Claims History Research Articles

Chiropractic Episodes and the Co-Occurrence of Chiropractic and Health Services Use Among Older Medicare Beneficiaries

ObjectiveThe purpose of this study was to define and characterize episodes of chiropractic care among older Medicare beneficiaries and to evaluate the extent to which chiropractic services were used in tandem with conventional medicine. MethodsMedicare Part B claims histories for 1991 to 2007 were linked to the nationally representative survey on Assets and Health Dynamics among the Oldest Old baseline interviews (1993-1994) to define episodes of chiropractic sensitive care using 4 approaches. Chiropractic and nonchiropractic patterns of service use were examined within these episodes of care. Of the 7447 Assets and Health Dynamics among the Oldest Old participants, 971 used chiropractic services and constituted the analytic sample. ResultsThere were substantial variations in the number and duration of episodes and the type and volume of services used across the 4 definitions. Depending on how the episode was constructed, the mean number of episodes per chiropractic user ranged from 3.74 to 23.12, the mean episode duration ranged from 4.7 to 28.8 days, the mean number of chiropractic visits per episode ranged from 0.88 to 2.8, and the percentage of episodes with co-occurrent use of chiropractic and nonchiropractic providers ranged from 4.9% to 10.9% over the 17-year period. ConclusionTreatment for back-related musculoskeletal conditions was sought from a variety of providers, but there was little co-occurrent service use or coordinated care across provider types within care episodes. Chiropractic treatment dosing patterns in everyday practice were much lower than that used in clinical trial protocols designed to establish chiropractic efficacy for back-related conditions.

The Cost of Legal Restrictions on Experience Rating

We investigate whether an insured's claims experience contains valuable information about its latent risk type. Using data on households' claims histories in auto and home insurance, we estimate the variance-covariance matrix of unobserved heterogeneity and utilize the estimates to update a priori predictions about the households' claim risk. The estimates reveal that unobserved heterogeneity is positively correlated across coverages. We then explore how households' demand for insurance would respond to experience rating under different theories of risky choice, and we discuss what our findings imply about the economic consequences of legal restrictions on experience rating.

Australian wildfire litigation

Legal liability is an issue that concerns volunteer firefighters and may affect the ability of fire managers to perform their tasks. There are calls to guarantee firefighters will not be personally liable for actions undertaken in good faith. This paper reviews post-wildfire litigation in Australia and claims for compensation made against the New South Wales Rural Fire Service. Although the data are incomplete and likely to underestimate the actual claims history, analysis of the available data does show that the number of claims for compensation is small given the very large number of fires and hazard reduction burns across Australia. There is no evidence of extensive post-fire litigation or of fire agencies or firefighters being held liable for actions taken in the course of firefighting The evidence does not support assertions that there is an ‘increasing flood’ of legal claims arising from firefighting. Post-fire litigation is compared with other proceeding such as Royal Commissions and coronial inquiries. It is argued that it is not liability, but the lengthy post-event inquiry process and the risk of personal criticism that should be the concern of fire managers and firefighters.

Impact of blunted perception of dyspnea on medical care use and expenditure, and mortality in elderly people.

Dyspnea is an alarming symptom responsible for millions of patient visits each year. Poor perception of dyspnea might be reasonably attributed to an inappropriately low level of fear and inadequate earlier medical treatment for both patients and physicians, resulting in subsequent intensive care. This study was conducted to evaluate medical care use and cost, and mortality according to the perception of dyspnea in community-dwelling elderly people. We analyzed baseline data from a community-based Comprehensive Geriatric Assessment in 2002. The perception of dyspnea in 479 Japanese community-dwelling elderly people with normal lung function was measured in August 2002. The sensation of dyspnea during breathing with a linear inspiratory resistance of 10, 20, and 30 cmH2O/L/s was rated using the Borg scale. According to the perception of dyspnea, we divided the elderly into tertiles and compared all hospitalizations, out-patient visits, costs, and death through computerized linkage with National Health Insurance beneficiaries claims history files between August 2002 and March 2008. In-patient hospitalization days and medical care costs significantly increased with the blunted perception of dyspnea, resulting in an increase in total medical-costs with blunted perception of dyspnea. With low perception group as reference, the hazard ratios of all-cause mortality were 0.65 (95% CI 0.23–1.89) for intermediate perception group and 0.31 (0.10–0.97) for high perception group, indicating the mortality rate also significantly increased with the blunted perception of dyspnea after multivariates adjustment (p = 0.04). The blunted perception of dyspnea is related to hospitalization, large medical costs, and all-cause mortality in community-dwelling elderly people. These findings provide a rational for preventing serious illness with careful monitoring of objective conditions in the elderly.

P1-12-24: Adherence and Persistence with Lapatinib in Women with Metastatic Breast Cancer Who Were Previously Treated with Trastuzumab.

Abstract Background. Lapatinib is an oral small molecule dual tyrosine kinase inhibitor that binds intracellularly to the ATP binding site of the EGFR and HER2 receptors. In a randomized controlled trial (RCT) of women with HER2+ metastatic breast cancer (MBC) previously treated with trastuzumab, an anthracycline, and taxanes, lapatinib plus capecitabine improved time to progression versus capecitabine monotherapy. In an RCT of postmenopausal women with HR+ MBC, 1st-line therapy with lapatinib plus letrozole improved progressionfree survival vs. letrozole monotherapy in the primary analysis HER2+ population. Data on adherence and persistence with lapatinib in typical clinical practice are unavailable. Methods. This was retrospective observational study of adherence and persistence with lapatinib in women with MBC who were previously treated with trastuzumab. Data were from the Thomson MedStat MarketScan® Commercial and Medicare health insurance claims databases spanning 1/2000-3/2010 and representing >90 million covered lives. Subjects included women with ≥1 claims with a diagnosis of breast cancer, ≥1 claims with a diagnosis of distant metastases, ≥1 trastuzumab claim after first distant metastases diagnosis, and ≥1 lapatinib claim after first trastuzumab claim (date of first lapatinib claim="index date”). Pts with <12 mos. continuous enrollment pre-index or <3 mos. continuous enrollment post-index were excluded. Measures of lapatinib adherence and persistence were calculated from days supplied information on pharmacy claims and included medication possession ratio (MPR), time to discontinuation (end of supply), time to first treatment interruption (gap during treatment of ≥30 days without supply), and duration of continuous therapy (time to gap of ≥30 days without supply or end of supply). Results. A total of 1299 pts had ≥1 claims with a diagnosis of breast cancer, ≥1 claims with a diagnosis of distant metastases, ≥1 claims for trastuzumab, and ≥1 claims for lapatinib (1106 Commercial, 93 Medicare). Of these, 666 met all inclusion criteria (572 Commercial, 94 Medicare). Mean (SD) age was 52 (8) years in Commercial pts and 72 (6) years in Medicare pts. Among all pts, 73% had claims history of prior taxanes, 27% prior anthracylines, and 24% prior taxanes and prior anthracyclines. Mean (SD) initial lapatinib dosage was 1161 (339) mg daily; 84% initiated lapatinib on 1250 mg daily. Sixty-three percent received index lapatinib in combination with capecitabine; 6% in combination with an aromatase inhibitor. Median follow-up was 12 mos. Mean (SD) number of lapatinib claims was 7.1 (4.9). Mean (SD) MPR was 87% (19%); median MPR was 96%. Kaplan-Meier estimated median time to discontinuation of lapatinib was 7.4 months (95%CI 6.7−8.0 mos). Seventy three percent of patients had no treatment interruption during follow-up. Median duration of continuous therapy was 5.2 mos (95%CI 4.8−5.7 mos). Conclusions. In women with MBC previously-treated with trastuzumab, adherence and persistence with lapatinib in typical clinical practice are relatively high. Further research is needed to identify predictors and consequences of non-adherence so that efforts may be targeted to enhance adherence to effective treatment. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-12-24.

Abstract 16675: Assessment of Initial U.S. Dabigatran Utilization and Short-Term Persistence

Background: The U.S. Food and Drug Administration approved dabigatran in October 2010 to reduce the risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation, and it became available in November 2010. The purpose of this analysis is to assess early US dabigatran utilization patterns and short-term persistence. Methods: A retrospective analysis of a de-identified, integrated pharmacy-medical claims database is described. Patients with a prescription claim for dabigatran Nov 1-Dec 31, 2010, and with continuous eligibility of ≥12 months prior to and up to 4 months after initial dabigatran claim date were included. Demographic and clinical characteristics of patients, prescriber specialty, and 4-month persistence to dabigatran therapy were assessed. Medical diagnoses were determined by the presence of at least 2 ICD-9 or CPT codes in medical claims on 2 separate dates in the prior 12 months. Persistence at 120 days was calculated allowing a 45-day supply gap. Categorical and continuous variables were analyzed using chi-squared and t-tests, respectively (significance at p<0.05). Results: A total of 1,143 patients received dabigatran mainly through retail pharmacy distribution (Table). Of these, 152 (13%) did not have a claims history for atrial fibrillation. Overall, cardiologists were the highest prescribers (62%), however primary care physicians prescribed in 23%. Warfarin therapy was prescribed in 71% of patients during the prior 6 months. Conclusion: The 13% of patients with an unclear dabigatran indication appear distinct from those with atrial fibrillation. Overall, 17% do not persist on dabigatran therapy for 120 days, which may adversely affect stroke outcomes. Ongoing review and action on dabigatran patient selection and therapy maintenance to optimize clinical outcomes, as well as real-world comparative effectiveness with optimized warfarin therapy, are needed.

Early Retirement and Income Loss in Patients with Early and Advanced Parkinsonʼs Disease

The indirect costs of Parkinson's disease (PD) may be larger than direct healthcare costs, and the largest component of indirect costs is income loss related to early retirement. No recent retrospective analysis details PD-related early retirement and income loss in the US. We used an observational, matched cohort to study wages and labour force participation over 4 years and to simulate lifetime income losses conditional on being newly diagnosed with PD (naive) or having evidence of increasing disability. Actively employed primary beneficiaries of private insurance policies aged 18-64 years with more than two PD diagnoses (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM]: 332.x) or one diagnosis and a prescription of an antiparkinsonian drug were selected from a privately insured claims database. Continuous health coverage during analysis periods was required. Naive patients were defined as having no claims history indicative of PD during the year prior to first diagnosis or prescription use. A PD with ambulatory assistance devices (PDAAD) cohort was also followed from the date of first evidence of a wheelchair or walker. Controls without PD were matched on age, sex and region. Survival analysis and Wilcoxon rank sum tests were used to compare rates of early retirement and income loss. A simulation of projected economic loss was conducted for PD cohorts diagnosed at different ages using Bureau of Labor Statistics labour force participation and income data. Naive PD patients (n = 278) and PDAAD patients (n = 28) were on average aged 53 years and had significantly higher rates of co-morbidities at baseline versus controls. Conditional on being employed, there was no statistical difference in earnings. However, the hazard of early retirement associated with PD was 2.08 (p < 0.001) for the naive cohort and 5.01 (p < 0.001) for the PDAAD cohort. From age 40 to 79 years, earnings losses in year 2009 values were $US569 393, $US188 590, $US35 496 and $US2451 for those diagnosed at age 45, 55, 65 and 75 years, respectively. Estimates increased by 9% to 37% when using expected 2018 labour force participation estimates. The cost of early retirement associated with patients with PD was substantial. Given that the proportion of Americans participating in the labour force in older age groups is expected to increase, PD-related early retirement costs will likely rise.

A prediction rule for duration of disability benefits in workers with nonspecific low back pain

ObjectivesThis study examines factors collected within the first 4 weeks of work disability to predict outcomes for workers on benefits due to back pain at 6 & 24 months.MethodsRoutinely collected...

From Paris to London: The Legal History of European Reparation Claims 1946-1953

One of a series of both published and planned studies of the history of European reparations following World War II. This paper narrates the history of the first period of that era, from 1945 to approximately 1952. This period is marked by the disappointment of the expectations of former Allies, especially those that had been under German occupation, to obtain adequate reparations through multilateral arrangements; a frustration that led to later bilateral reparations treaties with the Federal Republic of Germany. It also marks the beginning of the era in which individual subjects who had suffered persecution struggled to establish their own agency - efforts that contributed to the establishment of international human rights in later decades.

Medical Cost Savings for Web-Based Wellness Program Participants from Employers Engaged in Health Promotion Activities

Assess whether an insurer-provided Web-based wellness program results in cost and utilization improvements. Quasi-experimental, pre-post, treatment-comparison design. Variables of interest were participation rates; medical, professional, and pharmacy expenditures; inpatient admissions; emergency room visits; and preventive service utilization. Six hundred forty-three employer-based wellness programs in Pennsylvania. Forty-seven employers engaged in the Web-based wellness program and 596 employers who were not engaged. The engaged employer group included 10,463 wellness participants; an equal number of matched nonparticipant employees were identified from employers who were not engaged. Web-based wellness program features were added to an on-site program in 2004. The program was followed through 2007. Outcomes were calculated using health insurance enrollment and claims history. Participating employees were compared to nonparticipants using generalized linear mixed models to study changes in costs and utilization. During the 2003 baseline year, engaged employers had greater costs, greater chronic disease prevalence, and greater hospitalization. Costs of program participants showed a lower rate of increase in 2004, and then dropped below those of the nonparticipants for the duration of the study. Between 2003 and 2007, the increase in medical expenditures of the participant group was significantly less than that of the nonparticipant group (31% vs. 46%, p < .01). In addition, the participant group showed a lower increase in professional service expenditures (p = .02) and greater utilization of preventive services (p < .01). Web-based insurer-provided wellness programs may decrease health care costs and encourage preventive service utilization.

Bridging the gap between philosophers of mind and brain researchers: The example of addictionFNx08

Philosophers and psychologists have long tried to understand people’s irrational behaviour through concepts such as weakness of will, compulsion and addiction. The scientific basis of the project has been greatly enhanced by advances in cognitive psychology and neuroscience. However, some philosophers have also been critical of the more general conclusions drawn by the scientists. This is especially true when scientific researchers start making claims that go to philosophical issues, such as free will and responsibility. Conversely, some scientists have been critical of philosophical approaches for not understanding the results of recent research. I examined some of the recent history of scientific claims about addiction, and the rise of the claims from scientists to have shown that addiction is a brain disease and that addictive behaviour is compulsive. Given the well-confirmed evidence that addicts can modulate their behaviour in response to rewards, punishments and context, it is clear that according to normal definitions of compulsivity the behaviour of addicts is not typically compulsive, suggesting that neuroscientists are making an error in their interpretation of data. Since philosophers have expertise in making distinctions between different kinds of action and categorising them as free, weak-willed and compulsive, we will achieve a better interpretation of the neuroscience of addiction when taking this philosophical work into account. Conversely, given the status of science in the modern world, philosophers have to grapple with the latest neuroscientific discoveries and show the compatibility of their philosophical theories with the data for their approaches to maintain credibility.

Racial differences in treatment and survival in older patients with diffuse large B-cell lymphoma (DLBCL).

BackgroundDiffuse large B-cell lymphoma (DLBCL) comprises 31% of lymphomas in the United States. Although it is an aggressive type of lymphoma, 40% to 50% of patients are cured with treatment. The study objectives were to identify patient factors associated with treatment and survival in DLBCL.MethodsUsing Surveillance, Epidemiology, and End Results (SEER) registry data linked to Medicare claims, we identified 7,048 patients diagnosed with DLBCL between January 1, 2001 and December 31, 2005. Patients were followed from diagnosis until the end of their claims history (maximum December 31, 2007) or death. Medicare claims were used to characterize the first infused chemo-immunotherapy (C-I therapy) regimen and to identify radiation. Multivariate analyses were performed to identify patient demographic, socioeconomic, and clinical factors associated with treatment and with survival. Outcomes variables in the survival analysis were all-cause mortality, non-Hodgkin's lymphoma (NHL) mortality, and other/unknown cause mortality.ResultsOverall, 84% (n = 5,887) received C-I therapy or radiation treatment during the observation period: both, 26%; C-I therapy alone, 53%; and radiation alone, 5%. Median age at diagnosis was 77 years, 54% were female, 88% were white, and 43% had Stage III or IV disease at diagnosis. The median time to first treatment was 42 days, and 92% of these patients had received their first treatment by day 180 following diagnosis. In multivariate analysis, the treatment rate was significantly lower among patients ≥ 80 years old, blacks versus whites, those living in a census tract with ≥ 12% poverty, and extra-nodal disease. Blacks had a lower treatment rate overall (Hazard Ratio [HR] 0.77; P < 0.001), and were less likely to receive treatment within 180 days of diagnosis (Odds Ratio [OR] 0.63; P = 0.002) than whites. In multivariate survival analysis, black race was associated with higher all-cause mortality (HR 1.24; P = 0.01) and other/unknown cause mortality (HR 1.35; P = 0.01), but not mortality due to NHL (HR 1.16; P = 0.19).ConclusionsIn elderly patients diagnosed with DLBCL, there are large differences in treatment access and survival between blacks and whites.

Bargaining in the Shadow of the Website: Disclosure's Impact on Medical Malpractice Litigation

This study investigates the significance of confidentiality and disclosure for medical malpractice litigation. Starting in the mid-1990s, seventeen states began posting information on a doctor’s specific history of medical malpractice claims on state-run websites. The laws creating these sites altered the level of confidentiality that would accompany litigation and settlement. Taking into account the varying disclosure requirements across the states, we examine the impact of the altered levels of confidentiality on litigant behavior. We find evidence of two, non-exclusive effects of disclosure. First, we find evidence that defendants value confidentiality and are no longer willing to pay a confidentiality premium when websites disclose settlement outcomes. Second, we find evidence that website disclosure changes the composition of claims.

Efficiency and Economic Benefits of a Payer‐based Electronic Health Record in an Emergency Department

The objective was to evaluate the use of a payer-based electronic health record (P-EHR), which is a clinical summary of a patient's medical and pharmacy claims history, in an emergency department (ED) on length of stay (LOS) and plan payments. A large urban ED partnered with the dominant health plan in the region and implemented P-EHR technology in September 2005 for widespread use for health plan members presenting to the ED. A retrospective observational study design was used to evaluate this previously implemented P-EHR. Health plan and electronic hospital data were used to identify 2,288 ED encounters. Encounters with P-EHR use (n = 779) were identified between September 1, 2005, and February 17, 2006; encounters from the same health plan (n = 1,509) between November 1, 2004, and March 31, 2005, were compared. Outcomes were ED LOS and plan payment for the ED encounter. Analyses evaluated the effect of using the P-EHR in the ED setting on study outcomes using multivariate regressions and the nonparametric bootstrap. After covariate adjustment, among visits resulting in discharge (ED-only), P-EHR visits were 19 minutes shorter (95% confidence interval [CI] = 5 to 33 minutes) than non-P-EHR visits. Among visits resulting in hospitalization, the P-EHR was associated with an average 77-minute shorter ED LOS (95% CI = 28 to 126 minutes), compared to non-P-EHR visits. The P-EHR was associated with an average of $1,560 (95% CI = $43 to $2,910) lower total plan expenditures for hospitalized visits. No significant difference in total payments was observed among discharged visits. In the study ED, the P-EHR was associated with a significant reduction in ED LOS overall and was associated with lower plan payments for visits that resulted in hospitalization.

Crossing the Zambezi: the politics of landscape on a Central African frontier

This book is a history of claims to the Zambezi, focussed on the stretch of the river extending from the Victoria Falls downstream into Lake Kariba, which today constitutes the border between Zambia and Zimbabwe. It is a story of 150 years of conflict over the changing landscape of the river, in which the tension between the Zambezi's 'river people' and more powerful others has been central. The Zambezi is one of Africa's longest and most important rivers - securing access to its waters and control over its banks, traffic and commerce were crucial political priorities for leaders of precolonial states no less than their colonial and postcolonial successors. The book is about the ways in which the course of the Zambezi has shaped history, its shifting role as link, barrier or conduit, the political, economic and cultural uses of the technological projects that have transformed the landscape, and their legacies in the conflicts of today. By investigating how the claims made today by Zambezi 'river people' relate to longer history of claims and appropriations, the book contributes to long-standing debates over the relationship between geography and history, landscape and power.

Chariots of Discord: Great Britain, Nationalism and the ‘Doomed’ 1924 Paris Olympic Games

The connection between international sport and national prowess emerged as a salient feature of early modern Olympic competition. As the progenitor of modern sport, Britain's declining competitiveness in the Olympics became a cause of national concern, especially when defeat was translated as proof of British decadence. This paper will explore how the politically Conservative members of the British Olympic Association (BOA) embraced the 1924 Paris Olympic Games as a platform for national projection. A coordinated attempt between high-ranking members of the Conservative Party and some of the nation's most eminent patricians to reclaim Britain's lost athletic prowess demythologises the long history of claims that the BOA was historically a private and apolitical body. This paper also reveals how the chauvinism that marred the 1924 Paris games reaffirms the popular scholarly opinion that the Olympics are a politico-sporting contest between nation-states.

Book Reviews

Books reviewed in this issue. “It's Still in my Heart, This is My Country”: The Single Noongar Claim History. By South West Aboriginal Land and Sea Council, John Host with Chris Owen The Unforgiving Rope: Murder and Hanging on Australia's Western Frontier. By Simon Adams The Water Dreamers: The Remarkable History of our Dry Continent. By Michael Cathcart Work and Strife in Paradise: the History of Labour Relations in Queensland 1859–2009. Edited by Bradley Bowden et al. Andrew Fisher: An Underestimated Man. By Peter Bastian Our Unswerving Loyalty: A Documentary Survey of Relations between the Communist Party of Australia and Moscow, 1920–1940. Edited by David W. Lovell and Kevin Windle So Many Firsts. By Margaret Fitzherbert The City's Outback. By Gillian Cowlishaw Reclaiming Patriotism: Nation‐Building for Australian Progressives. By Tim Soutphommasane Rights and Redemption: History, Law and Indigenous Peoples. By Ann Curthoys, Ann Genovese and Alexander Reilly Reconciliation and Colonial Power: Indigenous Rights in Australia. By Damien Short Every Assistance and Protection: A History of the Australian Passport. By Jane Doulman and David Lee Replenishing the Earth: The Settler Revolution and the Rise of the Anglo‐World, 1783–1939. By James Belich The Ivory Tower and Beyond: Participant Historians of the Pacific. By Doug Munro. “Pacific Focus” series, no 6 Journeys Towards Progress: Essays of a Geographer on Development and Change in Oceania. By Ray Watters. Ed. Ginny Sullivan Immortal Longings: F.W.H. Myers and the Victorian Search for Life After Death. By Trevor Hamilton Imperialismus vom Grünen Tisch: Deutsche Kolonialpolitik zwischen wirtschaftlicher Ausbeutung und ‘zivilisatorischen’ Bemühungen. By H Pogge von Strandmann Weimar Germany: Promise and Tragedy. By Eric D. Weitz The Reluctant Revolutionary. Dietrich Bonhoeffer's Collision with Prussian‐German History. By John A. Moses Inside the Gas Chambers: Eight Months in the Sonderkommando of Auschwitz. By Shlomo Venezia The Will to Believe: Woodrow Wilson, World War I, and America's Strategy for Peace and Security. By Ross A. Kennedy Veil: Mirror of Identity. By Christian Joppke Doomed to Repeat? Terrorism and the Lessons of History. Sean Brawley, ed.

Burden of schizophrenia in recently diagnosed patients: healthcare utilisation and cost perspective

Background:Inpatient care to manage relapse of patients with schizophrenia contributes greatly to the overall financial burden of treatment. The present study explores to what extent this is influenced by duration of illness.Methods:Medical and pharmaceutical claims data for patients diagnosed with schizophrenia (ICD-9 295.xx) were obtained from the PharMetrics Integrated Database, a large, regionally representative US insurance claims database, for the period 1998–2007. Recently diagnosed (n = 970) and chronic patients (n = 2996) were distinguished based on ICD-9 295.xx classification, age and claims history relative to the first year (recently diagnosed) and the third year onwards (chronic) after the first index schizophrenia event.Results:The medical resource use and costs during the year following the index schizophrenia event differed significantly between cohorts. A higher proportion of recently diagnosed patients were hospitalised compared with chronic patients (22.3% vs 12.4%; p < 0.0001), spending a greater mean number of days in hospital (5.1 days vs 3.0 days; p = 0.0065) as well as making more frequent use of emergency room (ER) resources during this time. The mean annual healthcare costs of recently diagnosed patients were also greater ($20,654 vs $15,489; p < 0.0001) with inpatient costs making up a higher proportion of total costs (62.9%) compared with chronic patients (38.5%).Conclusions:There is a considerably higher overall economic burden in the year following their first schizophrenia event in the treatment of recently diagnosed schizophrenia patients compared with chronic patients. Since hospitalisations and ER visits are the most significant components contributing to this finding, efforts that focus on measures to reduce the risk of relapse, particularly amongst recently diagnosed patients, such as improved adherence programs, may lead to better clinical and economic outcomes in the management of schizophrenia.Limitations:Only commercially insured patients and direct medical costs were included, therefore, results may underestimate the economic burden of schizophrenia.

A retrospective claims analysis of combination therapy in the treatment of adult attention-deficit/hyperactivity disorder (ADHD)

BackgroundCombination therapy in managing psychiatric disorders is not uncommon. While combination therapy has been documented for depression and schizophrenia, little is known about combination therapy practices in managing attention-deficit/hyperactivity disorder (ADHD). This study seeks to quantify the combination use of ADHD medications and to understand predictors of combination therapy.MethodsPrescription dispensing events were drawn from a U.S. national claims database including over 80 managed-care plans. Patients studied were age 18 or over with at least 1 medical claim with a diagnosis of ADHD (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 314.0), a pharmacy claim for ADHD medication during the study period July2003 to June2004, and continuous enrollment 6 months prior to and throughout the study period. Dispensing events were grouped into 6 categories: atomoxetine (ATX), long-acting stimulants (LAS), intermediate-acting stimulants (IAS), short-acting stimulants (SAS), bupropion (BUP), and Alpha-2 Adrenergic Agonists (A2A). Events were assigned to calendar months, and months with combined use from multiple categories within patient were identified. Predictors of combination therapy for LAS and for ATX were modeled for patients covered by commercial plans using logistic regression in a generalized estimating equations framework to adjust for within-patient correlation between months of observation. Factors included age, gender, presence of the hyperactive component of ADHD, prior diagnoses for psychiatric disorders, claims history of recent psychiatric visit, insurance plan type, and geographic region.ResultsThere were 18,609 patients identified representing a total of 11,886 months of therapy with ATX; 40,949 months with LAS; 13,622 months with IAS; 38,141 months with SAS; 22,087 months with BUP; and 1,916 months with A2A. Combination therapy was present in 19.7% of continuing months (months after the first month of therapy) for ATX, 21.0% for LAS, 27.4% for IAS, 23.1% for SAS, 36.9% for BUP, and 53.0% for A2A.For patients receiving LAS, being age 25–44 or age 45 and older versus being 18–24 years old, seeing a psychiatrist, having comorbid depression, or having point-of-service coverage versus a Health Maintenance Organization (HMO) resulted in odds ratios significantly greater than 1, representing increased likelihood for combination therapy in managing adult ADHD.For patients receiving ATX, being age 25–44 or age 45 and older versus being 18–24 years old, seeing a psychiatrist, having a hyperactive component to ADHD, or having comorbid depression resulted in odds ratios significantly greater than 1, representing increased likelihood for combination therapy in managing adult ADHD.ConclusionATX and LAS are the most likely drugs to be used as monotherapy. Factors predicting combination use were similar for months in which ATX was used and for months in which LAS was used except that a hyperactive component to ADHD predicted increased combination use for ATX but not for LAS.

Inadequate BCR-ABL monitoring in imatinib-treated patients with chronic myelogenous leukemia

7077 Background: Recommendations for baseline and quarterly measurement of the BCR-ABL fusion transcript to monitor imatinib response in patients with chronic myelogenous leukemia (CML) were formally introduced in October 2006, and have been incorporated into nationally recognized treatment guidelines. Methods: To assess BCR-ABL testing rates, we conducted a retrospective cohort analysis using a &gt;10 million-member health plan database comprised of integrated pharmacy and medical claims. The study cohort was defined as patients with an index imatinib pharmacy claim from July 1, 2006, to December 31, 2006, who had a CML diagnosis (ICD-9 205.1X; N = 504), and a minimum of 3 months continuous follow-up by claims history (N = 465). Over a period of up to four quarters from the index imatinib prescription date, BCR-ABL testing in each quarter was assessed by the presence of any of a set of 19 CPT-4 codes. BCR-ABL testing rates in each individual quarter and in consecutive quarters were measured. Results: The overall study cohort was 57% male; mean (±SD) age was 52±14 y/o, with 26% 19–44 y/o, 57% 45–64 y/o, and 15% ≥65 y/o. Median duration of f/u was 559 days (interquartile range 302–628 days), and a cohort of 359 patients had 4 quarters of f/u. At least one BCR-ABL test was recorded in 60% of patients. The rate of first quarter BCR-ABL testing was 40%, and remained at 42%-43% in quarters 2 thru 4. Consecutive quarterly testing rates were 24% through the second quarter, 18% through the third quarter, and 14% through the fourth quarter. Conclusions: In this retrospective claims database analysis, only 14% of a large cohort of CML patients treated with imatinib had BCR-ABL testing recorded in each of 4 consecutive quarters. Inadequate compliance with recommended BCR-ABL testing can delay treatment decisions, and may be associated with poor clinical outcome. [Table: see text]