Breast-feeding and cognitive development: a meta-analysis

Although the results of many clinical studies suggest that breast-fed children score higher on tests of cognitive function than do formula-fed children, some investigators have suggested that these differences are related to confounding covariables such as socioeconomic status or maternal education...

Real-world practice patterns, health-care utilization, and costs in patients with low back pain: the long road to guideline-concordant care.

BACKGROUND CONTEXT: Treatment guidelines suggest that most acute low back pain (LBP) episodes substantially improve within a few weeks and that immediate use of imaging and aggressive therapies should be avoided. PURPOSE: Assess the actual practice patterns of imaging, noninvasive therapy, medication use, and surgery in patients with LBP, and compare their costs to those of matched controls without LBP. STUDY DESIGN: A retrospective analysis of claims data from 40 self-insured employers in the United States. PATIENT SAMPLE: The study sample included 211,551 patients, aged 18 to 64 years, with one LBP diagnosis or more (per Healthcare Effectiveness Data and Information Set specification) during 2004 to 2006, identified from a claims database. Patients had continuous eligibility for 12 months or more after their index LBP diagnosis (study period), for 6 months or more before their index diagnosis (baseline period), and no other LBP diagnosis during the baseline period. Patients with LBP were matched to a random cohort of patients without LBP by age, gender, employment status, and index year. OUTCOMES MEASURES: Physiological measures (eg, imaging and diagnostic tests), functional measures (eg, pharmacologic and nonpharmacologic treatment for LBP, health-care resource use), and direct (medical and prescription drug) and indirect (disability and medically related absenteeism) costs were assessed within the year after the LBP diagnosis. METHODS: Univariate analyses described treatment patterns and compared baseline characteristics and study period costs. RESULTS: Patients with LBP had significantly higher rates of baseline comorbidities and resource use compared with controls. Of patients with LBP, 41.6% had imaging mean (median) [standard deviation] 34.3 (0) [78.6] days after the LBP diagnosis. Most patients with LBP (69.4%) used medications starting 51.9 (8) [86.2] days after the diagnosis. Opioids were commonly prescribed early (41.6% of patients; after 82.8 (25) [105.9] days). Of patients with LBP, 2.05% had surgery during the study period. Patients with LBP were likely to have chiropractic treatment first, followed by pharmacotherapy with muscle relaxants and nonsteroidal anti-inflammatory drugs. Except for less surgery, these findings also held for patients with only nonspecific LBP. Patients with LBP had higher mean direct costs compared with controls ($7,211 vs. $2,382, respectively; p<.0001), with surgery patients having mean direct costs of $33,931. CONCLUSIONS: Contrary to clinical guidelines, many patients with LBP start incurring significant resource use and associated expenses soon after the index diagnosis. Achieving guideline-concordant care will require substantial changes in LBP practice patterns.

Antipsychotic medication use patterns and associated costs of care for individuals with schizophrenia.

BACKGROUND: Schizophrenia is a costly and complicated disorder to treat. A variety of schizophrenia treatment guidelines have been developed to provide valuable expert advice to practicing psychiatrists on various treatment options that are presumed to result in the best outcomes. However, examination of antipsychotic medication use patterns has suggested that current prescribing practices do not mirror recommended treatment guidelines and may have adverse economic consequences. AIM OF THE STUDY: This study seeks to describe antipsychotic medication treatment patterns and estimate the total costs of care associated with treatment patterns for individuals diagnosed with schizophrenia in usual care settings. METHODS: Use of outpatient antipsychotic medications and other health services during 1997 was obtained for 2,082 individuals with a diagnosis of schizophrenia in the IMS Health LifeLink employer claims database. We describe outpatient antipsychotic treatment patterns, estimated the costs of schizophrenia care by treatment pattern, and compared costs by treatment pattern using regression models. RESULTS: During 1997, 26% (n=536) of individuals diagnosed with schizophrenia received no antipsychotic medication in the outpatient setting, while 52% (n=1,088) were treated with only one antipsychotic (Monotherapy). For individuals who received more than one antipsychotic medication during 1997 (n=458), 13% (n=262) switched antipsychotic medications (Switch), 7% (n=154) augmented their original antipsychotic therapy with an additional antipsychotic (Augment), and 2% (n=42) of individuals were on more than one antipsychotic therapy at the start of the year. After adjusting for covariates, Switch and Augment patterns were associated with significant increases in total costs (an increase of 4,706 dollars (p<0.0001) and 4,244 dollars (p=0.0002), respectively) relative to Monotherapy. DISCUSSION: These results indicate that a substantial proportion of individuals with a diagnosis of schizophrenia were not treated with or had low exposure to antipsychotic therapy. Individuals treated with antipsychotic monotherapy experienced nearly half the annual costs as individuals who were treated with antipsychotic polytherapy or who switched antipsychotic medications. These observations should be interpreted in the context of the study limitations. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: This analysis indicates that there may be considerable room for improvement in the treatment for individuals diagnosed with schizophrenia. IMPLICATIONS FOR HEALTH POLICIES: Though schizophrenia affects a very small portion of the population, the individual and societal burden associated with the disorder is quite high. This paper suggests that antipsychotic monotherapy and continuous therapy, commonly recommended by published treatment guidelines, may be associated with economic savings. IMPLICATIONS FOR FURTHER RESEARCH: Future research should evaluate the impact of newer antipsychotic medications on patterns of care and economic outcomes. More information is also needed on which individual patient characteristics are likely to predict success or failure on specific treatments. Finally, more detailed information on the reasons or rationale for switching or augmenting original pharmacotherapy would be valuable in improving medication management in these complex and often difficult to treat patients.

The Schizophrenia Care and Assessment Program Health Questionnaire (SCAP-HQ): an instrument to assess outcomes of schizophrenia care.

Advances in treatment technologies and development of evidence-based standards of care demand better methods for routine assessment of outcomes for schizophrenia in systems of care. This article describes the development and psychometrics of a new instrument to assess outcomes of routine care for persons with schizophrenia in service systems. Candidate items for the Schizophrenia Care and Assessment Program Health Questionnaire (SCAP-HQ) were drawn from existing measures. Domains covered include disease outcomes (symptoms, subjective medication effects, substance abuse), functional status, health status, quality of life, and public safety. A sample of 1,584 patients with schizophrenia or schizoaffective disorder who were recruited into a large prospective, naturalistic study on the course of treatment for schizophrenia completed the SCAP-HQ at baseline and 1 year later (n = 434), providing data for factor analysis, assessment of internal consistency, convergent validity, and responsiveness to change. A subsample of 121 patients completed a test-retest protocol. Fifteen scales were derived by factor analysis from 55 outcome items on the SCAP-HQ. These factors covered psychiatric symptoms, life satisfaction, instrumental activities of daily living, health-related disability, subjective medication side effects, vitality, legal problems, social relations, mental health-related disability, suicidality, drug and alcohol use, daily activities, victimization, violence, and employment. For most scales, standard psychometric parameters, including internal consistency and test-retest reliability, convergent validity, and responsiveness to change, were acceptable for application to large sample evaluations of care systems. This new measure represents an advance in the development of outcome measures for schizophrenia for use in large-scale studies of routine care.