The Peanut Allergy Burden Study: Real-world impact of peanut allergy on resource utilization and productivity

Background

There is limited research demonstrating the real-world economic burden of peanut allergy (PA) in the United States. The Peanut Allergy Burden Study (PABS) is a cross-sectional quantitative survey designed to determine the real-world experience of patients and caregivers with PA. The objective of the study was to understand the real-world utilization of PA-related healthcare resources and the impact of PA on productivity.

Methods

Participants completed an online survey to examine the real-world 12-month and lifetime healthcare utilization and past week productivity impact of PA in children (as reported by caregiver proxy), adolescents with PA, adults with PA, and caregivers of children with PA.

Results

Healthcare resource use over the past 12 months was frequent for adults (n = 153), adolescents (n = 102), and children (as reported by caregivers) (n = 382) with PA. Patients and caregivers reported the following rates of PA-related utilization in the past 12 months: at least 3 regular allergist appointments (28.8%–39.3%), unscheduled allergist appointments (15.6%–18.3%), general practitioner appointments (16.7%–24.2%), over-the-counter (OTC) medication usage (28.5%–35.7%), and epinephrine autoinjector usage (17.7%–26.2%). Additionally, over half of patients and caregivers reported ≥1 PA-related emergency department (ED)/urgent care visit (57.5%–59.9%), overnight hospital admission (36.3%–47.4%), IV epinephrine use (37.2%–52.3%), or intubation (26.2%–39.8%) over the past 12 months for PA. Healthcare resource use was high among all groups. Regarding productivity, PA significantly impacted household work, schoolwork, and employed work for patients and caregivers. PA-related reactions also impacted school attendance of children with PA.

Conclusion

Many healthcare resources were utilized by patients with PA and there was a loss of productivity associated with PA for patients and caregivers. New treatments to prevent or lower the risk of PA reactions could potentially help reduce healthcare resource utilization and PA-related productivity loss among patients and their families, particularly for patients for whom avoidance as a treatment strategy has not been reliable.

Impact of non-medical switching of prescription medications on health outcomes: an e-survey of high-volume medicare and medicaid physician providers

BACKGROUND

Non-medical switching refers to a change in a stable patient's prescribed medication to a clinically distinct, non-generic, alternative for reasons other than poor clinical response, side-effects or non-adherence.

OBJECTIVE

To assess the perceptions of high-volume Medicare and/or Medicaid physician providers regarding the impact non-medical switching has on their patients' medication-related outcomes and health-care utilization.

METHODS

We performed an e-survey of high-volume Medicare and/or Medicaid physicians (spending >50% of their time caring for Medicare and/or Medicaid patients), practicing for >2 years but <30 years post-residency and/or fellowship; working in a general, internal, family medicine or specialist setting; spending ≥40% of their time providing direct care and having received ≥1 request for a non-medical switch in the past 12 months. Physicians were queried on 15-items to assess perceptions regarding the impact non-medical switching on medication-related outcomes and health-care utilization.

RESULTS

Three-hundred and fifty physicians were included. Respondents reported they felt non-medical switching, to some degree, increased side-effects (54.0%), medication errors (56.0%) and medication abandonment (60.3%), and ~50% believed it increased patients' out-of-pocket costs. Few physicians (≤13.4% for each) felt non-medical switching had a positive impact on effectiveness, adherence or patients' or physicians' confidence in the quality-of-care provided. Non-office visit and prescriber-pharmacy contact were most frequently thought to increase due to non-medical switching. One-third of physicians felt office visits were very frequently/frequently increased, and ~ 1-in-5 respondents believed laboratory testing and additional medication use very frequently/frequently increased following a non-medical switch. About 1-in-10 physicians felt non-medical switching very frequently/frequently increased the utilization of emergency department or in-hospital care.

CONCLUSION

This study suggests high-volume Medicare and/or Medicaid physician providers perceive multiple negative influences of non-medical switching on medication-related outcomes and health-care utilization.

Communication of Medication Nonmedical Switching Policies and Procedures by Insurance Companies: Results of an E-Survey

PURPOSE

Nonmedical switching is defined as a change in a stable patient's prescribed medication to a clinically distinct, nongeneric alternative for reasons other than lack of clinical response, adverse effects, or poor adherence. Nonmedical switching often results from formulary changes implemented by insurers to lower medication costs. We sought to survey randomly sampled physicians to elicit their opinions regarding insurers' communication about nonmedical switching.

METHODS

We performed an online, cross-sectional survey of licensed, practicing physicians who were >2 years but <30 years out of residency and/or fellowship, who practiced in an internal medicine, family medicine, or specialist setting, spent ≥10% of their work time providing direct patient care, and had received at least 1 request for a nonmedical switch for ≥1 patient in the prior 12 months. The survey was fielded from November to December 2018. We report weighted percent responses categorized from 5- or 7-point Likert scale questions.

FINDINGS

E-mail invitations were sent to 13,117 randomly sampled physicians, and 1818 opened the e-mail and followed the embedded survey link to participate. Of these, 1010 total physicians (55.5%), 606 primary care and 404 specialists, who treated patients experiencing nonmedical switching in the prior 12 months completed the survey. A few physicians were notified about nonmedical switches by insurers; more frequently physicians learned about them from pharmacies serving their patients. Notification frequently occurred at or after a refill came due. Notification via electronic medical record or insurer letter was less frequent. Few thought that insurers clearly communicated information about alternative medications when a nonmedical switch was required, and most disagreed that insurers provided clear procedures, timelines, and methods to track challenges. Nearly all agreed that insurers should provide supporting documentation or rationale for nonmedical switches and specifics on alternatives. Respondents overwhelmingly agreed that steps to improve communication and physicians' and patients' ability to navigate nonmedical switches or challenge procedures should be implemented.

IMPLICATIONS

This survey of primary care and speciality physicians suggests that physicians believe that insurers' current level of communication regarding nonmedical switching is suboptimal. Respondents suggested that insurers did not optimally communicate information about alternative medications when a nonmedical switch was required and did not provide clear procedures, timelines, and methods to track challenges. A preponderance of physicians agreed that steps to improve physician-insurer communication to aid in the navigation of nonmedical switch and to challenge procedures should be implemented. If not addressed, these identified nonmedical switch communication issues may have a negative effect on achieving the quadruple aim of enhancing patient experience, improving population health, reducing costs, and improving the work life of health care practitioners and their staff.

Specialist physician perspectives on non-medical switching of prescription medications

Introduction: A non-medical switch is a change to a patient's medication regimen for reasons other than lack of clinical response, side-effects or poor adherence. Specialist physicians treat complex patients who may be vulnerable to non-medical switching. Objectives: To evaluate specialist physicians' perceptions regarding the frequency of non-medical switch requests, and the impact on their patients' outcomes and healthcare utilization. Methods: An online survey of randomly sampled physicians spending ≥10% of time providing patient care and having received ≥1 non-medical switch request during the prior 12-months. Results: Among 404 specialist physicians surveyed, non-medical switch requests were reported as very frequent or frequent by 35.0% of oncologists (for injectable cancer agents) and up to 80.3% of endocrinologists (for injectable anti-hyperglycemics). Respondents reported decreased medication effectiveness (25.0% of oncologists to 75.0% of dermatologists) and increased side-effects (32.5% of oncologists to 66.7% of psychiatrists). Most specialists reported very frequent or frequent increases in non-office visits (52.5% of oncologists to 75.3% of endocrinologists) and calls with pharmacies (57.5% of oncologists to 80.5% of rheumatologists) due to non-medical switching. Conclusions: Receipt of non-medical switching requests were common among specialist physicians. Non-medical switching may lead to negative effects on patient care and require increased healthcare utilization.

Physicians' perspectives regarding non-medical switching of prescription medications: Results of an internet e-survey

Background

Physicians are in an ideal position to describe the impact of medication non-medical switching (switching commonly due to formulary changes by insurer for reasons unrelated to patient health) on their practice dynamics and patient care. We sought to examine physicians’ openness to requests for non-medical switching and their experiences and opinions regarding the impact of non-medical switching on their practice, staff and patients.

Methods

An online survey of randomly-sampled physicians spending ≥10% of time providing patient care and having received ≥1 non-medical switch request during the prior 12-months. The impact of non-medical switching on clinical decision-making process; professional experience with clinical practice, patient-physician relationship, insurance process; and perceived impact on practice, staff and patients were assessed. Weighted percent responses were calculated.

Results

We sampled 1,010 physicians (response rate = 55.5%). Many responded being frequently not amenable (26.0%) or had reservations (41.8%) to non-medical switch requests; with >50% indicating patient stability on current therapy and suboptimal alternatives as factors frequently influencing amenability. Physicians agreed non-medical switching can create ethical concerns (clinical judgement, autonomy, ability to treat per guidelines; 74.8%, 82.3%, 53.5%, respectively), while forcing them to take responsibility for insurers’ decisions (81.1%) and diverting their clinical time (84.3%). Most indicated non-medical switching increased practice burden (administrative, non-billable interactions, additional staffing, non-office patient contact, calls to/from the pharmacy; 85.0%, 72.5%, 62.2%, 64.2%, 69.5%, respectively). Physicians felt insurer processes discouraged non-medical switch challenges (76.7%) and required inconvenient lengths-of-time (76.1%) speaking to insurer representatives without proper expertise (62.0%). They believed non-medical switching negatively impacted aspects of care (effectiveness, side-effects, medication adherence and abandonment, out-of-pocket costs, medication errors; 46.5%, 53.2%, 50.6%, 49.4%, 59.6%, 54.5%, respectively).

Conclusions

Physicians were frequently not amenable or had reservations regarding non-medical switching. They noted ethical concerns due to non-medical switching. Most felt non-medical switches burdened their practice and negatively impacted care.

A Survey of Payer Perspectives on Cannabis Use Disorder

BACKGROUND

Cannabis use disorder (CUD) as described/defined in DSM 5, is characterized by impaired control of marijuana use and related personal, health, and legal consequences. CUD is a serious public health problem, affecting nearly 6 million individuals in the United States. There are no FDA approved medications to treat this disorder. The lack of available treatment options contributes to uncertainties by drug sponsors about formulary and reimbursement decision-making for CUD pharmacotherapies.

OBJECTIVE

To addresses this gap by presenting the first findings on managed care payers' perceptions of CUD treatments and clinical trial end points.

METHODS

An online survey was conducted with 50 payers from managed care organizations. The survey inquired about perceptions of unmet need in CUD treatment, relevant clinical trial end points, disease knowledge, and likelihood of review of new pharmacotherapies.

RESULTS

The majority of payers (62%) reported that they were at least moderately familiar with CUD treatment end points. Most (80%) rated the unmet need for new pharmacotherapies for CUD as at least moderately important. Payers rated the most important end points for clinical trials as abstinence and decreased resource utilization. Most participants said an FDA approved CUD treatment would be formally reviewed by payers within 6 months (58%) or a year (36%).

CONCLUSIONS

Based on these findings, payers see an unmet need for CUD treatment. Furthermore, FDA-approved pharmacotherapies for CUD will likely be reviewed quickly by payers, especially if data are provided on the likelihood of achieving abstinence and reduced resource utilization.

Use and cost comparison of clobazam to other antiepileptic drugs for treatment of Lennox-Gastaut syndrome

Background: Lennox-Gastaut syndrome (LGS) is a severe form of childhood-onset epilepsy associated with serious injuries due to frequent and severe seizures. Of the antiepileptic drugs (AEDs) approved for LGS, clobazam is a more recent market entrant, having been approved in October 2011. Recent AED budget impact and cost-effectiveness analyses for LGS suggest that adding clobazam to a health plan formulary may result in decreased medical costs; however, research on clinical and economic outcomes and treatment patterns with these AED treatments in LGS is limited. Objectives: To compare the baseline characteristics and treatment patterns of new initiators of clobazam and other AEDs among LGS patients and compare healthcare utilization and costs before and after clobazam initiation among LGS patients. Methods: A retrospective study of probable LGS patients was conducted using the MarketScan® Commercial, Medicare Supplemental, and Medicaid databases (10/1/2010-3/31/2014). Results: In the Commercial/Medicare Supplemental population, clobazam users were younger, had fewer comorbidities, and more prior AED use than non-clobazam users. In the 12 months pre-treatment initiation, clobazam users had significantly more seizure-related inpatient stays and outpatient visits and higher total seizure-related (P < 0.001) and all-cause (P < 0.001) costs than non-clobazam users. Among clobazam users, when compared to the 12 months pre-clobazam initiation, seizure-related medical utilization and costs were lower in the 12 months post-clobazam initiation (P = 0.004). Total all-cause (P < 0.001) and seizure-related (P = 0.029) costs increased post-clobazam initiation mainly due to the increase in outpatient pharmacy costs. Similar results were observed in the Medicaid population. Conclusions: Baseline results suggest a prescribing preference for clobazam in severe LGS patients. Clobazam users had a reduction in seizure-related medical utilization and costs after clobazam initiation. The improvement in medical costs mostly offset the higher prescription costs following clobazam initiation.

Fall-related healthcare use and costs in neurogenic orthostatic hypotension with Parkinson's disease

AIMS

To compare patient characteristics, rates, and costs of medically attended falls among patients with Parkinson's disease (PD) and probable PD plus neurogenic orthostatic hypotension (PD + nOH).

MATERIALS AND METHODS

MarketScan Commercial and Medicare Supplemental databases (January 1, 2009-December 31, 2013) were used to identify PD and probable PD + nOH patients. The first medical or prescription claim suggesting these diagnoses served as the index date. Baseline characteristics and post-index all-cause and fall-related healthcare utilization and costs were compared between patient groups.

RESULTS

A total of 17,421 PD and 281 PD + nOH patients were identified. Compared with PD patients, PD + nOH patients were older (77 vs 74 years; p < .0001) and had more comorbidities. Pre- and post-index date, more PD + nOH patients had a medically attended fall than PD patients (25% vs 20% [p = .0159] and 30% vs 21% [p = 0.0002], respectively). Fallers in both groups had similar numbers of medically attended falls 12-months pre-index (mean =1.9), but PD + nOH fallers had more falls post-index (2.5 vs 2.0; p = .0176). Compared with PD patients, more PD + nOH patients (all p < .01) had fall-related emergency department (ED) visits (18% vs 10%), hospitalizations (7% vs 3%), and non-office visit outpatient services (15% vs 10%). Adjusted total post-index medical costs for falls ($2,260 vs $1,049; p = .0002) and total all-cause costs ($31,260 vs $20,910; p < .0001) were higher for PD + nOH vs PD patients.

LIMITATIONS

This study had some limitations. There is no ICD-9-CM diagnosis code for nOH, so a combination of PD and OH diagnoses (with confounding conditions excluded) served as a proxy for an nOH diagnosis. Also, the rate of falls and associated costs in these cohorts might be under-reported because only medically attended falls were evaluated.

CONCLUSIONS

PD + nOH patients had a higher prevalence of pre-existing comorbidities and a higher rate of medically attended falls than those with PD alone, leading to increased costs of care.

Development of a patient-reported outcome instrument to assess complex activities of daily living and interpersonal functioning in persons with mild cognitive impairment: The qualitative research phase

INTRODUCTION

As drug development research efforts move toward studying patients earlier in the course of Alzheimer's disease (AD), it is important to incorporate the patient's perspective into measurement of outcomes.

METHODS

This article summarizes the qualitative work of the Patient-Reported Outcome Consortium's Cognition Working Group in the development of a new self-reported outcome measure in persons with mild cognitive impairment (MCI) due to suspected AD, herein referred to as MCI.

RESULTS

The draft measure captures the patient's voice for two functional domains, complex activities of daily living and interpersonal functioning.

DISCUSSION

This work represents a series of initial steps in the development of this rating scale. The next steps are to conduct psychometric analysis and evaluate the role of insight.

The impact of increasing neurological disability of multiple sclerosis on health utilities: a systematic review of the literature

BACKGROUND

Multiple sclerosis (MS) is a debilitating disease, accompanied by neurological symptoms of varying severity. Utilities are a key summary index measure used in assessing health-related quality of life in individuals with MS.

OBJECTIVES

To provide a systematic review of the literature on utilities of relapsing-remitting MS (RRMS) and secondary progressive MS (SPMS) patients and to review changes in utilities associated with the increasing neurological disability of different stages of MS, as measured by the Expanded Disability Status Scale (EDSS).

METHODS

Employing pre-defined search terms and inclusion/exclusion criteria, systematic searches of the literature were conducted in EMBASE, MEDLINE, PsycINFO, the Health Economic Evaluation Database (HEED), and the NHS Economic Evaluations Database (NHS/EED). Proceedings for the International Society for Pharmacoeconomics and Outcomes Research (ISPOR), the European Society for Treatment and Research in MS (ECTRIMS), the American Society for Treatment and Research in MS (ACTRIMS), and the Latin American Society for Treatment and Research in MS (LACTRIMS) were reviewed in addition to the UK National Institute for Health and Clinical Excellence website and the table of contents of PharmacoEconomics and Value in Health.

RESULTS

This review identified 18 studies reporting utilities associated with health states of MS. Utilities ranged from 0.80 to 0.92 for patients with an EDSS score of 1, from 0.49 to 0.71 for patients with an EDSS score of 3, from 0.39 to 0.54 for patients with an EDSS score of 6.5, and from -0.19 to 0.1 for patients with an EDSS score of 9.

LIMITATIONS

Several of the studies reviewed relied on data from patient organizations, which may not be fully representative of the general patient populations. Additionally, the majority of the studies relied on retrospective data collection.

CONCLUSIONS

Utilities decrease substantially with increasing neurological disability. Cross-country differences are minimal with utility scores following a similar pattern across countries for patients at similar disease severity levels. This consistency in findings is noteworthy, as there is a reliable evidence base for selecting utility values for economic evaluation analyses. However, more research is needed to explore potential differences in utilities between RRMS and SPMS patients.

Economic burden of multiple sclerosis: a systematic review of the literature

Multiple sclerosis (MS) is a disease of the CNS, typically striking adults during the primary productive time of their life. The symptoms of MS can restrict the individual's physical activity and income-earning ability, resulting in a major financial burden on the patient, family, health system and society. This systematic literature review was conducted to document the economic burden of MS. Employing pre-defined search terms and inclusion/exclusion criteria, systematic searches were conducted in MEDLINE, EMBASE, PsycINFO, the Health Economic Evaluations Database (HEED), the NHS Economic Evaluation Database (EED) and the UK National Institute for Health and Clinical Excellence (NICE) website as well as conference abstracts. We identified 29 cost-of-illness studies that met the a priori inclusion criteria. The cost categories responsible for the majority of costs associated with MS varied across countries. There was a significant increase in costs associated with an increase in disease severity as measured by the Kurtzke Expanded Disability Status Scale (EDSS) score. The increase in magnitude was coupled with changes in the distribution of costs; although direct medical costs were important contributors in earlier stages of disease, they were outweighed by indirect costs in later stages, mainly due to relapses and productivity losses. Considering the increased costs associated with relapse occurrence and increasing disease severity, pharmaceutical or non-pharmaceutical interventions aimed at delaying the progression of disease may help to reduce the economic burden of MS.

Social cost of heavy drinking and alcohol dependence in high-income countries

OBJECTIVE

A comprehensive review of cost drivers associated with alcohol abuse, heavy drinking, and alcohol dependence for high-income countries was conducted.

METHOD

The data from 14 identified cost studies were tabulated according to the potential direct and indirect cost drivers. The costs associated with alcohol abuse, alcohol dependence, and heavy drinking were calculated.

RESULTS

The weighted average of the total societal cost due to alcohol abuse as percent gross domestic product (GDP)--purchasing power parity (PPP)--was 1.58%. The cost due to heavy drinking and/or alcohol dependence as percent GDP (PPP) was estimated to be 0.96%.

CONCLUSIONS

On average, the alcohol-attributable indirect cost due to loss of productivity is more than the alcohol-attributable direct cost. Most of the countries seem to incur 1% or more of their GDP (PPP) as alcohol-attributable costs, which is a high toll for a single factor and an enormous burden on public health. The majority of alcohol-attributable costs incurred as a consequence of heavy drinking and/or alcohol dependence. Effective prevention and treatment measures should be implemented to reduce these costs.