Outcomes and healthcare resource utilization associated with medically attended hypoglycemia in older patients with type 2 diabetes initiating basal insulin in a US managed care setting

Objective: To assess health outcomes and the economic burden of hypoglycemia in older patients with type 2 diabetes initiating basal insulin (BI).

Research design and methods: Medicare Advantage claims data were extracted for patients with type 2 diabetes initiating BI and patients were stratified into two groups: those with medically attended hypoglycemia during the first year of BI treatment (HG group) and those without (non-HG group). Main outcome measures were hospitalization, mortality, healthcare utilization and costs 1 year before and 1 year after BI initiation.

Results: Of 31,035 patients included (mean age 72 years [SD 9.2]), 3066 (9.9%; HG group) experienced hypoglycemia during 1 year post-BI initiation. After adjustment for demographic, comorbidity and medication history, hypoglycemia was associated with risk of hospitalization (HR 1.59; 95% CI: 1.53–1.65) and death (HR 1.50; 95% CI: 1.40–1.60). Healthcare utilization was higher pre-index and showed greater increases post-BI initiation in the HG vs. the non-HG group. Per-patient healthcare costs were substantially higher for the HG group than the non-HG group, both pre-index ($54,057 vs. $30,249, respectively) and post-BI initiation ($75,398 vs. $27,753, respectively).

Conclusions: Based on available claims data, hypoglycemia during the first year of BI treatment is associated with risk of hospitalization or death in older people, increasing healthcare utilization and costs. Due to the observational nature of this study, causality cannot be attributed, and further prospective studies into the effect of hypoglycemia on health outcomes in this population are warranted.     

Healthcare resource utilization and costs among women diagnosed with uterine fibroids compared to women without uterine fibroids

Objective: To perform a retrospective, matched-cohort, longitudinal evaluation of annual pre- and post-diagnosis costs incurred among women with uterine fibroids (UF) (cases) compared to controls without UF.

Methods: Data were derived from the IBM Watson Health MarketScan Commercial Claims and Encounters and Medicaid Multi-State databases. Women aged 18–64?years with ≥1 inpatient or outpatient medical claim with an initial UF diagnosis (index date) from 1 January 2010 to 31 December 2014 were included. Healthcare resource utilization (HCRU) data including pharmacy, outpatient and inpatient hospital claims were collected for 1?year pre-index and ≤5?years post-index. All-cause costs (adjusted to 2017 $US) were compared between cases and controls using multivariable regression models.

Results: Analysis included 205,098 (Commercial) and 24,755 (Medicaid) case–control pairs. HCRU and total all-cause healthcare costs were higher for cases versus controls during the pre-index year and all years post-index. Total unadjusted mean all-cause costs were $1197 higher (p?<?.0001; Commercial) and $2813 higher (standardized difference 0.08; Medicaid) for cases during the pre-index year. Total adjusted mean all-cause costs in the first year post-index were $14,917 for cases versus $5717 for controls in the Commercial population, and $20,244 versus $10,544, respectively, in the Medicaid population. In Years 2–5 post-index, incremental mean adjusted total costs decreased, but remained significantly higher for cases versus controls at all time points in both populations (all p?<?.05).

Conclusions: Costs were higher for women with UF compared to women without UF during the pre-index year and over 5?years post-index; differences were greatest in the first year post-index.     

A Markov cost-utility analysis of escitalopram and duloxetine for the treatment of major depressive disorder

ABSTRACT

Objective: To estimate the costs and quality-adjusted life weeks of duloxetine and escitalopram.

Research design: A probabilistic Markov cost-utility analysis with a time horizon of 1 year using data from placebo controlled randomized clinical trials for both products.

Methods: Efficacy was defined as remission of depressive symptoms and converted to utilities. Side effects were incorporated using rates from clinical trials and converted to utilities to define treatment effective­ness. The effectiveness outcome was quality adjusted life weeks (QALWs). Estimates of effectiveness (efficacy and side effects) used beta distributions and costs used gamma distributions. Using a managed care perspective, medication costs and physician office visits were included in the model, along with costs associated with treatment failure. Antidepressant costs were obtained using average wholesale price minus 20%. Physician visit costs were obtained from the 2006 US Medicare fee schedule for physician services. A Monte Carlo simulation was conducted using 1000 trials with both first- and second-order sampling.

Results: Over 1 year, the estimated mean quality-adjusted life weeks was 41.0 (95% confidence interval [CI]: 40.7–41.3) for escitalopram and 38.2 (95% CI: 37.9–38.4) for duloxetine. The mean annual total medical cost for escitalopram was $907 (95% CI: $894–$919) and $1633 (95% CI: $1614–$1654) for duloxetine. Limitations to this analysis include using separate studies examining the efficacy and adverse events of either escitalopram or duloxetine, assuming the switch, augmentation, and titration rates for duloxetine to be similar to escitalopram, and using utility estimates from published literature for the antidepressant adverse events.

Conclusion: This analysis suggests that escitalopram was more effective in terms of QALWs and less costly than duloxetine for treatment of depression.     

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.     

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.     

Risk of stroke/systemic embolism,major bleeding and associated costs in non-valvular atrial fibrillation patients who initiated apixaban,dabigatran or rivaroxaban compared with warfarin in the United States Medicare population

Objective: To compare the risk and cost of stroke/systemic embolism (SE) and major bleeding between each direct oral anticoagulant (DOAC) and warfarin among non-valvular atrial fibrillation (NVAF) patients.

Methods: Patients (≥65 years) initiating warfarin or DOACs (apixaban, rivaroxaban, and dabigatran) were selected from the Medicare database from 1 January 2013 to 31 December 2014. Patients initiating each DOAC were matched 1:1 to warfarin patients using propensity score matching to balance demographics and clinical characteristics. Cox proportional hazards models were used to estimate the risks of stroke/SE and major bleeding of each DOAC vs. warfarin. Two-part models were used to compare the stroke/SE- and major-bleeding-related medical costs between matched cohorts.

Results: Of the 186,132 eligible patients, 20,803 apixaban–warfarin pairs, 52,476 rivaroxaban–warfarin pairs, and 16,731 dabigatran–warfarin pairs were matched. Apixaban (hazard ratio [HR]?=?0.40; 95% confidence interval [CI] 0.31, 0.53) and rivaroxaban (HR?=?0.72; 95% CI 0.63, 0.83) were significantly associated with lower risk of stroke/SE compared to warfarin. Apixaban (HR?=?0.51; 95% CI 0.44, 0.58) and dabigatran (HR?=?0.79; 95% CI 0.69, 0.91) were significantly associated with lower risk of major bleeding; rivaroxaban (HR?=?1.17; 95% CI 1.10, 1.26) was significantly associated with higher risk of major bleeding compared to warfarin. Compared to warfarin, apixaban ($63 vs. $131) and rivaroxaban ($93 vs. $139) had significantly lower stroke/SE-related medical costs; apixaban ($292 vs. $529) and dabigatran ($369 vs. $450) had significantly lower major bleeding-related medical costs.

Conclusions: Among the DOACs in the study, only apixaban is associated with a significantly lower risk of stroke/SE and major bleeding and lower related medical costs compared to warfarin.     

Safety,effectiveness, and health care cost comparisons among elderly patients with venous thromboembolism prescribed warfarin or apixaban in the United States Medicare population

Abstract

Objective: To compare safety, effectiveness, and healthcare costs of major bleeding (MB), clinically relevant non-major (CRNM) bleeding, recurrent venous thromboembolism (VTE), and all-cause hospitalization among elderly Medicare VTE patients prescribed warfarin vs apixaban.

Methods: Using 100% Medicare data, elderly patients prescribed apixaban or warfarin within 30 days after a VTE encounter were identified. Patients had continuous health plan enrollment and no parenteral or oral anticoagulant use ≤6 months preceding the VTE encounter. Cohorts were balanced using 1:1 propensity score matching (PSM). Cox proportional hazard models were used to assess the risk of MB, CRNM bleeding, recurrent VTE, and all-cause hospitalization. Generalized linear and two-part models were used to estimate MB-, recurrent VTE-, and all-cause related costs (per patient per month [PPPM]).

Results: In the pre-matched cohort, 25,284 (66.9%) patients were prescribed warfarin and 12,515 (33.1%) apixaban. After 1:1 PSM, 11,363 matched pairs of apixaban-warfarin patients were included for a mean follow-up of 4.0 and 4.4 months, respectively. Matched cohorts had a mean age of 78 years and mean Charlson Comorbidity Index score of 2.9. Warfarin was associated with a higher risk of MB (hazard ratio [HR]?=?1.31; 95% confidence interval [CI]?=?1.10–1.57) and CRNM bleeding (HR?=?1.31; 95% CI?=?1.19–1.43) vs apixaban. The risks of recurrent VTE (HR?=?0.96; 95% CI?=?0.70–1.33) and all-cause hospitalization (HR?=?1.05; 95% CI?=?0.99–1.12) were similar among warfarin and apixaban patients. Warfarin patients had higher MB-related ($147 vs $75; p?=?.003) and all-cause costs PPPM ($3,267 vs $3,033; p?<?.001), but similar recurrent VTE-related medical costs PPPM ($30 vs $36; p?=?.516) vs apixaban patients.

Conclusions: Warfarin was associated with significantly higher risk of MB and CRNM bleeding as well as higher MB-related and all-cause costs vs apixaban patients. Recurrent VTE risk and costs were similar among warfarin and apixaban patients.     

Clinical and economic outcomes by first-line treatment among women with HR+/HER2– metastatic breast cancer in a large US health plan database

Background: Guidelines recommend that women with hormone receptor–positive/human epidermal growth factor receptor 2–negative (HR+/HER2–) metastatic breast cancer (mBC) initiate hormonal therapy before chemotherapy. This study compared outcomes of women with mBC who received chemotherapy first vs hormonal therapy.

Methods: A retrospective cohort study of women with mBC was conducted using a large US commercial health plan database between January 1, 2008–April 30, 2013. Subjects had evidence of a HR+/HER2– tumor sub-type in a cancer registry and use of chemotherapy or hormonal therapy in claims. Subjects were continuously enrolled for ≥6 months after metastasis and assigned to cohorts for receiving chemotherapy only or hormonal therapy only during first-line (CT-1L vs HT-1L). Adjusted incidence rates of clinically significant events were compared using a negative binomial model, and adjusted healthcare costs were compared using a generalized linear model.

Results: Three hundred and twenty-four women with HR+/HER2– mBC met the selection criteria; 179 (55%) received CT-1L and 145 (45%) received HT-1L. Mortality rates did not differ between cohorts (unadjusted incidence rate ratio (IRR)?=?1.67, 95% CI?=?0.82–3.46; adjusted IRR?=?0.64, 95% CI?=?0.32–1.27). Adjusted average total all-cause healthcare costs were $11?090 for women with CT-1L and $6743 for women with HT-1L (cost ratio =1.64, 95% CI =1.36–1.99).

Conclusions: Observed use of first-line chemotherapy (>50%) was higher than expected given the HR?+?molecular profile of the tumors. Chemotherapy use during first-line did not appear to be associated with a survival benefit, but was associated with significantly higher costs compared with the use of hormonal therapy during first-line; however, this comparison is limited by demographic and baseline characteristic differences between the two cohorts. This study contributes to understanding real-world treatment patterns and the associated clinical and economic outcomes of using chemotherapy vs hormonal therapy as a first-line treatment option for the HR+/HER2– mBC population.     

Economic impacts attributable to the early clinical benefit of atorvastatin therapy – a US managed care perspective

ABSTRACT

Objective: The clinical literature suggests that atorvastatin therapy achieves a reduction in major cardiovascular events within the first year of therapy. Aside from obvious clinical benefits, economic advantage may also result from this observation. The present analysis modeled the clinical and economic consequences of initiating atorvastatin versus generic simvastatin in defined US managed care organization patient populations.

Research design and methods: A cost-consequence model was developed to estimate the differential rate and associated costs of cardiovascular events occurring over 2 years using real world price and adherence data. Four defined patient populations were included from representative atorvastatin trials: (1) diabetes mellitus; (2) multiple risk factors; (3) coronary heart disease; and (4) acute coronary syndrome. Costs of care included drug costs and costs of managing cardiovascular events. Univariate sensitivity analyses and multivariate sensitivity analysis via Monte Carlo simulation were conducted to test the robustness of the results.

Main outcome measures: The number of cardiovascular events avoided per 100^?000 patients initiated on atorvastatin as compared with simvastatin, and total treatment costs.

Results: The model predicts that, relative to simvastatin, atorvastatin will prevent 941 (95% confidence interval [CI] 481–1367) cardiovascular events after 1 year and 1426 (95% CI 833–1987) events after 2 years, per 100?000 patients. This is expected to reduce the cost of cardiovascular events by $365 (95% CI $192–$527) and $552 (95% CI $327–$763) per patient (US$ 2006), respectively, offsetting 80% and 75% of the medication cost difference between atorvastatin and simvastatin after 1 and 2 years, respectively. The incremental costs associated with atorvastatin treatment were estimated at $94 (95% CI –$68 to $267) and $175 (95% CI –$37 to $399) per patient after 1 and 2 years, respectively. Results were sensitive to assumptions regarding simvastatin efficacy and drug acquisition costs.

Conclusions: Although the present analysis is based in part on indirect comparisons and on trials not designed or statistically powered to specifically test the early benefits hypothesis, it suggests that atorvastatin's assumed early reduction of cardiovascular events partly offsets the acquisition price difference between atorvastatin and generic simvastatin in various groups of high-risk patients newly initiated on statin treatment.     

Early initiation of long-acting injectable antipsychotic treatment is associated with lower hospitalization rates and healthcare costs in patients with schizophrenia: real-world evidence from US claims data

Objective: Early initiation of antipsychotic treatment in schizophrenia is associated with improved outcomes. This study aimed to determine if initiation of long-acting injectable (LAI) antipsychotic treatment early in a new schizophrenia episode is associated with lower hospitalization rates and healthcare costs in a real-world setting.

Methods: This retrospective (January 1, 2007–June 30, 2016) cohort analysis used claims from Truven Health Analytics MarketScan Commercial, Medicaid, and Medicare Supplemental databases. In adults ≥18?years with a new episode of schizophrenia, two mutually exclusive cohorts were identified based on time from first recorded schizophrenia diagnosis date to first date of LAI initiation (index date): ≤1?year (early initiators) and >1?year (late initiators). Logistic and general linear regression models were performed to estimate adjusted hospitalization rate and healthcare costs in a 1-year follow-up, controlling patient demographic and clinical characteristics, insurance type, baseline all-cause hospitalizations and ED visits, and baseline psychiatric medication use.

Results: Of the subjects, 32% (n?=?1388) initiated treatment early and 68% (n?=?2978) initiated treatment later. In risk-adjusted models, all-cause hospitalization rates were 22.2% (95% CI?=?19.9–24.6%) in early initiators and 26.9% (95% CI?=?25.2–28.7%) in late initiators (p?=?.002). Of early initiators, 14.1% (95% CI?=?12.3–16.1%) had a psychiatric hospitalization vs 19.2% (95% CI?=?17.7–20.8%) of late initiators (p?<?.001). Adjusted psychiatric healthcare costs were significantly lower in early initiators compared with late initiators [mean (95% CI)?=?$21,545 (20,355–22,734) vs $24,132 (23,330–24,933)] (p?<?.001).

Conclusions: LAI initiation within 1 year of a new schizophrenia episode led to lower hospitalization rates and healthcare costs compared with LAI initiation more than 1 year after a new episode.     

Increased healthcare resource utilization in higher disease activity levels in initiators of TNF inhibitors among US rheumatoid arthritis patients

Objective: Determine healthcare resource utilization (HCRU) in biologic-naïve initiators of TNF inhibitors (TNFis) associated with their disease activity from a national cohort of rheumatoid arthritis (RA) patients.

Methods: RA patients were identified at their first TNFi initiation (index date) in the Corrona registry. Patients with age of RA onset <18, comorbid psoriasis/psoriatic arthritis, fibromyalgia, or osteoarthritis were excluded. Patients were categorized into disease activity (DA) strata by the lowest level of DA (and sustaining low levels for at least two visits) using the Clinical Disease Activity Index (CDAI) across all visits in Corrona while on a TNFi during 1 year after initiation. Rates of all-cause and RA-related hospitalizations, rheumatologist visits, and joint surgeries while on TNFi therapy were reported and compared across DA levels along with the incidence rate ratio (IRR) adjusted for age, gender, and RA duration using Poisson mixed models.

Results: Of 1931 RA patients: 15% achieved sustained remission, 22% remission, 14% sustained low DA, 23% low DA and 27% moderate/high DA (M/HDA). Those in M/HDA had statistically higher rates of hospitalizations (37.3 per 100 patient years (py), 95% CI: 31.6–43.7 and joint surgeries (20.8 per 100 py, 95% CI: 16.6–25.8) compared to the sustained remission cohort, resulting in respective IRRs of 2.3 (p?<?0.001) and 1.7 (p?=?0.046).

Conclusion: Many biologic naïve RA patients initiating TNFi failed to achieve sustained remission during a 1 year period while remaining on TNFi therapy. Patients in higher DA levels had higher HCRU rates vs. patients in sustained remission, suggesting that achieving treat-to-target goals would reduce health care expenses.     

Hospitalization costs and resource allocation in cholecystectomy with use of intravenous versus oral acetaminophen

Objective: To evaluate intravenous (IV) acetaminophen (APAP) vs oral APAP use as adjunctive analgesics in cholecystectomy patients by comparing associated hospital length of stay (LOS), hospital costs, opioid use, and rates of nausea/vomiting, respiratory depression, and bowel obstruction.

Methods: We conducted a retrospective analysis of the Premier Database (January 2012 to September 2015) including cholecystectomy patients who received either IV APAP or oral APAP. Differences in LOS, hospitalization costs, mean daily morphine equivalent dose (MED), and potential opioid-related adverse events were estimated. Multivariable logistic regression was performed for the binary outcomes and instrumental variable regressions, using the quarterly rate of IV APAP use for all hospitalizations by hospital as the instrument in two-stage least squares regressions for continuous outcomes. Models were adjusted for patient demographics, clinical risk factors, and hospital characteristics.

Results: Among 61,017 cholecystectomy patients, 31,133 (51%) received IV APAP. Subjects averaged 51 and 57 years of age, respectively, in the IV and oral APAP cohorts. In the adjusted models, IV APAP was associated with 0.42 days shorter LOS (95% CI?=?–0.58 to –0.27; p?p?p?=?.0005), and lower rates of respiratory depression (odds ratio [OR]?=?0.89, 95% CI?=?0.82–0.97; p?=?.006), and nausea and vomiting (OR?=?0.86, 95% CI?=?0.86–0.86; p?Conclusions: In patients having cholecystectomy, the addition of IV APAP to perioperative pain management is associated with shorter LOS, lower costs, reduced opioid use, and less frequent nausea/vomiting and respiratory depression compared to oral APAP. These findings should be confirmed in a prospective study comparing IV and oral APAP.     

Epidemiology,clinical and economic outcomes of admission hyponatremia among hospitalized patients

ABSTRACT

Background: Hyponatremia, the most frequent electrolyte derangement identified among hospitalized patients, is associated with worsened outcomes in patients with pneumonia, heart failure and other disorders.

Research design and methods: We performed a retrospective cohort study of hospitalized patients to quantify the attributable influence of admission hyponatremia on hospital costs and outcomes. Data were derived from a large administrative database with laboratory components, representing 198,281 discharges from 39 US hospitals from January 2004 to December 2005. Hyponatremia was defined as admission serum [Na⁺]?<?135?mEq/L.

Results: The incidence of hyponatremia at admission was 5.5?%?(n?=?10,899). Patients with hyponatremia were older (65.7?±?19.6 vs. 61.5?±?21.8, p?<?0.001) and had a higher Deyo-Charlson Comorbidity Index score (1.8?±?2.1 vs. 1.3?±?1.8, p?<?0.001) than those with normal [Na⁺]. A higher proportion of hyponatremic patients required intensive care unit (ICU) (17.3?%?vs. 10.9?%?, p?<?0.001) and mechanical ventilation (MV) (5.0?%?vs. 2.8?%?, p?<?0.001) within 48?hours of hospitalization. Hospital mortality (5.9?%?vs. 3.0?%?, p?<?0.001), mean length of stay (HLOS, 8.6?±?8.0 vs. 7.2?±?8.2 days, p?<?0.001) and costs ($16,502?±?$28,984 vs. $13,558?±?$24,640, p?<?0.001) were significantly greater among patients with hyponatremia than those without. After adjusting for confounders, hyponatremia was independently associated with an increased need for ICU (OR 1.64, 95?%?CI 1.56–1.73) and MV (OR 1.68, 95?%?CI 1.53–1.84), and higher hospital mortality (OR 1.55, 95?%?CI 1.42–1.69). Hyponatremia also contributed an increase in HLOS of 1.0 day and total hospital costs of $2,289.

Conclusions: Hyponatremia is common at admission among hospitalized patients and is independently associated with a 55?%?increase in the risk of death, substantial hospital resource utilization and costs. Potential for bias inherent in the retrospective cohort design is the main limitation of our study. Studies are warranted to explore how prompt normalization of [Na⁺] may impact these outcomes.     

Healthcare resource utilization of second-generation long-acting injectable antipsychotics in schizophrenia: risperidone versus paliperidone palmitate

Objective: This retrospective longitudinal cohort study aimed to compare treatment patterns, healthcare resource utilization (HRU), and costs in patients with schizophrenia treated with second-generation antipsychotic long-acting injectables (SGA-LAIs): biweekly risperidone LAI versus once-monthly paliperidone palmitate.

Methods: Patients who initiated risperidone LAI or paliperidone palmitate between 1 July 2007 and 31 December 2012 (index date) were identified from the Truven MarketScan Commercial, Medicare Supplemental, and Medicaid Multi-State insurance databases. Outcomes were assessed 12 months after the index date. Propensity score matching (1:1) based on patients’ demographics and comorbidities was conducted. Outcome differences between the two cohorts were evaluated using t-tests for continuous variables, chi-square tests for categorical variables, and Wilcoxon rank-sum tests for count and cost variables. Regression models estimated the difference in medication use and adherence, likelihood of HRU, number of HRU events, and healthcare costs when comparing risperidone LAI versus paliperidone palmitate, while further adjusting for patient characteristics and pre-index HRU.

Results: Patient characteristics were well balanced between the two cohorts (n?=?499 each). Significantly lower discontinuation rates (36.5% vs. 53.3%; p?<?0.001) and longer days of LAI coverage (233.6 vs. 131.7 days; p?<?0.001) were observed in the paliperidone palmitate cohort versus the risperidone LAI cohort, respectively. Patients treated with paliperidone palmitate were 12.5 (95% confidence interval [CI]: 9.0–17.8) and 11.7 (95% CI: 8.0–17.4) times more likely to be adherent based on medication possession ratio and proportion of days covered, respectively (p?<?0.001). Patients treated with paliperidone palmitate had reduced likelihood of hospitalization (adjusted odds ratio [95% CI]: 0.72 [0.55–0.95]), fewer emergency department (ED) visits (adjusted incidence rate ratio [aIRR]: 0.67 [0.61–0.73]) and reduced length of inpatient stay (aIRR: 0.86 [0.82–0.90]), which resulted in lower monthly inpatient hospitalization costs (-$77.58; p?=?0.038) and ED visits (-$9.77; p?=?0.021) relative to risperidone LAI.

Limitations: Pharmacy costs were derived from health plan payment in the claims data and do not account for any discounts or rebates. This may have overestimated the branded drug costs in this analysis.

Conclusions: These findings highlight the value of once-monthly paliperidone palmitate in the treatment of patients with schizophrenia.     

Healthcare resource use and cost associated with timing of pharmacological treatment for major depressive disorder in the United States: a real-world study

Abstract

Background: Guidelines recommend selective serotonin reuptake inhibitors (SSRI) and serotonin norepinephrine reuptake inhibitors (SNRI) as first-line treatments for major depressive disorder (MDD) and emphasize the importance of early pharmacological treatment as key factors to treatment success.

Objectives: To compare the MDD-related healthcare resource utilization (HCRU) and cost among patients (1) with early vs late pharmacological treatment initiation and (2) achieving minimum therapeutic dose (MTD) early vs late.

Methods: The MarketScan database (2010–2015) was used. Adults who were newly-treated with SSRI/SNRI within 12?months after the initial MDD diagnosis (index) were included. Patients who initiated SSRI/SNRI within 2?weeks of the index date were defined as early initiators; those who reached MTD within 4?weeks of index date were defined as early MTD achievers. MDD-related HCRU and costs per year after the index date were compared between early and late initiators and between early and late achievers using propensity score matching and generalized linear models.

Results: Of the 55,539 patients, 60% were early initiators and 61% were early MTD achievers. The mean number of MDD-related outpatient visits per year were significantly higher for late initiator (6.7 vs 4.2, p?<?.001) and late MTD achievers (6.5 vs 4.5, p?<?.001) vs their early counterparts. Mean annual MDD-related outpatient, drug, and total cost were significantly higher for late initiators and MTD achievers vs the early groups.

Conclusions: There is an opportunity to improve outcomes by treating MDD patients with SSRI/SNRI within 2?weeks and at or above the MTD within 4?weeks of diagnosis or less.     

Real-world impact of glycated hemoglobin reduction on treatment intensification and glycated hemoglobin goal attainment in type 2 diabetes mellitus patients initiated on a sodium glucose co-transporter 2 (SGLT2) inhibitor (SGLT2i)

Objective: To evaluate the impact of a 0.2% reduction in glycated hemoglobin (HbA1c) on treatment intensification, poor HbA1c control and HbA1c goal attainment in patients with type 2 diabetes mellitus (T2DM) initiated on a sodium glucose co-transporter 2 (SGLT2) inhibitor (SGLT2i).

Methods: IQVIATM Health Plan Claims Data – US and IQVIATM Ambulatory EMR Data – US databases (29 October 2012–31 March 2016) were used to identify adults with T2DM initiated on an SGLT2i (index date) who had HbA1c measurements pre- and post-index, and ≥6?months of eligibility pre-index (baseline). HbA1c change was defined as the difference between the first post-index and the last pre-index measurements. Cox regression models were used to assess treatment intensification, poor HbA1c control (i.e. HbA1c?>?9%, among patients <9% at baseline) and goal attainment (HbA1c?<?7%, <8%; among patients with HbA1c above goal at baseline) adjusting for HbA1c change and baseline characteristics. Patients were observed up to one year after the first HbA1c measurement or end of eligibility. Hazard ratios (HRs) and 95% confidence intervals (CIs) were reported.

Results: A total of 938 patients (mean age 54.9, 42.5% female, mean HbA1c 8.5%) were selected. Following SGLT2i initiation, each 0.2% reduction in HbA1c levels was associated with a decreased risk of treatment intensification (HR [95% CI]?=?0.90 [0.86–0.92]), a decreased likelihood of reaching HbA1c?>?9% (HR [95% CI]?=?0.85 [0.79–0.88]) and higher likelihoods of achieving a treatment goal of HbA1c?<?7% (HR [95% CI]?=?1.17 [1.12–1.21]) and HbA1c?<?8% (HR [95% CI]?=?1.08 [1.04–1.10]).

Conclusions: In T2DM patients, each HbA1c reduction of 0.2% following the initiation of an SGLT2i was associated with a significant positive impact on treatment intensification and HbA1c goal attainment.     

The economics of coeliac disease: a population‐based study

Aliment Pharmacol Ther 2010; 32: 261–269

Summary

Background Despite increasing prevalence, the economic implications of coeliac disease are just emerging. Aims To assess the impact of coeliac disease diagnosis on healthcare costs and the incremental costs associated with coeliac disease. Methods Administrative data for a population‐based cohort of coeliac disease cases and matched controls from Olmsted County, Minnesota were used to compare (i) direct medical costs 1 year pre‐ and post‐coeliac disease diagnosis for 133 index cases and (ii) 4‐year cumulative direct medical costs incurred by 153 index cases vs. 153 controls. Analyses exclude diagnostic‐related and out‐patient pharmaceutical costs. Results Average total costs were reduced by $1764 in the year following diagnosis (pre‐diagnosis cost of $5023 vs. $3259; 95% CI of difference: $688 to $2993). Over a 4‐year period, coeliac disease cases experienced higher out‐patient costs (mean difference of $1457; P = 0.016) and higher total costs than controls (mean difference of $3964; P = 0.053). Excess average total costs were concentrated among males with coeliac disease ($14 191 vs. $4019 for male controls; 95% CI of difference: $2334 to $20 309). Conclusions Coeliac disease‐associated costs indicate a significant economic burden of disease, particularly for diseased males. Diagnosis and treatment of coeliac disease reduce medical costs of care suggesting an economic advantage to earlier detection and treatment.     

All-cause hospitalization and associated costs in patients with schizophrenia or bipolar disorder initiating long-acting injectable antipsychotics

Objective: To compare all-cause hospitalization and associated costs among patients with schizophrenia or bipolar disorder (BD) treated with long-acting injectable antipsychotics (LAIs).

Methods: The Truven MarketScan Medicaid claims database was used to identify patients with schizophrenia; MarketScan Medicaid and commercial claims databases were used to identify BD. Adult patients with ≥1 LAI claim from January 1, 2013–June 30, 2014 (ID period) were identified. The first day of LAI initiation was the index date; patients were followed for ≥1 year. Logistic and general linear regression models were used to estimate the risk of hospitalization and associated costs.

Results: Adjusted analyses showed that, in the schizophrenia cohort, risks of hospitalization were statistically significantly higher in the haloperidol [OR (95% CI)?=?1.51 (1.05–2.16); HR (95% CI)?=?1.35 (1.05–1.73)] and risperidone [OR (95% CI)?=?1.58 (1.07–2.33); HR (95% CI)?=?1.33 (1.01–1.74)] cohorts than in the aripiprazole once monthly extended release (AOM 400) cohort. Similarly, in patients with BD, risks of hospitalization were significantly higher in haloperidol [OR (95% CI)?=?1.49 (1.01–2.19); HR (95% CI)?=?1.33 (1.03–1.73)] and risperidone [OR (95% CI)?=?1.78 (1.19–2.66); HR (95% CI)?=?1.33 (1.01–1.75)] than in AOM400. No statistically significant differences in hospitalization costs were observed in either disease group.

Conclusions: Although the study results may be subject to confounding variables that are not contained in claims databases, such as disease severity, it appears that AOM400 may be more effective than haloperidol and risperidone LAIs among patients with schizophrenia or BD.