An Evaluation of the Clinical and Economic Burden Among Older Adult Medicare-Covered Beneficiaries With Treatment-Resistant Depression.

OBJECTIVE: To compare the clinical and economic burden of treatment-resistant depression (TRD) among older adult patients with major depressive disorder (MDD) to non-TRD MDD and non-MDD patients. METHODS: Retrospective cohort study using 5% Medicare data (January 1, 2012-December 31, 2015) for MDD patients aged ≥65 years who were defined as TRD if they received ≥2 antidepressant treatments in the current episode. MDD patients not meeting TRD criteria were deemed non-TRD MDD; those without an MDD diagnosis were categorized as non-MDD. All were required to have continuous health plan enrollment for ≥6 months pre- and ≥12 months postindex date (index: first antidepressant claim/random [non-MDD]). Three cohorts were matched, and generalized linear and Cox proportional hazards models were used to compare medication use, healthcare resource utilization, costs, and risks of initial hospitalization and readmission ≤30 days postdischarge from initial hospitalization. RESULTS: After matching, 178 patients from each cohort were analyzed. During 12 months of follow-up, TRD patients had higher use of different antidepressants and antipsychotics, higher inpatient and emergency room visits, longer inpatient stays, and higher total healthcare costs ($24,543 versus $16,059, $8,058) than non-TRD MDD and non-MDD cohorts, respectively (all p <0.05). Risk of initial hospitalization was higher in the TRD (hazard ratio [HR] = 3.60, 95% confidence interval [CI] = 2.08-6.23) and non-TRD MDD cohorts (HR = 1.82, 95% CI = 1.02-3.25) than the non-MDD cohort. CONCLUSIONS: The burden of MDD among older adult Medicare beneficiaries is substantial, and even greater among those with TRD compared to non-TRD MDD, demonstrating the need for more effective treatments than those currently available.

Economic burden of treatment-resistant depression among veterans in the United States.

OBJECTIVE: Evidence is limited on the economic burden associated with treatment-resistant depression (TRD) among US veterans. We evaluated the economic burden among patients with major depressive disorder (MDD) with and without TRD, and those without MDD in the Veterans Health Administration (VHA). METHODS: Three cohorts were identified using VHA claims data (01APR2014-31MAR2018). Patients with MDD (aged ≥18) who failed ≥2 antidepressant treatments of adequate dose and duration were defined as having TRD; patients with MDD not meeting this criterion constituted the non-TRD MDD cohort (index: first antidepressant claim). The non-MDD cohort included those without MDD diagnosis (index: randomly assigned). Patients with psychosis, schizophrenia, manic/bipolar disorder, or dementia in the 6-month pre-index period were excluded. Patients with non-TRD MDD and non-MDD were matched 1:1 to patients with TRD based on demographic characteristics (age, gender, race, index year). Health care resource utilization (HRU) and costs were analyzed during the post-index period using a negative binomial model and ordinary least squares regression model, respectively. RESULTS: After 1:1 exact matching, 10,449 patients were included in each cohort (mean age: 48.9 years). Patients with TRD had higher per patient per year (PPPY) HRU than non-TRD MDD (all-cause inpatient visits: incidence rate ratio [IRR]: 1.70 [95% confidence interval: 1.57-1.83]) and non-MDD (IRR: 5.04 [95% confidence interval: 4.51-5.63]), and incurred higher total all-cause health care costs PPPY than non-TRD MDD (mean difference: $5,906) and non-MDD (mean difference: $11,873; all p<.0001). CONCLUSION: Among US veterans, TRD poses a significant incremental economic burden relative to non-TRD MDD and non-MDD.

Use of home health and other healthcare delivery pathways among privately insured patients with and without treatment-resistant depression.

Objective: To assess the real-world use of home health services (HHS) among patients with major depressive disorder (MDD) with and without treatment-resistant depression (TRD).Methods: Adults (18-64 years) from a commercial claims database (07/2009 to 03/2015) were categorized into three cohorts: "TRD"(N = 6411), "non-TRD MDD"(N = 33,068), "non-MDD"(N = 149,884) stratified based on use of HHS (HHS vs. no-HHS). Healthcare resource utilization (HRU) and costs were evaluated up to two years following the first antidepressant pharmacy claim using descriptive statistics. HRU (e.g. inpatient, outpatient, emergency department visits) and costs were measured per-patient-per-year (PPPY) in 2015 USD.Results: During the follow-up period, 18.0% of TRD, 12.4% of non-TRD MDD, and 6.5% of non-MDD patients received HHS. Mean all-cause healthcare costs PPPY were numerically higher among patients with HHS use. Among the TRD cohort, patients using HHS had healthcare costs of $40,040 PPPY while patients with TRD and no-HHS had healthcare costs of $12,272 PPPY. Within the non-TRD MDD cohort, HHS users incurred healthcare costs of $28,767 PPPY and non-HHS users incurred costs of $7227 PPPY. Patients without MDD who used HHS had annual healthcare costs of $22,340 while non-MDD patients who did not use HHS had healthcare costs of $3479 PPPY. However, among HHS users, HHS costs represented a relatively small proportion of total healthcare costs.Conclusions: The high proportion of TRD patients using HHS suggests it is a utilized healthcare delivery pathway by TRD patients.

US Integrated Delivery Networks Perspective on Economic Burden of Patients with Treatment-Resistant Depression: A Retrospective Matched-Cohort Study.

OBJECTIVE: Our objective was to assess healthcare resource utilization (HRU) and costs among patients with major depressive disorder (MDD) with and without treatment-resistant depression (TRD) and those without MDD in US Integrated Delivery Networks (IDNs). METHODS: This was a retrospective matched-cohort study. The Optum© Integrated Claims Electronic Health Record de-identified database was used to identify adult patients with TRD (January 2011-June 2017) across US IDNs. TRD patients were propensity score matched 1:1 with non-TRD MDD and non-MDD patients on demographics. Rates of HRU and costs were compared up to 2 years following the first antidepressant pharmacy claim (or randomly imputed date for non-MDD patients) using negative binomial and ordinary least squares regressions, respectively, with 95% confidence intervals (CIs) from nonparametric bootstraps (costs only) adjusted for baseline comorbidity index and costs. RESULTS: All 1582 TRD patients were matched to non-TRD MDD and non-MDD patients and evaluated. TRD patients were on average 46 years old, and 67% were female. Mean duration of observation was 20.1, 19.6, and 17.9 months in the TRD, non-TRD MDD, and non-MDD cohorts, respectively. Patients with TRD had significantly higher rates of HRU than did non-TRD MDD patients (inpatient visits 0.35 vs. 0.16 per patient per year [PPPY]; adjusted incidence rate ratio [IRR] 2.04 [95% CI 1.74-2.39]) and non-MDD patients (0.35 vs. 0.09 PPPY, adjusted IRR 3.05 [95% CI 2.54-3.66]). TRD patients incurred significantly higher costs PPPY than did non-TRD MDD patients ($US25,807 vs. 13,701, adjusted cost difference $US9479 [95% CI 7071-11,621]) and non-MDD patients ($US25,807 vs. 8500, adjusted cost difference $US11,433 [95% CI 8668-13,876]). CONCLUSIONS: HRU and costs associated with TRD are significant in US IDNs.

Medicaid spending burden among beneficiaries with treatment-resistant depression.

AIM: To evaluate Medicaid spending and healthcare resource utilization (HRU) in treatment-resistant depression (TRD). MATERIALS & METHODS: TRD beneficiaries were identified from Medicaid claims databases (January 2010-March 2017) and matched 1:1 with major depressive disorder (MDD) beneficiaries without TRD (non-TRD-MDD) and randomly selected patients without MDD (non-MDD). Differences in HRU and per-patient-per-year costs were reported in incidence rate ratios (IRRs) and cost differences (CDs), respectively. RESULTS: TRD beneficiaries had higher HRU than 1:1 matched non-TRD-MDD (e.g., inpatient visits: IRR = 1.41) and non-MDD beneficiaries (N = 14,710 per cohort; e.g., inpatient visits: IRR = 3.42, p < 0.01). TRD beneficiaries incurred greater costs versus non-TRD-MDD (CD = US$4382) and non-MDD beneficiaries (CD = US$8294; p < 0.05). CONCLUSION: TRD is associated with higher HRU and costs versus non-TRD-MDD and non-MDD. TRD poses a significant burden to Medicaid.

Economic Burden of Treatment-Resistant Depression Among Patients Hospitalized for Major Depressive Disorder in the United States.

Objectives: This study aimed to evaluate hospital length of stay (LOS) and cost as well as readmission risk and the associated economic burden among patients hospitalized for treatment-resistant and non-treatment-resistant major depressive disorder. Methods: Adult patients with a primary hospital discharge diagnosis of major depressive disorder were identified from the Premier Hospital Database (January 1, 2012-September 30, 2015). Patients were stratified into two cohorts: those whose hospital treatment was suggestive of treatment-resistant depression and those with non-treatment-resistant depression. Hospital LOS and cost during the initial admission and readmissions rates, LOS, and cost within the 6-month follow-up were compared between cohorts with a propensity score-matched sample. Results: After matching, 45,066 patients were included in each cohort. For index hospitalizations, mean hospital LOS was longer (7.4 vs. 5.9 days, p<0.001) and mean hospital cost higher ($8,681 vs. $6,632, p<0.001) for patients with treatment-resistant depression vs. non-treatment-resistant depression. Rates for all-cause (24.4% vs. 20.0%, p<0.001), major depressive disorder-related (17.0% vs. 13.3%, p<0.001), and suicidal ideation/suicide attempt-related (12.8% vs. 9.5%, p<0.001) readmissions were higher for patients with treatment-resistant depression. Mean LOS and total hospital costs per patient for readmissions were also greater for patients with treatment-resistant depression vs. non-treatment-resistant depression. Correspondingly, the combined hospital cost (index hospitalization+all-cause readmissions) was greater for patients with treatment-resistant depression ($12,370 vs. $9,429, p<0.001). Conclusions: Treatment-resistant depression was associated with substantial economic burden among patients hospitalized for major depressive disorder. More-effective treatment and care for this patient population may reduce the hospital burden of patients with treatment-resistant depression.

Is clinician impression of depression symptom severity associated with incremental economic burden in privately insured US patients with treatment resistant depression?

BACKGROUND: Among patients with major depressive disorder (MDD), those with treatment-resistant depression (TRD) have a higher economic burden. However, the healthcare resource utilization (HRU) and costs may vary by severity status in TRD patients. This study quantified the incremental economic burden of severity status in TRD patients. METHODS: In a US database of privately insured employees and dependents (07/01/2009-03/31/2015), a claims-based algorithm identified adult TRD patients who were stratified into mild, moderate, and severe cohorts based on the information in the last observed MDD ICD-9-CM code. HRU and costs of moderate and severe cohorts were compared to those of the mild cohort during the 2-year follow-up after the first antidepressant claim. RESULTS: Among 6411 TRD patients, 455 (7.1%) were identified as mild, 2153 (33.6%) as moderate, and 1455 (22.7%) as severe. Moderate and severe patients compared to mild had 45% and 150% more inpatient admissions, 65% and 164% more inpatient days, 18% and 54% more emergency department visits and 8% and 10% more outpatient visits per-patient-per-year (PPPY), respectively (all-cause; all p < 0.05). Mean all-cause direct total healthcare costs were $12,123, $16,885, and $18,911 PPPY in mild, moderate, and severe patients, respectively. The all-cause total healthcare cost differences adjusted for baseline characteristics amounted to $3455 in moderate and $5150 in severe versus mild patients, respectively (PPPY; all p < 0.05). LIMITATIONS: Not all TRD patients had a severity specifier; the severity specifier was not cross-validated against a depression scale. CONCLUSIONS: Increased severity status is associated with incremental economic burden in TRD patients.

Factors Associated with Initial Mode of Breast Cancer Detection among Black Women in the Women's Circle of Health Study.

Mammogram-detected breast cancers have a better prognosis than those identified through clinical breast exam (CBE) or through self-detection, primarily because tumors detected by mammography are more likely to be smaller and do not involve regional nodes. In a sample of 1,322 Black women, aged 40-75 years, diagnosed with breast cancer between 2002 and 2016, we evaluated factors associated with CBE and self-detection versus screening mammogram as the initial mode of breast cancer detection, using multivariable logistic regression models. Compared with screening mammogram, history of routine screening mammogram (OR 0.20, 95% CI: 0.07, 0.54) and performance of breast self-examination (BSE) (OR 0.31, 95% CI: 0.13, 0.74) before diagnosis were associated with lower odds of CBE as the initial mode of detection, while performance of CBEs before diagnosis (OR 11.04, 95% CI: 2.24, 54.55) was positively associated. Lower body mass index (<25.0 kg/m2 vs. ≥35.0 kg/m2: OR 2.46, 95% CI: 1.52, 3.98), performance of BSEs before diagnosis (less than once per month: OR 4.08, 95% CI: 2.45, 6.78; at least monthly: OR 4.99, 95% CI: 3.13, 7.97), and larger tumor size (1.0-2.0 cm vs. <1.0 cm: OR 2.92, 95% CI: 1.84, 4.64; >2.0 cm vs. <1.0 cm: OR 6.41, 95% CI: 3.30, 12.46) were associated with increased odds of self-detection relative to screening mammogram. The odds of CBE and self-detection as initial modes of breast cancer detection among Black women are independently associated with breast care and breast cancer screening services before diagnosis and with larger tumors at diagnosis.