Months Of Continuous Enrollment Research Articles

Comparing adherence and persistence across 6 chronic medication classes.

The National Quality Forum recently endorsed the proportion of days covered (PDC)-a measure of medication adherence-as an indicator of quality in drug therapy management. To inform initial efforts to improve the quality of drug therapy management, we compared PDC and persistence among new users of 6 commonly used chronic medication categories. A retrospective analysis of pharmacy claims in a database of more than 64 million members enrolled in 100 health plans assessed persistence and adherence to drug therapy in 6 chronic conditions. Patients were included in the analysis if they initiated a prescription drug of interest in any of 6 drug classes-prostaglandin analogs, statins, bisphosphonates, oral antidiabetics, angiotensin II receptor blockers (ARBs), and overactive bladder (OAB) medications-between January 1 and December 31, 2005. The first claim for a drug of interest during this period was considered a patient's index date. Patients were required to have a minimum of 12 months of continuous enrollment both preceding and following their index date. New users of a treatment were identified by excluding patients who filled a prescription for any drug in the same class during the previous 12 months and were followed for a minimum of 12 months. Nonpersistence was defined as discontinuation of the therapy class following an allowed gap between refills-30-, 60-, and 90-day refill gaps were used. Adherence was defined as a continuous measure of the proportion of days covered (PDC) during the 12-month post-index period. Logistic regression analyses predicted (a) nonpersistence during the 12-month post-index period and (b) adherence (PDC) of at least 80%, with drug class as the predictor variable of interest, controlling for demographic variables, insurance and plan type, history of hospitalization, Charlson comorbidity score, copayment for index medication, and number of medications at index. A total of 167,907 patients were identified across 6 cohorts. Using the 60-day gap, 6-month persistence rates were prostaglandin analogs 47%, statins 56%, bisphosphonates 56%, oral antidiabetics 66%, ARBs 63%, and OAB medications 28%. After the first 90 days of therapy, relative persistence was stable across cohorts, and rates declined consistently from 6 months post-index to study end. Logistic regression models showed that oral antidiabetic users had a 59%, 36%, 37%, and 79% decreased risk of nonpersistence in a 12-month follow-up period compared with patients taking prostaglandin analogs, statins, bisphosphonates, or OAB medications, respectively. Risk of nonpersistence decreased with increasing age. Mean (SD) 12-month adherence rates were: prostaglandin analogs 37% (26%), statins 61% (33%), bisphosphonates 60% (34%), oral antidiabetics 72% (32%), ARBs 66% (32%), and OAB medications 35% (32%). Logistic regression indicated that oral antidiabetic use was a significant predictor of adherence (PDC) of at least 80% compared with other therapy classes. Adjusted odds ratios for oral antidiabetics were 17.60 (95% confidence interval [CI] = 15.38-20.14) versus prostaglandin analogs, 2.06 (95% CI = 1.99-2.12) versus statins, 1.92 (95% CI = 1.83-2.02) versus bisphosphonates, 1.29 (95% CI = 1.24-1.34) versus ARBs, and 5.77 (95% CI = 5.38-6.19) versus OAB medications. This analysis of adherence (PDC) and persistence across a sample of 6 chronic therapies found variable but uniformly suboptimal medication use. Adherence to prostaglandin eye drops and OAB medications was lower than to cardiovascular, oral antidiabetic, and oral osteoporosis therapies. These findings provide useful baseline information for the development of initiatives to improve the quality of drug therapy management.

Economic Outcomes Associated with Microvascular Complications of Type 2 Diabetes Mellitus

Patients with diabetes mellitus have been shown to be at high risk for both macrovascular and microvascular complications (MVC). Recent studies have focused on MVC and their effect on the healthcare system, but limited published data exist on long-term costs associated with MVC in patients with type 2 diabetes mellitus (T2DM). The objective of this study was to compare resource utilization and medical costs over a 12-month period among patients diagnosed with T2DM with versus without MVC in a managed-care population. Patients aged >/=18 years, diagnosed with T2DM between 1 January 2003 and 31 December 2004 were identified in an administrative claims database of approximately 55 million beneficiaries in private and public health plans. The date of the first T2DM diagnosis during this period was the 'index date' for each patient. All patients had to have a minimum of 12 months of continuous enrolment both prior to and following the index date. MVC was identified during the 12 months prior to the first T2DM diagnosis and these patients were matched (1 : 2) by age, sex and ten co-morbid conditions to those with no evidence of MVC during the entire study period. Among the 15 326 MVC patients included in the study, 61% had a history of peripheral neuropathy, 28% diabetic retinopathy and 19% nephropathy. Compared with 30 652 patients without MVC, the MVC patients were more likely to use oral antidiabetics and insulin and had a higher co-morbidity score. Over 12 months, patients with MVC had more (mean 0.3 vs 0.2; p < 0.001) and longer (mean length of stay 1.79 days vs 0.85 days; p < 0.001) hospital stays; physician office visits (19.7 vs 13.7; p < 0.001); and prescriptions for oral antidiabetic (6.3 vs 5.6 scripts; p < 0.001) and insulin (0.7 vs 0.2 scripts; p < 0.001) use. Average total costs per patient over 12 months were $US14 414 with MVC versus $US8669 without MVC (p < 0.001). This study indicates that in patients with T2DM, MVC is associated with significant consumption of healthcare resources. Mean total costs with MVC were almost double those of patients without MVC over a 12-month period.

Differences in annual medication costs and rates of dosage increase between tumor necrosis factor-antagonist therapies for rheumatoid arthritis in a managed care population

Background: Tumor necrosis factor (TNF) antagonists are commonly used to treat rheumatoid arthritis (RA). Differences in the dosage and mode of administration of these agents may result in differential rates of dosage adjustment and costs of care.Objective: This study compared dosing patterns and annual costs associated with the use of the subcutaneous TNF antagonists adalimumab and etanercept, and the intravenous TNF antagonist infliximab.Methods: A large managed care database (PharMetrics) was used to identify patients with RA who newly initiated TNF-antagonist therapy with adalimumab, etanercept, or infliximab on or after January 1, 2003, and had at least 6 months of continuous health plan enrollment before initiation of therapy and 12 months of continuous enrollment after initiation. The patients were followed over 12 months of enrollment. Annual pharmacy, inpatient, and outpatient costs were estimated based on plan reimbursements and were compared between cohorts. The average daily dosage (ADD) between prescription refills was used to compare the percentages of patients with greater-than-expected dosing (GTED), defined as 2 consecutive increases in ADD relative to the patient's established maintenance dosage.Results: A total of 2382 patients (568 adalimumab, 1181 etanercept, 633 infliximab) were included in the analysis. Significantly more patients had GTED with infliximab compared with adalimumab and etanercept (32.1%, 8.5%, and 4.7%, respectively; both comparisons, P < 0.05). For patients with a dosage increase, the mean time to the first GTED was significantly shorter for infliximab compared with adalimu-mab and etanercept (154.5, 173.3, and 167.9 days; both, P < 0.05). The mean annual costs of anti-TNF therapy, adjusted for baseline differences, were significantly greater for infliximab compared with adalimumab and etanercept ($15,617, $12,200, and $12,146; both, P < 0.05). There were also significant differences between infliximab relative to adalimumab and etanercept in total RA-related medication costs ($16,280, $12,989, and $12,794; P < 0.05) and total pharmacy costs ($17,854, $14,805, and $14,398; P < 0.05).Conclusion: Patients initiating TNF-antagonist treatment for RA with infliximab incurred annual medication costs that were nearly 30% greater than costs in those initiating therapy with adalimumab or etanercept, in part because of the significantly greater rate of GTED in infliximab recipients.

Impact of a Pentavalent Combination Vaccine on Immunization Timeliness in a State Medicaid Population

Use of combination vaccines has been associated with improved coverage rates, but their effect on timeliness remains to be explored. This study assessed the effect of diphtheria-tetanus-acellular pertussis/hepatitis B/inactivated polio vaccine (DTaP/HepB/IPV) on the timeliness of vaccine administration. This retrospective cohort study used administrative claims data from the Georgia Medicaid program. Children with 24 months of continuous enrollment and at least 4 vaccine-related office visits were stratified into 2 cohorts: those with at least 3 DTaP/HepB/IPV doses (DTaP/HepB/IPV cohort) and those with at least 3 doses of DTaP but no doses of DTaP/HepB/IPV (reference cohort). Children who received any dose of HepB/Hib were excluded to isolate the effect of the study vaccine. Timeliness was measured as the percentage of children who received their vaccines on time and the cumulative days undervaccinated. There were 2880 children in the DTaP/HepB/IPV cohort and 2672 in the reference cohort. After controlling for covariates, receipt of DTaP/HepB/IPV was associated with significantly improved timeliness for 3 doses of DTaP (on-time rates: 66.3% vs. 60.8%, P < 0.0001; cumulative days undervaccinated: 29.5 vs. 70.4 days, P < 0.0001). Significantly improved timeliness was also observed in the DTaP/HepB/IPV cohort for IPV, HepB, Hib, 4 DTaPs, and the combination series assessed (P < 0.001 for all comparisons). Use of DTaP/HepB/IPV in this Medicaid population was associated with improved on-time vaccination and fewer undervaccinated days. These findings, along with previous research associating combination vaccines with improved coverage rates, provide quantitative data to support the ACIP, AAP, and AAFP preference for combination vaccines.

Prevalence of other diabetes-associated complications and comorbidities and its impact on health care charges among patients with diabetic neuropathy

Introduction Diabetic neuropathy (DN) is a common complication associated with diabetes. This study assesses the prevalence of other diabetes-related complications or comorbidities among DN patients and its marginal contribution to health care charges. Methods Using administrative claims database, we studied commercially insured patients below 65 years old with at least one claim of DN anytime from July 2004 through June 2005 (Year 1). Using propensity scoring, a 10:1 ratio of demographically matched controls with diabetes but no DN was constructed. Both DN patients and controls had 12 months of continuous enrollment in Year 1 and Year 2 (July 2005–June 2006). We compared the Year 1 prevalence of other diabetes-associated complications or comorbidities between DN patients and diabetic controls. Controlling for comorbidities, we used multivariate regressions to examine the incremental impact of DN or any other diabetes-related complication or comorbidity on Year 2 health care charges. Results A higher percentage of DN patients had at least one other diabetes-related complication or comorbidity than diabetic controls. Individuals with DN had a higher prevalence of each individual other diabetes-related complication or comorbidity. Controlling for comorbidities, the presence of any other diabetes-related complication or comorbidity was statistically associated with higher outpatient pharmacy and total charges for both DN patients and controls. Total and outpatient pharmacy charges were also significantly higher for DN patients than for controls, among those with or without any other diabetes-related complications or comorbidities. Conclusions DN can occur in the absence of other diabetes-related complications or comorbidities. The presence of DN and any other diabetes-related complications or comorbidities significantly increases health care charges.

Economic burden prior to COPD diagnosis: A matched case-control study in the United States

In the United States, chronic obstructive pulmonary disease (COPD) diagnosis is often a lengthy process, and consequently results in delays in treatment in early stages. Disease progression and complication may result in increased levels of healthcare service use. To understand the economic burden of COPD prior to diagnosis in the U.S., trends in utilization and costs during the period before initial COPD diagnosis were compared with matched controls. A retrospective case-control study was conducted using medical and pharmacy claims data from a large managed care health plan representing a base population of over 30 million covered lives in the U.S. COPD patients with at least 12 months of continuous enrollment and aged 40 years or older were identified (n=28,968) and matched to up to three random controls (n=81,322) by age, gender, region of plans and index date. Multivariate regression models were used to estimate average incremental service use and cost between COPD patients and controls. Moreover, trends in utilization and costs for the COPD patients were examined over 36 months before diagnosis. COPD patients used 1.5-1.6 times more inpatient/emergency department (IP/ED) services and office visits compared to control patients. The average incremental annual costs for IP/ED services, office visits, and medical and pharmacy services were estimated at $550, $238, $1438 and $401, respectively, after adjusting for age, gender, region and comorbid conditions. The 36-month trend analysis showed that COPD patients' healthcare utilization and costs increased gradually over time, often with a marked increase in the month before COPD diagnosis. COPD patients in the U.S. consumed substantial healthcare services and costs prior to diagnosis. More timely diagnosis and subsequent treatment may avoid costly healthcare utilization and unnecessary mortality and morbidity post-diagnosis.

Risk of hospitalizations/emergency department visits and treatment costs associated with initial maintenance therapy using fluticasone propionate 500 µg/salmeterol 50 µg compared with ipratropium for chronic obstructive pulmonary disease in older adults

Background: Cost-effective treatments for chronic obstructive pulmonary disease (COPD) are needed to reduce the burden on the Medicare system. Objectives: The objectives of this retrospective study were to compare the effects of fluticasone propionate 500 µg/salmeterol 50 µg (FSC 500/50) with those of ipratropium (IPR) in older adult patients with COPD on the following factors: (1) the risk of all-cause and COPD-related hospitalization and emergency department (ED) visits; and (2) all-cause and COPD-related treatment costs. Methods: This retrospective, observational cohort study assessed commercially insured patients aged ≥65 years (Medicare eligible) with COPD-related medical costs ( International Classification of Diseases, Ninth Revision, Clinical Modification codes 490.xx, 491.xx, 492.xx, or 496.xx), 18 months of continuous enrollment (12 months' pre-study and 6 months' poststudy), and ≥1 prescription claim (ie, the index event) for FSC 500/50 or IPR between January 2, 2001, and August 12, 2003. Exacerbation events (hospitalizations/ED visits) were assessed using Cox proportional hazards regression models controlling for baseline factors and preindex events. Treatment costs were estimated using multivariate generalized linear models to adjust for baseline characteristics and preindex utilization and costs. A propensity-matched comparison was conducted as a sensitivity analysis. Results: A total of 1051 patients (540 women, 511 men) were identified: 952 in the IPR group (mean age, 74.26 years) and 99 in the FSC 500/50 group (mean age, 72.38 years). Treatment with FSC 500/50 was not associated with a reduction in the risk of all-cause hospitalization or ED visit compared with IPR (adjusted hazards ratio [HR], 0.913 [95% CI, 0.673-1.238]); however, FSC 500/50 was associated with a significantly lower risk (45%) of a COPD-related event (adjusted HR, 0.547 [95% CI, 0.301-0.995]). Although treatment with FSC 500/50 was associated with significantly lower annual mean all-cause medical costs compared with IPR ($18,642 vs $25,556, P < 0.05), the use of FSC 500/50 was also associated with significantly higher annual all-cause pharmacy costs ($2813 vs $2244, P < 0.05). Compared with the IPR cohort, the FSC 500/50 cohort had lower mean annual COPD-related medical costs (-$464 [ P = NS]) and higher COPD-related pharmacy costs ($260 [ P < 0.01]). However, increased pharmacy costs may be compensated for by decreased medical costs in both all-cause and COPD-related services. Results from the sensitivity analysis with the propensity score-matched sample of 194 patients were similar. Conclusions: Compared with the IPR cohort, the FSC 500/50 cohort was 45% less likely to have a COPD-related exacerbation event and had similar medical costs. FSC 500/50 was a more effective initial maintenance therapy than IPR for this Medicare population, and, despite the $260 increase in COPD-related pharmacy costs, there was no significant difference in COPD-related medical costs.

Assessing Direct and Indirect Costs in Ulcerative Colitis

Purpose: To advance understanding of the cost drivers associated with UC and benchmark the impact on a large self-insured provider. Methods: Claimant records for a retrospective cohort of pts with UC (ICD-9 code 556.x) from a database of a self-insured employer, consisting of approx. 500000 employees, retirees, or dependents from 2002 to 2004 were analyzed to determine costs attributed to direct utilization and short-term disability (STD). 18 months of continuous enrollment was required [6-month pre and 12 months post-index date]. A randomly selected, age and gender matched control group, of non-UC claimants was the comparator. Individual claimants (UC and Controls) with costs ≥ 3 SDs from the overall mean were excluded on a basis of outlier status (N = 13, n = 50). Multiple linear regression technique was used to determine the predictors of cost, adjusting for CMS-HCC scores. A disease severity stratification algorithm classified UC pts into 3 mutually exclusive cohorts, mild [untreated or treated with aminosalicylates or topical therapy]; moderate [additional therapies (e.g., oral corticosteroids, immunomodulators)]; or severe [requiring hospitalization for UC] cohort. Results: Healthcare costs were evaluated for 1044 UC pts. Mean annual unadjusted total costs for all UC pts were $12120 vs $5128 for the non-UC group (N = 4178). The regression model indicated UC was a predictor of higher costs vs the control group (coefficient = 5136.37, p < 0.005). When stratified by disease severity, the severe UC cohort had 79.6% higher mean total costs vs the moderate group ($21999 vs $12248) and the moderate UC cohort had a 24.3% higher mean total costs vs the mild group ($12248 vs $9847). After adjustment for CMS-HCC scores in the regression analysis, the severe group was a significant predictor of increased cost, vs the mild and moderate pts (coefficient = 5847.84, p= 0.03). Additionally indirect costs for 211 (19.96%) UC pts filed claims for disability dispensation, with a mean payment of $2366. Conclusions: Utilization expenditures for the UC cohort were over 2 times more costly vs pts without UC. Healthcare costs were highest for pts with severe UC. These results highlight the impact of UC healthcare expenditures on a self-insured employer. Increased awareness and attention to UC is warranted.

Comparative Effectiveness of Total Population versus Disease-Specific Neural Network Models in Predicting Medical Costs

The objective of this research was to compare the accuracy of two types of neural networks in identifying individuals at risk for high medical costs for three chronic conditions. Two neural network models-a population model and three disease-specific models-were compared regarding effectiveness predicting high costs. Subjects included 33,908 health plan members with diabetes, 19,264 with asthma, and 2,605 with cardiac conditions. For model development/ testing, only members with 24 months of continuous enrollment were included. Models were developed to predict probability of high costs in 2000 (top 15% of distribution) based on 1999 claims factors. After validation, models were applied to 2000 claims factors to predict probability of high 2001 costs. Each member received two scores-population model score applied to cohort and disease model score. Receiver Operating Characteristic (ROC) curves compared sensitivity, specificity, and total performance of population model and three disease models. Diabetes-specific model accuracy, C = 0.786 (95%CI = 0.779-0.794), was greater than that of population model applied to diabetic cohort, C = 0.767 (0.759-0.775). Asthma-specific model accuracy, C = 0.835 (0.825-0.844), was no different from that of population model applied to asthma cohort, C = 0.844 (0.835-0.853). Cardiac-specific model accuracy, C = 0.651 (0.620-0.683), was lower than that of population model applied to cardiac cohort, C = 0.726 (0.697-0.756). The population model predictive power, compared to the disease model predictive power, varied by disease; in general, the larger the cohort, the greater the advantage in predictive power of the disease model compared to the population model. Given these findings, disease management program staff should test multiple approaches before implementing predictive models.

Economic burden of uncontrolled chemotherapy-induced nausea and vomiting among working-age cancer patients

6053 Background: Poorly controlled CINV may lead to additional office or emergency room visits, thus, increasing the overall costs of cancer care. This study estimates the societal costs of uncontrolled CINV for working-age cancer patients (pts). Methods: Employees or spouse/dependents with (w/) cancer who received highly or moderately emetogenic chemotherapy were identified from a 1997–2002 proprietary dataset linking medical claims to work-loss information. Pts were followed from the earliest date of chemotherapy for up to 6 months, excluding pts w/ < 3 months of continuous enrollment. Three groups, pts w/ uncontrolled CINV and no ER visit, w/ uncontrolled CINV and ER visit, and w/ controlled CINV, were compared in univariate analyses. Uncontrolled CINV was identified by ICD-9 diagnosis codes. Direct medical costs were measured using payments, normalized as monthly, and updated to 2004 $US. Work loss days were identified from employment records. Costs of uncontrolled CINV were derived by comparing costs and days for pts w/ controlled vs. uncontrolled CINV. We used the Wilcoxon Mann-Whitney test to compare costs/days in univariate analyses. All pts w/ uncontrolled CINV were pooled as one group in multivariate analysis. Results: 2,071 pts were identified; 25% required medical care for uncontrolled CINV; 2% had ER visits. (Table) Total direct costs for pts w/ CINV exceeded controlled pts by $2000 - $4000; work loss days were also significantly higher. After controlling for demographics, geographic regions, and comorbidities, the difference in monthly medical costs between the controlled and uncontrolled group was $2,619(P<0.001). However, the difference in work loss was no longer significant. Conclusions: Uncontrolled CINV was associated w/ a significant increase in medical costs. For pts w/ uncontrolled CINV but no ER visit, increases in cost were driven by outpatient care, whereas for those w/ ER visits, inpatient care was the major cost driver. Author Disclosure Employment or Leadership Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration MGI

Adherence to asthma controller medication regimens

Improved adherence to inhaled corticosteroids (ICS) is recognized as an important factor in reduced morbidity, mortality and consumption of health care resources. The present study was designed to replicate previous reports of patient adherence with fluticasone/salmeterol in a single inhaler (FSC), fluticasone and salmeterol in separate inhalers (FP+SAL), fluticasone and montelukast (FP+MON), fluticasone alone (FP) and montelukast alone (MON). A 24-month observational retrospective study was conducted using administrative claims data. Subjects were 12 years old with 24 months of continuous enrollment; had 1 asthma claim (ICD-9: 493), 1 short-acting beta(2)-agonist claim, and 1 FSC, FP, SAL, or MON claim. Outcomes included asthma medication refill rates and persistence measured by treatment days. This study was designed with a unique population of patients with asthma from different health plans to validate previous findings. A total of 3,503 subjects were identified based on their index medication: FSC (996), FP+SAL (259), FP+MON (101), FP (1254) and MON (893). Mean number of prescription refills for FSC (3.98) was significantly higher than FP (2.29) and the FP component of FP+SAL (2.36), and FP+MON (2.15), P<0.05. No significant differences were observed between FSC and MON fill rates (4.33). Mean number of treatment days was greater for FSC compared to FP, FP+SAL, and FP+MON (P<0.0001). This study confirms a previous report that adherence profiles of fluticasone and salmeterol in a single inhaler are significantly better when compared to the controller regimens of fluticasone and salmeterol in separate inhalers, fluticasone and montelukast, or fluticasone alone and similar to montelukast alone.

PAM8: COST COMPARISON OF TREATING OSTEOPOROSIS PATIENTS WITH ESTROGENS OR SELECTIVE ESTROGEN RECEPTOR MODULATOR IN A MANAGED CARE POPULATION

OBJECTIVE: To compare osteoporosis treatment charges among patients treated with an estrogen versus a selective estrogen receptor modulator (SERM) in a managed care population. METHODS: Patients 40 years of age with a diagnosis of osteoporosis between January 1 and June 30, 1999 and 2 pharmacy claims for an estrogen or SERM were selected from the PharMetrics Integrated Outcomes Database. Patients were excluded if they had less than 6 months of continuous enrollment following the first (index) prescription claim for an estrogen or SERM or received other drugs for osteoporosis, such as bisphosphonates or calcitonin-salmon. The frequency of of hip, vertebral, forearm/wrist or other fracture and/or related surgical procedures and osteoporosis-specific charges were assessed over the 6-month period following the index prescription. RESULTS: 252,892 patients met the selection criteria, including 245,650 treated with estrogen and 7,242 with SERMs. The estrogen cohort was significantly younger than the SERM cohort (mean age: 54.3 vs. 59.0 years, p < 0.001) and had less frequent fractures/surgical procedures (1.0% vs. 1.6%, p < 0.001). The SERM group had higher mean osteoporosis-related pharmacy ($309 vs. $106) and medical charges ($73 vs. $29) resulting in a total charge difference of $247 (p < 0.001). Stratified analyses indicated that the SERM cohort had consistently higher mean charges across all age ranges compared to the estrogen cohort. CONCLUSION: In this initial cost comparison between SERM and estrogen therapy for osteoporosis, short-term (6-month) osteoporosis-related charges were significantly higher in the SERM group primarily due to the difference in drug costs. Longer-term studies are required to examine all of the costs associated with these therapies.

PCV15: ECONOMIC EVALUATION OF OUTPATIENT ANTICOAGULANT/ANTIPLATELET THERAPY FOLLOWING CORONARY STENTING IN A MANAGED CARE POPULATION

OBJECTIVE: To determine the impact of outpatient anticoagulant/antiplatelet therapy on treatment charges in patients receiving coronary artery stents in a managed care population. METHODS: Patients were selected from the PharMetrics Integrated Outcomes Database who underwent coronary angioplasty and stent insertion between January 1 and June 30, 1999 and who had at least 6 months of continuous enrollment in their health plan following the beginning of the treatment episode. Patients were grouped according to whether they received outpatient anticoagulant/antiplatelet prescription drug therapy following their stent procedure. Patients were also stratified by history of acute myocardial infarction (AMI) and presence of comorbid conditions (diabetes and hypertension). Total charges associated with the stenting treatment episode (up to 6 months following the procedure) were assessed. RESULTS: 2,713 patients receiving anticoagulant/antiplatelet therapy and 438 untreated patients met all selection criteria. The two treatment groups were similar in age (58.6 vs. 58.0 years respectively, p = 0.322) and in the frequency of AMI (37.7% vs. 37.9% respectively, p = 0.939) and of one or more comorbidities (73.3% vs. 71.5% respectively, p = 0.427). Mean charges over the study period for the anticoagulant/antiplatelet cohort exceeded those in the untreated cohort by $4,748 (p = 0.014). Pharmacy charges accounted for only $297 of this excess ($660 vs. $363, respectively). Most of the difference between treatment groups was in the medical costs of interventional cardiology. CONCLUSION: Among coronary stent recipients, the mean charge for a 6-month period in patients who also received anticoagulant/antiplatelet prescription drug therapy was 14% higher than in the untreated cohort, due mainly to higher medical charges. It is possible that untreated patients were less severely ill or had a favorable risk profile. Further investigation of these data will examine this issue.

PAM9: COST COMPARISON OF TREATING RHEUMATOID ARTHRITIS PATIENTS WITH COX-2 INHIBITORS OR NSAIDS IN A MANAGED CARE POPULATION

OBJECTIVE: To compare rheumatoid arthritis (RA) treatment charges with a cyclooxygenase-2 specific inhibitor (COX-2) versus a non-steroidal anti-inflammatory drug (NSAID) therapies in a managed care population. METHODS: Patients with a diagnosis of RA between January 1 and June 30, 1999 who had prescriptions for COX-2s or NSAIDs were selected from the PharMetrics Integrated Outcomes Database. Patients were excluded if they had osteoarthritis or did not have 6 months of continuous enrollment following the first (index) COX-2 or NSAID pharmacy claim. COX-2 and NSAID-treated groups were compared on their demographics, comorbidities, and total RA-specific charges during the 6 month follow-up period RESULTS: A total of 5,261 patients met the patient selection criteria, including 668 who received COX-2 and 4,593 who received NSAID. The COX-2 group was older (53.7 versus 49.6 years, p < 0.0001) on average and more likely to have at least one comorbidity (46.0% vs. 31.9%, p < 0.001) compared to the NSAID group. They also had higher RA-related pharmacy ($914 versus $636) and medical charges ($611 versus $566). Total mean charges for the COX-2 cohort were $323 higher (p = 0.019) than the NSAID cohort. CONCLUSION: In this initial cost comparison between COX-2s and NSAIDs, the mean charge for a 6-month period with COX-2s was 27% higher than with NSAIDs, mainly due to higher pharmacy charges. Longer-term studies are required to examine whether the higher acquisition costs of COX-2 are offset by savings in the costs of treating gastrotoxicity.

Adolescent enrollees in Medicaid managed care: the provision of well care and sexual health assessment.

(1) To estimate the proportion of adolescents receiving outpatient care, well care, and sexual health assessment during 12 months of continuous enrollment in Medicaid managed care. (2) To investigate factors associated with provision of these categories of service. Chart reviews were completed for a statewide random sample of adolescent Medicaid enrollees in Washington State. Multivariate logistic regression models included age, gender, race, language, residence, enrollment plan, and service level as independent variables. Dependent variables were receipt of outpatient care, well care, and sexual health assessment. Of 2000 enrollees' records, 78.3% provided evidence of outpatient service, 30.5% included well care, and 20.8% documented a sexual health assessment. Among adolescents who obtained service, younger enrollees and non-Whites were more likely to receive well care; females, older enrollees, and those with well care were more likely to have sexual health assessments. Use of standardized charting tools increased the likelihood that sexual health assessments would be documented. The variable most strongly associated with provision of outpatient service was plan of enrollment. Plan rankings on provision of outpatient care were not associated with organizational descriptions, such as for-profit status or plan structure. The low rates of well care and sexual health assessment documented for adolescents in Medicaid managed care suggest that interventions are needed.