Regional Differences in Appropriateness of Cholecystectomy in a Prepaid Health Insurance System

This study describes the quality of antidepressant medication use at hospital discharge for depressed elderly inpatients and compares quality of care before and after implementation of Medicare's Prospective Payment System (PPS). The study reviewed data from medical records of 2746 depressed, elderly, hospitalized patients in acute-care general medical hospitals in five U.S. states (pre-PPS period 1981-82; post-PPS period 1985-86). The majority were discharged on antidepressant medication both pre-PPS and post-PPS. After PPS' implementation, sedating medications were used less often in all treatment settings. In general medical wards, a higher percentage post-PPS (24%) than pre-PPS (14%) were discharged 48 hours or less after first starting an antidepressant medication. In both time periods, one-third of patients receiving antidepressant medications were prescribed daily dosages at discharge below recommended, minimum, therapeutic levels, whether treated in general medical wards or psychiatric units. Otherwise, patients previously treated in psychiatric units received higher quality of medication management than those treated in general medical wards. Over time, patients discharged on antidepressant medication were less likely to use sedating medication, suggesting improved quality of care. In general medical wards, however, patients were discharged more rapidly after starting medication, possibly suggesting lower quality of care. A substantial percentage of patients received subtherapeutic dosages of medication or sedating medications, suggesting that improved management of discharge antidepressant medication in the elderly is needed in general medical hospitals.