Predictors of Medication Adherence and Associated Health Care Costs in an Older Population With Overactive Bladder Syndrome: A Longitudinal Cohort Study

Overactive bladder medication adherence when medication is free to patients

PURPOSE

We examined overactive bladder medication compliance in a health care system in which patients do not pay for medication.

MATERIALS AND METHODS

Pharmacy dispensing records were reviewed for antimuscarinic agents from January 2003 to December 2006 for the United States Military Health System National Capital Region. Medication nonpersistence, switching and adherence were examined. Kaplan-Meier survival analysis was done to compare medication persistence duration.

RESULTS

Overactive bladder medications were dispensed to 7,879 adults. Tolterodine extended release (4,716 patients or 60%) and oxybutynin immediate release (2,003 or 25.5%) were most commonly prescribed. The medication nonpersistence rate, defined as the proportion of patients who never refilled a prescription for antimuscarinics during the study period, was 35.1% (2,760 of 7,858). Of 5,098 patients who refilled a prescription 1,305 changed the medication or dose at least once for a medication switch rate of 25.6%. The overall median medication possession ratio, defined as the total days of medication dispensed except for the last refill divided by the number of days between the first dispense date and the last refill date, was 0.82 in all cases. Men had a significantly higher median medication possession ratio than women (0.86 vs 0.81, p <0.001). Of patients who obtained at least 1 refill women remained on medication longer than men (median 606 vs 547 days, p = 0.01). Patients on tolterodine extended release had a higher medication nonpersistence rate than those on oxybutynin immediate release (0.89 vs 0.68, p <0.01). There was no difference between extended release medications.

CONCLUSIONS

In a health care system in which patients do not pay for medications 35% of patients did not refill a prescription for overactive bladder medication, similar to previous reports. However, other measures of medication compliance were higher than those published previously in systems with copays.

Predictors of discontinuing overactive bladder medications

OBJECTIVE

To identify predictors of self-reported discontinuation of overactive bladder (OAB) medication using a three-phase survey.

PATIENTS AND METHODS

In January 2005, a phase 1 survey was sent to 260 000 households in the USA to assess the prevalence of OAB symptom bother, treatment patterns and healthcare consulting behaviour. In July 2005, a detailed phase 2 follow-up survey was sent to 6577 phase 1 respondents who had used one or more OAB medications within the 12 months before phase 1; the phase 2 survey included questions about respondents' sociodemographic characteristics, general health status, OAB symptom bother, healthcare consulting behaviour, beliefs about OAB and treatment options, and medication usage. Six months later, a phase 3 survey was sent to 3387 phase-2 respondents who were persistent with OAB medication or had discontinued within <18 months of phase 2; the phase 3 survey measured the same variables as phase 2. Only phase 3 respondents who were persistent with OAB medication at phase 2 were included in the analyses reported here. Assessed were the proportions of respondents who were still persistent with OAB medication at phase 3 and who discontinued OAB medication between phases 2 and 3. The variables measured during the phase 2 survey were screened as potential predictors of discontinuation at phase 3 using univariate analysis and then assessed using multivariate logistic regression.

RESULTS

Among 2838 respondents at phase 3 (84% response rate), 1194 had recently discontinued and 1644 were persistent with medication at phase 2. Among phase-3 respondents who were persistent at phase 2, 1040 (66%) continued to be persistent at phase 3, 280 (18%) had discontinued between phases 2 and 3, and 261 (17%) had switched medication between phases 2 and 3; 63 respondents had missing prescription information at phase 3. Predictors of discontinuing at phase 3 included smoking (odds ratio 1.80; 95% confidence interval 1.15-2.83; P = 0.010), not knowing whether treating bladder problems requires multiple daily doses of medication (1.71, 1.10-2.67; P = 0.018), believing (2.11, 1.34-3.33; P = 0.001) or not knowing (1.76, 1.23-2.52; P = 0.002) whether adverse effects of OAB medications are often severe, and being bothered 'quite a bit or more' by a sudden urge to urinate (1.54, 1.05-2.26; P = 0.028). Respondents taking two or more medications were less likely to discontinue (odds ratio 0.45-0.58; P < 0.05).

CONCLUSION

Persistence with OAB medications might be improved by addressing predictors of discontinuation in the management of OAB, by proactively informing patients about the severity of antimuscarinic adverse effects, and dosing regimens. Bother associated with the key OAB symptom, urgency, is a predictor of discontinuation of treatment.

Tolterodine extended release is well tolerated in older subjects

OBJECTIVES

To investigate the tolerability of tolterodine extended release (ER) in older subjects with overactive bladder (OAB).

METHODS

This was a retrospective analysis of pooled data from five large, randomised, double-blind, placebo-controlled trials. Subjects with OAB symptoms, including urinary frequency and urgency (and nocturia in two studies) with or without urgency urinary incontinence, received qd treatment with tolterodine ER (4 mg) or placebo for 8-12 weeks. Data were stratified post hoc by age group: < 65 (n = 2531), 65-74 (n = 1059) and > or = 75 years (n = 573). Tolerability was assessed by evaluating the occurrence of adverse events (AEs). AE occurrences from each study were mapped to the MedDRA coding dictionary of preferred terms.

RESULTS

Discontinuation rates were slightly higher among subjects > or = 75 years of age vs. those < 65 years of age; however, this was observed in subjects treated with placebo as well as tolterodine ER. Overall, there were no significant differences in the occurrence of dry mouth, headache, constipation, nausea, urinary tract infection, blurred vision, dry eye, dizziness and micturition disorder in older (65-74 or > or = 75 years) vs. younger (< 65 years) subjects treated with tolterodine ER relative to placebo (treatment x age; all p > 0.1). Dry mouth was the only AE consistently associated with tolterodine ER treatment (< 65 years, 17%; 65-74 years, 16%; > or = 75 years, 15%). The occurrence of all other AEs was < or = 5% in most age and treatment cohorts. Most AEs were mild or moderate in all age and treatment cohorts.

CONCLUSION

The nature and frequency of AEs associated with tolterodine ER treatment were similar across age groups in subjects with OAB, suggesting that tolterodine ER was not associated with an increased risk of AEs in older vs. younger subjects and, thus, is a suitable first-line pharmacotherapy treatment for OAB in this population.

A review of adherence to drug therapy in patients with overactive bladder

Drug therapy for overactive bladder (OAB) is associated with improvements in symptoms and quality of life, but the short- and long-term adherence and persistence is suboptimal. In this review we outline methods of measuring, and factors affecting, adherence to pharmacotherapy in patients with OAB. Clinical practice suggests that adherence rates reported in clinical trials are much greater than in real practice. Factors affecting adherence include psychological and social variables that might alter patients' perception of the benefits of taking medication, and the effect of comorbidity and polypharmacy. Whilst there is some evidence that lack of efficacy and side-effects are contributory, these additional factors are also important.

Illness severity and total visits in family medicine

OBJECTIVE

The purpose of this study was to estimate the independent effect of clinical severity on visit utilization by family medicine patients so that disease management programmes can be targeted accurately and immediately towards patients most likely to benefit from them.

DESIGN

A convenience sample of 698 primary care patients was analysed. All patients had been referred to a medical specialist. Utilization of all types of medical services including laboratory, radiology and ancillary services was used to classify patients as high-utilizers (the top 20%) or not high-utilizers. Patients were stratified into three severity categories based on point scores assigned to specific diseases. The diagnoses included in the Charlson severity index were used to score each patient and the Charlson point scores were used to measure severity. The odds of being a high-utilizer were adjusted for severity category and demographic variables.

RESULTS

Severity was independently related to the odds of being a high-user (adjusted odds ratio = 2.7 for severity = 1 and 5.7 for severity = 2, with the reference category being severity = 0). Age was related to high-use in univariate analyses but not in multivariate analyses.

CONCLUSIONS

Case management programmes in primary care practices should consider using disease severity to identify cases. Severity data can be abstracted by medical secretaries who review narrative problem lists as well as billing codes.

Predictors of tamoxifen discontinuation among older women with estrogen receptor-positive breast cancer

PURPOSE

Five years of adjuvant tamoxifen therapy for estrogen receptor (ER) -positive breast cancer is more effective than 2 years of use. However, information on tamoxifen discontinuation is scanty. We sought to identify predictors of tamoxifen discontinuation among older women with breast cancer.

PATIENTS AND METHODS

Within six health care delivery systems, we identified women >or= 65 years old diagnosed with stage I to IIB ER-positive or indeterminant breast cancer between 1990 and 1994 who had filled a prescription for adjuvant tamoxifen. We observed them for 5 years after initial tamoxifen prescription. We used automated pharmacy records to validate tamoxifen prescription information abstracted from medical records. The primary end point was tamoxifen discontinuation, operationalized as ever discontinuing tamoxifen during 5 years of follow-up. We used Cox proportional hazards to identify predictors of tamoxifen discontinuation.

RESULTS

Of 961 women who were prescribed tamoxifen, 49% discontinued tamoxifen before the completion of 5 years. Discontinuers were more likely to be aged 75 to less than 80 years (v < 70 years; hazard ratio [HR] = 1.41; 95% CI, 1.06 to 1.87), be aged >or= 80 years (HR = 2.02; 95% CI, 1.53 to 2.66), have an increase in Charlson Comorbidity Index at 3 years from diagnosis (HR = 1.52; 95% CI, 1.18 to 1.95), have an increase in the number of cardiopulmonary comorbidities at 3 years (HR = 1.75; 95% CI, 1.34 to 2.28), have indeterminant ER status (v ER-positive status; HR = 1.36; 95% CI, 1.00 to 1.85), and have received breast-conserving surgery (BCS) without radiotherapy (v mastectomy; HR = 1.62; 95% CI, 1.18 to 2.22).

CONCLUSION

Attention to nonadherence among older women at risk of discontinuation, particularly those receiving BCS without radiotherapy, might improve breast cancer outcomes for these women.

Depressive symptomatology, medication persistence, and associated healthcare costs in older adults with glaucoma

PURPOSE

Depressive symptoms may impact patients' medication use behavior and utilization of healthcare services. This study examined association between depressive symptoms and Glaucoma medication-related persistence and predictors of associated healthcare charges in older adults with primary open angle Glaucoma.

METHODS

This study used a retrospective cohort of older adults with primary open angle Glaucoma who completed health status assessment, used Glaucoma medications, and were enrolled in a Medicare Health Maintenance Organization. Baseline assessment surveyed patients on demographics, healthcare service utilization in year before enrollment, lifestyle, and quality of life. Demographic, clinical, and utilization-related economic variables were retrieved from administrative claims database of patients' Health Maintenance Organization. Survival techniques were used to measure time to discontinuation (persistence) and Center for Epidemiologic Studies Depression Scale a 20-item self-reporting scale assessed depressive symptomatology on a range of 0 to 60. Associations were examined using mixed-model regression approach. Sensitivity analysis that considered log-transformed and untransformed specifications of cost variable tested model appropriateness.

RESULTS

In total 268 patients were followed for 2 years (N=536). After controlling for potential confounders and temporal effects, depressive symptomatology was associated with decreased Glaucoma medication-related persistence (P<0.005). Patients who lived alone and had cardiovascular disease showed higher odds of experiencing depressive symptoms (P<0.005). Healthcare charges increased with number of comorbidities and prescriptions (P<0.005).

CONCLUSIONS

Presence of depressive symptoms in patients lead to poor Glaucoma medication use behavior. Healthcare expenditures increased for patients with increase in comorbidities. Plan enrollees' risk assessment offers advantage of improving health outcomes and reduces healthcare utilization.

Solifenacin provides effective antimuscarinic therapy for the complete management of overactive bladder

Solifenacin is an antimuscarinic agent, administered once daily, which has been newly approved for the treatment of overactive bladder (OAB). Solifenacin administered at 5- and 10-mg once-daily doses shows efficacy for all the symptoms of OAB in both 'wet' and 'dry' patients, including improvements in patient quality of life and satisfaction. These improvements are observed as early as week 2 of treatment and are maintained over 12-week and 1-year time periods, without being compromised by the age or gender of the patient. Solifenacin demonstrates a favourable tolerability profile, with mild dry mouth as the most common adverse event associated with its use, both at the 5- and 10-mg doses; this allows for flexibility in the dosing regimen, in which physicians can administer solifenacin 5 mg, with the option to safely increase the dose to 10 mg if necessary based on the severity of patient's symptoms. The favourable efficacy and safety profile of solifenacin, coupled with its dose flexibility, are consistent with solifenacin being a convenient treatment option for patients with OAB.