Total All-cause Healthcare Research Articles

Estimating the Impact of Adherence to and Persistence with Atypical Antipsychotic Therapy on Health Care Costs and Risk of Hospitalization.

To estimate the impact of adherence to and persistence with atypical antipsychotics on health care costs and risk of hospitalization by controlling potential sources of endogeneity. Retrospective cohort study using medical and pharmacy claims data. Humana health care insurance database. A total of 32,374 patients with a diagnosis of schizophrenia or bipolar disorder and who had a prescription for noninjectable atypical antipsychotics (aripiprazole, asenapine, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, or ziprasidone), after a washout period of at least 180days during which there was no use of any atypical antipsychotics, between January 2007 and June 2013. The effects of adherence (proportion of days covered by all atypical antipsychotic prescription fills) to and persistence (time from initiation to discontinuation of therapy) with atypical antipsychotics on outcomes (all-cause total health care costs, medication costs, medical services costs, and inpatient admissions) were examined. To exclude potential bias due to mutual causality between drug use patterns and health care utilization, the effects of adherence and persistence measured in the first year on outcomes measured in the second year were investigated. Instrumental variable regressions using reimbursement rate and mail order as instrumental variables were conducted to correct potential endogeneity due to omitted variable bias. Being adherent decreased total costs by $19,497 (p<0.05), increased medication costs by $8194 (p<0.001), decreased medical services costs by $27,664 (p<0.001), and reduced hospitalization risk by 27% (p<0.001). Being persistent decreased individual total costs by $23,927 (p<0.05), increased medication costs by $10,278 (p<0.001), and decreased medical services costs by $34,178 (p<0.001). We could not identify a significant association between persistence and the risk of hospitalization. Good adherence to and persistence with atypical antipsychotics led to lower total costs than poor adherence and persistence. Thus efforts should be made to improve adherence and persistence in patients taking atypical antipsychotics.

Economic Burden of HIV Antiretroviral Therapy Adverse Events in the United States.

To estimate health care costs associated with medical events identified as antiretroviral therapy (ART)-attributable adverse events (AEs). During September 2006 to June 2012, adults with ≥1 HIV International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code (042/V08), ≥1 claim for ART prescription (March 2007-June 2011; index date), and continuous health plan enrollment for ≥6 months pre- and ≥12 months postindex were included (IMS' PharMetrics Plus Health Plan Claims Database). Patients with events of interest/ART claim during preindex period or with pregnancy/hepatitis C virus diagnosis/hepatitis B virus/cancer/tuberculosis during the study period were excluded. Postindex medical events were defined as first diagnosis code of event with ART claim ≤60 days prior to start of the event. Differences in median total all-cause health care costs observed for diabetes/insulin resistance management (US$14,547 median all-cause health care costs during time periods identified as diabetes/insulin resistance medical events versus US$11,237 without diabetes/insulin resistance events; P=.0021), lipid disorders (US$12,825 versus US$10,033; P=.0004), and renal disorders (US$1389 versus US$0; P<.0001). Health care costs of ART AEs should be key consideration for payers/providers in HIV management.

Abstract 301: Healthcare Costs Following Stroke and Major Bleeding Events in Nonvalvular Atrial Fibrillation Patients

Objectives: We sought to determine the impact of stroke and major bleeding excluding intracranial hemorrhage (MB) events on healthcare costs in a real-world nonvalvular atrial fibrillation (NVAF) population. Methods: Healthcare claims data from U.S. commercial and Medicare health plans were used to identify beneficiaries with NVAF during 2008-2012. Patients were classified into cohorts according to event type (No event, Stroke only, MB only, or Stroke plus MB). All-cause total healthcare costs and inpatient costs related to stroke and MB were calculated during 1-year period following the index date (date of initial event or first qualifying AF claim for No event group). Inpatient hospitalizations related to events were identified using ICD-9-CM diagnosis codes. Costs were standardized to 2012 US dollars. Results: Of the 40,654 patients included in the study, 28% had events (8.9% Stroke only, 14.5% MB only, and 4.7% Stroke plus MB). Relative to the No event cohort, all-cause unadjusted per-patient per-month (PPPM) total costs were $4,669 higher for Stroke only and $4,160 for MB only. For Stroke plus MB patients, unadjusted all-cause PPPM total costs were $6,322 higher compared to the No event cohort. Among Stroke only and MB only patients, the economic burden of hospitalizations related to MB (57% of total costs) was similar to Stroke only (63% of total costs). Hospitalizations related to stroke or MB accounted for 65% of total costs for Stroke plus MB. Conclusions: NVAF patients who have a stroke or MB event incur higher healthcare costs relative to patients without events. Interventions preventing stroke or MB events have the potential to reduce the healthcare burden associated NVAF.

Adding Rapid-Acting Insulin or Glp-1 Receptor Agonist to Basal Insulin: Outcomes in A Community Setting

To evaluate real-world outcomes in patients with type 2 diabetes mellitus (T2DM) receiving basal insulin who initiate add-on therapy with a rapid-acting insulin (RAI) or a glucagon-like peptide 1 (GLP-1) receptor agonist. Data were extracted retrospectively from a U. S. health claims database. Adults with T2DM on basal insulin who added an RAI (basal + RAI) or GLP-1 receptor agonist (basal + GLP-1) were included. Propensity score matching (with a 1 up to 3 ratio) was used to control for differences in baseline demographics, clinical characteristics, and health resource utilization. Endpoints included prevalence of hypoglycemia, pancreatic events, all-cause and diabetes-related resource utilization, and costs at 1-year follow-up. Overall, 6,718 matched patients were included: 5,013 basal + RAI and 1,705 basal + GLP1. Patients in both groups experienced a similar proportion of any hypoglycemic event (P = .4079). Hypoglycemic events leading to hospitalization were higher in the basal + RAI cohort (2.7% vs. 1.8%; P = .0444). The basal + GLP-1 cohort experienced fewer all-cause (13.55% vs. 18.61%; P<.0001) and diabetes-related hospitalizations (11.79% vs. 15.68%; P<.0001). The basal + GLP-1 cohort had lower total all-cause health care costs ($18,413 vs. $20,821; P = .0002) but similar diabetes-related costs ($9,134 vs. $8,985; P<.0001) compared with the basal + RAI cohort. Add-on therapy with a GLP-1 receptor agonist in T2DM patients receiving basal insulin was associated with fewer hospitalizations and lower total all-cause costs compared with add-on therapy using an RAI and could be considered as an alternative to an RAI in certain patients with T2DM who do not achieve effective glycemic control with basal insulin.

Health Care Utilization Patterns and Costs for Patients With Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic cutaneous disease with acutely painful flares that require appropriate and timely treatment. To assess how individuals with HS utilize medical care, especially emergency department (ED) care, a high-cost setting, and to describe the health care costs for this group. Cohort cost-identification study of 150 493 individuals with claims from the MarketScan medical claims database. Patients with claims for HS and psoriasis (16 736 and 110 266, respectively) and a control group with neither condition (23 491) during the study period, January 2008 to December 2010, were included. An HS cohort was formed from all the patients who had 2 or more claims for HS (International Classification of Diseases, Ninth Revision [ICD-9] code 705.83) during the 3-year period. A psoriasis cohort was used as a comparison group, since it is another chronic inflammatory condition with prominent skin findings. This group included randomly selected patients who had 2 or more claims for psoriasis (ICD-9 code 696.1) during the 3-year period. A second control group included randomly selected patients who had no claims for either condition during the 3-year period. From these cohorts only patients that were continuously enrolled for the 3-year period were included. Health care utilization measures including inpatient length of stay, emergency department and outpatient visits, and number of days supplied of prescription medication were investigated. Cost variables were also investigated and included inpatient, outpatient, emergency department, prescription drug, and total all-cause health care expenditures, which were adjusted for inflation and reported in 2010 US dollars. The largest component of the total 3-year cost for the HS group was inpatient cost (37.4%). In contrast, for the psoriasis group this was drug costs (46.5%) and for the control group, inpatient costs (40.9%). The proportion of people who were hospitalized in the HS cohort (15.8%) was higher than the psoriasis (10.8%) or control (8.6%) groups (P < .001). The proportion of patients who used the ED over the 3-year period was higher in the HS cohort (27.1%) than the psoriasis (17.4%) or control groups (17.2%) (P < .001). Similarly, the mean (SD) 3-year ED cost for the HS group was $2002 ($6632) and was higher than both comparison groups (P < .001). After adjustment for age, sex, and comorbidities, ED utilization remained higher in the HS group compared with the control (P < .001) and psoriasis (P = .02) cohorts. Hidradenitis suppurativa affects a younger, predominantly female population of patients. High-cost settings, such as ED and inpatient care, are used more frequently for patients with HS. Both patients and clinicians should be aware of this finding, and further research is needed to investigate the impact of health care utilization on patient outcomes.

Characteristics, Treatment, and Health Care Expenditures of Medicare Supplemental-Insured Patients with Painful Diabetic Peripheral Neuropathy, Post-Herpetic Neuralgia, or Fibromyalgia

To describe the characteristics, treatment, and health care expenditures of Medicare Supplemental-insured patients with painful diabetic peripheral neuropathy (pDPN), post-herpetic neuralgia (PHN), or fibromyalgia. Retrospective cohort study. United States clinical practice, as reflected within a database comprising administrative claims from 2.3 million older adults participating in Medicare supplemental insurance programs. Selected patients were aged ≥65 years, continuously enrolled in medical and prescription benefits throughout years 2008 and 2009, and had ≥1 medical claim with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for DPN, PHN, or fibromyalgia, followed within 60 days by a medication or pain intervention procedure used in treating pDPN, PHN, or fibromyalgia during 2008-2009. Utilization of, and expenditures on, pain-related and all-cause pharmacotherapy and medical interventions in 2009. The study included 25,716 patients with pDPN (mean age 75.2 years, 51.2% female), 4,712 patients with PHN (mean age 77.7 years, 63.9% female), and 25,246 patients with fibromyalgia (mean age 74.4 years, 73.0% female). Patients typically had numerous comorbidities, and many were treated with polypharmacy. Mean annual expenditures on total pain-related health care and total all-cause health care, respectively, (in 2010 USD) were: $1,632, $24,740 for pDPN; $1,403, $16,579 for PHN; and $1,635, $18,320 for fibromyalgia. In age-stratified analyses, pain-related health care expenditures decreased as age increased. The numerous comorbidities, polypharmacy, and magnitude of expenditures in this sample of Medicare supplemental-insured patients with pDPN, PHN, or fibromyalgia underscore the complexity and importance of appropriate management of these chronic pain patients.

Economic burden of irritable bowel syndrome with constipation: a retrospective analysis of health care costs in a commercially insured population.

The prevalence of irritable bowel syndrome with constipation (IBS-C) is estimated to be between 4.3% and 5.2% among adults in the United States. Little is known about the health care resource utilization and costs associated with IBS-C. To (a) evaluate the annual total all-cause, gastrointestinal (GI)-related, and IBS-C-related health care costs among IBS-C patients seeking medical care in a commercially insured population and (b) estimate the incremental all-cause health care costs among IBS-C patients relative to matched controls. Patients aged ≥ 18 years with continuous medical and pharmacy benefit eligibility in 2010 were identified from the HealthCore Integrated Research Database, which consists of administrative claims from 14 geographically dispersed U.S. health plans representing 45 million lives. IBS-C patients were defined as those with ≥ 1 medical claim with an ICD-9-CM diagnosis code in any position for IBS (ICD-9-CM 564.1x) and either ≥ 2 medical claims for constipation (ICD-9-CM 564.0x) on different service dates or ≥ 1 medical claim for constipation plus ≥ 1 pharmacy claim for a constipation-related prescription on different dates of service during the study period. Controls were defined as patients without any medical claims for IBS, constipation, abdominal pain, or bloating or pharmacy claims for constipation-related prescriptions. Controls were randomly selected and matched with IBS-C patients in a 1:1 ratio based on age (± 4 years), gender, health plan region, and health plan type. Patients with diagnoses or prescriptions suggesting mixed IBS, IBS with diarrhea, chronic diarrhea, or drug-induced constipation were excluded. Total health care costs in 2010 U.S. dollars were defined as the sum of health plan and patient paid costs for prescriptions and medical services, including inpatient visits, emergency room (ER) visits, physician office visits, and other outpatient services. The total cost approach was used to assess total all-cause or disease-specific health care costs for patients with IBS-C, while the incremental cost approach was used to examine the excess all-cause costs of IBS-C by comparing IBS-C patients with matched controls. Generalized linear models with bootstrapping were used to assess the incremental all-cause costs attributable solely to IBS-C after adjusting for demographics, Elixhauser Comorbidity Index (ECI) score, and other general and GI-related comorbidities not included in the ECI score. A total of 7,652 patients (n = 3,826 each in the IBS-C and control cohorts) were included in the analysis. The mean (± SD) age was 48 (± 17) years, and 83.6% were female. The mean annual all-cause health care costs for IBS-C patients were $11,182, with over half (53.7%) of the costs attributable to outpatient services, including physician office visits and other outpatient services (13.1% and 40.6%, respectively). Remaining total all-cause costs were attributable to hospitalizations (21.8%), prescriptions (19.1%), and ER visits (5.4%). GI-related costs ($4,456) comprised 39.8% of total all-cause costs, while IBS-C-related costs ($1,335) accounted for 11.9% and were primarily driven by costs of other outpatient services (50.3%). After adjusting for demographics and comorbidities, the incremental annual all-cause health care costs associated with IBS-C were $3,856 ($8,621 for IBS-C patients vs. $4,765 for controls, P less than 0.01) per patient per year, of which 78.1% of the incremental costs were due to medical services, and 21.9% were due to prescription fills. IBS-C imposes a substantial economic burden in terms of direct health care costs in a commercially insured population. Compared with matched controls, IBS-C patients incurred significantly higher total annual all-cause health care costs even after controlling for general and GI-related comorbidities. Incremental all-cause costs associated with IBS-C were mainly driven by costs related to more frequent use of medical services as opposed to prescriptions.

Abstract P3-06-08: Patterns of health care utilization and costs by chemotherapy and endocrine therapy sequencing among patients with hormone receptor positive (HR+)/HER2- negative advanced breast cancer

Abstract Background: Little is known about health care costs and health services utilization of patients with HR+/HER2- advanced breast cancer, particularly in relation to the order in which patient receive endocrine and chemotherapy treatments. Methods: A proprietary database with physician-reported clinical data on patients with breast cancer was linked to medical and pharmacy claims (2008-2012) from a national US health plan. Patients included in the study had HR+ and HER2- status. Advanced cancer included stage III or IV (SIV) at initial diagnosis, or developed metastases following initial diagnosis. The first date of advanced cancer diagnosis or date of metastases following initial diagnosis was designated as the index date. Health plan enrollment for 3 months pre- and ≥12-months post- index date was required; patients who died within 12 months after index date and were continuously enrolled were retained. A 3-month baseline period assessed prior treatment; variable follow-up (until disenrollment or 31 Oct 2012) assessed patterns of endocrine and chemotherapy treatments following index date. All-cause and cancer-specific health care utilization and paid costs were assessed over 12-months following index date. Costs were calculated as per-patient-per-month (PPPM), and utilization measured as rates per patient-month. Cancer-related medication costs included drug costs for endocrine, chemotherapy, targeted therapy, and treatments for pain or chemotherapy-induced nausea/ vomiting. In addition, costs for anti-cancer systemic therapies (chemotherapy, endocrine, and targeted therapy) were calculated PPPM including costs for medication administration. Results: Of 651 study patients, 65% initiated chemotherapy prior to initiating endocrine therapy (CH). Remaining patients (OT) either had no chemotherapy (n = 132 endocrine only, n = 16 neither endocrine nor chemotherapy), or used endocrine therapy prior to chemotherapy (n = 77). Compared with OT, the CH group had more office (4.04 vs. 2.68 visits, P&amp;lt;0.001) and outpatient hospital visits (3.08 vs. 2.10 visits, P&amp;lt;0.001). In addition, 56% of CH vs. 41% of OT had inpatient hospital admissions during the follow-up (P&amp;lt;0.001; rate ratio 0.97, P = NS). Similarly, 60% of CH patients were admitted to emergency rooms vs. 51% of OT (P = 0.033; rate ratio 1.01, P = NS). Mean total all-cause health care costs varied ($11,525 CH vs. $8,196 OT, P&amp;lt;0.001). The largest source of difference in costs were office visits (mean $3,257 CH vs. $1,896 OT, P&amp;lt;0.001), and outpatient hospital ($5,813 CH vs. $3,721 OT, P&amp;lt;0.001). Cancer-related costs comprised the majority of costs (mean $10,249 CH vs. $7,118 OT, P&amp;lt;0.001). The CH group had higher mean cancer-related medication costs than the OT group ($2,051 vs. $1,405 respectively, P = 0.040). Overall mean anti-cancer systemic therapy costs (including administration) were higher in the CH than OT group ($2,934 vs. $1,875, P = 0.012). Conclusions: Among HR+/HER2- advanced breast cancer patients, health care utilization and costs were higher for patients who initiated chemotherapy prior to endocrine therapy compared to other patients. Further investigation of the drivers behind these differences is warranted. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-06-08.

Healthcare expenses associated with multiple vs singleton pregnancies in the United States

The purpose of this study was to document cost that is associated with multiple births vs singleton births in the United States. This was a retrospective cohort study that used a claims database. Women 19-45 years old with live-born infants from 2005-2010 were identified. Infant deliveries were identified by International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes. The cost entailed all payment made by insurers and patients. For mothers, the cost included expenses from 27 weeks before delivery to 1 month after delivery. For infants, the cost contained all expenses until their first birthday. Adjusted cost was estimated by generalized linear models after adjustment for the potential confounding variables with a gamma distribution and a log link. The analysis included 437,924 eligible deliveries. Of them, 97.02% were singletons; 2.85% were twins, and 0.13% was triplets or more. Women with multiple pregnancies had higher systemic and localized comorbidities compared with women with singleton pregnancies (P < .0001). Twins and triplets or more were more likely to have stayed in a neonatal intensive care unit than were singletons (P < .0001). On average, adjusted total all-cause health care cost was $21,458 (95% confidence interval [CI], $21,302-21,614) per delivery with singletons, $104,831 (95% CI, $103,402-106,280) with twins, and $407,199 (95% CI, $384,984-430,695) with triplets or more. Pregnancies with the delivery of twins cost approximately 5 times as much when compared with singleton pregnancies; pregnancies with delivery of triplets or more cost nearly 20 times as much.

The association between use of mealtime insulin pens versus vials and healthcare charges and resource utilization in patients with type 2 diabetes: a retrospective cohort study

Objective:To compare all-cause and diabetes-related resource utilization and healthcare charges among adults with type 2 diabetes mellitus who initiated therapy with mealtime insulin disposable pens or vials.Methods:Data were obtained from the Innovus inVision™ database from January 1, 2006 through June 30, 2010. Generalized linear models with a gamma distribution and log link estimated the association between medical charges and use of mealtime insulin pens vs vials in the 1 year post-index date, while generalized linear models with a negative binomial distribution estimated resource utilization.Results:Controlling for patient characteristics, general health, and patient copayments, insulin therapy initiation with disposable pens, compared to vials, was associated with significantly fewer all-cause hospitalizations (1.45 vs 1.66; p < 0.0001) as well as a significantly shorter hospital length of stay (2.16 days vs 3.53 days; p < 0.0001). Pen use, compared to vials, was also associated with significantly fewer diabetes-related hospitalizations (1.36 vs 1.47; p < 0.0001), and shorter hospital length of stay (1.12 days vs 1.72 days; p < 0.0001). Despite higher diabetes-related drug charges ($3593 vs $2755; p < 0.0001) associated with the use of pens, results showed significantly lower all-cause total healthcare charges ($42,150 vs $53,340; p < 0.0001) and significantly lower diabetes-related total healthcare charges ($12,722 vs $14,540; p < 0.0001) for patients who initiated therapy on mealtime insulin with pens compared to vials.Limitations:Data were drawn from administrative claims and included only patients with medical and outpatient prescription drug benefit coverage. Hence, the results may not be generalizable. The retrospective analyses relied on diagnostic codes to identify patients, assess patient general health, and determine other values, rather than formal, clinical assessments. The analyses did not include indirect healthcare costs.Conclusions:The administration of mealtime insulin via disposable pens, compared to vials, was associated with a significant reduction in all-cause and diabetes-related resource utilization and total healthcare charges.

AB1353 Comorbidity and cost burden of patients prior to use of second line biologic for rheumatoid arthritis

BackgroundPatients with rheumatoid arthritis (RA) often have significant comorbidity which, along with underlying RA severity, may impact both choice and response to treatment. We have previously shown that patients initiating...

Impact of a step-therapy protocol for pregabalin on healthcare utilization and expenditures in a commercial population

Objective:To compare changes in healthcare resource utilization and costs among members with painful diabetic peripheral neuropathy (pDPN), postherpetic neuralgia (PHN), or fibromyalgia (FM) in a commercial health plan implementing pregabalin step-therapy with members in unrestricted plans.Methods:Retrospective study of outcomes associated with implementation of a pregabalin step-therapy protocol using claims data from Humana (‘restricted’ cohort) and Thomson Reuters MarketScan (‘unrestricted’ cohort). Members aged 18–65 years receiving treatment for pDPN, PHN, or FM during 2008 or 2009 were identified; cohorts were matched on diagnosis and geographic region. Baseline to follow-up changes in healthcare resource utilization and costs were determined using difference-in-differences (DID) analysis. Statistical models adjusting for covariates explored relationships between restricted access and outcomes.Results:A total of 3876 restricted cohort members were identified and matched to 3876 unrestricted cohort members. FM was the predominant diagnosis (84.7%). The unrestricted cohort was older (mean = 49.0 (SD = 10.4) years vs 47.6 (SD = 10.5) years; p < 0.001), and had greater comorbidity (RxRisk-V score = 5.4 (SD = 3.2) vs 4.4 (SD = 2.9), p < 0.001) than the restricted cohort. Compared with the unrestricted cohort, the restricted cohort demonstrated a greater year-over-year decrease in pregabalin utilization (−2.6%, p = 0.008), and greater increases in physical therapy and disease-related outpatient utilization (3.7%, p = 0.010 and 3.6%, p = 0.022, respectively). There were no statistically significant net differences in all-cause or disease-related total healthcare, medical, or pharmacy costs between cohorts. After adjusting for baseline compositional differences between cohorts, restricted plan membership was associated with a net increase in all-cause medical ($1222; p = 0.016) and disease-related healthcare costs ($859; p = 0.002). Limitations include use of a combined analysis for pDPN, PHN, and FM, especially since the observed results were likely driven by FM; an inability to link the prescribing of a medication with the condition of interest, which is common to claims analyses; and lack of pain severity information.Conclusions:Implementation of a pregabalin step-therapy protocol resulted in lower pregabalin utilization, but this restriction was not associated with reductions in total healthcare costs, medical costs, or pharmacy costs.

Community-acquired pneumonia episode costs by age and risk in commercially insured US adults aged ≥50 years.

BackgroundCommunity-acquired pneumonia (CAP) causes substantial clinical and economic burden. While several studies have reported the cost to treat CAP, there is little information on the cost to treat by age, risk profile, and hospitalization in US adults aged ≥50 years.ObjectiveTo quantify the cost, from a payer perspective, of treating CAP at the episode level, stratified by age, risk profile, and hospitalization.MethodsA retrospective study of claims data from a large US health plan (1 January 2006–31 December 2008) was conducted. Patients aged ≥50 years having at least one medical claim with a primary diagnosis for pneumonia were identified. A CAP episode was defined as the period between the first and last pneumonia ICD-9 code with a chest X-ray claim. Episode-level variables included risk stratum based on presence of an immunocompromising/chronic condition, age group, number and length of inpatient and outpatient CAP episodes, and all-cause and CAP-related healthcare costs (adjusted to 2011 costs).ResultsAmong the 27,659 study patients, 28,575 CAP episodes (20,454 outpatient; 8,121 inpatient) occurred. Mean age of patients with a CAP episode was 62.6. Low-risk patients accounted for 44.4 % of all CAP episodes. Mean CAP episode length was 31.8 days for an inpatient episode and 10.2 days for an outpatient episode. Mean all-cause total healthcare cost for an inpatient CAP episode ranged from $11,148 to $51,219 depending on risk stratum and age group. Mean outpatient episode-related costs were much lower than inpatient episode-related costs.ConclusionsCost to treat CAP requiring hospitalization is high regardless of age or the presence of underlying comorbidities. Given that almost half of the patients in this study did not have traditional risk factors for CAP, it is clear that better preventative strategies are needed.Electronic supplementary materialThe online version of this article (doi:10.1007/s40258-013-0026-0) contains supplementary material, which is available to authorized users.

Health Care Utilization and Costs Among Patients With AD With and Without Dysphagia

To assess health care utilization and associated costs among patients with Alzheimer disease (AD), with and without dysphagia. MarketScan Commercial and Medicare databases were analyzed. Patients with a diagnosis of AD with and without dysphagia between October 2006 and September 2010 were included. Acetylcholinesterase inhibitor usage, the number of outpatient and emergency room (ER) visits and hospitalizations, and associated health care costs were assessed. All variables were measured 1 year after the initial diagnosis of AD at the patient level. Patients with dysphagia were matched to patients without dysphagia using propensity score-matching (PSM) methods. Regression models were conducted to compare utilization and costs between the 2 groups. A total of 485 patients with dysphagia and 8492 patients without dysphagia were included. Before matching, patients with dysphagia were older (81.1 vs. 79.8 y), and had higher Charlson Comorbidity Index scores (2.4 vs. 1.7). After matching, all baseline covariates were not statistically different between the 2 groups. Multivariate regression results showed that patients with dysphagia had a higher likelihood of all-cause hospitalizations [odds ratio (OR)=2.26, 95% confidence interval (CI)=1.70-2.99, P=0.001] and all-cause ER visits (OR=1.45, 95% CI=1.12-1.87, P=0.007) compared with patients without dysphagia; they also had a higher likelihood for AD-related hospitalizations and ER visits. The difference in all-cause total health care, ER, and hospitalization costs between patients with and without dysphagia were $3620 (95% CI=$2863-$4375), $258 (95% CI=$241-$274), and $3547 (95% CI=$3325-$3770), respectively. This study suggests that patients with AD and dysphagia have higher health care utilization and costs compared with patients without dysphagia.

Economic Burden Associated with Extrapyramidal Symptoms in a Medicaid Population with Schizophrenia

No studies have assessed the economic impact of extrapyramidal symptoms due to atypical antipsychotics in schizophrenia. To assess healthcare resource use and medical costs associated with extrapyramidal symptoms in patients with schizophrenia. A retrospective analysis of Marketscan® Medicaid Multi-State Database (2004–2009) was conducted. Patients with schizophrenia and newly initiated on an AAP were included. Patients with and without extrapyramidal symptoms were matched using propensity-score matching. Healthcare utilization and costs were assessed in the 12-month follow-up period using logistic and two-part (gamma) regression models. Of 4,621 patients, 583 (12.6 %) had extrapyramidal symptoms. Patients with extrapyramidal symptoms had significantly more schizophrenia-related and all-cause hospitalizations and schizophrenia-related emergency room visits, as well as significantly higher schizophrenia-specific and all-cause total healthcare, inpatient, and prescription drug costs compared to patients without extrapyramidal symptoms. Extrapyramidal symptoms in patients with schizophrenia is associated with increased healthcare resource utilization and higher medical costs.

Association between oral 5-ASA adherence and health care utilization and costs among patients with active ulcerative colitis.

BackgroundObservational cohort study to assess the association between adherence to oral 5-aminosalicylates (5-ASAs) and all-cause costs and health care utilization among patients with active ulcerative colitis (UC) in the United States.MethodsRetrospective analysis of insurance claims from June 1997 to August 2006 in the LifeLink Database. Patient criteria: aged 18 or older with one or more claim(s) between June 1997 and August 2005 for a UC diagnosis and at least one oral 5-ASA prescription on or after the first observed UC diagnosis; continuous enrollment for at least 6 months prior to and 12 months following 5-ASA initiation (index date). As a proxy for active disease, patients needed to have at least two UC-specific non-pharmacy claims, at least 30 days of 5-ASA treatment and at least one corticosteroid prescription within the 12-month post-index period. Cumulative exposure to oral 5-ASAs over the 12-month period was calculated using the medication possession ratio (MPR). Patients with an MPR of at least 0.80 were classified as adherent. All-cause medical and pharmacy resource utilization and costs were computed over the 12-month post-index period and compared between adherent and nonadherent patients.Results1,693 UC patients met study inclusion criteria: 72% were nonadherent to 5-ASA treatment (n = 1,217) and 28% were adherent (n = 476) in the 12-month study period. Compared with nonadherent patients, adherent patients had 31% fewer hospitalizations (P = 0.0025) and 34% fewer emergency department admissions (P = 0.0016). Adherent patients had 25% more pharmacy prescriptions overall (P <0.0001) and 71% more UC-related pharmacy prescriptions (P <0.0001) than did nonadherent patients. Total all-cause health care utilization was 1.13 times higher for adherent patients than for nonadherent patients (P = 0.0002). After adjusting for covariates, total all-cause costs were 29% higher for nonadherent patients than for adherent patients (mean [95% confidence interval]: $13,465 [$13,094, $13,835] vs $17,339 [$17,033, $17,645]).ConclusionsApproximately three-quarters of patients with active UC were not adherent with their prescribed doses of oral 5-ASA. Nonadherence was associated with higher total all-cause costs. The key driver of decreased costs among adherent patients was inpatient hospitalizations, which more than offset these patients’ expected higher pharmacy costs.

Costs of pregabalin or gabapentin for painful diabetic peripheral neuropathy

Objective:To characterize and compare healthcare resource utilization and costs among patients with painful diabetic peripheral neuropathy (pDPN) newly prescribed pregabalin or gabapentin in a real-world clinical setting.Study Design:Retrospective cohort analysis using the MarketScan Commercial Claims and Encounters and Medicare Supplemental Databases (2007–2009).Methods:Patients with new prescriptions for pregabalin or gabapentin (index event) in 2008 and ≥1 healthcare encounter with an ICD-9 code for pDPN (250.6 or 357.2) within 30 days prior to the first prescription were identified and propensity score matched; continuous enrollment 12 months pre- and post-index was required. Pre- to post-index changes in 12-month all-cause and pDPN-attributable resource utilization and costs were compared between pregabalin and gabapentin using a difference-in-difference (DID) approach.Results:A total of 910 pregabalin patients (48.6% female; mean age 63.3 ± 12.1 years) were matched with 910 gabapentin patients (48.8% female; mean age 63.3 ± 12.1 years). The DID showed no significant differences between cohorts for pre- to post-index changes in any of the all-cause resource utilization categories. While prescription costs increased significantly more with pregabalin (DID −$563; p < 0.0001), the DID of $1603 for total healthcare costs per patient indicated that the pre- to post-index increases of $3081 for pregabalin and $4684 for gabapentin patients were comparable (p = 0.8474). Total pDPN-attributable healthcare costs were significantly higher with pregabalin (DID −$385; p < 0.0001), resulting from higher prescription costs (DID −$432; p < 0.0001). Limitations of this study include the inability to specifically link pDPN with medication prescribing; differences between groups despite propensity score matching; use of proxy measures for adherence parameters; and inability to capture efficacy outcomes.Conclusions:Among patients initiating pregabalin or gabapentin, there were no significant differences between the drugs in the pre- to post-index changes in all-cause total healthcare costs, despite the increase in prescription costs for pregabalin.

Abstract P55: Comparison of Real World Adherence, Healthcare Resource Utilization, and Cost for Valsartan/Amlodipine Single Pill Combination versus Angiotensin-Receptor Blocker/Calcium-Channel Blocker Free Combination Therapy

Objective: To evaluate adherence, healthcare resource utilization and cost outcomes of valsartan/amlodipine single pill combination (SPC) versus angiotensin-receptor blocker (ARB)/calcium-channel blocker (CCB) free combination (FC) therapy in hypertensive patients. Methods: A retrospective database study was conducted using a large US commercial insurance claims database for the period 01/01/2007-04/30/2008. Two cohorts of patients receiving valsartan/amlodipine SPC or ARB/CCB FC were identified. All patients were ≥18 years old with at least 1 medical claim for hypertension (ICD 9 401.x-404.x) with ≥6 months pre- and ≥12 months post-index follow up and ≥2 filled prescriptions with days supply ≥90 days for the index therapy over follow up. Primary outcomes were proportion of days covered, days to discontinuation (defined as a gap in therapy of 30 days), and all-cause healthcare cost and utilization. Multivariate regression analysis was conducted to control for baseline characteristics, including age, gender, region, comorbidities, pill burden, and resource utilization and cost. Results: A total of 3259 (13.1%) of patients were included in the valsartan/amlodipine SPC cohort and 21,597 (86.9%) in the ARB/CCB FC cohort. At baseline, patients taking SPC were more likely to be male, older, and reside in the Southern US. After adjusting for baseline differences through risk-adjusted logistic regression, adherence rates for patients taking SPC therapy were significantly higher compared to patients taking FC therapy (OR 1.38, 95% CI 1.27-1.51). Patients taking SPC therapy were also significantly less likely to discontinue their index therapy (HR 0.87, p&lt;0.001). Total all-cause health care costs were 11% greater for patients in the FC cohort compared to patients taking SPC therapy (p&lt;0.001). In addition, patients in the SPC cohort were less likely to have ER visits and hospitalizations during the follow up period. Conclusion: Use of valsartan/amlodipine single pill combination therapy in hypertensive patients was associated with significantly better adherence and lower cost and healthcare resource utilization compared to ARB/CCB free combination therapy.

Analysis of the comparative effectiveness of 3 oral bisphosphonates in a large managed care organization: adherence, fracture rates, and all-cause cost.

Despite widespread availability and use of oral bisphosphonates, fracture rates and associated medical costs are still high. Differences in fracture risk among these agents, if any, have not been quantified due to the lack of high-quality, head-to-head, randomized, controlled trials assessing this outcome. Randomized, placebo-controlled trials have shown that alendronate and risedronate reduce rates of both vertebral and nonvertebral fractures, whereas only reduction in vertebral fractures has been found for ibandronate. To determine if there were any differences among 3 oral bisphosphonates in adherence, total cost of care, and effectiveness in reducing fracture rates in a large managed care population. Administrative, longitudinal pharmacy and medical claims data were obtained from 14 geographically diverse health plans in the United States covering approximately 14 million members. Sampled members had at least 1 pharmacy claim for alendronate, risedronate, or ibandronate during the intake period (January 1, 2005, through October 31, 2007). The date of the first pharmacy claim for osteoporosis medications within the intake period was the index date. Members were followed for either 12, 24, or 36 months, depending on length of continuous health plan eligibility. Medication possession ratio (MPR) was measured using a total days supply that was calculated by multiplying the total quantity dispensed by the suggested days supply per unit of dispensing based on manufacturer-recommended dosing. For members who switched bisphosphonate strengths or medications, the estimated days supply was summed for all osteoporosis medications during the follow-up, including overlapping days supply. Outcomes included (a) the first incident fracture and percentages of members with at least 1 fracture after 6 months post-index; (b) the number of days from index to the first incident fracture, measured as time to event in Cox proportional hazards regression analysis; and (c) total all-cause health care costs (health plan allowed amount including member cost share). A total of 45,939 members were included (n = 24,909 alendronate, n = 13,834 risedronate, n = 7,196 ibandronate). In the 12-month analysis, MPRs were comparable (means = 0.57-0.58) for the 3 medications. After 24 months, MPRs had dropped for all medications, but those of both alendronate (mean = 0.50, 95% CI = 0.49-0.50) and risedronate (mean = 0.50, 95% CI = 0.49-0.51) were slightly higher than that of ibandronate (mean = 0.47, 95% CI = 0.46-0.48). At 36 months, again the MPRs had dropped for all 3 medications (means = 0.44-0.47) but were similar. There were no statistically significant differences among agents in the percentages of subjects with at least 1 fracture at 12, 24, or 36 months (36-month rates: alendronate 4.41%, risedronate 4.38%, ibandronate 6.28%, P = 0.102). The numbers of subjects with fracture(s) per month of follow-up were 0.0020 for alendronate, 0.0021 for risedronate, and 0.0022 for ibandronate (P = 0.087 overall). However, after adjusting for member characteristics, alendronate users had a 12% lower risk of experiencing any incident fracture than ibandronate users (hazard ratio = 0.88, 95% CI = 0.78-0.99, P = 0.034) within the follow-up period. In the first 12 post-index months, ibandronate users had higher mean [SD] unadjusted total all-cause health care costs ($7,464 [$15,975]) compared with alendronate ($7,233 [$16,671]) and risedronate ($ 6,983 [$16,870], P less than 0.001 for both comparisons), differences of approximately $19 per month and $40 per month, respectively. The results of the unadjusted 24-month analysis were similar, but there were no significant cost differences at 36 months. Total cost differences for the 3 medication groups were nonsignificant at 12, 24, and 36 months after adjusting for member characteristics. This retrospective analysis of an administrative claims database in a large managed care population showed similar rates of adherence and total adjusted all-cause health care costs for alendronate, risedronate, and ibandronate. Absolute unadjusted rates of fracture were small and did not significantly differ among agents, but after controlling for differences in member characteristics, the risk of fracture was 12% lower for alendronate users than for ibandronate users.

Health Care Costs in Patients with Fibromyalgia on Pregabalin vs. Duloxetine

The economic burden associated with fibromyalgia in the U.S. is substantial. The objective of this study was to compare changes in health care costs in fibromyalgia patients initiated on pregabalin and duloxetine in real-world settings. Patients (≥ 18 years old) initiating pregabalin or duloxetine between June 1, 2007 and December 31, 2008 were identified using a U.S. managed care database. Patients were selected if they had ≥ 2 medical claims for fibromyalgia (ICD-9-CM, 729.1) at least 90 days apart or ≥ 1 claim for fibromyalgia followed within 30 days by a pharmacy claim for pregabalin. The date of the first pregabalin or duloxetine prescription was defined as the index date, and continuous enrollment for 6-month pre- and postindex periods was required. A total of 1,616 pregabalin and 207 duloxetine patients were identified. Treatment differences between pregabalin and duloxetine in the pre-/postindex change in mean [SD] all-cause total health care costs ($1,307 [16,747] vs. -$158 [17,337]; P = 0.24) or fibromyalgia-related total health care costs ($584 [3,834] vs. $759 [2,133]; P = 0.32) were not significant. Multivariate analysis using difference-in-differences models showed no significant difference in all-cause costs (mean cost ratio = 1.05, 95% CI: 0.84 to 1.31) or fibromyalgia-related costs (0.85, 95% CI: 0.61 to 1.18) between treatments during the postindex period. No significant differences were found between pregabalin and duloxetine in the pre- to postindex change in mean all-cause or fibromyalgia-related total health care costs.