Exploring kidney dialysis costs in the United States: a scoping review.

AIMS: The increasing prevalence of end-stage renal disease (ESRD) in the United States (US) represents a considerable economic burden due to the high cost of dialysis treatment. This review examines data from real-world studies to identify cost drivers and explore areas where dialysis costs could be reduced. METHODS: We identified and synthesized evidence published from 2016-2023 reporting direct dialysis costs in adult US patients from a comprehensive literature search of MEDLINE, Embase, and grey literature sources (e.g. US Renal Data System reports). RESULTS: Most identified data related to Medicare expenditures. Overall Medicare spending in 2020 was $29B for hemodialysis and $2.8B for peritoneal dialysis (PD). Dialysis costs accounted for almost 80% of total Medicare expenditures on ESRD beneficiaries. Private insurance payers consistently pay more for dialysis; for example, per person per month spending by private insurers on outpatient dialysis was estimated at $10,149 compared with Medicare spending of $3,364. Dialysis costs were higher in specific high-risk patient groups (e.g. type 2 diabetes, hepatitis C). Spending on hemodialysis was higher than on PD, but the gap in spending between PD and hemodialysis is closing. Vascular access costs accounted for a substantial proportion of dialysis costs. LIMITATIONS: Insufficient detail in the identified studies, especially related to outpatient costs, limits opportunities to identify key drivers. Differences between the studies in methods of measuring dialysis costs make generalization of these results difficult. CONCLUSIONS: These findings indicate that prevention of or delay in progression to ESRD could have considerable cost savings for Medicare and private payers, particularly in patients with high-risk conditions such as type 2 diabetes. More efficient use of resources is needed, including low-cost medication, to improve clinical outcomes and lower overall costs, especially in high-risk groups. Widening access to PD where it is safe and appropriate may help to reduce dialysis costs.

Previous papers have studied the cost of treating patients who need dialysis for kidney failure. We reviewed these costs and looked for patterns. Dialysis was the most expensive part of treatment for people with kidney disease who have Medicare. Dialysis with private insurance was much more expensive than with Medicare. People with diabetes experienced higher costs of dialysis than those without diabetes. Dialysis in a hospital costs more than dialysis at home. There are opportunities to reduce the cost of dialysis that should be explored further, such as more use of low-cost medication that can prevent the worsening of kidney disease and reduce the need for dialysis.

Adverse events and costs among non-metastatic castration-resistant prostate cancer patients.

BACKGROUND: Limited real-world evidence exists on the economic burden of adverse events (AEs) to the healthcare system among patients with non-metastatic castration-resistant prostate cancer (nmCRPC) treated with second-generation androgen receptor antagonists (ARAs). Current data is needed to understand real-world clinical event rates among ARAs and the cost of these events. OBJECTIVES: Describe the incidence of non-central nervous system (CNS)-related AEs and CNS-related AEs among nmCRPC patients treated in the United States with second-generation ARAs (apalutamide and enzalutamide) and evaluate healthcare resource utilization (HCRU) and costs for these patients. METHODS AND STUDY DESIGN: This was a retrospective observational cohort study using claims data from Optum Clinformatics Data Mart to identify adult males with prostate cancer, castration, no metastases, and >1 claim for apalutamide or enzalutamide. The study was conducted from January 2017 to March 2020, with a patient index identification period from January 2018 to December 2019. AEs were classified as CNS-related or non-CNS-related. RESULTS: Of 605 patients (156 apalutamide and 449 enzalutamide), most were ≥65 years (94%) and had ≥1 non-CNS-related AE (55%). Many had ≥1 CNS-related AE (32%). Pain (12%) and arthralgia (11%) were the most frequently reported non-CNS-related AEs. Fatigue/asthenia (14%) and dizziness (7%) were the most frequently reported CNS-related AEs. Among patients with versus without non-CNS-related AEs, 34% versus 8% had emergency room (ER) events, and 25% versus 2% had inpatient events. Among patients with versus without CNS-related AEs, 41% versus 14% had ER events, and 38% versus 4% had inpatient events. Adjusted per-patient per-year cost (in 2020 USD) differences were significant between patients with and without non-CNS-related AEs ($30,765, p = 0.0018) and between patients with and without CNS-related AEs ($40,689, p = 0.0017). CONCLUSION: There is significant HCRU and cost burden among nmCRPC patients treated with ARAs developing AEs, highlighting the need for treatments with improved tolerability. Additional studies are warranted to include recently approved agents.

Descriptive study of the economic burden among patients with type 2 diabetes mellitus, chronic kidney disease, and chronic kidney disease and type 2 diabetes mellitus in a large US commercially insured population.

BACKGROUND: Chronic kidney disease (CKD) is a major public health concern that affects 37 million adults in the United States. It is well known that CKD presents a large economic burden, especially in the Medicare population. However, studies of the economic burden of CKD in younger populations are scarce. In particular, there is a gap in understanding how the presence of type 2 diabetes mellitus (T2DM) affects the burden of CKD in commercially insured populations. OBJECTIVE: To describe the economic and health care resource utilization (HCRU) burden of CKD within 3 patient groups (T2DM only, CKD only, and CKD and T2DM) aged 45-64 years overall and by Kidney Disease Improving Global Outcomes (KDIGO) CKD estimated glomerular filtration rate-based stage categories. METHODS: A descriptive, observational retrospective cohort study was conducted using administrative medical and pharmacy claims integrated with laboratory results data available in the HealthCore Integrated Research Database from January 1, 2017, to December 31, 2019. Three mutually exclusive groups of commercially insured patients aged 45-64 years were identified: T2DM only, CKD only, and CKD and T2DM. All-cause and disease-specific HCRU and costs in total, by medical and pharmacy benefits and across all places of service, were described for each of these groups 12 months after index date. For the CKD only and CKD and T2DM groups, costs were also described by KDIGO CKD stage. RESULTS: The CKD and T2DM group (n = 13,052) had numerically higher 12-month post-index all-cause and CKD/T2DM-related HCRU across all places of service. Mean 12-month all-cause costs for this group were $35,649, whereas costs for the CKD only group (n = 7,876) were $25,010 and costs for the T2DM only group (n = 120,364) were $16,121. Costs also tended to increase as CKD stage increased, with the greatest increases beginning at KDIGO stage 3b and higher. Mean 12-month all-cause costs for the CKD and T2DM group ranged from $29,993 to $41,222 for stages 1 to 3a and from $46,796 to $119,944 for stages 3b to 5. CONCLUSIONS: Commercially insured patients aged 45-64 years with CKD, especially those who also have T2DM, present a substantial burden in terms of elevated HCRU and costs. Costs tend to increase across KDIGO CKD stages and increase most rapidly at stage 3b and later. Therefore, there is an opportunity to reduce the burden of CKD in this population by investing in interventions to prevent or delay CKD disease progression. DISCLOSURES: HealthCore, Inc, received funding to perform this research, as well as funding from multiple pharmaceutical companies to perform various research studies outside of the submitted work. Mr Crowe and Dr Willey are employees of HealthCore, Inc., a wholly owned subsidiary of Elevance Health, Inc. Ms Chung was an employee of HealthCore, Inc., a wholly owned subsidiary of Elevance Health, Inc, at the time of study performance. Ms Chung and Dr Willey are shareholders of Elevance Health, Inc. Dr Kong, Dr Singh, Mr Farej, Dr Elliot, and Dr Williamson are employees of Bayer US, LLC. Dr Singh is a shareholder of Bayer US, LLC.

CKD Progression and Economic Burden in Individuals With CKD Associated With Type 2 Diabetes.

Rationale & Objective: To evaluate progression patterns and associated economic outcomes, using estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (UACR) based on the Kidney Disease: Improving Global Outcomes (KDIGO) risk categories, among patients with type 2 diabetes (T2D) and chronic kidney disease (CKD). Study Design: Patients with T2D and moderate- or high-risk CKD were selected from the Optum electronic health records database (January 2007-December 2019). Progression patterns and post-progression economic outcomes were assessed. Setting & Participants: Adults with T2D and CKD in clinical settings. Predictor: Baseline KDIGO risk categories. Outcomes: Progression to a more severe KDIGO risk category; healthcare resource utilization and medical costs. Analytical Approach: Progression probability was estimated using cumulative incidence. Healthcare resource utilization and costs were compared across progression groups. Results: Of 269,187 patients (mean age 65.6 years) with T2D and CKD of moderate or high baseline risk, 18.9% progressed to the very high-risk category within 5 years. Among moderate-risk patients, 17.8% of CKD stage G1-A2, 44.0% of stage G2-A2, and 61.3% of stage G3a-A1 patients progressed to a higher KDIGO risk category. Among high-risk patients, 63.9% of stage G3b-A1/G3a-A2 and 56.0% of stage G2-A3 patients progressed to very high risk. Within the same eGFR stage, a higher UACR stage was associated with 4- to 7-times higher risk of progressing to very high risk and faster eGFR decline. Nonprogressors had lower annual medical costs ($16,924) than patients who progressed from moderate risk to high risk ($22,117, P < 0.05), from high risk to very high risk ($32,204, P < 0.05), and from moderate risk to very high risk ($35,092, P < 0.05). Limitations: Infrequent lab testing might have caused lags in identifying progression; medical costs were calculated using unit costs. Conclusions: Patients with T2D and CKD of moderate or high risk per KDIGO risk categories had high probabilities of progression, incurring a substantial economic burden. The results highlight the value of UACR in CKD management.

Medical costs for managing chronic kidney disease and related complications in patients with chronic kidney disease and type 2 diabetes.

OBJECTIVE: To provide cost estimates for chronic kidney disease (CKD) management and major CKD complications among patients with CKD and type 2 diabetes (T2D). STUDY DESIGN: A retrospective cohort study of 52,599 adults with CKD and T2D using Optum Clinformatics claims data from 2014 to 2019. METHODS: Medical costs associated with CKD management, renal replacement therapies (RRTs), major CKD complications (eg, myocardial infarction, stroke, heart failure, atrial fibrillation, and hyperkalemia), and death were estimated using generalized estimating equations adjusting for baseline demographics, complications, and medical costs. Costs for CKD management, RRT, and major CKD complications were assessed in 4-month cycles. Mortality costs were assessed in the month before death. RESULTS: The estimated 4-month CKD management costs ranged from $7725 for stage I to II disease to $11,879 for stage V (without RRT), with high additional costs for dialysis and kidney transplantation ($87,538 and $124,271, respectively). The acute event costs were $31,063 for heart failure, $21,087 for stroke, and $21,016 for myocardial infarction in the first 4 months after the incident event, which all decreased substantially in subsequent 4-month cycles. The acute event costs of atrial fibrillation and hyperkalemia were $30,500 and $31,212 with hospitalization, and $5162 and $1782 without. The costs associated with cardiovascular-related death, renal-related death, and death from other causes were $17,031, $12,605, and $9900, respectively. CONCLUSIONS: Management of CKD and its complications incurs high medical costs for patients with CKD and T2D. Results from this study can be used to quantify the economic profile of emerging treatments and inform decision-making.

Quantifying the economic burden of unintended pregnancies due to drug-drug interactions with hormonal contraceptives from the United States payer perspective.

Background: In the United States of America (USA), nearly 10 million women use oral contraceptives (OCs). Concomitant administration of certain medications can result in contraceptive failure, and consequently unintended pregnancies due to drug-drug interactions (DDIs). The objective of this analysis was to estimate the economic impact of unintended pregnancies due to DDIs among women of reproductive age using an OC alone or in combination with an enzyme inducer co-medication in the USA from a payer perspective. Methods: A Markov model using a cohort of 1,000 reproductive-age women was developed to estimate costs due to contraceptive failure for OC alone versus OC with concomitant enzyme inducer drugs. All women were assumed to begin an initial state, continuing until experiencing an unintended pregnancy. Unintended pregnancies could result in birth, induced abortion, spontaneous abortion, or ectopic pregnancy. The cohort was analyzed over a time horizon of 1 year with a cycle length of 1 month. Estimates of costs and probabilities of unintended pregnancy outcomes were obtained from the literature. Probabilities from the Markov cohort trace was used to estimate number of pregnancy outcomes. Results: On average, enzyme inducers resulted in 20 additional unintended pregnancies with additional unadjusted and adjusted costs median (range) of USD136,304 (USD57,436-USD320,093) and USD65,146 (USD28,491-USD162,635), respectively. The major component of the direct cost is attributed to the cost of births. Considering the full range of events, DDIs with enzyme inducers could result in 16-25 additional unintended pregnancies and total unadjusted and adjusted costs ranging between USD46,041 to USD399,121 and USD22,839 to USD202,788 respectively. Conclusion: The direct costs associated with unintended pregnancies due to DDIs may be substantial and are potentially avoidable. Greater awareness of DDI risk with oral contraceptives among payers, physicians, pharmacists and patients may reduce unintended pregnancies in at-risk populations.

Healthcare Costs of Diabetes and Microvascular and Macrovascular Disease in Individuals with Incident Type 2 Diabetes Mellitus: A Ten-Year Longitudinal Study.

OBJECTIVE: The objective of this study was to estimate the incremental long-term costs associated with T2DM attributable to vascular diseases. RESEARCH DESIGN AND METHODS: This retrospective cohort study identified newly diagnosed (incident) T2DM patients in 2007 (baseline to 01/01/2006) using the HealthCore Integrated Research Database, a repository of nationally representative claims data. Incident T2DM patients were 1:1 exact matched on age, gender and other factors of interest to non-DM patients, and followed until the earlier of 8 follow-up years or death. Patients with documented vascular disease diagnosis were identified during the study period. All-cause and T2DM/vascular disease-related annual healthcare costs were examined for each follow-up year. RESULTS: The study included 13,883 individuals with T2DM and matched non-DM controls. Among individuals with T2DM, 11,792 (85%) had vascular disease versus 9251 (66.6%) non-T2DM between 01/01/2006 and 12/31/2015. Among T2DM patients, mean all-cause annual costs were greater than in non-T2DM patients ($13,806 vs $7,243, baseline, $21,745 vs $8,524, post-index year 1, $12,756-$14,793 vs $8,349-$9,940 years 2-8, p< 0.001), respectively. A similar trend was observed for T2DM/vascular disease-related costs (p< 0. 001). T2DM/vascular disease-related costs were largest during post-index year 1, accounting for the majority of all-cause cost difference between T2DM patients and matched non-DM controls. Incident T2DM individuals without vascular disease at any time had significantly lower costs compared to non-DM controls (p< 0. 001) between years 2-8 of follow-up. CONCLUSION: Vascular disease increased the cost burden for individuals with T2DM. The cost impact of diabetes and vascular disease was highest in the year after diagnosis, and persisted for at least seven additional years, while the cost of T2DM patients without vascular disease trended lower than for matched non-DM patients. These data highlight potential costs that could be offset by earlier and more effective detection and management of T2DM aimed at reducing vascular disease burden.

The prevalence of cardiovascular disease by vascular bed and impact on healthcare costs in a large, real-world population with type 2 diabetes.

INTRODUCTION: The purpose of this study was to assess prevalence of atherosclerotic cardiovascular disease (ASCVD) according to number of affected vascular beds and the impact on healthcare utilization and costs in persons with type 2 diabetes mellitus (type 2 DM) and established ASCVD. METHODS: In this retrospective, cross-sectional analysis, adults with type 2 DM and ASCVD in a large US administrative claims database were categorized by number of ASCVD-affected vascular beds (brain, heart, peripheral vasculature). Annual healthcare utilization and costs for 2015 were determined, including subgroup analyses by age group (18-44, 45-64, ≥65 years). RESULTS: Among 539 089 individuals with type 2 DM and ASCVD, 47.0% had ASCVD affecting >1 vascular bed. The most prevalent ASCVD diagnoses were acute coronary syndrome (26.6%), peripheral arterial disease (24.5%) and stroke (18.6%). Mean annual total healthcare costs per person increased with increasing number of vascular beds, from 1 ($17 741) to 2 ($25 877) to 3 ($33 412). A similar pattern of increased healthcare utilization with increasing number of vascular beds was observed. Among individuals with 1 affected vascular bed, mean total healthcare costs per person were comparable across age subgroups; however, if >1 vascular bed was affected, the mean total healthcare costs were highest in the youngest age cohort. CONCLUSIONS: These real-world data showed that almost half of individuals with type 2 DM and ASCVD had ASCVD affecting >1 vascular bed. A higher number of affected vascular beds were associated with higher mean total healthcare costs and utilization, with a disproportionate increase noted in younger relative to older people.

Impact of atherosclerotic cardiovascular disease on healthcare resource utilization and costs in patients with type 2 diabetes mellitus in a real-world setting.

BACKGROUND: This study evaluated the impact of atherosclerotic cardiovascular disease (ASCVD) on healthcare resource utilization and costs in patients with type 2 diabetes mellitus (T2DM). METHODS: This study was a retrospective, cross-sectional study using US claims data. Adult patients with T2DM were stratified by presence or absence of ASCVD and compared regarding annual (2015) healthcare resource utilization and associated costs. Subgroup analyses were conducted for three age groups (18-44, 45-64, and ≥ 65 years). RESULTS: Among 1,202,596 eligible patients with T2DM, 45.2% had documented ASCVD. The proportions of patients with inpatient and ER-based resource utilization during 2015 were three-to-four times greater in the ASCVD cohort as compared to the non-ASCVD cohort for the categories of inpatient visits (15.6% vs 4.4% of patients), outpatient ER visits (18.4% vs 5.2% of patients), and inpatient ER visits (4.3% vs 0.9% of patients). Outpatient utilization also was higher among patients with ASCVD as compared to those without ASCVD (mean number of annual office visits per patient, 9.1 vs 5.6), and more than twice as many patients with ASCVD had ≥ 9 office visits (43.5% vs 19.8%). Average per-patient total healthcare cost was $22,977 for ASCVD vs $9735 for non-ASCVD, with medical costs primarily driving the difference ($17,849 vs $6079); the difference in pharmacy costs was smaller ($5128 vs $3656). In the 18-44, 45-64, and ≥ 65 age subgroups respectively, total annual healthcare costs were 143, 127, and 114% higher in ASCVD vs non-ASCVD patients. CONCLUSIONS: These findings indicate significantly higher healthcare resource utilization and associated costs in patients having T2DM with ASCVD compared to T2DM without ASCVD.

A study of regional variation in the inpatient cost of lower extremity amputation among patients with diabetes in the United States.

OBJECTIVE: Understanding of the effects of providers' cost on regional variation in healthcare spending is still very limited. The objective of this study is to assess cross-state and cross-region variations in inpatient cost of lower extremity amputation among diabetic patients (DLEA) in relation to patient, hospital, and state factors. METHODS: Patient and hospital level data were obtained from the 2007 US Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project (HCUP). State level data were obtained from the US Census Bureau and the Kaiser Family Foundation websites. Regression models were implemented to analyze the association between in-patient cost and variables at patient, hospital, and state levels. RESULTS: This study analyzed data on 9066 DLEA hospitalizations from 39 states. The mean cost per in-patient stay was $17,103. Four out of the five most costly states were located on the East and West coasts (NY and NJ, CA and OR). Age, race, length of stay, level of amputation, in-patient mortality, primary payer, co-morbidities, and type of hospital were significantly correlated with in-patient costs and explained 55.3% of the cost variance. Based on the means of costs unexplained by those factors, the three West coast states had the highest costs, followed by five Midwestern states, and four Southern states, and Kansas were the least costly. CONCLUSIONS: Over 40% of the variations in DLEA hospital costs could not be explained by major patient-, hospital-, and state-level variables. Further research is needed to examine whether similar patterns exist for other costly surgical procedures among diabetic patients.

Outcomes research collaborations between third-party payers, academia, and pharmaceutical manufacturers: What can we learn from clinical research?

Research collaborations between academic researchers, regulatory agencies, and pharmaceutical manufacturers have made the drug development process more efficient and have frequently supported the successful documentation of quality, safety, and efficacy of pharmaceuticals (the so-called three hurdles). Over recent years issues of drug cost, access, and utilization have moved to center stage, giving rise to a "fourth hurdle approval" process by third-party payers. This requires new forms of collaborative research among new players. This contribution highlights the need for a "triangular" relationship in the field of outcomes research between scientists in academia, third-party payer institutions, and pharmaceutical manufacturers. We discuss, and illustrate by case studies, how successful models of collaboration from the drug development process might be relevant to research activities related to the fourth hurdle. Case studies which may provide useful models for collaborative outcomes research include the "International Conference on Harmonization" process, the voluntary consultation procedures established by drug regulatory agencies, and the Quebec experience in database sharing.

Use of cost-effectiveness analysis in health-care resource allocation decision-making: how are cost-effectiveness thresholds expected to emerge?

BACKGROUND: An increasing number of health-care systems, both public and private, such as managed-care organizations, are adopting results from cost-effectiveness (CE) analysis as one of the measures to inform decisions on allocation of health-care resources. It is expected that thresholds for CE ratios may be established for the acceptance of reimbursement or formulary listing. OBJECTIVE: This paper provides an overview of the development of and debate on CE thresholds, reviews threshold figures (i.e., cost per unit of health gain) currently proposed for or applied to resource-allocation decisions, and explores how thresholds may emerge. DISCUSSION: At the time of this review, there is no evidence from the literature that any health-care system has yet implemented explicit CE ratio thresholds. The fact that some government agencies have utilized results from CE analysis in pricing/reimbursement decisions allows for retrospective analysis of the consistency of these decisions. As CE analysis becomes more widely utilized in assisting health-care decision-making, this may cause decision-makers to become increasingly consistent. CONCLUSIONS: When CE analysis is conducted, well-established methodology should be used and transparency should be ensured. CE thresholds are expected to emerge in many countries, driven by the need for transparent and consistent decision-making. Future thresholds will likely be higher in most high-income countries than currently cited rules of thumb.

A cross-sectional retrospective assessment of anti-arthritic drugs in patients with arthritis in Korea.

BACKGROUND: Selective cyclo-oxygenase-2 (COX-2) inhibitors were recently introduced for the treatment of arthritis because of their lower rates of gastrointestinal adverse events compared with traditional non-steroidal anti-inflammatory drugs (NSAIDs). OBJECTIVE: To examine the medication usage patterns for both osteoarthritis (OA) and rheumatoid arthritis (RA) in Korea. METHODS: The medical charts of a convenience sample of 402 patients with OA or RA were reviewed by the Arthritis Study Group in 14 hospitals and ten clinics in Korea. RESULTS: Traditional oral NSAIDs were the most commonly prescribed drugs for OA (68.3%) and RA (65.1%) patients. Two-thirds (66.7%) of the RA patients taking COX-2 inhibitors were prescribed other arthritis medications concurrently and 85.1% of RA patients taking NSAIDs were prescribed other arthritis medications concurrently. Patients on NSAIDs were almost twice as likely to have a gastroprotective agent (GPA) concurrently compared to COX-2 inhibitor users (OA patients 38.1% vs 21.2%; RA patients 57.9% vs 30.6%). Overall, patients taking COX-2 inhibitors were less likely to take GPAs concurrently compared to patients not taking COX-2 inhibitors (unadjusted OR 0.36; adjusted OR 0.39). CONCLUSIONS: Traditional oral NSAIDs were commonly prescribed to arthritis patients in Korea. In this study, patients taking COX-2 inhibitors were prescribed less adjunctive arthritis treatments and less gastroprotective agents than traditional oral NSAID users.

An observational, retrospective, cohort study of dosing patterns for rofecoxib and celecoxib in the treatment of arthritis.

OBJECTIVE: This study assessed prescribing patterns for rofecoxib and celecoxib in the treatment of osteoarthritis (OA) and rheumatoid arthritis (RA), as well as differences in prescribing patterns across physician specialties. METHODS: This was an observational, retrospective, cohort study of a large, US pharmacy claims database. Eligible patients were initiating therapy with rofecoxib or celecoxib and had succeeds, equals 90 days' supply of medication, as well as > or =1 medical claim specific to OA or RA between June 1, 2000, and May 31, 2001. Analyses were stratified according to diagnosis, prescribing physician specialty, and patient demographics. The main outcome measure was mean daily usage (ie, mean daily dose [milligrams]; mean number of pills per day; and mean daily consumption [denoted as DACON], calculated as daily dose divided by most frequently prescribed strength). This was primarily a descriptive study. Tests of statistical significance were not performed because the large sample size would have rendered small differences significant. RESULTS: A total of 58,574 patients with OA (81.8% [n=47,935]) or RA (18.2% [n=10,639]) received 220,627 prescriptions for rofecoxib or celecoxib (47.7% [n=27, 924] and 52.3% [n=30, 650] of patients, respectively) during the study period. Overall, the most frequently prescribed strengths were rofecoxib 25 mg and celecoxib 200 mg. In both OA and RA, the most frequently prescribed mean daily dose of rofecoxib was 25 mg. In OA, the most frequently prescribed mean daily dose of celecoxib was 200 mg; in RA, it was 400 mg. Both pills per day and DACON were higher for celecoxib than rofecoxib. The DACON for rofecoxib was unrelated to physician specialty. Rheumatologists prescribed celecoxib at 20% to 40% higher mean daily doses than did primary care physicians, orthopedic specialists, or other specialists. Regardless of physician specialty, the DACON appeared higher for patients with RA than OA, for men than women, and for younger (aged <65 years) than older patients. CONCLUSIONS: In this analysis, relative to the most frequently prescribed strength, celecoxib-treated patients with OA and RA had higher DACONs than rofecoxib-treated OA and RA patients across all subgroups. These observations may have economic implications in terms of direct effects on cost and the need for formularies to consider overall use patterns in addition to pill costs. However, these conclusions are limited by lack of clinical information (other than an OA or RA diagnosis), inability to ascertain actual use, and potential for selection bias.