Impact of adherence to antidepressants on healthcare outcomes and costs among patients with type 2 diabetes and comorbid major depressive disorder.

OBJECTIVE: To evaluate the association between adherence to antidepressants and an effect on clinical outcomes and healthcare costs in patients with major depressive disorder (MDD) and comorbid type 2 diabetes (T2D). METHODS: This retrospective study used MarketScan claims data from January 2012 to March 2014. Study entry was the first claim for an antidepressant and a diagnosis code for MDD and T2D in the prior 6 months. Adherence and persistence with antidepressant therapy in the first 180 days were defined as medication possession ratio (MPR) ≥ 80% and length of therapy (LOT), with no treatment gap of >15 days, respectively. T2D control (HbA1c <7%), oral diabetes medication adherence, and healthcare costs were measured in the 12 month post-index period. The impact of antidepressant adherence and persistence on outcomes was assessed using multivariable analyses. RESULTS: Among the 1361 patients included, the mean age was 59 years and 55% were women. About one-third of the patients were adherent (35.9%, mean MPR = 40%), persistent (32.0%, average LOT = 100 days), and adherent/persistent (31.2%) on antidepressants. Being adherent, persistent, or adherent/persistent to antidepressants was associated with a two-fold improvement in adherence to oral diabetes medications. Of those with HbA1c data (n = 121), adherence or adherence/persistence to antidepressants was associated with patients being five times more likely to have T2D control (odds ratio [OR]: 4.95; 95% confidence interval [CI]: 1.39, 17.59, p = .0134). Comparison between antidepressant-persistent and non-persistent patients was not significant. Mean difference in adjusted all-cause annual costs showed lower costs among antidepressant-adherent and adherent/persistent patients (adherent: -$350, 95% CI: -$462, -$247; adherent/persistent: -$1165; 95% CI: -$1280, -$1060). CONCLUSIONS: Patients with better antidepressant adherence and adherence/persistence demonstrated better HbA1c control, with lower all-cause total and medical costs. Adherence, persistence, or adherence/persistence to antidepressants was associated with improved adherence to oral diabetes medications.

A Clinical and Economic Comparison of Rasburicase and Allopurinol in the Treatment of Patients With Clinical or Laboratory Tumor Lysis Syndrome.

BACKGROUND: The aim of the study was to compare reductions in uric acid (UA), length of stay (LOS), and hospitalization costs in patients with tumor lysis syndrome (TLS) treated with rasburicase or allopurinol. PATIENTS AND METHODS: This retrospective study of administrative data included hospitalized pediatric and adult patients who had clinical or laboratory TLS and received rasburicase or allopurinol. Each rasburicase-treated patient was propensity score-matched with 4 allopurinol-treated patients. Mean changes in UA within ≤ 2 days of treatment initiation were determined. Economic outcomes included mean number of days in the intensive care unit (ICU), total LOS, costs/hospitalization, and costs/percentage change in UA. RESULTS: Twenty-six rasburicase-treated patients were matched with 104 allopurinol-treated patients. Reduction in plasma UA was 5.3 mg/dL greater for patients treated with rasburicase than for patients treated with allopurinol (P < .0001). Length of ICU stay was 2.5 days less for patients treated with rasburicase than for patients treated with allopurinol (P < .0001), and total LOS was 5 days less for patients treated with rasburicase than for patients treated with allopurinol (P = .02). Total costs per patient were $20,038 lower for patients treated with rasburicase than for patients treated with allopurinol (P < .02). Cost per percentage UA reduction was also lower for patients treated with rasburicase versus patients treated with allopurinol ($3899 vs. $16,894; P < .001). CONCLUSION: In this analysis of TLS patients who received care in real-world settings, rasburicase versus allopurinol was significantly more effective in treating hyperuricemia and was associated with significantly shorter ICU and overall hospital stays and lower total inpatient costs.

Hospitalization Costs for Patients Undergoing Orthopedic Surgery Treated With Intravenous Acetaminophen (IV-APAP) Plus Other IV Analgesics or IV Opioid Monotherapy for Postoperative Pain.

INTRODUCTION: To assess the impact on hospitalization costs of multimodal analgesia (MMA), including intravenous acetaminophen (IV-APAP), versus IV opioid monotherapy for postoperative pain management in patients undergoing orthopedic surgery. METHODS: Utilizing the Truven Health MarketScan® Hospital Drug Database (HDD), patients undergoing total knee arthroplasty (TKA), total hip arthroplasty (THA), or surgical repair of hip fracture between 1/1/2011 and 8/31/2014 were separated into postoperative pain management groups: MMA with IV-APAP plus other IV analgesics (IV-APAP group) or an IV opioid monotherapy group. All patients could have received oral analgesics. Baseline characteristics and total hospitalization costs were compared. Additionally, an inverse probability treatment weighting [IPTW] with propensity scores analysis further assessed hospitalization cost differences. RESULTS: The IV-APAP group (n = 33,954) and IV opioid monotherapy group (n = 110,300) differed significantly (P < 0.0001) across baseline characteristics, though the differences may not have been clinically meaningful. Total hospitalization costs (mean ± standard deviation) were significantly lower for the IV-APAP group than the IV opioid monotherapy group (US$12,540 ± $9564 vs. $13,242 ± $35,825; P < 0.0001). Medical costs accounted for $701 of the $702 between-group difference. Pharmacy costs were similar between groups. Results of the IPTW-adjusted analysis further supported the statistically significant cost difference. CONCLUSIONS: Patients undergoing orthopedic surgery who received MMA for postoperative pain management, including IV-APAP, had significantly lower total costs than patients who received IV opioid monotherapy. This difference was driven by medical costs; importantly, there was no difference in pharmacy costs. Generalizability of the results may be limited to patients admitted to hospitals similar to those included in HDD. Dosing could not be determined, so it was not possible to quantify utilization of IV-APAP or ascertain differences in opioid consumption between the 2 groups. This study did not account for healthcare utilization post-discharge.

How patient cost-sharing trends affect adherence and outcomes: a literature review.

OBJECTIVE: We sought to assess the relationship between patient cost sharing; medication adherence; and clinical, utilization, and economic outcomes. METHODOLOGY: We conducted a literature review of articles and abstracts published from January 1974 to May 2008. Articles were identified using PubMed, Ovid, medline, Web of Science, and Google Scholar databases. The following terms were used in the search: adherence, compliance, copay, cost sharing, costs, noncompliance, outcomes, hospitalization, utilization, economics, income, and persistence. RESULTS: We identified and included 160 articles in the review. Although the types of interventions, measures, and populations studied varied widely, we were able to identify relatively clear relationships between cost sharing, adherence, and outcomes. Of the articles that evaluated the relationship between changes in cost sharing and adherence, 85% showed that an increasing patient share of medication costs was significantly associated with a decrease in adherence. For articles that investigated the relationship between adherence and outcomes, the majority noted that increased adherence was associated with a statistically significant improvement in outcomes. CONCLUSION: Increasing patient cost sharing was associated with declines in medication adherence, which in turn was associated with poorer health outcomes.

Clinical and economic impact of early versus delayed 5-alpha reductase inhibitor therapy in men taking alpha blockers for symptomatic benign prostatic hyperplasia.

BACKGROUND AND OBJECTIVE: Recent clinical trials indicate that combining an alpha blocker for rapid symptom improvement and a 5-alpha reductase inhibitor (5-ARI) to reduce the risk of clinical progression of benign prostatic hyperplasia (BPH) may be an optimal approach to management; however, few studies have evaluated the effect of combination therapy on clinical progression in a real-world setting. The purpose of our study was to assess the clinical and economic impact of early versus delayed 5-ARI therapy in patients treated with an alpha blocker for BPH. MATERIALS AND METHODS: A retrospective database analysis included men 50 years of age and older who were treated for BPH between 2003 and 2007. Clinical outcomes were evaluated for patients using 5-ARIs early (within 30 days of starting an alpha blocker) compared with those using delayed 5-ARI therapy (between 30 and 180 days after starting an alpha blocker). We assessed the likelihood of clinical progression (defined as the occurrence of acute urinary retention or prostate surgery) for each group over a one-year period following the start of alpha-blocker therapy. DATA SOURCE: The MarketScan Database, which was used to identify patients, contains medical and pharmacy claims data obtained directly from Medicare and commercial health plans and employers, representing 18 to 20 million lives annually. RESULTS: Of 8,617 men included in the analysis, 64.5% began 5-ARI therapy within 30 days of alpha-blocker therapy (the early cohort). These patients were less likely than those receiving delayed 5-ARI treatment to have clinical progression (12.8% vs. 17.4% respectively; P < 0.0001), acute urinary retention (10.2% vs. 13.8%, P < 0.0001), and prostate surgery (5% vs. 7%, P = 0.0002). The early group also incurred lower BPH-related medical costs ($572 vs. $730, P < 0.0001). Even though BPH-related pharmacy costs were significantly higher ($1,137 vs. $1,263, P = 0.0313), their total BPH-related costs were lower ($1,834 vs. $1,867, P = 0.0068). CONCLUSION: These results suggest that early 5-ARI therapy for men with symptomatic BPH who receive an alpha blocker may significantly reduce the risk of clinical progression (i.e., acute urinary retention or prostate surgery) over the next 12 months as well as lower BPH-related medical costs and BPH-related total costs.

Benign prostatic hyperplasia: racial differences in treatment patterns and prostate cancer prevalence.

OBJECTIVE: • To compare prostate cancer, prostate-related surgery and acute urinary retention rates, as well as associated healthcare resource use over 11 years in African American and Caucasian men with benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: • The BPH-related medical and surgical charges and events were determined for 398 African American men and 1656 Caucasian men followed for a mean of 10.2 years within a health maintenance organization. • Racial differences in clinical outcomes were evaluated using time-to-event analysis, stratifying results by baseline prostate-specific antigen (PSA) values. RESULTS: • Risk of a prostate cancer diagnosis was 2.2 times greater in African American than Caucasian men (95% CI 1.48-3.35, P < 0.001) in analyses adjusting for serum PSA level. • Although African Americans were more likely to receive medical therapy for symptoms of BPH than Caucasians (43.5% vs 37.2%, respectively; P= 0.029), there were no clinically meaningful differences with respect to subsequent acute urinary retention or BPH-related surgery between them, or BPH-related medical charges (US $407 vs US $405 per month). CONCLUSION: • As evidenced by this analysis of 'real-world' clinical practice, African Americans with BPH have a much greater risk of developing prostate cancer than similar Caucasian men highlighting the need for education and early detection in this population.

The economic impact of delaying 5-alpha reductase inhibitor therapy in men receiving treatment for symptomatic benign prostatic hyperplasia.

BACKGROUND: Pharmacologic treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia often includes alpha-blockers and 5-alpha reductase inhibitors. Many clinicians use alpha-blockers for rapid symptom control, later adding 5-alpha reductase inhibitors to modify long-term disease progression. Delaying the addition of these medications has been shown to result in reduced clinical outcomes. The economic impact of this practice has not been widely studied or reported to date. OBJECTIVE: The objective of this study was to assess the economic impact of delaying initiation of concomitant 5-alpha reductase inhibitor therapy (≥30 days) in patients receiving alpha-blockers for lower urinary tract symptoms. METHODS: Using 2 nationally representative databases (Integrated Health Care Information Solutions and PharMetrics), 2 retrospective analyses were conducted involving 2636 and 4260 men, respectively, aged ≥50 years treated for benign prostatic hyperplasia between 2000 and 2007. Economic outcomes (ie, the cost of therapy and the use of healthcare resources) were compared for adding 5-alpha reductase inhibitor therapy early (within <30 days of initiating an alpha-blocker) versus delaying these medications (≥30 days after initiating an alpha-blocker). RESULTS: In the Integrated Health Care Information Solutions analysis, patients in the early add-on therapy group (n = 1572) had lower benign prostatic hyperplasia-related medical costs in the posttreatment period than those in the delayed-therapy group (n = 1064), $349 versus $618 (P <.0001). Similar trends were seen in the PharMetrics analysis-the medical costs in the early add-on therapy group (n = 2604) and delayed group (n = 1656) were $344 versus $449, respectively (P <.001). Pharmacy costs were $1068 for the early-treatment cohort and $989 for the delayed-treatment cohort for the Integrated Health Care Information Solutions database, yielding total costs of $1417 and $1606, respectively, for a $189 savings per patient over the initial year of treatment (P <.0001). In the PharMetrics analysis, pharmacy costs were $1391 for the early-treatment cohort and $1237 for the delayed-treatment cohort, resulting in total cost of $1735 and $1686, respectively, yielding $59 in additional costs per patient annually for those treated early (P = .8645). CONCLUSION: These results suggest that patients receiving 5-alpha reductase inhibitor therapy within 30 days after initiating alpha-blocker treatment have lower benign prostatic hyperplasia-related medical costs than those who start combination treatment later. The increase in pharmacy costs associated with early initiation of 5-alpha reductase inhibitor therapy resulted in total costs that were similar or significantly lower than those of delayed combination users.

Impact of delaying 5-alpha reductase inhibitor therapy in men on alpha-blocker therapy to treat BPH: assessment of acute urinary retention and prostate-related surgery.

OBJECTIVE: Pharmacologic treatment of lower urinary tract symptoms from benign prostatic hyperplasia (BPH) commonly includes alpha-blockers (ABs) and 5alpha-reductase inhibitors (5ARIs). Many clinicians use ABs for rapid symptom control and 5ARIs to modify long-term disease progression. The purpose of this study was to assess the clinical impact of delayed 5ARI therapy in patients treated with AB for lower urinary tract symptoms. RESEARCH DESIGN AND METHODS: Using two nationally representative databases, two retrospective analyses were conducted including patients aged > or =50 years treated for BPH between 2000 and 2007. Clinical outcomes for those using add-on 5ARI therapy early (within 30 days of initiating AB) and late (>30 days after initiating AB) were compared. Likelihood of clinical progression, defined as the presence of acute urinary retention (AUR) and prostate surgery, was assessed over 1 year after AB initiation, and modeled as a function of the treatment cohorts and the following baseline covariates: AUR, BPH stage, Charlson Comorbidity Index, age, and number of unique diagnosis codes, unique non-BPH-related classes of prescriptions filled, and specialty care. RESULTS: Of 6896 men included in the analyses, approximately 60% initiated 5ARI therapy within 30 days of AB therapy (the early cohort). Patients in the early cohort were less likely to have clinical progression. Each 30-day delay in starting 5ARIs resulted in an increased likelihood of overall clinical progression (average 21.1%), AUR (average 18.6%), and prostate-related surgery (average 26.7%). CONCLUSIONS: These results suggest that delaying 5ARI therapy in men with BPH increases the risk of AUR and prostate surgery. LIMITATIONS: Confounding factors, such as symptom severity and prostate volume, may have influenced the findings of the study.

The burden of illness of hypertension and comorbid diabetes.

OBJECTIVE: To compare the impact of comorbid hypertension and diabetes on resource utilization and costs compared to diabetes mellitus (DM) or hypertension (HTN) alone. METHODS: A retrospective claims analysis assessed economic trends in patients without pre-existing CV disease in three cohorts: newly-treated HTN-only, DM-only, and newly-treated HTN and DM (comorbid cohort). Total, CV-specific, and DM-specific costs measured for up to 24 months were classified into five categories: inpatient, outpatient, emergency department (ED), physician, and other medical. Costs were compared using linear regression, controlling for age, gender, comorbidities, and non-CV- or DM-related prescriptions at baseline. RESULTS: The comorbid cohort had the highest inpatient ($1920), outpatient ($1664), ED ($126), other medical ($218), and pharmacy costs ($2388), plus significantly higher CV- and DM-specific costs. At 24 months, for HTN-related costs for the HTN cohort equaled $1604, while DM-related costs for the DM cohort totaled $2023. Comparatively, HTN-related costs for patients with HTNT + DM were $2678 while DM-related costs were $3094, being over $1000 and $1800 more than each individual cohort, respectively. A post-hoc analysis of CV events found the comorbid cohort had significantly more myocardial infarctions (MIs) and acute ischemic events than did the HTN-only cohort. CONCLUSION: Higher cost and resource utilization is associated with comorbid HTN and DM. Higher average disease-specific costs over 24 months indicate an intensity of care for patients with comorbid disease that is beyond that of simply managing an additional disease state. Study limitations include patient selection biases, which are possible with any administrative commercial database analysis.

Comparative analysis of alpha-blocker utilization in combination with 5-alpha reductase inhibitors for enlarged prostate in a managed care setting among Medicare-aged men.

OBJECTIVE: To evaluate the likelihood of alpha-adrenergic antagonist (alpha-blocker) discontinuation in combination with dutasteride or finasteride among patients aged > or =65 years with enlarged prostate. METHOD: This retrospective analysis used 2003-2006 data representing more than 30 million managed care members. Medical/pharmacy claims were used to select patients, matched 1:1 using propensity scoring. The proportion remaining on alpha-blocker therapy more than 12 months and time to discontinuation were compared between groups, controlling for covariates using survival analysis. RESULTS: The matched sample included 1674 patients. Alpha-blocker therapy discontinuation was observed at 90 days (86.9% dutasteride patients and 91.8% finasteride patients remained on alpha-blocker therapy). After 12 months, more dutasteride patients discontinued (38.1% remained) alpha-blocker therapy than finasteride patients (56.3% remained). CONCLUSIONS: Patients discontinued alpha-blocker therapy as early as 3 months. Those taking dutasteride were 64% more likely to discontinue alpha-blocker therapy than patients taking finasteride. Dutasteride's impact on discontinuation may have important implications and should be examined further.

Cost comparison of finasteride and dutasteride for enlarged prostate in a managed care setting among Medicare-aged men.

OBJECTIVE: To assess cost differences between dutasteride and finasteride use within the first year of initiating treatment for enlarged prostate (EP) among men aged > or =65 years in a managed care setting. METHODS: For this retrospective analysis, medical/pharmacy claims data from July 1, 2003, to June 30, 2006, were analyzed for EP patients aged > or =65 years who were treated with dutasteride or finasteride. Analysis of average monthly costs over each patient's 1-year follow-up period incorporated total charges for EP-related medical care, including physician, inpatient and outpatient hospital care, emergency department, and other ancillary services. RESULTS: A total of 4498 patients met selection criteria, with comparable demographics between treatment cohorts. Patients taking dutasteride incurred $51 less per month in medical expenses than finasteride-treated patients ($122 vs $173; P <.001), attributable to lower monthly inpatient hospitalization costs ($55.84 vs $70.34), outpatient costs ($22.07 vs $44.25), and physician office visit costs ($40.69 vs $51.10). CONCLUSION: Medicare-aged patients treated with dutasteride incurred $51 less per month in medical costs than those treated with generic finasteride, suggesting that the higher price of dutasteride may be offset by decreased medical resource consumption.

Antidepressant adherence and medical resource use among managed care patients with anxiety disorders.

OBJECTIVES: This study evaluated adherence with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) among patients who newly initiated therapy for anxiety with or without comorbid depression; the study also quantified the health-related economic consequences of nonadherence. METHODS: A large managed care database was used to gather retrospective data for patients with anxiety disorders who had a prescription for an antidepressant between July 1, 2001, and December 31, 2002. The relationship between antidepressant adherence and medical resource utilization was assessed; the analysis controlled for age, gender, utilization of mental health specialty care, change in medication, whether the dosage was titrated, costs in the six months before the prescription for an antidepressant, and comorbid physical conditions. RESULTS: Of the 13,085 patients with anxiety diagnoses who met the criteria for study inclusion, 57 percent were nonadherent to antidepressant therapy at six months. Patients who received mental health specialty care were more likely than those who did not receive such care to be adherent to therapy (48.5 percent compared with 40.7 percent; p<.001). Those with dual diagnoses of anxiety and depression were more likely than those with anxiety alone to be adherent to therapy (46.8 percent compared with 40.2 percent; p<.001). Those with a coded diagnosis of posttraumatic stress disorder had the highest medical costs. Patients with anxiety and depression had significantly higher total costs than patients with anxiety alone. Adherent patients who did not have a change in medication or a titrated dosage had significantly lower medical costs than nonadherent patients; however, total costs (medical plus pharmacy) were similar. CONCLUSIONS: Nonadherence with antidepressant therapy in anxiety disorders is common, but mental health specialty care may be associated with improved adherence. Lower medical costs for adherent patients who did not have a change in medication or a titrated dosage offset the increase in pharmacy costs, resulting in total costs (medical plus pharmacy) that were similar to those of nonadherent patients.

Clinical and economic outcomes in patients treated for enlarged prostate.

BACKGROUND: Benign prostatic hyperplasia (BPH), also referred to as enlarged prostate, is a highly prevalent condition in men aged 50 years or older. It is a progressive disease with significant morbidity from complications. OBJECTIVE: The purpose of this study was to assess the likelihood of having acute urinary retention (AUR) and prostate surgery after initiating therapy with an alpha blocker or 5-alpha reductase inhibitor in a real-world setting. STUDY DESIGN: This was a retrospective study of patients who were treated for BPH between January 1, 2003, and November 30, 2003, in a large, national managed care claims database. Outcomes measures of interest included rate of AUR, prostate surgery, and surgical complications. RESULTS: There were 2959 patient records with a diagnosis of BPH who were taking prostate medications in the database. Eighty-nine percent of patients were receiving alpha blocker therapy, whereas 11% of patients were receiving 5-alpha reductase inhibitors. Overall, the 1-year AUR rate was 12.1%, and the prostate surgery rate was 5.8%. Patients who initiated 5-alpha reductase inhibitor therapy only were less likely to have AUR or surgery compared with patients taking alpha blockers, although surgical differences did not reach statistical significance (P = .0576). Overall, the surgical complication rate was 49.4%, and the rate of AUR within 180 days of prostate surgery was 30.6%. Rates of prostate surgery, AUR, and surgical complications all increased with age. CONCLUSION: Patients receiving 5-alpha reductase inhibitor therapy alone were less likely to have AUR compared with patients receiving alpha blockers and tended to be less likely to have surgery (P = .054).

The cost of treating the 10 most prevalent diseases in men 50 years of age or older.

OBJECTIVE: Costs of treating the 10 most prevalent diagnosed diseases in men > or = 50 years of age were examined in hopes of identifying areas for better medical management and opportunities to decrease healthcare costs. METHODS: A retrospective analysis of a large national managed care database was utilized to assess the costs of treating the 10 most diagnosed diseases in aging men. All men initiating pharmacy treatment between July 1, 1997, and January 31, 2003, for (1) hypertension; (2) coronary artery disease (CAD); (3) type 2 diabetes; (4) enlarged prostate; (5) osteoarthritis; (6) gastroesophageal reflux disease; (7) bursitis; (8) arrhythmias; (9) cataracts; and (10) depression were included. Patients were continuously followed 6 months before and 12 months after initiating treatment. Costs of treatment and likelihood of experiencing a significant event were examined. RESULTS: One-year total disease-specific medical costs were highest for arrhythmias, osteoarthritis, cataracts, and CAD. Total medical costs for bursitis, type 2 diabetes, and enlarged prostate were between $400 and $500. Inpatient costs as a percentage of total medical costs were highest for CAD (75%), osteoarthritis (61%), arrhythmias (57%), and enlarged prostate (40%). For most diseases, pharmacy charges were <50% of the total cost. The likelihood of experiencing a significant clinical event within 1 year of initiating treatment was highest in men with bursitis (23%, surgery) and enlarged prostate (19.2%, acute urinary retention and/or surgery), hypertension (13.5%), and diabetes (9.5%). CONCLUSION: The most costly conditions in the 10 most prevalent diseases in men > or = 50 years of age were typically those that required substantial inpatient care. Conditions such as enlarged prostate, diabetes, and hypertension demonstrated a high likelihood of a clinical event within 1 year of initiating treatment. These conditions are therapeutic areas with the greatest likelihood of improvement, given what is known about the use of appropriate pharmacotherapy and the likelihood of treating to goal. Proactive patient management (eg, initiating/maximizing pharmacotherapy) may have the potential to positively impact clinical and economic outcomes for aging men.

Methods for evaluating patient adherence to antidepressant therapy: a real-world comparison of adherence and economic outcomes.

OBJECTIVE: The objective of this study was to differentiate between 3 measures of antidepressant adherence with regard to the number of patients deemed adherent to therapy and the association between adherence and resource utilization. DESIGN AND SETTING: The authors conducted a retrospective study of patients initiating selective serotonin reuptake inhibitor (SSRI) therapy for depression and/or anxiety between July 2001 and June 2002 in a large national managed care database. MAIN OUTCOME MEASURES: Rates of 6-month SSRI adherence were measured by 3 different metrics: length of therapy (LOT), medication possession ratio (MPR), and combined MPR/LOT. Differences in resource utilization for each adherence metric were measured for patients deemed as 1) adherent, 2) nonadherent, 3) therapy changers, and 4) dose titraters. RESULTS: There were 22,947 patients meeting study criteria. Although statistically different, 6-month adherence rates were numerically similar across all methods (LOT, 44.6%; MPR, 43.3%; and MPR/LOT, 42.9%, P < 0.001); approximately 57% of patients were nonadherent to therapy. Regardless of metric, the adherent cohort incurred the lowest yearly medical costs, followed by the nonadherent, titrate, and therapy change cohorts (P < 0.001 between adherent cohort and all other cohorts). The LOT method produced the greatest difference in yearly medical costs between adherent and nonadherent patients (Dollars 511) followed by MPR/LOT (Dollars 432) and MPR (Dollars 423). When antidepressant prescription costs were added to medical costs, patients requiring a therapy change and titrating therapy incurred higher costs than adherent patients, whereas nonadherent and adherent patients incurred similar costs. CONCLUSION: Regardless of adherence metric, approximately 43% of patients were adherent to antidepressant therapy, and adherent patients were associated with the lowest yearly medical costs.

Differences in compliance patterns across the selective serotonin reuptake inhibitors (SSRIs).

OBJECTIVE: To evaluate differential compliance rates between immediate-release (IR) selective serotonin reuptake inhibitors (SSRI) and a controlled-release (CR) SSRI in patients initiating SSRI therapy. METHODS: A retrospective analysis of patients initiating treatment with SSRIs identified in the IHCIS National Managed Care Database between July 2001 and December 2002 was conducted. Logistic regression models were used to assess differences in 6-month compliance rates, controlling for age, gender, utilization of mental health specialty care services, titration rates, diagnoses, and comorbidities. Compliance was defined as having a minimum medication possession ratio of 80% over a 180-day period without evidence of a 15-day gap prior to 90 days of therapy. RESULTS: There were 116 090 patients included in the study, with approximately 4% receiving a CR SSRI and 96% receiving IR SSRIs. Approximately 25% of patients had a diagnosis for depression, 16% had a diagnosis for anxiety, and 13% had a 16% had a diagnosis for anxiety, and 13% had a diagnosis for both anxiety and depression. Overall, diagnosis for both anxiety and depression. Overall, 54.2% were noncompliant with therapy, while 30.2% of patients were compliant with therapy, and 15.7% had evidence of a therapy change. After controlling for baseline covariates, patients initiating IR SSRIs were 14% less likely to be compliant compared to those initiating paroxetine CR (p < 0.0001). Patients initiating on paroxetine IR were least likely to be compliant (odds ratio [OR] 0.788; p < 0.0001), followed by escitalopram (OR 0.850; p = 0.0179), sertraline (OR 0.877; p = 0.0005), citalopram (0.909; p = 0.0114), and fluoxetine (OR 0.916; p = 0.0250). CONCLUSIONS: Approximately 54% of patients initiating SSRI therapy were noncompliant with SSRI therapy over a 6-month period, with the lowest level of compliance found in patients receiving IR SSRI agents. Future studies should assess the effect of compliance on economic measures and determine if reductions in resource utilization are found across specific SSRI agents.

Differences in total medical costs across the SSRIs for the treatment of depression and anxiety.

There is growing evidence that adherence to the recommended duration of antidepressant therapy results in reduced medical costs compared with nonadherence, and that the likelihood of adhering to therapy is not equivalent across the selective serotonin reuptake inhibitors (SSRIs). As such, the purpose of this study was to assess differences in 6-month medical costs between paroxetine controlled-release (CR) and immediate-release (IR) SSRI agents in a retrospective analysis of patients initiating SSRI therapy identified from the Integrated Healthcare Information Services National Managed Care Benchmark Database during a 2.5-year time frame. Inferential analyses were performed to evaluate differences in 6-month medical costs, controlling for differences in age, sex, utilization of psychiatric specialty care services, titration, pre-period costs, and comorbidity measures. Of the 146 075 patients included in this study, approximately 7% received paroxetine CR. Approximately 29.5% of patients had an anxiety disorder diagnosis; 26.0% had a depression-only diagnosis; and 13.2% had comorbid anxiety and depression. The 6-month medical costs were 244 US dollars lower for patients initiating with paroxetine CR compared with the average medical costs for patients receiving IR SSRIs. Paroxetine CR also had the lowest medical costs compared with each individual SSRI evaluated. After log transformation of costs and adjustment for baseline covariates, the aggregated IR SSRIs were associated with 8.7% higher 6-month medical costs than paroxetine CR (P <.001) and even greater costs after stratifying by diagnosis: 12.5% higher costs in patients with anxiety, 14.3% higher costs in patients with depression, and 15.9% higher costs in patients with comorbid anxiety and depression (P <.001 for all). Each individual IR SSRI was also associated with significantly higher medical costs than paroxetine CR, irrespective of diagnosis. As demonstrated, medical costs over a 6-month time frame were significantly greater for IR SSRIs versus paroxetine CR, even after adjusting for background characteristics and stratifying by diagnosis. Future studies should measure rates of adherence in relation to medical outcomes over an expanded time frame.

Adherence to paroxetine CR compared with paroxetine IR in a Medicare-eligible population with anxiety disorders.

There are many challenges in the pharmacologic management of elderly patients with anxiety disorders, including an increased sensitivity to drug effects, reduced drug metabolism, and socioeconomic barriers leading to poor medication adherence. As such, the purpose of this study was to evaluate differential rates of adherence between paroxetine controlled release (CR) and paroxetine immediate release (IR) in the treatment of anxiety disorders in a Medicare-eligible population. Patients aged 65 years or older initiating therapy with paroxetine CR or paroxetine IR with a diagnosis of anxiety were identified from the Integrated Healthcare Information Services National Managed Care Benchmark database from July 2001 to February 2004. Logistic regression models were used to assess differences in 6-month adherence rates, controlling for differences in multiple background characteristics. Adherence was defined as having a minimum medication possession ratio of 80% over 180 days without evidence of a 15-day gap before 90 days of therapy. Of the 604 patients included in the study, 18% received paroxetine CR and 82% received paroxetine IR; comorbid anxiety and depression were present in 37.3% of patients. Overall, only 37.3% of patients adhered to therapy, with a greater percentage of patients adhering to paroxetine CR (45.0%) compared with paroxetine IR (35.6%). After controlling for background characteristics, patients receiving paroxetine IR were 38.7% less likely to adhere to therapy compared with patients receiving paroxetine CR (P = .0328). When stratified by those with comorbid anxiety and depression, patients receiving paroxetine IR were 55.1% less likely to adhere to therapy compared with patients receiving paroxetine CR (P = .0292). This study demonstrates that antidepressant nonadherence is common in patients older than 65 years of age, with overall rates of nonadherence at 62.7% and patients receiving paroxetine IR having the lowest levels of adherence. Future work should assess differences in all available selective serotonin reuptake inhibitors while also directly assessing the economic impact of nonadherence in the elderly population.

Relationship of total health care charges to selective serotonin reuptake inhibitor utilization patterns including the length of antidepressant therapy--results from a managed care administrative claims database.

OBJECTIVE: Administrative claims data analysis performed in the early 1990s found lower total medical costs for patients with depression who remained on antidepressant therapy with selective serotonin reuptake inhibitors (SSRIs) for at least 90 days compared with patients who discontinued therapy prior to 60 days. Over the past decade, many changes in the health care system have occurred that might impact the reproducibility of these findings. The purpose of this study was to investigate the association between SSRI utilization patterns and the use of health care services in the managed care environment. METHODS: A large managed care claims database was used to identify patients receiving 2 or more SSRI prescriptions between June 2001 and December 2002. In order to ensure that patients were newly started on SSRI therapy, patients were required to have 6 months of enrollment data prior to their index date, without evidence of antidepressant therapy. Continuous enrollment for 12 months following their index prescription was also required. Patients with schizophrenia, bipolar disorder, or who received antipsychotic medications were excluded from this analysis. Patients were placed into 1 of 5 mutually exclusive antidepressant utilization cohorts: (1) <90 days, (2) e 90 days, (3) titration, (4) partial compliance, and (5) therapy change. Total medical costs, with and without pharmacy costs, were then compared between antidepressant utilization cohorts for 12 months of claims data. RESULTS: There were 65,753 patients included in the study. Medical charges without pharmacy charges were lowest in the e 90-day cohort ($5,143) compared with the partial compliance ($5,909, P<0.05), <90-day ($6,289, P<0.001), titration ($6,375, P<0.001), and therapy change ($7,858, P<0.001) cohorts. Differences in total medical charges without pharmacy charges were primarily influenced by inpatient charges. The addition of pharmacy charges, including the charges for antidepressants, resulted in total medical charges that were not statistically different for the e 90-day cohort compared with the <90-day cohort, $7,454 and $7,829, respectively, P=0.606. CONCLUSION: Medical charges without pharmacy charges were lower for patients remaining on antidepressant drug therapy for at least 90 continuous days compared with patients who used antidepressants for less than 90 continuous days, but total health care charges, including pharmacy charges, were not different between the 2 groups.