Economic value of nonsurgical weight loss in adults with obesity.

BACKGROUND: Obesity imposes a substantial economic burden on the United States. The short-term value of nonsurgical weight loss (WL) and nonsurgical sustained WL (i.e., WL not resulting from bariatric surgery) is poorly understood. OBJECTIVES: To assess short-term (1 year) effect of nonsurgical WL and sustained nonsurgical WL (i.e., approximately 2 years) on per-patient-per-month (PPPM) total all-cause health care costs among adults with obesity in the United States. METHODS: In this retrospective cohort study, we analyzed data from the IBM MarketScan Explorys Claims-EMR Data Set from January 1, 2012, through June 30, 2018. Adults aged 18-64 years with a body mass index (BMI) measurement ≥ 30 kg/m2 on the index date and BMI measurements at 12, 24, and 36 months were classified into weight-gain (≥ 3%), no-weight-change (within ± 3%), and WL (≥ 3%-≤ 5%, > 5%-≤ 10%, and > 10%-≤ 20%) cohorts based on the change from first to second BMI measurements (baseline), and sustained nonsurgical WL based on WL during baseline and < 3% weight gain from second to third BMI measurement. PPPM all-cause health care costs were calculated for baseline, first year, and second year of follow-up. Generalized linear models were used to examine if PPPM all-cause health care cost change (ΔPPPM) from baseline to follow-up differed significantly between nonsurgical WL/sustained WL and no-weight-change cohorts. Analyses were stratified by index obesity class (class 1: BMI 30- < 34.9 kg/m2, class 2: BMI 35- < 39.9 kg/m2, class 3: BMI ≥ 40 kg/m2). Specific nonsurgical WL treatments used by individuals in the study were not studied. RESULTS: The sample included 20,488 adults who were grouped as follows: weight-gain cohort (24.8%), no-weight-change cohort (56.6%), ≥ 3%- ≤ 5% WL cohort (8.2%), > 5%- ≤ 10% WL cohort (7.7%), and > 10%- ≤ 20% WL cohort (2.8%). Compared with the no-weight-change cohort, adjusted mean ΔPPPM all-cause health care cost from baseline to first year of follow-up was lower in all WL cohorts (≥ 3%- ≤ 5% WL: -$57.36, > 5%- ≤ 10% WL: -$135.35 [P < 0.05], > 10%- ≤ 20% WL: -$193.54 [P < 0.05]). In the second year of follow-up (n = 15,307), the cohorts were weight-gain (43.4%), no-weight-change (59.4%), ≥ 3%- ≤ 5% sustained WL (7.3%), ≥ 5%- ≤ 10% sustained WL (6.3%), and > 10%- ≤ 20% sustained WL (1.8%). Adjusted mean ΔPPPM all-cause health care cost was lower in all sustained WL groups (-$26.38, -$157.41 [P < 0.05], and -$185.41 for ≥ 3%- ≤ 5%, ≥ 5%- ≤ 10%, and > 10%- ≤ 20% WL, respectively). Greater nonsurgical WL and sustained nonsurgical WL were generally associated with larger reduction in short-term all-cause health care costs. Results stratified by index obesity class were mixed, due to small samples. CONCLUSIONS: Substantial all-cause health care cost savings were observed 1 year after nonsurgical WL and after sustained (on average for 2 years) nonsurgical WL in adults with obesity, with greater nonsurgical WL and sustained nonsurgical WL associated with greater cost savings. Comprehensive solutions to chronic weight management, including improved access to antiobesity medications in combination with lifestyle interventions, could be valuable to patients, employers, and payers. DISCLOSURES: This study was sponsored by Novo Nordisk, which also purchased the data. Blanchette is an employee of Novo Nordisk. Smolarz and Ramasamy are employees of Novo Nordisk and hold equity in Novo Nordisk. Ding, Fan, and Weng were employees of Novo Nordisk at the time this study was conducted. The findings from this study were previously presented at Obesity Week 2019; November 3-7, 2019; Las Vegas, NV.

Comorbidity Associations with AATD Among Commercially Insured and Medicare Beneficiaries with COPD in the US.

Introduction: Alpha-1 antitrypsin deficiency (AATD) is often not identified in patients with chronic obstructive pulmonary disease (COPD) until advanced stages of disease, despite the availability of genetic testing. While clinical practice guidelines provide recommendations on patients who should be tested, more refined algorithms are needed to identify COPD patients who are likely candidates for AATD testing and to prevent delays in diagnosis and treatment. The objective of this study was to identify comorbid associations with AATD among patients diagnosed with COPD in the United States. Methods: Using data from the 2012-2017 PharMetrics Plus Administrative Claims Database and 2011-2014 Medicare Fee for Service 5% Sample, patients with COPD (ICD-9-CM: 491.xx, 492.xx, or 496, ICD-10-CM J41, J42, J43, J44) and AATD (ICD-9-CM: 273.4, ICD-10-CM: E88.01) were identified. Patient demographic and diagnostic characteristics were assessed. Logistic regression models were developed to identify significant predictors of AATD. Results: A cohort of 344,528 Medicare beneficiaries with COPD (of which 302 (0.09%) also had two diagnoses of AATD) and a cohort of 340,259 commercially insured patients with COPD (of which 1076 (0.3%) also had a diagnosis of AATD) were constructed. Associations with AATD identified in both models included ICD-9-CM and ICD-10-CM codes for chronic pulmonary heart disease, chronic liver disease and cirrhosis, and liver transplant. Discussion: Significant associations with a diagnosis of AATD among patients with COPD were consistently represented in each of the datasets evaluated, which suggests meaningful comorbidity implications in AATD patients. These findings reinforce the need to test individuals with COPD for AATD as early as possible to help reduce the development of associated comorbid conditions.

Survival associated with chronic obstructive pulmonary disease among SEER-Medicare beneficiaries with non-small-cell lung cancer.

Objective: We investigated the impact of preexisting COPD and its subtypes, chronic bronchitis and emphysema, on overall survival among Medicare enrollees diagnosed with non-small-cell lung cancer (NSCLC). Methods: Using SEER-Medicare data, we included patients ≥66 years of age diagnosed with NSCLC at any disease stage between 2006 and 2010 and continuously enrolled in Medicare Parts A and B in the 12 months prior to diagnosis. Preexisting COPD in patients with NSCLC were identified using ICD-9 codes. Kaplan-Meier method and log-rank tests were used to examine overall survival by COPD status and COPD subtype. Multivariable Cox proportional hazards models were fit to assess the risk of death after cancer diagnosis. Results: We identified 66,963 lung cancer patients. Of these, 22,497 (33.60%) had documented COPD before NSCLC diagnosis. For each stage of NSCLC, median survival was shorter in the COPD compared to the non-COPD group (Stage I: 692 days vs 1,130 days, P<0.0001; Stage II: 473 days vs 627 days, P<0.0001; Stage III: 224 days vs 229 days; P<0.0001; Stage IV: 106 days vs 112 days, P<0.0001). For COPD subtype, median survival for patients with preexisting chronic bronchitis was shorter compared to emphysema across all stages of NSCLC (Stage I: 672 days vs 811 days, P<0.0001; Stage II 582 days vs 445 days, P<0.0001; Stage III: 255 days vs 229 days, P<0.0001; Stage IV: 105 days vs 112 days, P<0.0001). In Cox proportional hazard model, COPD patients exhibited 11% increase in risk of death than non-COPD patients (HR: 1.11, 95%CI: 1.09-1.13). Conclusion: NSCLC patients with preexisting COPD had shorter survival with marked differences in early stages of lung cancer. Chronic bronchitis demonstrated a greater association with time to death than emphysema.

Differences in Patient Demographics and Healthcare Costs of Patients with PIDD Receiving Intravenous or Subcutaneous Immunoglobulin Therapies in the United States.

BACKGROUND: Primary immune-deficiency disease (PIDD) is a rare, debilitating disease of the immune system that predisposes the affected individual to infection, autoimmune conditions, and neoplasm. A major component of the cost of treating PIDD is the high price of immunoglobulin drugs, which can be administered via an intravenous (IV) or subcutaneous (SC) route. OBJECTIVE: To compare real-world costs for patients with PIDD who are receiving IV immunoglobulin (IVIG) or SC immunoglobulin (SCIG) treatment, from a US payer perspective, using a large claims database. METHODS: Based on 2011 to 2013 data from the PharMetrics Plus database, a large national healthcare claims database, patients who were newly diagnosed with PIDD were included in the study if they had ≥2 claims for PIDD that were ≥90 days apart, and if they were treatment-naïve for a minimum of 1 year before the study period. Patients who switched the route of immunoglobulin administration were excluded, with the exception of patients who received SCIG who could initially receive ≤2 IV-loading infusions, as directed by treatment guidelines. We used propensity score analysis to match the patients in the SCIG cohort to patients in the IVIG cohort based on age, sex, and all Elixhauser comorbidities. We compared the patient characteristics and direct medical costs (all-cause, PIDD-related, and pharmacy-related) before and after matching, using t-tests for continuous variables, chi-square test for categorical variables, and Wilcoxon rank-sum test for differences in medians. RESULTS: A total of 1639 patients with PIDD (986 who received IVIG and 653 who received SCIG) met all the study inclusion criteria. Compared with the patients who received IVIG, the patients who received SCIG were predominantly female (58% vs 63%, respectively) and significantly younger (mean age, 49.1 vs 40.3 years, respectively). Significantly fewer patients who received SCIG than those receiving IVIG had claims with International Classification of Diseases, Ninth Revision codes for Elixhauser comorbidities, including cardiovascular and pulmonary conditions, diabetes, renal failure, liver disease, cancers, weight loss, fluid and electrolyte disorders, and psychoses (P <.05 for all), and their Charlson Comorbidity Index scores were lower than those receiving IVIG (1.74 vs 3.01, respectively; P ≤.05 for all). After matching the 2 cohorts (N = 553 in each), the 1-year postindex median total PIDD-related costs were significantly lower in the IVIG group than in the SCIG group ($38,064 vs $43,266, respectively; P = .002). CONCLUSIONS: In matched analyses, PIDD-related treatment costs were higher for patients who received SCIG than for those who received IVIG. Furthermore, patients who received SCIG were significantly younger and had significantly less comorbidities than their counterparts who received IVIG, suggesting that patient characteristics that reflect a desire and greater capacity for autonomy may affect physicians' choice of the route of administration for immunoglobulin.

Healthcare utilization and costs associated with COPD among SEER-Medicare beneficiaries with NSCLC.

AIM: To estimate the healthcare utilization and costs in elderly lung cancer patients with and without pre-existing chronic obstructive pulmonary disease (COPD). METHODS: Using Surveillance, Epidemiology and End Results (SEER)-Medicare data, this study identified patients with lung cancer between 2006-2010, at least 66 years of age, and continuously enrolled in Medicare Parts A and B in the 12 months prior to cancer diagnosis. The diagnosis of pre-existing COPD in lung cancer patients was identified using ICD-9 codes. Healthcare utilization and costs were categorized as inpatient hospitalizations, skilled nursing facility (SNF) use, physician office visits, ER visits, and outpatient encounters for every stage of lung cancer. The adjusted analysis was performed using a generalized linear model for healthcare costs and a negative binomial model for healthcare utilization. RESULTS: Inpatient admissions in the COPD group increased for each stage of non-small cell lung cancer (NSCLC) compared to the non-COPD group per 100 person-months (Stage I: 14.67 vs 9.49 stays, p < .0001; Stage II: 14.13 vs 10.78 stays, p < .0001; Stage III: 28.31 vs 18.91 stays, p < .0001; Stage IV: 49.5 vs 31.24 stays, p < .0001). A similar trend was observed for outpatient visits, with an increase in utilization among the COPD group (Stage I: 1136.04 vs 796 visits, p < .0001; Stage II: 1325.12 vs 983.26 visits, p < .0001; Stage III: 2025.47 vs 1656.64 visits, p < .0001; Stage IV: 2825.73 vs 2422.26 visits, p < .0001). Total direct costs per person-month in patients with pre-existing COPD were significantly higher than the non-COPD group across all services ($54,799.16 vs $41,862.91). Outpatient visits represented the largest cost category across all services in both groups, with higher costs among the COPD group ($41,203 vs $31,140.08). CONCLUSION: Healthcare utilization and costs among lung cancer patients with pre-existing COPD was ∼2-3-times higher than the non-COPD group.

The value of self-medication: summary of existing evidence.

AIM: The aim of this review was to identify the international evidence that is currently available on the economic value of self-care through responsible self-medication, in terms of the measures related to access to treatment, time, and productivity. METHODS: A targeted literature search was conducted for 1990-2016, including data gathered from members of the World Self-Medication Industry and searches on PubMed, EBSCOHost, and Google Scholar. Specific searches of individual drug classes known to be switched to non-prescription status in this period were also conducted. RESULTS: A total of 71 articles were identified, of which 17 (11 modeling studies, six retrospective analyses) were included in the review. Evidence from modeling studies and retrospective analyses of grouped data across a range of common conditions for which non-prescription medications are available in different countries/regions showed that the use of non-prescription products for the treatment of common conditions or for symptom management (e.g. allergies, chronic pain, migraine, vaginitis, gastrointestinal symptoms, or common cold symptoms) had considerable value to patients, payers, and employers alike in terms of cost savings and improved productivity. Potential benefits of self-medication were also identified in preventative healthcare strategies, such as those for cardiovascular health and osteoporosis. LIMITATIONS: This review was limited by a targeted, but non-systematic approach to literature retrieval, as well as the inclusion of unpublished reports/white papers and patient self-reported data. CONCLUSIONS: The evidence identified in this literature review shows that responsible, appropriate self-medication with non-prescription products can provide significant economic benefits for patients, employers, and healthcare systems worldwide.

Healthcare Cost and Utilization before and after Diagnosis of Pseudomonas aeruginosa among Patients with Non-Cystic Fibrosis Bronchiectasis in the U.S.

Non-cystic fibrosis bronchiectasis (NCFBE) is a rare, chronic lung disease characterized by bronchial inflammation and permanent airway dilation. Chronic infections with P. aeruginosa have been linked to higher morbidity and mortality. To understand the impact of P. aeruginosa in NCFBE on health care costs and burden, we assessed healthcare costs and utilization before and after P. aeruginosa diagnosis. Using data from 2007 to 2013 PharMetrics Plus administrative claims, we included patients with ≥2 claims for bronchiectasis and >1 claim for P. aeruginosa; then excluded those with a claim for cystic fibrosis. Patients were indexed at first claim for P. aeruginosa and were required to have >12 months before and after the index P. aeruginosa. The mean differences in utilization and costs were assessed using paired Student's t-tests for statistical significance. Mean total healthcare costs per patient were $36,213 pre-P. aeruginosa diagnosis versus $67,764 post-P. aeruginosa, an increase of 87% (p < 0.0001). Inpatient costs represented the largest proportion of total healthcare costs post-P. aeruginosa (54%) with an increase of four hospitalizations per patient (p < 0.0001). NCFBE patients with evidence of P. aeruginosa incur substantially greater healthcare costs and utilization after P. aeruginosa diagnosis. Future research should explore methods of earlier identification of NCFBE patients with P. aeruginosa, as this may lead to fewer severe exacerbations, thereby resulting in a reduction in hospitalizations and healthcare costs.

One-year Prevalence, Comorbidities, and Cost of Hospitalizations for Alpha-1 Antitrypsin Deficiency among Patients with Chronic Obstructive Pulmonary Disease in the United States.

Objectives: Little is known about severe chronic obstructive pulmonary disease (COPD) exacerbations among patients with Alpha-1 Antitrypsin Deficiency (AATD). We assessed inpatients with AATD and COPD among a sample of COPD inpatients to ascertain demographic, clinical and economic differences in the course of disease and treatment. Methods: Using data from the 2009 Nationwide Inpatient Sample (NIS), we identified COPD (ICD-9-CM: 491.xx, 492.xx, or 496.xx) patients with AATD (273.4). We compared patient demographics and healthcare outcomes (eg, length of stay, inpatient death, type and number of procedures, and cost of care) between COPD patients with and without alpha-1 antitrypsin deficiency. Frequencies and percentages for patient demographics were compared using bivariate statistics (eg, chi-square test). Recognizing the non-parametric nature of length of stay and cost, we calculated median values and interquartile ranges for these variables for each group of patients. Finally, the risk of inpatient death was estimated using logistic regression. Results: Of 840 242 patients with COPD (10.8% of the NIS sample population), 0.08% (684) had a primary or secondary diagnosis code for AATD. COPD+AATD were younger (56 vs 70, p<0.0001) and as a result, less likely to be covered by Medicare (44% vs 62%, p<0.0001). AATD patients were also more likely to have comorbid non-alcoholic liver disease (7% vs 2%, p<0.0001), depression (17% vs 13%, p=0.0328), and pulmonary circulation disorders (7% vs 4%, p=0.0299). Patients with AATD had a 14% longer length of stay (IRR = 1.14, 95% CI 1.07, 1.21) and a mean cost of $1487 (p=0.0251) more than COPD inpatients without AATD. Conclusions: AATD is associated with increased mean length of stay and cost, as well as higher frequency of comorbid non-alcoholic liver disease, depression, and pulmonary circulation disorders. Future research should assess other differences between AATD and the general COPD population such as natural history of disease, treatment responsiveness and disease progression.

Evaluating cost benefits of combination therapies for advanced melanoma.

BACKGROUND: Although a number of monoimmunotherapies and targeted therapies are available to treat BRAF+ advanced melanoma, response rates remain relatively low in the range of 22-53% with progression-free survival (PFS) in the range of 4.8-8.8 months. Recently, combination targeted therapies have improved response rates to about 66-69%, PFS to 11.0-12.6 months and overall survival (OS) to 25.1-25.6 months. While combination immunotherapies have improved response rates of 67 compared with 19-29% with monotherapies and improved PFS of 11.7 compared with 4.4-5.8 months with monotherapies, the OS benefit is yet to be established in phase 3 trials. As healthcare costs continue to rise, US payers have a predominant interest in assessing the value of available treatments. Therefore, a cost-benefit model was developed to evaluate the value of treating BRAF+ advanced melanoma with two combination therapies: nivolumab + ipilimumab (N+I) and dabrafenib + trametinib (D+T). SCOPE: The model was used to estimate total costs, total costs by expenditure category, cost per month of PFS and cost per responder for the payer, and societal perspectives of treating advanced melanoma patients with the BRAF V600 mutation using combination targeted therapy (D+T) or combination immunotherapy (N+I). The model followed patients from initiation of treatment to the point of progression or death. Deterministic and probabilistic sensitivity analyses were conducted to evaluate the robustness of the results and to understand the dispersion of simulated results. FINDINGS: Based on a hypothetical payer with one million covered lives, it was expected that fourteen metastatic melanoma patients with the BRAF V600 mutation would be treated each year. Cost-benefit with N+I and D+T was simulated from the payer perspective. The cost per month of PFS for N+I was $22,162, while that for D+T was $17,716 (-$4,446 cost difference); the cost per responder for N+I was $388,746 and that for D+T was $282,429 (-$106,316 cost difference). The cost per month of PFS and per responder from the societal perspective resembled the patterns observed from the payer's perspective: the cost per month of PFS for N+I was $22,843, while that for D+T was $18,283 (-$4,560 cost difference). The cost per responder for N+I was $400,695 and that for D+T was $291,473 (-$109,222 cost difference). The totals of travel and treatment time for N+I and D+T were 58 hours and 3.9 hours per patient, respectively, of which total infusion time for N+I accounted for a majority - 59% - of the 58 hours. Sensitivity analyses indicated that results were most sensitive to model inputs for median PFS, body weight, and drug cost. Moreover, D+T is likely associated with a lower cost per month of PFS and cost per responder than N+I, except at low body weights (less than 57 kg). CONCLUSION: The model presented in this study was used to analyze the clinical and economic benefit of using combination therapies in advanced melanoma patients with the BRAF V600 mutation. This analysis suggests D+T therapy is associated with less patient time and lower costs relative to N+I to gain similar PFS and overall response rate (ORR) benefits.

Incidence and Cost of Ankle Sprains in United States Emergency Departments.

BACKGROUND: Ankle sprains represent a common injury in emergency departments, but little is known about common complications, procedures, and charges associated with ankle sprains in emergency departments. HYPOTHESIS: There will be a higher incidence of ankle sprains among younger populations (≤25 years old) and in female patients. Complications and procedures will differ between ankle sprain types. Lateral ankle sprains will have lower health care charges relative to medial and high ankle sprains. STUDY DESIGN: Descriptive epidemiological study. LEVEL OF EVIDENCE: Level 3. METHODS: A cross-sectional study of the 2010 Nationwide Emergency Department Sample was conducted. Outcomes such as charges, complications, and procedures were compared using propensity score matching between lateral and medial as well as lateral and high ankle sprains. RESULTS: The sample contained 225,114 ankle sprains. Female patients sustained more lateral ankle sprains (57%). After propensity score adjustment, lateral sprains incurred greater charges than medial ankle sprains (median [interquartile range], $1008 [$702-$1408] vs $914 [$741-$1108]; P < 0.01). Among complications, pain in the limb (1.92% vs 0.52%, P = 0.03), sprain of the foot (2.96% vs 0.70%, P < 0.01), and abrasion of the hip/leg (1.57% vs 0.35%, P = 0.03) were more common in lateral than medial ankle sprain events. Among procedures, medial ankle sprains were more likely to include diagnostic radiology (97.91% vs 83.62%, P < 0.01) and less likely to include medications than lateral ankle sprains (0.87% vs 2.79%, P < 0.01). Hospitalizations were more common following high ankle sprains than lateral ankle sprains (24 [6.06%] vs 1 [0.25%], P < 0.01). CONCLUSION: Ankle sprain emergency department visits account for significant health care charges in the United States. Age- and sex-related differences persist among the types of ankle sprains. CLINICAL RELEVANCE: The health care charges associated with ankle sprains indicate the need for additional preventive measures. There are age- and sex-related differences in the prevalence of ankle sprains that suggest these demographics may be risk factors for ankle sprains.

Cachexia among US cancer patients.

BACKGROUND: Cancer cachexia is a debilitating condition and results in poor prognosis. The purpose of this study was to assess hospitalization incidence, patient characteristics, and medical cost and burden of cancer cachexia in the US. METHODS: This study used a cross-sectional analysis of the Nationwide Inpatient Sample (NIS) for 2009. Five cancers reported to have the highest cachexia incidence were assessed. The hospitalization incidence related to cachexia was estimated by cancer type, cost and length of stay were compared, and descriptive statistics were reported for each cancer type, as well as differences being compared between patients with and without cachexia. RESULTS: Risk of inpatient death was higher for patients with cachexia in lung cancer (OR = 1.32; CI = 1.20-1.46) and in all cancers combined (OR = 1.76; CI = 1.67-1.85). The presence of cachexia increased length of stay in lung (IRR = 1.05; CI = 1.03-1.08), Kaposi's sarcoma (IRR = 1.47; CI = 1.14-1.89) and all cancers combined (IRR = 1.09; CI = 1.08-1.10). Additionally, cachectic patients in the composite category had a longer hospitalization stay compared to non-cachectic patients (3-9 days for those with cachexia and 2-7 days for those without cachexia). The cost of inpatient stay was significantly higher in cachexic than non-cachexic lung cancer patients ($13,560 vs $13 190; p < 0.0001), as well as cachexic vs non-cachexic cancer patients in general (14 751 vs 13 928; p < 0.0001). CONCLUSIONS: Cachexia increases hospitalization costs and length of stay in several cancer types. Identifying the medical burden associated with cancer cachexia will assist in developing an international consensus for recognition and coding by the medical community and ultimately an effective treatment plans for cancer cachexia.

Inpatient resource use and costs associated with switching from oral antipsychotics to aripiprazole once-monthly for the treatment of schizophrenia.

BACKGROUND: Schizophrenia is associated with high direct healthcare costs due to progression of disease and frequent occurrence of relapses. Aripiprazole once-monthly (AOM) has been shown to reduce total psychiatric hospitalizations among patients who switched from oral standard of care (SOC) therapy to AOM in a multicenter, open-label, mirror-image study of patients with schizophrenia. Because of the increasing need to improve patient outcomes while containing costs, it is important to understand the impact of AOM treatment initiation on medical costs associated with psychiatric hospitalizations and antipsychotic pharmacy costs. METHODS: In the current study, an economic model was developed using data from the AOM mirror-image study to evaluate the psychiatric hospitalization-related medical costs and antipsychotic pharmacy costs during a 6-month period before (retrospective period) and after (prospective period) the AOM treatment initiation. The economic model evaluated cost-saving potential of AOM among all patients (n=433) as well as a subset of patients with ≥1 prior hospitalization (n=165) who switched from oral SOC to AOM. Unit cost data were obtained from publicly available sources. RESULTS: Both hospitalizations and hospital days were reduced following a switch from oral SOC to AOM. As a result, psychiatric hospitalization-related costs were lower during the prospective period when compared with the retrospective period. Furthermore, the increase in antipsychotic pharmacy costs due to switching from oral SOC to AOM was offset by a reduction in psychiatric hospitalization-related medical costs. Per-patient costs were reduced by $1,046 (USD) in the overall population and by $20,353 in a subset of patients who had at least 1 psychiatric hospitalization during the retrospective period. Results were most sensitive to changes in hospitalization costs. CONCLUSIONS: AOM is associated with reducing the risk of relapse among patients with schizophrenia. The increase in antipsychotic pharmacy costs due to switching from oral SOC to AOM was offset by a reduction in costs associated with psychiatric hospitalizations, thereby presenting a cost-saving opportunity for health plans.

Racial differences in antipsychotic use: Claims database analysis of Medicaid-insured patients with schizophrenia.

BACKGROUND: Database analyses have indicated that medical treatment for schizophrenia varies among racial groups. This study assessed antipsychotic use and healthcare utilization across races in Medicaid-insured patients with schizophrenia. METHODS: A Medicaid database of inpatient/outpatient medical claims and outpatient prescription claims for more than 28 million enrollees in 11 geographically diverse states was analyzed. The primary outcome, racial differences in antipsychotic use in 2012, was examined in 5 multivariable logistic regression models: (1) any antipsychotic, (2) first-generation (FG) long-acting injectables (LAIs), (3) FG oral antipsychotics, (4) second-generation (SG) LAIs, and (5) SG oral antipsychotics. RESULTS: Odds ratios and adjusted predicted probabilities were comparable for any antipsychotic use between black and white patients. Black patients were less likely to receive SG oral antipsychotics (P < .001) and more likely to receive SG or FG LAIs (P = .001 and P < .001, respectively) and FG oral antipsychotics (P = .003) vs white patients. Further, black patients had a higher mean number of emergency room visits (P < .001) and a lower mean number of hospitalizations (P < .05) vs white patients; the mean number of physician visits was comparable. CONCLUSIONS: Disparities in antipsychotic use and healthcare utilization across races in patients with schizophrenia warrant further investigation and elimination of these disparities should be a national goal.

End-stage renal disease in autosomal dominant polycystic kidney disease: a comparison of dialysis-related utilization and costs with other chronic kidney diseases.

BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD) is the leading inheritable cause of end-stage renal disease (ESRD) and one of the leading causes of ESRD overall. ADPKD patients differ from the overall dialysis population; however, there is little published data regarding health care costs for ADPKD patients on dialysis. METHODS: This retrospective observational cohort study was designed to quantify health care utilization and costs for ADPKD patients with ESRD who received initial services at a single large dialysis organization between January 1, 2007 and December 31, 2009. Parallel results and baseline patient characteristics for control patients with ESRD etiologies other than ADPKD were performed for reference. Dialysis-related utilization and health care costs for patients with ADPKD in ESRD overall and during time horizons that correspond to Medicare-eligibility benchmarks were analyzed. Baseline patient characteristics were described for all patients and included demographics, comorbid illnesses, and clinical characteristics. Dialysis-related utilization, hospitalization rates, and health care costs were considered longitudinally. RESULTS: Total health care costs for ADPKD patients were high at US$51,048 per patient-year based on the overall analysis. Total health care costs were lower for ADPKD patients than for control patients on dialysis. Patients with ADPKD were generally younger, had a lower Charlson Comorbidity Index, and had lower rates of comorbid conditions, which may have contributed to the lower overall costs seen for patients with ADPKD. CONCLUSION: Health care resource utilization and costs for patients with ADPKD in ESRD requiring dialysis were high, and therapeutic interventions that can prevent or delay the progression to ESRD may increase dialysis-free life for patients with ADPKD.

Assessing disparities in the receipt of inhaled corticosteroid prescriptions for asthma by Hispanic and non-Hispanic white patients.

RATIONALE: Inhaled corticosteroids (ICS) are widely used in the management of asthma. Prior research suggests that access to ICS among patients with asthma may vary by ethnicity. OBJECTIVES: Study objectives were to determine if there is a difference in the proportion of Hispanic and non-Hispanic white patients with asthma in the receipt of an ICS prescription and to determine independent predictors for the receipt of an ICS prescription for asthma. METHODS: The 2009 U.S. Medical Expenditure Panel Survey data were used to compare the receipt of ICS prescription among patients with asthma with the following inclusion criteria: Hispanic and non-Hispanic white ethnicity, age over 4 years, and diagnostic codes for asthma. Multiple logistic regression was used to determine the influence of race/ethnicity and other significant factors on the receipt of an ICS prescription. MEASUREMENTS AND MAIN RESULTS: There were 1,469 patients with asthma, corresponding to a weighted sample of 14,401,069 U.S. patients with asthma who met the inclusion criteria, represented by 16.1% Hispanic, 59.5% female, and mean age of 39.9 years. Among non-Hispanic white patients with asthma, 39.7% (35% children and 41% adults) had a receipt of an ICS prescription compared with 22.2% of Hispanic patients (23.9% children and 21.2% adults); P < 0.001. In the multiple regression model, Hispanic patients aged 18 years or older had 43% lower odds (odds ratio, 0.6; 95% confidence interval, 0.3-0.9) of having a receipt of an ICS prescription compared with non-Hispanic white patients, independent of other factors. There was no significant difference in receipt of an ICS prescription between Hispanic and non-Hispanic white children with asthma (aged 4-17 yr). CONCLUSIONS: The disparity in the receipt of ICS prescription between Hispanic and non-Hispanic white adult patients with asthma could result in suboptimal asthma management, a higher rate of exacerbations, and higher health care costs in this growing minority population. The differences and potential disparities in the receipt of an ICS prescription between Hispanic and non-Hispanic white patients with asthma warrant further investigation to better understand the reasons for such disparities, along with their impact on the U.S. health care burden and interventions that can be undertaken to reduce these disparities.

Hospital-based inpatient resource utilization associated with autosomal dominant polycystic kidney disease in the US.

OBJECTIVE: Polycystic kidney disease (PKD) is a clinically and genetically heterogeneous class of genetic disorders characterized by development of renal cysts leading to renal failure and end stage renal disease (ESRD). Autosomal dominant polycystic kidney disease (ADPKD) accounts for the majority of PKD cases and is the predominant monogenic cause of ESRD. Limited information on patient characteristics and healthcare resource utilization is available in this population. This study assessed hospital-based inpatient utilization of patients with ADPKD in the US to help further understand the disease, which may lead to treatments that delay progression and reduce healthcare resource utilization. METHODS: A cross-sectional analysis was conducted using MedAssets Health System Data to investigate inpatient resource utilization for a total of 1876 patients hospitalized with ADPKD or chronic kidney disease (CKD). Patient characteristics and inpatient resource utilization were compared between hospitalized patients with ADPKD and CKD, including demographic and clinical characteristics, overall health, rates of complications and surgical interventions, and average length of hospital and intensive care unit stay. RESULTS: Compared with patients with CKD, patients with ADPKD were more likely to have commercial insurance as their primary payer (36.1 vs 17.8%) and were significantly younger (mean age 57.9 vs 69.5 years) and generally healthier (Charlson Comorbidity Score of 2.0 vs 3.3). Patients with ADPKD also had a substantially shorter average length of hospital stay (6.3 vs 10.3 days). However, patients with ADPKD experienced more kidney-related complications and a higher surgical procedure rate (mainly for transplant and complete nephrectomy). CONCLUSIONS: Although patients with ADPKD were generally healthier than patients with CKD, specific kidney function complications were more frequent. Patients with ADPKD had a higher rate of major kidney procedures, which may contribute to the high burden of ADPKD-related hospital-based inpatient resource utilization.

One-year prevalence, comorbidities and cost of cachexia-related inpatient admissions in the USA.

BACKGROUND: Cachexia is a condition characterized as a loss in body mass or metabolic dysfunction and is associated with several prevalent chronic health conditions including many cancers, COPD, HIV, and kidney disease, with between 10 and 50% of patients with these conditions having cachexia. Currently there is little research into cachexia and our objective is to characterize cachexia patients, their healthcare utilization, and associated hospitalization costs. Given the increasing prevalence of chronic diseases, it is important to better understand cachexia so that the condition can be better diagnosed and managed. METHODS: We utilized one year (2009) of the Nationwide Inpatient Sample (NIS). The NIS represents all inpatient stays at a random 20% sample of all hospitals within the United States. We grouped cachexia individuals by primary or secondary discharge diagnosis and then compared those with cachexia to all others in terms of length of stay (LOS) and total cost. Finally we looked into factors predicting increased LOS using a negative binomial model. RESULTS: We estimated US prevalence for cachexia-related inpatient admissions at 161,898 cases. Cachexia patients were older, with an average age of 67.95 versus 48.10 years in their non-cachexia peers. Hospitalizations associated with cachexia had an increased LOS compared to non-cachexia patients (6 versus 3 days), with average costs per stay $4641.30 greater. Differences were seen in loss of function (LOF) with cachexia patients, mostly in the major LOF category (52.60%), whereas non-cachexia patients were spread between minor, moderate, and major LOF (36.28%, 36.11%, and 21.26%, respectively). Significant positive predictors of increased LOS among cachexia patients included urban hospital (IRR=1.21, non-teaching urban; IRR=1.23, teaching urban), having either major (IRR=1.41) or extreme (IRR=2.64) LOF, and having a primary diagnosis of pneumonia (IRR=1.15). CONCLUSION: We have characterized cachexia and seen it associated with increased length of stay, increased cost, and more severe loss of function in patients compared to those without cachexia.

Rising Costs of COPD and the Potential for Maintenance Therapy to Slow the Trend.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) affects an estimated 14% of adults in the United States between the ages of 40 and 79 years. This progressive disease is characterized by persistent airflow limitation. The management of patients with COPD is focused on reducing risk factors, relieving symptoms, and preventing exacerbations. OBJECTIVE: To examine the peer-reviewed literature on the impact of maintenance therapy on the direct treatment costs of patients with COPD in the United States. METHODS: PubMed was searched for articles written in English that were published between 2000 and 2013, using the search terms "COPD," "economics," "exacerbation," "maintenance," and related terms. Articles reporting the results of longitudinal studies of the costs associated with the management of patients with COPD, the costs associated with hospitalizations for acute exacerbations of COPD, and randomized clinical trials evaluating the effects of maintenance therapy on the incidence of COPD exacerbations were included in this review. RESULTS: The search identified a total of 277 articles, and 11 of these articles were deemed appropriate for inclusion in this review. The direct healthcare costs for patients with COPD increased by 38% between 1987 and 2007, and continued to increase by approximately 5% annually between 2006 and 2009. The costs associated with hospital admissions for patients with COPD accounted for the largest absolute increase ($2289 per admission in constant 2007 US dollars). Recent estimates suggest that the aggregate costs associated with the treatment of acute exacerbations are between $3.2 billion and $3.8 billion, and that annual healthcare costs are 10-fold greater for patients with COPD associated with acute exacerbations than for patients with COPD but without exacerbations. The results of 2 large clinical trials of maintenance therapy, including a long-acting cholinergic antagonist or a long-acting beta-2 agonist, showed a 16% to 17% reduction in the incidence of exacerbations compared with placebo. Nevertheless, maintenance therapy remains underutilized, with only 30% to 35% of patients with COPD in private and public health insurance plans receiving prescriptions for maintenance therapy. CONCLUSIONS: The treatment of acute exacerbations of COPD remains the major driver of increasing healthcare costs associated with this condition. The appropriate use of maintenance therapy has been shown to reduce the incidence of exacerbations and has the potential to reduce overall costs associated with the management of patients with COPD.

Direct medical costs for complications among children and adults with diabetes in the US commercial payer setting.

BACKGROUND: Complications associated with diabetes are a major contributor to the burden of the disease. To better inform decision modelling, there is a need for cost estimates of specific diabetes-related complications, stratified by diabetes type and patient age group. OBJECTIVE: To obtain direct medical costs of managing and treating diabetes-related complications over a 2-year period, for adults and children with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM), using data from a large commercially insured US subscriber database. METHODS: We examined records from a large US multi-payer claims database to identify patients with any diabetes-related complications included in nine pre-specified categories, filed between January 2009 and September 2010, and with pre-index evidence of T1DM or T2DM. Patients were required to have continuous health plan enrolment 12 months before and 24 months after each index complication. Patients were classified into cohorts based on their diabetes type and age status at the time of the complication. The direct medical cost associated with each complication was calculated for the 12- and 24-month follow-up periods. Mean paid and allowed total costs were calculated and inflation-adjusted to the year 2011. RESULTS: Of the 119,715 patients who met the inclusion criteria, 211 (0.2 %) were categorized as children with T1DM, 55 (0.05 %) as children with T2DM, 6,227 (5.2 %) as adults with T1DM and 113,222 (94.6 %) as adults with T2DM. The respective mean cohort ages were 13.5, 14.9, 48.5 and 58 years. Proteinuria/albuminuria was the most common complication for T1DM and T2DM child cohorts, with this complication occurring in almost one third of these children. Among the child cohorts, renal disease accounted for the highest mean paid cost for T1DM patients (US$6,053) whereas for T2DM patients, the complication associated with the highest mean paid cost was lactic acidosis (US$25,053). For the adult T1DM cohort, the complications with the highest occurrence and highest mean total paid cost were non-proliferative retinopathy (40.3 %) and renal disease (US$28,076), respectively. Similarly, for the adult T2DM cohort, these complications were neuropathy (26.8 %) and peritoneal dialysis (US$32,826). CONCLUSION: With the continuing and increasing interest in child and adult T1DM and T2DM, stakeholders will need relevant and timely information to guide treatment decision making. This cost research may directly inform the economic models that are often developed to better identify, understand and manage key economic considerations that drive the costs of this chronic disease.