Substance use disorders and risk of suicide in a general US population: a case control study.

BACKGROUND: Prior research suggests that substance use disorders (SUDs) are associated with risk of suicide mortality, but most previous work has been conducted among Veterans Health Administration patients. Few studies have examined the relationship between SUDs and suicide mortality in general populations. Our study estimates the association of SUDs with suicide mortality in a general US population of men and women who receive care across eight integrated health systems. METHODS: We conducted a case-control study using electronic health records and claims data from eight integrated health systems of the Mental Health Research Network. Participants were 2674 men and women who died by suicide between 2000-2013 and 267,400 matched controls. The main outcome was suicide mortality, assessed using data from the health systems and confirmed by state death data systems. Demographic and diagnostic data on substance use disorders and other health conditions were obtained from each health system. First, we compared descriptive statistics for cases and controls, including age, gender, income, and education. Next, we compared the rate of each substance use disorder category for cases and controls. Finally, we used conditional logistic regression models to estimate unadjusted and adjusted odds of suicide associated with each substance use disorder category. RESULTS: All categories of substance use disorders were associated with increased risk of suicide mortality. Adjusted odds ratios ranged from 2.0 (CI 1.7, 2.3) for patients with tobacco use disorder only to 11.2 (CI 8.0, 15.6) for patients with multiple alcohol, drug, and tobacco use disorders. Substance use disorders were associated with increased relative risk of suicide for both women and men across all categories, but the relative risk was more pronounced in women. CONCLUSIONS: Substance use disorders are associated with significant risk of suicide mortality, especially for women, even after controlling for other important risk factors. Experiencing multiple substance use disorders is particularly risky. These findings suggest increased suicide risk screening and prevention efforts for individuals with substance use disorders are needed.

Disease and economic burden for rare diseases in Taiwan: A longitudinal study using Taiwan's National Health Insurance Research Database.

BACKGROUND: High-cost orphan drugs are becoming increasingly available to treat rare diseases that affect a relatively small population. Little attention has been given to the prevalence of rare diseases and their health-related economic burden in Taiwan. OBJECTIVES: This study examined the national trends in the prevalence of rare diseases and their health-related economic burden (including medication costs) in Taiwan. METHODS: Rare disease-related claims data from 2003-2014 (12 years) from the National Health Insurance Research Database were used in this study. We used a time series analysis to assess trends in the yearly rates of treated patients with rare diseases, overall healthcare use, and expenditures, including drugs. RESULTS: During the 12-year study period, the estimated prevalence of rare diseases increased from 10.57 to 33.21 per 100,000 population, an average rate of a 19.46% increase per year. Total health expenditures for treatment of rare diseases increased from US$18.65 million to US$137.44 million between 2003 and 2014, accounting for 0.68% of the total national health expenditures in 2014. Drug expenditures for treatment of rare diseases increased from US$13.24 million to US$121.98 million between 2003 and 2014, which accounted for 71.00% and 88.75% of the health expenditures for patients with rare diseases in 2003 and 2014, respectively. In 2014, we found a 20.43-fold difference in average health expenditures and a 69.46-fold difference in average drug expenditures between patients with rare diseases and the overall population. CONCLUSIONS: The prevalence of rare diseases and the related economic burden have grown substantially in Taiwan over the past 12 years, and these trends are likely to continue. Drug expenditures accounted for almost 90% of health expenditures for rare diseases. Further analyses are underway to examine the economic burden of individual rare diseases.

Geographic Variations and Time Trends in Cancer Treatments in Taiwan.

BACKGROUND: Targeted therapies have become important treatment options for cancer care in many countries. This study aimed to examine recent trends in utilization of antineoplastic drugs, particularly the use of targeted therapies for treatment of cancer, by geographic region in Taiwan (northern, midwestern, southern, and eastern regions and the outer islands). METHODS: This was a retrospective observational study of antineoplastic agents using 2009-2012 quarterly claims data from Taiwan's National Health Insurance Research Database. Yearly market shares by prescription volume and costs for targeted therapies among total antineoplastic agents by region were estimated. We used multivariate regression model and ANOVA to examine variations in utilization of targeted therapies between geographic regions and used ARIMA models to estimate longitudinal trends. RESULTS: Population-adjusted use and costs of antineoplastic drugs (including targeted therapies) were highest in the southern region of Taiwan and lowest in the outer islands. We found a 4-fold difference in use of antineoplastic drugs and a 49-fold difference in use of targeted therapies between regions if the outer islands were included. There were minimal differences in use of antineoplastic drugs between other regions with about a 2-fold difference in use of targeted therapies. Without considering the outer islands, the market share by prescription volume and costs of targeted therapies increased almost 2-fold (1.84-1.90) and 1.5-fold (1.26-1.61) respectively between 2009 and 2012. Furthermore, region was not significantly associated with use of antineoplastic agents or use of targeted therapies after adjusting for confounders. Region was associated with costs of antineoplastic agents but it was not associated with costs of targeted therapies after confounding adjustments. CONCLUSIONS: Use of antineoplastic drugs overall and use of targeted therapies for treatment of cancer varied somewhat between regions in Taiwan; use was notably low in the outer islands. Strategies might be needed to ensure access to cancer care in each region as economic burden of cancer care increase due to growing use of targeted therapies.

10-year trends in statin utilization in Taiwan: a retrospective study using Taiwan's National Health Insurance Research Database.

OBJECTIVE: Statins have been commonly used to treat patients with hypercholesterolaemia and to prevent cardiovascular disease (CVD) worldwide. This study examined trends in use of statins in Taiwan from 2002 to 2011. DESIGN: This is a retrospective observational study focusing on the utilisation of statins. SETTING: The monthly claims data for statins between 2002 and 2011 were retrieved from Taiwan's National Health Insurance Research Database. MAIN OUTCOME MEASURES: We calculated the yearly prescription rate per new user for each statin. Products were classified as high-intensity/moderate-intensity/low-intensity statins by type of statin and dosage. Users were also classified based on disease histories. RESULTS: The number of statin users increased from 10 299 (~1.4% of adults) in 2002 to 50 687 (~6.3% of adults) in 2011. Atorvastatin was the most commonly used agent (28.4%-36.7%) during the study period. After 2007, simvastatin ranked second with 21.7% market share, followed by rosuvastatin, a newer agent that exhibited a substantial growth in prescription rates (3.4% in 2005 and 19.5% in 2011). In 2011, 94.0% of new statin users used statin monotherapies, and 6.0% used combination therapies. Use of moderate-intensity statins increased from 49.0% in 2002 to 71.0% in 2011, while high-intensity statins remained low. Patients with history of coronary events or cerebrovascular events were more likely to be prescribed higher intensity statins compared with those without. Prescribing of higher intensity statins was not greater among people with diabetes compared with those without during 2007-2011. Selection of statins did not differ between people with versus without history of myopathy or liver injury. CONCLUSION: Atorvastatin was the most commonly used statin in Taiwan during 2002-2011. While patients with history of CVD were more likely to be prescribed higher intensity statins compared with those without, this difference was not found comparing those with and without diabetes.

Longitudinal trends in use and costs of targeted therapies for common cancers in Taiwan: a retrospective observational study.

OBJECTIVES: Some targeted therapies have improved survival and overall quality of cancer care generally, but these increasingly expensive medicines have led to increases in pharmaceutical expenditure. This study examined trends in use and expenditures of antineoplastic agents in Taiwan, and estimated market shares by prescription volume and costs of targeted therapies over time. We also determined which cancer types accounted for the highest use of targeted therapies. DESIGN: This is a retrospective observational study focusing on the utilisation of targeted therapies for treatment of cancer. SETTING: The monthly claims data for antineoplastic agents were retrieved from Taiwan's National Health Insurance Research Database (2009-2012). MAIN OUTCOME MEASURES: We calculated market shares by prescription volume and costs for each class of antineoplastic agent by cancer type. Using a time series design with Autoregressive Integrated Moving Average (ARIMA) models, we estimated trends in use and costs of targeted therapies. RESULTS: Among all antineoplastic agents, use of targeted therapies grew from 6.24% in 2009 to 12.29% in 2012, but their costs rose from 26.16% to 41.57% in that time. Monoclonal antibodies and protein kinase inhibitors contributed the most (respectively, 23.84% and 16.12% of costs for antineoplastic agents in 2012). During 2009-2012, lung (44.64% of use; 28.26% of costs), female breast (16.49% of use; 27.18% of costs) and colorectal (12.11% of use; 13.16% of costs) cancers accounted for the highest use of targeted therapies. CONCLUSIONS: In Taiwan, targeted therapies are increasingly used for different cancers, representing a substantial economic burden. It is important to establish mechanisms to monitor their use and outcomes.

Longitudinal trends in use of targeted therapies for treatment of malignant neoplasms of the eye: a population-based study in Taiwan.

OBJECTIVES: This study examined the recent trend in use and costs of antineoplastic agents for treatment of eye malignancies in Taiwan from 2009 to 2012. We also forecasted use and costs of targeted therapies up to and including year 2016 based on the current patterns. DESIGN: Retrospective observational study focusing on the usage of targeted therapies for treatment of eye malignancy. SETTING: The monthly claims data for eye malignancy-related antineoplastic agents were retrieved from Taiwan's National Health Insurance Research Database (2009-2012). MAIN OUTCOME MEASURES: We calculated the number of prescriptions and costs for each class of medications, and analysed their time trends. In addition, using a time series design with ARIMA models, we estimated the market share by prescription volume and the proportion of costs for targeted therapies for year 2016. RESULTS: The market share by prescription volume of targeted therapies grew from 1.56% in 2009 to 9.98% in 2012 among all antineoplastic agents, and the proportion of costs for targeted therapies rose from 15.12% in 2009 to 58.88% in 2012. Especially, the proportion of costs for protein kinase inhibitors grew from 25.62% to 45.28% among all antineoplastic agents between 2010 and 2012. The market share by prescription volume and the proportion of costs for targeted therapies for treatment of eye malignancies were predicted to reach 27.33% and 91.39% by the fourth quarter in 2016, respectively. CONCLUSIONS: This is the first study that examined and forecasted use and costs of targeted therapies for treatment of eye malignancies in Taiwan. Our findings indicate that, compared with other classes of drugs, targeted therapies are having a more and more relevant share among all treatment strategies for eye malignancies in Taiwan, and due to their high costs they are likely to cause great economic burden.

Net clinical benefit of oral anticoagulants: a multiple criteria decision analysis.

BACKGROUND: This study quantitatively evaluated the comparative efficacy and safety of new oral anticoagulants (dabigatran, rivaroxaban, and apizaban) and warfarin for treatment of nonvalvular atrial fibrillation. We also compared these agents under different scenarios, including population with high risk of stroke and for primary vs. secondary stroke prevention. METHODS: We used multiple criteria decision analysis (MCDA) to assess the benefit-risk of these medications. Our MCDA models contained criteria for benefits (prevention of ischemic stroke and systemic embolism) and risks (intracranial and extracranial bleeding). We calculated a performance score for each drug accounting for benefits and risks in comparison to treatment alternatives. RESULTS: Overall, new agents had higher performance scores than warfarin; in order of performance scores: dabigatran 150 mg (0.529), rivaroxaban (0.462), apixaban (0.426), and warfarin (0.191). For patients at a higher risk of stroke (CHADS2 score≥3), apixaban had the highest performance score (0.686); performance scores for other drugs were 0.462 for dabigatran 150 mg, 0.392 for dabigatran 110 mg, 0.271 for rivaroxaban, and 0.116 for warfarin. Dabigatran 150 mg had the highest performance score for primary stroke prevention, while dabigatran 110 mg had the highest performance score for secondary prevention. CONCLUSIONS: Our results suggest that new oral anticoagulants might be preferred over warfarin. Selecting appropriate medicines according to the patient's condition based on information from an integrated benefit-risk assessment of treatment options is crucial to achieve optimal clinical outcomes.

Impacts of drug reimbursement reductions on utilization and expenditures of oral antidiabetic medications in Taiwan: an interrupted time series study.

OBJECTIVES: To control increasing pharmaceutical expenditures, Taiwan's National Health Insurance has implemented a series of drug reimbursement price reductions since 2000. This study examined changes in use and expenditures of oral antidiabetic medications following the price regulation in November 2006. METHODS: We obtained claims data between January 2006 and August 2007 from Taiwan's National Health Insurance Research Database. We categorized oral antidiabetic products as affected by the reimbursement reduction ("targeted") or not ("non-targeted"), by level of relative price reduction, and by manufacturer type (international vs. local manufacturers). We used an interrupted time series design and segmented regression models to estimate changes in monthly per capita prescribing rate, volume, and insurance reimbursement expenditures following the policy. RESULTS: The majority (129/178; 72.5%) of oral antidiabetic products were targeted by this round of price reductions. There was a relative reduction of 9.5% [95%CI: -12.68, -6.32] in total expenditures at ten months post-policy compared to expected rates. For targeted products, there were 2.04% [95%CI: -4.15, 0.07] and 13.26% [95%CI: -16.64, -9.87] relative reductions in prescribing rate and expenditures, respectively, at ten months post-policy. Non-targeted products increased significantly (22% [95%CI: 10.49, 33.51] and 22.85% [95%CI: 11.69, 34.01] relative increases in prescribing rate and expenditures respectively). Larger reimbursement cuts led to greater reductions in prescribing rate, volume, and insurance reimbursement expenditures of targeted products. Prescribing rates of both targeted and non-targeted products by international manufacturers declined after the policy while rates of prescribing non-targeted products by local manufacturers increased. CONCLUSIONS: While total government expenditures for oral antidiabetic medications were contained by the policy, our results indicate that prescribing shifted at the margin from targeted to non-targeted products and from international to local products. Further research is warranted to understand how changes in medication use due to price regulation policies affect medication adherence and patient health outcomes.

Accessing health outcome data on high-cost medicines in Australia.

Data on health outcomes resulting from the use of medicines provide important evidence of cost-effectiveness. Currently, clinical information on individual patients, collected by Medicare Australia to assess eligibility for subsidised treatment with high-cost medicines, is inaccessible for research. Comprehensive data on drug use and health outcomes should be made accessible, with appropriate regulation, so that the effectiveness, utility and appropriateness of our systems of access to medicines can be independently analysed. In the interests of continuous improvement in medical care and optimal use of limited resources, we strongly advocate the enhancement of Medicare Australia databases and liberalisation of arrangements for access to administrative and clinical data.