined as the 13 months preceding and included the month of therapy initiation. All patients were required to have at least 12 months of follow-up.RESULTS -At initiation of therapy, black patients had higher average A1C values compared with whites (9.8 vs. 8.9, a difference of 0.88; P Ͻ 0.0001). Blacks had lower average medication adherence during the first year of therapy (72 vs. 78%; P Ͻ 0.0001). Although more frequent medication refills were associated with lower average A1C values, adjustment for adherence did not eliminate the black-white gap.CONCLUSIONS -We found persistent racial differences in A1C that were not explained by differences in medication adherence. Our findings suggest that targeting medication adherence alone is unlikely to reduce disparities in glycemic control in this setting. Further research is needed to explore possible genetic and environmental determinants of higher A1C among blacks at diagnosis, which may represent a critical period for more intensive intervention.

Objective The objective of this study is to characterize racial/ethnic variation in mental health diagnoses and treatments in large not-for-profit healthcare systems. Method Participating systems were 11 private, not-for-profit healthcare organizations constituting the Mental Health Research Network (MHRN) and had a combined 7,523,956 patients aged 18 years or older, who received care during 2011. Rates of diagnoses, psychotropic medications, and formal psychotherapy sessions received were obtained from insurance claims and electronic medical record databases across all healthcare settings. Results Of the 7,523,956 patients in the study, 1,169,993 (15.6%) received a mental health diagnosis in 2011. This varied significantly by race/ethnicity with Native American/Alaskan Native patients having the highest rates of any diagnosis (20.6%) and Asians having the lowest rates (7.5%). Among patients with a mental health diagnosis, 73% (n = 850,585) received a psychotropic medication. Non-Hispanic white patients were significantly more likely (77.8%) than other racial/ethnic groups (range 61.5% to 74.0%) to receive medication. In contrast, only 34% of patients with a mental health diagnosis (n = 548,837) received formal psychotherapy. Racial/ethnic differences were most pronounced for depression and schizophrenia where non-Hispanic blacks were 20% more likely to receive formal psychotherapy for their depression and 2.64 times more likely to receive formal psychotherapy for their schizophrenia when compared to whites. Conclusions There were significant racial/ethnic differences in diagnosis and treatment of mental health conditions across 11 U.S. healthcare systems. Further study is needed to understand underlying causes of these observed differences and whether processes and outcomes of care are equitable across these diverse patient populations.