Cost impact of hydroxocobalamin in the treatment of patients with known or suspected cyanide poisoning due to smoke inhalation from closed-space fires.

BACKGROUND & OBJECTIVES: Cyanide poisoning can occur due to exposure to smoke in closed-space fires. With no point of care cyanide test at the scene of a fire, first responders and clinicians base decisions to treat with cyanide antidote on patient history, clinical signs, and other indirect data points that have not been proven to correspond with actual systemic levels of cyanide. The aim of this exploratory study was to determine the economic implications of treating patients with known or suspected cyanide poisoning due to smoke inhalation with hydroxocobalamin. METHODS: A decision analysis model was developed from the US hospital perspective. Healthcare resource utilization was estimated from a retrospective evaluation of clinical outcomes in hydroxocobalamin-treated patients and in historical controls without hydroxocobalamin use (Nguyen, et al. 2017). Epidemiologic parameters and costs were estimated from the published literature, and publicly-available hospital charges were identified. Outcomes reported in the analysis included expected healthcare resource utilization in the US population and per-patient costs with and without the use of hydroxocobalamin. A cost-to-charge ratio was applied so that all costs would reflect hospital costs rather than hospital charges. Deterministic sensitivity analysis was performed to identify the most influential model parameters. All costs were reported in 2017 US dollars. RESULTS: Use of hydroxocobalamin reduces healthcare resource utilization and contributes to decreased per-patient hospital costs ($15,381 with hydroxocobalamin treatment versus $22,607 with no cyanide antidote). The most substantive cost-savings resulted from decreased hospital length of stay (i.e., intensive care unit [ICU] and non-ICU). Costs attributed to mechanical ventilation also decreased with use of hydroxocobalamin. A univariate sensitivity analysis demonstrated that the most impactful variables in the cost analysis were related to hospital length of stay (ICU followed by non-ICU stay), followed by the daily cost of ICU stay. CONCLUSIONS: Use of hydroxocobalamin in patients with known or suspected cyanide poisoning from closed-space fire smoke inhalation may decrease hospital costs and contribute to more efficient healthcare resource utilization.

Adherence, persistence of use, and costs associated with second-generation antipsychotics for bipolar disorder.

OBJECTIVE: A retrospective study using Medicaid claims identified patients with bipolar disorder for whom oral second-generation antipsychotics were prescribed and compared rates of adherence, persistence of use, and costs across five groups of patients taking aripiprazole, olanzapine, quetiapine, risperidone, or ziprasidone. METHODS: Medicaid claims data for 2,446 bipolar patients were analyzed from eight states. The 18-month observation period included the six months before and the 12 months after the index prescription date. Adherence was defined as a medication possession ratio >80%. Persistence of use was measured by the number of days of medication therapy before a 30-day gap. Mental health-related prescription costs, total prescription costs, total mental health-related costs, and total costs were assessed. Ziprasidone was the comparator. RESULTS: Clinically recommended doses of second-generation antipsychotic medications were prescribed for 45% of the patients (N = 1,102). Of these, 58% (N = 642 of 1,102) were adherent with the prescribed medication, with no significant differences between medication groups. Median time to nonpersistence of use averaged 96 days. Patients taking olanzapine were about 35% more likely than patients taking ziprasidone to discontinue taking their medication (hazard ratio = 1.34, 95% confidence interval = 1.02-1.76, p = .04). Mental health-related prescription costs and total prescription costs were lower for risperidone than ziprasidone. No statistically significant differences were found between the groups for all mental health-related costs or total costs. CONCLUSIONS: Among patients in a sizeable Medicaid cohort for whom a second-generation antipsychotic medication was prescribed, less than half had a clinically recommended dose, and less than two-thirds with a clinically recommended dose were adherent to the medication, confirming that many patients with bipolar disorder do not receive clinically recommended doses of second-generation antipsychotics.

Outcome assessment of an antipsychotic drug algorithm: effects of the Mississippi State Hospital algorithm project.

OBJECTIVE: This study evaluated a state psychiatric hospital's algorithm for prescribing antipsychotic drugs for inpatients with schizophrenia to determine whether its emphasis on cost efficiency is compatible with quality of care. METHODS: Outcomes were compared for patients who received medication that was algorithm adherent or nonadherent. Risperidone and ziprasidone were first-step oral antipsychotics. Documentation of clinical rationale was acceptable for nonpreferred drug use. Outcomes of interest were length of hospitalization and "much improved" or "very much improved" status on the Clinical Global Impression severity scale (CGI-S). RESULTS: Of 401 patients, 70% were male. The CGI-S modal rating of severity was "markedly ill." Duration of illness was longer for patients given algorithm-nonadherent (17.6±9.7 years) versus -adherent (14.9±11.6 years, p=.013) medication. No statistically significant between-group differences were observed for mean length of stay (51.4±35.5 days versus 43.8±27.4 days, adjusted difference p=.18) or median improvement time (adherent, 41 days; nonadherent, 42 days; CI=34-48 days for both group medians). CONCLUSIONS: Prescription algorithm adherence was not associated with significantly increased length of inpatient stay or delayed time to improvement.

Therapeutic dose assessment of patient switching from atorvastatin to simvastatin.

OBJECTIVE: Patient switching of prescription drug brands within a therapeutic class has become more prevalent with tiered drug plan formularies. Although switching from more expensive brand name drugs to generic equivalents may reduce aggregate prescription costs, therapeutic benefit may be compromised if the patient is not switched to a drug with an equivalent therapeutic profile. This study examined whether patients switching from branded atorvastatin to either a branded or generic simvastatin were prescribed a therapeutically equivalent or higher dose, as opposed to a lower therapeutic dose. METHODS: Study patients were selected from a national longitudinal database of 1.4 billion annual prescription drug claims. All patients active in the database during the study period (9/01/2005 to 9/30/2006) with a prescription drug claim for atorvastatin in the index month (9/2005) were selected. The 453,409 patients in the study period were followed for 12 months to determine the percent switching to simvastatin and their relative therapeutic doses after switching. Patients switching to the same or lower milligram dose of simvastatin were classified as receiving a lower therapeutic dose compared with their atorvastatin dosing. RESULTS: Among patients using atorvastatin at the beginning of the study, 13,530 (3%) switched to simvastatin by the end of the study period. Medication changes resulted in a lower therapeutic dose in 38% of the switches. The percent of switches resulting in a lower therapeutic dose were 18% for those switching from 10 mg, 43% for those switching from 20 mg, 73% for those switching from 40 mg, and 100% for those switching from 80 mg. CONCLUSIONS: A significant proportion of patients switching from atorvastatin to simvastatin received a lower therapeutic dose, which may have an adverse impact on patients' quality of care and health status. Further research is needed to assess the potential negative effect on patient outcomes.