Lower Total Medical Costs Research Articles

Evaluating the Impact of Enhanced Recovery After Surgery (ERAS) on Postoperative Outcomes in Pancreatic Cancer Patients: A Historical Control Study

Objective: This study evaluates the impact of the Enhanced Recovery After Surgery (ERAS) program on postoperative outcomes in patients undergoing pancreatic cancer surgery. It compares traditional perioperative care with ERAS-based interventions, focusing on key rehabilitation indicators such as postoperative intestinal function recovery, length of hospital stays, medical costs, and the incidence of complications. Methods: A total of 74 patients were studied, with 37 receiving traditional perioperative care and 37 managed under the ERAS protocol. Data collection included intraoperative indicators such as operation time, fluid input, blood loss, and postoperative recovery measures like first ambulation, pain scores, and complications. Results: The ERAS group demonstrated significantly faster recovery of gastrointestinal function, earlier mobilization, and reduced postoperative pain within the first 12 hours compared to the control group (p<0.05). The incidence of postoperative complications was lower in the ERAS group (13.51% vs. 37.84%, p=0.0166). Furthermore, the ERAS protocol led to a shorter length of hospital stay and lower total medical costs (p<0.0001). Conclusion: The implementation of the ERAS protocol for pancreatic cancer surgery significantly improves recovery outcomes, reduces complications, and lowers healthcare costs. These findings support the broader adoption of ERAS protocols in pancreatic cancer management to optimize clinical and economic outcomes.

Early Use of Biologics Reduces Healthcare Costs in Crohn's Disease: Results from a United States Population-Based Cohort.

Early initiation of biologics in moderate-to-severe Crohn's disease (CD) may significantly alter disease progression, resulting in better patient outcomes. Limited real-world data exist on the impact of early biologic use in patients with CD in the United States. We aimed to characterize biologic initiation and subsequent healthcare resource utilization (HCRU) in adults with recently diagnosed CD. Patients with CD who initiated biologic treatment within 2years of diagnosis (index date) were identified from medical and pharmacy claims (Merative L.P. MarketScan Database from 2010 to 2016) and classified as early (≤ 12months post-index) or late (> 12-24months post-index) biologic initiators. Propensity score matching balanced patient characteristics up to 1year post-index. Differences in HCRU frequency and costs 1-2years post-index were compared between the matched groups. After propensity score matching, 672 pairs of early and late biologic initiators were identified. Patients who initiated biologics early had fewer outpatient visits (15.5 vs 19.8, 95% confidence interval [CI] for difference: 2.7, 6.1) and lower total medical costs ($13,646.20 vs $22,180.70, 95% CI for difference: 4748.9, 12,320.1) 1-2years post-index than late biologic initiators. Early biologic initiators had higher medication costs 1-2years post-index ($33,766.30 vs $30,580.70, 95% CI: 546.1, 5825.1) but lower combined medical and medication costs ($47,412.50 vs $52,761.50, 95% CI: 801.5, 9896.40). While biologic treatments are costly, patients initiating biologics sooner after diagnosis appear to have better HCRU outcomes and require fewer healthcare resources at 1-2years post-index, potentially leading to overall cost savings.

Systematic performance status assessment by primary care providers in patients with advanced cancer and its impact on referral to palliative care and cost in a value-based practice.

6595 Background: Value Based (VB) Care model has been growing in the primary care (PrC) Medicare population, its role in oncology and integration with VB PrC has not been well defined. Key initiatives in VB include reducing hospitalizations by multidisciplinary management of chronic conditions. Earlier Palliative Care (PaC) has shown to favorably impact outcomes. Eastern Cooperative Oncology Group Performance Status (ECOG-PS) is a validated tool used for decision making. Poor PS is associated with worse outcomes and futile end of life care; Guidelines recommend using ECOG-PS to decide on involvement of PaC in patients (pts) with metastatic cancer (mCa). ECOG-PS is subject to significant variability among oncologists and rarely used by PrC providers (PCPs). We created a standardized system for ECOG-PS documentation and monitoring by PCPs in a VB model in a large Medicare Advantage (MA) population with the goal of increasing earlier PaC referrals. Methods: Pts with mCa managed by PCPs in a multi-state MA practice were identified via EMR from February 2021 to September 2021. At every visit, an automated alert asked PCPs to determine pts’ ECOG-PS and for those ≥ 2, recommendation to refer to PaC. PCPs were trained on use of the tool and were given a script to discuss with pts the role of PaC. Hospital admissions as well as total cost of care was measured in pts comanaged by PCP’s & PaC versus those managed by PCPs &Oncology without PaC. Statistical analysis between the groups was done using Pearson's Chi-squared test with Yates' continuity correction. Results: An ECOG-PS was measured in a total of 565 pts with mCa during the study period. Median age was 73 years, 40% were ≥75 yrs. 55% were female. Breast, Prostate, Lung, Colorectal and Gyn ca accounted for 75% cases. ECOG was documented in 97% of patients; 250 (44%) had ECOG ≥ 2, 124 (22%) had ECOG ≥ 3. Of those PaC referral was done by the PCP in 70%, in total 69 patients were comanaged by PC vs 181 who did not. Pts that had PaC involvement were 43% less likely (RR 0.57 [95%CI 0.33,0.98 p = 0.043]) to be admitted compared to patients without PC. Pts without PaC that were admitted had 238% higher admission days per 1,000 pts compared to pts comanaged by PaC. Total medical costs of pts comanaged by PaC was 86% lower after PaC involvement $18,541 3-months prior vs $2,742 3-months after PaC involvemen, driven by lower part A and part B costs (p=0.001) Conclusions: ECOG PS monitoring of pts with mCa by PCPs was very successful, easy to perform and implement in a PrC. Poor PS is common in this medicare advantage population. PaC involvement in pts with poor ECOG-PS was associated with lower admission rates at the end of life, and significantly lower total medical costs. [Table: see text]

Association Between Systemic Corticosteroid Use and Mortality in Patients with Epiglottitis.

To clarify whether treatment with systemic corticosteroids at a certain dose was associated with better outcomes in patients with epiglottitis requiring airway management (tracheotomy or airway intubation). This was a retrospective cohort study on patients hospitalized for epiglottitis requiring airway management from a nationwide inpatient database (between July 2010 and March 2019). Patients treated with systemic corticosteroids equivalent to methylprednisolone ≥40 mg/d within 2 days of admission and patients who were not treated with corticosteroids within 2 days of admission were compared after inverse probability of treatment weighting using covariate balancing propensity score. The primary outcome was all-cause 30-day in-hospital mortality, and secondary outcomes included all-cause 7-day in-hospital mortality, length of hospital stay, and total medical cost. There were 1986 and 1771 patients in the corticosteroid and control groups, respectively. A total of 72 of 3757 (1.9%) patients died within 30 days of admission, including 17 of 1986 (0.9%) patients in the corticosteroid group and 55 of 1771 (3.1%) in the control group (weighted odds ratio, 0.28 [95% confidence interval, 0.11-0.70]; weighted risk difference, -2.2% [-3.2% to -1.3%]). Treatment with corticosteroids was associated with lower total medical costs (weighted median, $6,187 vs. $6,587; weighted difference, $-1,123 [-2,238 to -8]) but not all-cause 7-day in-hospital mortality (weighted odds ratio, 0.63 [0.22-1.82]; weighted risk difference, -0.3% [-0.9 to 0.2]) and length of hospital stay (weighted median, 13 vs. 13 days; weighted difference, -0.2 days [-2.1 to 1.8]). Systemic corticosteroids may be beneficial to patients with epiglottitis requiring airway management. 3 Laryngoscope, 133:344-349, 2023.

Medical Costs Among Youth Younger Than 20 Years of Age With and Without Diabetic Ketoacidosis at the Time of Diabetes Diagnosis.

While diabetic ketoacidosis (DKA) is common in youth at the onset of the diabetes, the excess costs associated with DKA are unknown. We aimed to quantify the health care services use and medical care costs related to the presence of DKA at diagnosis of diabetes. We analyzed data from the U.S. MarketScan claims database for 4,988 enrollees aged 3-19 years insured in private fee-for-service plans and newly diagnosed with diabetes during 2010-2016. Youth with and without DKA at diabetes diagnosis were compared for mean health care service use (outpatient, office, emergency room, and inpatient visits) and medical costs (outpatient, inpatient, prescription drugs, and total) for 60 days prior to and 60 days after diabetes diagnosis. A two-part model using generalized linear regression and logistic regression was used to estimate medical costs, controlling for age, sex, rurality, health plan, year, presence of hypoglycemia, and chronic pulmonary condition. All costs were adjusted to 2016 dollars. At diabetes diagnosis, 42% of youth had DKA. In the 60 days prior to diabetes diagnosis, youth with DKA at diagnosis had less health services usage (e.g., number of outpatient visits: -1.17; P < 0.001) and lower total medical costs (-$635; P < 0.001) compared with youth without DKA at diagnosis. In the 60 days after diagnosis, youth with DKA had significantly greater health care services use and health care costs ($6,522) compared with those without DKA. Among youth with newly diagnosed diabetes, DKA at diagnosis is associated with significantly higher use of health care services and medical costs.

BPI19-013: Use of Clinical Decision Support and Peer Review to Increase NCCN Guidelines Adherence

Background: eviCore healthcare uses the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) to support its proprietary program for medical oncology drug management. All treatment regimens assigned NCCN Category of Evidence 1, 2A, or 2B are considered NCCN-adherent treatment selections in the eviCore program. The purpose of this study was to evaluate the pattern of NCCN adherence during the first year following program launch in regional payer markets. Methods: All cancer drug treatment authorization requests submitted in month 1 and month 12 following program launch for 4 regional third-party payers representing 13 different states were included, each of whom had management of high cost oncology drugs in place prior to eviCore program launch. Month 1 data were used as a surrogate for pre-program NCCN adherence, which is an overestimate as there is significant eviCore program impact on patients initiating therapy during that time. Requests with incomplete clinical data were excluded from analysis. Included requests were stratified by month 1 or month 12 from initial program launch date for each health plan. NCCN adherence was assigned based on the results of the clinical decision support and peer consultation processes utilized by eviCore to adjudicate the treatment request. NCCN adherence rate was calculated for each subgroup and a cumulative NCCN adherence rate for all included cases was calculated using weighted average accounting for volume differences by market. Results: There were 2,028 treatment regimen requests that were fully evaluable, with 1,285 occurring in month 1 and 743 occurring in month 12 following program launch. The rate of NCCN adherence increased for each health plan during the first program year, ranging from 69%–84% in month 1 and rising to 79%–91% in month 12. The weighted cumulative NCCN adherence during month 1 for all included plans was 75% and rose to 88% at month 12 following program launch. Conclusions: Use of clinical decision support supplemented by peer consultation is an effective means of increasing oncologists’ adherence to NCCN-recommended therapies across a broad range of regional provider markets. Additional study is warranted to determine whether this methodology can be applied to NCCN Categories of Preference to direct more patients toward preferred regimens with superior efficacy, safety, and affordability to further improve quality of care and lower total medical costs.

PDB42 - Economic Impact of Diabetes Self-Management Education

Recent studies had shown evidence of the benefit of Diabetes Self-Management Education (DSME) on diabetic glycaemic control and cost of diabetes care. However, the impact of DSME on drug utilization cost and total medical cost among Medicare diabetes patients is not well known. We aim to examine the impact of DSME on total medical cost, diabetes-related total medical cost, total prescription cost and total anti-diabetes cost. This study is a pooled cross-sectional study design using 2006, 2008, 2010 and 2012 Medicare Current Beneficiary Survey (MCBS) data. Participants were aged 65 and older who were diagnosed of diabetes, and do not have End-Stage Renal Disease (ESRD) and disability. Our study analyzed economic impact of DSME on cost measuring approaches such as total medical cost, diabetes-related total medical cost, total prescription cost and total anti-diabetes cost using Generalized Linear Modelling. All estimation was analysed using SAS 9.4. A total of 3,033 eligible diabetics were identified of which 35.15 % (n=1,066) had DSME (DSME group) and 64.85% (n=1,937) never had DSME (Control group). Majority of the participants were aged between 65-74 in both DSME group (55.12%) and control groups (47.91%). Majority of participants were female in both DSME group (52.42%) and control groups (51.12%) and majority were Hispanic-Whites DSME group (79.17%) and control group (73.88%). The result of our bivariate analysis showed that total prescription cost significantly varies across DSME group and control group at (alpha=0.05). We found that compared to the control group, the DSME group had 16.35% [CI: -0.26, -0.10] lower total medical costs on average and 12.83% [CI: -0.208, -0.066] lower total prescription drug on average after adjusting for other variables. Use of DSME is associated with lower total medical cost and lower total prescription medical cost. Given our findings, we recommend more promotion, patient’s enrolment and participation in DSME.

Economic and Clinical Outcomes Resulting From the Stage 4 Chronic Kidney Disease Case Management Quality Improvement Initiative.

Purpose of Study:Chronic kidney disease (CKD) is a costly and burdensome public health concern. The goal of this study was to evaluate the impact on outcomes and utilization of a pilot program to identify and engage beneficiaries with CKD at risk for progression from Stage 4 to Stage 5.Primary Practice Settings:A quality improvement initiative was conducted to assess the impact of case management on costs and outcomes among 7,720 Cigna commercial medical beneficiaries with Stage 4 CKD enrolled in the United States between January 2012 and October 2012.Methodology and Sample:Claims data were analyzed to compare 3,861 beneficiaries randomized to receive condition-focused case management with 3,859 controls, with follow-up through July 2013. After using an algorithm to identify beneficiaries at highest risk of progression, a case management team implemented, among those assigned to the intervention, an evidence-based assessment tool, provided education and follow-up, engaged nephrologists and other providers, and conducted weekly rounds. Primary outcome measures were hospital admissions, emergency department visits, nephrologist visits, dialysis, arteriovenous (AV) fistula creation, and total medical costs. Analysis of variance techniques were used to test group differences.Results:As compared with controls, intervention beneficiaries were 12% more likely to have fistula creation (p = .004). Intervention beneficiaries were observed to have savings of $199 per member per month (PMPM), F = 23.05, p = .04. This difference equated to 6% lower total medical costs in the intervention group. Savings observed were derived half from improved in-network utilization and half from reduced hospital costs.Implications for Case Management Practice:The observed 12% increased rate of creation of AV fistulas and $199 (6%) decrease in PMPM cost between the intervention and control groups corresponded to a savings of more than $18 million in 2015 U.S. dollars (USD).On the basis of observation of substantial improvements in outcomes and cost savings, health plan administrators could better serve those at highest risk of progression by implementing focused case management.Our findings support the value of care coordination between nephrologists, providers, and health plan case managers in improving outcomes and reducing total medical costs among beneficiaries at risk for CKD progression from Stage 4 to Stage 5.

Cost-effectiveness of ‘Program We Care’ for patients with chronic obstructive pulmonary disease: A case-control study

ObjectivesTo evaluate the effectiveness of a discharge program for patients with chronic obstructive pulmonary disease (COPD) patients on discharge from an emergency medical ward on discharge home rate, hospital length of stay (LOS), inpatient admission rate and cost. BackgroundFrequent visits to the emergency department (ED) and subsequent hospital admission are common among patients with COPD, which adds a burden to ED and hospital care. A discharge program was implemented in an ED emergency medical ward. The program consisted of multidisciplinary care, discharge planning, discharge health education on disease management, and continued support from the community nursing services. MethodsA retrospective case-control study was used. Data were retrieved and compared between 478 COPD program cases and 478 COPD non-program cases. ResultsNo significant difference was found in age, gender, and triage category, LOS in ED, and readmission rate between the program and non-program groups. The program group demonstrated a significantly higher discharge home rate from the ED (33.89% vs. 20.08%) and fewer medical admissions (40.59% vs. 55.02%) compared with the non-program group, resulting in lower total medical costs after the program was implemented. ConclusionThe program provides insight on the strategic planning for discharge care in a short stay unit of emergency department.

Long-term care benefits may reduce end-of-life medical care costs.

Abstract This study explores whether personal care services for functionally dependent or cognitively impaired individuals paid for by a long-term care (LTC) insurance policy can reduce health care utilization and costs at the end of life. This retrospective study uses propensity score matching methodology, hierarchical multiple regression, and Poisson regression to compare 830 decedents who utilized benefits from a voluntary LTC insurance plan ("claimants") to 6860 decedents who never purchased coverage but were similar to claimants on 17 variables, including age, sex, frailty, burden of illness markers, and propensity to have needed LTC services. Claimants using LTC benefits experienced significantly lower health care costs at end of life, including 14% lower total medical costs, 13% lower pharmacy costs, 35% lower inpatient admission costs, and 16% lower outpatient visit costs. They also experienced 8% fewer inpatient admissions and 10% fewer inpatient days. The presence of dementia at the end of life moderated these effects. This study suggests that use of insurance-based LTC services measurably reduces health care expenditures at the end of life. (Population Health Management 2014;17:332-339).

Analysis of Buprenorphine/Naloxone Dosing Impact on Treatment Duration, Resource Use and Costs in the Treatment of Opioid-Dependent Adults: A Retrospective Study of US Public and Private Health Care Claims

Objectives: The buprenorphine/naloxone combination is used to treat the chronic relapsing disorder of opioid dependence. Adequate dosing levels are important to control cravings, prevent withdrawal syndrome, and maintain patients in treatment. The objective of this study was to estimate the impact of dosing on treatment persistence, resource utilization, and total direct health care costs. Methods: A retrospective cohort analysis was performed using administrative claims extracted from the MarketScan and Clinformatics databases from January 2007 to June and November 2012. Patients initiating treatment with buprenorphine/naloxone were classified into 2 groups based on the prescribed average dose over the entire treatment period and matched by multiple criteria. The threshold for differentiating the dosing groups was set at 15 and 15.7 mg/day for publicly and privately insured patients, respectively. Resource utilization and related costs were calculated over the 12-month period after the treatment initiation. Results: Patient characteristics at baseline were considerably different between the privately and publicly insured patients. Publicly insured patients were slightly younger (33.1 vs 34.3 years old for privately insured) and had a higher prevalence of mental disorders (70.9% vs 64.9%). In both groups, patients treated with higher doses (> 15 mg and > 15.7 mg per day for publicly and privately insured patients, respectively) had lower risk of discontinuation (public: 11% lower; private: 9% lower) and lower probability of a psychiatric hospitalization than patients treated with lower doses (public: 17% lower; private: 41% lower). Total costs were comparable between the 2 groups (public: $14 600; private: $21 000) despite the expected higher cost of pharmacy in the higher-dose group. Conclusions: Treatment with higher doses of buprenorphine/naloxone was associated with a longer time to treatment discontinuation, less resource use, and lower total medical costs despite higher pharmacy acquisition cost.

Cost-effectiveness of Telaprevir Combination Therapy for Chronic Hepatitis C

ObjectiveTo explore the expected long-term health and economic outcomes of telaprevir (TVR) plus peginterferon alfa-2a and ribavirin (PR), a regimen that demonstrated substantially increased sustained virologic response (SVR) compared with PR alone in adults with chronic genotype 1 hepatitis C virus (HCV) and compensated liver disease in the Phase III studies ADVANCE (treatment-naïve patients) and REALIZE (relapsers, partial responders, and null responders to previous PR treatment).Study DesignA decision-analytic model was developed to assess the cost-effectiveness of TVR+PR vs. PR in the United States (US).MethodsPatients first moved through the 72-week decision-tree treatment phase of the model and then entered the cyclic Markov post-treatment phase. Clinical data (patient characteristics, SVR rates, and adverse event rates and durations) were obtained from ADVANCE and REALIZE. Health-state transition probabilities, drug and other costs (in 2012/2013 US dollars), and utility values were obtained from the trials, published studies, and publicly available sources. Outcomes were discounted at 3% per year.ResultsRegardless of treatment history, patients receiving TVR+PR were projected to experience fewer liver-disease complications, more life-years, and more quality-adjusted life-years (QALYs) than patients receiving PR. In prior relapsers, TVR+PR was dominant, with lower total medical costs and more QALYs. For the other patient subgroups, incremental costs per QALY gained were between $16,778 (treatment-naïve patients) and $34,279 (prior null responders). Extensive sensitivity analyses confirmed robust model results.ConclusionsAt standard willingness-to-pay thresholds, TVR+PR represents a cost-effective treatment option compared with PR alone for patients with chronic genotype 1 HCV and compensated liver disease in the US. Future analyses are needed to compare TVR+PR with all existing HCV treatment options.

Direct Medical Costs and Medication Compliance among Fibromyalgia Patients: Duloxetine Initiators vs. Pregabalin Initiators

To assess and compare direct medical costs and medication compliance between patients with fibromyalgia who initiated duloxetine and patients with fibromyalgia who initiated pregabalin in 2008. A retrospective cohort study design was used based on a large US national commercial claims database (2006 to 2009). Patients with fibromyalgia aged 18 to 64 who initiated duloxetine or pregabalin in 2008 and who had continuous health insurance 1year preceding and 1year following the initiation were selected into duloxetine cohort or pregabalin cohort based on their initiated agent. Medication compliance was measured by total supply days, medication possession ratio (MPR), and proportion of patients with MPR≥0.8. Direct medical costs were measured by annual costs per patient and compared between the cohorts in the year following the initiation. Propensity score stratification and bootstrapping methods were used to adjust for distribution bias, as well as cross-cohort differences in demographic, clinical and economic characteristics, and medication history prior to the initiation. Both the duloxetine (n=3,033) and pregabalin (n=4,838) cohorts had a mean initiation age around 49years, 89% were women. During the postindex year, compared to the pregabalin cohort, the duloxetine cohort had higher totally annual supply days (273.5 vs. 176.6, P<0.05), higher MPR (0.7 vs. 0.5, P<0.05), and more patients with MPR≥0.8 (45.1% vs. 29.4%, P<0.05). Further, relative to pregabalin cohort, duloxetine cohort had lower inpatient costs ($2,994.9 vs. $4,949.6, P<0.05), lower outpatient costs ($8,259.6 vs. $10,312.2, P<0.05), similar medication costs ($5,214.6 vs. $5,290.8, P>0.05), and lower total medical costs ($16,469.1 vs. $20,552.6, P<0.05) in the postinitiation year. In a real-world setting, patients with fibromyalgia who initiated duloxetine in 2008 had better medication compliance and consumed less inpatient, outpatient, and total medical costs than those who initiated pregabalin.

PHP33 IMPACT OF PHARMACY AND MEDICAL PLAN INTEGRATION ON OVERALL MEDICAL COSTS

Studies published by Aetna and Health Partners have demonstrated the value of integrated medical and pharmacy benefits in their populations. Combined coverage provides the opportunity for coordinated patient outreach and aligned policy decisions. The purpose of this analysis is to determine if integrated benefits result in lower total medical costs when compared to plans that utilize a carve-out pharmacy benefit. A retrospective matched cohort study was utilized in order to compare the total medical costs associated with customers in integrated health plans with customers with a carve-out PBM. Individual customers were included if they were continuously enrolled for at least 12 months within the same plan type, had a full set of demographic, risk, and clinical data, and were between the ages of 18 and 65. The two groups were matched based on demographic, comorbidity, and employer characteristics. This analysis matched 39,896 customers in 2007 (19,948 in each group) and 151,144 customers in 2008 (75,572 in each group) for the final analysis. Medical costs were $13.77 (p-value 0.067) and $11.39 (p-value 0.006) per customer per month lower for customers with an integrated pharmacy benefit as compared to carve-out customers in 2007 and 2008 respectively. In 2007 and 2008 the bulk of the savings ($6 and $7 pcpm respectively) were associated with lower utilization of outpatient services. When controlling for demographic, clinical, and employment characteristics, there is a significant savings associated with integrating medical and pharmacy benefits.

Cost Efficiency of Anticoagulation With Warfarin to Prevent Stroke in Medicare Beneficiaries With Nonvalvular Atrial Fibrillation

in controlled trials, anticoagulation with warfarin reduces stroke risk by nearly two thirds, but the benefit has been less pronounced in clinical practice. This report describes the extent of warfarin use, its effectiveness, and its impact on medical costs among Medicare patients with nonvalvular atrial fibrillation. using claims from >2 million beneficiaries in the Centers for Medicare and Medicaid Services 5% Sample Standard Analytic Files, we identified patients with nonvalvular atrial fibrillation from 2004 to 2005. Warfarin use was inferred from 3 or more tests of the international normalized ratio within 1 year. Incidence of ischemic/hemorrhagic stroke and major bleeding was evaluated. Adjusted risk was calculated by Cox proportional-hazards regression. Medical costs (reimbursed amounts in 2006 US dollars) were estimated by multivariate linear regression. of patients with nonvalvular atrial fibrillation (N=119 764, mean age=79.3 years), 58.5% were categorized as warfarin users based on the study definition. During an average of 2.1 years' follow-up, the rate of ischemic stroke was 3.9 per 100 patient-years. After multivariate adjustment, ischemic stroke incidence was 27% lower in patients taking warfarin than in patients not taking warfarin (P<0.0001), with no increase in hemorrhagic stroke and a slightly elevated risk of a major bleed. Use of warfarin was independently associated with lower total medical costs, averaging $9836 per patient per year. these results indicate that 41.5% of Medicare patients with nonvalvular atrial fibrillation are not anticoagulated with warfarin. The incidence of stroke and overall medical costs were significantly lower in patients treated with warfarin.

Glatiramer acetate and interferon beta-1a for intramuscular administration: a study of outcomes among multiple sclerosis intent-to-treat and persistent-use cohorts

Objective:To study outcomes of multiple sclerosis (MS) patients treated with either glatiramer acetate (Copaxone) or interferon beta-1a for once-weekly, intramuscular administration (Avonex).Methods:An ‘intent-to-treat’ (ITT) cohort (n = 1282) was established, consisting of patients diagnosed with MS who began therapy on either glatiramer acetate (GA) or intramuscular interferon beta-1a (IFN beta-1a-IM) and had continuous insurance coverage from 6 months before to 24 months after the date when they began taking the medication. A ‘persistent use’ (PU) cohort (n = 639) was also constructed, consisting of individuals who, in addition to the criteria listed above, had a claim for GA or IFN beta-1a-IM within 28 days of the end of the 2-year post-period. Data were obtained from the i3 InVision Data Mart Database from July 2001 to June 2006. Multivariate regressions were used to examine both the 2-year total direct medical costs and the likelihood of relapse associated with the use of each of these alternative MS medications. A relapse was defined as either being hospitalized with a principal diagnosis of MS or having an outpatient visit with a MS diagnosis followed within 7 days by a claim for a corticosteroid. All regressions controlled a wide range of factors that may potentially affect outcomes.Results:In the ITT cohort, patients who started therapy on GA had a significantly lower 2-year risk of relapse (10.01 vs. 5.18%; p = 0.0034) as well as significantly lower 2-year total medical costs ($44,201 vs. $41,121; p = 0.0294). In the PU cohort, patients who used GA also had a significantly lower 2-year risk of relapse (7.25 vs. 2.16%; p = 0.0048) as well as significantly lower total medical costs ($67,744 vs. 63,714; p = 0.0445).Limitations:The analyses relies on an administrative claims database of an insured population and hence, may not be generalizeable to other populations. In addition, such a database precludes measurement of lost work time, unemployment, caregiver burden or other costs associated with MS.Conclusions:Results from this study indicate that the use of GA is associated with significantly lower probability of relapse as well as significantly lower 2-year total direct medical costs than IFN beta-1a-IM.

Outcomes and costs of patients with persistent asthma treated with beclomethasone dipropionate hydrofluoroalkane or fluticasone propionate

Examine outcomes and costs of patients with persistent asthma who initiated treatment with beclomethasone dipropionate hydrofluoroalkane (BDP-HFA) or fluticasone propionate (FP). MedStat's Commercial Claims and Encounters database (July 1, 2002-June 30, 2007) was utilized. Patients (n=13,968) were included if they initiated treatment with BDP-HFA or FP (first use=index date). Patients also met these criteria: (a) no receipt of other study medication in the 1-year post-period; (b) persistent asthma in the 1-year pre-period; (c) age 5-64 years; (d) no diagnosis of chronic obstructive pulmonary disease; and (e) continuous insurance coverage from 1 year pre-period to 1 year post-period. Multivariate regressions examined the probability of an ER visit or hospitalization, probability of reaching alternative adherence thresholds, and costs. Receipt of BDP-HFA, compared with FP, was associated with a 17% reduction in the odds of an ER visit (OR=0.834, 95% CI 0.751 to 0.925), a 30% reduction in the odds of an asthma-related ER visit (OR=0.697, 95% CI 0.571 to 0.852), and an increase in the odds of obtaining a medication possession ratio (MPR) of at least 50% (OR=1.324; 95% CI 1.164 to 1.506) or 75% (OR=1.311; 95% CI 1.072 to 1.604). Total medical costs ($5063 vs. $5377, P=0.0042), prescription drug costs ($2336 vs. $2581, P<0.0001), and ER costs ($185 vs. $249, P<0.0001) were significantly lower among the BDP-HFA cohort. Asthma-related outpatient ($191 vs. $224, P<0.0001) and ER costs ($28 vs. $45, P<0.001) were significantly lower in the BDP-HFA group, while asthma-related inpatient ($101 vs. $59, P<0.0001) and drug costs ($451 vs. $540, P<0.0001) were significantly lower in the FP cohort. Results indicate that receipt of BDP-HFA, compared with receipt of FP, is associated with a decreased probability of ER visits or asthma-related ER visits and higher odds of reaching a medical possession ratio threshold of 50% or 75%. Receipt of BDP-HFA was also associated with lower total drug costs and lower total medical costs.

Medical costs of sorafenib compared with sunitinib in treatment of patients &lt;65 years with renal cell carcinoma: A retrospective claims database analysis

e17536 Background: Sorafenib (SR) and sunitinib (SU) are FDA approved (12/05 and 1/06, respectively) tyrosine kinase inhibitors for patients (pts) with advanced renal cell carcinoma (RCC). Little is known of their cost impact. We conducted this study to quantify overall direct costs (inpatient, outpatient, pharmacy) for each treatment in privately insured pts (&lt;65 y). Given differences between private and public insurer payment scales, pts ≥65 y were not included in this study but are the subject of a planned further analysis. Methods: A retrospective US claims-based study was conducted using data covering all US census regions for ≥18 million lives from MarketScan MedStat (1/02–12/07). Inclusion criteria were ≥2 RCC claims (ICD-9 189.0, 198.0), continuous health care coverage, &gt;180 days of coverage before RCC diagnosis. SR and SU pts were identified based on oral therapy after initial RCC-related claim (intent-to-treat). Observation period was from first drug-dispensing date until ≤12 mo or first of therapy switch, nephrectomy, disenrollment, or study end (12/31/07). Univariate and multivariate Tobit analyses were conducted; control factors included age, sex, region, plan type, comorbidity, prior Tx/procedures, and time since RCC Dx. Results: Of 10,462 RCC pts identified, 144 and 220 received initial therapy with SR and SU, respectively. In the 180 days before RCC diagnosis, total direct medical costs, baseline demographics, and comorbidities were similar between groups. The univariate incremental total monthly medical cost for SU was $2,049 (P&lt;.001) more than for SR, representing yearly costs for SU $24,588 more than for SR. Multivariate analyses for incremental total monthly costs for SU also remained significant at $1,399 (P&lt;.001). Conclusions: Retrospective analysis of this US claims database for RCC pts &lt;65 treated first with SR showed statistically significant lower total medical costs (particularly inpatient costs) than for pts treated first with SU. [Table: see text] [Table: see text]

Comparison of costs among patients with type 2 diabetes treated with exenatide or sitagliptin therapy

Exenatide (Byetta, Amylin Pharmaceuticals Inc., CA, USA) and sitagliptin (Januvia, Merck & Co, NJ, USA) are two antidiabetic agents recently approved by the US Food and Drug Administration. The purpose of this analysis was to compare costs among patients with type 2 diabetes (T2D) treated with either of these agents. Data with dates of service from September 1, 2005 through August 31, 2007, were obtained from a large US retrospective claims database. Intent-to-treat cohorts of adults diagnosed with T2D who began taking either exenatide (n=1885) or sitagliptin (n=2482) and did not use the alternate medication in the 6-month follow-up period were created. Six-month total medical costs were estimated using stepwise multivariate regressions. Six-month total diabetes-related medical costs, a component of total medical costs, were also estimated using stepwise multivariate regressions. In addition, other cost components were examined using either stepwise multivariate regressions or a two-part model that controlled for the probability of using the medical service. Smearing estimates were used to transform estimated log costs into costs. The analysis controlled for the potential impact of patient demographics, general health, prior resource use, comorbidities, and timing of treatment initiation. Exenatide was associated with lower total 6-month direct medical costs ($9340 vs. $9995; P<0.0001), despite some component costs being slightly higher with exenatide: diabetes-related drug costs ($1765 vs. $1743; P=0.0062), diabetes-related medical costs ($4142 vs. $4002; P<0.0001), and emergency room costs ($43 vs. $29; P=0.0388). Exenatide was associated with lower outpatient costs ($4498 vs. $5942; P<0.0001). Compared with the use of sitagliptin, exenatide was associated with lower total medical costs (difference of $655) despite higher total diabetes-related costs (difference of $140). As a result, there appears to be overall cost savings associated with the use of exenatide relative to sitagliptin.

The use of family psychoeducation for schizophrenia may result in lower total medical costs

The use of family psychoeducation for schizophrenia may result in lower total medical costs