Relationship Between Buprenorphine Adherence and Health Service Utilization and Costs Among Opioid Dependent Patients

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

Pharmacy and medical costs associated with switching between venlafaxine and SSRI antidepressant therapy for the treatment of major depressive disorder

BACKGROUND: While much has been published on utilization of antidepressants and associated resource use, surprisingly little information is available on the relationship between a change in antidepressant agent and health care utilization. Given that many patients will not respond to initial therapy (and therefore would be candidates for switching treatment) and the array of antidepressant medications on the market, information on the impact of switching would be beneficial to both providers and policymakers. OBJECTIVE: To explore patterns of antidepressant drug use and depression-related and all-cause medical costs for patients who switched therapy between 2 drug classes, selective serotonin reuptake inhibitors (SSRIs) and the selective norepinephrine reuptake inhibitor (SNRI) venlafaxine. METHODS: Using an administrative claims database of 36 million members from 61 health plans, this retrospective cohort analysis examined patients who had (1) a diagnosis of major depressive disorder (MDD, International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 296.2x for MDD single episode, 296.3x for MDD recurrent episode, 300.4 for dysthymic disorder, and 311 for depressive disorder not elsewhere classified) and (2) a newly prescribed antidepressant during the year 2002. Costs were defined as amounts paid by health plans for all inpatient, outpatient, physician and pharmacy services (i.e., allowed charges after subtraction of member cost-share). Depression-related costs were defined using (1) medical claims with primary diagnosis of depression and (2) pharmacy claims for antidepressants. Using an index date of the first antidepressant claim, 12 months of pre-index and postindex data were available for all eligible patients. Switching was defined as occurring between the SSRIs and venlafaxine (i.e., patients who switched within the SSRI drug class across different SSRIs were treated as non-switchers until they switched to venlafaxine), and there was no minimum or maximum gap in therapy. The SSRIs included fluoxetine, citalopram, sertraline, and paroxetine; the only SNRI on the market at the time was venlafaxine. Multivariate regression analyses determined predictors of switching and factors influencing overall and depression-related costs, while controlling for confounding factors. For the 12-month period following the index date (fixed length of follow-up), the study compared per-patient per-year (PPPY) costs for (1) patients who switched versus those who did not switch and (2) patients with single versus multiple trials of SSRI for the subgroup of patients who switched from an SSRI to venlafaxine. For the time periods before versus after the switch (variable lengths of follow-up), per-patient means and medians of monthly cost averages (with follow-up periods <1 month set to 1 month for 16.5% [n=272] of SSRI-to-venlafaxine switchers and 14.1% [n=103] of venlafaxine-to-SSRI switchers) were calculated for the subgroup of patients who made a switch. RESULTS: A total of 48,950 patients were included in the study, with 43,653 (89.2%) treated first with SSRIs and 5,297 (10.8%) treated first with venlafaxine. Of the initial SSRI users, 1,645 (3.8%) switched to venlafaxine, and of the initial venlafaxine users, 733 (13.8%) switched to an SSRI. Mean (standard deviation [SD]) 12-month total (medical plus pharmacy) depression-related costs in 2002-2003 dollars were 118.0% higher for SSRI switchers ($1,225 [$3,438] vs. $562 [$2,153], P<0.001) and 18.4% higher for venlafaxine switchers ($863 [$1,503] vs. $729 [$1,185], P=0.021) as compared with non-switchers. From the pre-switch to post-switch periods, depression-related mean monthly medical costs declined by 66.4% among switchers from SSRIs ($113 [$912] vs. $38 [$347], P=0.001) and by 61.1% among switchers from venlafaxine ($54 [$299] vs. $21 [$138], P=0.005). Monthly mean depression-related pharmacy costs increased by 62.2% following a switch from an SSRI to venlafaxine (from $45 [$38] to $73 [$62], P<0.001) and declined by 17.3% following a switch from venlafaxine to an SSRI (from $52 [$45] to $43 [$38], P<0.001). After adjustment for multiple covariates including demographic characteristics, 10 selected comorbidities, and physician specialty, general linear models with log-transformed costs as the dependent variables demonstrated significant associations between switching and total costs (both all-cause and depression-related) in both the SSRI and the venlafaxine cohorts. CONCLUSIONS: Although relatively few patients switched antidepressant drug classes, patients who made a switch had higher all-cause health care costs and higher depression-related costs than patients who did not switch. Switching drug classes was associated with lower mean monthly depression-related health care costs following the switch. For those patients switching from an SSRI to venlafaxine, mean medical cost reductions offset higher pharmacy costs; for patients switching from venlafaxine to an SSRI, mean medical and pharmacy costs declined.     

The Association Between Stimulant,Opioid, and Multiple Drug Use on Behavioral Health Care Utilization in a Safety-Net Health System

Background: Prior studies show an association between drug use and health care utilization. The relationship between specific drug type and emergent/urgent, inpatient, outpatient, and behavioral health care utilization has not been examined. We aimed to determine if multiple drug use was associated with increased utilization of behavioral health care. Methods: To assess health care utilization, we conducted a retrospective cohort study of patients who accessed health care at a safety-net medical center and affiliated clinics. Using electronic health records, we categorized patients who used stimulants, opioids, or multiple drugs based on urine toxicology screening tests and/or International Classification of Diseases, 9th Revision (ICD-9). Remaining patients were categorized as patients without identified drug use. Health care utilization by drug use group and visit type was determined using a negative binomial regression model. Associations were reported as incidence rate ratios. Utilization was described by rates of health care–related visits for inpatient, emergent/urgent, outpatient, and behavioral health care among patients who used drugs, categorized by drug types, compared with patients without identified drug use. Results: Of 95,198 index visits, 4.6% (n = 4340) were by patients who used drugs. Opioid and multiple drug users had significantly higher rates of behavioral health care visits than patients without identified drug use (opioid incidence rate ratio [IRR] = 7.2; 95% confidence interval [CI]: 3.8–13.8; multiple drug use IRR = 5.6, 95% CI: 3.3–9.7). Patients who used stimulants were less likely to use behavioral health services (IRR = 1.3, 95% CI: 0.9–2.0) when compared with opioid and multiple drug users, but were more likely to use inpatient (IRR = 1.6, 95% CI: 1.4–1.8) and emergent/urgent care (IRR = 1.4, 95% CI: 1.3–1.5) services as compared with patients without identified drug use. Conclusions: Integrated medical and mental health care and drug treatment may reduce utilization of costly health care services and improve patient outcomes. How to capture and deliver primary care and behavioral health care to patients who use stimulants needs further investigation.     

Five-year trajectories of health care utilization and cost in a drug and alcohol treatment sample

BACKGROUND: The study examined the effect of individual characteristics on longitudinal patterns of health care utilization and cost among individuals entering chemical dependency (CD) treatment. METHOD: Structured interviews and computerized administrative databases were linked to obtain severity, utilization and cost data. Total medical costs and their components were examined for the 6 months prior to intake through 5 years post-intake. Statistical analyses were conducted using the hierarchical linear modeling framework. RESULTS: Age was positively correlated with total medical costs. Women had higher inpatient utilization and higher inpatient, primary care and total cost at baseline (p<.05). However, they had steeper decline in primary care costs. While age was not related to inpatient and ER use at baseline (after controlling for psychiatric and medical severity), older individuals had smaller declines in hospital days and inpatient cost over time. Individuals with high medical and psychiatric severity had higher utilization and costs (p<.01). Those who were abstinent had higher costs. CONCLUSIONS: There are important differences in patient characteristics and treatment outcomes that influence utilization and cost trajectories. The relationship between medical severity at intake and primary care cost pre-intake among patients with drug and alcohol problems suggests an opportunity to identify and treat drug and alcohol problems in primary care settings. It also suggests that medical evaluations and treatment should not be overlooked during CD treatment. The positive association between abstinence and trajectories of primary care and total medical costs suggests that maintaining abstinence over a long term requires some kind of continuing care either in primary care settings or via additional contacts with specialty CD departments.     

Actuarial analysis of private payer administrative claims data for women with endometriosis

BACKGROUND: Endometriosis is a painful, chronic disease affecting 5.5 million women and girls in the United States and Canada and millions more worldwide. The usual age range of women diagnosed with endometriosis is 20 to 45 years. Endometriosis has an estimated prevalence of 10% among women of reproductive age, although estimates of prevalence vary greatly. Endometriosis is the most common gynecological cause of chronic pelvic pain, but published information on its associated medical care costs is scarce. OBJECTIVE: The aim of this study was to determine (1) the prevalence of endometriosis in the United States, (2) the amount of health care services used by women coded with endometriosis in a commercial medical claims database during 1999 to 2003, and (3) the endometriosis-related costs for 2003, the most recent data available at the time the study was performed. METHODS: This study was a retrospective review of administrative data for commercial payers, which included enrollment, eligibility, and claims payment data contained in the Medstat Marketscan database for approximately 4 million commercial insurance members. All claims and membership data were extracted for each woman aged 18 to 55 years who had at least 1 medical or hospital claim with a diagnosis code for endometriosis (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 617.00-617.99) for 1999 through 2003. Claims data from 1999 through 2003 were used to determine prevalence and health care resource utilization (i.e., annual admission rate, annual surgical rate, distribution of endometriosis-related surgeries, and prevalence of comorbid conditions). The cost analysis was based on claims from 2003 only. Cost was defined as the payer-allowed charge, which equals the net payer cost plus member cost share. RESULTS: The prevalence of women with medical claims (inpatient and/or outpatient) containing ICD-9-CM codes for endometriosis was 1.1% for the age band of 30 to 39 years and 0.7% over the entire age span of 18 to 55 years. The medical costs per patient per month (PPPM) for women with endometriosis were 63% greater ($706 PPPM) than those of the average woman per member per month ($433) in 2003; inpatient hospital costs accounted for 32% of total direct medical costs. Between 1999 and 2003, these women with endometriosis who were identified by either inpatient and/or outpatient claims had high rates of hospital admission (53% for any reason; 38% for an endometriosis-related reason) and a high annual surgical procedure rate (64%). Additionally, women with endometriosis frequently suffered from comorbid conditions, and these conditions were associated with greater PPPM costs of 15% to 50% for women with an endometriosis diagnosis code, depending on the condition. Interstitial cystitis was associated with 50% greater cost ($1,061 PPPM); depression, 41% ($997 PPPM); migraine, 40% ($988 PPPM); irritable bowel syndrome, 34% ($943 PPPM); chronic fatigue syndrome, 29% ($913 PPPM); abdominal pain, 20% ($846 PPPM); and infertility, 15% ($813 PPPM). CONCLUSIONS: Women with endometriosis have a high hospital admission rate and surgical procedure rate and a high incidence of comorbid conditions. Consequently, these women incur total medical costs that are, on average, 63% higher than medical costs for the average woman in a commercially insured group.     

Economic burden of anemia in an insured population

OBJECTIVE: Anemia is a common hematological disorder characterized by reduced hemoglobin concentrations. Despite information on prevalence and associated outcomes, little is known about the impact of anemia on health care utilization and costs. This study examines anemia prevalence and associated medical costs and utilization, using administrative claims for adults newly diagnosed with anemia, including up to 12 months of follow-up. METHODS: Patients predisposed to anemia, based on selected comorbid conditions (chronic kidney disease, human immunodeficiency virus, rheumatoid arthritis, inflammatory bowel disease, congestive heart failure, and solid-tumor cancers), were identified. Costs for anemic patients and a random sample of nonanemic patients with these conditions were compared. Associations were evaluated after adjustment for potential confounders using a regression model. Clinical care patterns were examined overall and by condition. RESULTS: Anemia was observed in 3.5% (81,423) of approximately 2.3 million health plan members in 2000; 15% of anemic patients received an identified treatment, with transfusion being the most frequent intervention. Utilization and costs were significantly higher for anemic patients (P < 0.001). Average annualized per-patient costs were 14,535 US dollars for anemic patients (55% outpatient, 33% inpatient, 13% pharmacy), 54% higher than the 9,451 US dollars average cost for nonanemic patients (45% outpatient, 36% inpatient, 19% pharmacy). After adjustment for age, other comorbidities (e.g., chronic kidney disease and cancer), sex, and insurance type (indemnity, preferred provider organization/point of service, or health maintenance organization, in the Medstat MarketScan database), anemic patients had average costs that were more than twice the adjusted costs of nonanemic patients. CONCLUSION: Medical costs for anemic patients are as much as twice those for nonanemic patients with the same comorbid conditions.     

Economic burden in direct costs of concomitant chronic obstructive pulmonary disease and asthma in a Medicare Advantage population

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a highly prevalent disease whose sufferers consume a large amount of resources. Among community-dwelling Medicare beneficiaries, 12% reported that they had COPD in 2002. For clinicians, differentiating COPD from asthma may be difficult, but among patients with COPD and asthma, approximately 20% have both conditions. The economic impact of concomitant asthma and COPD is potentially large but has not been studied. OBJECTIVE: To assess the cost burden of asthma in patients with COPD in a Medicare Advantage population. METHODS: We reviewed the database of a large health plan that contained information from more than 30 distinct plans covering approximately 25 million members. We identified Medicare beneficiaries aged 40 years or older with medical and pharmacy benefits and medical claims with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes for COPD or asthma over a 1-year identification period (calendar year 2004). We assigned patients to 2 cohorts based on diagnoses on medical claims (any diagnosis field) during 2004; the COPD cohort had at least 1 medical claim for COPD, and the COPD + asthma cohort had at least 1 claim for COPD and at least 1 claim for asthma. A patient's index date was the first date during 2004 in which there was a medical claim with a diagnosis code for COPD or asthma. To confirm diagnosis, each patient was required to have at least 1 additional claim for COPD (COPD cohort) or at least 1 claim for COPD and at least 1 claim for asthma (COPD + asthma cohort) during the 24-month period from 12 months before through 12 months after the index date. We excluded patients who (1) were not continuously enrolled during the 12 months before and after the index date and (2) did not have at least 1 pharmacy claim for a drug of any type (to verify pharmacy benefits). Outcome measures included the use of emergency room (ER) and hospital services, and cost (net provider payment after subtraction of member cost share), categorized as all-cause, non-respiratory, and respiratory-related. ER use and inpatient hospital stays were identified using place-of-service codes. A minimum of 2 consecutive dates of service (length of stay [LOS] of at least 1 day) was required to indicate an inpatient hospitalization. An LOS of at least 1 day was required to distinguish inpatient services from other services (e.g., procedures or tests) reported on claims with an inpatient place of service. Multivariate analyses adjusted for age, gender, census region, and Charlson Comorbidity Index (CCI). Ordinary least squares regression was used to predict respiratory-related total health care costs, and logistic regression was used to predict the occurrence of at least 1 acute event, defined as use of either an ER or an inpatient hospital. All 2-way interactions were considered, and only those with significant results were included in the models. All reported P values were 2-sided with a 0.05 significance level. RESULTS: During 2004, 68,532 individuals within the database were enrolled in a Medicare Advantage plan. After application of the other inclusion criteria, we excluded approximately 11% of the patients who did not have 1 pharmacy claim of any type. There were 8,086 patients (11.8%) who had at least 1 medical claim with diagnosis codes for COPD and at least 1 other medical claim for either COPD or asthma and were continuously enrolled for at least 24 months. The COPD + asthma cohort numbered 1,843 patients (22.8%), and the COPD cohort numbered 6,243 patients (77.2%). Compared with COPD patients without asthma, patients with COPD + asthma were slightly younger, and a higher proportion was female. There were differences between the 2 cohorts in geographic distribution, and the COPD + asthma cohort had a higher disease severity with a mean CCI score of 2.6 (standard deviation [SD], 2.1) compared with the COPD cohort (2.3 [2.3], P < 0.001). Respiratory-related pharmacy costs were a relatively small part of total respiratory-related health care costs: approximately 5.7% for the COPD cohort and 8.8% for the COPD + asthma cohort. Respiratory-related costs accounted for 22.0% of total all-cause health care costs for the COPD cohort and 28.7% for the COPD + asthma cohort. Mean ([SD], median) unadjusted respiratory-related health care costs were $7,240 ([$15,057], $1,957) for the COPD + asthma cohort and $5,158 ([$11,881], $808) in the COPD cohort. After adjusting for covariates, patients in the COPD + asthma cohort were more likely to have at least 1 acute event (e.g., ER visits and hospitalizations) than patients in the COPD cohort (adjusted odds ratio, 1.6; 95% CI, 1.4-1.7) and had $1,931 (37.1%) greater adjusted respiratory-related health care costs--$7,135 versus $5,204 for the COPD cohort (P < 0.001). CONCLUSION: Medicare beneficiaries with COPD and asthma incur higher health care costs and use more health care services than those with COPD without asthma.     

Costs associated with the management of overactive bladder and related comorbidities

STUDY OBJECTIVE: To evaluate the clinical and economic impact of overactive bladder (OAB) on the management of related comorbidities in a managed care population. DESIGN: Retrospective analysis of a claims database. SETTING: A large managed care organization in the United States. PATIENTS: A total of 11,556 patients with OAB who were aged 18 years or older and 11,556 control subjects without OAB who were matched on propensity score. MEASUREMENTS AND MAIN RESULTS: Patients and controls were identified from July 1-December 31, 2001, and followed for 360 days. The propensity score for matching controls was estimated based on patient demographics and diagnosis of important clinical conditions during a 180-day preindex period. Medical claims were examined for any diagnosis of the studied comorbidities. Submitted medical charges for claims with a primary or secondary diagnosis of the studied comorbidities were analyzed. Prevalence and medical charges for depression, skin infections, and vulvovaginitis were compared between patients with OAB and control subjects by using chi2 and t tests. Prevalence and medical charges for falls and fractures, urinary tract infections (UTIs), and any comorbidity were compared by using logistic regression and general linear modeling, to adjust for additional confounders not included in the matching process. Prevalence of all comorbid conditions was significantly higher (p<0.0001) for patients with OAB than for control subjects: falls and fractures, 25.3% versus 16.1%; depression, 10.5% versus 4.9%; UTIs, 28.0% versus 8.4%; skin infections, 3.9% versus 2.3%; vulvovaginitis, 4.7% versus 1.8%; any of these comorbidities, 52.1% versus 27.9%. Mean annual medical charges were significantly higher for patients than for controls for all comorbidities: falls and fractures, $934 versus $598 (p<0.0001); depression, $93 versus $23 (p<0.0001); UTIs, $603 versus $176 (p<0.0001); skin infections, $67 versus $10 (p=0.002); vulvovaginitis, $11 versus $3 (p<0.0001); any comorbidity, $1689 versus $829 (p<0.0001). CONCLUSION: This study quantifies the increased prevalence of and additional medical costs associated with related comorbidities in patients with OAB, emphasizing that the economic and clinical impact of OAB extends beyond the disease itself. Thus, management of patients with OAB should be of greater focus with both clinicians and health care payers.     

Health care costs and comorbidities for patients with inclusion body myositis

Objective: This study identifies the health care costs and utilization, as well as comorbidities, in a Medicare population of inclusion body myositis (IBM) patients.

Methods: Medicare patients aged ≥65 years with a diagnosis claim for IBM were identified and matched to a cohort of non-IBM patients based on age, sex, race, calendar year and census region. Generalized linear models were used to estimate health care costs and utilization during the follow-up period.

Results: The prevalence of IBM in this population, aged ≥65 years, was 83.7 cases per 1 million patients. Mean 1 year costs for the IBM cohort (N?=?361) were $44,838 compared to $10,182 for the matched non-IBM cohort (N?=?1805), an excess of $34,656. IBM was significantly associated with multiple unsuspected comorbidities, including hypertension (66% vs. 22%), hyperlipidemia (47% vs. 18%) and myocardial infarction (13% vs. 2%) (all p?Conclusions: IBM patients utilize more health care resources and incur higher health care costs than patients without IBM. Furthermore, IBM patients were more likely to have multiple comorbidities, including cardiovascular risk factors and events, muscle and joint pain, and pulmonary complications compared to those without IBM.

Limitations: The presence of a diagnosis code for a condition on a medical claim does not necessarily indicate the presence of the disease condition because the diagnosis code could be incorrectly entered in the database. Clinical and disease-specific parameters were not available in the claims data. Additionally, due to the observational study design, the analysis may be affected by unobserved differences between patients.     

Pharmacy cost evaluation of risperidone, olanzapine, and quetiapine for the treatment of schizophrenia in acute care inpatient settings

OBJECTIVE: This study examines total pharmacy cost and usage patterns of schizophrenic patients in acute mental health inpatient settings for three atypical antipsychotics -- risperidone, olanzapine, and quetiapine. Despite the readily available unit cost information for drugs, actual pharmacy costs may deviate significantly from 'labeled costs'. Recent research findings indicate the need for more robust evaluation of such pharmacy costs. RESEARCH DESIGN AND METHODS: This study used data from non-randomized inpatient retrospective charts from three acute care inpatient mental health facilities. The final pooled sample included 327 patients, of which 120 received risperidone, 153 received olanzapine, and 54 received quetiapine. Medication cost was defined as the average wholesale price (AWP) as listed in the 2001 'Red Book'. Propensity scoring methodology and multinomial regression were employed to reduce treatment selection bias. RESULTS: The observed mean daily antipsychotic drug doses were 4.45 mg (SD 2.44) for risperidone, 14.04 mg (SD 5.55) for olanzapine, and 350.33 mg (SD 228.24) for quetiapine. The corresponding mean daily drug costs were $7.66(SD $4.20) for risperidone, $8.11 (SD $5.29) for quetiapine and, $12.10 (SD $4.79) for olanzepine. Numbers adjusted for treatment selection bias show that the average daily total pharmacy cost of risperidone was $4.35 lower than olanzapine (p < 0.001) and $1.41 lower than quetiapine (p = 0.38). The adjusted average daily pharmacy cost of olanzapine was $4.02 higher than quetiapine (p < 0.001). After statistical adjustment there were no significant differences between study drugs in terms of length of stay or patient functioning. CONCLUSION: This study provides the first US comparison of medication utilization patterns and pharmacy costs for olanzapine, risperidone, and quetiapine administered in acute mental health care inpatient settings. While this study did not estimate the full economic value of the three antipsychotics in these inpatient settings, it demonstrated that the mean daily costs for risperidone were lower than the mean daily costs for olanzapine (p < 0.001) and quetiapine although the later difference was not statistically significant (p = 0.38).     

Medical service use and financial charges among opioid users at a public hospital

We examined the prevalence of drug use related infectious complications among opioid using or dependent individuals and service charges associated with medical care received over a 2-year period at a public hospital. A computerized medical record review was used to identify 3147 individuals with diagnoses related to opioid use or dependence. Forty-nine percent of these patients were treated for bacterial infections and 30% presented for treatment of medical problems arising from the effects of the drugs themselves (e.g. drug withdrawal, overdoses, and drug-induced psychiatric symptoms). Mean charges were $13393 for these patients, nearly 2.5 times the average per patient charges for non-opioid using patients during the study period. Patients with diagnoses related to opioid use or dependence comprised 2% of the total patient population for this period, yet accounted for 5% of total charges. Homeless patients were less likely to have used ambulatory services and were more likely than non-homeless patients to have used emergency and inpatient services. Early detection of patients with opioid use or dependence problems, coupled with effective strategies to engage them in ambulatory preventive services, could allow interventions to reduce morbidity and associated charges in this patient population. The findings suggest that health care providers and policy makers consider policies that promote ambulatory care use among opioid users seeking medical care through the public health care system.