The impact of myasthenia gravis severity on work and daily activities

INTRODUCTION/AIMS

People with myasthenia gravis (MG) experience impaired quality of life. However, the impact of MG symptoms on work productivity has not been well-studied. We aimed to evaluate this impact and to examine associations between disease severity and the degree of impairment.

METHODS

Data were drawn from the Adelphi MG Disease-Specific Programme™, a multinational (USA, France, Germany, Italy, Spain, UK) survey completed by physicians and their patients with MG in 2020. Patient-reported measures included the Work Productivity and Activity Impairment (WPAI): Specific Health Problem questionnaire.

RESULTS

The WPAI questionnaire was completed by 330 patients. Among those currently employed, the mean percentage of work time missed (absenteeism) was 13.3% (N = 116), percentage impairment of productivity at work (presenteeism) was 26.7% (N = 121), and overall work impairment was 30.0% (N = 110). Across all patients, impairment of non-work-related activities due to health problems (ADL impairment) was 39.2% (N = 330). Regression analysis indicated that impairment differed according to MG Foundation of America (MGFA) class (p = .0147, p < .0001, p < .0001 and p < .0001 for absenteeism, presenteeism, overall work impairment and ADL impairment, respectively). Being MGFA class III/IV was a predictor of presenteeism, overall work impairment and ADL impairment in a predictor model.

DISCUSSION

Patients with MG experience substantial work impairment particularly those with more severe symptoms, highlighting an important way in which patient quality of life is negatively affected. More effective treatment strategies would enable patients to lead more productive lives and could impact decisions relating to work and career.

Homelessness Among Acute Care Patients Within a Large Health Care System in Northern California

The impacts of homelessness on health and health care access are detrimental. Intervention and efforts to improve outcomes and increase availability of affordable housing have mainly originated from the public health sector and government. The role that large community-based health systems may play has yet to be established. This study characterizes patients self-identified as homeless in acute care facilities in a large integrated health care system in Northern California to inform the development of collaborative interventions addressing unmet needs of this vulnerable population. The authors compared sociodemographic characteristics, clinical conditions, and health care utilization of individuals who did and did not self-identify as homeless and characterized their geographical distribution in relation to Sutter hospitals and homeless resources. Between July 1, 2019 and June 30, 2020, 5% (N = 20,259) of the acute care settings patients had evidence of homelessness, among which 51.1% age <45 years, 66.4% males, and 24% non-Hispanic Black. Patients experiencing homelessness had higher emergency department utilization and lower utilization of outpatient and urgent care services. Mental health conditions were more common among patients experiencing homelessness. More than half of the hospitals had >5% of patients who identified as homeless. Some hospitals with higher proportions of patients experiencing homelessness are not located near many shelter resources. By understanding patients who self-identify as homeless, it is possible to assess the role of the health system in addressing their unmet needs. Accurate identification is the first step for the health systems to develop and deliver better solutions through collaborations with nonprofit organizations, community partners, and government agencies.

Racial disparities in utilization of first-generation versus second-generation long-acting injectable antipsychotics in Medicaid beneficiaries with schizophrenia

BACKGROUND

Multiple studies report racial disparities in antipsychotic prescription patterns. This study assessed demographic and clinical factors associated with the utilization of first-generation (FG) versus second-generation (SG) long-acting injectable (LAI) antipsychotics.

METHODS

This retrospective, observational cohort analysis used claims data from the IBM MarketScan® Multi-State Medicaid database. The study included adults with an LAI claim between 01-January-2009 and 31-December-2018, an ICD-9-CM or ICD-10-CM diagnosis of schizophrenia, race recorded as Black or White, and ≥12 months of continuous enrollment before the index LAI. Descriptive analysis detailed the relationship between race and FG or SG LAI initiation. Multivariate logistic regression was used to assess potential associations with FG vs. SG LAI initiation, including clinical and demographic factors, comorbidities, and index year.

RESULTS

A total of 10,773 patients were included: 6659 (62 %) Black and 4114 (38 %) White. Black patients had a higher utilization of FG LAIs than White patients (46.8 % vs. 38.9 %) over the 10 years analyzed. Black patients were more likely to utilize FG LAIs than White patients (odds ratio: 1.47; 95 % CI: 1.34, 1.62) after controlling for index year and covariates (race, age, gender, insurance plan type, Quan-Charlson Comorbidity index score, comorbidities, prior medications). Significant predictors of FG LAI utilization were older age, type of baseline oral antipsychotic (FG vs SG), type of coverage (managed care vs fee for service), and greater comorbidity burden.

CONCLUSION

The utilization of FG LAIs was greater in Black compared to White Medicaid beneficiaries with schizophrenia over a 10-year period. These findings suggest that racial disparities exist in LAI initiation, with implications for differential quality of schizophrenia treatment.

Factors associated with patient activation among individuals with depression within racial/ethnic groups in the United States

Increasing patient activation may be vital for improving quality of care for individuals with depression. Among adults with depression who reside in the United States, we sought to examine the association of depression severity, race/ethnicity, and household income with patient activation and within identify factors associated with patient activation within race/ethnicity groups. Data from the 2020 US National Health and Wellness Survey, a cross-sectional, general population survey, were used to identify White, Black/African American, Asian, and Hispanic respondents with self-reported physician-diagnosed depression. Generalized linear models were used to identify factors associated with patient activation. Analyses included 8,216 respondents (mean age = 44 years, 68.0% female). Depression severity was negatively associated with patient activation (β = -0.29, p < 0.001). Patient activation was significantly higher in Black vs. White respondents (β = 1.50, p = 0.001) and in respondents with a household income of $25,000-$49,999 (β = 0.96, p = 0.015), $50,000-$99,000 (β = 0.88, p = 0.031), and ≥$100,000 (β = 1.78, p < 0.001) vs. <$25,000. Adjusted mean patient activation scores were highest among Black respondents (61.1), followed by Hispanic (60.2), White (59.6), and Asian (59.0) respondents. Neither race/ethnicity nor household income moderated the relationship between depression severity and patient activation; however, the factors most strongly associated with patient activation differed by race/ethnicity. These results indicate that the pathway to improving patient activation in individuals with depression may vary by race/ethnicity. Understanding factors associated with patient activation can help inform the design of interventions to increase patient activation in individuals with depression.

Social determinants and distance from certified treatment centers are associated with initiation of esketamine nasal spray among patients with challenging-to-treat major depressive disorder

Indicated for treatment-resistant depression or major depression with suicidal ideation, esketamine (ESK) is self-administered under supervision at certified treatment centers. Our study was to determine if social determinants of health and distance were associated with ESK utilization. We conducted a retrospective cohort study among 308 US adults initiating ESK between October 11, 2019 and December 31, 2020 and 1540 propensity-score matched controls with treatment-resistant depression or major depression with suicidal ideation. Adjusting for demographics, prior health care utilization and comorbidities, social determinant variables and distance were regressed separately on each outcome: ESK initiation, failure to complete induction (8 treatments in 45 days), and discontinuation within 6 months. ESK initiation was associated with higher population density (odds ratio [OR]: 2.12), American Indian, Alaska Native, Native Hawaiian, Other Pacific Islander (OR: 3.19), and mental health (OR: 1.55) and primary care providers (OR: 1.55) per capita. Lower likelihood of ESK initiation was associated with living > 7.2 miles from a treatment center (OR: 0.75), living in rural areas (OR: 0.64), and percent non-Hispanic African American (OR: 0.58) and Hispanic (OR: 0.40). Health care providers should tailor patient engagement strategies to mitigate potential barriers to initiating and continuing appropriate treatment. Failing to complete induction was associated with substance use disorder and longer distance to treatment center was associated with discontinuation (hazard ratio: 1.48), as was percent Asian population (hazard ratio: 1.37). Prior psychiatric care and residence in counties with high rates of primary care providers per capita, unemployment, and high school graduation were associated with both higher likelihood of completing induction and lower likelihood of discontinuation.

Implementing universal suicide screening in a large healthcare system's hospitals: rates of screening, suicide risk, and documentation of subsequent psychiatric care

Implementation of suicide risk screening may improve prevention and facilitate mental health treatment. This study analyzed implementation of universal general population screening using the Columbia-Suicide Severity Rating Scale (C-SSRS) within hospitals. The study included adults seen at 23 hospitals from 7/1/2019-12/31/2020. We describe rates of screening, suicide risk, and documented subsequent psychiatric care (i.e., transfer/discharge to psychiatric acute care, or referral/consultation with system-affiliated behavioral health providers). Patients with suicide risk (including those with Major Depressive Disorder [MDD]) were compared to those without using Wilcoxon rank-sum -tests for continuous variables and χ2 tests for categorical variables. Results reported are statistically significant at p < 0.05 level. Among 595,915 patients, 84.5% were screened by C-SSRS with 2.2% of them screening positive (37.6% low risk [i.e., ideation only], and 62.4% moderate or high risk [i.e., with a plan, intent, or suicidal behaviors]). Of individuals with suicide risk, 52.5% had documentation of psychiatric care within 90 days. Individuals with suicide risk (vs. without) were male (48.1% vs 43.0%), Non-Hispanic White (55.0% vs 47.8%), younger (mean age 41.0 [SD: 17.7] vs. 49.8 [SD: 20.4]), housing insecure (12.5% vs 2.6%), with mental health diagnoses (80.3% vs 25.1%), including MDD (41.3% vs 6.7%). Universal screening identified 2.2% of screened adults with suicide risk; 62.4% expressed a plan, intent or suicidal behaviors, and 80.3% had mental health diagnoses. Documented subsequent psychiatric care likely underestimates true rates due to care fragmentation. These findings reinforce the need for screening, and research on whether screening leads to improved care and fewer suicides.

Predicting Poor Outcomes Among Individuals Seeking Care for Major Depressive Disorder

Objective

To develop and validate algorithms to identify individuals with major depressive disorder (MDD) at elevated risk for suicidality or for an acute care event.

Methods

We conducted a retrospective cohort analysis among adults with MDD diagnosed between January 1, 2018 and February 28, 2019. Generalized estimating equation models were developed to predict emergency department (ED) visit, inpatient hospitalization, acute care visit (ED or inpatient), partial-day hospitalization, and suicidality in the year following diagnosis. Outcomes (per 1000 patients per month, PkPPM) were categorized as all-cause, psychiatric, or MDD-specific and combined into composite measures. Predictors included demographics, medical and pharmacy utilization, social determinants of health, and comorbid diagnoses as well as features indicative of clinically relevant changes in psychiatric health. Models were trained on data from 1.7M individuals, with sensitivity, positive predictive value, and area-under-the-curve (AUC) derived from a validation dataset of 0.7M.

Results

Event rates were 124.0 PkPPM (any outcome), 21.2 PkPPM (psychiatric utilization), and 7.6 PkPPM (suicidality). Among the composite models, the model predicting suicidality had the highest AUC (0.916) followed by any psychiatric acute care visit (0.891) and all-cause ED visit (0.790). Event-specific models all achieved an AUC >0.87, with the highest AUC noted for partial-day hospitalization (AUC = 0.938). Select predictors of all three outcomes included younger age, Medicaid insurance, past psychiatric ED visits, past suicidal ideation, and alcohol use disorder diagnoses, among others.

Conclusions

Analytical models derived from clinically-relevant features identify individuals with MDD at risk for poor outcomes and can be a practical tool for health care organizations to divert high-risk populations into comprehensive care models.

Improving diversity in study participation: Patient perspectives on barriers, racial differences and the role of communities

INTRODUCTION

The lack of racial/ethnic diversity in research potentially limits the generalizability of findings to a broader population, highlighting the need for greater diversity and inclusion in clinical research. Qualitative research (i.e., focus groups) was conducted to identify (i) the potential motivators and barriers to study participation across different races and ethnicities; (ii) preferred delivery of education and information to support healthcare decision-making and the role of the community.

METHODS

Patient focus groups were conducted with 26 participants from the sponsor's Patient Engagement Research Councils selected through subjective sampling. Recruitment prioritized adequate representation across different race/ethnic groups. Participation was voluntary and participants underwent a confidential interview process before selection. Narrative analysis was used to identify themes and draw insights from interactions. Experienced research specialists identified emerging concepts, and these were tested against new observations. The frequency of each concept was examined to understand its importance.

RESULTS

Based on self-selected race/ethnicity, participants were divided into five focus groups (Groups: African American/Black: 2; Hispanic/Latino, Asian American, and white: 1 each) and were asked to share their experiences/opinions regarding the stated objectives. Barriers to study participation included: limited awareness of opportunities to participate in research, fears about changes in standard therapy, breaking cultural norms/stigma, religion-related concerns and mistrust of clinical research. Participants identified the importance of transparency by pharmaceutical companies and other entities to build trust and partnership and cited key roles that communities can play. The perceptions of the African American group regarding diversity/inclusion in research studies appeared to be different from other groups; a lack of trust in healthcare providers, concerns about historical instances of research abuse and the importance of prayer were cited.

CONCLUSION

This study provided insights into barriers to study participation, and also highlighted the need for pharmaceutical companies and other entities to authentically engage in strategies that build trust within communities to enhance recruitment among diverse populations.

PATIENT OR PUBLIC CONTRIBUTION

The data collected in the present study was provided by the participants in the focus groups.

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.

Depression and food insecurity among patients with rheumatoid arthritis in NHANES

Background

Social determinants of health (SDH), including food insecurity, are associated with depression in the general population. This study estimated the prevalence of depression and food insecurity and evaluated the impact of food insecurity and other SDH on depression in adults with rheumatoid arthritis (RA).

Methods

Adults (≥ 18 years) with RA were identified from the 2013–2014 and 2015–2016 National Health and Nutrition Examination Survey (NHANES). Depression was defined as a score of ≥ 5 (mild depression: 5–9; moderate-to-severe depression: 10–27) using the Patient Health Questionnaire-9 (PHQ-9). Food insecurity was assessed with the 18-item US Household Food Security Survey Module. Adults with household-level marginal-to-very-low food security were classified as experiencing food insecurity. The prevalence of depression and food insecurity among participants with RA were estimated. Weighted logistic regression was used to evaluate the association between depression and participants’ characteristics including SDH. Penalized regression was performed to select variables included in the final multivariable logistic regression.

Results

A total of 251 and 276 participants from the 2013–2014 and the 2015–2016 NHANES, respectively, had self-reported RA. The prevalence of depression among these participants was 37.1% in 2013–2014 and 44.1% in 2015–2016. The prevalence of food insecurity was 33.1% in 2013–2014 and 43.0% in 2015–2016. Food insecurity was associated with higher odds of having depression (OR 2.17, 95% CI 1.27, 3.72), and the association varied by depression severity. Compared with participants with full food security, the odds of having depression was particularly pronounced for those with very low food security (OR 2.96, 95% CI 1.48, 5.90) but was not significantly different for those with marginal or low food security. In the multivariable regression, being female, having fair/poor health condition, any physical disability, and ≥ 4 physical limitations were significantly associated with depression.

Conclusions

In adults with self-reported RA, the prevalence of depression and food insecurity remained high from 2013 to 2016. We found that depression was associated with SDH such as food insecurity, although the association was not statistically significant once adjusted for behavioral/lifestyle characteristics. These results warrant further investigation into the relationship between depression and SDH among patients with RA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-021-00236-w.

Understanding the Relationship Between Depression Symptom Severity and Health Care Costs for Patients With Treatment-Resistant Depression

Objective: To examine whether measures of depression symptom severity could improve understanding of health care costs for patients with major depressive disorder (MDD) or treatment-resistant depression (TRD) from the health plan perspective. Methods: In this retrospective cohort study within an integrated health system, cohorts consisted of 2 mutually exclusive groups: (1) adults with TRD based on a standard treatment algorithm and (2) adults with MDD, but no TRD, identified through ICD-9/10-CM codes. Depression severity was measured using the Patient Health Questionnaire-9 (PHQ-9). Patterns of health care resource utilization (HRU) and costs were compared between the TRD and MDD groups overall and within the groups at different symptom levels. A general linear model with a γ distribution and log link for cost outcomes, logistic regression for binary outcomes, and negative binomial regression for count outcomes were used. Results: Patients with TRD (n = 24,534) had greater comorbidity than those in the MDD group (n = 17,628). Mean age in the TRD group was 52.8 years versus 48.2 for MDD (P < .001). Both groups were predominantly female (TRD: 72.8% vs MDD: 66.9%; P < .001). Overall, the TRD group had greater costs than the MDD group, with 1.23 times (95% CI, 1.21-1.26; P < .001) greater total cost on average over 1 year following index date. Within both groups, those with severe symptoms had greater total mean (SD) costs (TRD: moderate: $12,429 [$23,900] vs severe: $13,344 [$22,895], P < .001; low: $12,220 [$31,864] vs severe: $13,344 [$22,895], P < .001; MDD: moderate: $8,899 [$20,755] vs severe: $10,098 [$22,853]; P < .001; low: $8,752 [$25,800] vs severe: $10,098 [$22,853], P < .001). Conclusions: MDD and TRD impose high costs for health systems, with increasing costs as PHQ-9 symptom severity rises. Better understanding of subgroups with different symptom levels could improve clinical care by helping target interventions.

Real-world analysis of insurance churn among young adults with schizophrenia using the Colorado All-Payer Claims Database

BACKGROUND: Most patients with schizophrenia are diagnosed in their early twenties and often have commercial insurance at diagnosis. These young adults can experience changes in insurance coverage, that is, "churn," which can lead to disruptions in care. OBJECTIVE: To examine the frequency, speed, and type of insurance churn events in a young adult schizophrenia population with commercial insurance coverage at diagnosis. METHODS: The Colorado All-Payer Claims Database, containing insurance claims data from commercial and public insurers for Colorado residents, was used for the study. Eligible patients were required to have at least 1 inpatient or 2 outpatient claims for schizophrenia or schizoaffective disorder, be of age 18-34 years at index, have previous insurance coverage for 12 consecutive months, and have commercial insurance at diagnosis. These patients were 1:5 propensity score matched (PSM) with nonschizophrenia members. Percentages of members on different insurance types were calculated monthly to assess churn events. Cohorts were compared using descriptive statistics, Cox proportional hazards, and generalized estimating equation models. RESULTS: The matched schizophrenia and nonschizophrenia cohorts comprised 501 and 2,510 members, respectively. Before PSM, cohorts were imbalanced (schizophrenia cohort had a younger median age and higher proportion of males). After matching, the cohorts were similar in terms of the matched baseline characteristics. Previous mental health disorders were more common in the schizophrenia cohort (75%) than in the nonschizophrenia cohort (26%). The proportion of members with at least 1 churn event for the schizophrenia and nonschizophrenia cohorts, respectively, were 53.8% vs 36.5% after 12 months and 84.6% vs 69.2% after 48 months. Time to first churn event was significantly shorter in the schizophrenia cohort (16 months) than the nonschizophrenia cohort (23 months; P < 0.001). Schizophrenia cohort members had 64.1 and 56.8 churn events per 1,000 members per month vs 43.0 (P ≤ 0.001) and 42.8 (P = 0.011) churn events for nonschizophrenia cohort members in the first and second 6-month periods, respectively. Proportions of members in the schizophrenia and nonschizophrenia cohorts on public insurance, respectively, were 22.9% vs 6.9% after 12 months and 52.4% and 10.7% after 48 months. In the schizophrenia cohort, the most common churn event type was from commercial to public insurance rather than to a different commercial insurance; notably, 41% of members were still on a commercial plan 4 years after diagnosis. CONCLUSIONS: Young adults with schizophrenia experienced churn events more rapidly and more frequently than those without schizophrenia for the first 4 years studied after the index date. These disruptions may be associated with reduced access to care and treatment gaps in this vulnerable patient population. DISCLOSURES: This research was sponsored by Janssen Scientific Affairs, LLC. Pesa, Benson, and Patel are employees of Janssen Scientific Affairs, LLC, and are stockholders of Johnson & Johnson. Potluri, Rotter, and Papademetriou are employees of SmartAnalyst Inc, and their work on this study was funded by Janssen Pharmaceuticals. A version of this study was presented as a poster at the Psych Congress 2020 Virtual Experience, September 10-13, 2020.

Applying the Health Belief Model to Characterize Racial/Ethnic Differences in Digital Conversations Related to Depression Pre– and Mid–COVID-19 (Preprint)

Background

Objective

Methods

Results

Conclusions

Mental Health Care Resource Utilization and Barriers to Receiving Mental Health Services Among US Adults With a Major Depressive Episode and Suicidal Ideation or Behavior With Intent

Objective: To examine the incremental mental health care resource utilization (MHRU) and barriers to receiving mental health services among adults with a major depressive episode (MDE) and suicidal ideation or behavior with intent. Methods: Data from adult participants in the 2017 National Survey on Drug Use and Health were used to identify 3 cohorts: MDE (determined by Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5] criteria) with suicidal ideation or behavior with intent (MDSI), MDE, and non-MDE. MHRU and barriers to receiving mental health services were compared among cohorts using logistic regression models. Results: The MDSI cohort had significantly higher odds (adjusted odds ratio [95% confidence interval]) of receiving mental health-related inpatient care, outpatient care, prescription medications, and any treatment versus the MDE cohort (10.2 [7.1-14.6], 2.4 [1.7-3.4], 2.4 [1.8-3.3], and 2.6 [1.8-3.7], respectively) and the non-MDE cohort (40.3 [27.3-59.5], 20.0 [14.5-27.7], 17.2 [12.9-22.9], and 19.6 [14.1-27.1], respectively). Compared to the MDE cohort, the MDSI cohort was significantly more likely to report barriers to receiving mental health services (2.6 [2.0-3.4]), with the largest differences between cohorts related to fear of negative impact (3.9 [2.8-5.4]). Additionally, 30.6% of the MDSI cohort and 47.0% of the MDE cohort did not receive any mental health treatment in the past year. Conclusions: Although respondents in the MDSI cohort reported substantially higher MHRU across all categories, they also reported greater barriers to receiving care than those in the MDE cohort. This study documents the extensive burden and unmet need in the MDSI population.

Economic burden to commercial payers of young adults with schizophrenia in Colorado

AIMS

The primary objective was to examine direct costs and health resource utilization (HRU) among commercially insured young adults with schizophrenia (SCZ) in Colorado.

MATERIALS AND METHODS

The Colorado All-Payer Claims Database, covering approximately 76% of the insured Colorado population was used. Members aged 18-34, with and without SCZ, having commercial insurance were included. All-cause, mental health (MH) related and non-MH related per patient per month (PPPM) costs and per hundred patients per month (PHPPM) HRU were compared between an SCZ cohort and a propensity score matched non-SCZ cohort before and after index date up to 48 months.

RESULTS

Five hundred and one patients with SCZ and 2,510 matched individuals without SCZ were included. HRU and costs were higher for SCZ patients both pre- and post-index date. Pre-index, there were 32.3 (24.0 MH; 8.4 non-MH) PHPPM more office visits; 2.1 (2.7 MH) PHPPM more admissions; 104.8 (67.02 MH; 37.7 non-MH) PHPPM more prescriptions in the SCZ cohort (all p<.01). After index date, the SCZ cohort had 89.6 (81.3 MH; 9.2 non-MH) more PHPPM office visits, 7.2 (6.1 MH; 0.9 non-MH) PHPPM more admissions, and 181.6 (123.1 MH; 58.6 non-MH) PHPPM more prescriptions (all p<.001). All-cause costs in the pre-index period were $457 PPPM ($373 MH) higher for the SCZ cohort (p<.001). In the post-index period, all-cause costs for the SCZ cohort were $1,687 PPPM ($1,258 MH; $412 non-MH) higher (all p<.001). Approximately, 40% of patients with SCZ were on commercial insurance after four years compared with approximately 75% in the non-SCZ cohort.

LIMITATIONS

This study was based on data from a single state, thus may not be generalizable to other states.

CONCLUSIONS

Healthcare costs and HRU for young adults diagnosed with SCZ are significantly more burdensome to commercial payers than matched patients without SCZ, both before and after an official SCZ diagnosis.

Development of a patient decision aid for treatment resistant depression

BACKGROUND

Shared decision-making (SDM) involves patients and clinicians choosing treatment jointly. SDM in mental health is hampered by lack of well-developed supporting tools. We describe an evidence-based patient decision aid (PDA) to facilitate SDM for treatment-resistant depression (TRD) following US National Quality Forum standards which are based upon the International Patient Decision Aid Standards (IPDAS).

METHODS

A web-based PDA was developed by a multidisciplinary steering committee of clinicians, patient advocates, patients and a decision scientist. Development included creating content consistent with decision-making domains that are impacted by patient preference in TRD. Development was guided by literature review, group conference calls/discussions, patient and clinician interviews (N = 8), high and lower literacy focus groups (N = 11) and pilot study (N = 5). The PDA presents risk-benefit information on domains (e.g., effectiveness, mode of administration, side effects, cost) and includes values clarification exercises. Pilot study patients were administered the Decisional Conflict Scale (DCS) and Decision Self-Efficacy Scale (DSES) prior to and following PDA interaction and clinician SDM.

RESULTS

During the pilot, prior to PDA interaction, mean (standard deviation) DCS score was 42.2 (14.4) and DSES score was 86.0 (14.6) out of 100. Following PDA interaction and SDM, DCS decreased (improved) to 28.1 (SD 4.1) and DSES increased to 95.5 (6.7). All patients endorsed that the PDA helped them to: recognize pros and cons of options; understand how treatments were administered, possible side-effects, and likelihood of benefit; recognize what was important relative to the decision; organize thoughts and prepare for a discussion with their clinician.

CONCLUSIONS

This PDA may support SDM in TRD. A future trial to determine impact of the present SMD on decision-making quality is warranted. It also highlights gaps in comparative effectiveness trials that could guide equitable shared decision-making.

Serious Mental Illness and Health-Related Factors Associated with Regional Emergency Department Utilization

Frequent emergency department (ED) utilization is an indicator of unmet health and social needs, especially among patients with mental and physical health problems. The authors aimed to characterize frequent ED utilizers and drivers of multiple ED use, including presence of serious mental illness (SMI), across 2 large health care systems in Northern California. Using electronic health records and a data-sharing platform, a cross-sectional analysis was conducted of patients aged 18+ years with ≥10 ED visits in 2016. Logistic regression was used to determine factors associated with multiple ED use versus single ED use. Among the 8036 patients who met inclusion criteria, the mean age was 55.9 years (95% CI = 55.5-56.4), 53% were female, 54% were non-Hispanic white, and 38% had any SMI. Overall, 51% of patients were single ED utilizers. Patients ages ≥65 years were less likely to use multiple EDs compared to younger patients (ages 18-23) (OR = 0.3, 95% CI = 0.2-0.4). African Americans exhibited more than 3 times the likelihood of multi-ED use compared to non-Hispanic whites (OR = 3.8, 95% CI = 3.3-4.3). A diagnosis of any SMI (OR = 2.3 [95% CI: 2.1-2.6]), major depressive disorder (OR = 1.3, 95% CI = 1.1-1.4), schizophrenia (OR = 2.1, 95% CI = 1.6-2.6), or suicidal attempts/ideation (OR = 2.7, 95% CI = 2.1-3.6) was significantly associated with increased likelihood of multi-ED use. Findings indicate heterogeneity in regional utilization patterns among frequent ED utilizers, with mental illness increasing the likelihood of multi-ED use.

Factors Associated with Diabetes-Related Clinical Inertia in a Managed Care Population and Its Effect on Hemoglobin A1c Goal Attainment: A Claims-Based Analysis

BACKGROUND

Despite evidence showing the benefits of treatment intensification following an elevated hemoglobin A1c (A1c), clinical inertia, or failure to establish and/or escalate treatment to achieve treatment goals, is a concern among patients diagnosed with type 2 diabetes (T2DM). Clinical inertia may contribute to increased health care utilization and costs due to poor clinical outcomes in MCOs.

OBJECTIVES

To (a) identify factors associated with clinical inertia in T2DM and (b) determine differences in A1c goal attainment between patients who experience clinical inertia versus treatment intensification in a commercially insured population.

METHODS

Medical and pharmacy claims data were used to identify commercially insured patients in a regional MCO with a recorded A1c ≥ 8.0% between January 1, 2013, and December 31, 2015. In the 4 months following the first elevated A1c value (index date), patients were classified into 2 groups: treatment intensification or clinical inertia. Treatment intensification was defined as the addition of ≥ 1 new noninsulin antihyperglycemic medication, the addition of insulin, or a dose increase of any current noninsulin antihyperglycemic medication. Patients were required to have ≥ 1 follow-up A1c value 6-12 months after the index date and continuous enrollment in the health plan for 12 months before and after the index date. Patients were excluded if they had a diagnosis for gestational diabetes or type 1 diabetes or if they were on insulin in the pre-index period. The primary outcome of attaining A1c < 7.0% was compared between groups after propensity score matching (PSM). Factors associated with clinical inertia were identified using logistic regression.

RESULTS

3,078 patients, with a mean (SD) age of 54.4 (10.6) years and a mean (SD) baseline A1c of 9.6% (1.7), were included in the study. Of these, 1,093 patients (36%) experienced clinical inertia. After PSM, 1,760 patients remained; 880 in each group. In the clinical inertia group, 23% of patients achieved an A1c < 7.0% in the post-index period, compared with 35% in the treatment intensification group (P < 0.001). A greater likelihood of experiencing clinical inertia was associated with baseline treatment with 2 (OR = 1.51, 95% CI = 1.22-2.86; P < 0.001) or ≥ 3 (OR = 1.78, 95% CI = 1.30-2.42; P < 0.001) antihyperglycemic medications (vs. none), baseline age ≥ 65 years (OR = 2.11, 95% CI = 1.63-2.74; P < 0.001), and diagnosis of coronary heart disease (OR = 1.44, 95% CI = 1.10-1.88; P = 0.007). A baseline A1c ≥ 9.0% (vs. 8.0%-8.9%) was associated with a lower likelihood of experiencing clinical inertia (OR = 0.56, 95% CI = 0.48-0.66; P < 0.001).

CONCLUSIONS

More than a third of patients in a commercially insured population with T2DM and a baseline A1c ≥ 8% experienced clinical inertia. Clinical inertia resulted in worse A1c outcomes over the 12-month follow-up period. Results of this study suggest that treatment intensification should be monitored, with efforts made to educate health care providers on strategies aimed at improving glycemic control for high-risk patients.

DISCLOSURES

This study was funded by a grant from Janssen Scientific Affairs, which was involved in study design, interpretation of results, and manuscript review. Wander reports consulting fees from Sanofi Aventis outside the submitted work. McAdam-Marx reports grants from Sanofi Aventis and AstraZeneca outside the submitted work. Pesa and Bailey were employees of Janssen Scientific Affairs during the conduct of the study. Bailey also reports stock ownership in Johnson and Johnson. This study was presented as a poster at the Academy of Managed Care Pharmacy Nexus 2017; October 16-19, 2017; Grapevine, TX.

Risk Factors, Health Care Resource Utilization, and Costs Associated with Nonadherence to Antiretrovirals in Medicaid-Insured Patients with HIV

BACKGROUND

Adherence to antiretrovirals (ARVs) is critical to achieving durable virologic suppression.

OBJECTIVE

To investigate risk factors of poor adherence and the effect of suboptimal adherence on health care resource utilization (HCRU) and costs in Medicaid patients.

METHODS

A retrospective longitudinal study was conducted using Medicaid data. Adults (aged ≥ 18 years) with human immunodeficiency virus (HIV)-1 initiating selected ARVs (index date) were identified. Adherence was measured using medication possession ratio (MPR) and proportion of days covered (PDC) at 6 and 12 months post-index. Risk factors of poor adherence (PDC < 80%) were assessed using a logistic regression. HCRU and costs were compared between suboptimal (80% ≤ PDC < 95%) and optimal (PDC ≥ 95%) adherence groups using Poisson and ordinary least square models, respectively.

RESULTS

In total, 3,477 patients were identified. Using MPR, 1,282 (39.0%) of the evaluable patients had poor adherence; 667 (20.2%) had suboptimal adherence; and 1,342 (40.8%) had optimal adherence versus 1,342 (51.1%), 509 (19.0%), and 804 (30.0%), respectively, using PDC at 6 months. PDC at 12 months was even lower. Younger age (OR = 1.58; 95% CI = 1.18-2.11; P = 0.002), noncapitated coverage (OR = 1.40; 95% CI = 1.16-1.69; P < 0.001), dual Medicaid/Medicare coverage (OR = 5.98; 95% CI = 4.39-8.16; P < 0.001), no baseline ARV treatment (OR = 1.98; 95% CI = 1.62-2.41; P < 0.001), and baseline asymptomatic HIV (OR = 1.37; 95% CI = 1.13-1.68; P = 0.002) were associated with higher risk of poor adherence. Suboptimal adherence patients had higher total number of days spent in a hospital (incidence rate ratio [IRR] = 1.62; 95% CI = 1.13-2.19; P = 0.008), total number of long-term care admissions (IRR = 3.11; 95% CI = 1.26-7.39; P = 0.008), total medical costs (mean monthly cost difference = $339; 95% CI = $153-$536; P < 0.001), and inpatient costs (mean monthly cost difference = $259; 95% CI = $122-$418; P < 0.001) compared with patients with optimal adherence.

CONCLUSIONS

Nonadherence to ARVs was observed in 60%-80% of Medicaid patients, depending on the adherence measure used, and was associated with incremental HCRU and costs. Age, insurance type and coverage, previous ARV treatment, and HIV symptoms were predictors of adherence. Treatment options that enhance adherence and prevent developing virologic failure with drug resistance should be considered for HIV patients.

DISCLOSURES

This study was supported by Janssen Scientific Affairs, which was involved in the study design, data collection, data analysis, manuscript preparation, and publication decisions. Emond, Lafeuille, Romdhani, and Lefebvre are employees of Analysis Group, a consulting company that received research grants from Janssen Scientific Affairs to conduct this study. Dunn, Woodruff, Pesa, and Tandon are current employees and stockholders of Johnson & Johnson, owner of Janssen Scientific Affairs. Jiao was an employee of Janssen at the time of the study. Emond has received grants from Novartis, Regeneron, Aegerion, Lundbeck, Bristol-Myers Squibb, Bayer, Millennium, Allergan, AbbVie, and GlaxoSmithKline unrelated to this study. Part of the material in this study was presented at the Academy of Managed Care Pharmacy 2017 Annual Meeting; March 27-30, 2017; Denver, CO, and at the 9th International AIDS Society Conference; July 23-26, 2017; Paris, France.

Medicaid Eligibility and Time to Re-incarceration Among Previously Incarcerated Subjects With Schizophrenia

Background: Many persons with severe mental illness qualify for Medicaid coverage. However, under federal law, states must either suspend or terminate eligibility once they are incarcerated. We hypothesize that prompt re-acquisition of Medicaid eligibility following release from incarceration lowers the risk of re-incarceration. Objective: To assess the relationship between Medicaid eligibility and risk of re-incarceration among previously incarcerated schizophrenia diagnosed subjects. Methods: Study subjects were selected between January 1, 2006 and September 30, 2011 from a single state Medicaid database that was combined with department of corrections data. Subjects were included if they had a schizophrenia diagnosis (International Classification of Diseases, 9th Revision, Clinical Modification [ICD- 9-CM] code 295.xx), were between the ages of 18 and 62, and had been released from incarceration. Covariates included age, race, gender, marital status, and reason for incarceration. Time to Medicaid eligibility after release from incarceration, cumulative days of eligibility, and whether they were eligible on the re-incarceration date were evaluated in independent models. One and three-year Cox Regression models analyses (p<0.05) were used to evaluate the hazard for re-incarceration. Results: The 932 subjects were 26.5% white, 73.7% male and were, on average, 37.6 years old on their index date (i.e., incarceration release date). They were 73.5% single or divorced and 12.7% were incarcerated for a substance abuse violation. In the 1-year follow-up period, 110 subjects (11.8%) were re-incarcerated. In the 3-year follow-up period 209 (22.4%) were re-incarcerated. Age (in years) was the only significant predictor of re-incarceration for the 1-year models (hazard ratio [HR]=0.976; confidence interval [CI]=0.957, 0.994). Eligibility was a significant predictor in the 3-year follow-up models. A longer 'time to first eligibility' (HR=1.046; CI=1.017, 1.075 was associated with a greater hazard for re-incarceration. Being eligible at the time of re-incarceration (HR=0.659; CI=0.498, 0.870) was associated with a lower hazard, and the cumulative number of months of eligibility (HR=0.978; CI=0.958, 0.997) and age were associated with a lower hazard for re-incarceration (HR=0.986; CI=0.973, 0.999). Conclusions: Access to Medicaid health services post-release may reduce the risk of re-incarceration.

Factors Associated with Adherence to the HEDIS Quality Measure in Medicaid Patients with Schizophrenia

BACKGROUND

Treatment continuity is a major challenge in the long-term management of patients with schizophrenia; poor patient adherence to antipsychotic drugs has been associated with negative clinical outcomes. Long-acting injectable therapies may improve adherence and lessen the risk for psychiatric-related relapse, often leading to rehospitalization and higher healthcare costs. Therefore, understanding the determinants of adherence to antipsychotics is critical in the management of patients with schizophrenia.

OBJECTIVE

To assess the impact of baseline patient characteristics on adherence as measured by the Healthcare Effectiveness Data and Information Set (HEDIS) measure of continuity of antipsychotic medications among patients with Medicaid coverage.

METHODS

Medicaid healthcare claims data between 2008 and 2011 from 5 states were used to identify patients who were diagnosed with schizophrenia (aged 25-64 years) and received ≥1 antipsychotic prescriptions in baseline year 2010 and in measurement year 2011. The HEDIS continuity of antipsychotic medications (ie, adherence) measure was defined as the proportion of days covered with any antipsychotic medication ≥80% during the measurement year. The 2 cohorts compared paliperidone palmitate with any other antipsychotics, including quetiapine, risperidone, and haloperidol. The baseline-year characteristics were evaluated as potential predictive factors of adherence in the measurement year using multivariate logistic regressions. The regression models incorporated the inverse probability of treatment weights to control for differences in baseline characteristics between the paliperidone palmitate and the other antipsychotics cohort.

RESULTS

Among the 12,990 patients who received an antipsychotic during the study period, 48.6% successfully achieved the continuity criteria in the measurement year. After controlling for other covariates, the odds of adherence were improved by adherence at baseline (odds ratio [OR], 9.42; 95% confidence interval [CI], 8.55-10.39). The use of paliperidone palmitate was associated with a 26% increase in the odds of achieving adherence compared with the use of the other antipsychotics studied (OR, 1.26; 95% CI, 1.14-1.39). In addition, female sex (OR, 1.11; 95% CI, 1.01-1.22), age 55 to 64 years (OR, 1.26; 95% CI, 1.09-1.46) versus age 25 to 34 years, Hispanic race (OR, 1.37; 95% CI, 1.05-1.81) versus white race, and an increase of $10,000 in baseline inpatient costs (OR, 1.11; 95% CI, 1.08-1.15) were associated with greater odds of treatment continuity.

CONCLUSIONS

In addition to sex, age, and race, the baseline characteristics that were associated with achieving the HEDIS continuity of antipsychotic medication measure included previous-year adherence, inpatient costs, and the use of paliperidone palmitate. These findings offer insight to healthcare plans that cover Medicaid populations on the effects that patient characteristics and treatment types may have on adherence among patients with schizophrenia.

Medicaid managed care penetration and drug utilization for patients with serious mental illness

OBJECTIVES

State Medicaid programs are under increasing pressure to contain pharmaceutical spending. Many states have attempted to limit spending through greater Medicaid managed care penetration, which rose nationally from 54.5% in 1999 to 74.9% in 2011. It is not clear how this expansion has affected beneficiaries with serious mental illness (SMI)-a vulnerable population that often has their drug spending "carved out" from their managed care benefit. We sought to assess the association between managed care penetration and pharmaceutical spending on drugs for SMIs in these states.

STUDY DESIGN

Retrospective cohort study.

METHODS

State-year observations were constructed to study the relationship between managed care penetration and pharmaceutical spending on drugs for SMIs over the period 1999 to 2011. We analyzed the relationship using both cross-sectional and panel-data methods.

RESULTS

Our cross-sectional analyses suggested that carve-out states with greater managed care penetration spend significantly less per enrollee on pharmaceuticals for the treatment of mental disorders: our panel data analyses did not generate statistically meaningful results.

CONCLUSIONS

Future studies should address whether any effects of managed care on mental health prescription utilization and spending reflect improved care coordination or worsening access to valuable care for the population with SMI.

Comparison of Real-world Outcomes Between Patients Treated with Tapentadol ER or Oxycodone CR

Background: The objective of this study was to compare health care utilization and costs between matched cohorts of chronic pain patients treated with the opioids tapentadol extended release (ER) or oxycodone controlled release (CR). Methods: This retrospective study used claims data from the Optum Research Database. Commercial and Medicare Advantage adult patients with ≥1 prescription fill for oxycodone CR or tapentadol ER between September 1, 2011 and September 30, 2012 were eligible. The date of the first observed oxycodone CR or tapentadol ER claim was the index date. Patients had continuous health plan enrollment for 6 months before and after the index date, ≥ 90 days supply of opioid therapy, and no index drug claims in the preindex period. Patients were propensity score matched in a 1:2 ratio (tapentadol ER : oxycodone CR). Results: The attributes of the matched cohorts (1,120 tapentadol ER and 2,240 oxycodone CR patients) appeared similar. In the 6 month post-index period, lower proportions of the tapentadol ER cohort than the oxycodone CR cohort had ≥1 inpatient stay (14.6% versus 20.5%; p<0.001) and ≥1 emergency department visit (33.4% versus 37.5%; p=0.021). The tapentadol ER compared with the oxycodone CR cohort had higher mean pharmacy costs ($4,263 versus $3,694; p <0.001), lower mean inpatient costs ($3,625 versus $6,309; p<0.001), and lower mean total healthcare costs ($16,510 versus $19,330; p=0.004). Conclusions: During follow-up, total mean healthcare costs were lower among tapentadol ER patients than oxycodone CR patients, and tapentadol ER patients were less likely to have an inpatient admission or emergency department visit.

Impact of paliperidone palmitate versus oral atypical antipsychotics on healthcare outcomes in schizophrenia patients

AIM

To assess impact of initial treatment and time-dependent treatment with paliperidone palmitate (PP) versus oral atypical antipsychotics (OAAs) on healthcare resource utilization and costs.

PATIENTS & METHODS

A retrospective longitudinal study was conducted among Medicaid beneficiaries with schizophrenia. Inverse probability treatment weighting method and marginal structural models were used to estimate the impact of treatment on healthcare resource utilization and costs, respectively.

RESULTS

Compared to OAAs, PP was associated with lower medical costs (mean monthly cost difference [MMCD] = -US$256; p = 0.008), which offset the higher pharmacy expense (MMCD = US$122; p < 0.001) resulting in nonsignificant cost savings associated with PP (MMCD = -US$91; p = 0.689).

CONCLUSION

PP was associated with comparable overall costs to OAAs, but with significantly lower medical costs, particularly attributable to reduced inpatient visits and long-term care admissions.

Healthcare utilization and costs of Veterans Health Administration patients with schizophrenia treated with paliperidone palmitate long-acting injection or oral atypical antipsychotics

OBJECTIVE

This study aimed to compare real world healthcare costs and resource utilization between patients with schizophrenia treated with paliperidone palmitate long-acting injection (PP) and oral atypical antipsychotics (OAT).

METHODS

Patients (18-64 years) were selected from the Veterans Health Administration dataset (1 July 2007-31 May 2012). Patients with 2+ claims for PP or 2+ claims for the same OAT comprised the two study cohorts with the first prescription date designated as the index date. Participation in the VA healthcare system for 24 months pre- and 12 months post-index, schizophrenia diagnosis (International Classification of Disease 9th Revision Clinical Modification [ICD-9-CM] code 295.1x-6x, 295.8x-9x) and ≥1 claim for an antipsychotic medication during the baseline period were required. Propensity scores and Mahalanobis metric distances with calipers were used to create two matched cohorts. All-cause healthcare utilization and costs for the 12-month follow-up period were compared between matched cohorts.

RESULTS

The matching process produced two cohorts of 335 patients with similar baseline characteristics. During the 12-month follow-up period, patients in the PP cohort had lower mean inpatient costs (18,560 vs $31,505, p = 0.002), lower frequency of hospitalization (34% vs 53%, p < 0.001) and fewer average inpatient days (13.24 vs 24.18, p = 0.002) vs matched OAT patients. While mean pharmacy costs were higher for the PP cohort ($10,063 vs $4167, p < 0.001), mean total healthcare costs were not significantly different ($45,529 vs $52,569, p = 0.128).

CONCLUSION

VA patients, diagnosed with schizophrenia and treated with PP, had lower inpatient costs and admission rates compared to a matched cohort of OAT patients. Total healthcare costs were not significantly different.

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.

The Impact of Medicaid Preferred Drug Lists on Utilization and Costs of Antipsychotic Medication

Background: Few studies have attempted to assess the effectiveness of formulary management in reducing the antipsychotic costs and utilization across U.S. state Medicaid programs, despite concerns about the potential impact of such formulary management on Medicaid patient health outcomes. Objectives: Compare antipsychotic utilization and total costs across Medicaid states with preferred drug list (PDL) programs vs. states without PDLs in place. Methods: The following data from 48 Medicaid fee-for-service (FFS) programs were collected for calendar year 2010: antipsychotic prescription use (IMS Health); formulary management (MediMedia, Medicaid FFS programs' websites), and patient enrollment (MediMedia). For each program, the total antipsychotic cost per capita was estimated by multiplying antipsychotic utilization by list price (First DataBank), then dividing by program enrollment. To control for differences in the prevalence of antipsychotic use among Medicaid patients across states, cost estimates were adjusted using state-level mental-health illness prevalence data (Kaiser Family Foundation, Substance Abuse and Mental Health Services Administration [SAMHSA], and Thomson Healthcare). Volume-based market share of branded antipsychotics was also calculated to compare branded vs. generic antipsychotic use across states. Significance of difference between the means of PDL and non-PDL states was tested using a two-sided, two sample t-test, assuming unequal variances between samples. Results: Among the 48 states studied, 33 (68.8%) used PDLs as a means to limit access to branded antipsychotic medications, including those states with the largest populations with a mental-health illness (e.g. New York, California, Texas). In our analyses, the average difference in antipsychotic costs per capita between PDL and non-PDL states was less than $0.6M or 1.5% (p=0.95). The average difference in antipsychotic utilization per capita was less than 2.8% (p=0.91) and in branded antipsychotic market share was 0.7% (p=0.59). Conclusions: Although a majority of Medicaid states use PDLs to manage antipsychotic utilization, this analysis found no evidence of significant advantages for these Medicaid programs in terms of lowering percapita antipsychotic costs or increasing generic utilization.

Opioid utilization patterns among medicare patients with diabetic peripheral neuropathy

BACKGROUND

Diabetic peripheral neuropathy (DPN) affects a large percentage of patients with type 2 diabetes and is associated with moderate-to-severe pain. Patients with DPN bear a substantial economic burden as a result of increased overall healthcare utilization. The reported costs of treating DPN are nearly $11 billion, with elderly (aged ≥65 years) patients with type 2 diabetes accounting for 93.1% ($10.2 billion) of the total costs.

OBJECTIVES

To describe the real-world utilization patterns of long-acting opioids (LAOs) and chronic short-acting opioids (SAOs) use in a sample of Medicare enrollees (aged ≥65 years) with painful DPN, and to identify potential areas for improvement in the management of elderly patients with painful DPN who are treated with opioids.

METHODS

In this retrospective pharmacy claims analysis, the Chronic Opioid Medication Use Evaluation (MUE) software was used to import and analyze individual plan, retrospective pharmacy utilization claims data from the MarketScan claims databases. Patients aged ≥65 years who had painful DPN as identified by ≥2 International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for painful DPN (250.6X or 357.2) in at least 2 quarters in 2009, and who had ≥1 claims for LAO and/or chronic use of SAO (≥60 days of continuous therapy), were selected for analysis. Pharmacy claim data were extracted for 12 months, and various opioid utilization measures were reported.

RESULTS

A total of 1448 unique Medicare patients with painful DPN were identified who had 11,740 claims for an LAO and/or chronic use of an SAO. Of the 1448 patients, 62% had chronic use of an SAO, and of these, 89% had no concurrent claim for LAO (minimum, 60-day overlap). The most frequently filled LAOs were fentanyl transdermal (38%), oxycodone controlled release (CR; 26%), and morphine CR/extended release (ER)/sustained release (SR; 20%). The daily average consumptions for fentanyl transdermal, oxycodone CR, and morphine CR/ER/SR were 0.3, 2.5, and 2.4, respectively. Among the study population, 15.2% of the patients filled an LAO or SAO prescription at ≥2 pharmacies. Furthermore, these elderly patients with painful DPN used greater doses of LAOs than what is recommended in the package insert, and 1.6% of patients used high doses of acetaminophen and 15.2% utilized multiple pharmacies to obtain their opioid prescriptions. Moreover, this population had prevalent concomitant use of opioids and prescribed gastrointestinal (GI) medications.

CONCLUSION

Results from our retrospective pharmacy claims analysis demonstrated that elderly patients with painful DPN use doses of LAOs above those recommended in the package insert, with some patients using high doses of acetaminophen and utilizing multiple pharmacies to obtain their opioid prescriptions. In addition, this population had prevalent concomitant use of opioids and prescription GI medications. The use of software, such as the Opioid MUE, to monitor opioid drug utilization trends and examine other utilization measures can assist healthcare decision makers and payers in their utilization reviews to appropriately manage this population.

Effect of antihypertensive medication adherence among employees with hypertension

OBJECTIVES

To determine if antihypertensive medication adherence is associated with decreased medical and drug costs, medical service utilization, and work absence days.

STUDY DESIGN

Retrospective database study using medical, pharmacy, sick leave, short-term and long-term disability, and workers' compensation claims data from multiple large US employers from 2001 to 2008.

METHODS

We used medical and pharmacy claims to identify employees with hypertension. The index date was the date of the first hypertension-related pharmacy claim. Eligible employees had health plan enrollment 6 months before the index date and at least 12 months after the index date. Employees younger than 45 years were excluded from the study. Regression models estimated the effect of the proportion of days covered (PDC) by hypertension medication on outcomes after the index date, including health benefit costs, medical service utilization, and work absence days, as well as some clinical outcomes calculated separately for high-prior-cost and low-prior-cost employees. High-prior-cost employees were those who accounted for the top 60.0% of total medical costs during the 6 months before the index date. The regression models controlled for demographics, job-related variables, and comorbidities.

RESULTS

Among low-prior-cost employees, high PDC was associated with increased medical and drug costs and work absence days. Among high-prior-cost employees, high PDC was associated with decreased medical and drug costs, fewer work absence days and inpatient hospital days, and increased hypertension-specific medical costs.

CONCLUSION

Antihypertensive medication adherence was associated with improvement in some short-term utilization measures among high-prior-cost employees, but significant short-term improvement was not seen among low-prior-cost employees.

One-year clinical and economic consequences of oral atypical antipsychotics in the treatment of schizophrenia

OBJECTIVE

To assess the clinical and economic consequences of oral atypical antipsychotic treatment (aripiprazole, olanzapine, paliperidone ER, quetiapine, risperidone, and ziprasidone) in schizophrenia over one-year from a US healthcare system perspective.

METHODS

The decision model captured rates of discontinuation, symptom response, frequency and duration of relapse, adverse events (extrapyramidal symptoms and weight gain), resource utilization, and unit costs. Published randomized, double-blind, placebo-controlled clinical trial data were used to obtain response rates for comparators. Published clinical trial data from long-term effectiveness trials reflective of typical clinical settings were used for time on therapy, rates of discontinuation, likelihood of switching, relapse rates, and adverse event rates. Drug costs were based on Wholesale Acquisition Cost weighted by Wolters Kluwer Retail and First Databank Pricing drug utilization data. PharMetrics Patient-Centric database was utilized for length of stay, frequency of relapse, and unit cost of healthcare resource data. A clinical expert panel provided resource-use information not available in published literature or healthcare databases. To test the robustness of the findings, sensitivity analyses were performed using plausible ranges of key model input parameters.

RESULTS

The model estimated that, over 1 year, clinical outcomes of patients administered oral atypical antipsychotics would not vary considerably. This is partly due to differences 'washing out' because of frequent switching and discontinuation of medication. Economic outcomes did vary among pharmacotherapies: paliperidone ER was associated with cost savings in direct medical costs per patient per year compared to risperidone (cost savings using paliperidone ER vs. risperidone: $793), quetiapine ($1191), olanzapine ($1259), ziprasidone ($2159), and aripiprazole ($2204)). Limitations of this analysis include the absence of direct head-to-head long-term comparative data for antipsychotics. However, the results of the decision analysis held true when tested through a multitude of sensitivity analyses.

CONCLUSION

This modeling study showed that paliperidone ER had the most favorable clinical and economic outcomes compared to other oral atypical antipsychotics for patients with schizophrenia. The analysis supports the notion that frequent discontinuation of medication is a problem with all oral antipsychotic treatments for schizophrenia.

Hospitalisation risks in the treatment of schizophrenia in a Medicaid population: comparison of antipsychotic medications

This study used administrative claims data to compare the relative risks for hospitalisation among patients with schizophrenia within a US Medicaid programme receiving atypical and typical antipsychotics. The newer atypical antipsychotics may be better tolerated among mentally ill patients receiving public assistance (Medicaid) who are less functional than other mentally ill populations. Risperidone, olanzapine, quetiapine and ziprasidone were compared with each other and to typical antipsychotics as a single category. Cox proportional hazard estimates, adjusted for differences in patient characteristics, showed numerically lower risks for each of the atypicals in comparison with the typicals, with that for quetiapine being statistically significant (HR: 0.672, p = 0.0413). There were no statistically significant differences among atypical pairs. This study provides evidence that risk for hospitalisation among Medicaid patients with schizophrenia may be lower with atypical antipsychotics, particularly quetiapine.

Assessment of antipsychotic-related risk of diabetes mellitus in a Medicaid psychosis population: Sensitivity to study design

PURPOSE

The effect of study design on findings regarding diabetes risk associated with antipsychotics was studied.

METHODS

This study was a retrospective analysis of data from more than 100,000 Medicaid patients. Diabetes odds ratios (ORs) for patients treated with clozapine, olanzapine, quetiapine, risperidone, ziprasidone, or conventional antipsychotics versus untreated patients were estimated with and without the following design enhancements: screening for preexisting diabetes, selecting for antipsychotic monotherapy, and identifying diabetes with prescription claims only. Logistic regression controlled for patient sex, race and ethnicity, type of psychosis, length of observation and treatment, antipsychotic dosage, pre-existing excess weight or dyslipidemia, and use of other drugs with potential diabetogenic effects.

RESULTS

Under the weakest study design (none of the above enhancements), all antipsychotics were associated with significantly higher odds of diabetes relative to no treatment (p < 0.05). Estimated ORs were as follows: clozapine, 1.468; olanzapine, 1.108; quetiapine, 1.270; ziprasidone, 1.226; risperidone, 1.232; and conventional antipsychotics, 1.159. Under the strongest design (all of the above enhancements), ORs relative to no treatment were significant for clozapine (1.484) and olanzapine (1.149) and nonsignificant for quetiapine (0.998), risperidone (1.124), ziprasidone (0.717), and conventional antipsychotics (1.025). The data also strongly suggest selection bias by clinicians (i.e., selecting antipsychotics based on preexisting diabetes or risk factors for diabetes), disfavoring risperidone and favoring olanzapine. Although the evidence is weaker, quetiapine may also have been affected by unfavorable selection bias.

CONCLUSION

In large database studies, estimated risks of diabetes among patients treated with antipsychotics appeared to be influenced by study design. When a more rigorous design was used, only clozapine and olanzapine were associated with diabetes risk significantly greater than that in untreated patients.

Relationship between initial quetiapine dose and effectiveness as reflected in subsequent mental health service use among patients with schizophrenia or bipolar disorder

OBJECTIVE

To investigate the association between initial quetiapine dose and effectiveness as gauged by subsequent use of mental health services.

METHODS

Using a health plan database, we identified patients with bipolar disorder or schizophrenia treated with quetiapine monotherapy for at least four consecutive months. The stability of each patient before and after quetiapine treatment was measured by use of mental health services other than antipsychotic drug, measured primarily by charges reported on claims. Regression models controlling for patient differences measured associations between initial quetiapine dose and subsequent mental health service use.

RESULTS

Commercially insured patients with schizophrenia (n = 581) or bipolar disorder (n = 2421) received quetiapine monotherapy at mean (SD) initial daily doses of 237 (198) mg and 147 (171) mg, respectively. Both groups showed negative associations between initial daily dose and subsequent mental health charges. Among patients with schizophrenia, mental health charges decreased by US 1.28 dollars for each additional milligram of quetiapine (P = 0.1097). Among patients with bipolar disorder, there was a significant decrease of US 1.31 dollars per additional milligram of quetiapine (P = 0.0484). For schizophrenia, hospitalizations were reduced by 0.4% for each additional milligram of quetiapine (P = 0.0189). For bipolar disorder, the association between quetiapine dose and outpatient charges was negative and trended toward significance (P = 0.074), showing a US 0.54 dollars reduction in these charges for each additional milligram of quetiapine; the association with hospitalization was not significant.

CONCLUSIONS

In patients with schizophrenia or bipolar disorder, higher initial doses of quetiapine may be more effective in stabilizing patients as reflected in lower subsequent mental health service use.

Comparison of mental health resources used by patients with bipolar disorder treated with risperidone, olanzapine, or quetiapine

OBJECTIVE

The atypical antipsychotics, risperidone, olanzapine, and quetiapine, have been approved by the U.S. Food and Drug Administration for treatment of mania associated with bipolar disorder. Information on the relative mental health resource use of these therapies is helpful to pharmacy managers since differences in efficacy and safety may translate into differences in mental health care utilization. We compared charges for other mental health services associated with risperidone, olanzapine, and quetiapine treatment of patients with bipolar disorder to assess whether there were significant differences between these therapies. A secondary analysis involved dose-equivalent adjustment of the average allowed charge of the 3 atypical antipsychotics.

METHODS

This was a retrospective study based on administrative data for 46 U.S. commercial health plans represented in a commercial database covering the period January 1998 through April 2002. The 6,625 patients included in the study had at least 2 contiguous pharmacy claims for a study antipsychotic, had received no other antipsychotics concurrently, and had not switched from an alternative antipsychotic in the preceding 90 days. Provider-submitted (billed) charges were selected in preference to paid amounts as being more accurate indicators of relative differences in the use of mental health resources. Mental health care charges were measured per patient per month (PPPM) and included charges for the study antipsychotics and charges for the other mental health care services (inpatient, physician and other ambulatory, and other psychotropic medications). Differences in other mental health care charges PPPM among the 3 therapies were assessed with multivariate regression, adjusting for differing patient characteristics. Differences in antipsychotic drug charges PPPM were assessed after adjustment to reflect an equivalent average daily dose.

RESULTS

Regression estimates adjusted for patient differences did not show statistically significant differences in other mental health care charges PPPM among the 3 antipsychotic drug therapies. Other mental health charges associated with quetiapine were estimated to be 14 US dollars, or 3% lower than those associated with risperidone, but this difference was not statistically significant (P = 0.069). The PPPM charges for quetiapine versus olanzapine and olanzapine versus risperidone were also not different (P = 0.231 and P = 0.39, respectively). After adjusting for differences in average daily dose, risperidone and quetiapine had antipsychotic drug charges that were 84 US dollars and 76 US dollars PPPM lower than those of olanzapine (P < 0.01); the difference between the adjusted drug charges PPPM for risperidone and quetiapine was not significant.

CONCLUSION

Total charges for mental health services other than the study drug were not different for risperidone, olanzapine, and quetiapine in patients treated for bipolar disorder. However, based on prescription charges, olanzapine appears to be considerably more costly at an equivalent daily dose than either risperidone or quetiapine.

The Medical Costs of Migraine and Comorbid Anxiety and Depression

OBJECTIVE

To examine the direct medical costs associated with migraine, when diagnosed alone and in conjunction with anxiety and/or depression in adults and children.

BACKGROUND

Migraine is a common disorder that can often be accompanied by comorbid anxiety and/or depression. Given the prevalence of migraine and the likelihood for comorbid conditions, it is not surprising that migraine is extremely costly for society.

METHODS

Migraine cohorts were identified in a 1999-2000 database capturing inpatient, outpatient, and prescription drug services from approximately 45 large employers. Four cohorts of adults (migraine only, migraine and anxiety, migraine and depression, migraine and both conditions), and two cohorts of children (migraine only, migraine and anxiety and/or depression), were compared to respective "healthy" cohorts. t-statistics were used to capture differences in costs between the migraine cohorts and the healthy cohorts whereas ANOVA was used to test for differences in costs between subgroups of migraine sufferers.

RESULTS

Compared to nonmigraineurs, adults and children with migraine had significantly higher total direct medical costs in all examined categories (P < .0001) (7,089 US Dollars vs US Dollars adults; 4,272 US Dollars vs 1,400 US Dollars children). For adults, the presence of depression and/or anxiety along with migraine equated to significantly greater total direct medical costs when compared to their matched healthy cohorts (P < .0001) (12,642 US Dollars vs 5,179 US Dollars anxiety; 11,290 US Dollars vs 3,135 US Dollars depression). Children with migraine and either anxiety or depression (or both) incurred an average of 9,875 US Dollars in total direct medical costs as compared with only 1,165 US Dollars for healthy comparators. For children and adults, the presence of comorbid anxiety or depression was associated with significantly higher medical costs when compared to migraine alone (P < .0001).

CONCLUSIONS

This analysis quantifies the economic impact of a migraine diagnosis for both adults and children. The results of this analysis demonstrate that individuals identified as migraineurs have significantly higher medical costs than healthy comparators, with or without comorbid anxiety and/or depression. This study also suggests that clinicians should be aware that while proper treatment of migraine with effective acute and prophylactic therapy is important, attention must also be directed to comorbid conditions.

Measuring satisfaction with migraine treatment: Expectations, importance, outcomes, and global ratings

BACKGROUND

Patients tend to express high satisfaction with treatment using global rating scales. Previous work in health services, marketing, and operations research suggested that global ratings of satisfaction need to account for multiple influences and differing patient values. Prior qualitative work with patients and clinicians supported a 4-part model that incorporates the gap between expectations and outcomes of treatment and accounts for the relative importance of different treatment attributes.

OBJECTIVE

The aim of this work ws to generate a small experimental data set to develop and evaluate the potential usefulness of the conceptual model and scoring algorithm for the application of this new measurement strategy, the Migraine Treatment Satisfaction Measure (MTSM).

METHODS

Before treatment, migraine patients who were beginning a new prescription for headache rated their expectations and the importance of 9 attributes of treatment: pain relief, speed of relied, freedom from pain, additional symptoms, confidence in treatment, disruption in life, dosing, freedom from relapse, and ease of use. After treatment, patients rates outcomes on these 9 attributes and provided global satisfaction ratings. Weights reflecting the gap between expectations and outcomes and the importance ratings were applied to these global ratings after treatment to produce the MTSM score. The weighted rating scales were then tested for internal consistency, reliability, and construct validity using the Short-Form 36-item Health Survey (SF-36), 24-hour Migraine Quality of Life Questionnaire (MQoLQ), a measure of symptom bothersomeness, and a measure of migraine intensity.

RESULTS

Forty-eight patients were screened and 29 patients completed this pilot study. Internal consistency of coefficients exceeded 0.90 for all 4 components of the MTSM (patients' expectations of treatment, ratings of the importance of individual attributes of treatment, assessments of outcome on each attribute, and global treatment satisfaction ratings). Derived or weighted scores expanded the distribution of unweighted global satisfaction ratings and improved statistical performance by reducing variability (from 20.5 to 14.8) for overall score). Hypothesized associations were confirmed between the MTSM, SF-36, MQoLQ, symptom bothersomeness, and migraine intensity.

CONCLUSION

The 4-part conceptual model reflecting multiple attributes of treatment and preliminary scoring system for the MTSM generated satisfaction scores that improved discrimination among patients. Further validation is warranted.

Psychosocial factors associated with dieting behaviors among female adolescents

This study determined whether female adolescents who were attempting weight loss (dieters) differ from those who were not (nondieters) with respect to a set of psychosocial factors. The sample consisted of 2,536 normal-weight and underweight female adolescents who participated in the National Longitudinal Adolescent Health Survey. Psychosocial factors examined included depression (four measures), self-esteem, trouble in school, school connectedness, family connectedness, sense of community (two measures), grades, autonomy, and protective factors. MANCOVA revealed significant differences between dieters and nondieters. Self-esteem was the strongest contributing factor differentiating dieters and nondieters. These results have implications for health education and health promotion with regard to both primary and secondary prevention. Self-esteem building should be incorporated within the parameters of a comprehensive school health program and certainly should be a component in any nutrition education program aimed at preventing unhealthy dieting behaviors. By understanding the factors associated with these behaviors, it may be easier to identify individuals attempting weight loss despite being of normal or low body weight.