Adherence to augmentation therapy for the treatment of major depressive disorder

BACKGROUND

Inadequate response to antidepressant medication is common. Often, adjunctive pharmacotherapy or psychotherapy is recommended.

OBJECTIVE

To measure adherence to adjunctive pharmacotherapy and psychotherapy among individuals with major depressive disorder (MDD).

METHODS

Retrospective cohort study of individuals with MDD on antidepressant monotherapy who added adjunctive pharmacotherapy and/or psychotherapy. Medication adherence was measured by proportion of days covered (PDC) with optimal adherence defined as PDC≥0.80 and psychotherapy adherence defined by count of visits (optimal 8+ visits). Factors associated with optimal adherence were assessed by logistic regression.

RESULTS

Among 218,192 individuals with adjunctive therapy, 185,349 added pharmacotherapy and 32,843 added psychotherapy. In the subsequent 12 months, 36.2% and 54.9% achieved optimal adherence to adjunctive pharmacotherapy and psychotherapy, respectively. Adherence to adjunctive pharmacotherapy was associated with adding psychotherapy, index antidepressant adherence, medical comorbidities, and MDD severity codes. Adherence to adjunctive psychotherapy was associated with adding another medication, previous psychiatry visit and psychiatric comorbidities.

CONCLUSION

Adjunctive psychotherapy appears under-utilized and adherence to adjunctive therapy was low. Low adherence to adjunctive therapy reinforces challenges in managing MDD. That a second adjunctive therapy enhanced adherence to the initial adjunctive therapy indicates an opportunity to explore alternative adjunctive therapies.

Factors associated with COVID-19 Infection among a national population of individuals with schizophrenia or schizoaffective disorder in the United States

BACKGROUND

Individuals with schizophrenia are a vulnerable and under-served population who are also at risk for severe morbidity and mortality following COVID-19 infection. Our research was designed to identify factors that put individuals with schizophrenia at increased risk of COVID-19 infection.

METHODS

This study was a retrospective cohort analysis of medical and pharmacy claims among 493,796 individuals residing in the United States with schizophrenia or schizoaffective disorder, between January 1, 2019 and June 30, 2020. A confirmed diagnosis of COVID-19 infection by September 30, 2020 was regressed on demographics, social determinants, comorbidity, and pre-pandemic (December 2019 - February 2020) healthcare utilization characteristics.

RESULTS

A total of 35,249 (7.1%) individuals were diagnosed with COVID-19. Elevated odds of COVID-19 infection were associated with age, increasing consistently from 40-49 years (OR: 1.16) to 80+ years (OR:5.92), male sex (OR: 1.08), Medicaid (OR: 2.17) or Medicare (OR: 1.23) insurance, African American race (OR: 1.42), Hispanic ethnicity (OR: 1.23), and higher Charlson Comorbidity Index. Select psychiatric comorbidities (depressive disorder, adjustment disorder, bipolar disorder, anxiety, and sleep-wake disorder) were associated with elevated odds of infection, while alcohol use disorder and PTSD were associated with lower odds. A pre-pandemic psychiatry (OR:0.56) or community mental health center (OR:0.55) visit were associated with lower odds as was antipsychotic treatment with long-acting injectable antipsychotic (OR: 0.72) and oral antipsychotic (OR: 0.62).

CONCLUSIONS

Among individuals with schizophrenia, risk of COVID-19 infection was substantially higher among those with fewer economic resources, with greater medical and psychiatric comorbidity burden, and those who resided in African American or Hispanic communities. In contrast, individuals actively engaged in psychiatric treatment had substantially lower likelihood of infection. These results provide insights for healthcare providers that can translate into improved identification of at-risk individuals and interventions to reduce the risk and consequences of COVID-19 infection.

Mental Health Care Provider's Perspectives Toward Adopting a Novel Technology to Improve Medication Adherence

Objective

To understand perspectives of mental health care providers regarding barriers and drivers of adopting a medication ingestible event monitoring (IEM) system in clinical practice.

Methods

Between April and October 2019, a cross‐sectional, online survey was conducted among 131 prescribing clinicians and 119 non‐prescribing clinicians providing care to patients with major depressive disorder, bipolar disorder, and schizophrenia.

Results

Most prescribing clinicians were physicians (79.4%) while most non‐prescribing clinicians (52.9%) were licensed clinical social workers, followed by counselors (30.8%), clinical psychologists (13.4%), and case managers (2.5%). Most respondents (93.2%) reported that clinicians can influence adherence, that the IEM technology was in their patients' best interest (63.6%), and a willingness to beta test the technology (54.8%). Support was positively associated with prescribing clinicians (OR: 2.2; 95% CI: 1.1, 4.5), belief that antipsychotics reduce the health, social, or financial consequences of the condition (OR: 3.8; 95% CI: 1.3, 11.0), concern for patients' well‐being without monitoring (OR: 3.3; 95% CI: 1.2, 8.7), and belief the technology will enhance clinical alliance (OR: 3.1; 95% CI: 1.5, 6.3) or improve patient engagement (OR: 3.0; 95% CI: 1.5, 6.2). Support was inversely related to concerns about appropriate follow‐up actions (OR: 0.4; 95% CI: 0.2, 0.9) and responsibilities (OR: 0.3; 95% CI: 0.1, 0.8) when using the technology.

Conclusions

Our results suggest that IEM sensor technology adoption will depend upon additional evidence that patients will actively engage in the use of the technology, will benefit from the technology through improved outcomes, and that the additional burden placed upon providers is minimal compared to the potential benefit.

Among clinicians with prescribing authority, 91.6% are concerned about the quality of self‐reported medication adherence and 75.6% reported that the IEM sensor technology would be in their patients' “best interest”.

Most prescribing (85.5%) and non‐prescribing (74.0%) clinicians believe that the IEM sensor technology will either improve patient outcomes or practice efficiency.

A key barrier to adoption appears to be concern about how to incorporate these data into practice.

Measuring Response to Adjunctive Therapy Among Individuals with Major Depressive Disorder

BACKGROUND

Incomplete or inadequate response to first-line antidepressant therapy (ADT) for major depressive disorder (MDD) is common. Response to adjunctive therapy is less understood.

OBJECTIVE

To estimate response to adjunctive pharmacotherapy or psychotherapy among individuals with MDD on an antidepressant using the PHQ-9 questionnaire.

METHODS

This was a retrospective cohort analysis using medical and pharmacy insurance claims among individuals with MDD or ADT who initiated adjunctive pharmacotherapy, psychotherapy, or both (dual). Eligible individuals initiated adjunctive therapy between 7/1/2014-12/31/2018. Symptom severity was measured by PHQ-9 score in the 6-month baseline and 12-month follow up. Multivariate logistic regression identified factors associated with improved symptom severity.

RESULTS

Most (81.8%) of the 2389 participants initiated adjunctive pharmacotherapy, followed by psychotherapy (12.7%) and dual adjunctive (5.5%). Only 30.2% had both a baseline and follow-up PHQ-9 score. Among those with mild or more severe PHQ-9 baseline scores, 36.7% had the same or worse MDD severity during follow-up. Among those with moderate or more severe baseline scores, 28.1% had the same or worse MDD severity during follow-up.

CONCLUSION

Most individuals with moderate-to-severe MDD did not receive a follow-up questionnaire, suggesting incomplete monitoring of treatment response. Among those with a PHQ-9 following initiation of adjunctive therapy, many continued to report impactful symptoms. Future studies should explore alternate treatment approaches and methods to support the utilization of the PHQ-9 for monitoring treatment response.

Reduced Healthcare Resource Utilization in Patients with Opioid Use Disorder in the 12 Months After Initiation of a Prescription Digital Therapeutic

BACKGROUND AND AIMS

reSET-O, an FDA-authorized prescription digital therapeutic (PDT) delivering cognitive behavioral therapy and contingency management to patients with opioid u^®se disorder (OUD), may help improve clinical outcomes. One-year differences in healthcare resource utilization (HCRU) and costs post-PDT initiation were evaluated.

METHODS

Retrospective analysis of healthcare claims data compared all-cause HCRU (across hospital facility encounters [sum of inpatient stays, treat-and-release emergency department [ED] visits, partial hospitalizations, and hospital outpatient department visits] and clinician services [procedure categories]) after PDT initiation (index) between reSET-O patients and controls. Overall and Medicaid-specific differences in HCRU, costs, and buprenorphine adherence were evaluated.

FINDINGS

Cohorts included 901 reSET-O patients (median age 36 years, 62.4% female, 73.9% Medicaid) and 978 controls (median age 38 years, 51.1% female, 65.4% Medicaid). Compared to the control group, the reSET-O group experienced 12% fewer total unique hospital encounters (non-significant), driven by 28% fewer inpatient stays (IRR 0.72; 95% CI 0.55-0.96; P = 0.02), 56% fewer hospital readmissions [IRR 0.44; 95% CI 0.20-0.93; P = 0.033]), and 7% fewer ED visits (IRR 0.93; 95% CI 0.79-1.09; P = 0.386). Total clinician services increased by 1391 events versus controls. Differences were greater among the Medicaid patients. Adjustment for concomitant baseline substance use and mental health disorders resulted in similar HCRU incidence rate ratios. Changes in all-cause HCRU drove per-patient per-year cost differences of - $2791 versus controls (- $3832 versus Medicaid controls). Adjusted mean medication possession ratio was 0.848 (SE 0.0118) at 12 months for reSET-O patients, which was significantly higher than controls (0.761 [SE 0.0108]; P < 0.001).

CONCLUSIONS

Use of reSET-O is associated with significant and durable real-world reductions in ED and inpatient (including readmissions) utilization, reduced net costs, and increased clinician services and buprenorphine adherence. Differences in costs versus controls were greatest among Medicaid patients. INFOGRAPHIC.

Real-World Reductions in Healthcare Resource Utilization over 6 Months in Patients with Substance Use Disorders Treated with a Prescription Digital Therapeutic

BACKGROUND AND AIMS

Substance use disorders (SUDs) affect approximately 40.3 million people in the USA, yet only approximately 19% receive evidence-based treatment each year. reSET^® is a prescription digital therapeutic (PDT) and the only FDA-authorized treatment for patients with cocaine, cannabis, and stimulant use disorders. This study evaluated real-world healthcare resource utilization (HCRU) and associated costs 6 months after initiation of reSET in patients with SUD.

METHODS

A retrospective analysis of HealthVerity PrivateSource20 data compared the 6-month incidence of all-cause hospital facility encounters and clinician services in patients treated with reSET (re-SET cohort) before (pre-index period) and after (post-index period) reSET initiation (index). Incidence was compared using incidence rate ratios (IRR). HCRU-related costs were also assessed.

RESULTS

The sample included 101 patients (median age 37 years, 50.5% female, 54.5% Medicaid-insured). A statistically significant decrease of 50% was observed in overall hospital encounters from pre-index to post-index (IRR 0.50; 95% CI 0.37-0.67; P < 0.001), which included inpatient stays (56% decrease; IRR 0.44; 95% CI 0.26-0.76; P = 0.003), partial hospitalizations (57% decrease; IRR 0.43; 95% CI 0.21-0.88; P = 0.021), and emergency department visits (45% decrease; IRR 0.55; 95% CI 0.38-0.80; P < 0.004). Additionally, some clinician services declined significantly including pathology and laboratory services: other (54% decrease; IRR 0.46; 95% CI 0.28-0.76; P = 0.003); pathology and laboratory services: drug assays prior to opioid medication prescription (37% decrease; IRR 0.63; 95% CI 0.41-0.96; P = 0.031); and alcohol and drug abuse: medication services (46% decrease; IRR 0.54; 95% CI 0.41-0.70; P < 0.001). Reductions in facility-encounters drove 6-month reSET per-patient cost reductions of $3591 post-index compared to pre-index.

CONCLUSIONS

Use of reSET by patients with SUD is associated with durable reductions in HCRU and lower healthcare costs over 6 months compared to the 6 months before PDT treatment, after adjusting for covariates, providing an economic benefit to the healthcare system.

Impact of the COVID-19 Pandemic on Healthcare Resource Utilization in Individuals with Major Depressive Disorder

Objective

To estimate the impact COVID-19 pandemic on healthcare resource utilization (HCRU) among individuals with major depressive disorder (MDD).

Method

A retrospective cohort study was conducted to compare HCRU in the twelve months prior to and six months following pandemic onset among 1,318,709 individuals with MDD and propensity-score matched controls. Outcomes were monthly rates of all-cause and MDD-specific outpatient, inpatient, and prescription medication HCRU. Piecewise random effects models were used to adjust for patient-level clustering, trends over time, and pre-pandemic factors.

Results

In the first month following onset, outpatient HCRU declined with primary care visits down 25.1%. Following this initial decline, outpatient HCRU increased, exceeding pre-pandemic rates within three months. By April 2020, three quarters of all psychotherapy sessions were delivered by telehealth, followed by psychiatry (62.3%), and primary care visits (30.1%). The use of telehealth remained highest for psychotherapy and psychiatry (representing 67.6% and 54.2% of visits, respectively, in September 2020). All-cause partial-day hospitalizations declined 50.5% and remained depressed through July 2020 (down 18.3%). Beginning in the first month post-onset, prescription medication HCRU increased for all antidepressant and antipsychotic medication classes: serotonin modulators ( + 11.8%), bupropion ( + 10.4%), SSRIs ( + 9.0%), SNRIs ( + 8.6%), and atypical antipsychotics ( + 7.5%).

Conclusions

Following pandemic onset, individuals with MDD realized an immediate, but short-lived, reduction in primary care HCRU. Telehealth use remained elevated through the first six months. The most significant and sustained reduction in HCRU was noted for partial-day hospitalizations and all-cause ED visits.

Comparison of Healthcare Resource Utilization Between Patients Who Engaged or Did Not Engage With a Prescription Digital Therapeutic for Opioid Use Disorder

Background

A prescription digital therapeutic (PDT) (reSET-O^®) may expand access to behavioral treatment for patients with opioid use disorder (OUD) treated with buprenorphine, but long-term data on effectiveness are lacking.

Objective

To compare real-world healthcare resource utilization (HCRU) among patients who engaged with reSET-O and buprenorphine compared to similar patients in recovery treated with buprenorphine who did not fill their reSET-O script or engage with the PDT beyond week one.

Methods

A retrospective analysis of facility and clinical service claims data was conducted in adults with PDT initiation and between 12 weeks and 9 months of continuous enrollment in a health plan after initiation. Patients who filled their prescription and engaged with the therapeutic were compared to patients who filled the prescription but did not engage beyond week one (NE), and patients who did not fill the prescription (NR) (the latter two groups combined into one group hereafter referred to as “non-engagers”). Comparisons were analyzed using a repeated-measures negative binomial model of encounters/procedures, adjusted for number of days in each period. Associated cost trends assessed using current Medicare reimbursement rates.

Results

A total of 444 patients redeemed a prescription and engaged with the PDT (mean age 37.5 years, 63.1% female, 84% Medicaid), and 64 patients did not engage with the PDT (mean age 39.5 years, 32.8% female, 73.4% Medicaid). Total cost of hospital facility encounters was $2693 for engaged patients vs $6130 for non-engaged patients. Engaged patients had somewhat higher rates of certain clinician services. Total facility and clinician services costs for engaged vs non-engaged patients were $8733 vs $11,441, for a net cost savings over 9 months of $2708 per patient who engaged with reSET-O.

Conclusion

Patients who engaged with an OUD-specific PDT had a net cost reduction for inpatient and outpatient services of $2708 per patient over 9 months compared to patients who did not engage with the PDT, despite similar levels of buprenorphine adherence.

Prescriber Attitudes, Experiences, and Proclivities Toward Digital Medicine and How They Influence Adoption of Digital Medicine Platforms

BACKGROUND

Psychiatric prescribers (prescribers) typically assess medication adherence by patient or caregiver self-report. Despite likely clinical benefit of a new digital medicine technology, the role of specific prescriber attitudes, behaviors, and experiences in the likelihood of adoption is unclear.

OBJECTIVE

To identify prescriber characteristics that may affect adoption of the ingestible event marker (IEM) platform.

DESIGN

A survey of prescribers treating seriously mentally ill patients was conducted. Factor analysis was performed on 11 items representing prescriber characteristics believed to be related to endorsement of the IEM platform. Four factors were extracted. Regression analysis was used to test the strength of the relationships between the factors and likelihood of adoption of the IEM platform.

RESULTS

A total of 131 prescribers completed the survey. Most (84%) agreed that visits allow enough time to monitor adherence. Factor analysis revealed four underlying dimensions: 1) perspectives on the value of adherence; 2) concerns about measuring adherence; 3) views toward digital health technologies; and 4) views on payer role/reimbursement. Factors 1 and 3 were related to gender, the belief that computerization benefits prescribers, the presence of office support staff, and the belief that new digital medicine (DM) technology will be cost prohibitive. Willingness to adopt the IEM platform was related to gender (p < 0.05) and perspectives on the value of adherence (p < 0.05), with those scoring higher on that measure also being more likely to adopt.

CONCLUSION

Psychiatric prescribers are concerned about medication adherence, perceive current monitoring tools to be problematic, and are open to using digital technologies to improve accuracy of adherence assessment. Relationships among prescriber characteristics, beliefs, and experiences should be considered when developing educational materials, particularly when the goal is to encourage adoption and use of the IEM platform.

Real-world reduction in healthcare resource utilization following treatment of opioid use disorder with reSET-O, a novel prescription digital therapeutic

INTRODUCTION

Buprenorphine medication assisted treatment (B-MAT) adherence for opioid use disorder (OUD) is suboptimal. reSET-O, an FDA-cleared prescription digital therapeutic, delivers neurobehavioral therapy (community-reinforcement approach+fluency training+contingency management) to B-MAT-treated OUD patients.

METHODS

This retrospective claims study (10/01/2018-10/31/2019) evaluated healthcare resource utilization up to 6 months before/after reSET-O initiation. Repeated-measures negative binomial models compared incidences of encounters/procedures. Net change in costs was assessed.

RESULTS

Among 351 patients (mean age 37; 59.5% female; 82.6% Medicaid), 334 had pharmacy claims and 240 (71.9%) received buprenorphine pre-/post-index (medication possession ratio 0.73 and 0.82, respectively; P = 0.004). Facility encounters decreased, with 45 fewer inpatient (P = 0.024) and 27 fewer emergency department (ED) visits (P = 0.247). Clinical encounters with largest changes were drug testing (638 fewer; P < 0.001), psychiatry (349 fewer; P = 0.036), case management (176 additional; P = 0.588), other pathology/laboratory (166 fewer; P = 0.039), office/other outpatient (154 fewer; P = 0.302), behavioral rehabilitation (111 additional; P = 0.124), alcohol/substance rehabilitation (96 fewer; P = 0.348), other rehabilitation (66 fewer; P = 0.387), mental health rehabilitation (61 additional; P = 0.097), and surgery (60 fewer; P = 0.070). Changes in facility/clinical encounters saved $2,150/patient.

CONCLUSION

reSET-O initiation was associated with fewer inpatient, ED, and other clinical encounters, increased case management/rehabilitative services, and lower net costs over six months.

EXPERT OPINION

Real-world evidence is helpful in evaluating the effectiveness of interventions in usual-care conditions, outside of controlled research environments. Large observational studies based on health care claims are important to understand the actual pharmacoeconomic and outcomes impact of interventions at the health care system and population level.

Predicting Incident Treatment-Resistant Depression: A Model Designed for Health Systems of Care

BACKGROUND

Major depressive disorder (MDD) is a prevalent and debilitating condition. While numerous treatment options are available, low treatment response and high remission rates remain common, leading to the concept of treatment-resistant depression (TRD): a classification applied to patients who fail multiple courses of therapy. A patient with TRD can only be identified after repeated, and often prolonged, therapeutic efforts.

OBJECTIVE

To use data readily available to integrated delivery networks to identify characteristics predictive of TRD among patients initiating pharmacotherapy for MDD.

METHODS

Decision Resources Group Real-World Data, an integrated medical/pharmacy claims and electronic health record dataset, was used to conduct a retrospective, longitudinal cohort study of patients with MDD who initiated antidepressant treatment between July 1, 2014, and December 31, 2015. Individuals were followed for 24 months to determine treatment resistance. Eligible individuals had integrated claims and electronic health record data available, completed at least 1 course of therapy of adequate dose and duration to achieve response, and had 30 months of continuous benefits eligibility (6 months before and 24 months after treatment initiation). Stepwise logistic regression and demographic, health history, health care utilization, medication, provider, and related characteristics were used to predict onset of TRD.

RESULTS

35,246 people met eligibility and 7,098 (20.1%) met TRD criteria after an average of 402 days. Significant predictors of TRD included patient age, diagnosis of insomnia and hypertension, psychiatric office visits, nurse telephonic encounters, anticonvulsant medication use, suicidality, physician specialty associated with index prescription, total prescription drug claims, unique antidepressants attempted, and duration of untreated illness (the lag between diagnosis and index prescription). The final model achieved an area under the curve (AUC) = 0.83. Structured patient-generated health data, specifically, the Patient Health Questionnaire-2 and the Patient Health Questionnaire-9 were only reported for 542 patients (1.5%).

CONCLUSIONS

TRD transition occurs after a prolonged treatment period, suggesting clinical inertia. Using data routinely available to integrated delivery networks and accountable care organizations, it is feasible to identify patients likely to qualify as treatment resistant. Monitoring risk factors may allow health systems to identify patients at risk for TRD earlier, potentially improving outcomes. Early identification of this at-risk population can allow for targeted resources for earlier intervention, more aggressive follow-up, and alternative treatment options. Furthermore, this model can be used to estimate future demand for specialized care resources, such as those delivered by mood disorder clinics.

DISCLOSURES

This project was sponsored by Janssen Scientific Affairs. Pesa, Chow, and Verbanac are employed by Janssen Scientific Affairs and report stock ownership in Johnson & Johnson. Liberman, Davis, Heverly-Fitt, and Ruetsch are employed by Health Analytics, which received funding from Janssen Scientific Affairs for work on this project. This study was presented as a poster at the U.S. Psych Congress; October 3-6, 2019; San Diego, CA.

A claims-based algorithm to reduce relapse and cost in schizophrenia

OBJECTIVES

To refine a payer algorithm identifying patients with schizophrenia at high risk of relapse within a managed Medicaid population and evaluate its effectiveness in a case management (CM) program.

STUDY DESIGN

Cross-sectional and longitudinal study design.

METHODS

The algorithm used a single payer's Medicaid medical and pharmacy claims (August 1, 2009, to July 31, 2014) for patients with schizophrenia (N = 12,353) to predict those at high risk for hospitalization. The final algorithm was used in a CM program (outbound communication to providers) at 3 payer service centers in 3 states. Based on the algorithm, 60 patients (20 from each site) with the highest risk scores were targeted for CM (CM group) and 60 (those patients ranked 21st-40th most at-risk at each site) comprised the control group. Chi-square tests compared groups on frequency measures (hospitalizations, emergency department [ED] visits). Pre- to postimplementation differences were tested using McNemar's test. A pre-post analysis of variance assessed mean numbers of inpatient admissions, inpatient days, and ED visits for both groups.

RESULTS

The algorithm had good positive predictive power (64.0%), negative predictive power (94.7%), sensitivity (40.2%), and specificity (97.9%). Following CM, the proportion of patients with at least 1 inpatient admission in the CM group decreased (23.3% to 13.3%), as did the rate of ED visits per month (by approximately 15%), whereas increases were observed in the control group.

CONCLUSIONS

Although not all of these differences were statistically significant, they suggest that the algorithm may be an effective case-finding tool for plans attempting to mitigate hospitalizations among high-risk patients with schizophrenia.

Association between meaningful use of electronic health records and patient health outcomes in schizophrenia: a retrospective database analysis

Improvements in patient outcomes from the meaningful use of electronic health records (EHRs) have not been extensively studied among patients with schizophrenia. This study assessed the association between EHR use, provision of quality care, and patient outcomes. Providers who were at least 50% compliant with current requirements for the CMS Electronic Health Records Incentive Program were classified as EHR providers. Quality of mental health care was assessed using 4 Healthcare Effectiveness Data and Information Set indicators. Patient outcomes included inpatient admissions and emergency department visits. A total of 18,305 providers (EHR: 16.6%; non-EHR: 83.3%) treated 27,153 patients with schizophrenia. EHR use was associated with improved rates of diabetes screening (77.9% vs 72.4%; P <.001), diabetes monitoring (72.1% vs 61.4%; P <.001), and better antipsychotic adherence (54.7% vs 36.6%; P <.001). EHR use was also associated with fewer inpatient admissions (15.9% vs 25.2%; P <.001) and emergency department visits (32.2% vs 49.3%; P <.001). These data suggest that EHR use may have a positive influence on the process and outcomes of psychiatric care when treating patients with schizophrenia. More research is needed to identify the drivers of the influence of EHRs and to develop programs that ensure all EHR users enjoy the same potential benefits as demonstrated here.

Claims-based proxies of patient instability among commercially insured adults with schizophrenia

Objective

Schizophrenia (Sz) patients are among the highest utilizers of hospital-based services. Prevention of relapse is in part a treatment goal in order to reduce hospital admissions. However, predicting relapse is a challenge, particularly for payers and disease management firms with only access to claims data. Understandably, such organizations have had little success predicting relapse. A tool that allows payers to identify patients at elevated risk of relapse could facilitate targeted interventions prior to relapse and avoid rehospitalization. In this study, a series of proxy measures of patient instability, calculated from claims data were examined for their utility in identifying Sz patients at elevated risk of relapse.

Methods

Aetna claims were used to assess the relationship between instability of Sz patients and valence and magnitude of antipsychotic (AP) medication change during a 2-year period. Six proxies of instability including hospital admissions, emergency department visits, medication utilization patterns, and use of outpatient services were identified. Results were replicated using claims data from Truven MarketScan^®.

Results

Patients who switched AP ingredient had the highest overall instability at the point of switch and the second steepest decline in instability following switch. Those who changed to a long-acting injectable AP showed the second highest level of instability and the steepest decrease in instability following the change. Patients augmented with a second AP showed the smallest increase in instability, up to the switch. Results were directionally consistent between the two data sets.

Conclusion

Using claims-based proxy measures to estimate instability may provide a viable method to better understand Sz patient markers of change in disease severity. Also, such proxies could be used to identify those individuals with the greatest need for treatment modification preventing relapse, improving patient outcomes, and reducing the burden of illness.

Heterogeneity of nonadherent buprenorphine patients: subgroup characteristics and outcomes

OBJECTIVES

To examine patient characteristics and outcomes associated with nonadherence to buprenorphine and to identify specific patterns of nonadherent behavior.

STUDY DESIGN

Cross-sectional, retrospective analysis of health claims data.

METHODS

Aetna's administrative claims data were used to categorize incident opioid use disorder (OUD) patients based on buprenorphine medication possession ratio (MPR) into adherent (n = 172) and nonadherent (n = 305) groups. Adherent groups were then divided into 5 subgroups based on level of MPR, as well as 2 a priori-defined groups: intermittent adherent (IA) and early treatment discontinuation-no consequences (ETDNC). Groups were compared on patient characteristics and outcomes.

RESULTS

Nonadherent members incurred significantly greater healthcare costs and were more likely to relapse (P <.05). The use of high-cost healthcare services increased as a function of decreasing MPR (P <.05). Assessment of the a priori groups revealed IA members to have outcomes similar to nonadherent patients, while ETDNC members exhibited outcomes similar to adherent members.

CONCLUSIONS

Administrative claims can be used to define subgroups of buprenorphine-medication assisted treatment (B-MAT) patients. Nonadherence was related to an increased likelihood of relapse, and there is an inverse relationship between MPR and cost. The heterogeneity observed within this sample indicates that treatment regimens effective for 1 subgroup may not be appropriate for all OUD patients. Increased understanding of B-MAT nonadherent subgroups may facilitate development of new interventions and medications specifically designed for nonadherent B-MAT patients, potentially leading to improved outcomes and reduced costs of care.

Access to credible information on schizophrenia patients' medication adherence by prescribers can change their treatment strategies: evidence from an online survey of providers

OBJECTIVE

Overestimating patients' medication adherence diminishes the ability of psychiatric care providers to prescribe the most effective treatment and to identify the root causes of treatment resistance in schizophrenia. This study was conducted to determine how credible patient drug adherence information (PDAI) might change prescribers' treatment decisions.

METHODS

In an online survey containing 8 clinical case vignettes describing patients with schizophrenia, health care practitioners who prescribe antipsychotics to patients with schizophrenia were instructed to choose a preferred treatment recommendation from a set of predefined pharmacologic and non-pharmacologic options. The prescribers were randomly assigned to an experimental or a control group, with only the experimental group receiving PDAI. The primary outcome was the prescribers' treatment choice for each case. Between-group differences were analyzed using multinomial logistic regression.

RESULTS

A convenience sample (n=219) of prescribers completed the survey. For 3 nonadherent patient vignettes, respondents in the experimental group were more likely to choose a long-acting injectable antipsychotic compared with those in the control group (77.7% experimental vs 25.8% control; P<0.001). For 2 adherent but poorly controlled patient vignettes, prescribers who received PDAI were more likely to increase the antipsychotic dose compared with the control group (49.1% vs 39.1%; P<0.001). For the adherent and well-controlled patient vignette, respondents in both groups made similar treatment recommendations across all choices (P=0.099), but respondents in the experimental arm were more likely to recommend monitoring clinical stability (87.2% experimental vs 75.5% control, reference group).

CONCLUSION

The results illustrate how credible PDAI can facilitate more appropriate clinical decisions for patients with schizophrenia.

An Assessment of the AGA and CCFA Quality Indicators in a Sample of Patients Diagnosed with Inflammatory Bowel Disease

BACKGROUND

Inflammatory bowel disease (IBD) is a chronic relapsing disease characterized by activation of the mucosal immune system and inflammation of the gastrointestinal tract. Management of IBD places a significant burden on the health care system because of the complexity of treatment, variability in patient outcomes, and chronic nature of the disease. 

OBJECTIVE

To investigate the American Gastroenterological Association (AGA) and Crohn's and Colitis Foundation of America's (CCFA) quality measurement sets in a sample of IBD patients.

METHODS

Fourteen quality measures were restated for application to a claims database and calculated using Optum Clinformatics DataMart database. Selected measures were calculated over calendar year 2011.

RESULTS

Performance measures ranged from 0.4% for AGA measure 9, prophylaxis for venous thromboembolism, to 66.9% for AGA measure 8, testing for Clostridium difficile. CCFA outcome measures ranged from 0.6% qualifying for CCFA O10, report of fecal incontinence, to 32.9% for CCFA O1, prednisone usage. In addition to Clostridium difficile testing, the use of appropriate corticosteroid-sparing therapy (51.1%) and testing for latent tuberculosis before initiating anti-tumor necrosis factor therapy (45.0%) were the highest achieved measures.

CONCLUSIONS

This is the first examination of IBD quality measures using administrative claims. Rates of achievement across measures were variable and likely affected by the ability to calculate certain measures with claims data. Future studies should further examine measurement of IBD quality indicators in claims data to assess the validity of claims-based analyses and to ascertain whether measure attainment translates into better overall health or IBD-related outcomes.

Assessment of Rheumatoid Arthritis Quality Process Measures and Associated Costs

The objective was to examine the relationship between health care costs and quality in rheumatoid arthritis (RA). Administrative claims were used to calculate 8 process measures for the treatment of RA. Associated health care costs were calculated for members who achieved or did not achieve each of the measures. Medical, pharmacy, and laboratory claims for RA patients (International Classification of Diseases, Ninth Revision, Clinical Modification 714.x) were extracted from the Optum Clinformatics Datamart database for 2011. Individuals were predominately female and in their mid-fifties. Measure achievement ranged from 55.9% to 80.8%. The mean cost of care for members meeting the measure was $18,644; members who did not meet the measures had a mean cost of $14,973. Primary cost drivers were pharmacy and office expenses, accounting for 42.4% and 26.3% of total costs, respectively. Regression analyses revealed statistically significant associations between biologic usage, which was more prevalent in groups attaining measures, and total expenditure across all measures (Ps < 0.001). Pharmacy costs were similar between both groups. Individuals meeting the measures had a higher proportion of costs accounted for by office visits; those not meeting the measures had a higher proportion of costs from inpatient and outpatient visits. These findings suggest that increased quality may lead to lower inpatient and outpatient hospital costs. Yet, the overall cost of RA care is likely to remain high because of intensive pharmacotherapy regimens.

Novel Adherence Measures for Infusible Therapeutic Agents Indicated for Rheumatoid Arthritis

BACKGROUND

Published studies on adherence to biologic medications show that many types of calculation methods are used. However, infused biologics are not well-suited to typical measures of adherence, such as proportion of days covered.

OBJECTIVE

To construct and assess 7 novel adherence measures potentially applicable to infusible biologic agents and compare outcomes for 2 infusible biologics used for the treatment of patients with rheumatoid arthritis (RA).

METHODS

Adults (aged ≥18 years) diagnosed with RA (ie, 2 or more 714.x claims) who received ≥24 months of continuous medical and pharmacy eligibility and who started taking abatacept or infliximab therapy were selected from a large commercial insurer database of medical and pharmacy claims. The 7 new adherence measures included cumulative amount of time with a refill gap ≥20% (CG20) beyond the expected infusion interval, cumulative time off treatment, days of uninterrupted use (DoUU), observed versus expected refill ratio (OvERR), repeated observations of underuse (RoUU), variance in time between infusions, and time to discontinuation (TTD). Mean observed infusion intervals were calculated and served as a reference measure of adherence.

RESULTS

The mean maintenance intervals approximated recommended guidelines. The mean observed infusion interval for abatacept recipients was 33 days (recommended, 28 days); it was 53 days (recommended, 56 days) for patients receiving infliximab. Three measures demonstrated a significant positive relationship to the mean observed infusion interval-CG20 (r = .258), DoUU (r = .212), and TTD (r = .081; P <.05). OvERR (r = -.072) and RoUU (r = -.189; P <.05) showed significant negative correlations. Real-world comparisons showed that adherence was significantly (P <.001) greater for the infliximab group according to most measures.

CONCLUSION

New measures of adherence correlate significantly with mean maintenance intervals. Future studies should examine relationships between these adherence measures and clinically relevant end points and/or cost outcomes to determine their predictive utility. Alternative methods of reporting adherence may have greater clinical significance than traditional measures.

Quality process measures for rheumatoid arthritis: performance from members enrolled in a national health plan

BACKGROUND

Health care quality problems are reflected in the underuse, overuse, and misuse of health care services. There is evidence suggesting that the quality of rheumatoid arthritis (RA) patient care is suboptimal, which has spurred the development of a number of systematic quality improvement metrics.

OBJECTIVE

To investigate a quality process measurement set in a sample of commercially insured RA patients.

METHODS

Medical, pharmacy, and laboratory claims for members with an RA diagnosis (ICD-9-CM 714.x) during calendar years 2008 through 2012 were extracted from the Optum Clinformatics Data Mart database. Eight process quality measures focused on RA patient response and tolerance to therapy were examined in the claims database. Measures were calculated for individual calendar years from 2009 to 2012, inclusive.

RESULTS

The majority of adult RA patients received at least 1 prescription for a disease-modifying antirheumatic drug (DMARD) across the 4 measurement years: range = 78.5%-81.6%. Erythrocyte sedimentation rate and C-reactive protein testing were also evident in the majority of the sample, with 67.1%-72.2% of newly diagnosed RA patients receiving baseline testing, and 56.0%-58.7% of existing RA patients receiving annual testing. Among methotrexate users, liver function tests were performed in 74.5%-75.7% of treated patients, serum creatinine tests in 70.1%-72.6% of patients, and complete blood count tests in 74.5%-76.0% of patients. Additionally, most patients initiating a new DMARD had a claim for a baseline serum creatinine test (68.0%-70.3%) and baseline liver function test (69.3%-71.0%).

CONCLUSIONS

Findings suggest that a majority of RA patients are attaining patient quality process measures, although a considerable proportion of patients (approximately 25%) may be receiving suboptimal care. Further studies are warranted to understand whether attainment of these measures translates into better outcomes.

Infliximab dosing patterns in a sample of patients with Crohn's disease: results from a medical chart review

BACKGROUND

Infliximab, a monoclonal antibody tumor necrosis factor-alpha inhibitor, is an effective therapy that is indicated for the treatment of patients with Crohn's disease. Although dose escalation from 5 mg/kg to 10 mg/kg is allowed according to the prescribing label of infliximab, conflicting results exist regarding the rate at which this escalation may occur, which may affect payers and providers.

OBJECTIVE

The goal of this exploratory study was to characterize and quantify the rate of infliximab dose escalation in a sample of patients with Crohn's disease.

METHODS

Administrative claims data from patients with Crohn's disease in a large mid-Atlantic managed care organization were collected and used to target and recruit providers into a chart review study of infliximab dosing. Data from the charts of 161 patients with Crohn's disease who were receiving infliximab between 2006 and 2010 were extracted. Patients were grouped into an infliximab dose-escalation group or a dose-stable group based on these data. The evidence of any infliximab dose ≥7.5 mg/kg or evidence of a mean maintenance interval of 42 days or less resulted in the placement of a patient in the dose-escalation group, with the balance of patients comprising the stable-dose group.

RESULTS

A total of 925 infliximab infusions were captured from 161 patients. Of the 161 patients identified, 110 had at least 4 infusions, and 4 had missing data; therefore, only 106 (66%) patients were qualified for the final infliximab dosing analysis. A total of 18 (17%) of these patients had evidence of infliximab dose escalation (dose-escalation group), and the remaining 88 (83%) patients had a consistent 5-mg/kg dose and schedule (stable-dose group). Of the 18 patients in the dose-escalation group, 9 (50%) had a decrease in maintenance interval, whereas 12 (66.7%) patients had an increase in their dosage. A total of 3 (16.7%) patients had both an increase in dose and a reduction in maintenance interval.

CONCLUSIONS

Infliximab has been shown to be a cost-effective treatment for patients with Crohn's disease. The rate of infliximab dose escalation in this study was within the lower range of published estimates for this medication. Studies using larger sample sizes are needed to validate the findings of the current study. In addition, studies that are focused on quantifying and describing the nature of infliximab dose escalation may be useful in the development of successful patient-treatment matching algorithms.

Relationship between buprenorphine adherence and health service utilization and costs among opioid dependent patients

Buprenorphine-medication assisted therapy (B-MAT) is an effective treatment for opioid dependence, but may be considered cost-prohibitive based on ingredient cost alone. The purpose of this study was to use medical and pharmacy claims data to estimate the healthcare service utilization and costs associated with B-MAT adherence among a sample of opioid dependent members. Members were placed into two adherence groups based on 1-year medication possession ratio (≥ 0.80 vs. <0.80). The B-MAT adherent group incurred significantly higher pharmacy charges (adjusted means; $6,156 vs. $3,581), but lower outpatient ($9,288 vs. $14,570), inpatient ($10,982 vs. $26,470), ER ($1,891 vs. $4,439), and total healthcare charges ($28,458 vs. $49,051; p<0.01) compared to non-adherent members. Adherence effects were confirmed in general linear models. Though B-MAT adherence requires increased pharmacy utilization, adherent individuals were shown to use fewer expensive health care services, resulting in overall reduced healthcare expenditure compared to non-adherent patients.

Opioid analgesic-treated chronic pain patients at risk for problematic use

OBJECTIVES

To characterize potentially problematic opioid use (PPOU) among opioid analgesic-treated chronic pain (OAT-CP) patients and to compare their healthcare service utilization and expenditures with those of a control group of OAT-CP patients not exhibiting these behaviors.

STUDY DESIGN

Cross-sectional, retrospective analysis of health claims data.

METHODS

Members of a national health plan (n = 3891) with chronic pain and an opioid prescription were categorized into 3 groups: PPOU group (n = 1499), those displaying evidence of doctor shopping or rapid opioid dose escalation; buprenorphine/naloxone group (n =199), those who filled a prescription for buprenorphine/naloxone, which served as a proxy for opioid dependence; and control group (n = 2193), those not meeting either of the above criteria. Groups were compared on 1-year healthcare service utilization and costs.

RESULTS

The PPOU group made up more than one-third of the study sample. Compared with the control group, they incurred significantly greater 1-year adjusted mean pharmacy costs ($6573 vs $6160), office costs ($5705 vs $4479), emergency department (ED) costs ($835 vs $388), inpatient costs ($15,646 vs $7445), and total healthcare costs ($39,048 vs $26,171) (all P <.05). The buprenorphine/naloxone group incurred significantly greater 1-year pharmacy costs ($6981 vs $6160) and ED costs ($1126 vs $388) (both P <.05) than the control group.

CONCLUSIONS

The PPOU group had the highest healthcare service utilization and costs. Although drivers of elevated service utilization and cost among this population are not clear, health plans may want to focus on PPOU case identification and development of interventions.

Trajectories of health care service utilization and differences in patient characteristics among adults with specific chronic pain: analysis of health plan member claims

Introduction

The lack of consistency surrounding the diagnosis of chronic non-cancer pain, treatment approaches, and patient management suggests the need for further research to better characterize the chronic non-cancer pain population.

Objective

The purpose of this study was to identify distinct trajectories of health care service utilization of chronic non-cancer pain patients and describe the characteristic differences between trajectory groups.

Patients and methods

This study utilized the MarketScan claims databases. A total of 71,392 patients diagnosed with either low back pain or osteoarthritis between 2006 and 2009 served as the study sample. Each subject’s claims data were divided into three time periods around an initial diagnosis date: pre-period, post-Year 1, and post-Year 2. Subjects were categorized as either high (H) or low (L) cost at each post period, resulting in the creation of four trajectory groups based on the post-Year 1 and 2 cost pattern: H-H, H-L, L-H, and L-L. Multivariate statistical tests were used to predict and discriminate between trajectory group memberships.

Results

The H-H, L-H, and H-L groups each utilized significantly greater pre-period high-cost venue services, post-Year 1 outpatient services, and post-Year 1 opioids compared to the L-L group (P < 0.001). Additionally, the H-H and L-H groups displayed elevated Charlson comorbidity index scores compared with the L-L group (P < 0.001), with each showing increased odds of having both opioid dependence and cardiovascular disease diagnoses (P < 0.01).

Conclusion

This study identified patient characteristics among chronic pain patients that discriminated between different levels of post-index high-cost venue service utilization and trajectories of change in the same. With implications for managed care program implementation and resource management, this study highlights results from a developed algorithm that employed a variety of accessible data elements to effectively discriminate between patients based on their pattern of high-cost venue service utilization over time.

The effect of telephonic patient support on treatment for opioid dependence: outcomes at one year follow-up

OBJECTIVE

The present study examined the impact of a telephonic patient support program known as HereToHelp™ (HTH) on compliance and treatment outcomes among opioid dependent (OD) patients new to buprenorphine treatment (BUP).

METHOD

A total of 1426 OD patients new to BUP were randomized to receive BUP alone (standard care) or BUP plus the HTH patient support program. All patients completed the Addiction Severity Index (ASI) at the time of enrollment, and at 12months post-enrollment.

RESULTS

Subjects randomized to the HTH support program who accepted at least 3 care coach intervention calls were more compliant with BUP than the standard care group at month 12 (64.4% vs. 56.1%, χ(2)=5.09, p<.025). Compared to patients who were non-compliant with BUP, compliant patients reported significantly lower scores on all 7 of the ASI composite scores, indicating lower severity on addiction-related problems.

CONCLUSIONS

The HTH intervention seemed to improve patient treatment outcomes indirectly by improving compliance with BUP. Supplementing BUP with a structured, telephonic compliance-enhancement program is an effective way to improve compliance with medication which then improves patient outcomes.

Compliance with buprenorphine medication-assisted treatment and relapse to opioid use

Opioid dependence (OD), often characterized as a chronic relapsing disorder, affects millions of people worldwide. The purpose of this study was to examine the effect of compliance with buprenorphine on reducing relapse among a sample of patients in treatment for OD. Patients new to buprenorphine (N = 703) completed the Addiction Severity Index (ASI) at baseline, and at 1, 2, and 3 months postbaseline. The ASI is a semistructured interview designed to measure problem severity in seven functional areas known to be affected by alcohol and drug dependence. Compliance was defined as taking buprenorphine medication on at least 22 of the past 28 days (80%), while relapse classification was based on resumed use of opioids during the follow-up period (months 2 and 3). Relapse was regressed onto demographic indicators, baseline ASI composite scores, and compliance with buprenorphine. Noncompliant patients were over 10 times more likely to relapse than those who were compliant (exp β= 10.55; p < .001). Neither demographics nor baseline ASI composite scores were predictive of relapse (p's > .05). Compliance with medication-assisted treatment supports abstinence, essential for patient recovery. Understanding the factors that drive treatment compliance and noncompliance may assist providers in supporting patient compliance and recovery. 

Practice strategies to improve compliance and patient self-management

BACKGROUND

Failure in treating opioid dependence is costly to the patient, the employer, managed care organizations, and the overall health care system. Opioid dependent patients tend to be less productive at work and in society and utilize a great many health care resources. Optimizing outcomes is essential.

OBJECTIVE

To introduce the benefit of integrated strategies and patient support in the treatment of opioid dependence.

SUMMARY

Health Analytics is currently studying the benefit of HereToHelp, a behavioral support program in which registered nurses or addiction treatment counselors with specialized training in addiction education provide information and encouragement to patients receiving pharmacologic treatment for opioid dependence. A total of 470 physicians in 41 states have been enlisted to participate in this patient support study. The study hypothesis is that patients who receive behavioral support and encouragement will be more compliant with their opioid replacement therapy, leading to better outcomes. Additional treatment strategies are also being developed to minimize the risk of abuse and diversion. Prodrugs and vaccines are also being investigated.

CONCLUSION

A coordinated team approach is essential in treating pain patients and opioid-dependent patients. Offering behavior modification in addition to pharmacotherapy and utilizing strategies such as prescription monitoring programs, pain contracts, and screening are all vital components necessary for positive outcomes.

Opioid dependence treatment and guidelines

BACKGROUND

In response to the growing incidence of opioid dependence, guidelines have been created, and new treatments are being developed to assist physicians in treating dependence and withdrawal of opioids.

OBJECTIVE

To review treatment modalities and guidelines utilized in opioid dependence.

SUMMARY

Guidelines for the treatment of opioid dependence have been developed by organizations such as the American Society of Interventional Pain Physicians (ASIPP) and the American Psychiatric Association (APA). Current guidelines recommend comprehensive treatment with pharmacological agents such as methadone, buprenorphine, or buprenorphine combined with naloxone as well as psychosocial therapy. These guidelines stress the need for an integrated approach to treatment. Office-based opioid treatment is currently being utilized to treat opioid dependent patients in a physician's office setting with buprenorphine/naloxone replacement therapy as an alternative to entering patients into a methadone clinic. These office-based programs offer a breakthrough in access to care for dependent patients.

CONCLUSION

Physicians need to be aware of and adhere to currently accepted guidelines and recommendations for treating opioid dependent patients, including integrating psychosocial treatments and behavior modification strategies for optimal results. Clinicians must be educated on the new treatment modalities and regulations surrounding the use of these therapies.

Empirical view of opioid dependence

BACKGROUND

The impact of opioid dependence on employers, managed care, and society is significant. Inappropriate use of narcotic analgesics leads to uncontrolled pain management, dependence, and may lead to patient deaths, creating a tremendous cost burden to the health care system.

OBJECTIVE

To provide an overview of the clinical and economic impact of treating opioid dependence on managed care, employers, and society.

SUMMARY

An estimated 6% to 15% of people in the United States abuse drugs, and approximately 20% of Americans report using prescription opioids for nonmedical use. This is associated with an annual cost of nearly half a trillion dollars, taking into account the medical, economic, social, and criminal impact of this abuse. A recent study showed that patients who abuse opioids generate mean annual direct health care costs 8.7 times higher than nonabusers. The National Survey on Drug Use and Health (NSDUH), conducted by the Substance Abuse and Mental Health Services Administration (SAM HSA), found that patients who report opioid abuse miss more than 2.2 days of work monthly, compared with the 0.83 days per month reported for the average person. Presenteeism and productivity are also affected by misuse and dependence on opioids.

CONCLUSION

The costs associated with opioid dependence are significant. Physicians, employers, and managed care organizations must be proactive in appropriately diagnosing and treating patients who suffer from substance abuse disorders in order to lessen this economic burden.

Psychometric evaluation of the Readiness for Discharge Questionnaire

OBJECTIVE

The Readiness for Discharge Questionnaire (RDQ) was developed as an easy to use tool for assessing readiness for discharge, independent of socio-economic factors, for inpatients with schizophrenia. The psychometric properties of the RDQ are described.

METHODS

The RDQ consists of 6 items assessing suicidality/homicidality, control of aggression/impulsivity, activities of daily living, medication-taking, delusions/hallucinations interfering with functioning and global status. A final yes/no question assesses readiness for discharge. Data derived from 3 studies (500 patients in 3 countries) were used in analyzing inter-rater and test-retest reliability, content and construct validity, and sensitivity to change.

RESULTS

The inter-rater reliability was high for all items of the RDQ (reliability coefficients >0.9) and moderate to high for the readiness for discharge status (Session I: 84% agreement, kappa 0.39, polychoric correlation r=0.81; Session II: 89% agreement, kappa 0.63, polychoric correlation r=0.81. Test-retest reliability was also high for all items of the RDQ (reliability coefficients >0.9) and the readiness for discharge status (kappa=0.743; tetrachoric correlation r=0.819). Overall, 84% of the raters agreed (mean score=5.0 of possible 6.0) that the RDQ was useful in assessing a patient's readiness for discharge from the hospital. Evidence of good construct validity included significant correlations with PANSS total and factor scores, and a significant relationship with actual discharge. Significantly more patients with symptom improvement were judged ready for discharge (compared to those without symptom improvement), indicating that the RDQ was sensitive to change over time.

CONCLUSIONS

The RDQ has favorable reliability and validity properties, and is an easy to use instrument in research studies for assessing readiness for discharge of inpatients with schizophrenia. Additional work in naturalistic settings is required to further validate the instrument for routine clinical use.

Characteristics of recipients of Supplemental Security Income (SSI) benefits for drug addicts and alcoholics

This study examined symptom severity and level of functioning in recipients of Supplemental Security Income (SSI) benefits for drug addicts and alcoholics (DA&A). Although substantial numbers of substance abusers received these benefits until the program was canceled in 1997, little information has been available on the characteristics of these individuals. Approximately 2500 SSI DA&A recipients were assessed at the point in which they were to be referred for treatment services. Results indicated that in addition to long histories of alcohol abuse and recent problems with employment, these DA&A recipients were characterized by high levels of medical and psychiatric problems. Problem severities in these latter two areas were found to be consistently high across several subgroupings of recipients, including those who reported no alcohol or drug use in the prior 30 days. These findings suggest that SSI DA&A recipients are often significantly impaired beyond their alcohol and drug use.

Testing for Equivalence of Measurement Scales: Simple Structure and Metric Invariance Reconsidered

Most quantitative comparisons of interest are based on scores obtained from multi-item scales. In order for such comparisons to be valid and meaningful, conventional thinking dictates that simple structure and metric invariance must be satisfied at the level of individual items. However, it is proposed here that the use of multi-item scales requires only that conditions of simple structure and metric invariance be satisfied at the scale level, that is, for hypothesized sets of items as a whole rather than each item individually. The proposed concepts can be implemented within the context of confirmatory factor analysis (CFA) by imposing constraints on mean factor loadings and intercepts of item sets rather than loadings and intercepts of each individual item. Further, the present method is proposed as a conceptual alternative to the specification of measurement models that is currently predominant in CFA.