Relationship between social determinants of health and hospitalizations and costs among patients with bipolar disorder 1

BACKGROUND

Bipolar disorder type 1 (BD-1) is a serious episodic mental illness whose severity can be impacted by social determinants of health (SDOH). To date the relationship of social and economic factors with health care utilization has not been formally analyzed using real-world data.

OBJECTIVE

To describe patient characteristics and assess the influence of SDOH on hospitalizations and costs in patients with BD-1 insured with commercial and managed Medicaid health plans.

METHODS

This retrospective observational study used data from the Medical Outcomes Research for Effectiveness and Economics (MORE2) Registry to identify patients aged 18 years and older with evidence of BD-1 between July 1, 2016, and December 31, 2018. SDOH were linked to patients at the "near neighborhood" level (based on ZIP9 area). Multivariable models assessed the relationship between patient characteristics and hospitalizations (incidence rate ratios [95% CI]) and costs (cost ratios [95% CI]).

RESULTS

Of 243,286 patients with BD-1, 62,148 were covered by commercial insurance and 181,138 by Medicaid. Mean ages [±SD] were similar (commercial 39.8 [±14.8]; Medicaid 40.1 [±13.6]), with more female patients in both cohorts (commercial 59.8%; Medicaid 65.4%). All-cause hospitalization rates were 21.6% for commercial and 35.1% for Medicaid patients; emergency department visits were 39.7% and 64.3%, respectively. All-cause costs were $15,379 [±$27,929] for commercial and $21,474 [±$37,600] for Medicaid. Older age was a significant predictor of fewer hospitalizations compared with those aged younger than 30 years, particularly ages 40-49 for both commercial (0.60 [0.57-0.64]) and Medicaid (0.82 [0.80-0.85]). Increasing age was associated with significantly higher costs, especially age 65 and older (commercial 1.37 [1.31-1.44]); (Medicaid 1.43 [1.38-1.49]). Initial treatment with antipsychotics plus antianxiety medications was a significant predictor of higher hospitalizations (commercial 2.12 [1.98-2.27]; Medicaid 1.62 [1.57-1.68]) and higher costs (commercial 1.86 [1.80-1.92]); Medicaid 1.80 [1.76-1.84]). Household income was inversely associated with hospitalizations for Medicaid (<$30,000 [1.16 (1.12-1.19)]; $30,000-$39,999 [1.11 (1.07-1.15)]; $40,000-$49,999 [1.08 (1.05-1.12)]; $50,000-$74,999 [1.06 (1.02-1.09)]). Not speaking English well or at all was associated with 90% higher hospitalizations for commercial patients (1.93 [1.36-2.76]) but 40% fewer hospitalizations for Medicaid patients (0.59 [0.53-0.67]). Low English language proficiency was associated with significantly higher costs for commercial patients (2.22 [1.86-2.64]) but lower costs for Medicaid patients (0.57 [0.53-0.61]).

CONCLUSIONS

Medicaid patients with BD-1 had high SDOH burden, hospitalizations, and costs. The association of lower English proficiency with fewer hospitalizations and lower costs in Medicaid patients suggests a potential disparity in access to care. These findings highlight the importance of addressing social risk factors to advance health equity in treatment of mental illness.

Economic and Humanistic Burden Among Medicare-Aged Women With Fragility Fracture in the United States

OBJECTIVE

Describe patient characteristics, health care resource utilization, costs, and humanistic burden of women with Medicare insurance with incident fragility fracture who were admitted to post-acute-care (PAC).

DESIGN

Retrospective cohort study using 100% Medicare Fee-for-Service (FFS) data.

SETTING AND PARTICIPANTS

Community-dwelling female Medicare beneficiaries with incident fragility fracture January 1, 2017, to October 17, 2019, resulting in PAC admission to a skilled nursing facility (SNF), home-health care, inpatient-rehabilitation facility, or long-term acute-care hospital.

METHODS

Patient demographic/clinical characteristics were measured during 1-year baseline. Resource utilization and costs were measured during baseline, PAC event, and PAC follow-up. Humanistic burden was measured among SNF patients with linked Minimum Data Set assessments. Multivariable regression examined predictors of PAC costs after discharge and changes in functional status during SNF stay.

RESULTS

A total of 388,732 patients were included. Compared with baseline, hospitalization rates were 3.5, 2.4, 2.6, and 3.1 times higher and total costs 2.7, 2.0, 2.5, and 3.6 times higher for SNF, home-health, inpatient-rehabilitation, and long-term acute-care, respectively, following PAC discharge. Utilization of dual-energy X-ray absorptiometry (DXA) and osteoporosis medications remained low: 8.5% to 13.7% received DXA during baseline vs 5.2% to 15.6% following PAC; 10.2% to 12.0% received osteoporosis medication during baseline vs 11.4% to 22.3% following PAC. Dual eligibility for Medicaid (ie, low income) was associated with 12% higher costs; Black patients had 14% higher costs. Activities of daily living scores improved 3.5 points during SNF stay, but Black patients had 1.22-point lower improvement than White patients. Pain intensity scores showed small improvement (-0.8 points).

CONCLUSIONS AND IMPLICATIONS

Women admitted to PAC with incident fracture had high humanistic burden with little improvement in pain and functional status and significantly higher economic burden after discharge compared with baseline. Disparities in outcomes related to social risk factors were observed, with consistently low utilization of DXA and osteoporosis medications even after fracture. Results indicate a need for improved early diagnosis and aggressive disease management to prevent and treat fragility fractures.

Investigating rates of CINV across settings of care in Medicare: A retrospective claims-based analysis

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Background: Clinical practice may differ according to settings of care and may impact both the quality of care delivered and, ultimately, patient outcomes. This study describes the differences in chemotherapy-induced nausea and vomiting (CINV) rates between chemotherapy (CT) naïve Medicare cancer patients starting CT in a hospital outpatient (HOP) or community outpatient (COP) setting. Methods: Using the 5% Medicare Fee-for-Service standard analytic files, patients with a new claim of CT and ≥1 outpatient cancer diagnosis claim between 1/1/10 – 6/30/11 were identified. Patients with a previous inpatient cancer diagnosis, multi-day CT cycles or who switched CT relevant to emetogenic potential were excluded. CINV was defined using relevant claims-based ICD-9-CM diagnosis and procedure codes within days 2-7 of the first 8 single-day CT cycles or the first 6 months following the index CT claim. CINV events were evaluated descriptively and using regression models. Results: Medicare patients receiving CT in HOP (n=1,007) vs. COP (n=1,080) were similar in demographics such as age, race, and baseline healthcare costs. However, Medicare patients receiving CT in COP compared to those in HOP settings were more likely to be female (57.0% vs. 44.7%), breast cancer patients (27.6% vs. 16.0%), live in the South region (37.7% vs. 32.3%), have higher Charlson Comorbidity Index scores (mean 5.2 vs. 4.8) and receive moderately to highly emetogenic CT (44.1% vs. 36.0%) (all p<0.05). Overall, 13.9% had any CINV in the evaluation period. More CINV events per patient were reported among those in COP compared to those in HOP settings (0.43 vs 0.27, p <0.05). However, differences between settings of care were not shown to be significantly different in adjusted regression analyses (p=0.177). Conclusions: We found the population characteristics between Medicare patients treated with CT in HOP and COP to vary on a number of factors. However, after controlling for these differences, our results suggest the number of CINV events was similar across settings of care. Future research should further clarify how differences in quality of care for antiemesis between COP and HOP settings may impact the incidence of CINV events in this population.

Understanding the impact of settings of care and the development of chemotherapy-induced nausea and vomiting within a population of commercially insured patients

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Background: Research evaluating the impact of different clinical practice patterns according to settings of care and oncology patient outcomes is limited. This study describes chemotherapy-induced nausea and vomiting (CINV) rates in chemotherapy (CT) naïve cancer patients starting CT in a hospital outpatient (HOP) or community outpatient (COP) setting. Methods: Using the Optum Normative Health Information Database, patients with a new claim of CT and ≥1 outpatient cancer diagnosis claim between 1/1/06 – 6/30/12 were identified. Patients with previous inpatient cancer diagnoses, multi-day CT regimens or Medicare/Medicaid patients were excluded. CINV was defined using relevant claims-based ICD-9-CM diagnosis and procedure codes or a prescription claim for antiemetics within days 2-7 of 1st 8 CT cycles or 1st 6 months following the index CT claim. CINV events were evaluated descriptively and using regression models Results: Patients receiving CT in HOP vs. COP were similar in age. Patients receiving CT in COP vs. HOP setting were more likely to be female (78.7% vs. 62.8%), breast cancer patients (66.8% vs. 46.7%), live in the South region (49.7% vs. 44.1%) and have higher baseline healthcare costs (mean $24,950 vs. $24,629) (all p<0.05). Patients in the HOP vs. COP settings had higher Charlson Comorbidity Index scores (mean 3.9 vs. 3.3, p < 0.05). More CINV events were reported for patients in COP vs. those in HOP settings (p < 0.05) (Table). After adjusting for clinical and demographic factors, number of CINV events remained higher for COP vs. HOP settings. However, we were unable to control for antiemetic prophylaxis use or CT emetogenic potential, due to coding irregularities. Conclusions: Results suggest cancer patients starting CT in COP vs. HOP settings may have more CINV events. However, further analyses are needed to explore the impact of antiemetic prophylaxis use or CT emetogenic potential on CINV events between settings of care. [Table: see text]

Providing patients with pharmacogenetic test results affects adherence to statin therapy: results of the Additional KIF6 Risk Offers Better Adherence to Statins (AKROBATS) trial

Despite the clinical benefit of statin therapy and the numerous strategies used to improve adherence, no strategy has used direct communication of genetic test results to the patient as an adherence and persistence motivator. We investigated in a real-world setting the effect of a process of providing KIF6 test results and risk information directly to 647 tested patients on 6-month statin adherence (proportion of days covered (PDC)) and persistence compared with concurrent non-tested matched controls. Adjusted 6-month statin PDC was significantly greater in tested patients: 0.77 (95% confidence interval (CI) 0.72-0.82) vs controls 0.68 (95% CI 0.63-0.73), P<0.0001. Significantly more tested patients were adherent (PDC⩾0.80) (63.4% (59.6-67.1%) vs 45.0% (41.1-48.8%), P<0.0001) and persisted on therapy (69.1% (65.4-72.5%) vs 53.3% (49.4-57.1%), P<0.0001). Similar results were observed in a secondary comparison with 779 unmatched patients who declined testing. The Additional KIF6 Risk Offers Better Adherence to Statins trial provides the first evidence that pharmacogenetic testing may modify patient adherence.

Abstract 290: Statin Adherence in Males and Females, and the Impact of Knowledge of a Genetic Test: Results from the AKROBATS Trial

Background A recent meta-analysis demonstrated that cardiovascular (CV) events and all-cause mortality are reduced in both sexes with statin therapy. Additionally, the Institute of Medicine and the American College of Cardiology advocate reporting of sex-specific CV treatment data. However, females are underrepresented in most CV clinical trials. We investigated the relationship between sex and other patient characteristics with regard to statin therapy adherence and persistence.

Methods AKROBATS ( NCT01068834 ) was a prospective, nonrandomized intervention trial of the effect on statin adherence and persistence of providing patients with information about KIF6 carrier status and their KIF6 test results. Eligible patients were ≥18 years old, new to statin therapy (none 6 months prior), and members of the same benefit plans. Controls and tested patients were matched for age, sex, prescription distribution channel, and number of chronic medications. The primary endpoint was statin adherence (proportion of days covered; PDC) at 6 months.

Results The study included 1294 patients (582 males & 712 females) (Figure). There was no significant difference in beta blocker (22.3% vs 18.7%), calcium channel blocker (13.7% vs 16.0%), angiotensin-converting enzyme inhibitor, (22.9% vs 19.4%), or angiotensin receptor blocker (13.7% vs 14.2%) use in males compared with females. More females received diuretics (30.6% vs 19.6%) and aspirin/non-steroidal anti-inflammatory agents (16.3% vs 13.2%) than males, p <0.05. More males received nitrates (3.8% vs 1.8%), anticoagulants (5.2% vs 2.4%), and antiplatelet agents (6.5% vs 3.1%) than females. Males were also more likely to have a history of acute coronary syndrome (15.1% vs 8.0%), stable coronary artery disease (13.2% vs 6.9%) and peripheral arterial disease (4.1% vs 2.01%), p<0.05. Despite these and other baseline differences, 6-month unadjusted statin PDC was similar between males and females [0.63 (95% CI 0.59-0.67) vs 0.60 (0.56-0.63), p=0.18], as was adjusted PDC [females 0.72 (0.66-0.78) vs males 0.74 (0.68-0.80), p=0.20)]. Predictors of statin PDC ranked by model weight were KIF6 testing, distribution channel, number of chronic medications, statin out-of-pocket spend, and income. Independent of sex, more KIF6 -tested patients were adherent (PDC >0.80; OR 1.95, 95% CI 1.54 - 2.47, p<0.0001).

Conclusions In this trial with a majority of females (55%), 6-month adherence and persistence to statin therapy did not vary by sex, and was significantly increased by individual knowledge of KIF6 test results in both males and females.

Abstract P212: Benchmark Analysis of Genetic Testing Practice Patterns in a Real-World Population of Patients Receiving Clopidogrel or Prasugrel Therapy

BACKGROUND: Cytochrome P450 2C19 genotype has been shown to modify cardiovascular outcomes on clopidogrel therapy in patients post-acute coronary syndromes or percutaneous coronary interventions. Recent clopidogrel label changes have incorporated this information; however real-world application of genetic testing in patients receiving thienopyridine antiplatelet therapy is unknown.

METHODS: A retrospective, integrated medical and pharmacy claims database, cohort analysis was conducted in patients with new clopidogrel or prasugrel prescriptions between 7/1/08-6/30/10, and continuous eligibility for 6 months pre- and 3 months post-initiation. Genetic testing was identified using CPT-4 codes present 1 month prior and 3 months post the index prescription date. Genetic testing incidence was calculated, and univariate comparisons of prescriber information, and patient demographic and clinical characteristics in cases tested vs not tested were performed.

RESULTS: The analysis included 95,381 clopidogrel and 1,819 prasugrel patients. Genetic testing was recorded in 522 (0.6%) clopidogrel and 15 (0.8%) prasugrel patients, rendering the latter sample too small for detailed analysis. Clopidogrel patients receiving genetic testing (vs patients not tested) were a mean age of 58±13 yrs (68±13 yrs, p<0.001), 29% were ≥65 yrs old (61%, p<0.001), 56% were male (59%), 33% were Western US residents (18%, p<0.001), 35% were recently hospitalized for stroke (8%, p<0.001), and were less often prescribed clopidogrel by a cardiologist (22% vs 32%, p<0.001) and more often by a neurology specialist (8% vs 2%, p<0.001). The incidence of genetic testing did not vary over time.

CONCLUSION: Although the FDA has provided numerous advisories that have lead to changes in clopidogrel provider information sheets, genetic testing is rarely employed in routine practice in patients prescribed clopidogrel or prasugrel therapy. Testing was biased toward younger clopidogrel patients with a recent stroke event, and non-cardiologist prescribers. While these data establish a national benchmark for future comparison, further exploration of barriers to testing, provider education and patient selection, and the impact of programmatic approaches to testing are warranted.

Abstract P241: One-Year Cost-Effectiveness of Cytochrome P450 2C19 Genotype-Guided Antiplatelet Therapy in Patients With Acute Coronary Syndromes

OBJECTIVES: Cytochrome P450 2C19 (CYP2C19) genotype has been shown to affect cardiovascular (CV) outcomes for clopidogrel but not prasugrel. This study evaluates the cost-effectiveness of CYP2C19-guided vs. routine antiplatelet therapy in ACS patients.

METHODS: We constructed a literature-based, decision analytic, Markov model (TreeAge 2009) to estimate the cost-effectiveness of CYP2C19-guided aspirin plus either clopidogrel or prasugrel therapy vs. no genotyping. Post-initial ACS CV events were based on the TRITON-TIMI 38 study and related costs were derived primarily using 2007 Healthcare Cost and Utilization Project DRGs for nonfatal MI and stroke, CV death, intracranial hemorrhage, other life-threatening bleed, and minor bleed. Additional costs and disease-state utilities were obtained from other published sources. All costs were adjusted to 2009 $US using the Consumer Price Index medical care component. The model allowed for clopidogrel/prasugrel discontinuation and aspirin monotherapy. Model sensitivity was assessed using 1-way and multi-way analysis of influential parameters.

RESULTS: The base case model demonstrated that CYP2C19 genotype guided antiplatelet therapy yielded lower overall annual cost and greater efficacy vs. no genotyping ( Table ). The model was sensitive to (in declining order): clopidogrel cost/day ($1 to $5.78), prasugrel cost/day ($4.09 to $ 6.81), % CYP2C19 extensive metabolizers on clopidogrel (60% to 100%), CYP2C19 test cost ($60 to $250), and monthly CV event management cost. A threshold value for clopidogrel at <$2.14/day favored the no genotyping strategy. However, the genotyping strategy was dominant when clopidogrel cost =$1/day and a CYP2C19 test cost threshold of <$125 on 2-way analysis.

CONCLUSIONS: CYP2C19 genotype-guided clopidogrel or prasugrel therapy is cost-effective for up to 1 year in ACS patients, and can remain a preferred strategy at a hypothetical generic clopidogrel cost of $1.00/day.

Table Strategy1 Annual Cost Incremental Cost Quality Adjusted Life Year (QALY) Incremental QALY Cost/QALY Incremental Cost Effectiveness (ICER) CYP2C19 Genotype-Guided $ 3,211 0.7212 $ 4,452 No Gentoyping $ 3,331 $120 0.6767 - (0.0445) $ 4,921 (Dominated)