Allergy immunotherapy: what is the evidence for cost saving?

PURPOSE OF REVIEW: Given the widespread prevalence of allergic disease, its substantially associated clinical and economic burden, the unique disease-modifying benefits of allergy immunotherapy (AIT), and increased availability of sublingual immunotherapy (SLIT), a critical update of the evidence for AIT-related cost savings [for both subcutaneous immunotherapy (SCIT) and SLIT] is particularly relevant and timely. The present article reviews the evidence for SCIT-related and SLIT-related cost savings derived from a systematic review of the published literature. RECENT FINDINGS: Examined were 24 publications pertaining to the health economics of AIT. Except for one early study comparing the costs of AIT to symptomatic drug treatment (SDT), the remainder provide compelling evidence for AIT cost savings (whether SCIT or SLIT) over SDT. Furthermore, of the six studies comparing cost outcomes of SLIT to SCIT, four reported cost savings favoring SLIT. SUMMARY: This review, spanning research from Southern Europe, Scandinavia, Northern Europe, North America, and the Czech Republic, encompasses a range of perennial and seasonal allergic conditions, including allergic asthma, allergic rhinitis with or without asthma, and rhinoconjunctivitis with or without allergic rhinitis due to house dust mite, grass or ragweed pollen, or a mixture of various allergens. All but one study compellingly demonstrate cost savings conferred by AIT over SDT.

Allergy immunotherapy: reduced health care costs in adults and children with allergic rhinitis.

BACKGROUND: Research demonstrates significant health care cost savings conferred by allergen-specific immunotherapy (AIT) to US children with allergic rhinitis (AR). OBJECTIVE: We sought to examine whether AIT-related cost benefits conferred to US children with AR similarly extend to adults. METHODS: A retrospective (1997-2009) Florida Medicaid claims analysis compared mean 18-month health care costs of patients with newly diagnosed AR who received de novo AIT and were continuously enrolled for 18 months or more versus matched control subjects not receiving AIT. Analyses were conducted for the total sample and separately for adults (age≥18 years) and children (age<18 years). RESULTS: Matched were 4,967 patients receiving AIT (1,319 adults and 3,648 children) and 19,278 control subjects (4,815 adults and 14,463 children). AIT-treated enrollees incurred 38% ($6,637 vs $10,644, P<.0001) lower mean 18-month total health care costs than matched control subjects, with significant savings observed within 3 months of AIT initiation. Compared with control subjects, significantly lower 18-month mean health care costs were demonstrated overall (38%; $6,637 for patients receiving AIT vs $10,644 for control subjects, P<.0001), and for both AIT-treated adults (30%; $10,457 AIT vs $14,854 controls, P<.0001) and children (42%; $5,253 AIT vs $9,118 controls, P<.0001). The magnitude of 18-month health care cost savings realized by AIT-treated adults and children did not significantly differ ($4,397 vs $3,965, P=.435). CONCLUSIONS: Patients with newly diagnosed AR initiating AIT incurred significantly lower health care costs than matched control subjects beginning 3 months after AIT initiation and continuing throughout the 18-month follow-up period. The significant cost benefits achieved by children with AR diagnoses who initiated AIT were also observed for adults with AR diagnoses who initiated AIT.

Medical costs and adherence in patients receiving aqueous versus pressurized aerosol formulations of intranasal corticosteroids.

Intranasal corticosteroid (INS) formulations have different sensory attributes that influence patient preferences, and thereby possibly adherence and health outcomes. This study compares health care use and costs and medication adherence in matched cohorts of patients with allergic rhinitis (AR) using a chlorofluorocarbon-propelled pressurized metered-dose inhaler (pMDI) or aqueous intranasal corticosteroid (A-INS). Florida Medicaid retrospective claims analysis was performed of enrollees aged ≥12 years with at least 1 year of continuous enrollment before their initial AR diagnosis, 1 year for continuous enrollment before their index INS claim, and 18 months of continuous enrollment after their index INS claim during which they received either pMDI or A-INS. pMDI and A-INS patients were matched 1:2 using propensity scores. Nonparametric analyses compared outcomes between matched cohorts at 6, 12, and 18 months of follow-up. A total of 585 patients were matched (pMDI = 195, A-INS = 390). pMDI patients were more adherent to INS, as reflected in their higher median medication possession ratio (53.2% versus 32.7%; p < 0.0001) and fewer median days between fills (73 days versus 111 days; p = 0.0003). Significantly lower median per patient pharmacy fills (34.0 versus 50.5; p < 0.05) and costs ($1282 versus $2178; p < 0.01) were observed among pMDI patients versus A-INS patients 18 months after INS initiation and were maintained when analyses excluded INS fills. Adherence to INS and health care utilization and costs following INS initiation for AR differed by type of formulation received. Our findings suggest patient preferences for INS sensory attributes can drive adherence and affect disease control, and ultimately impact health care costs.

Clinical and cost efficacy of advanced wound care matrices for venous ulcers.

BACKGROUND: In the United States, venous leg ulcers (VLUs) are commonly associated with substantial disability, impaired quality of life, and high economic costs. Compression therapy, which has remained the standard care for VLUs over several decades, is often insufficient to heal VLUs in a timely manner. VLU-related treatment costs are directly related to time to achieve complete wound closure. Advanced wound care matrices (AWCMs) developed to stimulate wound healing may reduce VLU-related costs associated with delayed healing. Randomized controlled trials (RCTs) have evaluated the wound-healing efficacy of several AWCMs in patients with VLUs. However, comparisons of products' clinical and cost efficacy, which may guide clinical and formulary determinations, are lacking. OBJECTIVE: To evaluate, in terms of number needed to treat (NNT), the comparative clinical and cost efficacy of targeted AWCMs as adjuncts to compression therapy for the treatment of chronic VLUs from the U.S. health care system (payer) perspective. METHODS: A review of published articles (from the earliest available Medline publication date to June 1, 2011) identified RCTs evaluating complete wound closure rates for up to 24 weeks in patients with VLUs treated with targeted AWCMs (Apligraf, Oasis, or Talymed) plus compression therapy compared with compression therapy alone. The most favorable estimates of product efficacy (i.e., those that were statistically significant compared with compression therapy) were used. These included statistically adjusted results for Apligraf as reported in the product insert and the biweekly application for Talymed. Based on the reported efficacy of targeted AWCMs, we calculated the NNT to achieve 1 additional treatment success (i.e., complete wound closure) over that which was achieved with standard therapy alone; 95% CIs were estimated using the Wilson score method proposed by Newcombe. Cost efficacy, defined as the incremental cost per additional successfully treated patient, was then calculated by multiplying the NNT associated with each treatment by the product acquisition cost per treated VLU episode. RESULTS: One study for each of 3 targeted AWCMs (Apligraf [n=130 treatment, n=110 control]; Oasis Wound Matrix [n=62 treatment, n=58 control]; and Talymed [n=22 treatment, n=20 control]) met inclusion criteria. Study designs and wound characteristics varied. Average VLU sizes were 1 cm2, 10-12 cm2, and 10-13 cm2 in the studies of Apligraf, Oasis, and Talymed, respectively. Ulcer duration exceeded 12 months for 50% of patients in the Apligraf study and was at least 7 months for 47% of patients in the Oasis study; patients with ulcers exceeding 6 months were excluded from the study of Talymed. Length of follow-up was 24 weeks for Apligraf, 12 weeks for Oasis, and 20 weeks for Talymed. NNT point estimates of clinical efficacy were 2 for Talymed, 5 for Oasis, and 6 for Apligraf; 95% CIs ranged from 2 to 8 for Talymed, 3 to 24 for Apligraf, and 3 to 39 for Oasis. Incremental costs (95% CIs) per additional successfully treated patient were $1,600 ($1,600-$6,400) for Talymed, $3,150 ($1,890-$24,570) for Oasis, and $29,952 ($14,976-$119,808) for Apligraf. CONCLUSIONS: The most expensive AWCM for the treatment of VLUs did not appear to provide the greatest comparative clinical or cost efficacy. Conclusions must be tempered by the small number of available studies (n=3), variability in trial duration (from 12 to 24 weeks) and baseline wound characteristics, and limitations in study quality. Given the high prevalence, economic burden, and substantial disability of VLUs, and the wide variation in costs for AWCMs, payers need more high-quality head-to-head comparisons to guide coverage and reimbursement determinations for these products.

A randomized, investigator-blinded, controlled pilot study to evaluate the safety and efficacy of a poly-N-acetyl glucosamine-derived membrane material in patients with venous leg ulcers.

BACKGROUND: Standard care for venous leg ulcers (VLUs) has remained unchanged over several decades despite high rates of initial treatment failure and ulcer recurrence. OBJECTIVE: We sought to evaluate the efficacy, safety, and tolerability of an advanced, poly-N-acetyl glucosamine (pGlcNAc), nanofiber-derived, wound-healing technology among patients with VLUs (Talymed, Marine Polymer Technologies Inc, Danvers, MA). METHODS: In this randomized, investigator-blinded, parallel-group, controlled study, eligible patients were randomized to treatment with standard care plus pGlcNAc (applied only once, every other week, or every 3 weeks) or to standard care alone. The primary end point was the proportion of patients with complete wound healing at week 20 in the intent-to-treat population (all randomized subjects), with last observation carried forward. RESULTS: Among 82 randomized patients, 71 completed the study with 7 lost to follow-up and 4 discontinued because of systemic infection. There were no significant group differences with regard to baseline demographic, illness, and VLU characteristics. At 20 weeks, the proportion of patients with completely healed VLUs was 45.0% (n = 9 of 20), 86.4% (n = 19 of 22), and 65.0% (n = 13 of 20) for groups receiving standard care plus pGlcNAc only once, every other week, and every 3 weeks, respectively, versus 45.0% (n = 9 of 20) for those receiving standard care alone (P < .01 for pGlcNAc every other week vs standard care). The novel pGlcNAc advanced wound-healing technology was well tolerated and safe. LIMITATIONS: Limitations were small sample size and patients unblinded to treatment allocation. CONCLUSION: These pilot study results suggest that the pGlcNAc advanced wound-healing technology is well tolerated and effective.

Patients with obsessive-compulsive disorder vs depression have comparable health care costs: a retrospective claims analysis of Florida Medicaid enrollees.

BACKGROUND: The health care burden of obsessive-compulsive disorder (OCD) is relatively unknown. OBJECTIVE: To compare the health care burden of patients with OCD vs depression. METHODS: This retrospective claims analysis compared the 2-year median per-patient health care claims and costs for Florida Medicaid adult enrollees (1997 to 2006) newly diagnosed with "pure OCD" (P-OCD; OCD without comorbid major depression, bipolar disorder, psychosis, organic mental disorder, pervasive developmental disorder, nonpsychotic brain damage, developmental delay, or mental retardation) with matched patients newly diagnosed with "pure depression" (P-D; similar to P-OCD but excluding OCD instead of depression). RESULTS: Eighty-five newly diagnosed P-OCD patients were matched with 14,906 P-D patients. Although median per-patient total health care costs were comparable across groups, patients with P-D incurred significantly higher median outpatient medical costs ($1,928 vs $363, P = .003), while those with P-OCD incurred almost three-fold greater psychiatric costs ($2,028 vs $759, P < .0001). The latter was due primarily to significantly higher costs of psychotropic medications among those with P-OCD ($4,307 vs $2,317, P = .0006) rather than to psychiatric outpatient care. CONCLUSIONS: Patients with P-D and P-OCD carry a similar burden in overall health care costs. However, the burden of those with P-D was largely attributable to outpatient medical costs while that of those with P-OCD was due to higher costs of psychotropic medications.

Agitation in the inpatient psychiatric setting: a review of clinical presentation, burden, and treatment.

Agitation among psychiatric inpatients (particularly those diagnosed with schizophrenia or bipolar disorder) is common and, unless recognized early and managed effectively, can rapidly escalate to potentially dangerous behaviors, including physical violence. Inpatient aggression and violence have substantial adverse psychological and physical consequences for both patients and providers, and they are costly to the healthcare system. In contrast to the commonly held view that inpatient violence occurs without warning or can be predicted by "static" risk factors, such as patient demographics or clinical characteristics, research indicates that violence is usually preceded by observable behaviors, especially non-violent agitation. When agitation is recognized, staff should employ nonpharmacological de-escalation strategies and, if the behavior continues, offer pharmacological treatment to calm patients rapidly. Given the poor therapeutic efficacy and potential for adverse events associated with physical restraint and seclusion, and the potential adverse sequelae of involuntary drug treatment, these interventions should be considered last resorts. Pharmacological agents used to treat agitation include benzodiazepines and first- and second-generation antipsychotic drugs. Although no currently available agent is ideal, recommendations for selecting among them are provided. There remains an unmet need for a non-invasive and rapidly acting agent that effectively calms without excessively sedating patients, addresses the patient's underlying psychiatric symptoms, and is reasonably safe and tolerable. A treatment with these characteristics could substantially reduce the clinical and economic burden of agitation in the inpatient psychiatric setting.

The health economics of allergen immunotherapy.

In contrast to symptomatic drug treatment, which only temporarily relieves allergy symptoms, allergen-specific immunotherapy (SIT) has the potential to alter the course of allergic disease, thereby reducing the need for long-term treatment, the progression of allergic rhinitis (AR) to asthma, and the development of new allergies. The clinical benefits of SIT have been shown to persist for an additional 3 to 12 years after discontinuation of a 2.5- to 5.0-year treatment. It therefore stands to reason that the clinical benefits of SIT also extend to economic benefits. A growing number of studies have evaluated the economic benefits of SIT in patients with AR and/or asthma. The authors critically examine each of these studies published from 1995 to present.

Allergen immunotherapy and health care cost benefits for children with allergic rhinitis: a large-scale, retrospective, matched cohort study.

BACKGROUND: Children with allergic rhinitis (AR) often experience significant impairment in quality of life and health, which increases health care utilization. OBJECTIVE: To determine whether allergen immunotherapy reduces health care utilization and costs in children newly diagnosed as having AR using a retrospective matched cohort design. METHODS: Among children (age <18 years) with a Florida Medicaid paid claim between 1997 and 2007, immunotherapy-treated patients were selected who had newly diagnosed AR, who had not received immunotherapy before their first (index) AR diagnosis, who had received at least 2 immunotherapy administrations after their index AR diagnosis, and who had at least 18 months of data after their first immunotherapy administration. A control group of patients with newly diagnosed AR who had not received immunotherapy either before or subsequent to their index AR diagnosis also were identified, and up to 5 were matched with each immunotherapy-treated patient by age at first AR diagnosis, sex, race/ethnicity, and diagnosis of asthma, conjunctivitis, or atopic dermatitis. RESULTS: Immunotherapy-treated patients had significantly lower 18-month median per-patient total health care costs ($3,247 vs $4,872), outpatient costs exclusive of immunotherapy-related care ($1,107 vs $2,626), and pharmacy costs ($1,108 vs $1,316) compared with matched controls (P < .001 for all). The significant difference in total health care costs was evident 3 months after initiating immunotherapy and increased through study end. CONCLUSIONS: This study demonstrates the potential for early and significant cost savings in children with AR treated with immunotherapy. Greater use of this treatment in children could significantly reduce AR-related morbidity and its economic burden.

Adequacy of pharmacotherapy among medicaid-enrolled patients newly diagnosed with obsessive-compulsive disorder.

OBJECTIVE: To determine the adequacy of pharmacotherapy received by patients with newly-diagnosed obsessive-compulsive disorder (OCD), based on current practice guidelines. METHODS: A 9 year (1997-2006) retrospective claims analysis of adults enrolled in Florida Medicaid for at least 3 continuous years was conducted to determine the percentage who received both a minimally effective duration (> 8 continuous weeks) and dose of first-line OCD pharmacotherapy during the year following their first ("index") OCD diagnosis. RESULTS: Among 2,960,421 adult (> 18 years of age) enrollees, 2,921 (0.1%) were diagnosed with OCD. Among the 2,825 OCD patients without comorbid Asperger syndrome or autism, 843 had newly-diagnosed OCD and at least 12 months of follow-up data after their index diagnosis. Among these 843 patients, 588 (69.7%) received first-line OCD pharmacotherapy but only 323 (38.3%) received a minimally effective pharmacotherapy trial in the year following their index diagnosis. CONCLUSIONS: Among clinically-diagnosed persons with OCD (<10% of those with the disorder), a minority of newly-diagnosed patients receive a minimally effective pharmacotherapy trial consistent with current standards of care. Reasons such as limited patient adherence and/or physician awareness of guidelines must be identified and redressed to ameliorate the patient, healthcare system, and economic burdens associated with OCD.

Allergy immunotherapy among Medicaid-enrolled children with allergic rhinitis: patterns of care, resource use, and costs.

BACKGROUND: Although research demonstrates that allergy immunotherapy (IT) improves allergic rhinitis (AR) outcomes, little is known about IT patterns of care and associated resource use and costs among US children with diagnoses of AR. OBJECTIVE: We sought to examine characteristics associated with receiving IT, patterns of IT care, and health care use and costs incurred in the 6 months before versus after IT. METHODS: We performed retrospective Florida Medicaid claims data (1997-2004) analysis of children (<18 years of age) given new diagnoses of AR. RESULTS: Of 102,390 patients with new diagnoses of AR, 3048 (3.0%) received IT. Male patients, Hispanic patients, and those with concomitant asthma were significantly more likely to receive IT. Approximately 53% completed less than 1 year and 84% completed less than 3 years of IT. Patients who received IT used significantly less pharmacy (12.1 vs 8.9 claims, P < .0001), outpatient (30.7 vs 22.9 visits, P < .0001), and inpatient (1.2 vs 0.4 admissions, P = .02) resources in the 6 months after versus before IT. Pharmacy ($330 vs $60, P < .0001), outpatient ($735 vs $270, P < .0001), and inpatient ($2441 vs $1, P < .0001) costs (including costs for IT care) were significantly reduced after IT. CONCLUSION: Despite suboptimal treatment persistence (only 16% of patients completed 3 years of IT), resource use and costs after treatment were significantly reduced from pre-IT levels.

Adverse events involving intravenous patient-controlled analgesia.

PURPOSE: This article systematically characterizes aspects of all Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) reports associated with i.v. patient-controlled analgesia (PCA) postoperative use during a two-year index period. METHODS: Intravenous PCA represents a well-accepted and satisfactory means of acute pain treatment; case reports and large case series have described the occurrence of i.v. PCA-related adverse drug events (ADEs). MAUDE data files were downloaded, and all records pertaining to i.v. PCA devices were extracted for the two-year period from January 1, 2002, through December 31, 2003. Medical device events were categorized by their reported cause, including patient-related event, device safety event, operator error, and adverse reactions to opioids. Because there was not sufficient information to grade the certainty of each reported cause, all reported causes were graded "possible," except for device safety events that were confirmed on inspection by the manufacturer. RESULTS: There were 2009 individual i.v. PCA-related MAUDE medical device events reported during the two-year period. Of these events, 1590 (79.1%) were classified as possible device safety events, 131 (6.5%) as possible operator error, 25 (1.2%) as possible adverse reactions to opioids, 12 (0.6%) as possible patient-related events, and 235 (11.7%) as indeterminate. CONCLUSION: Manufacturer-confirmed device malfunction was a major cause of reported ADE with i.v. PCA infusion pumps while operator errors were more likely to be associated with more serious adverse outcomes than device safety problems. To reduce the incidence of these problems, potential vulnerabilities in the design and manufacture of i.v. PCA pumps must be identified and addressed.

The illness burden of alcohol-related disorders among VA patients: the veterans health study.

Little is known about the illness burden associated with alcohol-related disorders (ie, problem drinking, alcohol abuse, and alcohol dependence) among patients in outpatient medical care. The objective of this study was to examine several aspects of illness burden-medical comorbidities, patterns of health services use, and functional status-among Veterans Health Administration (VA) ambulatory care patients with alcohol-related disorders. Male participants (N = 2425) were recruited at 1 of 4 Boston-area VA outpatient clinics. They completed self-report screening measures of current alcohol-related disorders (CAGE score > or =2 with past year alcohol consumption), health behaviors, medical comorbidities, and functional status (SF-36). A medical history interview, which assessed comorbid conditions and use of recent health services, was also administered. Screening criteria for current alcohol-related disorders were satisfied by 12%; however, only 40% of these reported ever receiving treatment specifically for alcohol-related disorders. Patients who screened positive for alcohol-related disorders reported significantly greater limitations in mental health function, longer hospitalizations for medical care in the prior year, and fewer outpatient medical visits in the previous 3 months. Findings suggest considerable illness burden associated with alcohol-related disorders among VA ambulatory care patients. Efforts to increase detection and treatment of alcohol-related disorders may lessen the illness burden and cost of alcohol-related disorders.

Posttraumatic stress disorder and health status: the veterans health study.

This article examines the association between self-reported prevalence of posttraumatic stress disorder (PTSD) and health status in a sample of 2425 male Department of Veterans Affairs (VA) ambulatory care patients who participated in the Veterans Health Study. Participants were recruited at 1 of 4 VA outpatient clinics in the Boston area. They completed self-report measures of PTSD (using the PTSD Checklist and measures of exposure to traumatic events), depression (using the Center for Epidemiologic Studies--Depression scale), and health status (using the Short-Form-36) and a medical history interview assessing 22 conditions and a history of psychiatric treatment. The screening prevalence of PTSD was 20.2% among all patients (24.3% among those exposed to traumatic events); another 15.5% met the criteria for depression but not PTSD. The health status of patients with either PTSD or depression was significantly worse than that of patients with neither disorder, even after controlling for age, education, and number of comorbid medical conditions. Patients with PTSD reported more medical conditions than did other patients. Patients with PTSD currently in mental health treatment had worse health status than did those who reported no treatment; the health status of patients who reported past mental health treatment was generally comparable to that of those with no treatment. The prevalence and comorbidity of PTSD among this sample of VA ambulatory care patients were higher than previously reported among samples of community-residing adults. The association of PTSD with health status was substantial, suggesting that the burden of PTSD is at least comparable to, and may be worse than, that of depression. Mental health treatment alleviated some of this burden. The potential impact of PTSD on health status should be more widely recognized.

Mental disorders and medical care utilization of VA ambulatory care patients: the veterans health study.

In this article, the authors examine patterns of medical services use among the Department of Veterans Affairs (VA) ambulatory care patients who screened positive for posttraumatic stress, depression, or alcohol-related disorders. On the basis of research linking mental disorders with increased use of medical services, the authors hypothesize that even after controlling for age and medical disease comorbidity, patients in VA ambulatory care who screen positive for targeted mental disorders would be more likely to use VA medical services and have higher rates of such use than those who did not screen positive. Baseline data were obtained from the Veterans Health Study, a longitudinal investigation of veterans' health. Four Boston-area VA ambulatory care facilities were used as study sites. A random sample of 2425 participants (mean age = 62) was drawn from male VA ambulatory care patients screened for eligibility during specified periods. Screening measures were Center for Epidemiological Studies-Depression Scale for depression, Posttraumatic Stress Disorder Checklist for posttraumatic stress disorder, and CAGE Questionnaire for alcohol-related disorders with endorsement of prior year consumption for alcohol-related disorders. Prior medical services use was assessed by self-report. Although unadjusted analyses of medical services use revealed clear effects of the screening presence of mental disorders on most outcomes, after adjusting for age and medical comorbidity, almost all these effects were reduced, and some previously nonsignificant results became significant. Findings suggest that healthcare policy and risk adjustment predicated upon the presumed relationship between mental disorders in the aggregate and medical services use should reconsider the important contributions of age, comorbid medical disorders, and specific mental disorder diagnoses.

Impact of methylphenidate delivery profiles on driving performance of adolescents with attention-deficit/hyperactivity disorder: a pilot study.

OBJECTIVE: Adolescents with attention-deficit/hyperactivity disorder (ADHD) are at high risk for driving accidents. One dose of methylphenidate (MPH) improves simulator driving performances of ADHD-diagnosed adolescents at 1.5 hours post-dose. However, little is known about the effects of different MPH delivery profiles on driving performance throughout the day. METHOD: This randomized, crossover, single-blind study compared osmotic, controlled-release oral system (OROS) MPH (Concerta) given q.d. to immediate-release MPH (Ritalin) given in equal doses t.i.d. on driving performance among six male ADHD-diagnosed adolescent drivers aged 16 to 19 years. Under each treatment condition, participants were maintained on their medication dosage for 7 days, then drove a sophisticated driving simulator at 2 p.m., 5 p.m., 8 p.m., and 11 p.m. The primary outcome measure was each participant's computer-quantified Impaired Driving Score (IDS). RESULTS: IDS worsened in the evenings for participants receiving MPH t.i.d. but remained stable when they received once-daily OROS MPH. Participants performed significantly better when receiving OROS MPH q.d. compared with MPH t.i.d. (F = 9.3, df = 1, p =.004). When MPH was given t.i.d., IDS significantly worsened beginning at 8 p.m. compared to OROS MPH (p =.01). CONCLUSIONS: Participants demonstrated significantly less variability and better driving performance when receiving OROS MPH q.d. compared to MPH t.i.d., particularly in the evenings.

Diagnostic cost groups (DCGs) and concurrent utilization among patients with substance abuse disorders.

OBJECTIVE: To assess the performance of Diagnostic Cost Groups (DCGs) in explaining variation in concurrent utilization for a defined subgroup, patients with substance abuse (SA) disorders, within the Department of Veterans Affairs (VA). DATA SOURCES: A 60 percent random sample of veterans who used health care services during Fiscal Year (FY) 1997 was obtained from VA administrative databases. Patients with SA disorders (13.3 percent) were identified from primary and secondary ICD-9-CM diagnosis codes. STUDY DESIGN: Concurrent risk adjustment models were fitted and tested using the DCG/HCC model. Three outcome measures were defined: (1) "service days" (the sum of a patient's inpatient and outpatient visit days), (2) mental health/substance abuse (MH/SA) service days, and (3) ambulatory provider encounters. To improve model performance, we ran three DCG/HCC models with additional indicators for patients with SA disorders. DATA COLLECTION: To create a single file of veterans who used health care services in FY 1997, we merged records from all VA inpatient and outpatient files. PRINCIPAL FINDINGS: Adding indicators for patients with mild/moderate SA disorders did not appreciably improve the R-squares for any of the outcome measures. When indicators were added for patients with severe SA who were in the most costly category, the explanatory ability of the models was modestly improved for all three outcomes. CONCLUSIONS: Modifying the DCG/HCC model with additional markers for SA modestly improved homogeneity and model prediction. Because considerable variation still remained after modeling, we conclude that health care systems should evaluate "off-the-shelf" risk adjustment systems before applying them to their own populations.