Commercially-insured Patients Research Articles

Effect of breakthrough pain on functional status, pain interference, and disability in cancer patients: Findings from the national breakthrough pain survey.

6627 Background: Few studies have evaluated the epidemiology of breakthrough pain (BTP) in community-dwelling populations with cancer and chronic pain. The National Breakthrough Pain Survey (NBTPS) assessed the prevalence, characteristics, and impact of BTP in a large commercially-insured population and determined the BTP-associated functional impairments and disability in cancer patients with controlled, persistent pain. Methods: Administrative claims from the HealthCore Integrated Research Database were utilized to identify commercially-insured adult patients with ≥2 medical claims at an interval ≥3 months with an ICD-9-CM code indicating a chronic pain condition (cancer or noncancer) and ≥3 opioid prescription claims. Patients were called and, after consent, completed the Brief Pain Inventory (BPI), Sheehan Disability Scale (SDS), and 12-Item Short-Form Health Survey (SF-12) by interview. Data from patients with cancer and controlled, persistent pain were included in this subanalysis. Results: Of 2198 patients surveyed, 1279 had controlled, persistent pain. Of these, 145 had cancer pain, 77.2% of whom reported BTP (BTP, 112; no BTP, 33). Compared to those without BTP, cancer patients with BTP had significantly higher total BPI pain interference scores (mean±SD 34.7±14.5 vs 23.4±16.7, P=.001) and significantly greater global functional impairment on the SDS (mean±SD 16.8±8.3 vs 12.4±8.3, P=.028). There also was a non-significant finding of decreased quality of life, as assessed by SF-12 physical and mental component scale scores, among cancer patients with BTP vs no BTP (mean±SD 27.8±9.1 vs 32.2±10.1, P=.11, and 47.0±11.9 vs 49.4±11.6, P=1.0, respectively). Conclusions: In a sample of commercially-insured patients, cancer patients with controlled, persistent pain and BTP had greater pain-related functional impairments and disability than those with controlled, persistent pain and no BTP. These data suggest that BTP is clinically important among populations receiving cancer care in the community.

PRS13 - Hospitalization Costs Related To Pulmonary Hypertension (Ph) Among Medicare Advantage Or Commercially Insured Patients With Pulmonary Arterial Hypertension (Pah) In The United States

PRS13 - Hospitalization Costs Related To Pulmonary Hypertension (Ph) Among Medicare Advantage Or Commercially Insured Patients With Pulmonary Arterial Hypertension (Pah) In The United States

PIN20 - Prevalence Of Hepatic Outcomes Among Commercially-Insured Patients Diagnosed With Chronic Hepatitis C Virus

PIN20 - Prevalence Of Hepatic Outcomes Among Commercially-Insured Patients Diagnosed With Chronic Hepatitis C Virus

Adherence to dornase alfa treatment among commercially insured patients with cystic fibrosis

Objective:To investigate adherence to dornase alfa therapy among commercially-insured patients with cystic fibrosis (CF) and to examine the impact of adherence on health and economic outcomes.Methods:This retrospective cohort analysis included CF patients with ≥1 dornase alfa (Pulmozyme) pharmacy claim between 1 October 2006 and 30 September 2008 and with continuous enrollment in the health insurance plan at least 1 year before and 1 year after their index dornase alfa claim. Adherence was measured with the medication possession ratio (MPR). Multivariate models were used to estimate the relationship between adherence and exacerbations, utilization, and cost.Results:Nine hundred and seven patients met the inclusion criteria. The mean age was 19.5 years (SD = 11.5) and 49.1% were female. Overall MPR was 0.59 and by age was 0.66 for patients of 5–12 years, 0.57 for 13–20 years, 0.54 for 21–30 years, and 0.56 for patients ≥31 years. Adherence was better in fall and winter than in spring and summer. There was no statistically significant difference in the proportion of patients with inpatient respiratory exacerbations across groups with low (<0.5), moderate (0.5–0.79), and high (≥0.8) adherence (24.5%, 22.3%, and 19.1%, respectively, p = 0.250). There was a trend toward higher total charges in more-adherent patients (mean $58,612 in the least-adherent group and mean $69,427 in the most adherent group, p = 0.107). In multivariate models, MPR was not significantly associated with the risk of inpatient respiratory exacerbations (hazard ratio = 1.16 for MPR <0.5 vs ≥0.8; 95% CI = 0.83–1.61).Limitations:Study data were derived from insurance claims; adherence measures were based on prescription fills, not observed medication use.Conclusion:Adherence to dornase alfa was generally low, but varied by age and season. Adherence was not found to be significantly associated with respiratory exacerbations or total charges, but was associated with shorter hospital length of stay.

Antiepileptic drug treatment patterns and economic burden of commercially-insured patients with refractory epilepsy with partial onset seizures in the United States

Objective:To assess the economic burden in direct healthcare utilization and costs for refractory epileptic patients with partial onset seizures (POS) and assess the antiepileptic drug (AED) treatment patterns among these patients.Methods:This retrospective database study analyzed administrative claims of commercially-insured patients with POS from 2004–2008. Healthcare costs and utilization were compared between refractory (defined as ≥3 AEDs) and non-refractory patients by calendar year and AED treatment patterns were described for refractory patients.Results:Of the 79,149 patients identified (mean age 33 years; 54.8% female), 8714 (11%) were classified as refractory. In 2008, average annual healthcare costs for refractory patients were significantly higher than non-refractory patients ($33,613 vs $19,085), also by settings for inpatient ($11,780 vs $6076), outpatient ($13,431 vs $8637), and pharmacy costs ($8402 vs $4372) (all p < 0.001). Among refractory patients, close to one-third of total costs were for POS-related services. Similar trends were observed when assessing POS-related utilization and costs. The differences were consistent across all calendar years examined. Among refractory patients, 80.5% were on monotherapy at the beginning of the follow-up period. Levetiracetam is the common AED in mono/combination therapy as well as add-on/switch-to.Limitations:The onset of seizure cannot be identified, and the indication of each AED could not be confirmed from the pharmacy claims. Only direct medical costs were assessed.Conclusions:Pattern of use was very dynamic, suggesting seizures are not well-controlled. Improving seizure control and reducing economic burden of refractory epilepsy remain important unmet medical needs in this population.

Use of select medications prior to duloxetine initiation among commercially-insured patients.

BackgroundThe purpose of this study was to assess select medication utilization prior to duloxetine initiation among patients with major depressive disorder, generalized anxiety disorder, diabetic peripheral neuropathic pain, fibromyalgia, and musculoskeletal pain associated with osteoarthritis or low back pain.MethodsCommercially insured duloxetine initiators between January 1, 2007 and March 31, 2010 were identified from a large US administrative claims database. Disease subgroups were constructed based on diagnosis from medical claims during the 12 months prior to duloxetine initiation. Prior use of antidepressants, anticonvulsants, opioids, nonsteroidal anti-inflammatory drugs, and muscle relaxants was assessed during the 12-month preinitiation period.ResultsThis study identified 56,845 (2007), 44,838 (2008), and 65,840 (January 2009 to March 2010) duloxetine initiators. Among the 2009 initiators, utilization patterns were similar for patients with major depressive disorder and generalized anxiety disorder, with antidepressants being the most used (84% and 80%, respectively), followed by opioids (58% and 55%, respectively). Patients across pain-related conditions also had similar utilization patterns, with opioid use being the highest (76%–82%), followed by antidepressants (65%–72%). Use of other medication classes was common (29%–63%) but less frequent, and over 50% of the patients used any antidepressants, 70% used any antidepressants or anticonvulsants, and 90% used any antidepressants, anticonvulsants, or opioids. Trends in the use of these select medications were similar between 2007 and 2009.ConclusionPatients used several types of medications over the 12 months prior to initiating duloxetine across disease states, with antidepressants and opioids being the most frequently used medications. Trends of select medication use were similar over time.

The cost to managed care of managing pulmonary hypertension

Objective:To estimate direct medical costs and resource use for commercially-insured patients within two pulmonary hypertension sub-groups: pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH).Research design and methods:Using a retrospective cohort design, subjects (≥18 years) with ICD-9 code 416.0 (PAH or CTEPH) or 416.8 (CTEPH) were identified during 2004–2009 within the MarketScan database. The date of the first observed claim was the index date. Each PAH and CTEPH patient was matched to one-to-five controls without PAH and CTEPH on age, gender, region, and payer type. Patients and controls were continuously enrolled for at least 12 months pre- and 12 months post-index date. Per-patient-per-month costs and resource use were compared using Wilcoxon rank-sum test.Results:PAH patients (1647) and controls (6352) were identified (mean age 63 years, 73% female). Total monthly costs before PAH diagnosis were: PAH patients $2064 vs controls $1094. After PAH diagnosis, PAH patients had significantly higher monthly costs and resource use vs controls: Total costs $4021 vs $1533, outpatient visits 1.1 vs 0.8, inpatient visits 0.7 vs 0.2, prescriptions 3.6 vs 2.7, all p-values <0.05. One hundred and forty-six CTEPH patients and 558 controls were identified (mean age 64 years, 54.8% female). Total monthly costs in the period before CTEPH diagnosis were higher for CTEPH patients ($3895) than controls ($1177). After CTEPH diagnosis, CTEPH patients had significantly higher monthly costs and resource use vs controls: Total costs $6198 vs $1579, Outpatient visits 1.2 vs 0.8, inpatient visits 2 vs 0.2, prescriptions 4.2 vs 2.8, all p-values <0.05.Key limitations:Identification of PAH is complicated, as there exists no precise ICD-9-CM code for the condition. CTEPH diagnosis was based upon claims data and was not verified clinically.Conclusions:CTEPH and PAH patients incurred higher costs and used more resources than controls in the baseline and follow-up periods.

Use of hypomethylating agents and associated care in patients with myelodysplastic syndromes: a claims database study

Objective:The purpose of this study is to describe patterns of hypomethylating agents (HMA) use and to compare treatment outcomes of decitabine (DAC) and azacitidine (AZA) with respect to transfusion dependence and the use of erythropoiesis-stimulating agents (ESA) treatment in commercially-insured patients with Myelodysplastic Syndromes (MDS).Research design and methods:A retrospective study using MarketScan Research Data, a large claims database studied patients who received DAC, AZA, or Supportive Care (SC) with at least two claims for MDS between January 1, 2006 and December 31, 2008. Poisson regressions were used to compare DAC and AZA on post-index number of red blood cell/platelet (RBC/PLT) transfusions and ESA treatment, controlling for age, gender, Charlson Comorbidity Index (CCI), time to HMA initiation, number of HMA cycles, and pretreatment RBC/PLT or ESA claims. No other adjustment for disease severity was made.Results:Approximately 48% of the patients were males with a mean age of 73 years (N = 2525). There were 37 DAC-treated and 60 AZA-treated patients. The length of follow-up did not significantly differ between the DAC- and AZA-treated groups (DAC = 349.2; AZA = 350.5 days); however, the number of days from MDS diagnosis to HMA therapy initiation was longer in the DAC cohort than in the AZA cohort (mean 93.7 days vs. 50.8 days, respectively, p = 0.029). Both DAC- and AZA-treated patients received similar number of treatment cycles (mean: 4.8 vs. 5.6 in DAC vs. AZA, p > 0.05), with means of 4.6 days per cycle for patients receiving DAC and 7.4 days for those receiving AZA (p = 0.003). Following treatment with HMA using Poisson regression analysis, DAC-treated patients had significantly lower use of RBC/PLT transfusions (RR 0.206, p = 0.034) and similar use of ESAs compared with AZA-treated patients. Limitations of the study included the small sample size, and the fact that the majority of patients were unspecified regarding their International Prognostic Scoring System (IPSS) risk category, which did not allow for accounting for differences in disease severity.Conclusions:In MDS patients treated with an HMA, treatment with DAC was associated with less frequent transfusions than with AZA treatment. Further studies with the ability to control for disease severity are warranted.

PCV106 RE-HOSPITALIZATION RATES OF ACUTE CORONARY SYNDROME PATIENTS IN REAL WORLD CLINICAL PRACTICE: OBSERVATIONS FROM A NATIONAL ADMINISTRATIVE CLAIMS DATA

RE-HOSPITALIZATION RATES OF ACUTE CORONARY SYNDROME PATIENTS IN REAL WORLD CLINICAL PRACTICE: OBSERVATIONS FROM A NATIONAL ADMINISTRATIVE CLAIMS DATA Tunceli O1, Gandhi SK2, Bhandary D2, Stephenson JJ1, Gold A2, Fu AC1, Kern DM1, Singer J1 1HealthCore, Inc., Wilmington, DE, USA, 2AstraZeneca Pharmaceuticals LP, Wilmington, DE, USA OBJECTIVES: Re-hospitalization and mortality rates are increasingly being used as quality of care measures that have significant reimbursement implications. We examine the rates of re-hospitalization and mortality of acute coronary syndrome (ACS) patients in real-world clinical practice. METHODS: Commercially-insured patients (age 18 years) with an inpatient hospitalization for ACS [ICD-9-CM codes for acute myocardial infarction or unstable angina (UA)] between 1/1/2007-5/31/ 2010 were identified from medical claims in the HealthCore Integrated Research Database (HIRD). Patients with ACS events within one year prior to index hospitalization were excluded. All-cause and ACS-related re-hospitalizations and mortality rates within 30 days and 12 months after index event were evaluated. RESULTS: Of 66,772 ACS patients (60% male; mean age 66.6 years), 21% had diagnostic coding for ST elevation myocardial infarction (STEMI), 31% had coding for non-ST elevation myocardial infarction (NSTEMI), 37% had UA, and 11% had not otherwise specified (NOS) ACS. Approximately, 90% and 52% of patients had 30-days and 12 months of continuous eligibility respectively. The 30-day all-cause re-hospitalization rate was 16.3 % (STEMI: 16.4%, NSTEMI: 19.0%, UA: 13.3%, NOS: 20.6%;) and 6.3 % (STEMI: 8.8%, NSTEMI: 6.6%, UA: 5.2%, NOS: 4.5%) for an ACS-related re-hospitalization. The 12-month all cause re-hospitalization rate was 41.3% (STEMI: 39.0%, NSTEMI: 46.4%, UA: 38.2%NOS: 46.6%, )and 16.6% for an ACS-related re-hospitalization. The 30-day post-index mortality rate was 2.4 % (STEMI:1 .8%, NSTEMI:4.3%, UA:0.5%, NOS:5.2%;) and the 12-month rate was 7.0%. For patients with ages 65 years, the 30-day all-cause and ACS-related re-hospitalization rates were 21.2% and 7.0%, respectively. CONCLUSIONS: The re-hospitalization and mortality rate for ACS patients within 30 days and 12-months post-index hospitalization discharge as observed in real-world clinical practice remain high. Use of more effective therapies may provide an opportunity to improve important clinical and economic outcomes in ACS patients.

Average daily dose, medication adherence, and healthcare costs among commercially-insured patients with fibromyalgia treated with duloxetine

Objective:What is the relationship between average daily dose (ADD) of duloxetine, adherence to therapy, and healthcare costs among patients with fibromyalgia?Methods:Employing a retrospective cohort design, this study assessed administrative claims data for commercially-insured fibromyalgia patients who initiated duloxetine in 2006. Initiation was defined as a 90-day clean period without access to duloxetine. Five study cohorts were constructed based on the ADD of duloxetine, calculated from all prescriptions dispensed over the 12-month follow-up period: <30 mg, 30 mg, 31–59 mg, 60 mg, and >60 mg (duloxetine starting dose: 30 mg/day; target dose: 60 mg/day). Medication possession ration (MPR) was used to assess duloxetine adherence, with MPR ≥0.8 as ‘high’ adherence. Multivariate regressions were applied to examine the association between ADD, duloxetine adherence, and healthcare costs (total, inpatient, outpatient, and pharmacy), adjusting for differences in demographic and clinical characteristics between cohorts.Results:Of the 4869 patients with fibromyalgia, 3% had an ADD of <30 mg, 12% had 30 mg, 21% had 31–59 mg, 46% had 60 mg, and 18% had >60 mg. High adherence to duloxetine ranged from 16% to 41% across cohorts. Controlling for demographic and clinical characteristics, patients with an ADD of 31–59 mg or >60 mg were more likely to adhere to duloxetine therapy than those in the 60 mg cohort, while patients in the <30 mg cohort were less likely to adhere to duloxetine (all p < 0.05). Total costs were significantly higher for individuals in the 31–59 mg or >60 mg ADD cohorts ($1834 and $5766) than those maintaining an ADD of 60 mg, as were outpatient ($1167 and $2275) and pharmacy costs ($502 and $2983) (all p < 0.05). Patients with an ADD of 30 mg had significantly lower total (−$1770), inpatient (−$1524), and pharmacy (−$827) costs (all p < 0.05) than those with an ADD of 60 mg.Limitations:This study is subject to selection bias because some confounders might be unobserved in the administrative claims database. Indirect costs or over-the-counter medication costs were also not available.Conclusions:Fibromyalgia patients with an ADD of 60 mg of duloxetine had better adherence than patients with an ADD ≤30 mg. Duloxetine patients with an ADD of 30 mg (31–59 or >60 mg) had significantly lower (higher) healthcare costs than those maintaining an ADD of 60 mg.

Medication adherence and healthcare costs among patients with diabetic peripheral neuropathic pain initiating duloxetine versus pregabalin

Objective:To examine the impact of medication choice between duloxetine or pregabalin on medication adherence and direct healthcare costs among patients with diabetic peripheral neuropathic pain (DPNP).Methods:A retrospective cohort study design was used with a large US national administrative claims database. Commercially-insured DPNP patients aged 18–64 years who initiated duloxetine or pregabalin in 2006 were selected, with the first initiation date as the index date. All selected patients had 12 months continuous enrollment in the pre- and post-index periods, and were grouped into the duloxetine or pregabalin cohort based on the index agent. The duloxetine and pregabalin cohorts were constructed via propensity score stratification with similar demographics, co-morbid medical conditions, pre-index healthcare utilization and costs, and prior treatment patterns. Medication possession ratio (MPR), proportion of patients with MPR ≥ 0.8 and healthcare costs over the 12-month post-index period were compared between cohorts.Results:Both the duloxetine (n = 794) and pregabalin (n = 1779) cohorts had a mean age of 56 years, and 58% of female. Common co-morbid conditions among duloxetine and pregabalin patients were cardiovascular disease (82.5 vs. 82.2%), neuropathic pain other than DPNP (71.1 vs. 72.7%), osteoarthritis (39.0 vs. 41.3%), and low back pain (29.4 vs. 30.5%). More than 73% of the patients had opioid use prior to the initiation of duloxetine or pregabalin. Among patients with similar demographic, clinical and economic characteristics, and prior treatment patterns, duloxetine-treated patients had significantly higher MPR (0.34 vs. 0.13), higher proportion of patients with MPR ≥ 0.8 (15.5 vs. 0.7%), and significantly lower total healthcare costs ($34 146 vs. 34 897) over the 12-month post-index period than pregabalin-treated patients (all p < 0.05).Conclusions:Commercially-insured DPNP patients initiating duloxetine had significantly higher medication adherence and lower healthcare costs than those initiating pregabalin.

Factors associated with pain medication selection among patients diagnosed with diabetic peripheral neuropathic pain: a retrospective study

Objective:To assess the demographic and clinical characteristics associated with initiation of duloxetine therapy compared with other pharmacologic therapies for treatment of diabetic peripheral neuropathic pain (DPNP).Methods:This study used administrative claims databases for commercially-insured individuals aged 18–64 years to examine factors associated with treatment among DPNP patients who initiated duloxetine versus tricyclic antidepressants (TCAs), venlafaxine, gabapentin, pregabalin, or opioids between 7/1/2005 and 12/31/2007. Treatment initiation was defined as no pill coverage of the same medication over the previous 90 days. Multiple logistic regression models were estimated to assess factors associated with initiating duloxetine versus each of the other DPNP therapies.Results:The study included 11,060 DPNP patients with average age of 55 years old. Cardiovascular disease (63–70%), cerebrovascular/peripheral vascular disease (26–33%), low back pain (24–39%), and osteoarthritis (17–26%) were the most common diabetes- and pain-related comorbidities. Controlling for demographic and clinical characteristics, patients who received duloxetine or pregabalin in the prior 12-month period were more likely to initiate duloxetine. Patients from other DPNP treatment cohorts, except for those in the pregabalin cohort, were more likely to re-initiate the same prior therapy than begin treatment with duloxetine (all p < 0.05). A history of anxiety disorder was significantly associated with initiation of all DPNP treatments other than duloxetine (all p < 0.05), except for TCAs. Patients with low back pain were more likely to initiate duloxetine than TCAs or venlafaxine, but less likely to initiate duloxetine than pregabalin or opioids. Patients with infections related to diabetes were less likely to initiate duloxetine than venlafaxine, gabapentin, or opioids.Limitations:Because a retrospective administrative claims database was used, this study is subject to selection bias due to unobservable confounders, inability to measure prescriber preferences or characteristics or disease severity.Conclusions:Among commercially-insured DPNP patients, those with prior use of duloxetine or pregabalin were more likely to initiate duloxetine than other treatments. The presence of select comorbidities was also associated with specific medication initiation.

The Impact of Health Insurance Coverage and Socioeconomic Status in Access to Care in Patients with Inflammatory Bowel Disease

Purpose: A study of prevalence of IBD in Puerto Rico showed a significant difference between patients with commercial insurance (CI) versus those insured through a government sponsored (GS) capitated managed care system (61.5 vs. 14.6 per 100,000).To determine if the type of health insurance, CI or GS, influenced the time to referral to a specialist, and overall patient satisfaction in patients attending the clinics of the UPR Center for IBD. Methods: 155 patients with a diagnosis of IBD from the UPR Center for IBD participated in the study. Three patients with Medicare insurance were excluded from the analysis. The data was collected through a questionnaire distributed at the clinics. Demographic, socioeconomic and health care utilization data was collected. STATA v10 was used for descriptive statistics and Pearson chi-square was used to calculate differences between proportions. A logistic regression analysis was conducted to assess several dependent variables simultaneously. The study was approved by the MSC IRB. Results: 97/152 (64.0%) were covered by commercial insurance and 55 (36.0%) were covered by the government sponsored health plan. CI patients reported higher levels of education (p=0.0003) and income (p=0.0001) as compared to GS patients. Both groups reported similar satisfaction with their medical insurance (91.8% and 89.1% respectively, p=0.58). Of the 113 patients referred to a gastroenterologist by their primary physician, 68 (60.0%) were CI and 45 (40.0%) were GS (p=0.05). Median delay before referral to a gastroenterologist was 1 month for CI and 6 months for GS. Ten patients were never referred to a gastroenterologist, 1 (10%) was CI and 9 (90%) were GS (p=0.0004). All 29 patients who directly visited a gastroenterologist were CI. Of the 36 patients referred to a gastroenterologist within one month of diagnosis, 30 (83.3%) were CI and only 6 (16.7%) were GS (p=0.0006). This difference was sustained after adjusting by gender, education and income. Conclusion: Our study shows that commercially insured patients with IBD attending the UPR IBD clinic are more timely referred to a gastroenterologist as compared to patients with a government sponsored plan. Delay in referral to subspecialty care could be a factor in the difference in prevalence between the CI and the GS individuals with IBD in Puerto Rico. A study of all patients participating in GS coverage is necessary to validate this finding, as we studied only patients who were receiving subspecialty care. If confirmed, this highlights the importance of appropriate educational intervention at the primary care level. Supported by the UPR SoM Endowed Health Services Research Center, Grants 5S21MD000242 and 5S21MD000138, NCMHD-NIH.

Opioid use and healthcare costs among patients with DPNP initiating duloxetine versus other treatments

Objective:To compare opioid utilization and healthcare costs over a 1-year period following the initiation with duloxetine versus other standard of care (SOC) treatments among patients with diabetic peripheral neuropathic pain (DPNP).Methods:This retrospective cohort study assessed commercially-insured DPNP patients between 18 and 64 years old who initiated duloxetine or other SOC treatments (tricyclic antidepressants, venlafaxine, gabapentin, pregabalin) between 3/1/2005 and 12/31/2005. Initiation was defined as a 90-day period without available study medication. The first dispense date of the study medication was denoted as the index date. Selected patients had no opioid pill coverage during the 90 days prior to initiation. Duloxetine and SOC patients were matched via propensity scoring (1:1 ratio), controlling for demographics, comorbidities, prior healthcare utilization and costs, and prior medication history. Opioid utilization and healthcare costs over the 12-month post-index period were compared between study cohorts.Results:The matched sample included 117 patients in each of the duloxetine and SOC cohorts. Compared with SOC-treated patients, duloxetine-treated patients were less likely to use any opioids (52.1 vs. 84.6%, p < 0.05) over the 12-month post-index period. Duloxetine-treated patients, on average, had two fewer opioid prescriptions dispensed, 27 fewer days on opioids, 121 days greater delay in subsequent opioid use, and 1815 mg lower morphine equivalent dosage than SOC-treated patients (all p < 0.05). Also, duloxetine-treated patients had significantly lower total ($18 623 vs. 30 602, p < 0.05) and outpatient costs ($7371 vs. 15 343, p < 0.05).Due to the use of a retrospective administrative claims database, limitations of this study include the potential for selection bias between study cohorts, and inability to measure unobservable confounding and disease severity and/or duration.Conclusions:Among commercially-insured DPNP patients, duloxetine-treated patients had delayed and reduced opioid use and lower healthcare costs than SOC-treated patients.

The use of prescribed pain medication during six or twelve months prior to the initiation of duloxetine therapy

Duloxetine is indicated for treatment of major depressive disorder (MDD), general anxiety disorder (GAD), diabetic peripheral neuropathic pain (DPNP), and fibromyalgia. It has also been prescribed for pain relief for chronic lower back pain (CLBP) and osteoarthritis. For each of these conditions, this study assessed the utilization of pain medications prior to patients initiating duloxetine. Employing a retrospective cohort design and administrative claims data, we identified duloxetine initiators (under-age-65 commercially insured and age-65+ Medicare supplemental insured) between October 1, 2004 and December 31, 2005 who had any of the 6 medical conditions mentioned above during the 12 months prior to initiation of duloxetine. The first duloxetine dispense date was set as the “index date”. Patterns of use of pain medications during 6 and 12 months prior to index date were compared between cohorts. Among commercially-insured duloxetine users (n = 45,076, mean age = 46) antidepressants were more commonly used in patients with MDD (79%) and GAD (77%), and less among patients in other cohorts (ranging from 38% to 45%) during 6 months prior to index date; selective serotonin reuptake inhibitors accounted for about half of antidepressants. Anticonvulsants utilization was highest in patients with DPNP (44%), GAD (38%) and MDD (35%), but similar in other disease states (ranging from 22% to 24%). Patients had similar opioid and non-steroidal anti-inflammatory drugs (NSAIDs) utilization regardless of condition. Medicare-insured patients (n = 8,051, mean age = 73.5) were more likely to use anticonvulsants (33% vs. 26%, p < 0.001), opioids (53% vs. 41%, p < 0.001) and NSAIDs (31% vs. 24%, p < 0.001) than those commercially-insured. Patterns of utilization of pain medication across disease states were very similar between Medicare- and commercially-insured patients and between 12-month and 6-month prior to index date. The findings from this analysis indicate that patients had been dispensed several types of pain medications prior to duloxetine initiation across disease states. Duloxetine is indicated for treatment of major depressive disorder (MDD), general anxiety disorder (GAD), diabetic peripheral neuropathic pain (DPNP), and fibromyalgia. It has also been prescribed for pain relief for chronic lower back pain (CLBP) and osteoarthritis. For each of these conditions, this study assessed the utilization of pain medications prior to patients initiating duloxetine. Employing a retrospective cohort design and administrative claims data, we identified duloxetine initiators (under-age-65 commercially insured and age-65+ Medicare supplemental insured) between October 1, 2004 and December 31, 2005 who had any of the 6 medical conditions mentioned above during the 12 months prior to initiation of duloxetine. The first duloxetine dispense date was set as the “index date”. Patterns of use of pain medications during 6 and 12 months prior to index date were compared between cohorts. Among commercially-insured duloxetine users (n = 45,076, mean age = 46) antidepressants were more commonly used in patients with MDD (79%) and GAD (77%), and less among patients in other cohorts (ranging from 38% to 45%) during 6 months prior to index date; selective serotonin reuptake inhibitors accounted for about half of antidepressants. Anticonvulsants utilization was highest in patients with DPNP (44%), GAD (38%) and MDD (35%), but similar in other disease states (ranging from 22% to 24%). Patients had similar opioid and non-steroidal anti-inflammatory drugs (NSAIDs) utilization regardless of condition. Medicare-insured patients (n = 8,051, mean age = 73.5) were more likely to use anticonvulsants (33% vs. 26%, p < 0.001), opioids (53% vs. 41%, p < 0.001) and NSAIDs (31% vs. 24%, p < 0.001) than those commercially-insured. Patterns of utilization of pain medication across disease states were very similar between Medicare- and commercially-insured patients and between 12-month and 6-month prior to index date. The findings from this analysis indicate that patients had been dispensed several types of pain medications prior to duloxetine initiation across disease states.

Comparing clinical and economic characteristics between commercially-insured patients with diabetic neuropathy and demographically-matched diabetic controls

ABSTRACTObjective: To examine medical conditions associated with diabetic neuropathy (DN) and to identify drivers of healthcare charges and utilization using administrative claims.Methods: The study examined commercially-insured under-age-65 individuals with 24 months continuous enrollment in a large US national health plan. DN patients were identified by having at least one claim with a DN diagnosis between July 2004 and June 2005. A demographically-matched control cohort of patients with diabetes but no DN (10: 1 ratio) was constructed using propensity scoring. Overall illness burden via a comprehensive disease classification, year 2 (July 2005 through June 2006) distribution of charges, and reasons for inpatient admissions and emergency room (ER) visits were compared between DN patients and diabetic controls. Multivariate regressions were used to assess the marginal contribution of DN to healthcare charges and utilization, and the most common reasons for ER and inpatient admissions, controlling for differences in overall illness burden.Results: Both DN patients (n = 8655) and diabetic controls (n = 86 550) had a mean age of 51 years, and 46% were female. Compared with controls, DN patients had more comorbid medical conditions (9.7 vs. 6.8, p < 0.05) and higher total healthcare charges. Controlling for differences in overall illness burden, DN patients had significantly more hospital days (0.67), more ER (0.09), physician office (0.62), and outpatient hospital visits (2.87), and higher total healthcare charges ($5696) than controls (all p < 0.05), with majority of the difference in charges from inpatient service ($3975, p < 0.05). Patients with DN were also far more likely to be hospitalized (ketoacidosis, neurological manifestation, heart disease, skin infection) or have an ER encounter (amputation) for diabetes-related complications. Due to the use of a retrospective claims database, limitations of this analysis include a lack of formal diagnostic testing of patients, inability to measure factors such as disease duration and severity that are not captured in such databases, and the possible lack of generalization from this group of patients with diabetes to other populations.Conclusions: DN patients had significantly more comorbid medical conditions and higher healthcare charges and utilization than age- and sex-matched diabetic controls. Controlling for differences in overall illness burden, DN patients incurred more ER visits and inpatient admissions.

Receipt of HIV and STD Testing Services During Routine General Medical or Gynecological Examinations: Variations by Patient Sexual Risk Behaviors

Clinical practice guidelines in the United States recommend screening patients who report high-risk sexual behaviors (HRSB) for human immunodeficiency virus (HIV) and selected sexually transmitted diseases (STDs). The objective of this study was to estimate HIV and STD diagnostic and testing practices during routine general medical examinations (RGME) or gynecological examinations (GYNE) of patients by their reported HRSB status. We analyzed medical claims data from commercially-insured patients in the United States who sought care during 2000-2003. International Classification of Disease-9 (ICD-9) diagnostic and Current Procedural Terminology procedural codes were used to identify claims for HRSB, RGME or GYNE, HIV and STD diagnoses, and HIV and STD tests. Of 4296 patients aged 15 to 54 years during RGME or GYNE, almost none had ICD-9 codes for HIV, syphilis, Chlamydia trachomatis (CT) or Neisseria gonorrhoeae (NG) infection. Patients with claims for HRSB were significantly more likely than patients without a claim for HRSB to be tested for HIV, syphilis, CT, and NG. Among patients with HRSB-RGME, men were significantly more likely to be tested for HIV (79.3% vs. 38.8%) and syphilis (39.1% vs. 27.6%) and less likely to be tested for CT (20.7% vs. 56.9%) and NG (20.7% vs. 50.9%) than were women. A large proportion of patients with HRSB at RGME or GYNE did not receive HIV and STD tests. Interventions to increase HIV and STD testing of patients at visits with claims for HRSB are needed to enhance guideline adherence.

The Direct and Indirect Cost Burden of Illness of Ulcerative Colitis

Purpose: To estimate the direct medical costs and indirect costs (productivity related) for commercially-insured patients with Ulcerative Colitis. Methods: Data were obtained from the 1999 to 2005 MarketScan Commercial Claims and Encounters (CCAE), Medicare Supplemental, and Health and Productivity Management databases. Patients with a diagnosis of Ulcerative Colitis and at least a 1-year disease-free pre-period were found resulting in 8,970 nonelderly patients with Ulcerative Colitis and 2,958 elderly patients with Ulcerative Colitis. 12-month direct medical care expenditures (medical and prescription drug) for patients with Ulcerative Colitis were compared to expenditures among an equal number of propensity-score matched comparison group members. Propensity scores were estimated via demographic characteristics and comorbidities. Indirect costs, as measured by absenteeism and short-term disability costs, were compared for a sub-sample of employees in each group. Regression analysis controlled for demographic and case mix factors. A range of cost burden estimates were produced by varying the estimation and matching techniques. Results: Average 12-month direct medical care expenditures were $4,982 for nonelderly and $8,572 for elderly comparison group members. Average estimated direct medical expenditures for patients with Ulcerative Colitis exceeded comparison group members by as much as $11,331 for nonelderly patients and $6,609 for elderly patients (all P < .01). Average absenteeism costs were $6,021 for employees with Ulcerative Colitis, although this was not significantly different from the comparison group. Average short term disability expenditures were $1,386, which was almost three times the amount for the comparison group (P < .05). Conclusion: Ulcerative Colitis is a costly disorder and merits consideration as interventions are developed to manage the burden of disease and improve productivity.

Warfarin and Antiplatelet Combination Use Among Commercially Insured Patients Enrolled in an Anticoagulation Management Service

Although warfarin and antiplatelet medications have documented efficacy for prevention of primary and secondary cardiovascular events, the appropriateness of warfarin and antiplatelet combination therapy is not well described in national consensus guidelines. Cross-sectional data from 4,557 Kaiser Permanente Colorado members > or = 18 years old who were receiving warfarin anticoagulation therapy were used to quantify the prevalence of warfarin and antiplatelet agent (ie, aspirin, clopidogrel, dipyridamole, and/or dipyridamole/aspirin) combination therapy as of September 30, 2005, and to identify characteristics of patients receiving combination therapy. The prevalence of warfarin and any antiplatelet combination therapy was 385/1,000 (95% confidence interval [CI], 371/1,000 to 399/1,000). The majority of combination therapy was warfarin and aspirin (prevalence, 378/1,000) with a daily dose of aspirin, 81 mg, being the most reported dose (prevalence, 328/1,000). Patients receiving combination therapy were more likely to be male (63.6% vs 46.4%; adjusted odds ratio, 1.5; 95% CI, 1.3 to 1.7) and have a comorbidity of heart failure (29.0% vs 15.6%; adjusted odds ratio, 1.2; 95% CI, 1.1 to 1.5), coronary artery disease (62.4% vs 17.5%; adjusted odds ratio, 7.6; 95% CI, 6.5 to 8.8), and/or stroke/transient ischemic attack (5.2% vs 1.6%; adjusted odds ratio, 3.5; 95% CI, 2.3 to 5.3). Nearly 4 of 10 patients receiving warfarin management care were receiving warfarin and antiplatelet combination therapy. The findings suggest that this practice is widespread, especially among patients with established cardiovascular disease, and involves a substantially higher number of patients than previously reported. The clinical outcomes associated with this practice require further investigation.

Evaluation of Breast Cancer Care under Puerto Rico's Health Care Reform

Puerto Rico has implemented Health Care Reform legislation that shifted medically indigent and underserved persons from direct care by public sector institutions to managed care arrangements through the private sector. Our aim is to assess how previously underserved women with breast cancer have fared during the first three years of the Reform. Medical claims data were obtained on breast cancer cases in San Juan who were either enrolled in the capitated Reform plan or in a commercial policy offered by the same insurer. A set of indicators reflecting initial therapy, use of key services, and cumulative utilization rates of various medical procedures were constructed. Statistical tests were conducted to assess whether these indicators differed between Reform- and commercially-insured patients. Failure to reject null hypotheses of indicator differences were then used to judge Reform progress. We found some differences, but they were neither pervasive nor unidirectional. On balance, we conclude that previously underserved women are being treated for breast cancer roughly on par with other patients. This conclusion, however, is preliminary and subject to important qualifications.