Prevalence and cost of medication nonadherence in Parkinson's disease: evidence from administrative claims data

Antiparkinson drug adherence and its association with health care utilization and economic outcomes in a Medicare Part D population

OBJECTIVES

We examine the associations of adherence to antiparkinson drugs (APDs) with health care utilization and economic outcomes among patients with Parkinson's disease (PD).

METHODS

By using 2006-2007 Medicare administrative data, we examined 7583 beneficiaries with PD who filled two or more APD prescriptions during 19 months (June 1, 2006, to December 31, 2007) in the Part D program. Two adherence measures--duration of therapy (DOT) and medication possession ratio (MPR)--were assessed. Negative binomial and gamma generalized linear models were used to estimate the rate ratios (RRs) of all-cause health care utilization and expenditures, respectively, conditional upon adherence, adjusting for survival risk, sample selection, and health-seeking behavior.

RESULTS

Approximately one-fourth of patients with PD had low adherence (MPR < 0.80, 28.7%) or had a short DOT (≤ 400 days, 23.9%). Increasing adherence to APD therapy was associated with decreased health care utilization and expenditures. For example, compared with patients with low adherence, those with high adherence (MPR = 0.90-1.00) had significantly lower rates of hospitalization (RR = 0.86), emergency room visits (RR = 0.91), skilled nursing facility episodes (RR = 0.67), home health agency episodes (RR = 0.83), physician visits (RR = 0.93), as well as lower total health care expenditures (-$2242), measured over 19 months. Similarly, lower total expenditure (-$6308) was observed in patients with a long DOT versus those with a short DOT.

CONCLUSIONS

In this nationally representative sample, higher adherence to APDs and longer duration of use of APDs were associated with lower all-cause health care utilization and total health care expenditures. Our findings suggest the need for improving medication-taking behaviors among patients with PD to reduce the use of and expenditures for medical resources.

Pharmaceutical care as a strategy to improve the safety and effectiveness of patients? pharmacotherapy at a pharmacy school: a practical proposal

Several patients experience at least one drug-related problem and Pharmaceutical Care can change this reality. This work describes a model for structuring the pharmaceutical care service at a pharmacy training unit of the Brazilian Public Health System based on pharmacotherapy follow-up program of Parkinson’s disease patients’ results. From the follow-up results (phase 1), a Therapy Management Scheme was designed (phase 2). Of the 57 patients followed-up, 30 presented at least one drug-related problem and 42% were non-adherent to treatment, which supported the need of pharmacotherapy management. The Pharmacotherapy Management Scheme was proposed as a pharmaceutical care service model, which presents 6 steps: first, the pharmacist fills out the dispensing form and assesses patient´s pharmacotherapy, if there is a suspect problem, he is invited to the follow-up (steps 1 and 2) and they agree the first appointment. After that, pharmacist studies the patient’s case (study phase, steps 3 and 4). At the second meeting, the pharmacist proposes the intervention needed, and at the third, assesses the intervention results and new problems (steps 5 and 6, respectively). The process ends when all therapeutics outcomes are reached. This practical model can significantly contributed to the development and organization of pharmaceutical care services.

Economic evaluation of ropinirole prolonged release for treatment of Parkinson's disease in the Netherlands

BACKGROUND

By using the findings obtained from the PREPARED study, we aimed to estimate the cost effectiveness of ropinirole prolonged release (PR) [Requip-Modutab(®)] in Parkinson's disease (PD) versus ropinirole immediate release (IR). In the PREPARED study, ropinirole PR provided a significantly greater improvement in time spent 'off' than ropinirole IR when used as an add-on to levodopa.

METHODS

A health state transition model was developed-based on Hoehn and Yahr (HY) stages in PD-to compare the two treatment strategies. The Markov model included the following treatment-related aspects: (i) rate of disease progression; (ii) rates of dyskinesia; and (iii) medication adherence.

RESULTS

In our approach, the base-case analysis showed a favourable pharmacoeconomic profile of ropinirole PR versus ropinirole IR. In particular, general cost savings were estimated combined with modest gains in quality of life, due to reduced disease progression and lower dyskinesia rates. Sensitivity analyses showed that this result was rather robust for varying parameters deterministically, although cost savings were lost in some instances. In particular, the treatment benefits of lower dyskinesia rates and improved adherence influenced the cost-effectiveness outcome. Nonetheless, the cost effectiveness remained acceptable within the limits that were investigated. Probabilistic sensitivity analysis revealed that the probability of accepting PR over IR exceeded 95 % for all relevant 'willingness-to-pay' thresholds.

CONCLUSION

The results of our study indicate a high likelihood of ropinirole PR being cost saving or at least being considered cost effective for use in the Netherlands. However, claims included in our model regarding dyskinesia and improved medication adherence should be further supported by data from daily practice.

Comparison of the bioavailability and adhesiveness of different rotigotine transdermal patch formulations

OBJECTIVE

Rotigotine transdermal patch is approved for the treatment of early and advanced idiopathic Parkinson's disease (PD) and moderate-to-severe idiopathic restless legs syndrome (RLS). A cold chain manufacturing and distribution process was temporarily implemented in 2008, as this reduced the crystal formation reported within patches stored at room temperature. In order to overcome the crystallization issue and meet EMA and FDA requirements, a new room temperature stable formulation was developed. The three studies reported here were conducted to determine whether the new room temperature stable patch demonstrated similar bioavailability and adhesiveness to the original and intermediate patches.

METHODS

Data are reported from three cross-over studies that compared the original, cold chain and room temperature stable patch. Two open-label bioequivalence studies investigated the 2 mg/24 h dosage in healthy individuals (SP951, n = 52 [Clinicaltrials.gov: NCT00881894]; SP0987, n = 50 [NCT01059903]) and a double-blind patch adhesiveness study investigated the 8 mg/24 h dosage in patients with PD (SP1066, n = 56 [NCT01338896]).

RESULTS

Plasma concentration-time curves and geometric means for pharmacokinetic parameters were similar for the cold chain vs. original patch in SP951 (AUC(0-tz): 2.68 vs. 2.71 ng/mL*h; point estimate: 0.99 [90% confidence interval (CI): 0.91, 1.07]) (Cmax: 0.131 vs. 0.136 ng/mL; 0.96 [0.89, 1.04]) and for the room temperature stable vs. cold chain patch in SP0987 (AUC(0-tz): 4.51 vs. 4.87 ng/mL*h; 0.90 [0.84, 0.97]) (Cmax: 0.23 vs. 0.23 ng/mL; 0.95 [0.88, 1.02]). In both studies, 90% CIs for ratios of AUC(0-tz) and Cmax were within the bioequivalence acceptance range (0.8-1.25). In SP1066, overall median adhesiveness scores were similar for cold chain (0.5 [range: 0-4]) and room temperature stable (0 [0-4]) formulations.

CONCLUSION

These results demonstrated bioequivalence and indicated similar adhesiveness of the approved room temperature stable rotigotine patch with the original and cold chain patches. Potential limitations include the enrolment of healthy volunteers in the bioequivalence studies, as these individuals were likely to be younger than the general PD or RLS population.

Medication reminder service for mobile phones: an open feasibility study in patients with Parkinson's disease

Parkinson's disease (PD) is a neurodegenerative disorder in which drug dosing regimens become increasingly complicated with the progression of the disease. This poses a significant risk of nonadherence to drug dosing and a failure in treatment response. We hypothesized that a medication reminder delivered by short message service (SMS) could be one way to ameliorate the problem of medication errors. We conducted an open feasibility study in 50 patients with advanced PD. The subjects set up the process to receive reminders by a Web tool, after which they started to receive automatically transmitted text messages as a medication reminder for 4 weeks. In total, 35 of 50 subjects (70.0%) were able to set up the reminder system without any help. The majority (69%) of the subjects rated the set-up process as "very easy" or "easy." Almost all (41 subjects, 91%) felt that SMS reminders worked well for them, and only 4 subjects (9%) felt that SMS texts were totally valueless. Almost half of the subjects (22 of 45, 49%) considered that there were clear benefits, and an additional 17 subjects (38%) enjoyed some benefits in using the medication reminder system. Our results indicate that an SMS medication reminder system is a feasible method, even in subjects with advanced PD.

Compliance with pharmacotherapy and direct healthcare costs in patients with Parkinson's disease: a retrospective claims database analysis

BACKGROUND

Parkinson's disease (PD) is a progressive neurological disorder for which, at present, there is no cure. Current therapy is largely based on the use of dopamine agonists and dopamine replacement therapy, designed to control the signs and symptoms of the disease. The majority of current treatments are administered in tablet form and can involve multiple daily doses, which may contribute to sub-optimal compliance. Previous studies with small groups of patients suggest that non-compliance with treatment can result in poor response to therapy and may ultimately increase direct and indirect healthcare costs.

OBJECTIVE

To determine the extent of non-compliance within the general PD population in the USA as well as the patient characteristics and healthcare costs associated with compliance and non-compliance.

METHODS

A retrospective analysis from a managed care perspective was conducted using data from the USA PharMetrics patient-centric claims database. PharMetrics claims data were complete from 31 December 2005 to 31 December 2009. Patients were included if they had at least two diagnoses for PD between 31 December 2005 and 31 December 2008, were older than 18 years of age, were continuously enrolled for at least 12 months after the date of the most recent PD diagnosis, and had no missing or invalid data. The follow-up period was the most recent 12-month block of continuous enrollment that occurred between 2006 and 2009. Patients were required to have at least one PD-related prescription within the follow-up period. The medication possession ratio (MPR) was used to categorise patients as compliant or non-compliant. Direct all-cause annual healthcare costs for patients with PD were estimated for each patient, and regression analyses were conducted to determine predictors for non-compliance.

RESULTS

A total of 15,846 patients were included, of whom 46 % were considered to be non-compliant with their prescribed medication (MPR <0.8). Predictors of non-compliance included prescription of a medication administered in multiple daily doses (p < 0.0001), a period of <2 years since the initial PD diagnosis (p = 0.0002), a diagnosis of gastrointestinal disorder (p < 0.0001), and a diagnosis of depression (p < 0.0001). Non-compliance was also found to be related to age, with a lower odds of non-compliance in patients aged 41-80 years than in patients aged ≥81 years (p < 0.05). Although total drug mean costs were higher for compliant patients than non-compliant patients (driven mainly by the cost of PD-related medications), the mean costs associated with emergency room and inpatient visits were higher for patients non-compliant with their prescribed medication. Overall, the total all-cause annual healthcare mean cost was lower for compliant ($77,499) than for non-compliant patients ($84,949; p < 0.0001).

CONCLUSION

Non-compliance is prevalent within the general USA PD population and is associated with a recent PD diagnosis, certain comorbidities, and multiple daily treatment dosing. Non-compliance may increase the burden on the healthcare system because of greater resource usage compared with the compliant population. Treatments that require fewer daily doses may have the potential to improve compliance, which in turn could reduce the economic burden associated with PD.

Prospective memory deficits are associated with poorer everyday functioning in Parkinson's disease

Although individuals with Parkinson's disease (PD) evidence moderate deficits in prospective memory (PM), it is not known whether PM deficits confer an increased risk of poorer everyday functioning. In the current study, 33 individuals with PD and 26 demographically similar normal controls (NC) were administered performance-based and self-report measures of PM and everyday functioning, including medication and financial management. As compared to NC, PD participants demonstrated significantly lower scores on performance-based measures of PM and financial capacity, worse performance at a trend level on performance-based medication management and endorsed significantly greater self-reported declines in PM and instrumental activities of daily living (iADLs). In the PD sample, the laboratory measure of PM significantly correlated with performance-based measures of financial capacity and medication management and a self-report measure of medication management. Self-reported PM failures significantly correlated with perceived declines in iADLs, worse medication management, and poorer health-related quality of life. Although future studies are needed to examine the incremental ecological validity of PM in PD, findings from this study extend prior research by providing preliminary evidence that PM impairment may play a significant role in a range of critical everyday functions in PD.

Role and clinical utility of pramipexole extended release in the treatment of early Parkinson's disease

The aim of this article is to provide a short review of the most relevant pharmacological and clinical data on pramipexole extended release (ER) as well as to address the clinical utility and potential advantages of a once-daily formulation especially in the treatment of early Parkinson's disease (PD). Pramipexole is widely established as a symptomatic treatment in early as well as advanced PD. The development of an ER formulation, with stable pramipexole plasma concentration over 24 hours, now offers a bioequivalent once-daily alternative. Double-blind randomized controlled trials in early and advanced PD, have established noninferiority of pramipexole ER compared with immediate release as well as superiority of both formulations over placebo. The overnight switch from the standard to the once-daily formulation was shown to be successful in >80% of patients without requiring any dose adjustments. Potential benefits of the prolonged-release design, which have not yet been formally demonstrated in the pivotal trial program, include improved compliance and a potential for better symptomatic control, particularly in patients with early disease that can be managed with monotherapy.

Treatment of Parkinson disease, time and dosage: "does simple dosage facilitate compliance and therapeutic goals?"

Current available treatment for Parkinson disease has many drawbacks: single action on the nigrostriatal pathway, no halt of disease progression, pulsatile dopaminergic stimulation, complex treatment regimens, and motor complications. Compliance with treatment may be irregular in a variable number of patients. Factors such as age, education, complexity of posology, stage of disease, disease comprehension, cognitive function, or family support significantly influence compliance either in a positive or negative way. The consequences of noncompliance include withdrawal symptoms, increase in number of admissions, or, in severe cases, hyperthermia syndrome secondary to levodopa deficit in the case of infradose. In situations of overdose, dyskinesia or psychiatric complications may arise. The ideal treatment should have the potency of levodopa but not its side effects, act on striatal D2 receptors in a continuous way with a single dose and have low potential of addiction. Thus far, simple regimens are only applicable in early stages.

Drug and treatment costs in Parkinson's disease patients in Sweden

BACKGROUND

Parkinson's disease (PD) is a chronic neurodegenerative disease expected to cause great costs. The aim of this study was to calculate drug and treatment costs in patients with PD in Sweden.

METHOD

All healthcare contacts of patients with PD in Stockholm County, Sweden, were extracted from registers together with information on reimbursements from the authorities to the caregivers. PD-related costs were calculated together with non-PD-related costs. Cost per patient was calculated and extrapolated to the whole Swedish population, taking population demographics into consideration. In addition, nationwide PD drug sales statistics were included.

RESULTS

The PD prevalence of Stockholm County was estimated to 196 per 100,000 inhabitants, resulting in an estimated total of about 22,000 patients with PD in Sweden. The cost per patient was estimated to SEK 76,000 of which drug costs accounted for SEK 15,880. The annual direct costs in patients with PD in Sweden were SEK 1.7 billion in 2009.

CONCLUSION

Our study estimates high direct costs in patients with PD in Sweden, SEK 1.7 billion, 52% for inpatient care, 27% for outpatient care and 21% for drugs. With an ageing population and the medical progress, the financial burden on society will most probably increase in the future. This study might initiate and provide information for discussions about future cost allocations and healthcare priorities.

Medication management and neuropsychological performance in Parkinson's disease

Medication non-adherence is associated with chronic disease and complex medication schedules, and Parkinson's disease (PD) patients also frequently have cognitive impairments that may interfere with effective medication management. The current study quantitatively assessed the medication management skills of PD patients and probed the neurocognitive underpinnings and clinical correlates of this skill. A total of 26 men with PD completed a neuropsychological battery and a modified version of the Hopkins Medication Schedule (HMS), a standard test of a person's ability to understand and implement a routine prescription medication. Estimated adherence rates from performance on the HMS were low. Memory, executive functioning, and processing speed were strongly related to different components of the HMS. A range of neuropsychological abilities is associated with the ability to understand and implement a medication schedule and pillbox in individuals with PD.

Depression and medication adherence in the treatment of chronic diseases in the United States: a meta-analysis

OBJECTIVE

To conduct a meta-analysis of the association between depression and medication adherence among patients with chronic diseases. Poor medication adherence may result in worse outcomes and higher costs than if patients fully adhere to their medication regimens.

DATA SOURCES

We searched the PubMed and PsycINFO databases, conducted forward searches for articles that cited major review articles, and examined the reference lists of relevant articles.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

We included studies on adults in the United States that reported bivariate relationships between depression and medication adherence. We excluded studies on special populations (e.g., substance abusers) that were not representative of the general adult population with chronic diseases, studies on certain diseases (e.g., HIV) that required special adherence protocols, and studies on interventions for medication adherence.

STUDY APPRAISAL AND SYNTHESIS METHODS

Data abstracted included the study population, the protocol, measures of depression and adherence, and the quantitative association between depression and medication adherence. Synthesis of the data followed established statistical procedures for meta-analysis.

RESULTS

The estimated odds of a depressed patient being non-adherent are 1.76 times the odds of a non-depressed patient, across 31 studies and 18,245 participants. The association was similar across disease types but was not as strong among studies that used pharmacy records compared to self-report and electronic cap measures.

LIMITATIONS

The meta-analysis results are correlations limiting causal inferences, and there is some heterogeneity among the studies in participant characteristics, diseases studied, and methods used.

CONCLUSIONS

This analysis provides evidence that depression is associated with poor adherence to medication across a range of chronic diseases, and we find a new potential effect of adherence measurement type on this relationship. Although this study cannot assess causality, it supports the importance that must be placed on depression in studies that assess adherence and attempt to improve it.

Dopaminergic agonists in Parkinson's disease

BACKGROUND

Non-ergoline dopamine agonists (DA) are effective treatments for Parkinson's disease (PD). This review presents the pharmacology, evidence of efficacy and safety profile of pramipexole, ropinirole, and rotigotine, and practical recommendations are given regarding their use in clinical practice.

RESULTS

Extended-release formulations of pramipexole and ropinirole and transdermal continuous delivery rotigotine patches are currently available; these may contribute to stabilising of plasma levels. In early PD, the three drugs significantly improve disability scales, delay time to dyskinesia and allow a later introduction of levodopa. In late PD they reduced total 'off'-time, improved Unified Parkinson's Disease Rating Scale (UPDRS) in both 'on' and 'off' state and allowed a reduction in total levodopa dosage. A significant improvement in quality of life scales has also been demonstrated. Extended-release formulations have proved to be non-inferior to the immediate release formulations and are better tolerated (ropinirole). Despite a generally good safety profile, serious adverse events, such as impulse control disorder and sleep attacks, need to be routinely monitored. Although combination therapy has not been addressed in scientific literature, certain combinations, such as apomorphine and another DA, may be helpful. Switching from one DA to another is feasible and safe, although in the first days an overlap of dopaminergic side effects may occur. When treatment with DA is stopped abruptly, dopamine withdrawal syndrome may present. Suspending any DA, especially pramipexole, has been linked to onset of apathy, which may be severe.

CONCLUSIONS

New non-ergotine DAs are a valuable option for the treatment of both early and late PD. Despite their good safety profile, serious adverse effects may appear; these effects may have a pathoplastic effect on the course of PD and need to be monitored.

Cost of non-persistence with oral bisphosphonates in post-menopausal osteoporosis treatment in France

BACKGROUND

During the last decade, oral bisphosphonates (BP) became the most widely prescribed pharmacologic class for post-menopausal osteoporosis. However, many surveys revealed the important issue of poor persistence with those drugs resulting in a failure of treatment to reduce fracture risk sufficiently. Using a published Markov model, this study analyses the economic impact of non-persistence with bisphosphonates in the context of the introduction of generics in France.

METHODS

Direct costs of vertebral, hip and wrist fracture were assessed and included in an existing 10-year Markov model developed to analyse consequences of non-persistence. Three alternatives of comparison were set: no treatment, real-world persistence, and ideal persistence. Simulated patients' characteristics matched those from a French observational study and the real-world adherence alternative employed persistence data from published database analysis. The risk of fracture of menopausal women and the risk reduction associated with the drugs were based on results reported in clinical trials. Incremental cost-effectiveness ratios (ICERs) were calculated first between real-world adherence and no treatment alternatives, and second between ideal and real-world persistence alternatives. The cost of non-persistence was defined as the difference between total cost of ideal and real-world persistence alternatives.

RESULTS

Within fractured women population, mean costs of 10-year management of fracture were significantly different between the three alternatives with €7,239 (± €4,783), €6,711 (± €4,410) and €6,134 (± €3,945) in the no-treatment, the real-world and ideal persistence alternatives, respectively (p < 0.0001). Cost-effectiveness ratio for real-world treatment persistence compared with no-treatment alternative was found dominant and as well, alternative of ideal persistence dominated the former. Each ten percentage point of persistence gain amounted to €58 per patient, and extrapolation resulted in a global annual cost of non-persistence of over €30 million to the French health care system, with a substantial transfer from hospital to pharmacy budgets.

CONCLUSION

Within term, improving persistence with oral bisphosphonates should be economically dominant on levels currently known in real-world. Given this potential savings, ambitious adherence-enhancing interventions should be considered in osteoporotic patients.

Pramipexole and its extended release formulation for Parkinson's disease

Pramipexole has been a widely used dopamine agonist for the last decade. Recently an extended release formulation of pramipexole has been introduced as both monotherapy for patients with early Parkinson’s disease as well as for patients with more advanced disease, as an adjunct to L-DOPA. Along with the enhanced patient compliance seen with once a day dosing, there are other potential advantages of extended release preparations of dopamine agonists. Patients initiated on pramipexole have a lower incidence of developing motor fluctuations including dyskinesia than those initiated on L-DOPA. Pramipexole requires a prolonged dose titration compared to L-DOPA, and generally does not have the efficacy of L-DOPA. The extended release form of pramipexole shows comparable mean and peak serum levels with once a day dosing as seen with three times a day dosing of the immediate release preparation. The extended release preparation has been studied in randomized multicenter clinical trial against both placebo and the immediate release preparation in the setting of early Parkinson’s disease as monotherapy and in more advanced patients with motor fluctuations on L-DOPA. In both settings the extended release preparation was superior to placebo and comparable to the immediate release form in efficacy with a similar side effect profile including nausea, sleepiness, leg edema, dyskinesias, hallucinations and impulse control disorders.