Carolina Medicaid Program Research Articles

Comparisons of Rosiglitazone Versus Pioglitazone Monotherapy Introduction and Associated Health Care Utilization in Medicaid-Enrolled Patients with Type 2 Diabetes Mellitus

Background: Outcomes in patients with type 2 diabetes mellitus (DM) can differ based on the antidiabetic medication that is used. Thiazolidinediones (TZDs) are a newer class of agents used for the treatment of type 2 DM. No previous study has compared health care utilization associated with the 2 TZDs on the market. Objective: The objective of this study was to compare health care utilization and costs associated with initiation of treatment with either rosiglitazone or pioglitazone by Medicaid-enrolled patients with type 2 DM. Methods: This was a retrospective data analysis comparing cohorts of patients with type 2 DM starting a new antidiabetic medication in terms of hospitalizations, emergency department visits, outpatient physician visits, and health care costs reimbursed by the North Carolina Medicaid program. The perspective adopted in this analysis was that of the third-party payer (ie, the North Carolina Medicaid program). Patients starting rosiglitazone between July 1, 2001, and June 30, 2002, were compared with patients starting pioglitazone during the same period. The patients were followed up for 30 months to examine the difference in health care utilization over time. Multivariate regression techniques were employed for comparisons between the 2 different antidiabetic therapies. Results: A total of 1705 patients with type 2 DM were identified and included in the final cohort. There were 660 patients (mean [SD] age, 49.0 [10.2] years) in the rosiglitazone arm and 1045 patients (mean [SD] age, 49.1 [10.5] years) in the pioglitazone arm. Multivariate analysis showed that the rosiglitazone monotherapy group was associated with a 12.2% decrease in the mean number of hospitalizations, a 10.4% decrease in the mean number of emergency department visits, and a 7.3% decrease in total health care costs compared with the pioglitazone monotherapy group (all, P < 0.05). This study only looked at patients who used the same drug for the entire follow-up period. It did not account for drug switching or addition of a new drug to an existing therapy. Conclusions: Introduction of rosiglitazone was associated with a decreased number of hospitalizations, emergency department visits, and total health care costs compared with pioglitazone. The utilization of oral antidiabetic agents, with documented clinical and economic benefits, should continue to be advocated to reduce avoidable medical care utilization and to improve patient outcomes in this population.

Primary care physicians enlisted to provide preventive dental services

A five-year demonstration project launched by the North Carolina Medicaid program to help reduce high levels of tooth decay in the state's most vulnerable children has proven successful. ![Figure][1] Dr. Rozier The effort, led by a broad coalition representing medicine, dentistry and

Direct Cost Analyses of Palivizumab Treatment in a Cohort of At-Risk Children: Evidence From the North Carolina Medicaid Program

Direct Cost Analyses of Palivizumab Treatment in a Cohort of At-Risk Children: Evidence From the North Carolina Medicaid Program

Outcomes Associated with Initiation of Different Controller Therapies in a Medicaid Asthmatic Population: A Retrospective Data Analysis

Background. Outcomes in asthmatic patients may vary depending on the controller medication used. Observational studies of outcomes of asthma therapy are needed to understand the implications of choice of controller in different populations. Objectives. To determine whether there are differences in health care use and costs of asthma treatment in asthma patients treated with montelukast compared with fluticasone proponiate 44 µg. Method. Using data from the North Carolina Medicaid program, we compared continuously enrolled asthmatic patients starting either fluticasone propionate 44 µg (FP44), an inhaled corticosteroid (ICS) (n = 312), or montelukast 5 and 10 mg, an oral leukotriene modifier (LM) (n = 398) between the years 1998 and 1999. A secondary analysis compared continuously enrolled asthmatic patients already using ICS as controller therapy initiating either salmeterol (long-acting β-agonist) (n = 97) or montelukast (n = 101) in the year 1998. Patients were followed for 1 year pre- and postcontroller or additional controller initiation for health care service use, medication refill patterns, and costs. Results. There were no significant differences in the adjusted asthma-related health care costs between the montelukast and FP44 groups. In both groups, physician visits were significantly higher in year 2 (p < 0.01) than in year 1. We found montelukast users to be more adherent with prescription refills (using measures of medication possession) even after allowing for a wider adherence range for FP (RR = 2.53; 95% CI = 1.50–4.26), although patients using montelukast were more likely than patients with fluticasone to switch controller pharmacotherapy (RR = 1.53; 95% CI = 1.12–2.09). Similarly, there were no differences in health care service use and costs between the montelukast and salmeterol groups, with the exception of a 33% reduction (p < 0.01) in number of inhaled corticosteroid refills in the second year in the salmeterol group. Conclusion. There were no cost and major health care use differences between the two primary or secondary controller therapies in the postinitiation year. Although FP was associated with lower rate of controller switch, montelukast use was associated with significantly better treatment adherence in patients with treatment persistence in this population of Medicaid-enrolled asthmatic patients. The addition of salmeterol as additional controller was associated with a significant decrease in inhaled corticosteroid use, suggesting decreased adherence in patients on the two-drug regimen.

Direct Cost Analyses of Palivizumab Treatment in a Cohort of At-Risk Children: Evidence From the North Carolina Medicaid Program

Use of palivizumab prophylactic therapy reduces the occurrence of hospitalizations for serious respiratory syncytial virus (RSV) lower respiratory tract infections in at-risk infants. The direct cost-benefit of palivizumab prophylaxis for infants who are born at 32 to 35 weeks' estimated gestational age (EGA) during their first year of life has not been systematically examined. The objective of this study was to compare the direct costs of palivizumab prophylaxis and RSV treatment in infants who were born at 32 to 35 weeks EGA and received and did not receive palivizumab. A cohort study was performed of infants who were younger than 1 year and were enrolled in an enhanced primary care case management model within the North Carolina Medicaid Program. Comparisons were made between infants who received (Synagis prophylaxis group) and did not receive palivizumab (nonprophylaxis group) during the study period. Cost was examined using the sum of Medicaid paid services for prophylaxis with palivizumab and treatment for RSV infections that occurred between October 1, 2002, and May 31, 2003. The Anderson framework was used to specify the regression cost models to compare the participants who received (Synagis prophylaxis) and did not receive (nonprophylaxis group) palivizumab. The primary outcomes were actual 7-month seasonal costs and standardized seasonal costs adjusting for the varied months of infant participation. The study sample included 185 Synagis prophylaxis and 182 nonprophylaxis participants who met the inclusion criteria. The average per-person total cost of RSV care and prophylaxis was 5117 dollars for the Synagis prophylaxis group and 371 dollars for the nonprophylaxis group. Five hospitalizations occurred in the prophylaxis group, and 12 occurred in the nonprophylaxis group (odds ratio: 0.27). No deaths occurred in either group. Palivizumab administered to infants who were born at 32 to 35 weeks' EGA did not provide direct cost savings related to hospitalization or ambulatory care in a Medicaid population. The primary difference in cost between the groups was attributable to the palivizumab prophylaxis.

A pharmacy management intervention for optimizing drug therapy for nursing home patients

Background: A drug therapy management service was designed to reduce polypharmacy among Medicaid recipients. This service selectively focused on patients who were high users of prescription drugs and had potential drug therapy problems (PDTPs). Objectives: This article reports the results of the first phase of the North Carolina Polypharmacy Initiative. The goals of this study were to determine: (1) the frequency with which recommendations were made by pharmacists in response to targeted profile alerts aimed at high-risk patients, (2) the frequency and type of drug therapy changes, and (3) the impact on drug-related quality and costs. Methods: A before—after design was used. Nursing home patient profiles with PDTP alerts for specific drugs and drug categories were provided to consultant pharmacists. Targeted patients had received ≥18 prescription fills within 90 days. Pharmacists were compensated for performing and documenting targeted drug regimen reviews. Interventions of pharmacists and results after physician consultation are described, and cost impacts of changes in drug therapy are reported. Monetary results are shown in year-2002 US dollars. Results: Prescription profiles were generated from Medicaid claims data and sent to consultant pharmacists for 9208 patients in 253 nursing homes. Pharmacists returned 7548 (82%) of all profiles sent to them. After excluding 1204 patients (13%) who were discharged or deceased, 6344 patients (69%) remained for analysis. At baseline, patients used a mean (SD) of 9.52 prescriptions per month, costing the North Carolina Medicaid program a mean (SD) of $502.96 (309.70). A mean of 1.58 recommendations were offered to prescribers. After physician consultation, ≥1 recommendation was implemented for 72% of patients with a change recommendation, 68% of whom experienced a switch to a lower-cost drug. Drug cost savings were a mean of $30.33/patient per month. Cost savings from 1 month alone covered the compensation paid to pharmacists for consultation efforts. Conclusions: This supplemental program of medication reviews for targeted nursing home patients resulted in a reduction of polypharmacy and was beneficial based solely on drug cost savings.

Healthcare costs and prescription adherence with introduction of thiazolidinedione therapy in Medicaid type 2 diabetic patients: a retrospective data analysis

SUMMARYObjectives: Outcomes in patients with type 2 diabetes may vary depending on the antidiabetic medication used. Observational studies of outcomes of diabetes pharmacotherapy are needed to understand the implications of choice of controller in different populations. This study compared differences in total health care costs, medication adherence, and persistence in patients with type 2 diabetes enrolled in the North Carolina Medicaid Program that were newly started on thiazolidinedione (TZD) therapy with patients starting other oral antidiabetics during the same period. In addition differences among the TZDs with respect to these outcomes were examined.Methods: A total of 1774 patients newly starting TZD therapy between July 2001 and June 2002 were compared to 1709 patients starting other oral antidiabetic medication (metformin or sulfonylureas) for health care costs and outcomes in the post-medication start year. In addition, a sub-group analysis of health care costs in patients starting either TZD (pioglitazone [n = 1086] versus rosiglitazone [N = 688]) was compared. All included patients had complete enrollment for the 24 months of follow-up. Multivariate techniques incorporating health care utilization in the year prior to start of new therapy were utilized to determine the cost impact of one therapy versus another.Results: Results of multiple regression analyses suggest that patients starting TZD have better treatment adherence and persistence in the post-medication start year compared to patients starting other oral antidiabetics (13% increase in Medication Possession Ratios, and 10% increase in therapy persistence index, both p < 0.001). In addition, patients starting TZDs had 16.1% lower total annual health care costs ( p < 0.01) compared to patients starting other oral antidiabetics. There were no differences in adherence and cost outcomes between the 2 TZDs.Conclusions: Introduction of thiazolidinedione therapy in a Medicaid-enrolled type 2 diabetic population was associated with significantly improved treatment adherence, persistence, and lower annual health care costs in the post-start year compared to patients starting other oral antidiabetics.

Restricting patients' medication supply to one month: saving or wasting money?

A state Medicaid program's pharmacy expenditures associated with dispensing one- and three-month supplies of drugs were examined. We simulated the effect of a policy change from a maximum of a 100-day supply of prescription medication to one where only a 34-day supply was allowed. All North Carolina prescription claims from Medicaid enrollees who filled a prescription for at least one of six medication categories during fiscal years 1999 and 2000 were included. The six categories were angiotensin-converting-enzyme inhibitors, antiulcers, antipsychotics, nonsteroidal antiinflammatory drugs, selective serotonin-reuptake inhibitors, and sulfonylureas. The dollar value of the medication wasted, the amount of medication wastage diverted after a change to a shorter prescription length, and the total costs incurred by the increases in prescription refills were calculated. For each therapeutic category, 255,000-783,000 prescription drug claims were analyzed. No valid drug claims were excluded for any reason. Although 5-14% of total drug wastage, attributed to switches of drug therapy, could be saved by dispensing a 34-day supply, this saving could not make up for a larger increase in dispensing costs, as consumers would fill prescriptions more often. In addition, reducing the amount of drug dispensed each time may be costly to consumers through increased transportation and other expenses. Simulated calculation showed that the cost of drug therapy to North Carolina's Medicaid program would probably increase if 34-day rather than 100-day supplies of medications are dispensed to patients.

Disasters and the Public Health Safety Net: Hurricane Floyd Hits the North Carolina Medicaid Program

Disasters and the Public Health Safety Net: Hurricane Floyd Hits the North Carolina Medicaid Program

Treatment outcomes and costs of dental sealants among children enrolled in Medicaid.

This retrospective cohort analysis of children enrolled in the North Carolina Medicaid program compared the likelihood of restorative treatments and associated cumulative Medicaid expenditures for teeth with or without dental sealants. We assessed the dental experience of the cohort of 15 438 children from 1985 to 1992 on the basis of enrollment and claims files. We conducted regression analyses for outcomes (caries-related services involving the occlusal surface [CRSOs] of permanent first molars) and cumulative expenditures, controlling for characteristics of the child, the treating dentist, and the child's county of residence. Overall, 23% of children received at least 1 sealant and 33% at least 1 CRSO. Sealants were effective in preventing CRSOs, although the degree of effectiveness was highest for children with the greater levels of CRSOs before sealant placement. Estimated cumulative Medicaid expenditures indicated expenditure savings from sealants within 2 years of application for children with 2 or more prior CRSOs. Sealant placement was associated with expenditure savings to Medicaid for certain high-risk children, so Medicaid and, more broadly, society will benefit by providing for sealant placement in these children.

Risperidone, Haloperidol and Clozapine in the South Carolina Medicaid Program

Objective: To determine whether the increased acquisition costs associated with the atypical antipsychotic risperidone are offset by reductions in other mental health care utilisation and expenditure. Design and setting: The study was population-based and used South Carolina Medicaid claims data to determine changes in mental healthcare utilisation and expenditures related to schizophrenia. Changes in mental health—related utilisation and expenditures over time were calculated; total mental health—related expenditures and utilisation were disaggregated into pharmaceuticals, inpatient hospitalisations, and ambulatory and inpatient physician services [Health Care Financing Administration (HCFA) 1500 claims]. Groups of patients were compared for two 6-month periods preceding the initial prescription (pre1 and pre2), and two 6-month periods following the initial prescription (post1 and post2). Costs were discounted to the index date. Perspective: Payor (South Carolina Medicaid). Patients: Those patients with schizophrenia who received initial prescriptions for risperidone (n = 862), haloperidol (n = 325) or clozapine (n = 66) between February 1994 and June 1995 (index date). Main outcome measures and results: The mean increase in level of expenditure per person for pharmaceuticals from the pre- to the post-treatment period was significantly greater in the risperidone [751 US dollars ($US)] and clozapine ($US1423) groups than in the haloperidol group ($US6). However, the change in mean level of total mental healthcare expenditure per person was not significantly different for the risperidone group ($US832) compared with the haloperidol group ($US540) over the same time period, but the increase in the clozapine group was significantly higher ($US2500.23; p < 0.0001 for clozapinevsrisperidone and clozapine vs haloperidol). As the difference between the risperidone and haloperidol groups in pharmaceutical expenditures was not reflected in total mental healthcare expenditures, the remaining component costs were investigated to identify where the difference was offset. Compared with haloperidol, risperidone had a significantly smaller change in per person mean level of ambulatory and inpatient physician services claims for expenditure ($US692 vs $US269, p = 0.01) and utilisation (+1.70 vs −0.21, p < 0.0001). Conclusions: Based on these findings, we conclude that, in this population of patients with schizophrenia increased costs associated with risperidone were offset by decreases in other mental healthcare utilization. Risperidone is a technical substitute for ambulatory healthcare services.

Use of antidepressant pharmacotherapy within the first year after diagnosis of diabetes mellitus: A study of a medicaid population

Structured diagnostic interviews indicate that the rate of depression among patients with diabetes mellitus (DM) is nearly 3 times that observed in the general population in the United States. Prevalence studies have reported a significant underdiagnosis of depression and a significant underutilization of antidepressant pharmacotherapy among patients with DM. The objective of this study was to determine the incidence of antidepressant utilization within the first year after diagnosis of type 1 (insulin-dependent) or type 2 (non-insulin-dependent) DM. This retrospective cohort study used adjudicated, patient-level, paid-claims data from the state of South Carolina's Medicaid program for the period January 1, 1990, through December 31, 1994. The study population comprised a statewide cohort of 3445 Medicaid beneficiaries diagnosed with type 1 or type 2 DM; aged 18 to 64 years; initiating pharmacotherapy with either insulin or a second-generation sulfonylurea (glipizide or glyburide); and without a prescription for antidepressant pharmacotherapy, insulin or an oral sulfonylurea (first- or second-generation) in the year before initiating a regimen to manage DM. Overall, 6.5% of patients (6.9% of patients with type 1 and 5.5% with type 2 DM) were prescribed antidepressant pharmacotherapy within the first year after beginning treatment with insulin or a second-generation sulfonylurea. Among patients with type 1 DM, 37.3% were prescribed a selective serotonin reuptake inhibitor compared with 50.9% of patients with type 2 DM. White patients were significantly more likely ( P < 0.05) to have been prescribed antidepressant pharmacotherapy compared with black patients. Under the conservative assumption that the tricyclic antidepressants were prescribed only for complications arising from DM (eg, retinopathy and neuropathy) only 2.6% of patients with DM received antidepressant pharmacotherapy. Further research is required to discern the reasons for the low incidence of antidepressant utilization in patients with DM and for observed differences in prescription rates by race. In addition, initiatives are required to foster the development of educational programs designed to enhance the rate of screening for depression and receipt of pharmacotherapeutic and/or psychotherapeutic intervention among patients with DM.

ID3 Prescribing Patterns for Treatment of Upper Respiratory Infections

OBJECTIVE: To characterize the treatment received by patients with an upper respiratory infection (URI) in the South Carolina Medicaid Population during 1996. Literature suggests that antibiotics are commonly prescribed to patients presenting with symptoms of an URI even though less than 20% are bacterial in origin. Overuse of antibiotics may lead to antibiotic resistance and unnecessary costs. METHODS: Patients with a diagnosis for a cold (ICD-9-CM 460) or URI (ICD-9-CM 465) between 01/01/96 and 12/31/96 were identified. The study design allowed for each subjects to have multiple diagnosis (episodes). for each episode, subjects with prescriptions for antibiotics or symptomatic cold medications within 7 days after the diagnosis were identified. Any episode within 14 days of a claim for a bacterial infection, sinustis or otitis was removed from the study, to rule out the possibility that the antibiotic was related to another infection. RESULTS: A total of 22,791 patients was eligible for inclusion in the study, incurring 27,847 episodes (Range 1–7 episodes). 9468 (34%) of the episodes were treated with an antibiotic, accounting for $166,702.33. This rate is lower than that seen in previous studies; however, our inclusion were more stringent than was used previously. If 20% of URIs are bacterial, approximately 3,900 of these antibiotics were unnecessary. A 25% reduction in the excess prescriptions would provide a cost savings of $17,169.75 for South Carolina Medicaid. CONCLUSION: In spite of comprehensive documentation arguing against using antibiotics for treatment of URIs, it appears that they still remain a popular choice for physicians, with 34% of subjects in this study receiving antibiotics. This represents an area for cost savings for the South Carolina Medicaid Program.

Effect of pharmaceutical formulation of diltiazem on the utilization of medicaid and health maintenance organization services

Hypertension is a silent disease, the full seriousness of which becomes evident only when the sequelae of long-standing high blood pressure are manifest as congestive heart failure, angina, myocardial infarction, cerebral vascular accident, or end-stage renal disease. A major barrier to the management of hypertension is the extent to which patients comply with treatment. We report the findings of retrospective analyses designed to determine the relationship between dosage formulation and administration schedule for the calcium channel antagonist diltiazem, and the utilization of health care services within the state of South Carolina's Medicaid program and a network-model health maintenance organization (HMO). The research objectives were threefold: (1) for patients prescribed 180 mg/d of diltiazem, compare financial outcomes of patients receiving three dosage formulations: 60 mg three times daily (TID), immediate-release (IR) diltiazem; 90 mg two times daily (BID), sustained-release (SR) diltiazem; or 180 mg once daily (QD), controlled-delivery (CD) diltiazem; (2) for patients prescribed 240 mg/d of diltiazem, compare financial outcomes of patients receiving three dosage formulations: 60-mg four times daily (QID) diltiazem IR, 120-mg BID diltiazem SR, or 240-mg QD diltiazem CD; and (3) determine the effect of the medication possession ratio (MPR), an index of compliance, on health service utilization. Multivariate regression analysis was used to determine the incremental influence of selected demographic characteristics, use of medical services 6 months before the diagnosis of hypertension, and the prescribed formulation of diltiazem on health service expenditures 1 year after the diagnosis of hypertension. Results indicate that patients initially prescribed a formulation and regimen facilitating once-daily administration have the fewest number of changes in antihypertensive pharmacotherapy, require fewer concomitant antihypertensives, achieve the highest MPR for antihypertensive pharmacotherapy, and record a decrease in the use of and expenditures for physician and hospital services ( P ≤ 0.05) under Medicaid and within the HMO.

Effect of pharmaceutical formulation on health care expenditures for hypertension: A study of verapamil in a medicaid population

A significant barrier to the management of hypertension is the extent to which patients comply with the treatment regimen. Recent pharmacotherapeutic advances in the treatment of hypertension have included the development of sustained-release (SR) dosage formulations, which provide patients with the convenience of once-daily administration. To determine the economic utility of providing prescription coverage for the SR formulation of verapamil, a calcium channel antagonist, under the state of South Carolina's Medicaid program, a 1-year retrospective analysis was undertaken. Data for this analysis were obtained from the state of South Carolina's Medicaid computed archive. The study population consisted of 481 ambulatory Medicaid beneficaries diagnosed with hypertension and prescribed either the SR or immediate-release (IR) formulation of verapamil. Multivariate regression analysis was used to determine the incremental influence of selected demographic characteristics, utilization of medical services before diagnosis for hypertension, and prescribed formulation of verapamil on health care expenditures 1 year postdiagnosis. Patients prescribed the SR formulation of verapamil achieved a significant increase ( P ⩽ 0.05) in the medication possession ratio, an index of compliance, compared with those prescribed the IR formulation (0.73 ± 0.62 versus 0.59 ± 0.83 in the SR and IR groups, respectively). The results indicate that the SR formulation of verapamil was associated with a significant decrease ( P ⩽ 0.05) in aggregate health care expenditures of $184.29 over the 1-year study period. The SR formulation was also associated with a significant increase in expenditures for antihypertensive therapy (+ $92.71; P ⩽ 0.05), and a decrease in financial commitments for physician (−$63.52; P ⩽ 0.05), hospital (−$173.96, P ⩽ 0.05), and laboratory (−$39.52) services. Evidence from this study suggests that economic evaluations involving pharmaceuticals must extend beyond the procurement cost of a given medication. At the managerial and policy levels, these data argue for an increased use of therapeutic alternatives that facilitate a reduction in a patient's daily dosing schedule for antihypertensive therapy.