Diagnosis of behavioral symptoms as a predictor of institutionalization among Medicaid patients with dementia.

OBJECTIVES: Behavioral symptoms are commonly observed in the course of dementia. This study aimed to assess the association of the diagnosis of a cluster of behavioral symptoms (e.g., agitation, aggression, psychotic symptoms, and delirium/wandering) with the likelihood of subsequent institutionalization. METHODS: A retrospective cohort study of adults aged 65 and above diagnosed with dementia identified in the IBM® MarketScan® Multistate Medicaid database between October 01, 2015, and September 30, 2019, was conducted. The index date was defined as the first diagnosis date of dementia. The presence or absence of behavioral symptoms was identified in the 6 months prior to the index date (baseline). Institutionalization was evaluated 12 months (follow-up) post the index date. The association between diagnosed behavioral symptoms during the baseline period and institutionalization in the follow-up period was assessed using a multivariable logistic regression, adjusting for baseline sociodemographic and clinical characteristics. RESULTS: The study cohort included 40,714 patients with dementia. A diagnosis of behavioral symptoms was found among 2,067 (5.1%) patients during the baseline period. An increased likelihood of institutionalization was found during the follow-up among patients with agitation and aggression in baseline (OR = 1.51 (95% CI: 1.18-1.92)) compared to patients without these symptoms at baseline. Patients with psychotic symptoms in baseline had significantly higher odds of getting institutionalized during the follow-up compared to patients without psychotic symptoms in baseline (OR = 1.36 (95% CI: 1.20-1.54)). Similarly, patients with symptoms of delirium and wandering in baseline had a higher likelihood of institutionalization than patients without these symptoms at baseline (OR = 1.61 (95% CI: 1.30-1.99)). CONCLUSION: Several diagnosed behavioral symptoms were associated with a higher risk of institutionalization among older adults with dementia and should be considered when planning treatment strategies for the effective management of the condition.

Prevalence and impact of antipsychotic discontinuation among commercially-insured patients with bipolar disorder.

BACKGROUND: Antipsychotic discontinuation is common among patients with bipolar disorder, especially when psychotic symptoms are remitted. This analysis describes the prevalence, predictors, and economic impact of antipsychotic discontinuation among patients with bipolar disorder. METHODS: A retrospective, observational study was conducted using administrative claims data in the IBM MarketScan Commercial Database. Patients with ≥1 claim with a diagnosis for bipolar disorder (manic or mixed) and newly-initiating antipsychotic therapy between 1 January 2011 and 30 June 2016 were included. Baseline characteristics were assessed in the 12 months prior to the initiation. Outcomes were assessed during a 24-month follow-up. Discontinuation of antipsychotic therapy was utilized as a predictor of healthcare costs in models adjusted for baseline characteristics. Using limited set of variables in the claims database, predictors of discontinuation were also assessed. RESULTS: A total of 18,259 commercially-insured patients were identified as initiators of antipsychotics. Common comorbidities among the cohorts included major depressive disorder and dyslipidemia. Discontinuation was very common among these patients (85%). Major depressive disorder, drug abuse, and other substance abuse/dependency were predictive of discontinuation. Controlling for differences in baseline characteristics, discontinuation was associated with 33% higher inpatient and emergency visit costs (p <.001) among those using these services, and 24% higher total healthcare costs (p <.001) for the overall cohort. CONCLUSIONS: Most patients with bipolar mania or mixed states discontinue antipsychotic treatment in less than 2 years. Antipsychotic discontinuation contributes to excess healthcare costs. Future research focusing on the reasons for discontinuation and tailoring disease management based on comorbidities may inform adherence improvement initiatives.

Development and Temporal Validation of an Electronic Medical Record-Based Insomnia Prediction Model Using Data from a Statewide Health Information Exchange.

This study aimed to develop and temporally validate an electronic medical record (EMR)-based insomnia prediction model. In this nested case-control study, we analyzed EMR data from 2011-2018 obtained from a statewide health information exchange. The study sample included 19,843 insomnia cases and 19,843 controls matched by age, sex, and race. Models using different ML techniques were trained to predict insomnia using demographics, diagnosis, and medication order data from two surveillance periods: -1 to -365 days and -180 to -365 days before the first documentation of insomnia. Separate models were also trained with patient data from three time periods (2011-2013, 2011-2015, and 2011-2017). After selecting the best model, predictive performance was evaluated on holdout patients as well as patients from subsequent years to assess the temporal validity of the models. An extreme gradient boosting (XGBoost) model outperformed all other classifiers. XGboost models trained on 2011-2017 data from -1 to -365 and -180 to -365 days before index had AUCs of 0.80 (SD 0.005) and 0.70 (SD 0.006), respectively, on the holdout set. On patients with data from subsequent years, a drop of at most 4% in AUC is observed for all models, even when there is a five-year difference between the collection period of the training and the temporal validation data. The proposed EMR-based prediction models can be used to identify insomnia up to six months before clinical detection. These models may provide an inexpensive, scalable, and longitudinally viable method to screen for individuals at high risk of insomnia.

Association of Antipsychotic-Related Weight Gain With Treatment Adherence and Switching Using Electronic Medical Records Data.

Objective: To leverage electronic health record (EHR) data to explore the relationship between weight gain and antipsychotic adherence among patients with schizophrenia and bipolar disorder (BD).Methods: EHR data were used to identify individuals with at least 60 days of continuous antipsychotic use between 2005 and 2019. Patients were diagnosed with schizophrenia, schizoaffective disorder, BD, or neither diagnosis (psychiatric controls). We examined the association of weight gain in the first 90 days with the proportion of days covered (PDC) with an antipsychotic and with the frequency of medication switching or stopping.Results: We identified 590 adults with schizophrenia or schizoaffective disorder, 819 adults with BD, and 642 psychiatric controls. In the first 90 days, the percentages of patients with a PDC ≥ 0.80 were 76.8% (schizophrenia), 77.1% (BD), and 70.7% (controls). Logistic regression models revealed that weight gain of ≥ 7% trended toward being significantly associated with greater adherence in the first 90 days (odds ratio = 1.29, P = .077) and was significantly associated with an increased likelihood of a medication switch in the first 180 days (odds ratio = 1.60, P = .003).Discussion: Patients whose weight increased by 7% or more in the first 90 days were more adherent but were also more likely to switch medications during the first 180 days.

Economic outcomes associated with diagnosed behavioral symptoms among patients with dementia in the United States: a health care claims database analysis.

BACKGROUND: Behavioral symptoms are common in patients with dementia. However, there is limited evidence of their economic burden. Among commercially insured patients with dementia in the United States, this study assessed the prevalence of diagnosed behavioral symptoms and whether healthcare resources utilization and costs were associated with these symptoms. METHODS: This retrospective observational study was conducted using the IBM® MarketScan® Commercial Claims and Encounters and Medicare Supplemental database from October 1, 2015, to September 30, 2019. Diagnoses of dementia and behavioral symptoms were identified using the International Classification of Diseases, 10th Modification codes. To test differences in patient characteristics among those with and without diagnosed behavioral symptoms, t-tests were used for continuous variables, and chi-square tests were used for categories. Generalized linear models were used to compare healthcare resource utilization and costs between patients with and without diagnosed behavioral symptoms, adjusted for baseline characteristics. RESULTS: Of the 62,901 patients with dementia included in the analysis, 16.5% had diagnosed behavioral symptoms 12 months post dementia diagnosis. Patients with diagnosed behavioral symptoms used more health care resources (mean annual pharmacy visits per patient: 39.83 vs. 33.08, mean annual outpatient visits per patient: 24.20 vs. 16.94, mean annual inpatient visits per patient: 0.98 vs. 0.47, mean annual ER visits per patient: 2.45 vs. 1.21) and incurred higher cost of care than those without diagnosed behavioral symptoms (mean annual total health care costs per patients: $63,268 versus $33,383). Inpatient care was the most significant contributor to total costs (adjusted annual mean cost per patient: $28,195 versus $12,275). CONCLUSION: Behavioral symptoms were significantly associated with higher healthcare resource utilization and costs among patients with dementia. Further research is warranted to address the unmet medical needs of this patient population.

Modeling acute care utilization: practical implications for insomnia patients.

Machine learning models can help improve health care services. However, they need to be practical to gain wide-adoption. In this study, we investigate the practical utility of different data modalities and cohort segmentation strategies when designing models for emergency department (ED) and inpatient hospital (IH) visits. The data modalities include socio-demographics, diagnosis and medications. Segmentation compares a cohort of insomnia patients to a cohort of general non-insomnia patients under varying age and disease severity criteria. Transfer testing between the two cohorts is introduced to demonstrate that an insomnia-specific model is not necessary when predicting future ED visits, but may have merit when predicting IH visits especially for patients with an insomnia diagnosis. The results also indicate that using both diagnosis and medications as a source of data does not generally improve model performance and may increase its overhead. Based on these findings, the proposed evaluation methodologies are recommended to ascertain the utility of disease-specific models in addition to the traditional intra-cohort testing.

The impact of antipsychotic adherence on acute care utilization.

BACKGROUND: Non-adherence to psychotropic medications is common in schizophrenia and bipolar disorders (BDs) leading to adverse outcomes. We examined patterns of antipsychotic use in schizophrenia and BD and their impact on subsequent acute care utilization. METHODS: We used electronic health record (EHR) data of 577 individuals with schizophrenia, 795 with BD, and 618 using antipsychotics without a diagnosis of either illness at two large health systems. We structured three antipsychotics exposure variables: the proportion of days covered (PDC) to measure adherence; medication switch as a new antipsychotic prescription that was different than the initial antipsychotic; and medication stoppage as the lack of an antipsychotic order or fill data in the EHR after the date when the previous supply would have been depleted. Outcome measures included the frequency of inpatient and emergency department (ED) visits up to 12 months after treatment initiation. RESULTS: Approximately half of the study population were adherent to their antipsychotic medication (a PDC ≥ 0.80): 53.6% of those with schizophrenia, 52.4% of those with BD, and 50.3% of those without either diagnosis. Among schizophrenia patients, 22.5% switched medications and 15.1% stopped therapy. Switching and stopping occurred in 15.8% and 15.1% of BD patients and 7.4% and 20.1% of those without either diagnosis, respectively. Across the three cohorts, non-adherence, switching, and stopping therapy were all associated with increased acute care utilization, even after adjusting for baseline demographics, health insurance, past acute care utilization, and comorbidity. CONCLUSION: Non-continuous antipsychotic use is common and associated with high acute care utilization.

Atypical Treatment Switches in Schizophrenia Patients: Drivers and Associated Outcomes.

Objective: To describe and compare demographics and outcomes among patients with schizophrenia who have switched atypical treatments versus non-switchers. Methods: Data were extracted from the Adelphi Schizophrenia Disease Specific Programme™ conducted from January to May 2014 in the United States. Participating physicians provided information on their next 10 consulting schizophrenia patients aged ≥ 18 years; the same patients were invited to voluntarily complete a patient self-completion form (PSC). Patients were considered switchers (S) or non-switchers (NS) based on their physician-provided treatment history. S were patients who had switched, stopped or added an atypical treatment within the last 2 years. NS had no treatment changes within the last 2 years or were receiving their first-line treatment (for ≥ 3 months). Demographics, clinical characteristics and outcomes among S and NS were compared using both descriptive and multivariate statistics. Results: One-hundred fifty physicians provided data on 1003 patients with schizophrenia (395 S, 608 NS); 500 patients completed a PSC (170 S, 330 NS). When compared with NS, S were more likely to be unemployed (p=0.0060), have a caregiver (p<0.0001), have greater activity impairment as assessed by Work and Productivity Activity Impairment (p=0.0031), be hospitalized for schizophrenia (p<0.0001) and have had a greater mean number of hospitalizations in the last 12 months (p=0.0012). NS vs S were more likely to have much or very much improved illness (p<0.0001) and less severe disease (p<0.0001) as assessed by Clinical Global Impression. Conclusion: Despite switching drugs, some schizophrenia patients continue to have high levels of disease burden, suggesting that currently available therapies are insufficiently effective in these patients.

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

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

Burden of Insomnia and Sleep Disturbances and the Impact of Sleep Treatments in Patients with Probable or Possible Alzheimer's Disease: A Structured Literature Review.

BACKGROUND: Sleep disturbances are frequent in Alzheimer's disease (AD). OBJECTIVE: To summarize the impact of sleep disturbances on AD patients and their caregivers and the effects of currently available sleep therapies. METHODS: Published studies (January 1985-March 2020) assessing the burden associated with insomnia/sleep disturbances in the AD population and insomnia treatment effects were identified by searching PubMed, Embase, and Cochrane Library and screened against inclusion criteria. RESULTS: 58 studies assessing patient and caregiver burden, institutionalization, and insomnia treatments in AD patients with sleep disturbances were identified. Sleep disturbances were associated with worse cognition, functional ability, and behavioral and neuropsychological functioning. Health status and quality of life of both patients and caregivers were reduced in the presence of sleep disturbances. Sleep disturbances were also associated with institutionalization. Although significant associations between sleep problems and clinical outcomes were apparent, there was generally no control for other influencing factors (e.g., cognitive status). Bright light and behavioral therapies as well as drugs showed some promise in AD patients, but studies were primarily small and limited data were available, particularly in regard to the effect on associated clinical burden. CONCLUSION: Sleep disturbances are a significant problem for AD patients and caregivers, associated with behavioral and psychological problems and cognitive decline. However, they remain poorly characterized and under-researched. As the global population is aging and AD is on thes rise, data from larger, prospective trials are required to fully understand the clinical correlates of sleep disturbances and the impact insomnia treatments can have.

Quality of Life and Caregiver Burden of Alzheimer's Disease Among Community Dwelling Patients in Europe: Variation by Disease Severity and Progression.

BACKGROUND: Alzheimer's disease (AD) is a significant burden on patients and caregivers. How this burden increases as disease progresses has not been well researched. OBJECTIVE: To assess the association of caregiver burden and quality of life with Alzheimer's disease severity and disease progression in community-dwelling patients in Germany, Spain, and the UK. METHODS: This was a prospective observational longitudinal study of mild-to-moderate AD patients (assessed by Mini-Mental State Examination, MMSE), and their caregivers. The humanistic burden was assessed using these instruments: [Rapid Assessment of Physical Activity (RAPA), EuroQoL-5-Dimension Level (EQ-5D-5L)] and caregiver-reported [Dependence Scale (DS), EQ-5D-5L, Zarit Burden Interview (ZBI)]. Caregiver-reported healthcare resource use was assessed using the Resource Use in Dementia (RUD) and ad-hoc questions. RESULTS: Of 616 patients recruited, 338 and 99 were followed-up at 12 and 18 months, respectively. The caregiver-reported EQ-5D-5L scores of patients' health-related quality of life (HRQoL) showed a negative trend over time (baseline: 0.76; 18 months: 0.67) while patient-reported HRQoL remained at 0.85. DS scores tended to worsen. Disease progression was an independent predictor of HRQoL and increased dependence.Mean ZBI score increased over time reflecting an increase in caregiver burden; MMSE being an independent predictor for caregiver burden. Patient resource utilization and caregiver time for caregiving tended to increase over time. CONCLUSION: We found significant association between disease progression and caregiver and patient burden. Independently, both disease-specific outcomes and disease burden measures increased over time, but as disease progresses, we also found incremental burden associated with it.

Incremental Healthcare Utilization and Cost Burden of Comorbid Insomnia in Alzheimer's Disease Patients.

BACKGROUND: Insomnia is associated with worsened clinical outcomes among Alzheimer's disease dementia (AD) patients, increased caregiver burden, and healthcare utilization. OBJECTIVE: This study aimed to characterize the incremental healthcare burden of insomnia in AD using real-world data. METHODS: A retrospective observational study was conducted on AD patients selected from the IBM® MarketScan Commercial and Medicare Supplemental Databases. AD patients with claims-based evidence of insomnia were direct matched to a non-insomnia cohort based on demographic factors. Healthcare utilization and associated costs were assessed for a 12-month follow-up period. RESULTS: A total of 3,500 insomnia AD patients and 9,884 non-insomnia AD patients were analyzed. The insomnia cohort had a higher comorbidity burden at baseline (mean score on Charlson Comorbidity Index 2.5 versus 2.2, p < 0.001) and higher proportions of patients with baseline diagnoses for other conditions including depression: 40%, insomnia cohort versus 25%, non-insomnia (p < 0.001). AD patients with insomnia were more likely to have a claim for inpatient hospitalizations (39.8%versus 32.3%), emergency room services (56.4%versus 48.0%), and skilled-nursing services (42.6%versus 31.9%) (all p < 0.05). Mean total annual healthcare costs during the 12-month follow-up period were significantly higher among AD patients with insomnia as compared to those without. (Mean costs: $37,356 versus $27,990, p < 0.001). CONCLUSION: AD patients with comorbid insomnia are more likely to use higher-cost healthcare services such as inpatient hospitalization, and skilled nursing, and have higher total healthcare costs. This real-world analysis provides evidence that AD disease management should consider proper treatment of comorbid insomnia due to the incremental burden and cost implications.

Changes in Healthcare Resource Use and Costs in Commercially Insured Insomnia Patients Initiating Suvorexant.

INTRODUCTION: Insomnia diagnosis has been associated with a significant clinical and economic burden on patients and healthcare systems. This study examined changes in healthcare resource use (HCRU) and costs in insomnia patients before and after initiation of suvorexant treatment. METHODS: This retrospective cohort study analyzed Optum Clinformatics Data Mart claims data (Jan 2010-Dec 2018). Patients with ≥ 2 insomnia diagnosis claims and ≥ 1 prescription for suvorexant were included. Prevalent and incident insomnia patients were analyzed separately. The change in the trends of HCRU and costs were examined for 12 months before and 12 months after suvorexant initiation. An interrupted time series (ITS) analysis was conducted to assess the level and slope changes. Subgroups of patients with mental health comorbidities were examined. RESULTS: The study included 18,919 and 5939 patients in the prevalent and incident insomnia cohorts, respectively. For the prevalent cohort, mean (SD) age was 64.5 (14.1) years, 65% were female, 74% had Medicare Advantage coverage, and 61% had a Charlson comorbidity index score ≥ 1. Characteristics for the incident cohort were similar. The ITS results suggested that the trend for monthly total healthcare cost (THC) was increasing before suvorexant initiation (US$52.51 in the prevalent cohort, $74.93 in incident insomnia cohort), but, after suvorexant initiation, the monthly total cost showed a decreasing trend in both cohorts. The decrease in slope for THC after suvorexant initiation were $72.66 and $112.07 per month in the prevalent and incident cohorts, respectively. The monthly trends in HCRU rates also decreased. The subgroup analysis showed that decreases were 1.5-3 times greater for patients with mental health comorbidities. CONCLUSIONS: In this real-world study, suvorexant initiation was associated with immediate and continued decreases in HCRU and costs in insomnia patients. Further research is needed to understand the effect of suvorexant initiation on direct medical costs as well as costs associated with lost productivity in other real-world settings.

Medications in Patients with Dementia and Behavioral Disturbance.

BACKGROUND: Behavioral disturbance (BD) is common in dementia patients, with no FDA approved medications for this condition. Little data exists on the real-world medication use in this population. OBJECTIVE: To describe real-world medications use in this population. METHODS: A cross-sectional study was conducted using the MarketScan database for outpatient medications and the Cerner database for inpatient medications. The study period was Oct 2015-Jun 2018. Patients with dementia and BD were identified through ICD-10-CM. We examined outpatient medications prescribed during 6-month before or after BD event date, and inpatient medications during inpatient visits, especially on central nervous systems (CNS) drugs including antidementia drugs, antidepressants, antipsychotics, anxiolytics, and anticonvulsants. RESULTS: A total of 56,544 outpatients and 34,245 patient hospitalizations were assessed separately. Among outpatients, patients filled more medications after a BD event. The use of the five CNS drug classes generally increased after a BD event, and the largest increase was seen in antipsychotics (23%to 33%). Among inpatients, the median number of medications used in each hospitalization was 14. The use of antipsychotics was particularly high (64%), followed by anxiolytics (51%). A list of 60 unique medications were suggested to be the commonly used drugs in dementia patients with BD. CONCLUSION: In dementia patients with BD, anti-dementia medications, antidepressants, anticonvulsants, hypnotics and antipsychotics were the most used drug classes. Antidepressants and antipsychotics use were more frequent after a BD event, which suggests a need for safe drugs targeting BD in dementia patients.

Impact of Dementia-Related Behavioral Symptoms on Healthcare Resource Use and Caregiver Burden: Real-World Data from Europe and the United States.

BACKGROUND: Dementia is commonly accompanied by neurobehavioral symptoms; however, the relationship between such symptoms and health-related outcomes is unclear. OBJECTIVE: To investigate the impact of specific neurobehavioral symptoms in dementia on healthcare resource use (HCRU), patient quality of life (QoL), and caregiver burden. METHODS: Data were taken from the 2015/16 Adelphi Real World Dementia Disease Specific Programme™, a point-in-time survey of physicians and their consulting dementia patients. Multiple regression analyses were used to examine associations between patient symptom groups and health-related outcomes. RESULTS: Each patient symptom group of interest (patients with agitation/aggression and related symptoms [AARS] with psychosis, patients with AARS without psychosis, and patients with other behavioral symptoms) had a positive association with HCRU variables (i.e., HCRU was greater), a negative association with proxy measures of patient QoL (i.e., QoL was decreased), and a positive association with caregiver burden (i.e., burden was greater) compared with patients with no behavioral symptoms (control group). The magnitude of effect was generally greatest in patients with AARS with psychosis. Regression analysis covariates that were found to be most often significantly related to the outcomes were dementia severity and the patients' living situation (i.e., whether they were in nursing homes or living in the community). CONCLUSION: Combinations of behavioral symptoms, particularly involving AARS plus psychosis, may have a detrimental impact on health-related outcomes such as HCRU, patient QoL, and caregiver burden in dementia. Our results have implications for intervention development in patients who report clusters of symptoms and caregivers, and for identifying at-risk individuals.

Assessing the Progression of Alzheimer's Disease in Real-World Settings in Three European Countries.

BACKGROUND: There exists considerable variation in disease progression rates among patients with Alzheimer's disease (AD). OBJECTIVE: The primary objective of this observational study is to assess the progression of AD by characterizing cognitive, functional, and behavioral changes during the follow-up period between 6 and 24 months. METHODS: A longitudinal prospective study with community-dwelling patients with an established clinical diagnosis of AD of mild to moderate severity was conducted in Germany, Spain and the UK. A sample of 616 patients from 69 sites was included. RESULTS: Patients had a mean of 1.9 years (SD = 1.9) since AD diagnosis at study inclusion. Cognitive symptoms were reported to have first occurred a mean of 1.1 years (SD = 1.7) prior to AD diagnosis and 1.4 (SD = 1.8) years prior to AD treatment. Patients initially diagnosed with mild and moderate AD spent a median (95%CI) of 3.7 (2.8; 4.4) and 11.1 (6.1, 'not reached') years until progression to moderate and severe AD, respectively, according to the Mini-Mental State Examination (MMSE) scores. A mixed model developed for cognitive, functional, and neuropsychiatric scores, obtained from study patients at baseline and during follow-up period, showed progressive deterioration of AD patients over time. CONCLUSION: The study showed a deterioration of cognitive, functional, and neuropsychiatric functions during the follow-up period. Cognitive deterioration was slightly faster in patients with moderate AD compared to mild AD. The duration of moderate AD can be overestimated due to the use of retrospective data, lack of availability of MMSE scores in clinical charts and exclusion of patients at time of institutionalization.

A Real-World Assessment of Outcomes in Schizophrenia Patients According to Treatment Response.

OBJECTIVE: To describe and compare demographics, outcomes, and comorbidities among schizophrenia patients according to treatment response. METHODS: A cross-sectional survey was conducted in the United States through the Adelphi Schizophrenia Disease Specific Program from January to May 2014. Participating physicians provided information on the first 10 schizophrenia patients aged ≥ 18 years they saw in daily clinical practice; these patients were invited to voluntarily complete a patient self-completion form. Patients were considered partial responders or responders based on the physician-reported Clinical Global Impressions improvement scale. Regression analyses were performed to identify potential drivers of response and the clinical and humanistic outcomes associated with response. RESULTS: 150 physicians provided data on 433 partial responders and 872 responders; 185 partial responders and 415 responders completed a patient self-completion form. A significant predictor of response was always being adherent with the medication regimen (P < .001). Positive symptoms (P = .006) and moderate (P = .004) or severe (P = .002) illness severity were significant predictors of inadequate response. Responders were more likely to have better EQ-5D (EuroQol 5 Dimensions) visual analog scale, Quality of Life Enjoyment and Satisfaction Questionnaire, and work productivity and impairment scores (all P < .05). CONCLUSIONS: Partial responders were more likely to have significantly poorer clinical and quality of life outcomes compared with responders. Improved therapeutic approaches, either new therapies or optimized treatments, could lead to both better outcomes and improved adherence in this population.

Assessment of Real-Life Outcomes in Schizophrenia Patients according to Compliance.

OBJECTIVE: To describe and compare demographics, outcomes and comorbidities in schizophrenia patients by treatment compliance. METHODS: This was a cross-sectional survey of hospital- or office-based psychiatrists who saw ≥6 schizophrenia patients per week and were responsible for treatment decisions. Recruited physicians completed a patient record form (PRF) for their first 10 consulted schizophrenia patients aged ≥18. These patients voluntarily completed a patient self-completion form (PSC). Compliance was measured by subjective physician assessment. Drivers of and outcomes associated with compliance were identified by regression analyses. RESULTS: A total of 150 physicians completed PRFs for 1489 patients (706 sometimes compliant (SC), 636 always compliant (AC)). A total of 680 patients completed a PSC (327 SC, 295 AC). AC patients were less likely to be male (52.2% vs. 58.6%; P = 0.021) and unemployed (odds ratio (OR) 0.91, 95% confidence interval (CI) 0.82-1.00; P < 0.001) or to have had a treatment regimen change (OR 0.56, 95% CI 0.40-0.80; P = 0.001) than SC patients. AC patients were less likely to have had more comorbidities (OR 0.91, 95% CI 0.82-1.00; P = 0.045) and hospitalizations in the past 12 months (OR 0.59, 95% CI 0.43-0.80; P = 0.001) than SC patients. Overall, AC patients had better clinical and humanistic outcomes. Weight gain was a common side effect for all patients; SC patients with weight gain had poorer outcomes than those without weight gain. CONCLUSION: Schizophrenia patients that were SC experienced poorer clinical outcomes and quality of life. Weight gain may exacerbate these poorer outcomes.

Multi-National, Cross-Sectional Survey of Healthcare Resource Utilization in Patients with All Stages of Cognitive Impairment, Analyzed by Disease Severity, Country, and Geographical Region.

BACKGROUND: Alzheimer's disease (AD) is one of the most disabling conditions worldwide and the disease burden increases with the aging global population. There are only a few prospective studies using real-world data to support effective healthcare resource utilization (HCRU) in AD. OBJECTIVE: To confirm the association between HCRU and AD severity in a real-world population, including patients with all cognitive impairment (CI) severities. METHODS: Data were drawn from a multi-national, cross-sectional survey of physicians and their consulted patients with all stages (very mild, mild, moderate, and severe) of CI including AD conducted in France, Germany, Italy, Spain, UK, US, and Canada. Elements of HCRU including medical consultations, professional caregiver hours, hospitalization, and institutionalization were compared between CI severity subgroups, and by country and region. RESULTS: 6,143 CI patients were included with very mild (n = 659), mild (n = 2,473), moderate (n = 2,603), and severe (n = 408) dementia. HCRU increased with increasing CI severity (p < 0.001) for the majority of elements measured. Further analyses of overall and regional populations also confirmed significant increases in most HCRU elements with increasing disease severity. The general trend toward increased HCRU with increased CI severity was also seen in individual countries. Individual country data appeared to indicate that earlier intervention decreased hospitalizations and full-time institutionalization at the later (more severe) disease stages. CONCLUSION: Our findings confirmed that HCRU increases with increasing CI severity. Effective intervention in early disease could therefore reduce or delay incurring greater HCRU costs associated with more severe disease. Further studies are needed to confirm this hypothesis.

Quantifying and Describing the Natural History and Costs of Alzheimer's Disease and Effects of Hypothetical Interventions.

BACKGROUND: A long-term horizon is necessary when the socioeconomic consequences and the potential effects of interventions in Alzheimer's disease (AD) are estimated. OBJECTIVES: To illustrate the potential societal costs of AD across the disease continuum and to illustrate the potential cost-effectiveness of a hypothetical intervention with disease modifying treatment (DMT). METHODS: Based on the Swedish dementia registry, a Markov model was used to simulate a virtual cohort of 100,000 people with mild cognitive impairment (MCI) due to AD (AD-MCI) in Sweden for 40 years starting at the age of 60. A simulated hypothetical intervention assumed a 25% reduction in progression rate during AD-MCI and mild AD-dementia. A comprehensive set of sensitivity analyses was included. RESULTS: The cumulative risk to develop dementia was 96%. The mean simulated survival was 19.0 years. The net present value for a person year with dementia was 252,843 SEK (about 29,500 US$). The cost effectiveness model illustrated how the hypothetical scenario of a 25% reduction in progression to AD-dementia would require 41 AD-MCI patients to be treated to prevent one case of AD-dementia (2,447 avoided AD-dementia cases of 100,000 with AD-MCI). Most scenarios illustrated hypothetical cost effectiveness (based on a willingness to pay level of 600,000 SEK (70,000 US$) per gained QALY), but not cost savings. DISCUSSION: Lifetime societal costs of AD are substantial. A future DMT may be potentially cost-effective given assumed treatment effects and costs, but cost savings are unlikely.