National trends in prescription drug expenditures and projections for 2024

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PURPOSE

To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2024 in the United States, with a focus on the nonfederal hospital and clinic sectors.

METHODS

Historical patterns were assessed by examining data on drug purchases from manufacturers using the IQVIA National Sales Perspectives database. Factors that may influence drug spending in hospitals and clinics in 2024 were reviewed-including new drug approvals, patent expirations, and potential new policies or legislation. Focused analyses were conducted for biosimilars, cancer drugs, endocrine drugs, generics, and specialty drugs. For nonfederal hospitals, clinics, and overall (all sectors), estimates of growth of pharmaceutical expenditures in 2024 were based on a combination of quantitative analyses and expert opinion.

RESULTS

In 2023, overall pharmaceutical expenditures in the US grew 13.6% compared to 2022, for a total of $722.5 billion. Utilization (a 6.5% increase), new drugs (a 4.2% increase) and price (a 2.9% increase) drove this increase. Semaglutide was the top drug in 2023, followed by adalimumab and apixaban. Drug expenditures were $37.1 billion (a 1.1% decrease) and $135.7 billion (a 15.0% increase) in nonfederal hospitals and clinics, respectively. In clinics, increased utilization drove growth, with a small impact from price and new products. In nonfederal hospitals, a drop in utilization led the decrease in expenditures, with price and new drugs modestly contributing to growth in spending. Several new drugs that will influence spending are expected to be approved in 2024. Specialty, endocrine, and cancer drugs will continue to drive expenditures.

CONCLUSION

For 2024, we expect overall prescription drug spending to rise by 10.0% to 12.0%, whereas in clinics and hospitals we anticipate an 11.0% to 13.0% increase and a 0% to 2.0% increase, respectively, compared to 2023. These national estimates of future pharmaceutical expenditure growth may not be representative of any health system because of the myriad of local factors that influence actual spending.

Adherence and persistence of HIV pre-exposure prophylaxis use in the United States

PURPOSE

To describe medication adherence and persistence of HIV PrEP overall and compare between sex and age groups of commercially insured individuals in the United States.

METHODS

We conducted a national retrospective cohort study of the Merative MarketScan Claims Database from 2011 to 2019 to describe adherence and persistence of PrEP overall and compared between sex and age groups. High adherence was defined as ≥80% of proportion of days covered and persistence was measured in days from initiation to the first day of a 60-day treatment gap.

RESULTS

A total of 29 689 new PrEP users identified. Overall adherence was high (81.9%; 95% confidence interval [CI]: 81.5%-82.3%). Females were more adherent than males (adjusted odds ratio [aOR] 1.87; 95% CI: 1.50-2.34), while those ≥45-years were less adherent than individuals <45-years (aOR 0.87: 95% CI: 0.81-0.93). More than half of individuals discontinued therapy within the first year (median 238.0 days; interquartile range 99.0-507.0 days). Females were less persistent than males (hazard ratio [HR] 1.49; 95% CI: 1.34-1.65), and people ≥45-years old were more persistent (i.e., lower risk of discontinuation) than those <45-years (HR 0.43; 95% CI: 0.33-0.55).

CONCLUSIONS

These findings show adherence to daily PrEP is high among commercially insured individuals but the majority still discontinue in the first year. Future research should investigate what factors influence PrEP discontinuation among this population and ways to reduce barriers to therapy maintenance to ensure the population-level benefits of PrEP treatment.

Trends of nonoccupational postexposure prophylaxis in the United States

OBJECTIVE

To describe national annual rates of nonoccupational postexposure prophylaxis (nPEP) in the United States.

DESIGN

Retrospective cohort study of commercially insured individuals in the Merative MarketScan Database from January 1, 2010 to December 31, 2019.

METHODS

Patients at least 13 years old prescribed nPEP per recommended Centers for Disease Control and Prevention guidelines were identified using pharmacy claims. Rates of use were described overall and stratified by sex, age group, and region. These rates were qualitatively compared to the diagnosis rates of human immunodeficiency virus (HIV) observed in the data. Joinpoint analysis identified inflection points of nPEP use.

RESULTS

Eleven thousand, three hundred and ninety-seven nPEP users were identified, with a mean age of 33.7 years. Most were males (64.6%) and lived in the south (33.2%) and northeast (32.4%). The rate of nPEP use increased 515%, from 1.42 nPEP users per 100 000 enrollees in 2010 to 8.71 nPEP users per 10 000 enrollees in 2019. The comparative nPEP use rates among subgroups largely mirrored their HIV diagnosis rates, that is, subgroups with a higher HIV rate had higher nPEP use. In the Joinpoint analysis significant growth was observed from 2012 to 2015 [estimated annual percentage change (EAPC): 45.8%; 95% confidence interval (CI): 29.4 - 64.3] followed by a more moderate increase from 2015 to 2019 (EAPC 16.0%; 95% CI: 12.6-19.6).

CONCLUSIONS

nPEP use increased from 2010 to 2019, but not equally across all risk groups. Further policy interventions should be developed to reduce barriers and ensure adequate access to this important HIV prevention tool.

Evaluating the use of methods to mitigate bias from non-transient medications in the case-crossover design: A systematic review

PURPOSE

The case-crossover design is a self-controlled study design used to compare exposure immediately preceding an event occurrence with exposure in earlier control periods. The design is most suitable for transient exposures in order to avoid biases that can be problematic when using the case-crossover design for non-transient (i.e., chronic) exposures. Our goal was to conduct a systematic review of case-crossover studies and its variants (case-time-control and case-case-time-control) in order to compare design and analysis choices by medication type.

METHODS

We conducted a systematic search to identify recent case-crossover, case-time-control, and case-case-time-control studies focused on medication exposures. Articles indexed in MEDLINE and EMBASE using these study designs that were published between January 2015 and December 2021 in the English language were identified. Reviews, methodological studies, commentaries, articles without medications as the exposure of interest, and articles with no available full text were excluded. Study characteristics including study design, outcome, risk window, control window, reporting of discordant pairs, and inclusion of sensitivity analyses were summarized overall and by medication type. We further evaluated the implementation of recommended methods to account for biases introduced by non-transient exposures among articles that used the case-crossover design on a non-transient exposure.

RESULTS

Of the 2036 articles initially identified, 114 articles were included. The case-crossover was the most common study design (88%), followed by the case-time-control (17%), and case-case-time-control (3%). Fifty-three percent of the articles included only transient medications, 35% included only non-transient medications, and 12% included both. Across years, the proportion of case-crossover articles evaluating a non-transient medication ranged from 30% in 2018 to 69% in 2017. We found that 41% of the articles that evaluated a non-transient medication did not apply any of the recommended methods to account for biases and more than half of which were conducted by authors with no previous publication history of case-crossover studies.

CONCLUSION

Using the case-crossover design to evaluate a non-transient medication remains common in pharmacoepidemiology. Researchers should apply appropriate design and analysis choices when opting to use a case-crossover design with non-transient medication exposures.

National trends in prescription drug expenditures and projections for 2023

PURPOSE

To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2023 in the United States, with a focus on the nonfederal hospital and clinic sectors.

METHODS

Historical patterns were assessed by examining data on drug purchases from manufacturers using the IQVIA National Sales Perspectives database. Factors that may influence drug spending in hospitals and clinics in 2023 were reviewed, including new drug approvals, patent expirations, and potential new policies or legislation. Focused analyses were conducted for biosimilars, cancer drugs, diabetes medications, generics, COVID-19 pandemic influence, and specialty drugs. For nonfederal hospitals, clinics, and overall (all sectors), estimates of growth of pharmaceutical expenditures in 2023 were based on a combination of quantitative analyses and expert opinion.

RESULTS

In 2022, overall pharmaceutical expenditures in the US grew 9.4% compared to 2021, for a total of $633.5 billion. Utilization (a 5.9% increase), price (a 1.7% increase) and new drugs (a 1.8% increase) drove this increase. Adalimumab was the top-selling drug in 2022, followed by semaglutide and apixaban. Drug expenditures were $37.2 billion (a 5.9% decrease) and $116.9 billion (a 10.4% increase) in nonfederal hospitals and clinics, respectively. In clinics, new products and increased utilization growth drove growth, with a small impact from price changes. In nonfederal hospitals, a drop in utilization led to a decrease in expenditures, with price changes and new drugs contributing to growth in spending. Several new drugs that will influence spending have been or are expected to be approved in 2023. Specialty and cancer drugs will continue to drive expenditures along with the evolution of the COVID-19 pandemic.

CONCLUSION

For 2023, we expect overall prescription drug spending to rise by 6.0% to 8.0%, whereas in clinics and hospitals we anticipate increases of 8.0% to 10.0% and 1.0% to 3.0%, respectively, compared to 2022. These national estimates of future pharmaceutical expenditure growth may not be representative of any particular health system because of the myriad of local factors that influence actual spending.

Adherence to HIV Pre-Exposure Prophylaxis Testing Guidelines in the United States

Testing guidelines for initiation of pre-exposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) have been developed to ensure appropriate use of PrEP, such as among those with renal dysfunction or at high risk of seroconversion. While many studies have looked at the trends of use of PrEP in the United States, little is known about compliance with these guidelines, the quality of care of PrEP at a national level, or what provider-level factors are associated with high-quality care. We conducted a retrospective claims analysis of providers of commercially insured new users of PrEP between January 1, 2011, and December 31, 2019. Of the 4200 providers, quality of care was low, with only 6.4% having claims for ≥60% of guideline-recommended testing for their patients in the testing window for all visits. More than half of the providers did not have claims for HIV testing at initiation of PrEP and ≥40% did not for sexually transmitted infections at both initiation and follow-up visits. Even when extending the testing window, quality of care remained low. Logistic regression models found no association between provider type and high quality of care, but did find that providers with one PrEP patient were more likely to have higher quality of care than those with multiple patients for all tests [adjusted odds ratio 0.47 (95% confidence interval: 0.33-0.67)]. The study findings suggest further training and interventions, such as integrated test ordering through electronic health records, are needed to increase quality of care for PrEP and ensure appropriate monitoring of patients.

National trends in prescription drug expenditures and projections for 2022

Purpose

To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2022 in the United States, with a focus on the nonfederal hospital and clinic sectors.

Methods

Historical patterns were assessed by examining data on drug purchases from manufacturers using the IQVIA National Sales Perspectives database. Factors that may influence drug spending in hospitals and clinics in 2022 were reviewed—including new drug approvals, patent expirations, and potential new policies or legislation. Focused analyses were conducted for biosimilars, cancer drugs, generics, COVID-19 pandemic influence, and specialty drugs. For nonfederal hospitals, clinics, and overall (all sectors), estimates of growth of pharmaceutical expenditures in 2022 were based on a combination of quantitative analyses and expert opinion.

Results

In 2021, overall pharmaceutical expenditures in the US grew 7.7% compared to 2020, for a total of $576.9 billion. Utilization (a 4.8% increase), price (a 1.9% increase) and new drugs (a 1.1% increase) drove this increase. Adalimumab was the top drug in terms of overall expenditures in 2021, followed by apixaban and dulaglutide. Drug expenditures were $39.6 billion (a 8.4% increase) and $105.0 billion (a 7.7% increase) in nonfederal hospitals and in clinics, respectively. In clinics and hospitals, new products and increased utilization growth drove growth, with decreasing prices for both sectors acting as an expense restraint. Several new drugs that are likely to influence spending are expected to be approved in 2022. Specialty and cancer drugs will continue to drive expenditures along with the evolution of the COVID-19 pandemic.

Conclusion

For 2022, we expect overall prescription drug spending to rise by 4.0% to 6.0%, whereas in clinics and hospitals we anticipate increases of 7.0% to 9.0% and 3.0% to 5.0%, respectively, compared to 2021. These national estimates of future pharmaceutical expenditure growth may not be representative of any particular health system because of the myriad of local factors that influence actual spending.

Risk of fall-related injury and all-cause hospitalization of select concomitant central nervous system medication prescribing in older adult persistent opioid users: A case-time-control analysis

BACKGROUND

Concomitant use of central nervous system (CNS) medications frequently occurs in older adults with persistent opioid use. The risks of adverse outcomes associated with combinations of opioids, sedative hypnotics, or skeletal muscle relaxants have not been sufficiently described in this population.

OBJECTIVE

To compare the overall and incremental risk of (1) fall-related injury and (2) all-cause hospitalization associated with sedative hypnotics and skeletal muscle relaxants among older persistent opioid users.

METHODS

A case-time-control study was conducted using administrative claims of adults ages ≥66 years with a history of persistent (≥90 days) opioid use. Cases included those with first (1) emergency department, hospital, or outpatient visit for a fall-related injury, or (2) all-cause hospitalization. Exposure to CNS medications prior to the case event versus earlier periods, and the risk associated with CNS drug class combinations and sequence of use, was estimated using conditional logistic regression, adjusted for time trends and time-varying covariates.

RESULTS

Among 140,101 older persistent opioid users, 20,723 experienced fall-related injury and 39,444 were hospitalized during follow-up. Skeletal muscle relaxant use was associated with an increased risk of fall-related injury (Odds ratio [OR] 1.28) and all-cause hospitalization (OR 1.11). Statistically significant associations were observed for the joint effects of interactions involving skeletal muscle relaxants on fall-related injury (with opioid: OR 1.25; with sedative hypnotic: OR 1.24), and interactions involving opioids on all-cause hospitalization (with sedative hypnotic: OR 1.10; with skeletal muscle relaxant: OR 1.17). The addition of a skeletal muscle relaxant to an opioid regimen was associated with a 25% increased risk of fall-related injury. Additions of other CNS medications did not have apparent incremental effects on the risk of all-cause hospitalization.

CONCLUSION

The excess risks of fall-related injury and hospitalization associated with various combinations of CNS medications among older persistent opioid users should be considered in therapeutic decision making. Further research is needed to confirm these findings.

National trends in prescription drug expenditures and projections for 2021

Purpose

To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2021 in the United States, with a focus on the nonfederal hospital and clinic sectors.

Methods

Historical patterns were assessed by examining data on drug purchases from manufacturers using the IQVIA National Sales Perspectives database. Factors that may influence drug spending in hospitals and clinics in 2021 were reviewed—including new drug approvals, patent expirations, and potential new policies or legislation. Focused analyses were conducted for biosimilars, cancer drugs, generics, coronavirus disease 2019 (COVID-19) pandemic influence, and specialty drugs. For nonfederal hospitals, clinics, and overall (all sectors), estimates of growth of pharmaceutical expenditures in 2021 were based on a combination of quantitative analyses and expert opinion.

Results

In 2020, overall pharmaceutical expenditures in the United States grew 4.9% compared to 2019, for a total of $535.3 billion. Utilization (a 2.9% increase) and new drugs (a 1.8% increase) drove this increase, with price changes having minimal influence (a 0.3% increase). Adalimumab was the top drug in 2020, followed by apixaban and insulin glargine. Drug expenditures were $35.3 billion (a 4.6% decrease) and $98.4 billion (an 8.1% increase) in nonfederal hospitals and clinics, respectively. In clinics, growth was driven by new products and increased utilization, whereas in hospitals the decrease in expenditures was driven by reduced utilization. Several new drugs that will influence spending are expected to be approved in 2021. Specialty and cancer drugs will continue to drive expenditures along with the evolution of the COVID-19 pandemic.

Conclusion

For 2021, we expect overall prescription drug spending to rise by 4% to 6%, whereas in clinics and hospitals we anticipate increases of 7% to 9% and 3% to 5%, respectively, compared to 2020. These national estimates of future pharmaceutical expenditure growth may not be representative of any particular health system because of the myriad of local factors that influence actual spending.

Comparison of Cardiac Events Associated With Azithromycin vs Amoxicillin

IMPORTANCE

Conflicting evidence exists on the association between azithromycin use and cardiac events.

OBJECTIVE

To compare the odds of cardiac events among new users of azithromycin relative to new users of amoxicillin using real-world data.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used data from Truven Health Analytics MarketScan database from January 1, 2009, to June 30, 2015. Patients receiving either amoxicillin or azithromycin and enrolled in a health care plan 365 days before (baseline period) the dispensing date (index date) were included in the study. Patients were matched 1:1 on high-dimensional propensity scores. Data were analyzed from October 1, 2018, to December 31, 2019.

EXPOSURES

New use of azithromycin compared with new use of amoxicillin.

MAIN OUTCOMES AND MEASURES

The primary outcome consisted of cardiac events, including syncope, palpitations, ventricular arrhythmias, cardiac arrest, or death as a primary diagnosis for hospitalization at 5, 10, and 30 days from the index date. Logistic regression models were used to estimate odds ratios (ORs) with 95% CIs.

RESULTS

After matching, the final cohort included 2 141 285 episodes of each index therapy (N = 4 282 570) (mean [SD] age of patients, 35.7 [22.3] years; 52.6% female). Within 5 days after therapy initiation, 1474 cardiac events (0.03%) occurred (708 in the amoxicillin cohort and 766 in the azithromycin cohort). The 2 most frequent events were syncope (1032 [70.0%]) and palpitations (331 [22.5%]). The odds of cardiac events with azithromycin compared with amoxicillin were not significantly higher at 5 days (OR, 1.08; 95% CI, 0.98-1.20), 10 days (OR, 1.05; 95% CI, 0.97-1.15), and 30 days (OR, 0.98; 95% CI, 0.92-1.04). Among patients receiving any concurrent QT-prolonging drug, the odds of cardiac events with azithromycin were 1.40 (95% CI, 1.04-1.87) greater compared with amoxicillin. Among patients 65 years or older and those with a history of cardiovascular disease and other risk factors, no increased risk of cardiac events with azithromycin was noted.

CONCLUSIONS AND RELEVANCE

This study found no association of cardiac events with azithromycin compared with amoxicillin except among patients using other QT-prolonging drugs concurrently. Although azithromycin is a safe therapy, clinicians should carefully consider its use among patients concurrently using other QT-prolonging drugs.

National trends in prescription drug expenditures and projections for 2020

Purpose

To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2020 in the United States, with a focus on the nonfederal hospital and clinic sectors.

Methods

Historical patterns were assessed by examining data on drug purchases from manufacturers using the IQVIA National Sales Perspectives database. Factors that may influence drug spending in hospitals and clinics in 2020 were reviewed, including new drug approvals, patent expirations, and potential new policies or legislation. Focused analyses were conducted for specialty drugs, biosimilars, and diabetes medications. For nonfederal hospitals, clinics, and overall (all sectors), estimates of growth of pharmaceutical expenditures in 2020 were based on a combination of quantitative analyses and expert opinion.

Results

In 2019, overall US pharmaceutical expenditures grew 5.4% compared to 2018, for a total of $507.9 billion. This increase was driven to similar degrees by prices, utilization, and new drugs. Adalimumab was the top drug in US expenditures in 2019, followed by apixaban and insulin glargine. Drug expenditures were $36.9 billion (a 1.5% increase from 2018) and $90.3 billion (an 11.8% increase from 2018) in nonfederal hospitals and clinics, respectively. In clinics, growth was driven by new products and increased utilization, whereas in hospitals growth was driven by new products and price increases. Several new drugs that will likely influence spending are expected to be approved in 2020. Specialty and cancer drugs will continue to drive expenditures.

Conclusion

For 2020 we expect overall prescription drug spending to rise by 4.0% to 6.0%, whereas in clinics and hospitals we anticipate increases of 9.0% to 11.0% and 2.0% to 4.0%, respectively, compared to 2019. These national estimates of future pharmaceutical expenditure growth may not be representative of any particular health system because of the myriad of local factors that influence actual spending.

National trends in prescription drug expenditures and projections for 2019

PURPOSE

Historical trends and factors likely to influence future pharmaceutical expenditures are discussed, and projections are made for drug spending in 2019 in nonfederal hospitals, clinics, and overall (all sectors).

METHODS

Drug expenditure data through calendar year 2018 were obtained from the IQVIA National Sales Perspectives database and analyzed. New drug approvals, patent expirations, and other factors that may influence drug spending in hospitals and clinics in 2019 were also reviewed. Expenditure projections for 2019 for nonfederal hospitals, clinics, and overall (all sectors) were made through a combination of quantitative analyses and expert opinion.

RESULTS

U.S. prescription sales in calendar year 2018 totaled $476.2 billion, a 5.5% increase from 2017 spending. The top 3 drugs by expenditures were adalimumab ($19.1 billion), insulin glargine ($9.3 billion), and etanercept ($8.0 billion). Prescription expenditures in nonfederal hospitals totaled $35.8 billion, a 4.8% increase from 2017. Expenditures in clinics in 2018 increased by 13.0% to $80.5 billion. The increase in spending in nonfederal hospitals was largely driven by new products and increased utilization of existing products. The list of the top 25 drugs by expenditures in nonfederal hospitals and clinics was dominated by specialty drugs.

CONCLUSION

We predict continued moderate growth of 4-6% in overall drug expenditures (across the entire U.S. market). We expect the clinic sector to continue to experience high (11-13%) growth in drug spending in 2019. Finally, for nonfederal hospitals we anticipate growth in the range of 3-5%. These estimates are at the national level. Health-system pharmacy leaders should carefully examine local drug utilization patterns to determine their own organization's anticipated spending in 2019.

Adherence and Persistence with DPP-4 Inhibitors Versus Pioglitazone in Type 2 Diabetes Patients with Chronic Kidney Disease: A Retrospective Claims Database Analysis

BACKGROUND

Adherence and persistence with diabetes medication play an important role in glycemic control and may differ by medication class. However, there is a lack of research comparing diabetes medications in patients with renal impairment, despite the challenges and higher burden associated with managing this population.

OBJECTIVE

To compare adherence and persistence among patients with type 2 diabetes mellitus (T2DM) and nondialysis chronic kidney disease (CKD) treated with dipeptidyl peptidase-4 (DPP-4) inhibitors versus pioglitazone.

METHODS

This retrospective cohort study used Truven MarketScan administrative claims databases from 2009 to 2015. One-year adherence for patients with T2DM and nondialysis CKD who initiated therapy with either a DPP-4 inhibitor or pioglitazone was measured by proportion of days covered (PDC) following an initial dispensing, and PDC ≥ 0.80 was coded as adherent. Persistence was calculated as the days between the index date and last day with the index medication on hand, based on the end of the last days supply or the end of follow-up (i.e., 365 days), whichever occurred first. Multivariate logistic regression and Cox proportional hazards models were used to estimate confounder-adjusted differences between the groups for adherence and persistence.

RESULTS

The final cohort included 9,019 patients (DPP-4 inhibitors: 7,002; pioglitazone: 2,017). In the adjusted analysis, DPP-4 inhibitor users demonstrated a 1.41 (95% CI = 1.25-1.59) higher odds of being adherent compared with pioglitazone users. Overall adjusted HR for persistence was 0.74 (95% CI = 0.69-0.79), which favored DPP-4 inhibitors compared with pioglitazone. Relative to 2010, persistence with pioglitazone decreased in 2011-2012 and then increased in 2013-2014. In the subgroup analysis, DPP-4 inhibitors first had lower (2010: OR = 0.78, 95% CI = 0.70-0.87; 2011-2012: OR = 0.60, 95% CI = 0.54-0.66) and then similar (2013-2014: OR = 1.03, 95% CI = 0.88-1.19) hazards of nonpersistence compared with pioglitazone.

CONCLUSIONS

Among patients with T2DM and nondialysis CKD, the use of DPP-4 inhibitors was associated with better adherence compared with pioglitazone. However, following the approval of generic pioglitazone and associated lower cost sharing after 2012, the magnitude of difference in adherence between the medication classes reduced. Similarly, safety warnings in 2011 and approval of generic products in 2012 may have affected pioglitazone persistence, leading to first higher and then similar hazards for nonpersistence with pioglitazone as compared with DPP-4 inhibitors. These shifts in the results for pioglitazone warrant further investigation and close monitoring of the population initiating this medication.

DISCLOSURES

No funding was received for this study. The authors have no conflicts of interest to disclose. An abstract for this study was presented as a podium presentation at the International Society of Pharmacoeconomics and Outcomes Research (ISPOR) 2019 Annual Meeting; May 18-22, 2019; New Orleans, LA.

Sodium-glucose co-transporter 2 inhibitors and the risk of fractures: A propensity score-matched cohort study

PURPOSE

To determine the risk of fractures associated with sodium-glucose co-transporter 2 inhibitors (SGLT2i) compared with dipeptidyl peptidase-4 inhibitors (DPP4i).

METHODS

We conducted a retrospective cohort study using data from the Truven Health MarketScan (2009-2015) databases. Our cohort included patients newly initiating treatment with SGLT2i or DPP-4i between 1 April 2013 and 31 March 2015 that were matched 1:1 using high dimensional propensity scores. Patients were followed up in an as-treated approach starting from initiation of treatment until the earliest of any fracture, treatment discontinuation, disenrollment, or end of data (31 December 2015). Risk of fractures was determined at any time during the follow-up, early in therapy (1-14 days of the follow-up), and later in therapy (15 days and beyond). Cox proportional hazards models were used to determine hazard ratios and robust 95% confidence intervals (95% CI).

RESULTS

After matching, our cohort included 30 549 patients in each treatment group. Over a median follow-up of 219 days, there were 745 fractures overall. The most common site for fractures was the foot (32.7%). The effect estimates for fracture risk occurring at any time during follow-up, early in therapy, and later in therapy were HR 1.11 [95% CI 0.96-1.28], HR 1.82 [95% CI 0.99-3.32], and HR 1.07 [95% CI 0.92-1.24], respectively.

CONCLUSION

There is a possible increase in risk for fractures early in therapy with SGLT2i. Beyond this initial period, SGLT2is had no apparent effect on the incidence of fractures.

Impact of multimorbidity subgroups on the health care use of early pediatric cancer survivors

BACKGROUND

Although pediatric cancer survivors in the United States are at an increased risk of developing chronic conditions, to the authors' knowledge there is limited information regarding the types and combinations of conditions they experience in the years immediately after the completion of cancer therapy.

METHODS

An observational cohort study of early pediatric cancer survivors (children who were ≥2 years from the end of therapy and aged ≤18 years) was conducted using the Truven Health MarketScan (r) Commercial Claims and Encounters database (2009-2014). Latent class analysis was used to identify comorbidity groups among the subset with ≥2 conditions. Group-level health care use was compared with survivors without chronic conditions using multivariate regression.

RESULTS

A total of 3687 early survivors were identified, of whom approximately 41.2% had no chronic conditions, 22.5% had 1 chronic condition, and 36.3% had ≥2 chronic conditions. Among those with ≥2 chronic conditions, 5 groups emerged: 1) general pediatric morbidity (35.4%); 2) central nervous system (CNS) (22.4%); 3) mental health conditions (22.2%); 4) endocrine (26.2%); and 5) CNS with endocrine (3.8%). The CNS group experienced the highest expenditures, at $17,964 more per year (95% CI, $1446-$34,482) compared with survivors without chronic conditions. The CNS group also had the highest odds of an emergency department visit (adjusted odds ratio, 1.71; 95% CI, 1.15-2.56). The endocrine group had the highest odds of hospitalization (odds ratio, 2.29; 95% CI, 1.24-4.22).

CONCLUSIONS

Multimorbidity is common among pediatric cancer survivors. The current study identified 5 distinct comorbidity subgroups, all of which experienced high, yet differential, rates of health care use. The results of the current study highlight the complex health care needs of early survivors and provide evidence for the design of targeted survivorship services and interventions.

Multimorbidity and healthcare utilization among early survivors of pediatric cancer

Early survivors of pediatric cancer are at increased risk of experiencing chronic conditions; however, little is known about the morbidity burden in this population. In this observational cohort study of commercially insured pediatric cancer survivors in the United States (2009-2014), we find that 22.5% of survivors had one chronic condition, and 36.3% had multiple. Compared with survivors without chronic conditions, the presence of multiple conditions significantly increased the odds of an emergency department visit by 70% (odds ratios [OR], 1.7; 95% confidence interval [CI], 1.4-2.1) and of a hospitalization almost four-fold (OR, 3.8; 95% CI], 2.5-5.5). Findings are important for informing pediatric survivorship care plans in the years following completion of therapy.

Risk of amputations associated with SGLT2 inhibitors compared to DPP-4 inhibitors: A propensity-matched cohort study

AIM

To determine the risk of amputations associated with sodium-glucose co-transporter-2 inhibitors (SGLT2i) relative to dipeptidyl peptidase-4 inhibitors (DPP4i).

MATERIALS AND METHODS

We conducted an active comparator, new user cohort study using data from the Truven Health MarketScan (2009-2015) databases. Patients aged ≥18 years newly initiating SGLT2i or DPP4i between April 1, 2013 and March 31, 2015 were included. Patients were matched 1:1 on high dimensional propensity scores and followed until the earliest of any amputation, treatment discontinuation, disenrollment or end of study period (December 31, 2015). Cox proportional hazards models were used to estimate hazard ratios (HR) and robust 95% confidence intervals (CI) for amputation risk.

RESULTS

There were 30 216 comparable patients in each arm after matching. Over a median follow-up of 0.6 years, there were 60 amputations (SGLT2i: 36; DPP4i: 24), most at the level of partial foot (75%) and associated with diabetes-related vascular disease (66.7%). The incidence of amputations was higher among SGLT2i patients (1.62 vs. 1.15 per 1000 person-years) with a HR of 1.38 (CI: 0.83-2.31). In subgroup analyses, risk differed by type of SGLT2i: canagliflozin, HR 1.15 (CI: 0.63-2.09); dapagliflozin or empagliflozin, HR 2.25 (CI: 0.78-6.47).

CONCLUSION

All SGLT2i had an elevated, though not statistically significant, risk for amputations.

Increased risk of mycotic infections associated with sodium-glucose co-transporter 2 inhibitors: a prescription sequence symmetry analysis

AIMS

To determine the risk of mycotic infections associated with the use of sodium-glucose co-transporter 2 inhibitors (SGLT2i) in a real-world setting.

METHODS

We conducted a prescription sequence symmetry analysis using data from Truven Health MarketScan (2009-2015). We selected continuously enrolled patients newly initiating both an SGLT2i and an antifungal between 1 April 2013 and 31 December 2015 within time periods of 30, 60, 90, 180 or 365 days of each other. Adjusted sequence ratios (ASR) were calculated for each time period as the ratio of patients initiating SGLT2i first over those initiating an antifungal first adjusted for time trends in prescribing. Analyses were stratified by sex and type of SGLT2i.

RESULTS

There were 23 276 patients who newly initiated both SGLT2i and an antifungal in our study period. These patients were further classified into those initiating the two drugs within 365 (n = 17 504), 180 (n = 11 873), 90 (n = 7697), 60 (n = 5856) or 30 (n = 3650) days of each other. Increased risks of mycotic infections were present across all time periods, with the strongest effect observed in the 90-day interval [ASR 1.53 (confidence interval, CI 1.43-1.60)]. Findings differed by sex [90-day ASR females: 1.65 (CI 1.56-1.74); males 1.25 (CI 1.14-1.36)] and by SGLT2i [90-day ASR canagliflozin 1.57 (CI 1.49-1.66); non-canagliflozin 1.42 (CI 1.31-1.55)].

CONCLUSION

Initiation of SGLT2i was associated with an increased risk for mycotic infections. Findings from this commercially insured population in the real world are consistent with evidence available from clinical trials.

Spending on Antineoplastic Agents in the United States, 2011 to 2016

PURPOSE:

Recent cancer drug approvals are lauded as being more effective with relatively fewer adverse effects, but these treatments come with a great cost to the US health care system. There is little information on recent trends in actual antineoplastic expenditures representative of the whole US health care system or by sector. Therefore, the objective of this study was to describe antineoplastic expenditures in the United States by year and sector.

METHODS:

This was a retrospective, cross-sectional study of IQVIA (formerly QuintilesIMS) National Sales Perspective data for the period of January 1, 2011, to December 31, 2016. Actual expenditures were totaled by health care sector and calendar year, then adjusted for medical-cost inflation to 2016 dollars. Growth was calculated as the percentage increase from the previous year.

RESULTS:

Total expenditures of antineoplastic agents across all channels grew from $26.8 billion in 2011 to $42.1 billion in 2016. Antineoplastic spending increased 12.2% in 2016 (compared with the previous year), followed by 15.6% in 2015, 13.4% in 2014, 6.3% in 2013, and 0.4% in 2012. Throughout the study period, 96.5% of total antineoplastic expenditures occurred within clinics, mail-order pharmacies, nonfederal hospitals, and retail pharmacies.

CONCLUSION:

Antineoplastic expenditures are expected to increase because of continuing development and approval of costly targeted cancer therapies. Cost containment and utilization management strategies must be balanced so as not to restrict access or disrupt innovation. Future policies should focus on ensuring safe and appropriate use of antineoplastics while balancing long-term drug costs.

Predicting Acute Exacerbations in Chronic Obstructive Pulmonary Disease

BACKGROUND

With increasing health care costs that have outpaced those of other industries, payers of health care are moving from a fee-for-service payment model to one in which reimbursement is tied to outcomes. Chronic obstructive pulmonary disease (COPD) is a disease where this payment model has been implemented by some payers, and COPD exacerbations are a quality metric that is used. Under an outcomes-based payment model, it is important for health systems to be able to identify patients at risk for poor outcomes so that they can target interventions to improve outcomes.

OBJECTIVE

To develop and evaluate predictive models that could be used to identify patients at high risk for COPD exacerbations.

METHODS

This study was retrospective and observational and included COPD patients treated with a bronchodilator-based combination therapy. We used health insurance claims data to obtain demographics, enrollment information, comorbidities, medication use, and health care resource utilization for each patient over a 6-month baseline period. Exacerbations were examined over a 6-month outcome period and included inpatient (primary discharge diagnosis for COPD), outpatient, and emergency department (outpatient/emergency department visits with a COPD diagnosis plus an acute prescription for an antibiotic or corticosteroid within 5 days) exacerbations. The cohort was split into training (75%) and validation (25%) sets. Within the training cohort, stepwise logistic regression models were created to evaluate risk of exacerbations based on factors measured during the baseline period. Models were evaluated using sensitivity, specificity, and positive and negative predictive values. The base model included all confounding or effect modifier covariates. Several other models were explored using different sets of observations and variables to determine the best predictive model.

RESULTS

There were 478,772 patients included in the analytic sample, of which 40.5% had exacerbations during the outcome period. Patients with exacerbations had slightly more comorbidities, medication use, and health care resource utilization compared with patients without exacerbations. In the base model, sensitivity was 41.6% and specificity was 85.5%. Positive and negative predictive values were 66.2% and 68.2%, respectively. Other models that were evaluated resulted in similar test characteristics as the base model.

CONCLUSIONS

In this study, we were not able to predict COPD exacerbations with a high level of accuracy using health insurance claims data from COPD patients treated with bronchodilator-based combination therapy. Future studies should be done to explore predictive models for exacerbations.

DISCLOSURES

No outside funding supported this study. Samp is now employed by, and owns stock in, AbbVie. The other authors have nothing to disclose. Study concept and design were contributed by Joo and Pickard, along with the other authors. Samp and Lee performed the data analysis, with assistance from the other authors. Samp wrote the manuscript, which was revised by Schumock and Calip, along with the other authors.

Risk of serious bacterial infection associated with tumour necrosis factor-alpha inhibitors in children with juvenile idiopathic arthritis

Objectives

TNF-α inhibitors (TNFIs) have a black box warning for increased risk of serious infection that was based on evidence from studies of adults. Evidence of the association is lacking for children. We aimed to examine the risk of infection posed by TNFIs compared with DMARDs in children with JIA.

Methods

We conducted a cohort study using the 2009-13 Truven MarketScan Commercial Claims and Encounters database. Children <16 years old with JIA who initiated monotherapy with TNFIs or DMARDs were identified and followed for occurrence of serious bacterial infection requiring hospitalization. Cox proportional hazard models were used to estimate hazard ratios for infection associated with TNFIs compared with DMARDs, adjusting for potential confounders with high-dimensional propensity scores and time-varying CS use.

Results

We identified 2013 DMARD initiators and 482 TNFI initiators with a mean follow-up of 255 and 307 days, respectively. We identified 18 and 11 patients with a serious infection in the DMARD and TNFI groups, resulting in crude rates of 1.28 (95% CI 0.76-2.02) and 2.72 (95%CI 1.36-4.86) per 100 person-years, respectively. In adjusted models, TNFIs were associated with an increased risk of serious bacterial infection compared with DMARDs (adjusted hazard ratio 2.72, 95% CI: 1.08, 6.86).

Conclusion

Use of TNFIs poses a higher risk of serious infection compared with DMARDs in children with JIA. Our analysis confirms the US Food and Drug Administration warning about TNFI-associated infection in children with JIA.

Risk of Diabetes Hospitalization or Diabetes Drug Intensification in Patients With Depression and Diabetes Using Second-Generation Antipsychotics Compared to Other Depression Therapies

Objective

Use of second-generation antipsychotics (SGAs) for treatment of depression has increased, and patients with depression and comorbid diabetes or cardiovascular disease are more likely to use SGAs than those without these conditions. We compared SGA and non-SGA depression pharmacotherapies on the risk of diabetes hospitalization or treatment intensification in adults with depression and preexisting diabetes.

Methods

This was a retrospective cohort study of US commercially insured adults (2009-2015 Truven MarketScan Commercial Claims and Encounters Database) aged 18-64 years old with type 2 diabetes mellitus and unipolar depression previously treated with a selective serotonin reuptake inhibitor or serotonin-norepinephrine reuptake inhibitor. New users of SGAs versus non-SGAs, as well as specific treatments (aripiprazole, quetiapine, bupropion, mirtazapine, and tricyclic antidepressants [TCAs]) were matched on class/medication-specific high-dimensional propensity score. Cox proportional hazard models were used to compare the risk of diabetes-related hospitalization or treatment intensification.

Results

We identified 6,625 SGA (aripiprazole = 3,461; quetiapine = 1,977; other = 1,187) and 23,921 non-SGA patients for inclusion (bupropion = 15,511; mirtazapine = 1,837; TCAs = 5,989; other = 584) with a mean age of 51 years. In the matched cohort, the rate of diabetes-related hospitalization or drug intensification was 47.9 per 100 person-years in the SGA group and 43.5 per 100 person-years in the non-SGA group (adjusted hazard ratio [aHR] = 1.03; 95% CI, 0.96-1.11). When comparing treatment subgroups, the risk of events was lower for bupropion versus TCAs (aHR = 0.85; 95% CI, 0.76-0.98), quetiapine versus mirtazapine (aHR = 0.82; 95% CI, 0.67-0.99), and quetiapine versus TCAs (aHR = 0.84; 95% CI, 0.72-0.98). For other comparisons, differences were small and not statistically significant.

Conclusions

While drug-specific effects on risk of diabetes hospitalization or treatment intensification most likely guide clinical decision making, we observed only modest differences in risk. The overall impact of SGAs on diabetes control depends not only on direct effects on glucose metabolism but also on effectiveness of depression symptom relief. Future studies evaluating other diabetes outcomes (glycosylated hemoglobin, diabetes complications) are needed.

National trends in prescription drug expenditures and projections for 2018

PURPOSE

Historical trends and factors likely to influence future pharmaceutical expenditures are discussed, and projections are made for drug spending in 2018 in nonfederal hospitals, clinics, and overall (all sectors).

METHODS

Drug expenditure data through calendar year 2017 were obtained from the IQVIA (formerly QuintilesIMS) National Sales Perspectives database and analyzed. New drug approvals, patent expirations, and other factors that may influence drug spending in hospitals and clinics in 2018 were also reviewed. Expenditure projections for 2018 for nonfederal hospitals, clinics, and overall (all sectors) were made based on a combination of quantitative analyses and expert opinion.

RESULTS

Total U.S. prescription sales in the 2017 calendar year were $455.9 billion, a 1.7% increase compared with 2016. The top drug based on expenditures was adalimumab ($17.1 billion), followed by insulin glargine and etanercept. Prescription expenditures in nonfederal hospitals totaled $34.2 billion, a 0.7% decrease in 2017 compared with 2016. Expenditures in clinics increased 10.9%, to a total of $70.8 billion. The decrease in spending in nonfederal hospitals was driven by lower utilization. The top 25 drugs by expenditures in nonfederal hospitals and clinics were dominated by specialty drugs.

CONCLUSION

We project a 3.0-5.0% increase in total drug expenditures across all settings, a 11.0-13.0% increase in clinics, and a 0.0-2.0% increase in hospital drug spending in 2018. Health-system pharmacy leaders should carefully examine their own local drug utilization patterns to determine their own organization's anticipated spending in 2018.

The impact of depression medications on oral antidiabetic drug adherence in patients with diabetes and depression

AIMS

To compare adherence and persistence to oral antidiabetic drugs (OAD) between patients who are new users of second generation antipsychotics (SGA) versus new users of other depression therapies in adults with type 2 diabetes mellitus (T2DM) and major depressive disorder (MDD).

METHODS

Adults 18-64 years with previously-treated T2DM and MDD (past OAD and SSRI/SNRI use) who are new users of SGA or non-SGA therapies (bupropion, lithium, mirtazapine, thyroid hormone, tricyclic antidepressant) were identified in the 2009-2015 MarketScan® Commercial Claims and Encounters database. Multivariate regression models were used to determine the odds of a ≥10% decline in OAD adherence over 180- and 365-days, and time to OAD discontinuation, adjusting for differences between groups.

RESULTS

A total of 8664 (21.5% SGA), 8311 (22.1% SGA), and 17,524 (21.3% SGA) patients met inclusion criteria for the 180-day adherence, 365-day adherence, and persistence cohorts, respectively. Over 180-days, 16.6% of SGA and 13.3% of non-SGA initiators had a ≥10% decline in OAD adherence (adjusted odds ratio [OR] = 1.41, 95% CI 1.21-1.63). Over 365-days, 22.3% of SGA and 18.9% of non-SGA initiators had a ≥ 10% decline (OR = 1.34, 95% CI 1.17-1.53). Time to OAD discontinuation was similar between groups (adjusted hazard ratio = 1.03, 95% CI 0.94-1.12).

CONCLUSION

Use of SGA was associated with a 1.3-1.4 times higher odds of a ≥10% decline in OAD adherence. Adherence to OAD is critical for optimal diabetes control and reductions in this magnitude may impact A1C. Close monitoring of OAD adherence after SGA initiation is warranted.

Tumor necrosis factor-alpha inhibitors and risk of non-Hodgkin lymphoma in a cohort of adults with rheumatologic conditions

Based on limited evidence, the U.S. Food and Drug Administration (FDA) issued a black box warning for the use of tumor necrosis factor-alpha inhibitors (TNFIs) and risk of non-Hodgkin lymphoma (NHL). Our objective was to determine the risk of NHL associated with TNFI use by duration and type of anti-TNF agent. We performed a nested case-control study within a retrospective cohort of adults with rheumatologic conditions from a U.S. commercial health insurance database between 2009 and 2015. Use of TNFIs (infliximab, adalimumab, etanercept, golimumab and certolizumab pegol) and conventional-synthetic disease-modifying antirheumatic drugs (csDMARDs) was identified, and conditional logistic regression models were used to estimate adjusted odds ratios (OR) and 95% confidence intervals (CI) for risk of NHL. From a retrospective cohort of 55,446 adult patients, 101 NHL cases and 984 controls matched on age, gender and rheumatologic indication were included. Compared to controls, NHL cases had greater TNFI use (33% vs. 20%) but were similar in csDMARD use (70% vs. 71%). TNFI ever-use was associated with nearly two-fold increased risk of NHL (OR = 1.93; 95% CI: 1.16-3.20) with suggestion of increasing risk with duration (P-trend = 0.05). TNF fusion protein (etanercept) was associated with increased NHL risk (OR = 2.73; 95% CI: 1.40-5.33), whereas risk with anti-TNF monoclonal antibodies was not statistically significant (OR = 1.77; 95% CI: 0.87-3.58). In sensitivity analyses evaluating confounding by rheumatologic disease severity, channeling bias was not likely to account for our results. Our findings support the FDA black box warning for NHL. Continued surveillance and awareness of this rare but serious adverse outcome are warranted with new TNFIs and biosimilar products forthcoming.

Pharmacy staffing, workload, and productivity benchmarks in state psychiatric hospitals

PURPOSE

Current benchmark statistics on staffing, workload, and productivity in hospital pharmacy departments of state psychiatric hospitals are described and assessed by hospital size.

METHODS

An electronic survey of state psychiatric hospitals was conducted. Hospitals were categorized based on number of occupied beds. Descriptive statistics using Student's t tests, Pearson's chi-square tests, and Pearson's correlation coefficients were used to characterize the data and compare productivity by hospital size.

RESULTS

Responses were received from 41 of 116 hospitals, yielding a response rate of 35.3%. Respondent hospitals did not differ from nonrespondents based on demographic data. Average inpatient census, patient days per year, expenditures, and workload were found to correlate positively with hospital size (r = 0.381-0.991, p < 0.05). Over 30% of hospitals reported using no indicators to monitor pharmacy productivity. Productivity ratios differed between very small-small and medium-large hospital groups: mean pharmaceutical expenditures per 100 occupied beds and per 1,000 patient days (p = 0.017 and 0.05, respectively), mean full-time equivalents (FTEs) per 1,000 doses dispensed or administered per month and per 100 occupied beds (p = 0.042 and 0.026, respectively), and mean pharmacist and technician FTEs per 100 occupied beds (p = 0.012 and 0.019, respectively).

CONCLUSION

A survey of pharmacies in state psychiatric hospitals provided metrics data on staffing, workload, and productivity that may be used as benchmarks in efforts to improve workforce efficiency, pharmaceutical care services, and financial performance.

Risk of Serious Bacterial Infection Associated With Tumor Necrosis Factor-Alpha Inhibitors in Children and Young Adults With Inflammatory Bowel Disease

BACKGROUND

Prior studies evaluating the relationship between tumor necrosis factor-alpha inhibitors (TNFI) and infection were conducted in adults and had conflicting findings. We sought to examine the risk of serious infection associated with TNFIs compared with nonbiologic immunomodulators in children and young adults with inflammatory bowel disease (IBD) and to compare the risk among individual TNFIs.

METHODS

We conducted a cohort study using the Truven MarketScan Commercial Claims and Encounters database of patients age <30 years with a diagnosis of IBD who initiated treatment with a TNFI or immunomodulator (thiopurines or methotrexate) between 2009 and 2013. The outcome of interest was serious infection, defined as a nongastrointestinal bacterial infection requiring hospitalization. Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for serious infection associated with TNFIs compared with immunomodulators.

RESULTS

We identified 10,838 children and young adults with IBD; 236 and 192 cases of serious infection were observed in 4502 TNFI initiators (5.25/100 person-years) and 6336 immunomodulator initiators (3.59/100 person-years), respectively. Compared with immunomodulators, TNFIs were associated with a higher risk of serious infection (HR, 1.36; 95% CI, 1.08-1.72). Among TNFI users, certolizumab showed a 3.38-fold (95% CI, 2.25-5.09) increased risk vs infliximab, and subcutaneously administered TNFIs also exhibited a higher risk (HR, 1.34; 95% CI, 1.18-1.53) than intravenous TNFIs.

CONCLUSIONS

TNFIs pose a higher risk of serious infection compared with immunomodulators in children and young adults with IBD, and this risk differs among individual TNFIs and routes of administration.

The Relationship Between Oseltamivir and Suicide in Pediatric Patients

PURPOSE

Studies examining the association between use of oseltamivir and neuropsychiatric events (including suicide) among children have had mixed findings and have been limited by small sample size, reliance on older data, and potential confounding. We undertook an analysis that addresses these limitations.

METHODS

Using a national administrative claims database and a case-crossover design that minimized confounding, we analyzed data from 5 contemporary influenza seasons (2009-2013) for individuals aged 1 to 18 years and ascertained oseltamivir exposure from pharmacy dispensing.

RESULTS

We identified 21,407 suicide-related events during this study period, 251 of which were in oseltamivir-exposed children. In case-crossover analysis, we did not find any significant association with suicide either for oseltamivir exposure (odds ratio = 0.64; 95% CI, 0.39-1.00; P = .05) or for influenza diagnosis alone (odds ratio = 0.63; 95% CI, 0.34-1.08; P = .10).

CONCLUSION

Our findings suggest that oseltamivir does not increase risk of suicide in the pediatric population.

Comparative effectiveness and patient-centered outcomes research: enhancing uptake and use by patients, clinicians and payers

Evidence from comparative effectiveness research (CER) and patient-centered outcomes research (PCOR) studies are increasingly available in the literature. However, there remain opportunities to better integrate that evidence into decision-making. An invitation-only conference held in January 2017, titled "Comparative Effectiveness and Patient-Centered Outcomes Research: Enhancing Uptake and Use by Patients, Clinicians and Payers", sought to identify and discuss both gaps in the uptake and use of CER/PCOR, and approaches to enhance the uptake and use of CER/PCOR evidence by patients, clinicians and payers. In this article, we summarize the conference proceedings, and highlight the themes and recommendations that resulted from the sessions. This paper also introduces other articles in this issue of CER from that conference.

Nine years of comparative effectiveness research education and training: initiative supported by the PhRMA Foundation

The term comparative effectiveness research (CER) took center stage with passage of the American Recovery and Reinvestment Act (2009). The companion US$1.1 billion in funding prompted the launch of initiatives to train the scientific workforce capable of conducting and using CER. Passage of the Patient Protection and Affordable Care Act (2010) focused these initiatives on patients, coining the term ‘patient-centered outcomes research’ (PCOR). Educational and training initiatives were soon launched. This report describes the initiative of the Pharmaceutical Research and Manufacturers Association of America (PhRMA) Foundation. Through provision of grant funding to six academic Centers of Excellence, to spearheading and sponsoring three national conferences, the PhRMA Foundation has made significant contributions to creation of the scientific workforce that conducts and uses CER/PCOR.

Antibiotic Expenditures by Medication, Class, and Healthcare Setting in the United States, 2010-2015

BACKGROUND

Improving antibiotic use has the potential to decrease healthcare costs by reducing the incidence of antibiotic-resistant infections, antibiotic-associated adverse events, and expenditures due to unnecessary prescriptions. Antibiotic expenditures in 2009 totaled $10.7 billion in the United States. Since then, national and local antibiotic stewardship initiatives have grown. The purpose of this study was to assess trends in antibiotic expenditures by healthcare setting in the United States between 2010 and 2015.

METHODS

Systemic (nontopical) antibiotic expenditures from January 2010 to December 2015 were extracted from the QuintilesIMS National Sales Perspectives database. These data represent a statistically valid projection of US medication purchases. Regression analyses evaluated trends in expenditures over the study period.

RESULTS

Antibiotic expenditures totaled $56.0 billion over the 6-year period; the majority (59.1%) of expenditures were associated with the outpatient setting. Overall antibiotic expenditures in 2015 ($8.8 billion) were 16.6% lower than in 2010 ($10.6 billion). Antibiotic expenditures similarly decreased in the community by 25.5% (P = .05), but outpatient clinics and mail service pharmacy expenditures experienced significant growth (148% and 67% increase, respectively; P < .01 for both). In 2015, 16.5% of antibiotic expenditures in the community were for parenteral formulations, an increase of 25%.

CONCLUSIONS

From 2010 to 2015, antibiotic expenditures decreased. The majority of antibiotic expenditures were in the outpatient setting, specifically community pharmacies. Expenditures for intravenous agents in the community are increasing and may represent increased use. These results reinforce the importance of antibiotic stewardship efforts across the spectrum of healthcare.

Lifestyle-related attitudes: do they explain self-rated health and life-satisfaction?

BACKGROUND

Strategies to improve public health may benefit from targeting specific lifestyles associated with poor health behaviors and outcomes. The aim of this study was to characterize and examine the relationship between health and lifestyle-related attitudes (HLAs) and self-rated health and life-satisfaction.

METHODS

Secondary analyses were conducted on data from a 2012 community wellness survey in Kirklees, UK. Using a validated HLA tool, respondents (n = 9130) were categorized into five segments: health conscious realists (33%), balanced compensators (14%), live-for-todays (18%), hedonistic immortals (10%), and unconfident fatalists (25%). Multivariate regression was used to examine whether HLAs could explain self-rated health using the EQ-5D visual analog scale (EQ-VAS) and life-satisfaction. Health conscious realists served as the reference group.

RESULTS

Self-rated health differed by HLA, with adjusted mean EQ-VAS scores being significantly higher (better) among balanced compensators (1.15, 95% CI 0.27, 2.03) and lower scores among unconfident fatalists (- 9.02, 95% CI - 9.85, - 8.21) and live-for-todays (- 1.96, 95% CI - 2.80, - 1.14). Balanced compensators were less likely to report low life-satisfaction (OR 0.75, 95% CI 0.62, 0.90), while unconfident fatalists were most likely to have low life-satisfaction (OR 3.51, 95% CI 2.92, 4.23).

SIGNIFICANCE

Segmentation by HLA explained differences in self-rated health and life-satisfaction, with unconfident fatalists being a distinct segment with significantly worse health perceptions and life-satisfaction. Health promotion efforts may benefit from considering the HLA segment that predominates a patient group, especially unconfident fatalists.

Comparative Effectiveness of Long-Acting Beta2 -Agonist Combined with a Long-Acting Muscarinic Antagonist or Inhaled Corticosteroid in Chronic Obstructive Pulmonary Disease

INTRODUCTION

Several dual bronchodilator fixed-dose inhaler medications were recently approved for the treatment of chronic obstructive pulmonary disease (COPD). These products combine a long-acting β₂ -agonist (LABA) and long-acting muscarinic antagonist (LAMA). In clinical trials, the separate mechanisms of the bronchodilators resulted in improved lung function. COPD treatment guidelines currently recommend combination LABA/LAMA as alternative therapy to combination LABA/inhaled corticosteroid (ICS). Evidence is limited on the comparative effectiveness of LABA/LAMA and LABA/ICS in COPD. The objective of this study was to compare real-world COPD exacerbation rates among patients treated with LABA/LAMA with those treated with LABA/ICS.

METHODS

This was a retrospective observational study of COPD patients in the United States treated with LABA/LAMA or LABA/ICS combination. Insurance claims from January 1, 2004, through December 31, 2014, were used as the data source. Patients were required to have greater than one prescription filled for the combination medications, and they were followed from 30 days after drug initiation. Individuals were censored if they discontinued a study medication, initiated medication from the opposite cohort (LAMA or ICS), lost enrollment eligibility, or at the study period end. Exacerbation rates were compared using Poisson regression.

RESULTS

There were 5384 patients in the LABA/LAMA cohort and 473,388 patients in the LABA/ICS cohort. The LABA/LAMA cohort was older, had more comorbidities, and more severe COPD. Unadjusted annual exacerbation rates were 2.87 events per person-year (standard deviation [SD] 5.14) in the LABA/LAMA cohort and 1.68 (SD 9.82) in the LABA/ICS cohort. The adjusted incidence rate ratio was 0.98 (95% confidence interval 0.95-1.01) for LABA/LAMA compared with LABA/ICS.

CONCLUSIONS

The LABA/LAMA combination had similar effectiveness to LABA/ICS as measured by exacerbation rates in COPD patients. As a result, characteristics other than effectiveness, such as symptom control, cost, patient preferences, and adverse events, may be important in selecting between the two regimens.

Risk of Cardiovascular and Cerebrovascular Events in COPD Patients Treated With Long-Acting β2-Agonist Combined With a Long-Acting Muscarinic or Inhaled Corticosteroid

BACKGROUND

The recent approval of several fixed-dose combination long-acting β₂-agonist (LABA) and long-acting muscarinic antagonist (LAMA) products has increased the use of dual bronchodilators in the treatment of chronic obstructive pulmonary disease (COPD). Understanding the comparative safety of this combination is important for informing treatment decisions.

OBJECTIVE

To compare the risk of cardiovascular and cerebrovascular (CCV) events associated with LABA/LAMA compared with a combination of LABA and inhaled corticosteroid (ICS).

METHODS

This was a retrospective, observational cohort study using health insurance claims data to identify COPD patients initiating LABA/LAMA or LABA/ICS. CCV outcomes included hospitalizations with a primary diagnosis for acute coronary syndrome, heart failure, cardiac dysrhythmia, stroke, or transient ischemic attack. Patients were followed until they experienced an event, discontinued treatment, initiated medication from the opposite cohort, or lost enrollment. Patients were matched 1:4 on propensity scores, and time to event was compared using Cox proportional hazards models.

RESULTS

After matching, there were 3842 patients in the LABA/LAMA cohort and 15 225 in the LABA/ICS cohort. Cardiovascular events in the LABA/LAMA cohort were lower than in the LABA/ICS: hazard ratio (HR) = 0.794; 95% CI = 0.623-0.997. No significant difference in the risk of cerebrovascular events (HR = 1.166; 95% CI = 0.653-1.959) was observed.

CONCLUSIONS

Despite concerns about the CCV effects of LAMA and LABA monotherapy, the LABA/LAMA combination had similar or lower risk of these events in comparison to LABA/ICS. Further studies are recommended to confirm these findings.

National trends in prescription drug expenditures and projections for 2017

PURPOSE

Historical trends and factors likely to influence future pharmaceutical expenditures are discussed, and projections are made for drug spending in 2017 in nonfederal hospitals, clinics, and overall (all sectors).

METHODS

Drug expenditure data through calendar year 2016 were obtained from the QuintilesIMS National Sales Perspectives database and analyzed. Other factors that may influence drug spending in hospitals and clinics in 2017, including new drug approvals and patent expirations, were also reviewed. Expenditure projections for 2017 for nonfederal hospitals, clinics, and overall (all sectors) were made based on a combination of quantitative analyses and expert opinion.

RESULTS

Total U.S. prescription sales in the 2016 calendar year were $448.2 billion, a 5.8% increase compared with 2015. More than half of the increase resulted from price hikes of existing drugs. Adalimumab was the top drug overall in 2016 expenditures ($13.6 billion); in clinics and nonfederal hospitals, infliximab was the top drug. Prescription expenditures in clinics and nonfederal hospitals totaled $63.7 billion (an 11.9% increase from 2015) and $34.5 billion (a 3.3% increase from 2015), respectively. In nonfederal hospitals and clinics, growth in spending was driven primarily by price increases of existing drugs and increased volume, respectively.

CONCLUSION

We project a 6.0-8.0% increase in total drug expenditures across all settings, an 11.0-13.0% increase in clinics, and a 3.0-5.0% increase in hospital drug spending in 2017. Health-system pharmacy leaders should carefully examine their own local drug utilization patterns to determine their own organization's anticipated spending in 2017.

Influence of drug class and healthcare setting on systemic antifungal expenditures in the United States, 2005-15

PURPOSE

Overall and specific class trends in systemic antifungal expenditures in various U.S. healthcare settings from 2005 through 2015 were evaluated.

METHODS

Systemic antifungal expenditures from January 1, 2005, through December 31, 2015, were obtained from the QuintilesIMS National Sales Perspective database, which provides a statistically valid projection of medication purchases from multiple markets throughout the United States. Summary data for total antifungal expenditures over the entire period are reported, as are growth and the percentage change in expenditures from one year to the next. Expenditures were also assessed specifically by year, class, and healthcare setting. Expenditure trends over the study period were assessed using simple linear trend regression models.

RESULTS

Overall expenditures for the 11-year period were $9.37 billion. The greatest proportion of expenditures occurred in nonfederal hospitals (47.2%) and for triazoles (57.6%). From 2005 through 2015, total expenditures decreased from $1.1 billion to $894 million (-18.8%, p = 0.09); however, expenditures in clinics and retail pharmacies increased (202%, p < 0.01, and 13.8%, p = 0.04, respectively), a trend most pronounced after 2012. Expenditures for flucytosine also increased (968.1%, p < 0.01), particularly in clinics where there was a dramatic 6,640.9% increase (p < 0.01).

CONCLUSION

From 2005 through 2015, an increase in systemic antifungal expenditures was observed in community settings, despite an overall decrease in total antifungal expenditures in the United States. Large increases in flucytosine expenditures were observed, particularly in the community.

Influenza Antiviral Expenditures and Outpatient Prescriptions in the United States, 2003-2012

STUDY OBJECTIVES

The clinical efficacy and cost-effectiveness of influenza antiviral use are controversial, with recent analyses suggesting potentially limited value. Thus, the objectives of this study were to describe influenza antiviral expenditures overall and by health care setting over a 10-year period (2003-2012) and to assess the correlation between outpatient influenza antiviral prescription use and influenza-like illness (ILI) outpatient visits.

DESIGN

Retrospective, cross-sectional study.

DATA SOURCES

IMS Health National Sales Perspectives and Xponent databases and Centers for Disease Control and Prevention ILINet national influenza surveillance system database.

PATIENTS

All prescriptions for oseltamivir, rimantadine, or zanamivir from community pharmacies, mail order pharmacies, clinics, nonfederal hospitals, and other health care settings (federal hospitals, military facilities, jails and prisons, universities, staff-model health maintenance organizations, veterinary hospitals and clinics, and long-term care facilities) between January 1, 2003, and December 31, 2012.

MEASUREMENTS AND MAIN RESULTS

Prescribing rates were calculated (prescriptions/1000 persons) for each year from 2003 to 2012 by using U.S. Census Bureau data. Influenza season was defined as July 1-June 30 of each calendar year. Linear regression assessed the correlation between influenza antiviral expenditures, prescription use, and ILI diagnoses. From 2003 to 2012, influenza antiviral drug expenditures accounted for $3.74 billion, with the majority from community pharmacies. After adjusting for inflation, no growth was observed for expenditures. A total of 32.8 million influenza antiviral prescriptions were dispensed from community pharmacies during the study period, and these prescriptions experienced 133.2% growth from 2003 to 2012. One third of expenditures and one quarter of dispensed prescriptions were in 2009. Influenza seasons were correlated with ILI and antiviral prescriptions. Annual community pharmacy expenditures were also associated with influenza antiviral prescriptions dispensed over the 10-year period.

CONCLUSION

Influenza antivirals totaled $3.74 billion in the United States from 2003 to 2012, with the majority in 2009 and from community pharmacies. Influenza antivirals constituted a small proportion of total medication expenditures, but unforeseen pandemics resulted in unusually high use and expenditures. Influenza antiviral prescriptions dispensed from community pharmacies were associated with ILI and drug expenditures.

Hospital Policies for Treatment of Acute Decompensated Heart Failure

Background:

It is unclear to what extent hospitals use guidelines or protocols in treating acute decompensated heart failure (ADHF) and whether nesiritide is included in these guidelines or protocols.

Objective:

To assess the formulary status of currently used drugs, therapeutic guidelines, and perceptions about the appropriateness of treatment of ADHF in community hospitals.

Methods:

A Web-based survey of pharmacy directors at community hospitals that were part of a national group purchasing organization was conducted.

Results:

One hundred seven hospitals participated in the survey (response rate 47.1%). Diuretics such as furosemide and bumetanide were more commonly included (100% and 94.4%, respectively) on hospital formularies than was torsemide (69.2%). Dopamine and dobutamine were more common (94.4% each) on the formulary than was milrinone (68.2%), Nitroprusside and nitroglycerin were listed on the formularies of more than 90% of participating institutions, while nesiritide was listed on the formularies in only 48.6% of hospitals and was placed on restricted status in 36.4% of hospitals. Guidelines for care of patients with ADHF were used in the emergency department (ED), inpatient care units, and outpatient clinics in 18.6%, 43.0%, and 8.5% of hospitals, respectively. Overall, ADHF care, including general treatment as well as specific use of nesiritide, was deemed appropriate in the majority of patients, but nearly twice as many respondents perceived the management of ADHF and specific use of nesiritide as inappropriate in the ED compared with inpatient treatment. Only 41.1% of the respondents reported following Braunwald recommendations for the use of nesiritide.

Conclusions:

A sizable percentage of responding community hospitals do not have guidelines for treatment of ADHF despite the existence of such guidelines in the literature. There are opportunities for improvement in the general treatment of ADHF as well as for the use of nesiritide in ADHF, especially in the ED or observation unit versus inpatient units.

National trends in prescription drug expenditures and projections for 2016

PURPOSE

Historical trends and factors likely to influence future pharmaceutical expenditures are discussed, and projections are made for drug spending in 2016 in nonfederal hospitals, clinics, and overall (all sectors).

METHODS

Drug expenditure data through calendar year 2015 were obtained from the IMS Health National Sales Perspectives database and analyzed. Other factors that may influence drug spending in hospitals and clinics in 2016, including new drug approvals and patent expirations, were also reviewed. Expenditure projections for 2016 were based on a combination of quantitative analyses and expert opinion.

RESULTS

Total U.S. prescription sales in the 2015 calendar year were $419.4 billion, which was 11.7% higher than sales in 2014. Prescription expenditures in clinics and nonfederal hospitals totaled $56.7 billion (a 15.9% increase) and $33.6 billion (a 10.7% increase), respectively, in 2015. In nonfederal hospitals, growth in spending was driven primarily by increased prices for existing drugs. The hepatitis C combination drug ledipasvir-sofosbuvir was the top drug overall in terms of 2015 expenditures ($14.3 billion); in both clinics and nonfederal hospitals, infliximab was the top drug. Individual drugs with the greatest increases in expenditures in 2015 were specialty agents and older generics; these agents are likely to continue to influence total spending in 2016.

CONCLUSION

We project an 11-13% increase in total drug expenditures overall in 2016, with a 15-17% increase in clinic spending and a 10-12% increase in hospital spending. Health-system pharmacy leaders should carefully examine local drug utilization patterns in projecting their own organization's drug spending in 2016.

Accuracy of annual prescription drug expenditure forecasts in AJHP

PURPOSE

The accuracy of the forecasts of drug expenditures in nonfederal hospitals and clinics published annually in the American Journal of Health-System Pharmacy (AJHP) relative to the accuracy of forecasts produced by the Centers for Medicare and Medicaid Services (CMS) was evaluated.

METHODS

AJHP-published forecasts of drug expenditure growth for nonfederal hospitals (for the years 2003 through 2013) and clinics (for the years 2004 through 2013) were compared with data on actual growth. Data on actual and projected growth published by CMS were analyzed for the years 2003 through 2012. The mean absolute error and directional accuracy of the forecasts published in AJHP for nonfederal hospitals and clinics and the CMS forecasts were determined and compared.

RESULTS

Actual spending growth was within the range of the forecast published in AJHP for 2 of 11 years for nonfederal hospitals and for 3 of 10 years for clinics; the forecasts for nonfederal hospitals and clinics were directionally accurate 27.3% and 60.0% of the time, respectively. The mean absolute errors of the AJHP-published drug expenditure forecasts for the nonfederal hospital and clinic sectors were 2.0 and 4.7 percentage points, respectively. The CMS forecasts of overall drug spending were directionally accurate 70% of the time, and the mean absolute error (2.2 percentage points) was not statistically different from that of either sector forecast published in AJHP.

CONCLUSION

The annual drug expenditure forecasts published in AJHP have been reasonably accurate for predicting growth in prescription expenditures when compared with other available drug expenditure forecasts.

Using linked electronic data to validate algorithms for health outcomes in administrative databases

The validity of algorithms used to identify health outcomes in claims-based and administrative data is critical to the reliability of findings from observational studies. The traditional approach to algorithm validation, using medical charts, is expensive and time-consuming. An alternative method is to link the claims data to an external, electronic data source that contains information allowing confirmation of the event of interest. In this paper, we describe this external linkage validation method and delineate important considerations to assess the feasibility and appropriateness of validating health outcomes using this approach. This framework can help investigators decide whether to pursue an external linkage validation method for identifying health outcomes in administrative/claims data.