Multi-State Medicaid Database Research Articles

Racial disparities in healthcare utilization and costs in pharmacologically treated medicaid enrollees with developmental disabilities and Type 2 diabetes

Objective: Adults with developmental disabilities have higher prevalence of chronic disease conditions such as diabetes, obesity, high blood pressure, arthritis, CVD and chronic pain. They also have poor healthcare utilization and are screened less for chronic disease conditions. Very few studies have looked at the diabetes related health outcomes in developmentally disabled adults, where distinct racial differences in medication use behaviors have been observed. The objective of this study was to examine the association of race with healthcare utilization and costs in pharmacologically treated Medicaid enrollees with developmental disabilities (DD) and type 2 diabetes. Methods: This was a retrospective cohort study that identified adults with DD and type 2 diabetes from the MarketScan® Multi-State Medicaid Database. Enrollees aged 18-64 years who received new medications for type 2 diabetes from January 1, 2004 and December 31, 2006 were included. An index diagnosis date was assigned to each patient and adults with a continuous enrollment for at least 12 months were included. Probabilities of type 2 diabetes related healthcare utilization (inpatient, outpatient and emergency department visits) in adults with DD were computed using multivariate logistic regression models. Multivariate negative binomial regression was used to measure the rate of change in type 2 diabetes related healthcare utilization in patients with DD. Multivariate linear regression with log-transformation was used to determine type 2 diabetes related healthcare costs in Medicaid enrollees with DD. Results: This study had a sample size of 1529 patients. After controlling for all the covariates, compared to Caucasians with DD, African Americans with DD were more likely to have type 2 diabetes related inpatient (OR=1.71; 95% CI, 1.02-2.85) and emergency department visits (OR, 1.67; 95% CI, 1.02-2.73). African Americans with DD and type 2 diabetes had significantly higher healthcare costs compared to Caucasians with DD and type 2 diabetes. Conclusion: Racial disparities exist in healthcare utilization in Medicaid patients with DD and type 2 diabetes. African Americans were more likely to have inpatient and ER visits respectively. Also, African Americans were more likely to have higher type 2 related healthcare costs compared to Caucasians.

Real-world treatment patterns among patients with non-muscle invasive bladder cancer (NMIBC) treated with intravesical Bacillus Calmette-Guerin (BCG).

404 Background: Intravesical BCG is a common treatment in high-risk NMIBC patients; however supply constraints and regimen demands for patients have been reported and may impact long term patient outcomes. This study examined treatment patterns in NMIBC patients receiving intravesical BCG. Methods: Adults with NMIBC treated with intravesical BCG during any line of therapy (LOT) on or after the index date (first date for transurethral resection of the bladder tumor [TURBT] or initiation of intravesical therapy) were selected from de-identified IBM MarketScan Commercial and Medicare Supplemental Databases (1/1/2010-2/28/2021) and Multi-State Medicaid Database (1/1/2010-12/31/2019). Classification of NMIBC on the index date required that patients have no prior systemic antineoplastic therapy, radiotherapy, or cystectomy. Treatment patterns were evaluated from the index date until the end of the NMIBC phase (earliest of initiation of systemic antineoplastic therapy, cystectomy, radiotherapy, diagnosis for metastatic cancer, end of insurance eligibility, or end of data availability). Discontinuation of a LOT was defined as having a treatment gap > 180 days for BCG (90 days for other agents) or switching to a new LOT. During each LOT, adequate BCG treatment was defined as having ≥5 claims during induction (first 42 days of treatment) and ≥2 claims during maintenance (beyond the first 42 days). Results: There were 5,410 NMIBC patients treated with BCG over a mean (median) follow up of 25.5 (18.9) months. The population was 79% male; mean age was 67 years. The majority of patients only received a single LOT (76%; TABLE). The predominant first LOT was BCG (93.1% of NMIBC patients); however, the majority (69.8%) did not receive adequate BCG induction/maintenance in first LOT. Nearly half (46.4%) of first LOT patients had reassessment for disease progression by TURBT. BCG retreatment after a six-month lapse was observed as the predominant second LOT, with > 90% receiving inadequate BCG induction/maintenance. Conclusions: While intravesical BCG remains the most common therapy for NMIBC, less than a third of patients receive adequate BCG treatment in the first LOT; with this percentage further decreasing in the few patients who receive a subsequent LOT. In light of supply and demand constraints, results of this study further emphasize a need for additional treatment options that are effective, safe, and tolerable for patients with NMIBC.[Table: see text]

Vital Signs: Use of Recommended Health Care Measures to Prevent Selected Complications of Sickle Cell Anemia in Children and Adolescents - Selected U.S. States, 2019.

IntroductionSickle cell disease (SCD), a group of inherited blood cell disorders that primarily affects Black or African American persons, is associated with severe complications and a >20-year reduction in life expectancy. In 2014, an expert panel convened by the National Heart, Lung, and Blood Institute issued recommendations to prevent or reduce complications in children and adolescents with the most severe SCD subtypes, known as sickle cell anemia (SCA); recommendations included 1) annual screening of children and adolescents aged 2–16 years with transcranial Doppler (TCD) ultrasound to identify those at risk for stroke and 2) offering hydroxyurea therapy to children and adolescents aged ≥9 months to reduce the risk for several life-threatening complications.MethodsData from the IBM MarketScan Multi-State Medicaid Database were analyzed. TCD screening and hydroxyurea use were examined for 3,352 children and adolescents with SCA aged 2–16 years and continuously enrolled in Medicaid during 2019. Percentage change during 2014–2019 and variation by health subgroups were assessed. Analyses were stratified by age.ResultsDuring 2014–2019, TCD screening increased 27% among children and adolescents aged 10–16 years; hydroxyurea use increased 27% among children aged 2–9 years and 23% among children and adolescents aged 10–16 years. However, in 2019, only 47% and 38% of children and adolescents aged 2–9 and 10–16 years, respectively, had received TCD screening and 38% and 53% of children and adolescents aged 2–9 years and 10–16 years, respectively, used hydroxyurea. For both prevention strategies, usage was highest among children and adolescents with high levels of health care utilization and evidence of previous complications indicative of severe disease.Conclusion and Implications for Public Health PracticeDespite increases since 2014, TCD screening and hydroxyurea use remain low among children and adolescents with SCA. Health care providers should implement quality care strategies within their clinics and partner with patients, families, and community-based organizations to address barriers to delivering and receiving recommended care.

Psychotropic Medication Utilization Among Children Diagnosed With Fetal Alcohol Spectrum Disorder.

To date, there has been no large, population-based study estimating the prevalence of psychotropic medication use and cooccurring medical conditions among children with fetal alcohol syndrome disorder (FASD). In addition, it is not known how psychotropic medication use varies by mental health status of the children with FASD and their health insurance coverage. This study attempts to fill this gap by analyzing a large health insurance claims database covering Medicaid and private insurance. The study used the 2017 IBM Watson Health MarketScan Multistate Medicaid and Commercial Claims databases. The sample for the analysis includes children between the ages of 0 and 17 with either an FASD diagnosis or a mental health diagnosis (N = 848 721 Medicaid; N = 511 061 private insurance). More than half of the children with an FASD diagnosis were prescribed psychotropic medications (63% Medicaid; 57% private). Utilization rates of psychotropic medication among children with cooccurring FASD and a mental health condition (79% Medicaid; 71% private) were higher compared to children with a mental health diagnosis but no FASD (57% Medicaid; 57% private). Stimulants were the most commonly prescribed. Encephalopathy, attention deficit hyperactivity disorder, and epilepsy were the 3 most common cooccurring diagnosis among children with FASD using psychotropic medication under Medicaid compared to encephalopathy, attention deficit hyperactivity disorder, and anxiety with private insurance. These results exemplify the complexity of the neurobehavioral profile of children with FASD and the challenge of treatment. Future studies may determine how supportive services for these children will affect psychotropic medication use.

Comparing Relapse Rates in Real-World Patients with Schizophrenia Who Were Adequately versus Not Adequately Treated with Paliperidone Palmitate Once-Monthly Injections Before Transitioning to Once-Every-3-Months Injections.

PurposeThis retrospective cohort study evaluated real-world data on relapses in adult patients with schizophrenia who transitioned to long-acting injectable paliperidone palmitate once-every-3-months (PP3M) following treatment with once-monthly paliperidone palmitate (PP1M).Patients and MethodsData derived from the IBM® MarketScan® Multi-State Medicaid Database were analyzed. Adults aged ≥18 years with ≥1 schizophrenia diagnosis claim and ≥12 months of continuous medical and prescription enrollment before and/or at index date of PP3M were eligible for inclusion. Patients were matched on propensity score to 2 PP3M cohorts: (1) adequately treated (AT), defined as patients treated with PP1M for ≥4 months, with the last 2 doses the same and a PP3M initiation dose meeting the corresponding PP1M-to-PP3M dose conversion, or (2) not adequately treated (NAT), defined as patients who received ≤2 or no PP1M doses. Relapse rates and time to relapse distributions based on the first occurrence of a qualifying event during the 2-year follow-up period were compared between PP3M cohorts using Kaplan–Meier survival curves and log rank test statistics. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards models. Two sensitivity analyses using different matched populations were performed to assess the robustness of the primary findings.ResultsPropensity score matching yielded a sample of 1314 patients (657 per group). Most patients were male (68.9%) and aged 25–64 years (90.1%). The relapse rate was significantly lower in the AT (18.4%) versus NAT cohort (26.8%), P = 0.0002. Risk of relapse decreased by 35% for AT versus NAT (HR: 0.65 [95% CI: 0.51–0.81]). Relapse reductions favored the AT cohort in both sensitivity analyses (HR: 0.67 [95% CI: 0.54–0.83] and HR: 0.74 [95% CI: 0.56–0.97]).ConclusionIn this analysis of Medicaid claims data, patients adequately treated with PP1M before transitioning to PP3M demonstrated significantly lower relapse rates and delayed time to relapse.

Assessment of Underuse and Overuse of Screening Tests for Co-occurring Conditions Among Children With Obesity

The American Academy of Pediatrics (AAP) recommends laboratory screening for diabetes, dyslipidemia, and liver disease every 2 years among children aged 10 years and older with obesity. Routine screening for hypothyroidism or hyperinsulinemia is not recommended. National data on rates of adherence to AAP-recommended screening and rates of potentially unnecessary endocrine testing are unavailable. To assess rates of AAP-adherent screening and potentially unnecessary endocrine testing among privately and publicly insured children diagnosed with obesity at well-child visits. This cross-sectional study used data from the 2018-2019 IBM MarketScan Commercial Database (which contains claims from privately insured patients across the US) and the 2018-2019 IBM MarketScan Multi-State Medicaid Database (which contains claims from Medicaid patients in multiple states). A total of 156 773 children aged 10 to 18 years with obesity diagnosis codes at a well-child visit from December 1, 2018, through November 30, 2019, were included. Analysis was performed from May 1 to October 31, 2021. Primary outcomes were the proportion of children who received AAP-adherent screening during the 729 days before to 30 days after a well-child visit and the proportion of children who received 1 or more potentially unnecessary thyroid or insulin tests during the same period. Proportions of children by payer type were compared using logistic regression models adjusted for age and sex. To assess screening that was potentially ordered by primary care clinicians, the proportion of children without AAP-adherent screening before visits who received this screening within 30 days was calculated. Of 156 773 children, the mean (SD) age was 13.5 years (2.5) years; 83 305 (53.1%) were male, and 97 595 (62.3%) were publicly insured. Among publicly insured children, 13 167 (13.5%) were Hispanic or Latino, 34 792 (35.6%) were non-Hispanic Black, 42 029 (43.1%) were non-Hispanic White, 3850 (3.9%) were of other race and/or ethnicity (specific races and ethnicities were not available in the database), and 3757 (3.8%) were of unknown race and ethnicity. Race and ethnicity were not available for privately insured children because these data are not reported in the commercial claims database. During the 729 days before to 30 days after well-child visits, 42 849 patients (27.3%) received AAP-adherent screening, including 13 939 (23.6%) of 59 178 privately insured children and 28 910 (29.6%) of 97 595 publicly insured children (average marginal effect for public insurance: 6.8 [95% CI, 6.3-7.2] percentage points). In addition, 46 592 children (29.7%) received potentially unnecessary thyroid or insulin tests, including 12 834 (21.7%) of 59 178 privately insured children and 23 198 (23.8%) of 97 595 publicly insured children (average marginal effect for public insurance: 2.4 [95% CI, 2.0-2.8] percentage points). Among 129 104 children who did not receive AAP-adherent screening before visits, 15 090 (11.7%) received this screening within 30 days. In this cross-sectional study, similar proportions of children diagnosed with obesity at well-child visits received recommended and nonrecommended screening tests for obesity-related co-occurring conditions, suggesting that specific actionable guidelines and interventions are needed to prevent overuse and underuse of screening tests among children with obesity.

Healthcare resource utilization and costs in individuals with Huntington’s disease by disease stage in a US population

Aims To quantify healthcare resource utilization (HRU) and costs by disease stage in individuals with Huntington’s disease (HD) in a US population. Materials and methods This retrospective cohort study used administrative claims data from the IBM MarketScan Commercial, Multi-State Medicaid, and Medicare Supplemental Databases between 1 January 2009 and 31 December 2018. Individuals with an HD claim between 1 January 2010 and 31 December 2017 were selected. Index date was the date of first HD diagnosis. Individuals were required to have continuous enrollment for ≥ 12 months pre-index, 3 months post-index, and have no pre-index HD claims. All-cause HRU and costs per patient per month (PPPM) (overall and stratified by disease stage) were assessed for individuals with HD. Results A total of 2,669 individuals with HD were identified. Of these, 1,432 (53.7%), 689 (25.8%), and 548 (20.5%) had early-, middle-, and late-stage HD at baseline, respectively. Mean HRU PPPM by post-index HD stage increased with disease stage for outpatient visits, pharmacy claims, and HD-related pharmacy claims (p < 0.05 for all). Mean inpatient visits and emergency room visits PPPM were highest in individuals with middle-stage HD (p <0.05 for all). Mean total all-cause healthcare cost PPPM for individuals with HD was $2,889, and it was significantly higher in middle-stage individuals, at $7,988, compared with early- and late-stage individuals, at $3,726 and $5,125, respectively; p <0.0001. Limitations In the absence of disease staging information in administrative claims data, staging was based on the presence of clinical markers in claims. Our evaluations didn’t include the indirect costs of HD, which may be substantial as HD typically affects people at their peak earning potential. Conclusions HRU and costs of care are high among individuals with HD, particularly among those with middle- and late-stage disease. This indicates that the disease burden in HD increases with disease stage, highlighting the need for interventions that can slow or prevent disease progression.

Analysis of Stimulant Prescriptions and Drug-Related Poisoning Risk Among Persons Receiving Buprenorphine Treatment for Opioid Use Disorder

ImportanceStimulant medication use is common among individuals receiving buprenorphine for opioid use disorder (OUD). Associations between prescription stimulant use and treatment outcomes in this population have been understudied.ObjectivesTo investigate whether use of prescription stimulants was associated with (1) drug-related poisoning and (2) buprenorphine treatment retention.Design, Setting, and ParticipantsThis retrospective, recurrent-event cohort study with a case-crossover design used a secondary analysis of administrative claims data from IBM MarketScan Commercial and Multi-State Medicaid databases from January 1, 2006, to December 31, 2016. Primary analyses were conducted from March 1 through August 31, 2021. Individuals aged 12 to 64 years with an OUD diagnosis and prescribed buprenorphine who experienced at least 1 drug-related poisoning were included in the analysis. Unit of observation was the person-day.ExposuresDays of active stimulant prescriptions.Main Outcomes and MeasuresPrimary outcomes were drug-related poisoning and buprenorphine treatment retention. Drug-related poisonings were defined using International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, codes; treatment retention was defined by continuous treatment claims until a 45-day gap was observed.ResultsThere were 13 778 567 person-days of observation time among 22 946 individuals (mean [SD] age, 32.8 [11.8] years; 50.3% men) who experienced a drug-related poisoning. Stimulant treatment days were associated with 19% increased odds of drug-related poisoning (odds ratio [OR], 1.19 [95% CI, 1.06-1.34]) compared with nontreatment days; buprenorphine treatment days were associated with 38% decreased odds of poisoning (OR, 0.62 [95% CI, 0.59-0.65]). There were no significant interaction effects between use of stimulants and buprenorphine. Stimulant treatment days were associated with decreased odds of attrition from buprenorphine treatment (OR, 0.64 [95% CI, 0.59-0.70]), indicating that stimulants were associated with 36% longer mean exposure to buprenorphine and its concomitant protection.Conclusions and RelevanceAmong persons with OUD, use of prescription stimulants was associated with a modest increase in per-day risk of drug-related poisoning, but this risk was offset by the association between stimulant use and improved retention to buprenorphine treatment, which is associated with protection against overdose.

Opioid Prescription Dispensing Patterns in Patients with Bipolar Disorder: Real-World Evidence from the IBM Market Scan Research Databases

Prescription opioid dispensing patterns over time were assessed for individuals with bipolar disorder (BD) vs matched controls. Health insurance claims data from the IBM MarketScan Commercial Database and Multi-State Medicaid Database were analyzed. Individuals aged 18 to 64 with ≥1 inpatient or ≥2 outpatient claims for BD during the year preceding the analysis year (2015-2019) were included, with age- and sex-matched controls. Baseline demographic and clinical characteristics were evaluated. Opioid dispensing during each analysis year was defined as either chronic (coverage for ≥70days in any 90-day period, or ≥6 prescriptions dispensed during analysis year) or nonchronic (≥1 prescription dispensed, not meeting chronic definition). BD patients had a higher prevalence of medical and psychiatric comorbidities, including pain diagnoses, vs controls. Among patients with BD in the Commercial database, chronic opioid dispensing decreased from 11% (controls: 3%) in 2015 to 6% (controls: 2%) in 2019, and in the Medicaid database, from 27% (controls: 12%) to 12% (controls: 5%). Among patients with BD in the Commercial database, nonchronic dispensing decreased from 26% (controls: 17%) in 2015 to 20% (controls: 12%) in 2019, and from 32% (controls: 26%) to 25% (controls: 14%) in the Medicaid database. Between 2015 and 2019, there was a significant decrease in chronic and nonchronic prescription opioid dispensing among BD patients and controls across both the Commercial and Medicaid databases. Despite this finding, it is important to note that both chronic and nonchronic opioid dispensing was consistently higher for BD patients vs controls over time, across both databases. Alkermes, Inc.

Costs of colorectal cancer screening with colonoscopy, including post-endoscopy events, among adults with Medicaid insurance

Objective To examine the healthcare utilization and costs associated with colorectal cancer (CRC) screening by colonoscopy, including costs associated with post-endoscopy events, among average-risk adults covered by Medicaid insurance. Methods This cohort study evaluated a population of adults (ages 50–75 years) with CRC screening between 1/1/2014 and 12/31/2018 (index = earliest test) from the IBM MarketScan Multi-State Medicaid database. Individuals at above-average risk for CRC or with prior CRC screening were excluded. CRC screening was reported by screening type: colonoscopy, fecal immunochemical test [FIT], fecal occult blood test [FOBT], multi-target stool DNA [mt-sDNA]. Frequency and costs of events potentially related to colonoscopy (defined as occurring within 30 days post-endoscopy) were reported overall, by event type, and by individual event. Results We identified a total of 13,134 average-risk adults covered by Medicaid insurance who received screening by colonoscopy; 63.6% (8350) had Medicare dual-eligibility while 36.4% (4785) did not have Medicare dual-eligibility. The mean (SD) cost of a colonoscopy procedure was $684 ($907) and mean (SD) out-of-pocket costs were $6 ($132). Serious gastrointestinal (GI) events (perforation and bleeding) were observed in 4.6% of individuals with colonoscopy, 4.3% had other GI events, and 3.0% had an incident cardiovascular/cerebrovascular event. Mean (SD) event-related costs were $1233 ($5784) among individuals with a serious GI event, $747 ($1961) among individuals with other GI events, and $4398 ($19,369) among individuals with a cardiovascular/cerebrovascular event. Conclusions This large, claims-based cohort study reports average (SD) out-of-pocket costs for Medicaid beneficiaries at $6 ($132), which could be one factor contributing to the accessibility of CRC screening by colonoscopy. The incidence of events potentially associated with colonoscopy (i.e. within 30 days after the screening) was 3–4%, and the event-related costs were considerable.

Healthcare Utilization and Costs Associated With Perinatal Depression Among Medicaid Enrollees

Differences in healthcare utilization and medical expenditures associated with perinatal depression are estimated. Using the MarketScan Multi-State Medicaid Database, the analytic cohort included individuals aged 15-44 years who had an inpatient live birth delivery hospitalization between January 1, 2017 and December 31, 2018. Multivariable negative binomial regression models were used to estimate the differences in utilization associated with perinatal depression, and multivariable generalized linear models were used to estimate the differences in expenditures associated with perinatal depression. Analyses were conducted in 2021. The cohort included 330,593 individuals. Nearly 17% had perinatal depression. Compared with individuals without perinatal depression individuals with perinatal depression had a larger number of inpatient admissions (0.19, 95% CI=0.18, 0.20), total inpatient days (0.95, 95% CI=0.92, 0.97), outpatient visits (14.02, 95% CI=13.81, 14.22), emergency department visits (1.70, 95% CI=1.66, 1.74), and weeks of drug therapy covered by a prescription (28.70, 95% CI=28.12, 29.28) and larger total expenditures ($5,078, 95% CI=$4,816, $5,340). Non-Hispanic Black individuals had larger differences in utilization and expenditures for inpatient services and outpatient visits but smaller differences in utilization for pharmaceutical services associated with perinatal depression than non-Hispanic White individuals. Hispanic individuals had larger differences in utilization for outpatient visits but smaller differences in utilization for pharmaceutical services associated with perinatal depression than non-Hispanic White individuals. Individuals with perinatal depression had more healthcare utilization and medical expenditures than individuals without perinatal depression, and differences varied by race/ethnicity. The findings highlight the need to ensure comprehensive and equitable mental health care to address perinatal depression.

Cardiometabolic outcomes among schizophrenia patients using antipsychotics: the impact of high weight gain risk vs low weight gain risk treatment

ObjectiveEvaluate the prevalence of cardiometabolic conditions among schizophrenia patients before and incidence after initiation of high (HWGR) and low weight gain risk (LWGR) antipsychotic (AP) regimens.MethodsA retrospective observational cohort study was conducted using administrative claims data from the IBM® MarketScan Commercial and Multi-State Medicaid Databases. Patients with > 1 medical claim with a diagnosis for schizophrenia and newly initiating AP therapy between 1/1/11–6/30/16 were included. Baseline characteristics were assessed in the 12-months before AP initiation; outcomes over 24-months following AP initiation. Patients were characterized by the AP regimen initiated at the index date. Adherence was defined by a medication possession ratio > 0.8 (medication on hand for 80% of follow-up). Multivariate modeling identified predictors of index AP weight gain risk profile and post-index dyslipidemia.ResultsTwo thousand seven hundred forty-eight commercially-insured and 8,748 Medicaid patients met the inclusion criteria. A majority of patients initiated on atypical AP and approximately 30% were adherent to their index AP regimen. Within both payers, patients indexing on LWGR AP regimens were more likely to have pre-index diagnoses of cardiometabolic conditions including hypertension, dyslipidemia, and diabetes. Significant predictors of post-index dyslipidemia included AP adherence and pre-index diabetes. Within both payers, odds of initiating HWGR AP regimens were higher among patients with evidence of drug abuse.ConclusionsThere is unmet need for reducing cardiometabolic consequences for patients on AP therapy and this analysis provides evidence that cardiometabolic conditions often develop during early stages of AP therapy. However, this does not appear to be related to the weight gain risk profile of the AP regimen.

A Real-world Claims Data Analysis of Meningococcal Serogroup B Vaccine Series Completion and Potential Missed Opportunities in the United States.

In the United States, meningococcal serogroup B (MenB) vaccination is recommended for 16-23-year-olds based on shared clinical decision-making. We estimated series completion among individuals initiating MenB vaccination for the 2 available vaccines: MenB 4-component (MenB-4C, doses at 0 and ≥1 month) and MenB factor H binding protein (MenB-FHbp, doses at 0 and 6 months). This retrospective health insurance claims data analysis included 16-23-year-olds who initiated MenB vaccination (index date) during January 2017 to November 2018 (MarketScan Commercial Claims and Encounters Database) or January 2017 to September 2018 (MarketScan Multi-State Medicaid Database) and had continuous enrollment for ≥6 months before and ≥15 months after index. The main outcome was MenB vaccine series completion within 15 months. Among noncompleters, preventive care/well-child and vaccine administrative office visits were identified as potential missed opportunities for series completion. Robust Poisson regression models identified independent predictors of series completion. In the Commercial (n = 156,080) and Medicaid (n = 57,082) populations, series completion was 56.7% and 44.7%, respectively, and was higher among those who initiated MenB-4C versus MenB-FHbp (61.1% versus 49.8% and 47.8% versus 33.9%, respectively; both P < 0.001). Among noncompleters, 40.2% and 34.7% of the Commercial and Medicaid populations, respectively, had ≥1 missed opportunity for series completion. Receipt of MenB-4C and younger age were independently associated with a higher probability of series completion. Series completion rates were suboptimal but were higher among those who initiated MenB-4C. To maximize the benefits of MenB vaccination, interventions to improve completion and reduce missed opportunities should be implemented.

Age of First Oral Health Examination and Dental Treatment Needs of Medicaid-Enrolled Children.

Early childhood caries (ECC), despite being preventable, remains the most prevalent disease of childhood, particularly in children between the ages of 2 and 5 y. The association between the type of health care provider completing initial oral health examinations and subsequent dental caries in children under 6 y of age is unclear. The objective of the current study is to longitudinally assess the association between age at first oral health examination and provider type at first oral health examination on dental treatment for children under 6 y of age. Deidentified administrative claims data were used from the IBM Marketscan Multi-State Medicaid Database (n = 2.41 million Medicaid-enrolled children younger than 6 y in 13 states from 2012 to 2017). A Kaplan-Meier survival analysis was used to examine the association between age at first oral health examination and provider type with first treatment of dental caries at follow-up. The adjusted hazard ratio (HR) of dental caries for children whose first oral health examination at 4 y of age is 5.425 times higher than for children whose first oral health examination was before 1 y of age (95% confidence interval [CI], 5.371-5.479). The adjusted HR of dental caries for children seen by pediatric dentists (HR = 1.215; 95% CI, 1.207-1.223) and physicians (HR = 2.618; 95% CI, 2.601-2.635) was higher than those seen by a general dentist. Findings from this study highlight the importance of children having their first oral health examination no later than 12 mo of age in accordance with existing guidelines and referrals from physicians to prevent the need for invasive treatment. Results of this study emphasize the need for a child's first oral health examination to be completed no later than 12 mo of age to prevent dental caries. Reinforcement and referrals by physicians based on this recommendation facilitate early establishment of a dental home in young children.

The incidence and economic burden of extrapyramidal symptoms in patients with schizophrenia treated with second generation antipsychotics in a Medicaid population

Background Extrapyramidal symptoms (EPS) are common side-effects of second-generation antipsychotics (SGA), that can negatively impact patient quality-of-life, and are associated with increased morbidity and mortality. This study examined the incidence and burden of EPS in patients with schizophrenia initiating SGAs. Methods Patients with schizophrenia initiating SGAs were identified in the MarketScan Multi-state Medicaid database from 1 January 2012 to 31 December 2018. Incidence of EPS (identified via ICD-9/ICD-10 diagnoses and medications) was assessed during the 12-months following SGA initiation. Cohorts with and without EPS were defined. Multivariate models were used to examine all-cause and schizophrenia-related hospitalizations and total costs in the 12 months following the first EPS claim (EPS) or randomly assigned index date (Non-EPS) while controlling for multiple baseline covariates. Logistic regression was used for hospitalization and two-part models were used for skewed cost data. Results A total of 11,642 patients with schizophrenia filled a prescription for an SGA; of which, 2,468 (21.2%) experienced EPS in the first year. The age- and gender-matched EPS group and non-EPS group included 2,295 and 5,607 patients, respectively. Multivariate analyses confirmed that EPS patients had 25% higher odds of all-cause (OR = 1.25; 95% CI = 1.11–1.40) and 75% increased odds of schizophrenia-related (OR = 1.75; 95% CI = 1.53–2.00) inpatient admissions compared to non-EPS patients. Multivariate adjustment of post-period costs between groups also found significant differences in both all-cause (EPS: $27,408 vs. non-EPS: $22,489, p < 0.001) and schizophrenia-related (EPS:$12,833 vs. non-EPS:$8,077, p < 0.0001) costs between the EPS and non-EPS cohorts. Conclusions Over one-fifth of patients initiating treatment with atypical antipsychotics in this study developed EPS in the 12 months following SGA initiation. Extrapyramidal side-effects associated with atypical antipsychotics increase the risk of hospitalization and contribute to higher healthcare costs. For patients with schizophrenia, treatment options that minimize the risk of EPS may reduce the economic burden associated with the disease.

The burden of neuropsychiatric disorders in patients living with HIV-1 treated with antiretroviral therapies-A perspective from US Medicaid data.

People with human immunodeficiency virus (HIV)-1 face challenges with treatment adherence for various reasons, including consideration of neuropsychiatric disorders and neuropsychiatric adverse reactions associated with antiretroviral therapy (ART). A retrospective cohort study was conducted using administrative claims data from the IBM MarketScan® Multi-State Medicaid Database (1/1/2014-12/31/2017). Adults (≥18years) diagnosed with HIV-1 and newly initiated on antiretroviral therapy with continuous health plan enrollment were included. Primary outcome was the 6-month period prevalence of neuropsychiatric events (NPEs) of interest after ART initiation. Among 1971 newly treated patients included in the study, mean age (standard deviation [SD]) was 38.5 (12.7) years, and 41.4% were female. During the 6months after ART initiation, 51.4% of patients had a claim for ≥1 NPE versus 30.3% of matched patients without HIV. Among newly treated patients, the most common (≥10%) NPE claims were for depression (42.2%), anxiety (15.8%), headache (11.9%), and bipolar/manic depression (10.1%). Also in this group, the mean (SD) total all-cause healthcare cost during the 6-month post-ART initiation was $16,632 ($33,928), of which $2914 ($18,233) was NPE-related. In summary, in this Medicaid study of people newly initiated on ART, there was a high prevalence of NPEs, and incremental NPE-associated costs were considerable.

863. Pre-Exposure Prophylaxis (PrEP) Prescriptions among Individuals at High Risk for HIV in the United States, 2012-2018

BackgroundTo describe trends in emtricitabine and tenofovir disoproxil fumarate (FTC/TDF) PrEP uptake in 2012-2018 and characterize high risk individuals who use PrEP.MethodsThe study identified individuals aged ≥ 15 years old with claims suggesting high risk for HIV infection in the IBM MarketScan® Commercial Claims and Multi-state Medicaid Databases. High risk was defined using ICD codes indicating high risk sexual behavior or rectal/repeated bacterial sexually transmitted infection (STI). The index date was defined as the earliest of the first high risk sexual behavior diagnosis, the first rectal bacterial STI diagnosis, or the second non-rectal bacterial STI diagnosis within 12 months. Individuals were considered PrEP users if they had at least one FTC/TDF PrEP prescription within 12 months of index date. Individuals with evidence of HIV prior to or within 30 days after PrEP initiation/index date were excluded. Comorbidities were assessed using a modified Charlson Comorbidity Index that excluded HIV/AIDS.ResultsFTC/TDF PrEP uptake increased from 0.1% to 7.3% among commercially insured individuals between 2012-2018, and from 0.01% to 0.5% among Medicaid insured individuals between 2012-2017. Individuals ≥ 35 years old had the largest increase in PrEP uptake (0.1% to 13.0%), while those 16-25 years old had the smallest increase (0.03% to 2.3%). The largest proportion of PrEP users across all years were aged 25-34 while the largest proportion of non-PrEP users were aged 18-24. Compared to PrEP users, a larger proportion of PrEP non-users were female (62.9% vs. 1.4%, p < 0.05) and blacks/African American (49.1% vs. 40.3%, p < 0.05). A larger proportion of PrEP users had a risk status of homosexual (46.6% vs. 1.5%, p < 0.05) or bisexual (3.9% vs. 0.8%, p < 0.05) behavior than non-PrEP users. PrEP users also had more comorbidities than non-users among individuals with Medicaid and were less likely to have fee-for-service insurance plans overall (p < 0.05).Table 1. Characteristics of people at high-risk for HIV who do vs. do not use FTC/TDF PrEP measured during the follow-up period ConclusionDespite an increase in FTC/TDF PrEP initiations, uptake was low, especially among young adults, women, heterosexuals and blacks/African Americans. Low initiation rates in these groups may illustrate that FTC/TDF PrEP is not meeting the needs of all high-risk individuals.Disclosures Mo Zhou, PhD, Merck & Co., Inc. (Consultant) Yan Song, PhD, Merck & Co., Inc. (Consultant) Emily Gao, MS, MPH, Merck & Co., Inc. (Consultant) Yohance Whiteside, PhD, MSPH, Merck & Co., Inc. (Employee) Emma Billmyer, BA, Merck & Co., Inc. (Consultant) James Signorovitch, PhD, Merck & Co., Inc. (Consultant)

Relapse and Treatment Adherence in Patients with Schizophrenia Switching from Paliperidone Palmitate Once-Monthly to Three-Monthly Formulation: A Retrospective Health Claims Database Analysis.

PurposeRelapse and treatment adherence to paliperidone palmitate once-monthly (PP1M) and three-monthly (PP3M) formulations in patients with schizophrenia were evaluated and compared using health claims data.Patients and MethodsData (June 2015─June 2018) obtained from the MarketScan® Multi-State Medicaid Database were retrospectively analyzed. Patients aged ≥18 years with ≥1 claim for schizophrenia diagnosis prior to and/or at index date (i.e., date of first PP3M prescription record for PP3M patients and same month/year as the matched PP3M patients for PP1M patients) and continuous enrollment in the insurance plan for ≥12 months prior to index date (baseline) were included. PP1M cohort included patients who received ≥4 PP1M doses. PP3M patients were matched with PP1M patients (1:3) using propensity score matching and prevalent new user design. Outcome measures were relapse rate, time to relapse, proportion of days covered (PDC), and level of treatment adherence defined by PDC in five levels. Time to relapse was compared by Kaplan–Meier survival curves and log-rank test with the hazard ratio calculated using Cox proportion hazards model; PDC by t-test, and relapse rate and PDC categories by chi-square test.ResultsA total of 1564 patients (428 PP3M and 1136 PP1M) were included. Relapse rate was lower in PP3M cohort (10.5%) compared with PP1M cohort (15.7%). Incidence rate of relapse was 8.98/100 person-years (PY) in PP3M cohort and 13.81/100 PY in PP1M cohort. After a mean (SD) follow-up of 456.1 (240.28) days in PP3M cohort and 465.4 (237.95) days in PP1M cohort, PP3M patients had a significantly lower relapse risk (hazard ratio: 0.65, 95% CI: 0.47, 0.90) than PP1M patients. Treatment adherence was significantly (p<0.0001) higher in PP3M versus PP1M cohort.ConclusionRisk of relapse was significantly lower, and treatment adherence was significantly higher in PP3M cohort compared with PP1M cohort. Higher treatment adherence was associated with lower relapse rate.

Influenza vaccination rates and hospitalizations among Medicaid enrollees with and without sickle cell disease, 2009-2015.

Personswith sickle cell disease (SCD) face increased risks for pulmonary and infection-related complications. This study examines influenza vaccination coverage and estimates influenza-related morbidity among Medicaid enrollees with and without SCD. Influenza vaccination coverage and hospitalizations related to influenza and pneumonia/acute chest syndrome (ACS) during each influenza season from 2009-2010 to 2014-2015 were assessed among enrollees in the IBM MarketScan® Multi-State Medicaid Database. Enrollees with SCD were identified as enrollees with greater than or equal to three claims listing SCD within a 5-year period during 2003-2017. Vaccinations were identified in outpatient claims. Hospitalizations associated with influenza or pneumonia/ACS were identified using inpatient claims. This study includes a series of cross-sectional assessments by season. From 2009-2010 through 2014-2015 seasons, the SCD sample ranged from 5044 to 8651 enrollees; the non-SCD sample ranged from 1,841,756 to 3,796,337 enrollees. Influenza vaccination coverage was higher among enrollees with SCD compared with enrollees without SCD for all seasons (24.5%-33.6% and 18.2%-22.0%, respectively). Age-standardized rates of influenza-related hospitalizations were 20-42 times higher among SCD enrollees compared with non-SCD enrollees, and ACS/pneumonia hospitalizations were 18-29 times higher. Among enrollees with SCD, influenza-related hospitalization rates were highest among children aged 0-9years. Among enrollees without SCD, influenza-related hospitalization rates were highest among adults aged 40-64years. Although vaccine coverage was higher in persons with versus without SCD, efforts to increase influenza coverage further are warranted for this high-risk group, who experienced markedly higher rates of influenza and ACS/pneumonia hospitalizations during each season.

Development and evaluation of standardized pregnancy identification and trimester distribution algorithms in U.S. IBM MarketScan® Commercial and Medicaid data.

Creation of new algorithms to identify pregnancies in automated health care claims databases is of public health importance, as it allows us to learn more about medication use and safety in a vulnerable population. Previous algorithms were largely created using international classification of disease codes, but despite the U.S. code transition in 2015, few algorithms are available with the latest ICD-10-CM codes. Using U.S. IBM MarketScan® Commercial Claims and Encounters and Multi-State Medicaid databases for women aged 10-64 years during 2014 and 2016, two pregnancy algorithms (ICD-9-CM and ICD-10-CM) were created using expert clinical review. The algorithms were evaluated by assessing the distribution of pregnancy outcomes (live birth and pregnancy losses) within each time-based cohort and the ability of the algorithms to identify select medication use during pregnancy. Medication exposure, demographics, comorbidities, and pregnancy outcomes were compared to published literature estimates for the two time periods. For the IBM MarketScan® Commercial database, the algorithms identified 687,228 pregnancies in 2014 and 444,293 in 2016. In the IBM MarketScan® Medicaid database, 389,132 pregnancies in 2014 and 406,418 in 2016 were identified. Percentages of most pregnancy outcomes identified using the algorithms were similar to national data sources; however, percentages of preterm births and pregnancy losses were not comparable. Most medication use estimates from the algorithms were similar to or higher than published estimates. By incorporating the latest ICD-10-CM codes, the new algorithms provide more complete estimates of medication use during pregnancy than algorithms using the outdated codes.