Resource utilization in patients with schizophrenia who initiated risperidone long-acting therapy: results from the Schizophrenia Outcomes Utilization Relapse and Clinical Evaluation (SOURCE).

BACKGROUND: Schizophrenia is a chronic mental health disorder associated with increased hospital admissions and excessive utilization of outpatient services and long-term care. This analysis examined health care resource utilization from a 24-month observational study of patients with schizophrenia initiated on risperidone long-acting therapy (RLAT). METHODS: Schizophrenia Outcomes Utilization Relapse and Clinical Evaluation (SOURCE) was a 24-month observational study designed to examine real-world treatment outcomes by prospectively following patients with schizophrenia initiated on RLAT. At baseline visit, prior hospitalization and ER visit dates were obtained for the previous 12 months and subsequent hospitalization visit dates were obtained at 3-month visits, if available. The health care resource utilization outcomes measures observed in this analysis were hospitalizations for any reason, psychiatric-related hospitalizations, and emergency room (ER) visits. Incidence density analysis was used to assess pre-event and postevent rates per person-year (PY). RESULTS: The primary medical resource utilization analysis included 435 patients who had a baseline visit, ≥1 postbaseline visits after RLAT initiation, and valid hospitalization dates. The number of hospitalizations and ER visits per PY declined significantly (p < .0001) after initiation with RLAT. A 41% decrease (difference of -0.29 hospitalizations per PY [95% CI: -0.39 to -0.18] from baseline) in hospitalizations for any reason, a 56% decrease (a difference of -0.35 hospitalizations per PY [95% CI: -0.44 to -0.26] from baseline) in psychiatric-related hospitalizations, and a 40% decrease (-0.26 hospitalizations per PY [95% CI: -0.44 to -0.10] from baseline) in ER visits were observed after the baseline period. The percentage of psychiatric-related hospitalizations decreased significantly after RLAT initiation, and patients had fewer inpatient hospitalizations and ER visits (all p < .0001). CONCLUSION: The results suggest that treatment with RLAT may result in decreased hospitalizations for patients with schizophrenia. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00246194.

Assessment of effectiveness measures in patients with schizophrenia initiated on risperidone long-acting therapy: the SOURCE study results.

BACKGROUND: To evaluate effectiveness outcomes in a real-world setting in patients with schizophrenia initiating risperidone long-acting therapy (RLAT). METHODS: This was a 24-month, multicenter, prospective, longitudinal, observational study in patients with schizophrenia who were initiated on RLAT. Physicians could change treatment during the study as clinically warranted. Data were collected at baseline and subsequently every 3 months up to 24 months. Effectiveness outcomes included changes in illness severity as measured by Clinical Global Impression-Severity (CGI-S) scale; functional scores as measured by Personal and Social Performance (PSP) scale, Global Assessment of Functioning (GAF), and Strauss-Carpenter Levels of Functioning (LOF); and health status (Medical Outcomes Survey Short Form-36 [SF-36]). Life-table methodology was used to estimate the cumulative probability of relapse over time. Adverse events were evaluated for safety. RESULTS: 532 patients were enrolled in the study; 209 (39.3%) completed the 24-month study and 305 (57.3%) had at least 12 months of follow-up data. The mean (SD) age of patients was 42.3 (12.8) years. Most patients were male (66.4%) and either Caucasian (60.3%) or African American (23.7%). All changes in CGI-S from baseline at each subsequent 3-month follow-up visit were statistically significant (p < .0001), indicating improvement in disease severity. Improvements were also noted for the PSP, GAF, and total LOF, indicating improvement in daily functioning and health outcome. CONCLUSIONS: Patients with schizophrenia who were initiated on RLAT demonstrated improvements in measures of effectiveness within 3 months, which persisted over 24 months. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00246194.

Effectiveness of injectable risperidone long-acting therapy for schizophrenia: data from the US, Spain, Australia, and Belgium.

BACKGROUND: Because wide variations in mental health care utilization exist throughout the world, determining long-term effectiveness of psychotropic medications in a real-world setting would be beneficial to physicians and patients. The purpose of this analysis was to describe the effectiveness of injectable risperidone long-acting therapy (RLAT) for schizophrenia across countries. METHODS: This was a pragmatic analysis of data from two prospective observational studies conducted in the US (Schizophrenia Outcomes Utilization Relapse and Clinical Evaluation [SOURCE]; ClinicalTrials.gov registration number for the SOURCE study: NCT00246194) and Spain, Australia, and Belgium (electronic Schizophrenia Treatment Adherence Registry [eSTAR]). Two separate analyses were performed to assess clinical improvement during the study and estimate psychiatric hospitalization rates before and after RLAT initiation. Clinical improvement was evaluated using the Clinical Global Impressions-Severity (CGI-S) and Global Assessment of Functioning (GAF) scales, and change from baseline was evaluated using paired t tests. Psychiatric hospitalization rates were analyzed using incidence densities, and the bootstrap resampling method was used to examine differences between the pre-baseline and post-baseline periods. RESULTS: The initial sample comprised 3,069 patients (US, n = 532; Spain, n = 1,345; Australia, n = 784; and Belgium, n = 408). In all, 24 months of study participation, completed by 39.3% (n = 209), 62.7% (n = 843), 45.8% (n = 359), and 64.2% (n = 262) of patients from the US, Spain, Australia, and Belgium, respectively, were included in the clinical analysis. Improvements compared with baseline were observed on both clinical assessments across countries (P < 0.001 at all post-baseline visits). The mean improvement was approximately 1 point on the CGI-S and 15 points on the GAF. A total of 435 (81.8%), 1,339 (99.6%), 734 (93.6%), and 393 (96.3%) patients from the US, Spain, Australia, and Belgium, respectively, had ≥1 post-baseline visit and were included in the analysis of psychiatric hospitalization rates. Hospitalization rates decreased significantly in all countries regardless of hospitalization status at RLAT initiation (P < 0.0001) and decreased significantly in the US and Spain (P < 0.0001) when the analysis was limited to outpatients only. CONCLUSIONS: RLAT in patients with schizophrenia was associated with improvements in clinical and functional outcomes and decreased hospitalization rates in the US, Spain, Australia, and Belgium, despite differences in health care delivery systems.

Predicting hospital admission and discharge with symptom or function scores in patients with schizophrenia: pooled analysis of a clinical trial extension.

BACKGROUND: The purpose of this analysis was to evaluate relationships between hospital admission or discharge and scores for symptom or functioning in patients with schizophrenia. METHODS: Data were from three 52-week open-label extensions of the double-blind pivotal trials of paliperidone extended-release (ER). Symptoms and patient function were measured every 4 weeks using the Personal and Social Performance (PSP) scale and the Positive and Negative Syndrome Scale (PANSS). The intent-to-treat analysis set was defined as open-label patients who had at least one post-baseline PSP and PANSS measurement. Time until first hospitalization was evaluated using the Cox proportional hazard model with categorical time-dependent measures for the PSP (1 to 30, 31 to 70, 71 to 100) or PANSS (< 75, >/= 75 to < 95, >/= 95), as well as age, gender, schizophrenia duration, and country. Similar analyses were performed for time to discharge. RESULTS: Of the 1,077 enrolled patients, 1,028 (95.5%) met study criteria; of these, 382 (37.2%) were hospitalized at open-label baseline. Compared with patients with PSP >/= 71 group, the hazard for new hospitalization was 8.351 times greater (P = 0.0001) for patients with the poorest functioning (PSP 1 to 30) and 1.977 times greater (P = 0.0295) for patients with PSP of 31-70 compared to the >/= 71 group. The hazard for new hospitalization was 5.457 times greater (P < 0.0001) for patients PANSS >/= 95 and 2.316 times greater (P = 0.0027) for the >/= 75 to < 95 group compared with the < 75 group. For patients hospitalized at baseline, the PANSS >/= 95 patients had a discharge hazard that was 0.456 times lower than for the < 75 patients (P < 0.0001). The hazard for discharge was 0.646 times lower (P = 0.0012) for the PANSS >/= 75 to < 95 group compared with the < 75 group. A patient's country was a significant predictor variable, with US patients being admitted and discharged faster. CONCLUSIONS: Better functioning or being less symptomatic is associated with reduced risk for hospitalization and greater chance for early discharge. Treatments or programs that reduce symptoms or improve function decrease the risk of hospitalization in community patients or increase the chance of discharge for hospitalized patients.

The economic burden of chronic obstructive pulmonary disease (COPD) in a U.S. Medicare population.

RATIONALE: Although the economic burden of COPD has gained attention in recent years, data on the costs of COPD among U.S. Medicare beneficiaries are lacking. METHODS: This study used administrative claims and eligibility records from a large U.S. multi-state Medicare managed care database. Study patients were 65+ years of age with paid claims during 2004. The COPD cohort comprised patients with 1+ inpatient/ER claims or 2+ outpatient claims (>30 days apart) for COPD (ICD-9-CM codes 491.xx, 492.x, 496). The comparison cohort included patients without COPD matched 3:1 to the COPD cohort on age, sex, enrollment months, and Medicare plan. Excess costs of COPD were estimated as the difference in overall health plan payments between the two cohorts during 2004. Attributable costs were calculated using medical claims with listed diagnoses of COPD or other respiratory-related conditions and pharmacy claims for respiratory medications. RESULTS: A total of 8370 patients were included in the COPD cohort and were matched to 25,110 comparison cohort patients. For both groups, mean (SD) age was 78 (8) years, 54% were female, and duration of eligibility was 11 (2) months. COPD patients were more likely to utilize healthcare services and had excess total healthcare costs about $20,500 higher (P<0.0001) than the comparison cohort. Comorbidities were high in the COPD cohort, accounting for 46% of the observed excess cost. The attributable cost of COPD averaged about $6,300; other respiratory-related costs averaged about $4,400. CONCLUSION: In this U.S. Medicare managed care population, COPD posed a substantial burden in terms of both respiratory-related and total healthcare costs. A comparison of these cost-of-illness estimates to those for elderly COPD patients in other countries would be of great interest, given the increasing age of populations in most Western countries.

Smoking cessation: the value of a comprehensive carved-in benefit.

This qualitative narrative review examines the potential returns from providing smoking cessation treatments (SCTs) through an insurance plan's standard benefit package versus through an optional supplementary wellness ('rider') program. Research indicates most employers offer SCTs as part of a rider available for purchase. Studies demonstrate that the higher the cost of SCTs, the lower the SCT participation rates; when employees receive SCTs, smoking cessation rates increase, effecting lower employee healthcare costs and improved productivity. Employers may receive a considerable return on the investment of offering SCTs as part of comprehensive insurance benefit for their employees as opposed to a rider.

Impacts of a smoking cessation benefit among employed populations.

OBJECTIVE: The objective of this study was to project the health and economic impacts of providing a workplace smoking cessation benefit. METHODS: The authors conducted an update of a previously published outcomes model using recently published data and clinical trial results. RESULTS: In four example workplace types evaluated, coverage of a cessation benefit resulted in greater numbers of successful cessations and decreased rates of smoking-related diseases. Total savings from benefit coverage (decreased healthcare and workplace costs) exceeded costs of the benefit within 4 years. Total savings per smoker ranged from 350 dollars to 582 dollars at 10 years and 1152 dollars to 1743 dollars at 20 years. Internal rate of return ranged from 39% to 60% at 10 years. CONCLUSION: Providing a workplace smoking cessation benefit results in substantial health and economic benefits with economic savings exceeding the cost of the benefit within a relatively short period. CLINICAL SIGNIFICANCE: Providing a workplace smoking cessation benefit is projected to increase the rate of smoking cessation as well as decrease the incidence of smoking-related conditions and healthcare costs. In addition, workplace cessation benefits can result in decreased absenteeism, increased productivity, and net cost savings within 4 years.

An employer-based cost-benefit analysis of a novel pharmacotherapy agent for smoking cessation.

INTRODUCTION: An employer-based cost-benefit analysis for varenicline versus bupropion was conducted using clinical outcomes from a recently published trial. METHODS: A decision tree model was developed based on the net benefit of treatment to produce a nonsmoker at 1 year. Sensitivity analyses were conducted based on quit rates with placebo and varenicline and the cost of varenicline. RESULTS: Estimated 12-month employer cost savings per non-smoking employee were $540.60 for varenicline, $269.80 for bupropion SR generic, $150.80 for bupropion SR brand, and $81.80 for placebo. Varenicline was more cost beneficial than placebo, which had quit rates of 16.9% or less. The quit rate with varenicline would have to be

The cost effectiveness of varenicline for smoking cessation.

A decision-analysis model was developed to evaluate health and economic effects of varenicline compared with other smoking-cessation aids for private health plans, Medicaid plans, or employee populations. Use of varenicline is projected to increase the number of successful smoking cessations after 10 years by approximately 14% compared with bupropion, 25% compared with nicotine patches, and 38% when compared with no pharmacologic aids. Varenicline use also results in immediate health care cost savings, compared with use of bupropion and savings within two years compared with nicotine patches or no aids. Comparing varenicline with no aids, the cost effectiveness of varenicline at two years ranged from $648 per additional cessation in the private health plan model to $836 per additional cessation in the Medicaid model. Employers often experience additional savings from decreased absenteeism and increased productivity, with combined savings in health care plus workplace costs associated with varenicline use of $165 to $457 per smoker over two years.

Evaluating Diagnosis and Treatment Patterns of COPD in Primary Care.

OBJECTIVE: Many patients with COPD are misdiagnosed or under-treated. The characteristics of COPD patients and the patterns of treatment have not been well characterized in primary care settings. The objective of this study was to identify patterns of COPD onset, diagnosis and treatment with the goal of facilitating appropriate treatment at earlier stages. METHODS: A national electronic medical record database was used to identify patients with at least a 6-month history prior to a diagnosis of COPD (ICD-9 codes 491.xx, 492.xx, and 496). Pulmonary function test (PFT) results closest to the first diagnosis of COPD were evaluated to characterize disease severity using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. Prescription data were evaluated at the time of diagnosis. All descriptive statistics were conducted using STATA statistical software. RESULTS: A total of 14 691 patients met the study criteria. Prescription data were available for 9354 (64%) of these patients. Of this group, only slightly over 50% (n = 5264) had a respiratory-related prescription on the date of diagnosis. For those not having a respiratory drug at the time of diagnosis, the average time between diagnosis and the first respiratory-related prescription was 106 (SD +/- 256.4) days. Only 389 (<3%) patients had any PFT data recorded on or prior to the day of their first diagnosis of COPD, and only 273 (2%) had sufficient PFT data available to determine their GOLD severity class. The average time between diagnosis and first COPD prescription was greatest for patients in the lowest severity category (Class 0/I; 163 +/- 288.2 days), and smallest for patients in the highest severity category (Class IV; 124 +/- 152.3 days). CONCLUSION: COPD is often not diagnosed or treated until the later stages of disease, and spirometry is not used routinely to diagnose, stage or guide treatment decisions.

Effect of smoking status on productivity loss.

OBJECTIVE: The objective of this study was to describe health-related productivity losses in nonsmokers, former smokers, and current smokers using a large, cross-sectional database of U.S. employees. METHODS: Volunteers completed the Wellness Inventory, an instrument measuring productivity losses related to 11 health conditions affecting employee health. Results are aggregated, dollarized, and reported by smoking group. RESULTS: Current smokers missed more days of work and experienced more unproductive time at work compared with former smokers and nonsmokers. The average annual cost for lost productivity for nonsmokers was 2623 dollars/year compared with 3246 dollars/year for former smokers and 4430 dollars/year for current smokers. More than half the costs were due to unproductive time at work. CONCLUSION: Current smokers incurred the highest productivity losses, which translated into higher costs to employers for current smokers. Costs were lower for former smokers and nonsmokers.

Meta-analysis of disease risk associated with smoking, by gender and intensity of smoking.

BACKGROUND: The risks associated with cigarette smoking can be substantial, particularly for females. In 2000, the mortality rate for lung cancer among women was higher than that for breast cancer. OBJECTIVE: To obtain overall risk for intensity of smoking for both males and females, a meta-analysis was performed on recent studies that assessed the morbidity and mortality associated with smoking. METHODS: Using the PubMed database, a literature search was conducted for cohort and case-control studies on the effect of smoking on morbidity and mortality. Only studies that had quantified the risk of disease associated with smoking were included. Nineteen studies were selected, with data obtained on the disease affected by smoking, point estimates of risk, 95% CIs, sample size, type of study, and the number of patients of each sex. Meta-analyses were performed for low level of use, defined as 1 to 20 cigarettes per day, and for high level of use, >20 cigarettes per day. RESULTS: For low level of use, the rate ratio point estimate of 1.77 (95% CI, 1.40-2.24) for females was higher than that of 1.42 (95% CI, 1.23-1.64) for males, indicating a gender effect associated with smoking as a disease risk. The point estimate for females who smoked at high levels was 2.75 (95% CI, 2.14-3.52), well beyond the estimate of 1.95 (95% CI, 1.70-2.24) for males, indicating there was a substantial gender effect with high-level use. All point estimates for low and high levels of smoking were significant; those for each sex at high levels of smoking exceeded those found for low levels. The increase in risk from low to high levels of smoking was greater for females than for males. CONCLUSIONS: Few systems in the body were unaffected by smoking, and intensity was a risk factor for disease. Results were consistent with and strengthened previous research demonstrating an increase in overall risk with an increase in smoking intensity. In addition, gender differences were noted that may contribute to risk magnitude.

Reduction in use of healthcare services with combination sulfonylurea and rosiglitazone: findings from the Rosiglitazone Early vs SULfonylurea Titration (RESULT) study.

OBJECTIVE: To assess and compare healthcare utilization and costs over a 2-year period in older patients (> or = 60 years) with type 2 diabetes receiving combination therapy with rosiglitazone plus a sulfonylurea (glipizide) or progressive up-titration of glipizide monotherapy. STUDY DESIGN: Two-year, randomized, double-blind, parallel-group clinical trial. PATIENTS AND METHODS: Older type 2 diabetic patients initially receiving submaximal doses of a sulfonylurea were randomized to receive rosiglitazone plus glipizide (n = 115) or up-titrated glipizide monotherapy (n = 110). Information on patient self-reported healthcare utilization (hospitalizations, emergency department [ED] visits, physician office visits) was collected prospectively for the duration of the trial. National average healthcare costs per unit were applied to calculate direct medical costs. RESULTS: Demographic characteristics of the 2 groups were similar. At the study's end, glycemic values were better in the rosiglitazone-plus-glipizide group. Compared with the glipizide group, patients receiving rosiglitazone plus glipizide had significantly fewer ED visits (P = .0006) and hospitalizations (P = .0263). Although the glipizide group had more unscheduled physician office visits, the difference was not statistically significant. Estimated treatment costs per patient per month were significantly lower for the rosiglitazone-plus-glipizide group than for the glipizide group (480 dollars vs 645 dollars; P < .05). CONCLUSION: Addition of rosiglitazone to sulfonylurea therapy was associated with decreased use of medical resources, in particular hospitalizations and ED visits, compared with progressive sulfonylurea up-titration. Although causality could not be established, this therapeutic approach could improve clinical outcomes in patients with type 2 diabetes and reduce healthcare utilization and costs.

Access to new medications to treat schizophrenia.

Between 1989 and 1997, the Food and Drug Administration approved four new-generation antipsychotic medications for use in the treatment of schizophrenia. This article examines factors associated with the use of new antipsychotic medications as compared with traditional antipsychotic medications from patient interviews, medical records, and a physician survey administered at schizophrenia treatment sites around the country as part of the Schizophrenia Care and Assessment Program. The following variables were significantly associated with a higher probability of receiving an atypical antipsychotic medication in multiple regression analysis at p < .05: female, younger age, younger age of onset, non-African American, having a higher Positive and Negative Syndrome Scale-Negative Syndrome subscale score. Some physician characteristics were statistically significant in the bivariate results but not in the multivariate analyses. Access to new atypical antipsychotic medications is dependent on more than clinical characteristics. In particular, barriers to access may exist for African Americans. Physician access to information about advances in drug therapies also may play a substantial role in the rate of diffusion of new medications.

An observational study of the effect of two thiazolidinediones on blood lipid levels: Rosiglitazone and pioglitazone in routine clinical practice.

BACKGROUND: Rosiglitazone maleate and pioglitazone hydrochloride are established antihyperglycemic agents that are effective when used as monotherapy or in combination with other medications. However, the data regarding the effects of these agents on blood lipid levels are contradictory. OBJECTIVE: The aim of this study was to determine whether the use of rosiglitazone and pioglitazone in clinical practice is associated with any changes in blood lipid levels. METHODS: A retrospective chart review using electronic medical record data was conducted of patients with type 2 diabetes mellitus who were newly treated with either rosiglitazone or pioglitazone and had 1 lipid measurement within 6 months prior to and 12 months following initial thiazolidinedione (TZD) therapy. Outcome measures were mean changes in low- and high-density lipoprotein cholesterol (LDL-C and HDL-C, respectively). To control for differences in baseline characteristics and/or selection bias, the treatment cohorts were compared using multivariate statistical techniques. RESULTS: A total of 371 patients were included in the study; the pioglitazone cohort comprised 148 patients (82 women, 66 men; mean [SD] age, 64.9 [10.8] years) and the rosiglitazone cohort comprised 223 patients (113 men, 110 women; mean [SD] age, 66.1 [11.9] years). Pioglitazone-treated patients had a statistically higher mean baseline LDL-C compared with rosiglitazone-treated patients (125.0 mg/dL vs 116.6 mg/dL; P = 0.04). On average, LDL-C levels decreased over the study period, with no significant differences between the 2 cohorts (9.9 mg/dL vs 4.3 mg/dL for pioglitazone and rosiglitazone, respectively), although changes in both cohorts were statistically significant (P < 0.001). CONCLUSIONS: TZD therapy appears to be associated with a small decrease in LDL-C within the first 6 months after initiation. No differences in changes in LDL-C or HDL-C could be discerned between patients treated with rosiglitazone compared with pioglitazone.

Do strict formularies replicate failure for patients with schizophrenia?

OBJECTIVES: We measure the impact of Medicaid formulary restrictions (FRs) on the rate at which patients who previously failed a drug therapy for schizophrenia are returned to that therapy. STUDY DESIGN: We collect drug-level information on FRs in state Medicaid programs and examine claims of noninstitutionalized Medicaid enrollees with schizophrenia. METHODS: A difference-in-differences technique is used to compute the change in the probability of adverse outcomes before and after a state adopts an FR. This change is compared with the change in failure probabilities in states with no FRs. RESULTS: Regardless of FRs, patients tend to resume the same drug after an adverse medical event. In 2005, 69% of inpatient mental health-related admissions resulted in patients resuming the same therapy within 6 months of the event, and 63% of patients resumed the same drug after a mental health-related emergency department admission. In states where FRs limit access to all atypicals, the likelihood of a patient resuming the same atypical after having ceased treatment for at least 30 days increases by 20.1% relative to patients in states without restrictions. Additionally, patients in states that impose FRs on all atypicals are 11.6% more likely to discontinue all treatments. CONCLUSIONS: FR may increase the likelihood that patients will return to failed treatments or cease treatment altogether. Although formularies are designed to reduce drug spending, an unintended consequence may be an increase in the use of other services needed to treat patients with schizophrenia.

Cost of schizophrenia in the Medicare program.

Medicare beneficiaries diagnosed with non-schizoaffective schizophrenia (MBS) in a 5% national Medicare fee-for-service sample from 2003-2007 were followed for 1-6 years. Medicare population and cost estimates also were made from 2001-2009. Service utilization and Medicare (and beneficiary share) payments for all services except prescription drugs were analyzed. Although adults with schizophrenia make up approximately 1% of the US adult population, they represent about 1.5% of Medicare beneficiaries. MBSs are disproportionately male and minority compared to national data describing the overall schizophrenia population. They also are younger than the general Medicare population (GMB): males are 9 years younger than females on average, and most enter Medicare long before age 65 through eligibility for social security disability, remaining in the program until death. The cost of care for MBSs in 2009 was, on average, 80% higher than for the average GMB per patient year (2010 dollars), and more than 50% of these costs are attributable to a combination of psychiatric and medical hospitalizations, concentrated in about 30% of MBSs with 1 or more hospitalizations per year. From 2004-2009, total estimated Medicare fee-for-service payments for MBSs increased from $9.4 billion to $11.5 billion, excluding Part D prescription drugs and payments for services to MBSs in Medicare for less than 1 year. Study results characterize utilization and costs for other services and suggest opportunities for further study to inform policy to improve access and continuity of care and decrease costs to the Medicare program associated with this population.

Medicaid prior authorization policies and imprisonment among patients with schizophrenia.

OBJECTIVE: To examine the impact of Medicaid prior authorization for atypical antipsychotics on the prevalence of schizophrenia among the prison population. Study DESIGN: We collected drug-level information on prior authorization restrictions from Medicaid programs in 30 states to determine which states had prior authorization requirements before 2004. We linked the regulatory data to a survey of prison inmates conducted in 2004. METHODS: We used a sample of 16,844 inmates from a nationally representative survey and analyzed the data using cross-sectional regression. To capture the impact of prior authorization, we estimated 2 models: the first included an indicator variable for states requiring prior authorization, and a second model used per capita atypical usage. RESULTS: Evidence indicated that prior authorization restrictions on atypical antipsychotics are associated with an increase in the odds of a schizophrenic resident being imprisoned in a state. State-level prior authorization requirements for atypical antipsychotics are associated with a 2.7% increase in the likelihood that an imprisoned inmate displays psychotic symptoms, and a 1.25 increase in the likelihood that an inmate was previously diagnosed with schizophrenia by a physician. Higher state-level atypical prescriptions per capita are also associated with lower likelihood of psychotic symptoms and of prior schizophrenia diagnosis among prisoners. CONCLUSIONS: Prior authorization requirements for atypical antipsychotics, which are designed to reduce healthcare costs, are associated with greater prevalence of mental illness within the criminal justice system.This association raises important questions about whether increased costs to the criminal justice system might mitigate or offset prescription drug savings created by prior authorization requirements.

Systematic review of long-acting injectables versus oral atypical antipsychotics on hospitalization in schizophrenia.

OBJECTIVE: To assess the impact of long-acting injectables (LAIs) versus oral antipsychotics (OAs) on hospitalizations among patients with schizophrenia by conducting a systematic literature review of studies with different study designs and performing a meta-analysis. METHODS: Using the PubMed database and major psychiatric conference proceedings, a systematic literature review for January 2000 to July 2013 was performed to identify English-language studies evaluating schizophrenia patients treated with atypical antipsychotics. Studies reporting hospitalization rates as a percentage of patients hospitalized or as the number of hospitalizations per person per year were selected. The primary meta-analysis assessed the percentage decrease in hospitalization rates before and after treatment initiation for matched time periods. The secondary meta-analysis assessed the absolute rate of hospitalization during follow-up. Pooled treatment-effect estimates were calculated using random-effects models. To account for differences in patient and study-level characteristics between studies, meta-regression analyses were used. Subset analyses further explored the heterogeneity across study designs. RESULTS: Fifty-eight studies evaluating 25 arms (LAIs: 13 arms, 4516 patients; OAs: 12 arms, 23,516 patients) in the primary meta-analysis and 78 arms (LAIs: 12 arms, 4481 patients; OAs: 66 arms, 96,230 patients) in the secondary meta-analysis were identified. Reduction in hospitalization rates for LAIs was 20.7 percentage points higher than that of OAs (random-effects estimates: LAIs = 56.2% vs. OAs = 35.5%, P = 0.023). Controlling for patient and study characteristics, the adjusted percentage reduction in hospitalization rates for LAIs was 26.4 percentage points higher than for OAs (95% CI: 3.3-49.5, P = 0.027). As for the secondary meta-analysis, no significant difference between LAIs and OAs was observed (random-effects estimate: -8.6, 95% CI: -18.1-1.0, P = 0.077). Subset analyses across type of study yielded consistent results. Limitations of this analysis include the long observation period, which may not reflect current treatment patterns, the use of all-cause hospitalization, which may not be solely related to schizophrenia, and the fact that most studies in the LAI cohort evaluated risperidone. CONCLUSION: The primary results of this meta-analysis, including studies with both interventional and non-interventional designs and using meta-regressions, suggest that LAIs are associated with higher reductions in hospitalization rates for schizophrenia patients compared to OAs.

A Medicaid and commercial insured claims-based study to estimate improved antipsychotic medication adherence among patients with schizophrenia.

Compliance with antipsychotic medication is clinically important but challenging for schizophrenia patients. Clinical trials and epidemiological studies strongly suggest that improved compliance results in reduced hospitalizations and other adverse outcomes. Examination of Medicaid and commercial claim data suggests that a significant portion of schizophrenia patients have a regular pattern of visits with one outpatient professional, yet are noncompliant with their medication. For many of these patients, results show that the administration of once-monthly verifiable therapy would improve compliance.