RESUMO
BACKGROUND: Our objective was to estimate the impact of universal varicella vaccination (UVV) on the use and costs of antibiotics and antivirals for the management of varicella among children in the United States (US). METHODS: A decision tree model of varicella vaccination, infections and treatment decisions was developed. Results were extrapolated to the 2017 population of 73.5 million US children. Model parameters were populated from published sources. Treatment decisions were derived from a survey of health care professionals' recommendations. The base case modelled current vaccination coverage rates in the US with additional scenarios analyses conducted for 0%, 20%, and 80% coverage and did not account for herd immunity benefits. RESULTS: Our model estimated that 551,434 varicella cases occurred annually among children ≤ 18 years in 2017. Antivirals or antibiotics were prescribed in 23.9% of cases, with unvaccinated children receiving the majority for base case. The annual cost for varicella antiviral and antibiotic treatment was approximately $14 million ($26 per case), with cases with no complications accounting for $12 million. Compared with the no vaccination scenario, the current vaccination rates resulted in savings of $181 million (94.7%) for antivirals and $78 million (95.0%) for antibiotics annually. Scenario analyses showed that higher vaccination coverage (from 0% to 80%) resulted in reduced annual expenditures for antivirals (from $191 million to $41 million), and antibiotics ($82 million to $17 million). CONCLUSIONS: UVV was associated with significant reductions in the use of antibiotics and antivirals and their associated costs in the US. Higher vaccination coverage was associated with lower use and costs of antibiotics and antivirals for varicella management.
Assuntos
Varicela , Antibacterianos/uso terapêutico , Antivirais/uso terapêutico , Varicela/tratamento farmacológico , Varicela/epidemiologia , Varicela/prevenção & controle , Vacina contra Varicela/uso terapêutico , Criança , Análise Custo-Benefício , Herpesvirus Humano 3 , Humanos , Estados Unidos/epidemiologia , VacinaçãoRESUMO
BACKGROUND: The landscape for hemophilia A prophylaxis is rapidly expanding from factor VIII replacement therapy to include novel treatments such as nonfactor replacement therapies that may enhance coagulation (e.g., emicizumab) or inhibit anticoagulant pathways (e.g., fitusiran and concizumab). For payers, this expansion presents challenges in balancing well-established treatments with new options that cost more and have lesser known real-world safety and efficacy. OBJECTIVE: To evaluate likely coverage practices for hemophilia A prophylaxis therapies among U.S. payers given evolving real-world data on safety and efficacy. METHODS: A 3-round modified Delphi process was conducted with representatives of U.S. commercial health plans who had considerable expertise in managing populations of patients with hemophilia. Round 1 consisted of an online questionnaire; round 2 involved an online discussion about the aggregated results from round 1; and round 3 allowed participants to revise their responses from round 1 based on insights gained during round 2. Questions elicited ratings, rankings, and estimates on access restrictions based on given safety and efficacy information for hemophilia A prophylaxis therapies. Consensus was reached if ≥ 74% of panelists (14 of 19) were within 1 SD of the median group estimate during round 3. RESULTS: 19 Payers participated in the research. Among them, 94% dealt with commercial insurance, 94% with Medicare, and 81% with Medicaid; 79% had spent ≥ 5 years in their current role. Panelists reported limited access restrictions on hemophilia A prophylaxis therapies; the most common restrictions were prior authorization (n = 16, 84%) and quantity level limits (n = 13, 67%). Tiering and step therapy were reported by 7 respondents (39%). Respondents agreed that there was an 80% median likelihood that ≥ 9 additional patients with any safety event (e.g., thrombotic event, death) per year would trigger access restrictions, with the median likelihood of restrictions increasing to 95% for another ≥ 10 patients with safety events per year. Respondents also agreed that > 5 thrombotic events requiring treatment per patient per year would have a 98% median likelihood of leading to access restrictions and that ≥ 5 years of real-world safety and efficacy data would be highly likely (95% median likelihood) to affect coverage decisions. Noncoverage was highly unlikely (ranked fifth or sixth of 6 by 14 respondents), as was no restriction-coverage parity (ranked sixth of 6 by 10 respondents). All else being equal, cost continues to affect access policies, with respondents agreeing that a 13%-30% difference in net cost may lead to preferred formulary treatment for a drug with superior efficacy and noninferior safety, inferior efficacy and noninferior safety, or noninferior efficacy and inferior safety. CONCLUSIONS: Payers prefer treatments with well-understood efficacy, safety, and cost over newer treatments with uncertain long-term effects. Relatively unrestricted access to legacy and new hemophilia A prophylaxis will likely continue unless additional real-world safety concerns or major cost differences emerge. DISCLOSURES: Financial support for this study was provided by Takeda Pharmaceutical Company, which was involved in study concept and design. Graf, Tuly, Harley, and Pednekar are employees of PRECISIONheor, a research consultancy to the health and life sciences industries that was contracted by Takeda to conduct this study and write the manuscript. Batt served as a consultant on this project through PRECISIONheor.
Assuntos
Coagulantes/economia , Coagulantes/uso terapêutico , Hemofilia A/tratamento farmacológico , Cobertura do Seguro , Política Organizacional , Técnica Delphi , Custos de Medicamentos , Humanos , Entrevistas como Assunto , Pesquisa Qualitativa , Inquéritos e Questionários , Estados UnidosRESUMO
BACKGROUND: Oncogenic types of human papillomavirus (HPV) have been linked to 99.7% of cervical cancer cases worldwide. METHODS: This retrospective claims-based analysis was conducted to assess patterns of use and costs associated with diagnostic and treatment procedures for disease attributed to HPV performed before the introduction of HPV vaccination (January 1, 2001-May 31, 2006). Percentages of commercially insured health plan enrollees who underwent each procedure of interest were calculated for each year. Annual costs (combined patient and health plan-paid amounts) were calculated from qualifying medical claims. Descriptive statistics were used to assess trends in procedure rates and costs. RESULTS: Data for approximately 14.2 million enrollees were obtained. Hysterectomy was the most commonly administered treatment. With the exception of colposcopy with LEEP, all other treatment procedures experienced a decline in rate of use. The most frequently performed diagnostic procedure was colposcopy with endocervical curettage (ECC). With the exception of ECC, rates of diagnostic procedures reached a peak among 20- to 24-year-olds, and followed a downward trend across older groups. Hysterectomy was the most expensive treatment (median $7,383; mean $8,384) per procedure in 2006. CONCLUSION: Results reveal high rates of use and high-associated costs of diagnostic procedures and treatments related to disease attributed to HPV. IMPACT: The data presented may be useful in cost-effectiveness analyses and to guide decision makers evaluating how best to optimize prevention strategies.
Assuntos
Colo do Útero/virologia , Custos de Cuidados de Saúde , Infecções por Papillomavirus/terapia , Adolescente , Adulto , Colo do Útero/cirurgia , Criança , Pré-Escolar , DNA Viral/análise , Dilatação e Curetagem/economia , Feminino , Humanos , Histerectomia/economia , Lactente , Recém-Nascido , Pessoa de Meia-Idade , Papillomaviridae/isolamento & purificação , Estudos Retrospectivos , Esfregaço Vaginal/economia , Esfregaço Vaginal/estatística & dados numéricosRESUMO
PURPOSE: With rising health care costs in the United States, clearly defined end-of-life (EOL) cancer costs are needed to help health administrators proactively manage this important care. Our objective was to examine EOL health care resource costs among oncology patients in a US commercial insurance population. METHODS: A retrospective claims database affiliated with OptumInsight was analyzed. Included patients had: a medical claim with cancer diagnosis between July 1, 2002, and December 31, 2009; death on or before December 31, 2009; continuous enrollment with medical/pharmacy benefits from diagnosis until death; ≥ 180 follow-up days; and active cancer in the last 6 months before death (MBD). Death was captured from facility discharge codes or Social Security Administration death files. Costs were determined by summing paid amounts on all services utilized within the last 6 MBD: cancer-related inpatient (IP) stays, cancer- related hospice care, and cancer-related outpatient (OP) services (ie, chemotherapy, erythropoiesis-stimulating agents, granulocyte colony-stimulating factors, radiation, cancer-related office or emergency room visits, cancer-related hospital OP procedures, and other services with cancer diagnosis). RESULTS: A total of 28,530 patients met inclusion criteria. Mean total cancer-related costs in the last 6 MBD were $74,212 (standard deviation, $112,740), comprising IP costs of $40,702 (55%), OP costs of $30,254 (41%), and hospice costs of $3,256 (4%). OP costs decreased from $6,021 in the sixth MBD to $2,238 in the last MBD, whereas IP care costs increased from $1,785 to $20,559. Hospice utilization increased from 0.7% in the sixth MBD to 35.6% in the last MBD. CONCLUSION: Oncology costs increase in the last 6 MBD largely because of increased IP costs, whereas OP costs decrease.
Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Neoplasias/economia , Assistência Terminal/economia , Idoso , Assistência Ambulatorial/economia , Assistência Ambulatorial/estatística & dados numéricos , Feminino , Pesquisa sobre Serviços de Saúde/métodos , Cuidados Paliativos na Terminalidade da Vida/economia , Cuidados Paliativos na Terminalidade da Vida/estatística & dados numéricos , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/terapia , Estudos Retrospectivos , Estados UnidosRESUMO
OBJECTIVE: Describe treatment patterns, resource use, and predictors of methylphenidate (MPH) switch among children (6-12 years), adolescents (13-17 years), and adults (≥ 18 years) with attention-deficit/hyperactivity disorder (ADHD). METHODS: This retrospective U.S. managed care database study used medical, pharmacy, and enrollment data to examine treatment patterns among patients with ≥ 1 ADHD diagnosis code (ICD-9 314.00-314.9), MPH pharmacy claims during 01/01/2004-09/30/2006, and no ADHD pharmacy claims in prior 6 months. Patients were followed for 1 year for dosage change, switch (change to non-MPH treatment), augmentation, persistence (number days on index medication) and adherence (days supplied/days persistent). End points were assessed by age group and MPH formulation. Cox proportional hazards modeling was conducted to determine predictors of MPH switch. RESULTS: Among 23,860 MPH users, 51.4% had a dosing change, 14% switched to a non-MPH agent, and 4% augmented MPH therapy. Among those prescribed long-acting (LA) MPH (N = 14,681), switching rates were 14% for children, 13% for adolescents, and 16% for adults. Augmentation rates for LA MPH were <5%. Overall, 53% of patients were adherent with mean persistence of 219 days. For the subgroup of patients prescribed LA MPH (n = 14,681), adherence ranged from 49% (adolescents) to 59% (children); persistence varied between 183 days (adults) to 256 days (children). During the 1-year follow-up, office/clinic visits were the major driver of health care resource use in MPH patients (mean 9.7 visits/patient). Patients with psychiatric comorbidity utilized significantly greater services. Predictors of MPH switch included psychiatric comorbidity (hazards ratio [HR] 1.37; 95% confidence interval [CI] = 1.26-1.48; p < 0.0001) and specialty prescribers (HR 1.19, 95% CI = 1.04-1.35; p = 0.011). Potential limitations of this study include use of claims data for definition of drug usage; inclusion of medications approved for use in ADHD; assessment of switching that may not have captured short-term augmentation; absence of economic, clinical and other variables from the claims dataset that may have influenced treatment selection, and outcomes. The 6-month baseline period to determine newly treated patients may not guarantee exclusion of all previously treated patients who restart therapy after an extended period. CONCLUSIONS: Children exhibited the highest persistence of MPH users. ADHD patients on MPH therapy with a psychiatric comorbidity may require additional follow-up to help improve adherence and reduce health care resource use.
Assuntos
Transtorno do Deficit de Atenção com Hiperatividade/tratamento farmacológico , Transtorno do Deficit de Atenção com Hiperatividade/psicologia , Metilfenidato/uso terapêutico , Adolescente , Idoso , Criança , Preparações de Ação Retardada/economia , Preparações de Ação Retardada/uso terapêutico , Humanos , Revisão da Utilização de Seguros , Programas de Assistência Gerenciada/estatística & dados numéricos , Adesão à Medicação , Metilfenidato/administração & dosagem , Metilfenidato/economia , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos , Adulto JovemRESUMO
OBJECTIVE: To examine cost and mortality among stage IV colorectal cancer (CRC) patients treated with 5-fluorouracil (5FU)/leucovorin/oxaliplatin (FOLFOX) or 5FU/leucovorin/irinotecan (FOLFIRI). METHODS: Adult CRC patients newly treated with FOLFOX or FOLFIRI were identified from a large database using medical and pharmacy claims for services delivered January 1, 2002 through December 31, 2005. Cancer stage for a subset of patients was abstracted from medical records. Outcomes were annualized costs calculated for 4 years of observation, and deaths as recorded by the National Death Index. Cost was analyzed using generalized linear modeling; mortality was modeled using Cox proportional hazards analysis. RESULTS: Unadjusted annualized median and mean costs were $134,401 and $152,213, respectively, for the FOLFOX cohort (n = 41) and $103,150 and $107,994 for the FOLFIRI cohort (n = 86). Death occurred among five (12%) FOLFOX and 42 (53%) FOLFIRI patients. Adjusted analysis revealed no significant difference in cost between cohorts, even after adjusting for reduced irinotecan costs due to generic availability. Incremental costs associated with one additional life saved per year were only $1,236 higher for patients treated with FOLFOX compared with FOLFIRI. Cox analysis revealed a significant survival advantage for FOLFOX over FOLFIRI (HR = 5.2; 95% CI: 1.7-15.8). CONCLUSIONS: A significant survival benefit was seen for CRC patients receiving FOLFOX versus FOLFIRI; multivariate analysis revealed no significant cost differences. However, the small sample size may have resulted in lack of adequate power to detect a difference between cohorts. There may be factors influencing mortality that were not included in the multivariate modeling.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/economia , Neoplasias Colorretais/economia , Neoplasias Colorretais/mortalidade , Custos de Cuidados de Saúde/estatística & dados numéricos , Antimetabólitos Antineoplásicos/economia , Antimetabólitos Antineoplásicos/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias Colorretais/tratamento farmacológico , Análise Custo-Benefício , Feminino , Fluoruracila/economia , Fluoruracila/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Retrospectivos , Estados UnidosRESUMO
PURPOSE: To evaluate the clinical outcomes and incremental health care costs of ischemic stroke in a US managed care population. PATIENTS AND METHODS: A retrospective cohort analysis was done on patients (aged 18+ years) hospitalized with noncardioembolic ischemic stroke from January 1, 2002, through December 31, 2003, identified from commercial health plan administrative claims. New or recurrent stroke was based on history in the previous 12 months, with index date defined as first date of indication of stroke. A control group without stroke or transient ischemic attack (TIA) was matched (1:3) on age, sex, and geographic region, with an index date defined as the first medical claim during the patient identification period. Patients with atrial fibrillation or mitral value abnormalities were excluded. Ischemic stroke and control cohorts were compared on 4-year clinical outcomes and 1-year costs. RESULTS: Of 2180 ischemic stroke patients, 1808 (82.9%) had new stroke and 372 (17.1%) had a recurrent stroke. Stroke patients had higher unadjusted rates of additional stroke, TIA, and fatal outcomes compared with the 6540 matched controls. Recurrent stroke patients had higher rates of adverse clinical outcomes compared with new stroke patients; costs attributed to recurrent stroke were also higher. Stroke patients were 2.4 times more likely to be hospitalized in follow-up compared with controls (hazard ratio [HR] 2.4, 95% confidence interval [CI]: 2.2, 2.6). Occurrence of stroke following discharge was 21 times more likely among patients with index stroke compared with controls (HR 21.0, 95% CI: 16.1, 27.3). Stroke was also predictive of death (HR 1.8, 95% CI: 1.3, 2.5). Controlling for covariates, stroke patients had significantly higher costs compared with control patients in the year following the index event. CONCLUSION: Noncardioembolic ischemic stroke patients had significantly poorer outcomes and higher costs compared with controls. Recurrent stroke appears to contribute substantially to these higher rates of adverse outcomes and costs.
Assuntos
Custos de Cuidados de Saúde , Programas de Assistência Gerenciada/economia , Avaliação de Processos e Resultados em Cuidados de Saúde/economia , Acidente Vascular Cerebral/economia , Adolescente , Adulto , Fatores Etários , Idoso , Distribuição de Qui-Quadrado , Feminino , Hospitalização/economia , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Estados Unidos , Adulto JovemRESUMO
OBJECTIVE: This study was designed to compare the burden of illness (BOI) in patients at high risk versus low risk of developing a major cardiovascular (CV) event. METHODS: This retrospective claims data analysis included commercial health plan members identified with a primary diagnosis on a medical claim for cardiovascular disease (CVD) from January 1, 2001 through December 31, 2002. Patients were categorized as: low risk (LR), high risk (HR), or high risk aged≥55 (HR55), based on the ONTARGET clinical trial. RESULTS: Most patients (85%) were in the LR category (8% in HR55, 7% in HR). A significantly greater proportion of patients in the HR55 group were hospitalized and experienced a greater number of ambulatory visits compared with LR and HR patients. Controlling for covariates, HR55 patients averaged $22,502 in paid healthcare services over 2 years versus $15,645 for HR patients and $11,423 for LR patients (p<0.001). CV-related costs represented about 46% of costs for the HR55 group, versus 41% for the HR group and 31% for the LR group. LIMITATIONS: Claims data are collected for the purpose of payment and not research and the presence of a diagnosis code is not proof of disease, due to possible coding errors or the use of a rule-out criterion. Also, patients who died in the follow-up were not included in the analyses, resulting in lower BOI estimates. Finally, the results of this study reflect treatment of CVD in managed-care settings, and may not be applicable to a different type of population. CONCLUSION: This study demonstrates the high BOI associated with CVD, especially for patients within the high-risk group aged≥55 years. Opportunities exist for reducing costs in this population.
Assuntos
Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/economia , Serviços de Saúde/economia , Adolescente , Adulto , Idoso , Doenças Cardiovasculares/terapia , Efeitos Psicossociais da Doença , Feminino , Serviços de Saúde/estatística & dados numéricos , Humanos , Revisão da Utilização de Seguros , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Medição de Risco , Estados Unidos , Adulto JovemRESUMO
OBJECTIVE: To develop a descriptive profile of attention-deficit/hyperactivity disorder (ADHD) pharmacological treatment patterns in terms of persistence, adherence, augmentation, switching, and dosing changes; and to assess differences in treatment patterns with regard to ADHD medication type, class, and duration of action. METHODS: This retrospective claims database analysis used medical data, pharmacy data, and enrollment information to examine treatment patterns among patients with at least one claim with a diagnosis code for ADHD and a filled prescription for ADHD medication (index therapy) during the period 01 January 2004 through 30 September 2006. Treatment persistence and adherence (days supplied/days persistent) were calculated. Dose changes, medication switching, and augmentation were analyzed at three levels of comparison: class (stimulant vs nonstimulant [atomoxetine]), drug type (amphetamine vs methylphenidate), and duration of action (short, intermediate, long). Statistical comparisons were made using the chi-square test for proportions and Student's t-test or the F-test from one-way ANOVA for means. RESULTS: Of 60,010 patients meeting eligibility criteria, 58.4% were younger than age 18. Most (78.4%) were prescribed a stimulant as their index therapy. Persistence and adherence were greater for patients on stimulants (vs the nonstimulant), for patients on amphetamines (vs methylphenidates), and for patients on long-acting medications (vs short- and intermediate-acting medications; all p < 0.0001). Index drug dose changes were least likely among individuals taking the nonstimulant (vs stimulants), methylphenidates (vs amphetamines), or intermediate-acting drugs (vs short- and long-acting drugs; all p < 0.0001), and medication switches were more frequent among those on nonstimulants, methylphenidates, or short-acting drugs (all p < 0.0001). Subjects taking long-acting medication were less likely to augment with a drug with a different duration of action than those taking intermediate- or short-acting medication (p < 0.0001). This claims-based study is limited by possible discrepancies between claims and patient behaviors (i.e., a claim for a prescription does not necessarily indicate that the medication was taken as prescribed). CONCLUSIONS: Patients were more stable on treatment compared with their respective comparator groups if their index therapy was a stimulant, long-acting drug, or amphetamine.
Assuntos
Inibidores da Captação Adrenérgica , Transtorno do Deficit de Atenção com Hiperatividade/tratamento farmacológico , Estimulantes do Sistema Nervoso Central , Revisão de Uso de Medicamentos , Adesão à Medicação , Padrões de Prática Médica , Adolescente , Adulto , Fatores Etários , Anfetamina , Cloridrato de Atomoxetina , Criança , Preparações de Ação Retardada , Feminino , Sistemas Pré-Pagos de Saúde , Humanos , Masculino , Metanfetamina , Pessoa de Meia-Idade , Propilaminas , Estudos Retrospectivos , Estados UnidosRESUMO
OBJECTIVE: To estimate the prevalence of HIV-associated weight loss among HIV patients in a US managed care population, and compare demographic and clinical characteristics of HIV patients with and without evidence of HIV-associated weight loss. RESEARCH DESIGN AND METHODS: A retrospective observational study was conducted using a large, geographically diverse US managed care population to identify commercial enrollees with HIV/AIDS from 1/1/2005-7/31/2007, based on a combination of HIV/AIDS diagnosis codes or antiretroviral treatment. HIV-associated weight loss status was defined according to an algorithm combining evidence for weight loss-associated conditions, anorexia symptoms, and various treatments for weight loss or wasting. Among HIV patients continuously enrolled in the health plan for one year, patient demographics, treatments, and comorbidities were compared between patients with and without evidence for weight loss. RESULTS: A total of 22,535 patients with HIV/AIDS were identified, including 2098 who met the criteria for weight loss (estimated prevalence 9.3%; 95% CI: 8.9% - 9.7%). Among 12,187 continuously enrolled patients with HIV, 1006 (8.3%) had evidence of HIV-associated weight loss. Patients with HIV-associated weight loss were older (44.1 vs. 42.6 years), and more men had HIV-associated weight loss than women (8.8% vs. 5.3%). A number of comorbidities were more common among patients with HIV-associated weight loss. On average, these patients also had more ambulatory (24.0 vs. 13.4), ER (1.4 vs. 0.8), and inpatient visits (0.5 vs. 0.1). Total annual health care costs for patients with HIV-associated weight loss were more than double (mean $45,686 vs. $19,960) the costs for HIV patients without weight loss. CONCLUSIONS: Despite the availability of effective antiretroviral therapy, weight loss remains a problem among patients with HIV. Based on this analysis, almost 1 in 10 managed care patients with HIV have evidence of HIV-associated weight loss. These patients tend to have more comorbidities, use more health care resources, and incur greater costs compared to patients without HIV-associated weight loss. Patients with HIV-associated weight loss were generally sicker than the non-weight loss cohort; thus, the increased costs observed in this population may not be directly or wholly attributable to HIV-associated weight loss. In addition, limitations common to analyses of administrative claims data should be considered when interpreting these results.
Assuntos
Infecções por HIV/complicações , Síndrome de Emaciação por Infecção pelo HIV/economia , Síndrome de Emaciação por Infecção pelo HIV/epidemiologia , Programas de Assistência Gerenciada/economia , Redução de Peso , Adulto , Estudos de Coortes , Comorbidade , Efeitos Psicossociais da Doença , Atenção à Saúde/economia , Atenção à Saúde/estatística & dados numéricos , Feminino , Infecções por HIV/economia , Infecções por HIV/epidemiologia , Síndrome de Emaciação por Infecção pelo HIV/terapia , Humanos , Masculino , Programas de Assistência Gerenciada/estatística & dados numéricos , Pessoa de Meia-Idade , Grupos Populacionais/estatística & dados numéricos , Prevalência , Estudos Retrospectivos , Classe Social , Redução de Peso/fisiologiaRESUMO
BACKGROUND AND PURPOSE: Prior stroke confers an increased risk of future cardiovascular events. Because the incremental economic impact of this added risk is unknown, we assessed the additional cardiovascular costs and hospitalizations associated with ischemic stroke. METHODS: Patients hospitalized for ischemic stroke during 2002 to 2005 were identified from a large US managed-care plan and matched to control patients hospitalized for a noncardiovascular acute event. Cumulative stroke-related and non-stroke-related cardiovascular medical costs were determined for each group. Stroke and nonstroke cardiovascular hospitalization rates were calculated with the Kaplan-Meier method; risk of hospitalization was estimated with a Cox regression model. RESULTS: Stroke patients and matched controls (N=11 883) were identified (mean age approximately 58 years; 47.8% female). Compared with controls, patients hospitalized for ischemic stroke had higher stroke and nonstroke cardiovascular medical costs at 6 months (stroke: $1756 vs $50, P<0.01; nonstroke cardiovascular: $1437 vs $658, P<0.01) and 12 months (stroke: $2109 vs $68, P<0.01; nonstroke cardiovascular: $2203 vs $1167, P<0.01) of follow-up. Among stroke patients, cumulative stroke and nonstroke cardiovascular hospitalization rates were 9.06% and 5.63% at 6 months, respectively, and 21.09% and 22.05% at 36 months, respectively. Stroke patients were at significantly increased risk of repeat stroke hospitalization (hazard ratio=12.55; 95% CI, 10.50 to 15.01) and nonstroke cardiovascular hospitalization (hazard ratio=1.95; 95% CI, 1.77 to 2.14). CONCLUSIONS: After ischemic stroke, patients have significantly greater stroke and nonstroke cardiovascular costs and hospitalizations than do matched controls. Attention to total cardiovascular risk reduction in this population could potentially reduce downstream costs.
Assuntos
Isquemia Encefálica/economia , Cardiopatias/economia , Custos Hospitalares/estatística & dados numéricos , Programas de Assistência Gerenciada/economia , Acidente Vascular Cerebral/economia , Doenças Vasculares/economia , Adulto , Idoso , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/terapia , Comorbidade , Bases de Dados Factuais , Feminino , Recursos em Saúde/economia , Recursos em Saúde/estatística & dados numéricos , Cardiopatias/epidemiologia , Cardiopatias/terapia , Humanos , Estimativa de Kaplan-Meier , Masculino , Programas de Assistência Gerenciada/estatística & dados numéricos , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/terapia , Doenças Vasculares/epidemiologia , Doenças Vasculares/terapiaRESUMO
OBJECTIVE: To compare change in low-density lipoprotein cholesterol (LDL-C) levels and National Cholesterol Education Program (NCEP) Adult Treatment Panel III LDL-C goal attainment in diabetic patients treated with rosuvastatin versus other statins in a large, managed care health plan. RESEARCH DESIGN AND METHODS: This retrospective cohort analysis used medical and pharmacy claims linked to laboratory results from a commercial/MedicareAdvantage health plan. Study participants were >or= 18 years of age, had a diagnosis of diabetes, were newly treated with statins from 8/1/03 to 2/28/05, and were considered at high risk for cardiovascular events as defined by NCEP guidelines. Subjects were continuously enrolled for 12 months pre-index and >or= 30 days post-index, with variable follow-up until therapy discontinuation or end of health plan eligibility. MAIN OUTCOME MEASURES: Change in LDL-C from baseline, and attainment of NCEP LDL-C goal among patients not at goal before starting therapy. RESULTS: A total of 3337 adult patients with diabetes were identified with new use of statin therapy during the identification period. A total of 9% (n = 301) started on rosuvastatin, 49.4% (n = 1,649) on atorvastatin, 20.7% (n = 690) on simvastatin, 7.0% (n = 234) on pravastatin, 11.7% (n = 391) on lovastatin and 2.2% (n = 72) on fluvastatin. After controlling for covariates, rosuvastatin patients experienced a significantly greater decrease in LDL-C from baseline (38.7%) than patients taking atorvastatin (34.2%) (p = 0.05), simvastatin (31.5%), pravastatin (24.2%), fluvastatin (26.3%) or lovastatin (24.9%) (p < 0.0001). Rosuvastatin users were significantly more likely to attain LDL-C goal than those taking the other statins (odds ratio: 0.44, 0.28, 0.14, 0.14, 0.19, respectively; p < 0.001). Predicted percent attaining goal was significantly greater for those taking rosuvastatin (87.3%) than for those taking atorvastatin (76.9%), simvastatin (68.7%), pravastatin (55.0%), lovastatin (55.3%) or fluvastatin (61.3%) (p < 0.001). CONCLUSION: For diabetic patients, rosuvastatin is more effective at reducing LDL-C levels and attaining NCEP ATP III LDL-C goal than other statins in real-world clinical practice.
Assuntos
Doenças Cardiovasculares/prevenção & controle , LDL-Colesterol/efeitos dos fármacos , Complicações do Diabetes/prevenção & controle , Fluorbenzenos/uso terapêutico , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Pirimidinas/uso terapêutico , Sulfonamidas/uso terapêutico , Adulto , Idoso , Atorvastatina , Doenças Cardiovasculares/etiologia , LDL-Colesterol/sangue , Estudos de Coortes , Ácidos Graxos Monoinsaturados/uso terapêutico , Feminino , Fluvastatina , Ácidos Heptanoicos/uso terapêutico , Humanos , Indóis/uso terapêutico , Lovastatina/uso terapêutico , Masculino , Programas de Assistência Gerenciada , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Pravastatina/uso terapêutico , Pirróis/uso terapêutico , Estudos Retrospectivos , Fatores de Risco , Rosuvastatina Cálcica , Sinvastatina/uso terapêutico , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: Reducing low-density lipoprotein cholesterol (LDL-C) levels lowers the risk of consequences of cardiovascular disease. Research has confirmed these benefits in elderly patients. The 3-hydroxy-3-methylglutaryl coenzyme A inhibitors (ie, statins) have long-standing proven efficacy in reducing levels of LDL-C and total cholesterol. OBJECTIVE: The goal of this study was to compare change in LDL-C from baseline and National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III LDL-C goal attainment in a population of elderly patients (aged > or =65 years) treated with rosuvastatin versus other statins in routine clinical practice. METHODS: This was a retrospective cohort analysis using medical and pharmacy claims data linked to clinical laboratory results from a large managed care health plan of commercial and Medicare Advantage members in the United States. Included were members aged > or =65 years who were newly treated with statins (index date) from August 1, 2003, through February 28, 2005. All subjects were continuously enrolled for 12 months preindex and > or =30 days postindex, with variable follow-up until therapy discontinuation or end of health plan eligibility. Based on NCEP ATP III guidelines, patients were grouped into risk categories with associated LDL-C goals. The primary outcomes were change in LDL-C from baseline and attainment of NCEP ATP III LDL-C goal among patients not at goal before starting therapy. Generalized linear modeling was used to assess percent change in LDL-C from baseline, controlling for covariates (including age, sex, NCEP risk level, medication possession ratio, preindex LDL-C value, days from index date to postindex LDL-C value, and number of preindex office visits for dyslipidemia). In the subset of patients not at goal before starting therapy, logistic regression was used to estimate the odds of individual patients on other statins reaching goal as compared with rosuvastatin and to produce predicted percent attaining LDL-C goal on individual statins. RESULTS: Of the 2227 elderly new users of statin therapy, 8.0% started on rosuvastatin, 38.9% started on atorvastatin, 3.0% on fluvastatin, 31.0% on lovastatin, 5.5% on pravastatin, and 13.6% on simvastatin. Females comprised 57.7% of the population, and the mean (SD) age was 73 (5.8) years (range, 65-94 years). The mean (SD) doses of rosuvastatin, atorvastatin, fluvastatin, lovastatin, pravastatin, and simvastatin were 10.65 (4.59), 16.0 (12.78), 66.31 (23.56), 27.38 (14.07), 32.86 (16.46), and 28.1 (26.2) mg, respectively. After controlling for covariates, rosuvastatin-treated patients had a 35.8% decrease in LDL-C from baseline, which was significantly greater compared with patients in the atorvastatin, fluvastatin, lovastatin, pravastatin, and simvastatin (29.3%, 21.9%, 22.5%, 22.0%, and 24.9%, respectively; P < 0.05) groups. Atorvastatin (odds ratio [OR], 0.25; 95% CI, 0.12-0.52), fluvastatin (OR, 0.05; 95% CI, 0.02-0.14), lovastatin (OR, 0.10; 95% CI, 0.05-0.20), pravastatin (OR, 0.08; 95% CI, 0.03-0.20), and simvastatin (OR, 0.14; 95% CI, 0.06-0.30) were less likely to attain LDL-C goal compared with rosuvastatin (all, P < 0.001). Predicted percent attaining goal was 93.6% among rosuvastatin users, significantly greater than users of atorvastatin, fluvastatin, lovastatin, pravastatin, and simvastatin (81.2%, 55.8%, 66.8%, 64.1%, and 72.8%, respectively; P < 0.05). CONCLUSION: In this elderly patient population, rosuvastatin was a more effective treatment for reducing LDL-C levels and attaining NCEP ATP III LDL-C goals than the other statins.
Assuntos
Anticolesterolemiantes/uso terapêutico , LDL-Colesterol/efeitos dos fármacos , Fluorbenzenos/uso terapêutico , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Hipercolesterolemia/tratamento farmacológico , Pirimidinas/uso terapêutico , Sulfonamidas/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Atorvastatina , Estudos de Coortes , Doença das Coronárias/prevenção & controle , Bases de Dados Factuais , Ácidos Graxos Monoinsaturados/uso terapêutico , Feminino , Fluvastatina , Ácidos Heptanoicos/uso terapêutico , Humanos , Indóis/uso terapêutico , Lovastatina/uso terapêutico , Masculino , Programas de Assistência Gerenciada , Razão de Chances , Pravastatina/uso terapêutico , Pirróis/uso terapêutico , Estudos Retrospectivos , Rosuvastatina Cálcica , Sinvastatina/uso terapêutico , Resultado do TratamentoRESUMO
BACKGROUND: Bipolar disorder is the most expensive mental disorder for US employer health plans. No published studies have examined the impact of comorbid diabetes on the cost of treating bipolar disorder. The objectives of this work were to determine the direct costs incurred by patients with bipolar disorder in a US managed care plan, and to examine the influence (1) of drug therapy regimen on bipolar-related costs, and (2) of diabetes on bipolar-related and all-cause costs. METHODS: A retrospective analysis of claims in a US private insurance database from January 1, 1999 through December 31, 2002 was performed. The database included at least 4.7 million enrollees each year. Diagnosis codes were used to identify patients with bipolar disorder; patients with diabetes were identified using diagnosis codes and medication use. RESULTS: From 1999-2002, treated bipolar disorder was identified in 262 (33.9) [mean (standard deviation)] cases per 100,000 enrollees. Among patients with bipolar disorder in this cohort, between 6.3 and 7.4% were treated for diabetes each year. Among patients with newly treated bipolar disorder, 61.8% received initial therapy with only mood stabilizers, 24.3% received only atypical antipsychotics, and 13.9% received both. Mean all-cause cost for patients with bipolar disorder was US$2,690 in the 6 months before the first bipolar-related claim, and US$6,826 in the following year. Of the latter cost, bipolar-related cost was US$1,272. Patients with comorbid diabetes had much higher all-cause cost (US$11,317) than those without diabetes in the year following the first bipolar-related claim, but only slightly higher bipolar-related cost (US$1,349). Among newly treated bipolar disorder patients, all-cause and bipolar-related cost in the year after diagnosis was lowest in patients receiving only mood stabilizers. Ordinary least squares regression analysis found that treatment with mood stabilizers only was associated with 41% lower bipolar-related cost than treatment with atypical antipsychotics only (P < .001). Significant individual associations were also found between bipolar-related cost and bipolar disorder I diagnosis, severe bipolar disorder and comorbid personality disorders (P < .001 for each) but not comorbid diabetes (P = .27). CONCLUSIONS: These results suggest that patients with bipolar disorder who receive only mood stabilizer therapy incur lower bipolar-related and all-cause cost than those receiving only atypical antipsychotics. In contrast to that for all-cause cost, comorbid diabetes had little impact on direct costs related to treating bipolar disorder itself.
Assuntos
Transtorno Bipolar/tratamento farmacológico , Transtorno Bipolar/economia , Diabetes Mellitus Tipo 2/economia , Custos Diretos de Serviços , Uso de Medicamentos/estatística & dados numéricos , Sistemas Pré-Pagos de Saúde/economia , Psicotrópicos/economia , Psicotrópicos/uso terapêutico , Adolescente , Adulto , Transtorno Bipolar/complicações , Criança , Pré-Escolar , Estudos de Coortes , Diabetes Mellitus Tipo 2/complicações , Uso de Medicamentos/economia , Humanos , Lactente , Pessoa de Meia-Idade , Vigilância da População/métodos , Prevalência , Setor Privado/economia , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: To compare the performance of the Elixhauser, Charlson, and RxRisk-V comorbidity indices and several simple count measurements, including counts of prescriptions, physician visits, hospital claims, unique prescription classes, and diagnosis clusters. STUDY DESIGN: Each measurement was calculated using claims data during a 1-year period before the initial filling of an antihypertensive medication among 20 378 members of a managed care organization. The primary outcome variable was the log-transformed sum of prescription, physician, and hospital expenditures in the year following the prescription encounter. METHODS: In addition to descriptive statistics and Spearman rank correlations between measurements, the predictive performance was determined using linear regression models and corresponding adjusted R(2) statistics. RESULTS: The Charlson index and the Elixhauser index performed similarly (adjusted R(2) = 0.1172 and 0.1148, respectively), while the prescription claims-based RxRisk-V (adjusted R(2) = 0.1573) outperformed both. An age- and gender-adjusted regression model that included a count of diagnosis clusters was the best individual predictor of payments (adjusted R(2) = 0.1814). This outperformed age- and gender-adjusted models of the number of unique prescriptions filled (adjusted R(2) = 0.1669), number of prescriptions filled (R(2) = 0.1573), number of physician visits (adjusted R(2) = 0.1546), logtransformed prior healthcare payments (adjusted R(2) = 0.1359), and number of hospital claims (adjusted R(2) = 0.1115). CONCLUSION: Simple count measurements appear to be better predictors of future expenditures than the comorbidity indices, with a count of diagnosis clusters being the single best predictor of future expenditures among the measurements examined.
Assuntos
Comorbidade , Gastos em Saúde , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Previsões , Humanos , Masculino , Pessoa de Meia-Idade , Estados UnidosRESUMO
Drug tolerability strongly influences patients' persistence with treatment. In this study, patterns of medication persistence with cyclooxygenase 2 (COX-2)-specific inhibitors and nonspecific nonsteroidal anti-inflammatory drugs (NSAIDs) were compared in a managed care setting. Pharmacy, enrollment, and medical claims data from 19 health plans were used to match subjects newly treated with celecoxib, rofecoxib, ibuprofen, naproxen, or diclofenac between July 1, 1999 and June 30, 2000. By using multiple regression analysis, users of COX-2-specific inhibitors were found to be 56.8% less likely to discontinue medication use and 60.3% less likely to switch treatment than were users of nonspecific NSAIDs (P < .001). Celecoxib users were 4.6% less likely to discontinue treatment than were rofecoxib users (P < .001). The greater persistence observed among users of COX-2 inhibitors might reflect improved treatment efficacy and patient satisfaction.
Assuntos
Anti-Inflamatórios não Esteroides/uso terapêutico , Artrite/tratamento farmacológico , Inibidores de Ciclo-Oxigenase/uso terapêutico , Revisão de Uso de Medicamentos/estatística & dados numéricos , Programas de Assistência Gerenciada/economia , Cooperação do Paciente/estatística & dados numéricos , Anti-Inflamatórios não Esteroides/economia , Artrite/classificação , Artrite/economia , Celecoxib , Ciclo-Oxigenase 2 , Inibidores de Ciclo-Oxigenase 2 , Inibidores de Ciclo-Oxigenase/economia , Diclofenaco/uso terapêutico , Feminino , Custos de Cuidados de Saúde/classificação , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Ibuprofeno/uso terapêutico , Revisão da Utilização de Seguros , Isoenzimas , Lactonas/uso terapêutico , Masculino , Programas de Assistência Gerenciada/organização & administração , Proteínas de Membrana , Pessoa de Meia-Idade , Naproxeno/uso terapêutico , Modelos de Riscos Proporcionais , Prostaglandina-Endoperóxido Sintases , Pirazóis , Análise de Regressão , Sulfonamidas/uso terapêutico , Sulfonas , Estados UnidosRESUMO
OBJECTIVE: To examine treatment compliance and dosage administration associated with infliximab, etanercept, and methotrexate therapy for rheumatoid arthritis (RA). STUDY DESIGN: Retrospective analysis using administrative and claims data from a large US health plan. PATIENTS AND METHODS: Patients were Medicare or commercial enrollees in a health plan with a pharmacy benefit and had a diagnosis of RA. The first (index) claim for infliximab, etanercept, or methotrexate occurred between July 1, 1998, and December 31, 2000. Continuous enrollment in the plan was required from 182 days before to 365 days after the index claim. Treatment groups were compared according to compliance (defined as the actual number of therapy administrations or filled prescriptions divided by the expected number) and changes in dosage administration over time. The costs of infliximab therapy also were explored. RESULTS: A total of 2662 patients (infliximab = 141; etanercept = 853; and methotrexate = 1668) were included in the analyses. Infliximab patients were older and more likely to have a Medicare benefit. In addition, infliximab patients had more comorbidities and had greater medical costs preceding the index claim. Compliance with at least 80% of the expected dosages was significantly lower for etanercept (odds ratio [OR] 0.462; 95% confidence interval [CI] 0.290-0.736) and methotrexate (OR 0.385; 95% CI 0.245-0.604) patients than infliximab patients. Methotrexate patients had the largest dosage increases (61.6%), followed by infliximab (37.4%) and etanercept (7.4%) patients. Assuming 6.5 dosages per year, the annual cost of infliximab was dollars 10446 to dollars 12363, or dollars 1887 to dollars 1902 per administration, depending on site of service. CONCLUSIONS: Compliance is higher with infliximab compared with etanercept or methotrexate; whereas, fewer etanercept patients change dosages. The cost of infliximab was lower than expected based on previous predictions, even with a 37% increase in dosage.
Assuntos
Antirreumáticos/uso terapêutico , Artrite Reumatoide/tratamento farmacológico , Fidelidade a Diretrizes , Adulto , Idoso , Anticorpos Monoclonais/administração & dosagem , Anticorpos Monoclonais/economia , Anticorpos Monoclonais/uso terapêutico , Antirreumáticos/administração & dosagem , Esquema de Medicação , Custos de Medicamentos , Etanercepte , Feminino , Humanos , Imunoglobulina G/administração & dosagem , Imunoglobulina G/uso terapêutico , Infliximab , Masculino , Metotrexato/administração & dosagem , Metotrexato/uso terapêutico , Pessoa de Meia-Idade , Receptores do Fator de Necrose Tumoral/administração & dosagem , Receptores do Fator de Necrose Tumoral/uso terapêutico , Estudos Retrospectivos , Estados UnidosRESUMO
BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to cause abnormalities in renal function. This is an important concern in patients with cardiorenal risk factors, including hypertension, congestive heart failure, edema, renal impairment, and advanced age. OBJECTIVES: The goals of this study were to determine the prevalence of cardiorenal risk factors in patients with rheumatoid arthritis (RA) or osteoarthritis and ascertain whether these risk factors are associated with prescribing patterns of cyclooxygenase (COX)-2-selective inhibitors and other NSAIDs. METHODS: This was a retrospective, longitudinal claims analysis using data from 19 large independent-practice-model managed care health plans in the United Stated. Three cohorts were identified based on claims for celecoxib, rofecoxib, or other NSAIDs from October 1, 1999, through September 30, 2000. Logistic regression models were used to explore whether baseline cardiorenal risk factors were related to choice of therapy. RESULTS: A total of 77,552 patients received celecoxib (n = 6779 [8.74%]), rofecoxib (n = 7189 [9.27%]), or other NSAIDs (n = 63,584 [81.99%]). Patients prescribed COX-2-selective inhibitors were older than those receiving other NSAIDs and had a diagnosis of RA more often. Overall, 42% of patients had >or=1 cardiorenal risk factor, and approximately one third had hypertension. Cardiorenal risk factors were not related to physicians' prescribing of celecoxib or rofecoxib, but the presence of any cardiorenal risk factor was associated with an increase in the use of COX-2-selective inhibitors compared with other NSAIDs, from 12% for cerebrovascular disease (point estimate, 1.124; P<0.001) to 74% for chronic renal failure/nephritis (point estimate, 1.738; P=0.025). RA and advanced age were associated with the use of celecoxib rather than rofecoxib. CONCLUSIONS: The prevalence of cardiorenal risk factors was found to be similar in patients prescribed celecoxib or rofecoxib for arthritis. Patients with these risk factors were more likely to receive a COX-2-selective inhibitor than other NSAIDs.