RESUMO
Objective: Little U.S. pharmacoepidemiologic study is based on treatment during continuous enrollment for periods more than a year. This study aims to show pediatric patterns of stimulant use (alone or with other psychotropic classes) from Medicaid administrative claims data for stimulant patterns of 3- to 8-year continuous enrollees. Methods: A retrospective cohort study was derived from Medicaid enrollment, pharmacy, and diagnosis claims data (2007-2014) in a mid-Atlantic state. Youth aged 2-17 years with 3-8 years of continuous enrollment treated with stimulants were compared with a date-matched comparison group treated without stimulants. Major outcomes include prevalence and duration of stimulant use and patterns of stimulant polypharmacy across relatively long enrollments (3-8 years). Results: Among 264,518 unique 2- to 17-year olds with 3-8 years of continuous enrollment, 16.5% had stimulant prescription dispensings, doubling the annual national prevalence of 8.1%. Subgroup analysis showed that the highest prevalence of stimulant use was for 6- to 11-year olds (20.4%), foster care eligible youth (42.3%), and those with 7-8 years of continuous enrollment (20.1%). Externalizing psychiatric disorders were far more common in those treated with stimulants than in those treated without stimulants. The duration of stimulant exposure overall was a median of 487 days, half that of foster care stimulant users. Stimulant polypharmacy with two or more psychotropic classes concomitantly characterized 29.8% of stimulant users. Among those with three or four or more class polypharmacy, 85% and 88%, respectively, had concomitant stimulant and antipsychotic use. The adjusted odds ratio (AOR) of three or more class polypharmacy significantly increased in 12- to 17-year-old age group (AOR = 1.8), foster care eligibility (AOR = 4.5), and among those with the longest enrollment (AOR = 1.7). Conclusions and Relevance: Stimulant prevalence in Medicaid-insured youth with continuous enrollment of 3-8 years was twice as common as in annual data sets. Future research should investigate three to five interclass stimulant polypharmacy effectiveness in reliably diagnosed community populations.
Assuntos
Antipsicóticos , Estimulantes do Sistema Nervoso Central , Transtornos Mentais , Estados Unidos , Criança , Humanos , Adolescente , Estudos Retrospectivos , Medicaid , Psicotrópicos/uso terapêutico , Antipsicóticos/uso terapêutico , Transtornos Mentais/tratamento farmacológico , Estimulantes do Sistema Nervoso Central/uso terapêuticoRESUMO
PURPOSE: Combined modality therapy (CMT; radiation and chemotherapy) is indicated for fit, elderly patients with inoperable, locally advanced non-small cell lung cancer. We used population level data to examine effects of CMT on survival. METHODS: Medicare patients who are 66 years or older with locally advanced non-small cell lung cancer (stages IIIA and IIIB without pleural effusion) from 1997 to 2002 were identified in Surveillance Epidemiology and End Results-Medicare. Detailed insurance claims were used to characterize treatment modality (none, chemotherapy only, radiotherapy only [XRT-ONLY], or CMT). CMT was further categorized as sequential (CMT-SEQ), or concurrent chemoradiation alone (CMT-ONLY), with induction (CMT-IND), or with consolidation chemotherapy (CMT-CON). Nonparametric models estimated survival effects of treatment regimens, controlling for patient characteristics, including claims-based indicators of performance status. Propensity score analysis adjusted for treatment selection. RESULTS: Of the 6325 patients, 66% received therapy, with 41% (N = 1745) receiving XRT-ONLY and 45% (N = 1909) receiving CMT (12.5% CMT-SEQ, 35.3% CMT-ONLY, 11.3% CMT-IND, and 20.3% with CMT-CON). CMT had a survival benefit relative to XRT-ONLY (hazard ratio: 0.782, 95% confidence interval: 0.750-0.816; additional 4.4 months median survival; adjusted 10.7% increase in 1-year survival). Relative to CMT-SEQ, concurrent CMT-ONLY was associated with an increased mortality risk, whereas CMT-IND regimens provided a survival benefit (hazard ratio: 0.731, 95% confidence interval: 0.600-0.891; additional 3.8 months; and adjusted 14.4% increase in 1-year survival). CONCLUSION: Survival benefits associated with CMT in clinical trials can extend to the elderly in routine care settings. CMT-ONLY is associated with the greatest mortality risk, suggesting that more gradual strategies (CMT-IND) may be more appropriate for the elderly population.
Assuntos
Adenocarcinoma/mortalidade , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Carcinoma de Células Escamosas/mortalidade , Neoplasias Pulmonares/mortalidade , Recidiva Local de Neoplasia/mortalidade , Adenocarcinoma/epidemiologia , Adenocarcinoma/terapia , Idoso , Carcinoma Pulmonar de Células não Pequenas/epidemiologia , Carcinoma Pulmonar de Células não Pequenas/terapia , Carcinoma de Células Escamosas/epidemiologia , Carcinoma de Células Escamosas/terapia , Terapia Combinada , Feminino , Seguimentos , Humanos , Neoplasias Pulmonares/epidemiologia , Neoplasias Pulmonares/terapia , Masculino , Medicare , Recidiva Local de Neoplasia/epidemiologia , Recidiva Local de Neoplasia/terapia , Estadiamento de Neoplasias , Radioterapia , Programa de SEER , Taxa de Sobrevida , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: To update knowledge of the prevalence of the use of psychotherapeutic medications in preschoolers with Medicaid insurance as requested by the Best Pharmaceuticals for Children Act of 2002 (BPCA). METHOD: Prescription, enrollment, and outpatient visit data from 7 state Medicaid programs were used to identify 274,518 youths continuously enrolled in 2001 and aged 2 to 4 on January 1, 2001. Annual prevalence of use was defined as one or more dispensed prescriptions for a psychotherapeutic medication and adjusted for anticonvulsant and anxiolytic/sedative/hypnotic use according to ICD-9 diagnostic groupings. Prevalence ratios adjusted for age, race/ethnicity, and gender were estimated. RESULTS: 2.30% (CI = 2.24, 2.36) of preschoolers received one or more dispensings for a psychotherapeutic medication in 2001, approximately doubling the usage of comparable youth from 2 other state Medicaid programs studied in 1995. Boys were 2.4 times more likely than girls to receive psychotherapeutic medication. Whites were 4 times more likely than Hispanics and twice as likely as Blacks to receive medication for psychiatric or behavioral conditions. Since the mid-1990s, usage increased, especially for atypical antipsychotics and antidepressants. The prominent use of anticonvulsants (78.8%) and anxiolytic/sedative/hypnotic drugs (91.4%) in those with no psychiatric diagnosis, but with other medical diagnoses, shows that much use therein reflects treatment for seizures, rather than mood stabilization, and for minor medical conditions, rather than psychiatric disorders. CONCLUSION: Preschool psychotherapeutic medication use increased across ages 2 to 4 for stimulants, antipsychotics, and antidepressants, reflecting use for psychiatric/behavioral disorders. However, the use of anxiolytic/sedative/hypnotics and anticonvulsants was more stable across these years, suggesting medical usage. Additional research to assess the benefits and risks of psychotherapeutic drugs is needed, particularly when such usage is off-label for both psychiatric and nonpsychiatric conditions.
Assuntos
Medicaid , Transtornos Mentais/epidemiologia , Psicotrópicos/administração & dosagem , Fatores Etários , Pré-Escolar , Prescrições de Medicamentos/estatística & dados numéricos , Uso de Medicamentos , Feminino , Humanos , Masculino , Transtornos Mentais/diagnóstico , Transtornos Mentais/tratamento farmacológico , Prevalência , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: To compare antidepressant prevalence data in youths across three western European countries (Denmark, Germany, and the Netherlands) with US regional data in terms of age and gender and to show proportional subclass antidepressant (ATD) use. METHOD: A population-based analysis of administrative claims data for the year 2000 was undertaken in 0 to 19-year-old enrollees who were part of the insured populations from four countries having a total of from 72,570 to 480,680 members. RESULTS: ATD medication utilization in the US dataset (1.63%) exceeded that of three Western European countries (prevalence ranged from 0.11 to 0.54%) by at least 3-fold. There were major variations in the use of subclasses: tricyclic antidepressants (TCAs) predominated in Germany while selective serotonin reuptake inhibitors (SSRIs) predominated in the US, Denmark and the Netherlands. CONCLUSIONS: Cross-national variations should be further explored to understand the factors related to these differences and how prevalence differences relate to effectiveness and safety. Community-based cohorts should be followed to establish outcomes in the usual practice setting.
Assuntos
Antidepressivos/uso terapêutico , Padrões de Prática Médica/estatística & dados numéricos , Adolescente , Distribuição por Idade , Antidepressivos/classificação , Antidepressivos Tricíclicos/uso terapêutico , Criança , Pré-Escolar , Estudos Transversais , Dinamarca/epidemiologia , Transtorno Depressivo/tratamento farmacológico , Transtorno Depressivo/epidemiologia , Uso de Medicamentos/estatística & dados numéricos , Alemanha/epidemiologia , Humanos , Lactente , Formulário de Reclamação de Seguro/estatística & dados numéricos , Países Baixos/epidemiologia , Farmacoepidemiologia , Vigilância da População , Prevalência , Inibidores Seletivos de Recaptação de Serotonina/uso terapêutico , Distribuição por Sexo , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: This study compared the prevalence of anticonvulsant treatment for youths with a diagnosis of a psychiatric disorder to youths with a diagnosis of a seizure disorder. METHODS: Administrative claims from outpatient visits and prescriptions were organized for a data set of 258,472 youths who were younger than 18 years of age in a mid-Atlantic state Medicaid program and were continuously enrolled in 2000. Youths dispensed an anticonvulsant were grouped into the following ICD-9 diagnostic categories: a diagnosis of a psychiatric disorder without a seizure disorder, a diagnosis of a seizure disorder without a psychiatric disorder, and a diagnosis of both a psychiatric and a seizure disorder. Anticonvulsant use was analyzed for specific diagnostic classes by age, gender, race or ethnicity, and Medicaid eligibility categories. RESULTS: A total of 4,522 youths in the one-year data set received an anticonvulsant (1.75 percent): 3,061 had a psychiatric disorder only, 251 had a seizure disorder only, and 611 had both psychiatric and seizure disorders. Among anticonvulsant-treated youths with diagnosis information in their records (3,923 of 4,522 youths), 81 percent had a psychiatric diagnosis and 19 percent had a seizure disorder; 71 percent of those with a seizure disorder also had a psychiatric disorder. Anticonvulsant use for seizure control was proportionally greater for those younger than five years. By contrast, a vast majority of anticonvulsant users with a psychiatric diagnosis were between five and 17 years. Among anticonvulsant-treated youths with a psychiatric diagnosis, males were approximately twice as common as females. For youths with a seizure disorder, no difference was found for gender. Mood disorders and attention-deficit hyperactivity disorder were the major psychiatric diagnoses associated with anticonvulsant use. Valproic acid products were the most commonly dispensed type of anticonvulsant. CONCLUSIONS: Recent state Medicaid data reveal that youths who use anticonvulsants are far more likely to have a psychiatric diagnosis than a seizure diagnosis. Widespread off-label use of anticonvulsants for psychiatric disorders among youths warrants attention to ensure benefits and minimize risks.
Assuntos
Anticonvulsivantes/uso terapêutico , Transtornos Mentais/tratamento farmacológico , Convulsões/tratamento farmacológico , Adolescente , Fatores Etários , Assistência Ambulatorial , Criança , Pré-Escolar , Serviços Comunitários de Saúde Mental/estatística & dados numéricos , Comorbidade , Uso de Medicamentos , Definição da Elegibilidade , Feminino , Humanos , Formulário de Reclamação de Seguro/estatística & dados numéricos , Masculino , Medicaid/estatística & dados numéricos , Transtornos Mentais/epidemiologia , Mid-Atlantic Region/epidemiologia , Convulsões/epidemiologia , Fatores Sexuais , Fatores Socioeconômicos , Ácido Valproico/uso terapêuticoRESUMO
OBJECTIVE: The aim of this study was to compare multiple psychotropic use among youths enrolled in two U.S. mid-Atlantic state Medicaid and state Children's Health Insurance Programs (SCHIP). METHODS: Administrative data were used to examine multiple psychotropic use among youths less than 20 years of age and who were continuously enrolled in Medicaid or SCHIP programs in two states during 1999. Multiple psychotropic use referred to multiclass combinations and was defined by the number of months of multiple use. Main outcome measures were the prevalence of multiple psychotropic use and months of multiple use. Demographic and clinical characteristics, mental health visits, and common combinations were examined according to months of multiple use. RESULTS: Among continuously enrolled youths, 21%-22% had at least one mental health-related visit, 8%-10% received a psychotropic medication, and 2%-3% received multiple psychotropic medications. Nearly one third (28%-30%) of youths with any psychotropic use received multiple medications, of which almost half was for 5-12 months. Multiclass use was more common in male, white, aged 10-14, disabled, and foster-care youths. Stimulants with antidepressants, antipsychotics, or alpha-agonists were the most common combinations. CONCLUSIONS: Multiple use occurred in nearly one third of youths with any psychotropic treatment. Additional research is needed to investigate switching patterns and the effectiveness of combined pharmacotherapy.
Assuntos
Psicotrópicos/uso terapêutico , Planos Governamentais de Saúde , Adolescente , Adulto , Criança , Pré-Escolar , Estudos Transversais , Quimioterapia Combinada , Feminino , Humanos , Seguro Saúde , Masculino , Medicaid , Estados UnidosRESUMO
OBJECTIVE: This study sought to determine the degree to which Medicaid eligibility categories modify disparities between black and white youths in the prevalence of psychotropic medication. METHODS: Computerized claims for 189,486 youths aged two to 19 years who were continuously enrolled in a mid-Atlantic state Medicaid program for the year 2000 were analyzed to determine population-based annual prevalence of psychotropic medication by race or ethnicity and by whether the youths were eligible for Medicaid for reasons of family income, disability, or foster care placement. Logistic regression was used to assess the interaction of eligibility category and race. RESULTS: The mean annual prevalence of psychotropic medication for the population was 9.9 percent. The prevalence was 2.17 times higher for white youths than for black youths (16.5 percent compared with 7.6 percent). However, within eligibility categories, the white-to-black disparity was 3.8 among youths who were eligible for Medicaid because their family income was below the federal poverty level and 3.2 for youths enrolled in the State Children's Health Insurance Program. CONCLUSIONS: Medicaid eligibility categories had a profound impact on the racial disparity associated with the prevalence of psychotropic medications for youths. Eligibility category should be taken into account when ascertaining the role of access, undertreatment, and culture in disparities in mental health treatment.
Assuntos
Uso de Medicamentos/estatística & dados numéricos , Definição da Elegibilidade , Medicaid/legislação & jurisprudência , Transtornos Mentais/tratamento farmacológico , Transtornos Mentais/etnologia , Serviços de Saúde Mental/provisão & distribuição , Psicotrópicos/uso terapêutico , Adolescente , Psiquiatria do Adolescente/economia , Adulto , Criança , Psiquiatria Infantil/economia , Pré-Escolar , Família/psicologia , Feminino , Humanos , Masculino , Serviços de Saúde Mental/estatística & dados numéricos , Prevalência , Fatores Socioeconômicos , Estados Unidos/epidemiologiaRESUMO
The one-year prevalence of use of psychotropic medications among youths enrolled in a Mid-Atlantic State Children's Insurance Program (SCHIP) in 1999 or 2000 was compared with the 1998-2000 prevalence findings for youths enrolled in four large multistate private medical insurance programs. Prevalence was significantly higher among youths enrolled in the SCHIP than among those with private insurance in all eight medication group comparisons. Unlike private insurance, the surveyed state SCHIP program did not require a copayment or have a restrictive formulary. These administrative differences may partly explain the comparatively higher rate of psychotropic use under the SCHIP.
Assuntos
Uso de Medicamentos/estatística & dados numéricos , Seguro de Serviços Farmacêuticos , Seguro Psiquiátrico , Transtornos Mentais/tratamento farmacológico , Transtornos Mentais/epidemiologia , Serviços de Saúde Mental/organização & administração , Setor Privado/estatística & dados numéricos , Psicotrópicos/uso terapêutico , Setor Público/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Humanos , Serviços de Saúde Mental/economia , Mid-Atlantic Region/epidemiologia , Prevalência , Psicotrópicos/economia , Planos Governamentais de Saúde , Estados UnidosRESUMO
OBJECTIVE: To examine changes in antidepressant (ATD) prevalence and the sociodemographic and clinical correlates of ATD use among youths who are treated in community practice settings. METHODS: A retrospective study was undertaken using large data sets from 3 US sites. Outpatient prescription and clinical service records of youths who were aged 2 to 19 and enrolled in Midwestern Medicaid (MWM) and mid-Atlantic Medicaid (MAM) state programs and a group-model health maintenance organization (HMO) were organized into seven 1-year cross-sectional data sets from 1988 through 1994 to evaluate ATD utilization patterns. RESULTS: In 1994, ATD prevalence per 1000 youths was 19.10 (MWM), 17.78 (MAM), and 12.85 (HMO), which represented a consistent increase in prevalence from 1988-1994: 2.9-fold (MWM), 4.6-fold (MAM), and 3.6-fold (HMO). Despite the rapidly expanding use of selective serotonin reuptake inhibitors prescribed mainly for depression, more than half of ATD use in 1994 was still attributable to tricyclic antidepressants prescribed mainly for attention-deficit/hyperactivity disorder. ATD prevalence was generally predominant among 10- to 14-year-old boys and among 15- to 19-year-old girls. In the Medicaid populations, 42% (MAM) and 72% (MWM) of ATD-treated youths had primary care services, whereas the bulk of the remainder had psychiatric services. Attention-deficit/hyperactivity disorder followed by depression led the physician-reported primary care diagnoses associated with ATD use, whereas that diagnostic rank order was reversed for youths who received psychiatric services. CONCLUSIONS: ATD treatments among youths substantially increased in the 1990s. This was generated primarily by primary care providers, and thus evaluations of the outcome of ATD treatment need to target primary care in addition to psychiatric providers. Longitudinal study designs are needed to evaluate the use of ATDs in youths in regard to the duration of treatment, combination medications, and the reasons for treatment.
Assuntos
Antidepressivos/uso terapêutico , Transtornos Mentais/tratamento farmacológico , Transtornos de Adaptação/tratamento farmacológico , Adolescente , Fatores Etários , Antidepressivos/administração & dosagem , Transtorno do Deficit de Atenção com Hiperatividade/tratamento farmacológico , Serviços Comunitários de Saúde Mental/estatística & dados numéricos , Transtorno Depressivo/tratamento farmacológico , Quimioterapia Combinada , Uso de Medicamentos , Feminino , Sistemas Pré-Pagos de Saúde/estatística & dados numéricos , Humanos , Masculino , Medicaid/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: The objective was to study the association of age, comorbid illness, race, and type of hospital with resource use in patients undergoing hysterectomy and lymph node dissection for endometrial cancer. METHODS: The study was a population-based analysis of patients undergoing hysterectomy with a diagnosis of endometrial cancer in Maryland 1994-1996. Chi-square and t tests determined differences in means or proportions. Multivariate logistic regression methods were used to build predictive models. RESULTS: The 1281 women underwent total abdominal hysterectomy, 91%; total vaginal hysterectomy, 6%; radical hysterectomy, 2.5%, laparoscopically assisted total vaginal hysterectomy, 0.3%; 32% also underwent lymph node dissection. Neither age, nor race, nor comorbid illness influenced admission to teaching hospitals. Co-morbidity was documented in 56% of cases. African Americans were more likely to have one (P = 0.002) or >1 co-morbid illness (P = 0.045) than Caucasians. The most common complications were anemia (13.6%), infection/fever (12%), cardiac (9.4%), pneumonia (8%), ileus (5%), and bowel obstruction (5%). These complications occurred with higher frequency in teaching hospitals (P = 0.0001), In large hospitals (P = 0.0001), and in African American patients compared to Caucasians (P = 0.028). Multivariate regression analysis revealed that older age, admission to teaching or large hospitals, lymph node dissection, heart disease, and African American race were associated with significantly higher resource use. CONCLUSION: We documented age and racial/ethnic differences in comorbid illness, complications, and resource utilization for patients undergoing hysterectomy for endometrial cancer. The differences in resource use for teaching hospitals may be reflective of the severity of complications, which are indirectly determined by length of stay. Given the higher costs and skills required to care for elderly women with comorbid disease and complications, quantification of the complexity of care is of utmost importance for allocation of sufficient resources for the care of women with endometrial cancer.