Association of teriparatide adherence and persistence with clinical and economic outcomes in Medicare Part D recipients: a retrospective cohort study.

BACKGROUND: Improper medication adherence is associated with increased morbidity, healthcare costs, and fracture risk among patients with osteoporosis. The objective of this study was to evaluate the healthcare utilization patterns of Medicare Part D beneficiaries newly initiating teriparatide, and to assess the association of medication adherence and persistence with bone fracture. METHODS: This retrospective cohort study assessed medical and pharmacy claims of 761 Medicare members initiating teriparatide in 2008 and 2009. Baseline characteristics, healthcare use, and healthcare costs 12 and 24 months after teriparatide initiation, were summarized. Adherence, measured by Proportion of Days Covered (PDC), was categorized as high (PDC ≥ 80%), moderate (50% ≥ PDC < 80%), and low (PDC < 50%). Non-persistence was measured as refill gaps in subsequent claims longer than 60 days plus the days of supply from the previous claim. Multivariate logistic regression evaluated the association of adherence and persistence with fracture rates at 12 months. RESULTS: Within 12 months of teriparatide initiation, 21% of the cohort was highly-adherent. Low-adherent or non-persistent patients visited the ER more frequently than did their highly-adherent or persistent counterparts (χ2 = 5.01, p < 0.05 and χ2 = 5.84, p < 0.05), and had significantly lower mean pharmacy costs ($4,361 versus $13,472 and $4,757 versus $13,187, p < 0.0001). Furthermore, non-persistent patients had significantly lower total healthcare costs. The healthcare costs of highly-adherent patients were largely pharmacy-related. Similar patterns were observed in the 222 patients who had fractures at 12 months, among whom 89% of fracture-related costs were pharmacy-related. The regression models demonstrated no significant association of adherence or persistence with 12-month fractures. Six months before initiating teriparatide, 50.7% of the cohort had experienced at least 1 fracture episode. At 12 months, these patients were nearly 3 times more likely to have a fracture (OR = 2.9, 95% C.I. 2.1-4.1 p < 0.0001). CONCLUSIONS: Adherence to teriparatide therapy was suboptimal. Increased pharmacy costs seemed to drive greater costs among highly-adherent patients, whereas lower adherence correlated to greater ER utilization but not to greater costs. Having a fracture in the 6 months before teriparatide initiation increased fracture risk at follow-up.

Perceived barriers to medical-error reporting: an exploratory investigation.

Medical-error reporting is an essential component for patient safety enhancement. Unfortunately, medical errors are largely underreported across healthcare institutions. This problem can be attributed to different factors and barriers present at organizational and individual levels that ultimately prevent individuals from generating the report. This study explored the factors that affect medical-error reporting among physicians and nurses at a large academic medical center located in the midwest United States. A nominal group session was conducted to identify the most relevant factors that act as barriers for error reporting. These factors were then used to design a questionnaire that explored the likelihood of the factors to act as barriers and their likelihood to be modified. Using these two parameters, the results were analyzed and combined into a Factor Relevance Matrix. The matrix identifies the factors for which immediate actions should be undertaken to improve medical-error reporting (immediate action factors). It also identifies factors that require long-term strategies (long-term strategy factors) as well as factors that the organization should be aware of but that are of lower priority (awareness factors). The strategies outlined in this study may assist healthcare organizations in improving medical-error reporting, as part of the efforts toward patient-safety enhancement. Although factors affecting medical-error reporting may vary between different organizations, the process used in identifying the factors and the Factor Relevance Matrix developed in this study are easily adaptable to any organizational setting.

Persistence with biologic therapies in the Medicare coverage gap.

OBJECTIVES: To describe persistence with teriparatide and other biologic therapies in Medicare Part D plans with and without a coverage gap. STUDY DESIGN: Retrospective (2006) cohort study of Medicare Part D prescription drug plan beneficiaries from a large benefits company. Two plans with a coverage gap (defined as "basic") were combined and compared with a single plan with coverage for generic and branded medications (defined as "complete"). METHODS: Patients taking alendronate (nonbiologic comparator), teriparatide, etanercept, adalimumab, interferon ß-1a, or glatiramer acetate were selected for the study. For patients with complete coverage, equivalent financial thresholds were used to define the "gap."The definition of discontinuation was failure to fill the index prescription after reaching the gap. RESULTS: For alendronate, 27% of 133,260 patients had enrolled in the complete plan. Patients taking biologic therapies had more commonly enrolled in complete plans: teriparatide (66% of 6221), etanercept (58% of 1469), adalimumab (52% of 824), interferon ß-1a (60% of 438), and glatiramer acetate (53% of 393). For patients taking either alendronate or teriparatide, discontinuation rates were higher in the basic, versus complete, plan (adjusted odds ratios, 2.02 and 3.56, respectively). Discontinuation did not significantly vary by plan type for etanercept, adalimumab, interferon ß-1a, or glatiramer acetate. CONCLUSIONS: For patients who reached the coverage gap, discontinuation was more likely for patients taking osteoporosis (OP) medication. Not having a coverage gap was associated with improved persistence with OP treatment.

Financial and clinical characteristics of fibromyalgia: a case-control comparison.

OBJECTIVE: To compare healthcare utilization and costs between subjects with and without fibromyalgia (FM) using claims data from a large health benefits company in the United States. STUDY DESIGN: Retrospective cohort. METHODS: We analyzed 24 months of medical and pharmacy claims data comparing healthcare utilization and costs among Humana members diagnosed with FM to a propensity score matched control group without a diagnosis for FM. FM cases were identified as members aged 18 years and older, with at least 2 medical claims for International Classification of Diseases, Ninth Revision, Clinical Modification codes 729.0 and/or 729.1. The first medical claim for FM was utilized as the index date. RESULTS: A total of 9988 FM cases and 9988 controls were included in the analysis. Compared with controls, the use of pain-related medications by FM cases was approximately 2 times higher with opioids being used most commonly. FM cases utilized a mean (SD) of 22.5 (23.9) and 31.1 (26.6) outpatient services per year in the prediagnosis and postdiagnosis periods, respectively, compared with 14.8 (20.5) and 16.3 (24.5) among controls (P <.01). Office visits, tests, and procedures represented the majority of utilization. During the postdiagnosis period, the mean per-patient per-month costs for outpatient services among FM cases was $377 ($760) and $217 ($740.87) among controls (P <.01). CONCLUSION: FM cases had significantly higher utilization and costs compared with controls. Office visits, tests and procedures, and the use of pain-related medications accounted for the largest absolute differences between the 2 groups.

Identifying HIV risk-reduction strategies for Hispanic populations in Broward County.

PURPOSE: To improve the effectiveness of behavioral interventions for Hispanic young adults, we studied their perceived risks for HIV infection, lifetime and more recent sexual experiences, use of condoms, and HIV-antibody testing histories. METHODS: Logistic regression was used to analyze computer-assisted telephone-interview surveys of 1,596 randomly selected Hispanic residents of 12 high AIDS-incidence ZIP-code areas. RESULTS: After we controlled for gender, age, marital status, educational attainment, and language of preference, differences were found by country of origin. Those coming from Peru (adjusted odds ratio [AOR]=3.45; 95%CI=1.85-6.43) and Colombia (AOR=1.94; 95%CI=1.12-3.36) were more likely than U.S.-native Hispanics to perceive their risk of acquiring HIV as above average. Sexually active Mexicans (AOR=1.80; 95%CI=1.04-3.10) were significantly more likely than U.S. natives to have used a condom in the past 12 months. Young adults coming from Puerto Rico (AOR=0.55; 95%CI=0.33-0.91) were less likely than U.S.-native Hispanics to have ever been tested for HIV. Virginity and sexual abstinence were unrelated to country of origin, but respondents interviewed in Spanish were more likely than those interviewed in English to be sexually active (AOR=2.57; 95%=1.39-4.75). CONCLUSIONS: To maximize the impact of behavioral interventions, risk-reduction programs must adjust for social and cultural differences within the Hispanic-American population.