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1.
BMC Geriatr ; 18(1): 243, 2018 Oct 16.
Artigo em Inglês | MEDLINE | ID: mdl-30326851

RESUMO

BACKGROUND: The objective of this study was to examine patient characteristics and health care resource utilization (HCRU) in the 36 months prior to a confirmatory diagnosis of Alzheimer's disease (AD) compared to a matched cohort without dementia during the same time interval. METHODS: Patients newly diagnosed with AD (with ≥2 claims) were identified between January 1, 2013 to September 31, 2015, and the date of the second claim for AD was defined as the index date. Patients were enrolled for at least 36 months prior to index date. The AD cohort was matched to a cohort with no AD or dementia codes (1:3) on age, gender, race/ethnicity, and enrollment duration prior to the index date. Descriptive analyses were used to summarize patient characteristics, HCRU, and healthcare costs prior to the confirmatory AD diagnosis. The classification and regression tree analysis and logistic regression were used to identify factors associated with the AD diagnosis. RESULTS: The AD cohort (N = 16,494) had significantly higher comorbidity indices and greater odds of comorbid mental and behavioral diagnoses, including mild cognitive impairment, mood and anxiety disorders, behavioral disturbances, and cerebrovascular disease, heart disease, urinary tract infections, and pneumonia than the matched non-AD or dementia cohort (N = 49,482). During the six-month period before the confirmatory AD diagnosis, AD medication use and diagnosis of mild cognitive impairment, Parkinson's disease, or mood disorder were the strongest predictors of a subsequent confirmatory diagnosis of AD. Greater HCRU and healthcare costs were observed for the AD cohort primarily during the six-month period before the confirmatory AD diagnosis. CONCLUSION: The results of this study demonstrated a higher comorbidity burden and higher costs for patients prior to a diagnosis of AD in comparison to the matched cohort. Several comorbidities were associated with a subsequent diagnosis of AD.

2.
J Opioid Manag ; 13(5): 303-313, 2017 Sep/Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29199396

RESUMO

OBJECTIVE: To evaluate the impact of a pilot intervention for physicians to support their treatment of patients at risk for opioid abuse. SETTING, DESIGN AND PATIENTS, PARTICIPANTS: Patients at risk for opioid abuse enrolled in Medicare plans were identified from July 1, 2012 to April 30, 2014 (N = 2,391), based on a published predictive model, and linked to 4,353 opioid-prescribing physicians. Patient-physician clusters were randomly assigned to one of four interventions using factorial design. INTERVENTIONS: Physicians received one of the following: Arm 1, patient information; Arm 2, links to educational materials for diagnosis and management of pain; Arm 3, both patient information and links to educational materials; or Arm 4, no communication. MAIN OUTCOME MEASURES: Difference-in-difference analyses compared opioid and pain prescriptions, chronic high-dose opioid use, uncoordinated opioid use, and opioid-related emergency department (ED) visits. Logistic regression compared diagnosis of opioid abuse between cases and controls postindex. RESULTS: Mailings had no significant impact on numbers of opioid or pain medications filled, chronic high-dose opioid use, uncoordinated opioid use, ED visits, or rate of diagnosed opioid abuse. Relative to Arm 4, odds ratios (95% CI) for diagnosed opioid abuse were Arm 1, 0.95(0.63-1.42); Arm 2, 0.83(0.55-1.27); Arm 3, 0.72(0.46-1.13). While 84.7 percent had ≥1 psychiatric diagnoses during preindex (p = 0.89 between arms), only 9.5 percent had ≥1 visit with mental health specialists (p = 0.53 between arms). CONCLUSIONS: Although this intervention did not affect pain-related outcomes, future interventions involving care coordination across primary care and mental health may impact opioid abuse and improve quality of life of patients with pain.


Assuntos
Analgésicos Opioides/efeitos adversos , Dor Crônica/tratamento farmacológico , Educação Médica Continuada/métodos , Capacitação em Serviço/métodos , Transtornos Relacionados ao Uso de Opioides/etiologia , Manejo da Dor/efeitos adversos , Manejo da Dor/métodos , Médicos/psicologia , Transtornos Relacionados ao Uso de Substâncias/etiologia , Demandas Administrativas em Assistência à Saúde , Idoso , Dor Crônica/diagnóstico , Dor Crônica/psicologia , Prescrições de Medicamentos , Usuários de Drogas/psicologia , Feminino , Humanos , Modelos Logísticos , Masculino , Medicare , Pessoa de Meia-Idade , Análise Multivariada , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Transtornos Relacionados ao Uso de Opioides/psicologia , Projetos Piloto , Padrões de Prática Médica , Medição de Risco , Fatores de Risco , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Transtornos Relacionados ao Uso de Substâncias/prevenção & controle , Transtornos Relacionados ao Uso de Substâncias/psicologia , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
3.
J Manag Care Spec Pharm ; 21(9): 793-802, 802a-802i, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26308226

RESUMO

BACKGROUND: While step therapy (ST) policies are generally effective at reducing cost through the managed utilization of targeted medications, the clinical implications of ST policies are not clear and may vary across therapeutic areas. Guanfacine extended-release (GXR) is approved by the FDA for the treatment of attention-deficit/hyperactivity disorder (ADHD) as both monotherapy and adjunctive to stimulant treatment. At the introduction of GXR to the market, Humana implemented an ST policy on GXR requiring the documentation of previous treatment, intolerance, or contraindication to generic clonidine or guanfacine. OBJECTIVE: To examine the impact of a GXR ST coverage determination (i.e., approved vs. denied) on medication utilization and health care costs among members of a commercial health plan with an ST policy for GXR.  METHODS: This study was a retrospective cohort study of administrative claims data. Humana commercial members prescribed GXR who had an ST coverage determination review were identified. All members included in this analysis were required to be aged 6-17 years, have a diagnosis of ADHD or be receiving stimulant medication, have an ST coverage determination (index event) between September 1, 2009, and May 30, 2012, and have 6 months of pre- and post-index continuous enrollment. Members were assigned to either the approved or denied group based on the outcome of the ST coverage determination. Medical and pharmacy claims data were used to measure baseline demographic and clinical characteristics and to measure medication utilization and health care costs. Outcomes assessed during follow-up included ADHD medication use, proportion of days covered (PDC) with any ADHD medication treatment, time to first observed post-index ADHD treatment, and all-cause and mental health (MH)-related health care costs. Administrative costs associated with the coverage determination process were also estimated. Bivariate and multivariable adjusted analyses were conducted to compare medication utilization and health care costs between the approved and denied groups. RESULTS: A total of 642 members were included in the analysis (denied group n = 395 [61.5%], approved group n = 247 [38.5%]). The approved and denied groups were similar in terms of baseline demographics, provider characteristics, and baseline MH diagnoses, with the exception of anxiety disorders being more prevalent in the approved group compared with the denied group (18.2% vs. 10.6%, P = 0.006). A denied GXR coverage determination was associated with a greater percentage of members receiving no ADHD treatment post-index (13.9% vs. 3.2%, P less than 0.001), greater mean [SD] number of days between index and first observed post-index ADHD medication claim (44.5 [59.6] vs. 17.6 [33.4], P less than 0.001), and lower mean [SD] PDC with any ADHD medication post-index (0.59 [0.33] vs. 0.75 [0.26], P less than 0.001). These findings remained statistically significant in multivariable regression models. Unadjusted pre-index median total health care costs and MH-related costs were greater among the approved group compared with the denied group (total health care: $1,582 vs. $1,465, P = 0.033; MH-related: $993 vs. $981, P = 0.020). Likewise, post-index median total health care and MH-related costs were greater among the approved group compared with the denied group (total: $2,056 vs. $1,420, P less than 0.001; MH-related: $1,543 vs. $946, P less than 0.001). After adjustment for potentially confounding covariates including pre-index costs, there were no statistically significant differences between the approved and denied groups in all-cause total health care (P = 0.393) or MH-related health care costs (P = 0.054).  CONCLUSIONS: The current study found that GXR coverage denial was associated with lower rate of ADHD medication utilization, greater delay in receiving ADHD medication, and lower PDC with ADHD medication. There were no differences observed between the approved and denied group in terms of all-cause total health care or MH-related total health care costs after controlling for potentially confounding variables. Prior to implementation in the ADHD therapeutic area and others, payers should consider the potentially unintended consequences of ST policies, including delay in treatment and undertreatment.


Assuntos
Agonistas de Receptores Adrenérgicos alfa 2/administração & dosagem , Transtorno do Deficit de Atenção com Hiperatividade/tratamento farmacológico , Guanfacina/administração & dosagem , Custos de Cuidados de Saúde , Adolescente , Agonistas de Receptores Adrenérgicos alfa 2/economia , Agonistas de Receptores Adrenérgicos alfa 2/uso terapêutico , Transtorno do Deficit de Atenção com Hiperatividade/economia , Criança , Estudos de Coortes , Preparações de Ação Retardada , Feminino , Guanfacina/economia , Guanfacina/uso terapêutico , Gastos em Saúde , Humanos , Cobertura do Seguro , Masculino , Programas de Assistência Gerenciada , Estudos Retrospectivos , Fatores de Tempo , Estados Unidos
4.
Am J Manag Care ; 21(1): e62-70, 2015 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-25880269

RESUMO

OBJECTIVES: This study evaluated the usefulness of the Diabetes Complications Severity Index (DCSI) in assessing healthcare resource utilization (HRU) and costs among Medicare Advantage plan members diagnosed with type 2 diabetes mellitus (T2DM). STUDY DESIGN: A retrospective cohort study of medical and pharmacy claims of 333,576 Medicare members aged 18 to 89 years with ≥1 medical claim with primary diagnosis or ≥2 medical claims with secondary diagnosis, of T2DM (International Classification of Diseases, Ninth Revision, Clinical Modification code 250.x0 or 250.x2) during the period of January 1, 2010, to December 31, 2011. METHODS: DCSI was assessed concurrently with HRU and healthcare costs (total, medical, and pharmacy). The cohort was subdivided into 6 DCSI groups: DCSI = 0 (no complications) through DCSI = 5+ (≥5). Associations of complication severity with HRU and costs of care were summarized using regression models. RESULTS: A 1-point increase in DCSI was associated with a $2744 increase in total costs (a $2480 increase in medical costs plus a $264 increase in pharmacy costs). Increasing DCSI was associated with greater use of inpatient and emergency department (ED) services. Among the higher complications subgroups, there were greater representations of older patients, men, and cases of depressive disorders and hypoglycemia. CONCLUSIONS: DCSI is useful for identifying Medicare plan members with T2DM who should be targeted for clinical programs. HRU and costs increased with DCSI severity. Increases in high-cost HRU, driven by inpatient and ED visits, suggest that preventing or delaying utilization of these services are essential to driving down costs in the T2DM population. Furthermore, high rates of depression and hypoglycemia warrant early screening and necessary treatment to improve patient outcomes.


Assuntos
Complicações do Diabetes/economia , Diabetes Mellitus Tipo 2/economia , Custos de Cuidados de Saúde , Medicare Part C/economia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Idoso , Análise de Variância , Estudos de Coortes , Complicações do Diabetes/diagnóstico , Complicações do Diabetes/terapia , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/tratamento farmacológico , Feminino , Humanos , Revisão da Utilização de Seguros , Modelos Lineares , Masculino , Medicare Part C/estatística & dados numéricos , Pessoa de Meia-Idade , Estudos Retrospectivos , Índice de Gravidade de Doença , Estados Unidos
5.
Popul Health Manag ; 18(2): 115-22, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25290044

RESUMO

This retrospective cohort study evaluated associations of race/ethnicity and gender with outcomes of diabetes complications severity, health care resource utilization (HRU), and costs among Medicare Advantage health plan members with type 2 diabetes (T2DM). Medical and pharmacy claims were evaluated for 333,576 members continuously enrolled from January 1, 2010, to December 31, 2011, aged 18-89 years, with ≥1 primary diagnosis medical claim, or ≥2 claims with a secondary diagnosis of T2DM (International Classification of Diseases, Ninth Revision, Clinical Modification code 250.x0 or 250.x2). Complications severity assessment by Diabetes Complications Severity Index ranged from 0 (no complications) to 5+. Mean (SD) all-cause medical, pharmacy, and total costs were reported alongside all-cause HRU by place of service (outpatient, inpatient, emergency room [ER]) and number of visits. Multivariate regression showed being Hispanic, black, or male was associated with higher prevalence of more severe complications. This racial/ethnic disparity was more pronounced among females, among whom odds of having more severe complications were higher for Hispanic and black as compared to white females [(Hispanic vs. white odds ratio [OR], 1.40; 95% confidence interval [CI], 1.32-1.48), and (black vs. white OR, 1.22; 95% CI, 1.19-1.25)]. Regardless of gender, blacks had more ER visits than whites. White females incurred the highest total health care costs (mean annual costs: $13,086; 95% CI, $12,935-$13,240, vs. Hispanic females: $10,732; 95% CI, $10,406-$11,067). These effects held regardless of other demographic and clinical attributes. These findings suggest racial/ethnic and gender differences exist in certain T2DM clinical and economic outcomes.


Assuntos
Grupos de Populações Continentais , Complicações do Diabetes/etnologia , Grupos Étnicos , Revisão da Utilização de Seguros/economia , Medicare/economia , Idoso , Complicações do Diabetes/economia , Feminino , Humanos , Masculino , Morbidade/tendências , Estudos Retrospectivos , Estados Unidos/epidemiologia
6.
J Manag Care Spec Pharm ; 20(6): 592-600, 2014 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-24856597

RESUMO

BACKGROUND: Varenicline, a nicotinic acetylcholine receptor partial agonist, is a pharmacotherapy indicated for smoking cessation treatment. To date, no research has examined the relationship between out-of-pocket (OOP) expense and varenicline adherence among Medicare beneficiaries. OBJECTIVES: To (a) characterize medication utilization patterns of varenicline among Medicare members newly initiated on varenicline and (b) examine the relationship between member OOP expense and varenicline medication adherence. METHODS: In this retrospective cohort study, pharmacy claims data were used to identify Medicare Advantage Prescription Drug Plan (MAPD) members newly initiated on varenicline. Demographic and clinical characteristics, varenicline medication utilization patterns, and pharmacy costs (total and varenicline-specific) were determined for members included in the study. Varenicline adherence was measured by calculating the proportion of days covered (PDC) over a period of 84 days (12 weeks) after initiation. Multiple regression analysis was used to examine the relationship between varenicline OOP cost and varenicline medication utilization, while controlling for sociodemographic characteristics, clinical factors, and nonvarenicline pharmacy costs. RESULTS: A total of 15,452 MAPD members were included in the analysis. Mean (SD) subject age was 62.6 (10.0) years; 21.1% (n = 3,256) were dual eligible; and 33.0% (n = 5,106) received a low-income subsidy. Mean (SD) initial varenicline treatment episode duration was 50.8 (37.8) days, with a mean (SD) varenicline days' supply of 47.8 (32.6) obtained by members during the initial treatment episode. Mean (SD) PDC was 0.51 (0.24), and 14.9% (n = 2,302) of members were classified as adherent to treatment (PDC ≥ 0.80). Greater varenicline OOP expense was significantly associated with lower PDC (regression coefficient = -0.058, P less than 0.001) and significantly associated with lower odds of receiving a refill for varenicline (odds ratio 0.594, 95% CI: 0.540-0.655, P less than 0.001). CONCLUSIONS: Among Medicare beneficiaries newly initiated on varenicline, medication adherence was suboptimal, and greater OOP cost was associated with lower adherence and lower odds of refilling varenicline.


Assuntos
Benzazepinas/economia , Benzazepinas/uso terapêutico , Serviços Comunitários de Farmácia/economia , Custos de Medicamentos , Gastos em Saúde , Adesão à Medicação , Agonistas Nicotínicos/economia , Agonistas Nicotínicos/uso terapêutico , Quinoxalinas/economia , Quinoxalinas/uso terapêutico , Abandono do Hábito de Fumar/economia , Prevenção do Hábito de Fumar , Dispositivos para o Abandono do Uso de Tabaco/economia , Tabagismo/tratamento farmacológico , Idoso , Feminino , Humanos , Modelos Lineares , Modelos Logísticos , Masculino , Medicare , Pessoa de Meia-Idade , Razão de Chances , Estudos Retrospectivos , Fatores de Risco , Fumar/efeitos adversos , Fumar/economia , Fatores de Tempo , Tabagismo/economia , Resultado do Tratamento , Estados Unidos , Vareniclina
7.
J Am Geriatr Soc ; 62(3): 435-41, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24576203

RESUMO

OBJECTIVES: To compare medical condition burden, healthcare resource use, and healthcare costs of household members (HHMs) of individuals diagnosed with Alzheimer's disease (AD) with those of HHMs of matched individuals without AD. DESIGN: Retrospective cohort study based on administrative claims data collected between January 1, 2007, and December 31, 2011. SETTING: Medicare Advantage Prescription Drug (MAPD) plan. PARTICIPANTS: MAPD plan members with a diagnosis of AD (International Classification of Disease Ninth Revision, Clinical Modification, code 331.0) were selected and linked to a HHM to form patient-HHM dyads. AD dyads were matched to non-AD dyads. MEASUREMENTS: Health-related endpoints, including medical condition burden, healthcare resource use, and direct healthcare costs, were measured during 36 months of continuous health plan enrollment. RESULTS: Individuals with AD (n = 1,861) were linked to HHMs (n = 1,861), and these AD dyads were matched to 1,861 non-AD patient-HHM dyads. AD HHMs had greater medical condition burden scores than non-AD HHMs, with mood disorders, anxiety disorders, insomnia, substance abuse or dependence, cardiovascular disease, and rheumatoid arthritis being more prevalent in AD HHMs. Emergency department and outpatient service use were more common in AD HHMs than in non-AD HHMs, and AD HHMs had greater healthcare costs. CONCLUSION: HHMs of individuals diagnosed with AD demonstrated greater medical condition burden, healthcare resource use, and direct healthcare costs than non-AD HHMs. These findings demonstrate the significant clinical and financial impact of AD on HHMs of individuals with AD.


Assuntos
Doença de Alzheimer/economia , Efeitos Psicossociais da Doença , Características da Família , Custos de Cuidados de Saúde/estatística & dados numéricos , Recursos em Saúde/estatística & dados numéricos , Revisão da Utilização de Seguros/economia , Medicare Part C/economia , Idoso , Feminino , Seguimentos , Recursos em Saúde/economia , Nível de Saúde , Humanos , Masculino , Estudos Retrospectivos , Estados Unidos
8.
Pain Pract ; 14(3): E106-15, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24289539

RESUMO

PURPOSE: To measure the prevalence of diagnosed opioid abuse and prescription opioid use in a multistate managed care organization. METHODS: This retrospective claims data analysis reviewed the prevalence of diagnosed opioid abuse and the parallel prevalence of prescription opioid use in half-year intervals for commercial and Medicare members enrolled with Humana Inc., from January 1, 2008 to June 30, 2010. Diagnosis of opioid abuse was defined by ≥ 1 medical claim with any of the following ICD-9-CM codes: 304.0 ×, 304.7 ×, 305.5 ×, 965.0 ×, excluding 965.01, and opioid use was defined by ≥ 1 filled prescription for an opioid. The prevalence of opioid abuse was defined by the number of members with an opioid abuse diagnosis, divided by the number of members enrolled in each 6-month interval. RESULTS: The 6-month prevalence of diagnosed opioid abuse increased from 0.84 to 1.15 among commercial and from 3.17 to 6.35 among Medicare members, per 1,000. In contrast, there was no marked increase in prescription opioid use during the same time period (118.0 to 114.8 for commercial members, 240.6 to 256.9 for Medicare members, per 1,000). The prevalence of diagnosed opioid abuse was highest among members younger than 65 years for both genders in commercial (18- to 34-year-olds) and Medicare (35- to 54-year-olds) populations. CONCLUSIONS: Despite a stable rate of prescription opioid use among the observed population, the prevalence of diagnosed opioid abuse is increasing, particularly in the Medicare population.


Assuntos
Medicare/economia , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Analgésicos Opioides/economia , Bases de Dados Factuais , Humanos , Revisão da Utilização de Seguros/economia , Programas de Assistência Gerenciada , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Transtornos Relacionados ao Uso de Opioides/economia , Prevalência , Estudos Retrospectivos , Estados Unidos
9.
Pain Pract ; 14(3): E116-25, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24268019

RESUMO

OBJECTIVE: Growth in the number of patients with pain conditions, and the subsequent rise in prescription opioid use for treatment, has been accompanied by an increase in diagnosed opioid abuse. Understanding what drives the incremental healthcare costs of members diagnosed with prescription opioid abuse may assist in developing better screening techniques for abuse. DESIGN: This retrospective analysis examined costs, resource use, and comorbidities 365 days pre- and postdiagnosis in prescription opioid users diagnosed with abuse (cases) vs. their matched nondiagnosed controls. Inclusion criteria for cases were diagnosis of opioid abuse (ICD-9-CM: 304.0x, 304.7x, 305.5x, 965.0x). Multivariate analysis used generalized linear modeling with log-transformed cost as dependent variable, controlling for comorbidities. RESULTS: Final sample sizes were 8,390 cases and 16,780 matched controls. Postindex abuse-related costs were $2,099 for commercial members, $539 for Medicare members aged < 65, and $170 for Medicare members aged ≥ 65. A higher percentage of cases had pain conditions (82.0% vs. 57.4% commercial, 95.9% vs. 87.5% Medicare members aged < 65, 92.9% vs. 82.4% Medicare members aged ≥ 65, P < 0.0001), and a higher numbers of cases had multiple opioid prescribers (3.7 vs. 1.4 commercial, 3.3 vs. 2.2 Medicare < 65, 2.2 vs. 1.6 Medicare ≥ 65, P < 0.0001) than controls preindex. Cases had higher rates of substance abuse and psychiatric diagnoses pre- and postindex (P < 0.0001, all comparisons). Adjusted costs were 28% higher for cases than for controls (P < 0.0001). CONCLUSION: Costs of members diagnosed with prescription opioid abuse are driven by higher pain and psychiatric comorbidities relative to nonabuse controls.


Assuntos
Analgésicos Opioides/economia , Custos de Cuidados de Saúde , Medicare/economia , Transtornos Relacionados ao Uso de Opioides/economia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos , Adulto Jovem
10.
Pain Pract ; 14(2): 117-31, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23601620

RESUMO

Healthcare resource utilization (HCRU) and associated costs specific to pain are a growing concern, as increasing dollar amounts are spent on pain-related conditions. Understanding which pain conditions drive the highest utilization and cost burden to the healthcare system would enable providers and payers to better target conditions to manage pain adequately and efficiently. The current study focused on 36 noncancer chronic and 14 noncancer acute pain conditions and measured the HCRU and costs per member over 365 days. These conditions were ranked by per-member costs and total adjusted healthcare costs to determine the most expensive conditions to a national health plan. The top 5 conditions for the commercial line of business were back pain, osteoarthritis (OA), childbirth, injuries, and non-hip, non-spine fractures (adjusted annual total costs for the commercial members were $119 million, $98 million, $69 million, $61 million, and $48 million, respectively). The top 5 conditions for Medicare members were OA, back pain, hip fractures, injuries, and non-hip, non-spine fractures (adjusted annual costs for the Medicare members were $327 million, $218 million, $117 million, $82 million, and $67 million, respectively). The conditions ranked highest for both per-member and total healthcare costs were hip fractures, childbirth, and non-hip, non-spine fractures. Among these, hip fractures in the Medicare member population had the highest mean cost per member (adjusted per-member cost was $21,058). Further examination specific to how pain is managed in these high-cost conditions will enable providers and payers to develop strategies to improve patient outcomes through appropriate pain management.


Assuntos
Custos de Cuidados de Saúde , Seguro Saúde/economia , Manejo da Dor , Dor/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Dor nas Costas/economia , Dor Crônica/economia , Dor Crônica/etiologia , Feminino , Fraturas Ósseas/economia , Fraturas Ósseas/fisiopatologia , Fraturas do Quadril/economia , Fraturas do Quadril/fisiopatologia , Humanos , Revisão da Utilização de Seguros , Masculino , Medicare/economia , Pessoa de Meia-Idade , Osteoartrite/economia , Osteoartrite/fisiopatologia , Dor/etiologia , Manejo da Dor/economia , Parto , Estados Unidos , Ferimentos e Lesões/economia , Ferimentos e Lesões/fisiopatologia
11.
Pain Pract ; 14(5): 419-26, 2014 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23701733

RESUMO

BACKGROUND: Managed healthcare organizations often utilize formulary management strategies such as prior authorization and step therapy to guide appropriate medication use and to control medication expenditures. The objective of this study was to examine clinical and economic outcomes associated with implementation of a pregabalin step therapy (ST) policy among Medicare Advantage Prescription Drug (MAPD) members. METHODS: Pharmacy and medical claims data from Humana (restricted cohort; ST policy implemented 01/01/2009) and Thomson Reuters MarketScan(®) (unrestricted cohort) were analyzed for MAPD members aged 65 to 89 years receiving treatment for painful diabetic peripheral neuropathy (pDPN), postherpetic neuralgia (PHN) or fibromyalgia (FM). Difference-in-differences (DID) was used to examine year-over-year changes in disease-related and all-cause utilization and costs. Regression analyses examined medication utilization and healthcare expenditures after controlling for between-group compositional differences. RESULTS: We identified 13,911 members in the restricted cohort and matched to members from unrestricted health plans. FM (51.0%) and pDPN (41.8%) were the most common diagnoses. Members in the unrestricted cohort were older and had a greater level of comorbidity than members in the restricted cohort. The restricted cohort demonstrated greater year-over-year decrease in pregabalin utilization and increase in year-over-year gabapentin utilization compared with the unrestricted cohort. ST restriction was associated with an increase in disease-related pharmacy costs and a decrease in total medical costs for the restricted cohort compared with the unrestricted cohort. There was no difference between cohorts in total healthcare cost. CONCLUSION: After controlling for differences in age and comorbidity burden between the groups, implementation of a pregabalin ST restriction was associated with increased disease-related pharmacy costs and decreased total medical costs; however, there was no net difference in total healthcare cost or total pharmacy cost.


Assuntos
Medicare Part C/economia , Dor/tratamento farmacológico , Dor/economia , Ácido gama-Aminobutírico/análogos & derivados , Idoso , Idoso de 80 Anos ou mais , Analgésicos/administração & dosagem , Analgésicos/economia , Estudos de Coortes , Esquema de Medicação , Revisão de Uso de Medicamentos , Feminino , Humanos , Masculino , Dor/epidemiologia , Pregabalina , Estudos Retrospectivos , Estados Unidos/epidemiologia , Ácido gama-Aminobutírico/administração & dosagem , Ácido gama-Aminobutírico/economia
12.
Am J Manag Care ; 19(10): 816-23, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24304160

RESUMO

OBJECTIVE: To identify inefficiencies in drug and medical service utilization related to pain management in patients with osteoarthritis and chronic low back pain. STUDY DESIGN: This retrospective cohort study applied revised measures of pain management inefficiencies to Humana Medicare members with osteoarthritis and/or chronic low back pain. METHODS: Subjects had either 2 or more claims for osteoarthritis on different days or 2 or more claims for low back pain 90 or more days apart, from January 1, 2008, to June 30, 2010, with the first occurrence assigned the index date. Inefficiencies were identified for 365 days postindex.Pain-related healthcare costs postindex were compared between members with and without inefficiencies. A generalized linear model calculated adjusted costs per member controlling for age, sex, and comorbidities. RESULTS: Most members diagnosed with osteoarthritis, chronic low back pain, or both (N = 68,453) had at least 1 inefficiency measure (n = 37,863) during the postindex period. High per member costs were for repeated surgical procedures ($26,451) and inpatient admissions ($19,372) compared with members without inefficiencies ($781; P < .0001). High total costs (prevalence times per member cost) were for repeated diagnostic testing and excessive office visits. Members with an inefficiency had adjusted pain-related costs 5.42 times higher than those of members without an inefficiency (P <.0001). CONCLUSIONS: Pain management inefficiencies are common and costly among Humana Medicare members with osteoarthritis and/or chronic low back pain. Further work by providers and payers is needed to determine benefits of member identification and early intervention for these inefficiencies.


Assuntos
Dor Lombar/terapia , Osteoartrite/terapia , Manejo da Dor/economia , Adolescente , Adulto , Dor Crônica/economia , Dor Crônica/terapia , Humanos , Revisão da Utilização de Seguros , Dor Lombar/economia , Pessoa de Meia-Idade , Osteoartrite/economia , Avaliação de Resultados (Cuidados de Saúde) , Manejo da Dor/normas , Qualidade da Assistência à Saúde , Estudos Retrospectivos , Adulto Jovem
13.
J Med Econ ; 16(6): 784-92, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23565813

RESUMO

OBJECTIVE: To compare changes in healthcare resource utilization and costs among members with painful diabetic peripheral neuropathy (pDPN), postherpetic neuralgia (PHN), or fibromyalgia (FM) in a commercial health plan implementing pregabalin step-therapy with members in unrestricted plans. METHODS: Retrospective study of outcomes associated with implementation of a pregabalin step-therapy protocol using claims data from Humana ('restricted' cohort) and Thomson Reuters MarketScan ('unrestricted' cohort). Members aged 18-65 years receiving treatment for pDPN, PHN, or FM during 2008 or 2009 were identified; cohorts were matched on diagnosis and geographic region. Baseline to follow-up changes in healthcare resource utilization and costs were determined using difference-in-differences (DID) analysis. Statistical models adjusting for covariates explored relationships between restricted access and outcomes. RESULTS: A total of 3876 restricted cohort members were identified and matched to 3876 unrestricted cohort members. FM was the predominant diagnosis (84.7%). The unrestricted cohort was older (mean = 49.0 (SD = 10.4) years vs 47.6 (SD = 10.5) years; p < 0.001), and had greater comorbidity (RxRisk-V score = 5.4 (SD = 3.2) vs 4.4 (SD = 2.9), p < 0.001) than the restricted cohort. Compared with the unrestricted cohort, the restricted cohort demonstrated a greater year-over-year decrease in pregabalin utilization (-2.6%, p = 0.008), and greater increases in physical therapy and disease-related outpatient utilization (3.7%, p = 0.010 and 3.6%, p = 0.022, respectively). There were no statistically significant net differences in all-cause or disease-related total healthcare, medical, or pharmacy costs between cohorts. After adjusting for baseline compositional differences between cohorts, restricted plan membership was associated with a net increase in all-cause medical ($1222; p = 0.016) and disease-related healthcare costs ($859; p = 0.002). Limitations include use of a combined analysis for pDPN, PHN, and FM, especially since the observed results were likely driven by FM; an inability to link the prescribing of a medication with the condition of interest, which is common to claims analyses; and lack of pain severity information. CONCLUSIONS: Implementation of a pregabalin step-therapy protocol resulted in lower pregabalin utilization, but this restriction was not associated with reductions in total healthcare costs, medical costs, or pharmacy costs.


Assuntos
Analgésicos/economia , Neuropatias Diabéticas/tratamento farmacológico , Fibromialgia/tratamento farmacológico , Controle de Acesso/economia , Neuralgia Pós-Herpética/tratamento farmacológico , Assistência Farmacêutica/economia , Ácido gama-Aminobutírico/análogos & derivados , Adolescente , Adulto , Idoso , Analgésicos/uso terapêutico , Controle de Custos , Bases de Dados Factuais , Feminino , Gastos em Saúde , Humanos , Seguro de Serviços Farmacêuticos/economia , Masculino , Pessoa de Meia-Idade , Assistência Farmacêutica/estatística & dados numéricos , Pregabalina , Estudos Retrospectivos , Adulto Jovem , Ácido gama-Aminobutírico/economia , Ácido gama-Aminobutírico/uso terapêutico
14.
Psychiatr Serv ; 63(11): 1080-8, 2012 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-22910806

RESUMO

OBJECTIVE: Antipsychotic drug therapy is the cornerstone of treatment of persons with schizophrenia. Because most antipsychotics are metabolized by the hepatic cytochrome P450 system, concomitant use of an antipsychotic and medications that are competitively metabolized by the same system may cause a potentially harmful drug-drug interaction. This study used a large state's Medicaid claims database to examine the proportion of patients exposed to such interactions and the risk factors associated with exposure. METHODS: Claims from January 2000 through December 2003 for adult patients with a diagnosis of schizophrenia and at least one prescription for an antipsychotic (N=27,909) were examined for pairs of medications identified as potentially causing moderate or severe adverse drug effects. Logistic regression models were estimated to determine potential risk factors associated with exposure to the interaction pairs. RESULTS: A total of 6,417 (23%) patients were exposed to 14,213 potentially harmful interactions; 4,725 patients had at least one exposure from the same pharmacy, and 4,032 patients were exposed by the same physician. The greatest number of exposures (N=1,353) to potentially harmful combinations involved olanzapine and haloperidol. Patients prescribed risperidone were most likely to be exposed to an interaction (13.1%), followed by patients prescribed olanzapine (10.3%), quetiapine (3.3%), and clozapine (3.2%). A higher risk of exposure was associated with being female (odds ratio [OR]=.94), being white (OR=1.43), having depression (OR=1.21), or having impulse-control disorder (OR=1.98). CONCLUSIONS: Interventions by physicians and pharmacies to reduce the prescribing and dispensing of potentially harmful pairs of medications to patients with schizophrenia are recommended.


Assuntos
Antipsicóticos/uso terapêutico , Interações de Medicamentos , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Esquizofrenia/tratamento farmacológico , Esquizofrenia/epidemiologia , Adolescente , Adulto , Idoso , Antipsicóticos/metabolismo , Hidrocarboneto de Aril Hidroxilases/efeitos dos fármacos , Contraindicações , Prescrições de Medicamentos/estatística & dados numéricos , Métodos Epidemiológicos , Feminino , Humanos , Fígado/metabolismo , Masculino , Medicaid/estatística & dados numéricos , Pessoa de Meia-Idade , Polimedicação , Padrões de Prática Médica/estatística & dados numéricos , Fatores de Risco , Esquizofrenia/metabolismo , Falha de Tratamento , Estados Unidos/epidemiologia , Adulto Jovem
15.
J Am Acad Child Adolesc Psychiatry ; 51(6): 642-51, 2012 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-22632623

RESUMO

OBJECTIVES: This study used proton magnetic resonance spectroscopy ((1)H MRS) to evaluate the in vivo effects of extended-release divalproex sodium on the glutamatergic system in adolescents with bipolar disorder, and to identify baseline neurochemical predictors of clinical remission. METHOD: Adolescents with bipolar disorder who were experiencing a manic or mixed episode (N = 25) were treated with open-label, extended-release divalproex (serum levels 85-125 µg/mL) and underwent (1)H MRS scanning at baseline (before treatment) and on days 7 and 28. Healthy comparison subjects (n = 15) also underwent (1)H MRS scanning at the same time points. Glutamate (Glu) and glutamate+glutamine (Glx) concentrations were measured in three voxels: anterior cingulate cortex (ACC), left ventrolateral prefrontal cortex (LVLPFC), and right ventrolateral prefrontal cortex (RVLPFC), and were compared between bipolar and healthy subjects. Within the bipolar subjects, Glu and Glx concentrations at baseline and each time point were also compared between remitters and nonremitters after divalproex treatment. RESULTS: At baseline, no differences in Glu or Glx concentrations between bipolar and healthy subjects were observed. Group (HC vs. BP) by time effects revealed an interaction for Glu in the ACC, and change over time effects for Glx were noted in the ACC in patients with bipolar disorder (increase from day 0 to day 7 and then a decrease from day 7 to day 28) but not in HC. Remitters had significantly lower baseline Glx concentrations in LVLPFC, and in remitters the change in LVLPFC Glu correlated with the change in YMRS score. CONCLUSIONS: Successful treatment of mania with divalproex may be predicted by lower baseline concentrations of Glx in the LVLPFC. In addition, in remitters, the degree of symptomatic improvement is related to the change in Glu concentrations in this region, suggesting that divalproex may work via modulation of the prefrontal glutamatergic system in youth with bipolar disorder.


Assuntos
Transtorno Bipolar , Córtex Cerebral , Ácido Glutâmico/metabolismo , Espectroscopia de Ressonância Magnética/métodos , Ácido Valproico , Adolescente , Antimaníacos/farmacologia , Antimaníacos/uso terapêutico , Transtorno Bipolar/diagnóstico , Transtorno Bipolar/tratamento farmacológico , Transtorno Bipolar/metabolismo , Córtex Cerebral/efeitos dos fármacos , Córtex Cerebral/metabolismo , Córtex Cerebral/fisiopatologia , Feminino , Humanos , Masculino , Neurotransmissores/metabolismo , Escalas de Graduação Psiquiátrica , Indução de Remissão , Resultado do Tratamento , Ácido Valproico/farmacologia , Ácido Valproico/uso terapêutico
16.
Int Clin Psychopharmacol ; 26(1): 48-53, 2011 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-20861739

RESUMO

This study evaluated the efficacy and tolerability of ramelteon in ambulatory bipolar I disorder with manic symptoms and insomnia. Twenty-one outpatients with bipolar I disorder by Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria with mild-to-moderate manic symptoms and sleep disturbance were randomized to receive either ramelteon (N=10) or placebo (N=11) in an 8-week, double-blind, fixed-dose (8 mg/day) study. Ramelteon and placebo had similar rates of reduction in ratings of symptoms of insomnia, mania, and global severity of illness. However, ramelteon was associated with improvement in a global rating of depressive symptoms. It was also well tolerated and associated with no serious adverse events. The small sample size may have limited the ability of the study to detect potentially clinically important drug-placebo differences. Further studies of ramelteon in subgroups of bipolar patients with sleep disturbance, including those with depression or euthymia, seem indicated.


Assuntos
Transtorno Bipolar/tratamento farmacológico , Hipnóticos e Sedativos/uso terapêutico , Indenos/uso terapêutico , Distúrbios do Início e da Manutenção do Sono/tratamento farmacológico , Adulto , Transtorno Bipolar/complicações , Método Duplo-Cego , Feminino , Humanos , Hipnóticos e Sedativos/farmacologia , Indenos/farmacologia , Masculino , Pacientes Ambulatoriais , Distúrbios do Início e da Manutenção do Sono/complicações
17.
18.
Int J Psychiatry Med ; 39(4): 439-50, 2009.
Artigo em Inglês | MEDLINE | ID: mdl-20391864

RESUMO

INTRODUCTION: Current data regarding risk factors of neuroleptic malignant syndrome (NMS) are limited. This study aims to examine factors associated with increased risk of NMS in patients with bipolar disorder. METHODS: A retrospective, population-based, case-control study was performed using a medical claims database covering January 1998 to December 2002. Fifty cases with a diagnosis of NMS were identified and matched with 800 controls. Conditional logistic regression analysis was used to estimate crude and adjusted odds ratios (ORs) of risk of NMS. RESULTS: Antipsychotic use was associated with an increased risk of NMS after controlling for other pharmacologic and clinical factors (OR = 2.36, 95% CI = 1.08-5.19). Other factors associated with an increased risk of NMS included being male (OR = 2.07, 95% CI = 1.07-4.02), confusion (OR = 2.91, 95% CI = 1.17-7.28), dehydration (OR = 3.99, 95% CI = 1.50-10.57), delirium (OR = 4.93, 95% CI = 2.07-11.72), and extrapyramidal symptoms (OR = 3.50, 95% CI = 1.10-11.09). CONCLUSIONS: Given the widespread use of antipsychotics for the treatment of bipolar disorder, clinicians should be vigilant of the potential pharmacologic and clinical factors associated with increased risk of NMS in patients with bipolar disorder.


Assuntos
Antipsicóticos/efeitos adversos , Transtorno Bipolar/tratamento farmacológico , Transtorno Bipolar/epidemiologia , Síndrome Maligna Neuroléptica/diagnóstico , Síndrome Maligna Neuroléptica/epidemiologia , Adulto , Idoso , Antipsicóticos/uso terapêutico , Estudos de Casos e Controles , Comorbidade , Estudos Transversais , Quimioterapia Combinada , Feminino , Humanos , Masculino , Programas de Assistência Gerenciada/estatística & dados numéricos , Pessoa de Meia-Idade , Estudos Retrospectivos , Risco , Estados Unidos
19.
Pharmacoepidemiol Drug Saf ; 18(3): 196-202, 2009 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-19115419

RESUMO

OBJECTIVE: This study aimed to determine whether the degree of serotonin (5-HT) reuptake inhibition affects risk of hemorrhagic stroke associated with antidepressant use in patients with depression. METHOD: A population-based, nested case-control study was performed using a managed care medical claims database. Ninety two depressed patients with a diagnosis of hemorrhagic stroke were identified and matched with 552 controls by age, sex, and year of index date of depression (IDD). Diagnoses of depression, hemorrhagic stroke, and other medical comorbidities were identified using ICD-9 codes. Antidepressants were classified as high, medium, or low reuptake inhibition based on their affinities for the 5-HT reuptake transporter, determined using their respective equilibrium dissociation constants (K(D); high: K(D) < 1 nM; medium: 1 or= 10 nM). Conditional logistic regression analysis was performed to estimate the crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) of the risk of hemorrhagic stroke. RESULTS: Compared to non-users of antidepressants, risk of hemorrhagic stroke did not significantly differ between patients who had ever used antidepressants with high (OR = 0.82; 95% CI = 0.44-1.55), medium (OR = 0.93; 95% CI = 0.37-2.31), or low (OR = 0.38; 95% CI = 0.11-1.41) 5-HTT inhibition. CONCLUSION: Risk of hemorrhagic stroke associated with antidepressant use may not be related to an antidepressant's degree of 5-HT reuptake inhibition. Given the limitations of this study, additional studies are needed to confirm these findings.


Assuntos
Antidepressivos/efeitos adversos , Hemorragia Cerebral/induzido quimicamente , Inibidores de Captação de Serotonina/efeitos adversos , Acidente Vascular Cerebral/induzido quimicamente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antidepressivos/uso terapêutico , Hemorragia Cerebral/epidemiologia , Bases de Dados Factuais , Depressão/tratamento farmacológico , Relação Dose-Resposta a Droga , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Inibidores de Captação de Serotonina/uso terapêutico , Acidente Vascular Cerebral/epidemiologia , Estados Unidos/epidemiologia
20.
J Child Adolesc Psychopharmacol ; 18(6): 623-7, 2008 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-19108667

RESUMO

OBJECTIVE: Identifying neurochemical alterations in adolescent bipolar depression may enhance our understanding of the neurophysiology of bipolar disorder across the age spectrum. The objective of this study was to compare in vivo neurometabolite concentrations in bipolar adolescents with a depressed episode and healthy adolescents using proton magnetic resonance spectroscopy ((1)H MRS). METHOD: Bipolar adolescents with a depressed episode (n = 28) and healthy adolescents (n = 10) underwent a (1)H MRS scan. Anterior cingulate (ACC) and left and right ventral lateral prefrontal (LVLPFC, RVLPFC) metabolite concentrations were calculated and compared between groups using analysis of covariance (ANCOVA). RESULTS: ANCOVA showed significant group differences in ACC N-acetyl-aspartate (NAA) (F(1,33) = 17.8, p = 0.0002), LVLPFC choline (Cho) (F(1,32) = 13.1, p = 0.001), creatine/phosphocreatine (Cr) (F(1,32) = 18.5, p = 0.0002), and NAA (F(1,32) = 13.6, p = 0.0008), and RVLPFC Cr (F(1,32) = 9.6, p = 0.004), mI (F(1,32) = 11.1, p = 0.002), and NAA (F(1,32) = 11.4, p = 0.002) concentrations. In general, the bipolar depressed group had higher neurometabolite concentrations than the healthy group. CONCLUSIONS: There may be localized alterations in brain neurometabolites in adolescents with bipolar depression. Limitations include lack of bipolar adolescents in other mood states and potential confounding effects of prior psychotropic medication use. Confirmatory (1)H MRS studies in larger samples of youths with bipolar depression are needed.


Assuntos
Transtorno Bipolar/metabolismo , Transtorno Bipolar/fisiopatologia , Química Encefálica/fisiologia , Córtex Pré-Frontal/fisiopatologia , Adolescente , Anticonvulsivantes/uso terapêutico , Antidepressivos/uso terapêutico , Antipsicóticos/uso terapêutico , Ácido Aspártico/análogos & derivados , Ácido Aspártico/metabolismo , Transtorno Bipolar/tratamento farmacológico , Criança , Colina/metabolismo , Creatina/metabolismo , Feminino , Ácido Glutâmico/metabolismo , Glutamina/metabolismo , Humanos , Inositol/metabolismo , Espectroscopia de Ressonância Magnética , Masculino , Projetos Piloto , Ácido gama-Aminobutírico/metabolismo
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