Short-term rehospitalizations in young adults with schizophrenia treated with once-monthly paliperidone palmitate or oral atypical antipsychotics: a retrospective analysis

Objective: To compare rehospitalizations in patients with schizophrenia treated with paliperidone palmitate (PP1M) vs oral atypical antipsychotics (OAAs), with a focus on young adults (18–35 years).

Methods: The Premier Healthcare database (January 2009–December 2016) was used to identify hospitalizations of adults (≥18 years) with schizophrenia treated with PP1M or OAA between September 2009 and October 2016 (index hospitalizations). Rehospitalizations were assessed at 30, 60, and 90 days after each index hospitalization in young adults and in all patients. Proportions of index hospitalizations resulting in rehospitalization were reported and compared between groups using odds ratios (ORs) and 95% confidence intervals (CIs).

Results: A total of 8578 PP1M and 306,252 OAA index hospitalizations were included. Hospitalized young adults treated with PP1M (n?=?3791) were more likely to be seen by a psychiatrist (94.0% vs 90.0%), and had a longer length of stay (12.5 vs 8.6 days) compared to hospitalized young adults treated with OAA (n?=?96,502). Following their discharge, young adults receiving PP1M during an index hospitalization had a 25–27% lower odds of rehospitalization within 30, 60, and 90 days compared to young adults receiving OAAs (all p?<?.001). Similarly, when observing all patients, those receiving PP1M during an index hospitalization had 19–22% lower odds of rehospitalization within 30, 60, and 90 days compared to those receiving OAAs (all p?<?.001).

Conclusions: Following a hospitalization for schizophrenia, PP1M treatment was associated with fewer 90-day rehospitalizations among young adults (18–35 years) relative to OAA treatment. This finding was also observed in other hospitalized adults with schizophrenia.     

Comparison of Medicaid spending in schizoaffective patients treated with once monthly paliperidone palmitate or oral atypical antipsychotics

Background Compared to oral atypical antipsychotics (OAAs), long-acting injectable antipsychotics require less frequent administration, and thus may improve adherence and reduce risk of relapse in schizoaffective disorder (SAD) patients.

Objective To evaluate the impact of once monthly paliperidone palmitate (PP) versus OAAs on healthcare resource utilization, Medicaid spending, and hospital readmission among SAD patients.

Methods Using FL, IA, KS, MS, MO, and NJ Medicaid data (January 2009–December 2013), adults with ≥2 SAD diagnoses initiated on PP or OAA (index date) were identified. Baseline characteristics and outcomes were assessed during the 12month pre- and post-index periods, respectively. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were used to reduce confounding and compare the estimated treatment effect for PP versus OAA.

Results A total of 10,778 OAA-treated patients and 876 PP-treated patients were selected. Compared to OAAs, PP was associated with significantly lower medical costs (PSM: mean monthly cost difference [MMCD]?=?-$383, p?<?0.001; IPTW: MMCD?=?-$403, p?=?0.016), which offset the higher pharmacy costs associated with PP (PSM: MMCD?=?$270, p?<?0.001; IPTW: MMCD?=?$350, p?<?0.001) and resulted in similar total healthcare cost (PSM: MMCD?=?-$113, p?=?0.414; IPTW: MMCD?=?-$53, p?=?0.697) for PP versus OAA. Reduced risk of hospitalization (PSM: incidence rate ratio [IRR]?=?0.85, p?=?0.128; IPTW: IRR?=?0.96, p?=?0.004) and fewer hospitalization days (PSM: IRR?=?0.74, p?=?0.008; IPTW: IRR?=?0.85, p?<?0.001) were observed in PP versus OAA patients. Among hospitalized patients, PP was associated with a lower risk of 30 day hospital readmission compared to OAA (IPTW: odds ratio?=?0.89, p?=?0.041).

Limitations The Medicaid data may not be representative of the nation or other states, and includes pre-rebate pharmacy costs (potentially over-estimated). Also changes in treatment over time were possible.

Conclusions Total healthcare costs associated with the use of once monthly PP versus OAAs appeared comparable; higher pharmacy costs for PP users were offset by lower medical costs related to fewer and shorter inpatients visits.     

Transitioning from oral risperidone or paliperidone to once-monthly paliperidone palmitate: a real-world analysis among Veterans Health Administration patients with schizophrenia who have had at least one prior hospitalization

Abstract

Objective: To address gaps in the literature on healthcare resource utilization (HRU) and costs among patients with schizophrenia and prior hospitalization who transition from oral risperidone or paliperidone (oral ris/pali) to once-monthly paliperidone palmitate (PP1M) in a real-world setting by comparing treatment patterns, HRU, and costs 12-months pre- and post-transition to PP1M among Veterans Health Administration (VHA) patients affected by schizophrenia who have had ≥1 hospitalization.

Methods: VHA patients with schizophrenia (aged ≥18?years) who initiated oral ris/pali, had ≥1 all-cause inpatient stay, and transitioned to PP1M from January 2015–March 2017 were included from the VHA database. The first transition date to PP1M was identified as the index date. Patients were required to have continuous health plan eligibility for 12?months pre- and post-PP1M. Outcomes were compared using the Wilcoxon signed-rank and McNemar’s test, as appropriate.

Results: The study included 319 patients (mean [SD] age?=?51.6 [4.2] years) during 12 months of baseline and follow-up. During pre-PP1M transition, 7.2% of the patients were adherent (proportion of days covered [PDC]?≥?80%) to oral ris/pali. Post-PP1M transition, 27.6% of the patients were adherent to PP1M. Comparison of HRU outcomes from the pre- to post-PP1M transition revealed significantly lower all-cause inpatient stays (3.5 vs 1.4, p?<?.0001) and shorter inpatient length of stay (43.4 vs 18.3?days, p?<?.0001). Similar trends were seen for mental health and schizophrenia-related HRU. Cost outcome comparison indicated significantly lower all-cause inpatient costs ($64,702 vs $24,147, p?<?.0001), total medical costs ($87,917 vs $56,947, p?<?.0001), and total costs ($91,181 vs $69,106, p?<?.0001). A similar trend was observed for mental health and schizophrenia-related costs.

Conclusions: Transitioning from oral ris/pali to PP1M may significantly improve HRU and provide potential cost savings in VHA patients with schizophrenia and ≥1 prior hospitalization.     

The prospective economic impact of once monthly paliperidone palmitate versus oral atypical antipsychotics in Medicaid patients with schizophrenia

Objectives: Multiple real-world studies have reported potential cost savings associated with second-generation antipsychotic long-acting injectable therapies (SGA-LAIs), including once monthly paliperidone palmitate (PP1M). Yet, only about 12% of Medicaid patients with schizophrenia initiate SGA-LAIs, with poor adherence contributing to frequent relapse among patients on oral atypical antipsychotics (OAAs). The objective of this study was to project the economic impact when an incremental proportion of non-adherent patients with a recent relapse switched from OAAs to PP1M.

Methods: A 12?month decision-tree model was developed from a Medicaid payers’ perspective. The target population was non-adherent OAA patients with a recent relapse. At equal adherence, risk of relapse was equal between PP1M and OAAs, and OAA patients remained non-adherent until treatment switch. Outcomes included number of relapses, relapse costs and pharmacy costs.

Results: Based on a hypothetical health plan of 1 million members, 3037 schizophrenia patients were non-adherent on OAAs with a recent relapse. Compared to continuing OAAs, switching 5% of patients (n?=?152) to PP1M resulted in net schizophrenia-related cost savings of $674,975 at a plan level, $4445 per patient switched per year and $0.0562 per member per month, with a total of 92 avoided relapses over 12?months. Total annual plan level schizophrenia-related costs were $114.1?M when all patients switched to PP1M before any subsequent relapse (n?=?3037), $123.4?M when patients switched to PP1M after a first subsequent relapse (n?=?2631), and $127.6?M when all patients continued OAAs. Switching all patients to PP1M before any subsequent relapse averted 917 relapses, at a lower cost per patient switched ($37,559) compared to switching after a first subsequent relapse ($45,089) or continuing OAAs ($42,005).

Conclusion: Over 12?months, pharmacy costs associated with switching patients from OAAs to PP1M were offset by reduced relapse rates and schizophrenia-related healthcare expenditures, with earlier use of PP1M projected to generate greater cost savings.     

Risk of chemotherapy-induced febrile neutropenia with same-day versus next-day pegfilgrastim prophylaxis among patients aged ≥65 years: a retrospective evaluation using Medicare claims

Background: Two recent evaluations reported that risk of febrile neutropenia (FN) may be higher when pegfilgrastim prophylaxis (PP) is administered on same day as chemotherapy rather than per recommendation (1–3 days following chemotherapy). Such evidence is based largely on the experience of younger privately insured adults and may not be generalizable to older patients in US clinical practice.

Methods: A retrospective cohort design and data from Medicare Claims Research Identifiable Files (January 2008–September 2015) were employed. Patients were aged ≥65 years, had breast cancer or non-Hodgkin’s lymphoma, received chemotherapy with intermediate/high risk for FN, and received PP in ≥1 cycle; cycles with PP were stratified based on administration day (same-day [“Day 0”] vs. 1–3 days following chemotherapy [“Days 1–3”]) and were pooled for analyses. Adjusted odds ratios (ORs) for FN during the cycle were estimated for patients who received PP on Day 0 versus Days 1–3.

Results: Study population included 65,003 patients who received PP in 261,184 cycles; in 5% of cycles, patients received PP on Day 0. Incidence proportion for FN in cycle 1 was 11.4% for Day 0 versus 8.4% for Days 1–3; adjusted OR was 1.4 (p?p?p?p?Conclusions: Among Medicare patients receiving chemotherapy and PP in US clinical practice, PP was administered before the recommended timing in 5% of cycles and FN incidence was significantly higher in these cycles. Along with prior research, study findings support recently updated US practice guidelines indicating that PP should be administered the day after chemotherapy.     

Healthcare costs for allergic rhinitis patients on allergy immunotherapy: a retrospective observational study

Objective: Subcutaneous immunotherapy (SCIT) for allergic rhinitis (AR) has been shown to control symptoms for up to several years following treatment discontinuation, but the effect of SCIT on healthcare costs for commercially insured patients is unknown. The objective of this study was to compare healthcare costs and resource utilization for patients with AR who received SCIT compared with those who discontinued SCIT shortly after initiation.

Methods: This retrospective cohort study evaluated medical and pharmacy claims from the Optum Research Database from January 2009 through February 2014 for adults and pediatric patients with >7 (continuers) vs. ≤7 (discontinuers) injection visits for SCIT within 60 days of initiation.

Results: After 1:1 propensity score matching, each cohort included 6710 patients. Continuers were less likely than discontinuers to use oral corticosteroids (27.7% vs. 29.6%, p?=?.018), or to have ≥1 respiratory-related emergency room visit (5.4% vs. 6.5%, p?=?.008) and ≥1 inpatient stay (1.1% vs. 1.7%; p?=?.002). Continuers were more likely than discontinuers to have ≥1?AR-related office (98.8% vs. 94.6%, p?p?=?.002). Continuers had greater mean total AR-related costs than discontinuers ($1918 vs. $646, p?p?=?.077); when adjusted with a generalized linear model, these costs were significantly lower among continuers (p?Conclusions: Continued SCIT use is associated with decreased emergency room visits and inpatient stays, decreased oral corticosteroid use, and lower respiratory-related costs, compared with early discontinuation.     

Real-world costs of ischemic stroke by discharge status

Objective: The objective of this study was to estimate the acute healthcare costs of ischemic stroke during hospitalization and the quarterly all-cause healthcare costs for the first year after discharge by discharge status.

Methods: Adult patients with a hospitalization with a diagnosis of ischemic stroke (ICD-9-CM: 434.xx or 436.xx) between 1 January 2006 and 31 March 2015 were identified from a large US commercial claims database. Patients were classified into three cohorts based on their discharge status from the first stroke hospitalization, i.e. dead at discharge, discharged with disability, or discharged without disability. Third-party (medical and pharmacy) and out-of-pocket costs were adjusted to 2015 USD.

Results: A total of 7919 patients dead at discharge, 45,695 patients discharged with disability, and 153,778 patients discharged without disability were included in this analysis. The overall average age was 59.7 years and 52.3% were male. During hospitalization, mean total costs (third-party and out-of-pocket) were $68,370 for patients dead at discharge, $73,903 for patients discharged with disability, and $24,448 for patients discharged without disability (p?p?p?p?Conclusion: The results demonstrated the high economic burden of ischemic stroke, especially among patients discharged with disability with the highest costs incurred during the inpatient stays.     

Local infiltration for postsurgical analgesia following total hip arthroplasty: a comparison of liposomal bupivacaine to traditional bupivacaine

Objective: To assess postsurgical clinical and economic outcomes of patients who received local infiltration containing liposomal bupivacaine versus traditional bupivacaine for pain management following total hip arthroplasty (THA).

Methods: This retrospective study included two groups of consecutive patients undergoing THA. The experimental group received local infiltration with a combination of liposomal bupivacaine, bupivacaine HCl 0.25% with epinephrine 1:200,000, and ketorolac for postsurgical analgesia. The historical control group received the previous standard of care: local infiltration with a combination of bupivacaine HCl 0.25% with epinephrine 1:200,000 and ketorolac. Key outcomes included distance walked, length of stay (LOS), opioid medication use, numeric pain scores, hospital charges, hospital costs, all-cause 30?day readmission rate, and adverse events (AEs). Both unadjusted and adjusted (i.e. age, sex, insurance type, living situation, body mass index, procedure side, and comorbidity) outcomes were compared between the two groups.

Results: The experimental group (n?=?64) demonstrated statistically significant improvement versus the historical control group (n?=?66) in mean distance walked on discharge day (249.2 vs. 180.0 feet; unadjusted p?=?.025, adjusted p?=?.070), mean LOS (2.0 vs. 2.7 days; p?p?=?.002), proportion of patients who used opioid rescue medication on postoperative day (POD) 1 (29.7% vs. 56.1%; p?=?.002, p?=?.003) and POD 2 (7.8% vs. 30.3%; p?=?.001, p?=?.003), mean cumulative area under the curve for pain score on POD 0 (127.6 vs. 292.5; p?p?p?=?.006, both). Among a subgroup of patients with available financial information, mean hospital charges were lower in the experimental group ($43,794 [n?=?24] vs. $48,010 [n?=?66]; p?Conclusions: Infiltration at the surgical site with liposomal bupivacaine was associated with improved postsurgical outcomes when compared with traditional bupivacaine in patients undergoing THA.     

Effects of non-medical switching on outcomes among patients prescribed tumor necrosis factor inhibitors

Objective: To evaluate health care use and outcomes among patients who experienced a non-medical switch of their prescribed anti-tumor-necrosis-factor biological agent (anti-TNF) for cost containment reasons.

Methods: Retrospective evaluation of Humedica electronic health records of patients ≥18 years old with anti-TNF treatment for immune conditions. Using natural language processing, stable patients who experienced a non-medical switch (for cost reasons) of their anti-TNF between 2007 and 2013 were identified (NMS cohort, n?=?158) and matched to patients who did not (control cohort, n?=?4804). Rates of office visits, emergency department visits, and hospitalizations at 30, 90, and 365 days following were evaluated. Medication-related adverse events, defined as subsequent medication change due to a side effect and/or efficacy-related reason were also compared.

Results: Adjusted rates of office visits were higher among the NMS cohort than the control cohort at 30 (46.4% vs. 31.7%, p?p?p?p?=?.003), 90 (31.6% vs 9.6%, p?p?p?=?.001).

Conclusion: Non-medical switching among patients prescribed anti-TNFs was associated with increased health care use, medication-related side effects, and reports of diminished efficacy.     

Risk of chemotherapy-induced febrile neutropenia with early discontinuation of pegfilgrastim prophylaxis based on real-world data from 2010 to 2015

Objective: Evidence suggests that not all cancer chemotherapy patients who receive first-cycle pegfilgrastim prophylaxis (PP) continue to receive it in later cycles, and that these patients may be subsequently at higher risk of febrile neutropenia (FN). Available evidence, however, may not be reflective of current clinical practice. We undertook an evaluation to estimate the odds of FN, beginning with second chemotherapy cycle, among patients who received PP in that cycle and all previous cycles versus those who received PP in all previous cycles only, using recent real-world data.

Methods: A matched-cohort design and data from two US healthcare claims repositories (2010–2015) were employed. The source population comprised cancer patients who received intermediate/high-risk chemotherapy and first-cycle PP. From the source population, beginning with the second cycle, all patients who received PP in all previous cycles were identified. From this subset, patients who did not receive PP in the cycle of interest (“comparison patients”) were matched to those who received PP in that cycle (“PP patients”); the same process was repeated for subsequent cycles. Odds ratios (ORs) for FN (broad and narrow definitions) were estimated using generalized estimating equations.

Results: Among 47,254 patients in the source population, 9% did not receive second-cycle PP and were matched to those who did. FN odds in cycle 2 were significantly higher among comparison patients versus PP patients (OR [broad definition]: 1.7, p?p?p?p?Conclusions: In this real-world evaluation of cancer chemotherapy patients who received first-cycle PP, FN risk was substantially higher among patients who did not receive PP in subsequent cycles versus those who continued PP.     

Risk factors for venous symptoms in Russian patients with chronic venous disease

Objectives: The study aimed to investigate risk factors for venous symptoms in Russian patients with chronic venous disease (CVD).

Methods: Data on 487 patients with CVD aged 18?years and more were extracted from the database of a cross-sectional population-based study on the prevalence of CVD in a rural settlement. Risk factors for venous symptoms were calculated by multiple regression analysis. The study is registered at clinicaltrials.gov as NCT03900234, 1 April 2019.

Results: A total of 259 patients (53.2%) had venous symptoms. Female gender, hard labour (HRs 1.8 and 1.4, p?<?.01), age, family history of CVD and being employed (HRs 1.009, 1.3, 1.27, p?<?.05) are risk factors for development of symptoms. After calculating for different complaints separately, female gender was confirmed as a risk factor for all symptoms. Family history of CVD with HR 1.4 is a risk factor for heaviness (p?<?.01) and fatigue (p?<?0.05). Employment predicts heaviness, sensation of swelling and night cramps – HRs 1.38, 1.7 and 1.9 respectively (p?<?.05). Hard labour is a risk factor for sensation of swelling with HR 2.1 (p?<?.05), pain and night cramps (HRs 2.2 and 4.4, p?<?.01). Prolonged standing is associated with sensation of swelling – HR 1.05 (p?<?.05). Superficial venous reflux is a predictor only for venous pain (HR 2.4, p?<?.01).

Conclusions: This study presents independent risk factors for venous symptoms in CVD patients. It demonstrates that different symptoms are associated with different factors.     

Real-world outcomes post-transition to once-every-3-months paliperidone palmitate in patients with schizophrenia within US commercial plans

Objectives: To compare comorbidity-related outcomes, adherence to antipsychotics (APs), healthcare resource utilization (HRU), and costs pre- and post-transition to once-every-3-months paliperidone palmitate (PP3M) in commercially-insured patients with schizophrenia.

Methods: Adults with ≥1 claim for PP3M, ≥2 schizophrenia diagnoses, and adequate treatment with once-monthly paliperidone palmitate (PP1M; i.e. no gap of >45?days in PP1M coverage for ≥4?months, same PP1M dosage for the last two PP1M claims, and appropriate PP1M to PP3M dosing conversion) were selected from the IQVIA PharMetrics Plus database (May 2014–February 2018). Generalized estimating equation models adjusted for repeated measurements were used to compare patient characteristics, adherence to APs, HRU, and costs during the 6-month period pre- vs post-transition to PP3M.

Results: Of 152 included patients, the mean age was 41.0?years and 36.2% were females. Post-PP3M transition, patients were less likely to have a claim with a diagnosis for substance-related and addictive disorders (odds ratio [OR]?=?0.57), psychoses (OR?=?0.57), diabetes without chronic complication (OR?=?0.72), and drug abuse (OR?=?0.64; all p?<?.05). Patients were more likely to be adherent to APs (OR?=?2.01, p?=?.007), compared to the period pre-PP3M transition. There was no significant difference in HRU pre- vs post-transition. All-cause total (mean monthly cost difference [MMCD]?=?$242), pre-rebate pharmacy (MMCD?=?$65), and medical costs (MMCD?=?$176) remained similar pre- vs post-transition (all p?>?.05).

Conclusions: Transitioning to PP3M was associated with an improvement in adherence and in comorbidity-related outcomes related to substance-related and addictive disorders, psychoses, diabetes without chronic complication, and drug abuse. These findings suggest PP3M may enhance comorbidity-related outcomes and adherence while remaining cost neutral.     

Healthcare costs among adults with type 2 diabetes initiating saxagliptin or linagliptin: a US-based claims analysis

Objective: To compare healthcare costs of adults with type 2 diabetes (T2D) after initiation of saxagliptin or linagliptin, two antidiabetic medications in the dipeptidyl peptidase-4 inhibitor medication class.

Methods: Patients with T2D who were at least 18 years old and initiated saxagliptin or linagliptin (index date) between 1 June 2011 and 30 June 2014 were identified in the MarketScan Commercial and Medicare Supplemental Databases. All-cause healthcare costs and diabetes-related costs (T2D diagnosis on a medical claim and/or an antidiabetic medication claim) were measured in the 1 year follow-up period. Saxagliptin and linagliptin initiators were matched using propensity score methods. Cost ratios (CRs) and predicted costs were estimated from generalized linear models and recycled predictions.

Results: There were 34,560 saxagliptin initiators and 18,175 linagliptin initiators identified (mean ages 57 and 59; 55% and 56% male, respectively). Before matching, saxagliptin initiators had significantly lower all-cause total healthcare costs than linagliptin initiators (mean?=?$15,335 [SD $28,923] vs. mean =?$20,069 [SD $48,541], p?p?n?=?16,069 per cohort), saxagliptin initiators had lower all-cause follow-up costs than linagliptin initiators (CR?=?0.953, 95% CI?=?0.932–0.974, p?p?=?0.017; predicted costs?=?$3989 vs. $4159).

Conclusions: Adult patients with T2D initiating treatment with saxagliptin had lower total all-cause healthcare costs and diabetes-related medical costs over 1 year compared with patients initiating treatment with linagliptin.     

Protein-energy wasting significantly increases healthcare utilization and costs among patients with chronic kidney disease: a propensity-score matched cohort study

Background: Disease-related malnutrition is highly prevalent, and has prognostic implications for patients with chronic kidney disease (CKD); however, few studies have investigated the impact of malnutrition, or protein-energy wasting (PEW), on healthcare utilization and medical expenditure among CKD patients.

Methods: Using claim data from the National Health Insurance in Taiwan, this study identified patients with CKD between 2009–2013 and categorized them into those with mild, moderate, or severe CKD. Cases with PEW after CKD was diagnosed were propensity-score matched with controls in a 1:4 ratio. Healthcare resource utilization metrics were compared, including outpatient and emergency department visits, frequency and duration of hospitalization, and the cumulative costs associated with different CKD severity.

Results: From among 347,501 CKD patients, eligible cohorts of 66,872 with mild CKD (49.2%), 27,122 with moderate CKD (19.9%), and 42,013 with severe CKD (30.9%) were selected. Malnourished CKD patients had significantly higher rates of hospitalization (p?p?=?.015 for mild CKD, p?=?.002 for severe CKD) than non-malnourished controls. Cumulative medical costs for outpatient and emergency visits, and hospitalization, were significantly higher among all malnourished CKD patients than non-malnourished ones (p?p?Conclusions: In a nationally-representative cohort, CKD patients with PEW had significantly more healthcare resource utilization and higher aggregate medical costs than those without, across the spectrum of CKD: preventing PEW in CKD patients should receive high priority if we would like to reduce medical costs.     

Healthcare utilization and direct costs of non-infectious comorbidities in HIV-infected patients in the USA

Objective: To estimate the incremental healthcare utilization and costs associated with common non-infectious comorbid conditions among commercially and Medicaid-insured HIV-infected patients in the US.

Methods: US administrative claims were used to select adult HIV patients with chronic kidney disease (CKD), cardiovascular disease (CVD) events, or fracture/osteoporosis, three common comorbidities that have been associated with HIV and HIV treatment, between 1 January 2004 and 30 June 2013. Propensity score matched controls with no CKD, no CVD events, and no fracture/osteoporosis were identified for comparison. All-cause healthcare utilization and costs were reported as per patient per month (PPPM).

Results: The commercial cohort comprised 381 CKD patients, 624 patients with CVD events, and 774 fracture/osteoporosis patients, and 1013, 1710, and 2081 matched controls, respectively; while the Medicaid HIV cohort comprised 207 CKD and 271 CVD cases, and 516 and 735 matched controls, respectively. There was insufficient Medicaid data for fracture analyses. Across both payers, HIV patients with CKD or CVD events had significantly higher healthcare utilization and costs than controls. The average incremental PPPM costs in HIV patients with CKD were $1403 in the commercial cohort and $3051 in the Medicaid cohort. In those with CVD events, the incremental costs were $2655 (commercial) and $4959 (Medicaid) for HIV patients compared to controls (p?Conclusions: The results suggested a considerable increase in healthcare utilization and costs associated with CKD, CVD and fracture/osteoporosis comorbidities among HIV patients in the past decade. Because these conditions have been associated with treatment, it is critical to consider their impact on costs and outcomes when optimizing patient care.     

Adherence to iron chelation therapy in patients who switched from deferasirox dispersible tablets to deferasirox film-coated tablets

Objective: To compare real-world adherence to and persistence with deferasirox film-coated tablets (DFX-FCT) and deferasirox dispersible tablets (DFX-DT) among patients who switched from DFX-DT to DFX-FCT, overall and by disease type (sickle cell disease [SCD], thalassemia, and myelodysplastic syndrome [MDS]).

Methods: Patients were ≥2 years old and had ≥2 DFX-FCT claims over the study period and ≥2 DFX-DT claims before the index date (first DFX-FCT claim). The DFX-DT period was defined from the first DFX-DT claim to the index date; the DFX-FCT period was defined from the index date to the end of the study period. Adherence was measured as medication possession ratio (MPR) and proportion of days covered (PDC). Persistence was defined as continuous medication use without a gap ≥30 or 60 days between refills. Comparisons were conducted using paired-sample Wilcoxon sign-rank and McNemar’s tests.

Results: In total, 606 patients were selected (SCD: 348; thalassemia: 107; MDS: 106; other: 45). Adherence and persistence in the DFX-FCT vs DFX-DT period was significantly higher across all measures: mean MPR was 0.80 vs 0.76 (p?<?.001); 60.9% vs 54.3% of patients had MPR?≥?0.8 (p?=?.009); mean 3-month PDC was 0.83 vs 0.71 (p?<?.001); 64.2% vs 45.4% of patients had 3-month PDC?≥?0.8 (p?<?.001); 87.2% vs 63.4% of patients had 3-month persistence with no gap ≥30 days and 96.1% vs 79.9% with no gap ≥60 days (p?<?.001). Adherence and persistence improved after switching across all diseases, particularly MDS.

Conclusions: Adherence and persistence improved significantly after switching from DFX-DT to DFX-FCT for all diseases, but especially MDS.     

Risk of chemotherapy-induced febrile neutropenia with early discontinuation of pegfilgrastim prophylaxis: a retrospective evaluation using Medicare claims

Background: Two recent evaluations reported that many cancer chemotherapy patients discontinue pegfilgrastim prophylaxis (PP) following the first cycle, and that these patients have a higher subsequent risk of febrile neutropenia (FN). Such evidence is based principally on the experience of younger adults with private healthcare coverage, and the generalizability of results to elderly Medicare patients is unknown.

Methods: A matched-cohort design and data from the Medicare Claims Research Identifiable Files were employed. The source population comprised cancer patients aged ≥65 years who received chemotherapy with intermediate/high-risk for FN and first-cycle PP. From the source population, beginning with the second cycle, all patients who received PP in all previous cycles were identified. From this sub-set, patients who did not receive PP in the cycle of interest (“comparison patients”) were matched to those who received PP in that cycle (“PP patients”); the same process was repeated for subsequent cycles. Odds ratios (OR) for FN (broad and narrow definitions) were estimated using generalized estimating equations.

Results: Among 77,616 elderly patients in the source population, 5.3% did not receive second-cycle PP and were matched to those who did. In cycle 2, FN odds were significantly higher among comparison patients vs PP patients when employing the broad definition (OR?=?1.9, p?<?.001) and the narrow definition (OR?=?2.1, p?<?.001). Results for subsequent cycles (broad definition: OR?=?2.0, p?<?.001; narrow definition: OR?=?2.1, p?<?.001) and for the last cycle (broad definition: OR?=?1.4, p?=?.060; narrow definition: OR?=?1.7, p?=?.055) were largely comparable.

Conclusions: In this large-scale evaluation of elderly Medicare patients who received myelosuppressive chemotherapy and first-cycle PP in recent US clinical practice, FN risk was substantially lower among patients who continued to receive PP in subsequent cycles vs those who discontinued PP.     

Prevalence and economic burden of hyperkalemia in the United States Medicare population

Abstract

Objective: To estimate the prevalence and economic burden of hyperkalemia in the United States (US) Medicare population.

Methods: Patients were selected from a 5% random sample of Medicare beneficiaries (01 January 2010–31 December 2014) to estimate the prevalence and economic burden of hyperkalemia. The prevalence for each calendar year was calculated as the number of patients with hyperkalemia divided by the total number of eligible patients per year. To estimate the economic burden of hyperkalemia, patients with hyperkalemia (cases) were matched 1:1 to patients without hyperkalemia (controls) on age group, chronic kidney disease [CKD] stage, dialysis treatment, and heart failure. The incremental 30-day and 1-year resource utilization and costs (2016 USD) associated with hyperkalemia were estimated.

Results: The estimated prevalence of hyperkalemia was 2.6–2.7% in the overall population and 8.9–9.3% among patients with CKD and/or heart failure. Patients with hyperkalemia had higher 1-year rates of inpatient admissions (1.28 vs. 0.44), outpatient visits (30.48 vs. 23.88), emergency department visits (2.01 vs. 1.17), and skilled nursing facility admissions (0.36 vs. 0.11) than the matched controls (all p?<?.001). Patients with hyperkalemia incurred on average $7208 higher 30-day costs ($8894 vs. $1685) and $19,348 higher 1-year costs ($34,362 vs. $15,013) than controls (both p?<?.001). Among patients with CKD and/or heart failure, the 30-day and 1-year total cost differences between cohorts were $7726 ($9906 vs. $2180) and $21,577 ($41,416 vs. $19,839), respectively (both p?<?.001).

Conclusions: Hyperkalemia had an estimated prevalence of 2.6–2.7% in the Medicare population and was associated with markedly high healthcare costs.     

Everolimus compliance and persistence among tuberous sclerosis complex patients with renal angiomyolipoma or subependymal giant cell astrocytoma

Objective: Everolimus is the only FDA approved drug to treat renal angiomyolipoma or subependymal giant-cell astrocytoma (SEGA) in tuberous sclerosis complex (TSC). Potential differences exist between patients with commercial and Medicaid insurance on everolimus use; however, there is limited information from the real world. This study compared compliance and persistence of everolimus between commercial and Medicaid patients using US claims data.

Methods: Patients with ≥1 claim of TSC with renal angiomyolipoma or SEGA were selected from the MarketScan commercial (1 January 2009–31 August 2016) and Medicaid (1 January 2009–30 June 2015) databases. Patients were followed from index date (the earliest date of TSC, renal angiomyolipoma or SEGA diagnosis) to death or end of data. Non-persistence, defined as ≥60?day gap without everolimus, and medication possession ratio (MPR) were assessed among the subset of patients with ≥1 year of follow-up from the first everolimus claim.

Results: A total of 1497 TSC patients met the study criteria (896 renal angiomyolipoma only, 411 SEGA only and 190 both). Compared to Medicaid patients (N?=?513), commercial patients (N?=?984) had the same ages (22 years) but a shorter length of follow-up (38 vs. 48 months, p?<?.001). Medicaid and commercial patients had similar rates of being treated with everolimus (14.4% vs. 13.6%, p?=?.668), but it took Medicaid patients a longer time to start everolimus (871 vs. 704 days, p?<?.001). Although the non-persistence rate was not significantly different between commercial and Medicaid patients (42.5% vs. 35.1%, p?=?.561), the number of days from everolimus initiation to non-persistence was significantly lower for commercial patients (945 vs. 1132, p?<?.001). During the 1 year post everolimus initiation, commercial patients had a significantly higher MPR (0.81 vs. 0.74, p?<?.001) and higher percentage of patients with MPR ≥0.80 (67.8% vs. 58.1%, p?<?.001).

Conclusions: Among TSC patients with renal angiomyolipoma or SEGA and treated with everolimus, everolimus MPR was between 0.74 and 0.81. Medicaid patients had lower MPR than commercial patients but better persistence.