Retrospective analysis of long-term adherence to and persistence with DPP-4 inhibitors in US adults with type 2 diabetes mellitus

Introduction

Patients with type 2 diabetes mellitus (T2DM) must remain adherent and persistent on antidiabetic medications to optimize clinical benefits. This analysis compared adherence and persistence among adults initiating dipeptidyl peptidase-4 inhibitors (DPP-4is), sulfonylureas (SUs), and thiazolidinediones (TZDs) and between patients initiating saxagliptin or sitagliptin, two DPP-4is.

Methods

This retrospective cohort study utilized the US MarketScan^® (Truven Health Analytics, Ann Arbor, MI, USA) Commercial and Medicare Supplemental health insurance claims databases. Adults aged ≥18 years with T2DM who initiated a DPP-4i, SU, or TZD from January 1, 2009 to January 31, 2012 were included. Patients must have been continuously enrolled for ≥1 year prior to and ≥1 year following initiation. Adherence was measured using proportion of days covered (PDC), with PDC ≥ 0.80 considered adherent. Persistence was measured as time to discontinuation, defined as last day with drug prior to a 60+ days gap in therapy. Multivariable logistic regression and Cox proportional hazards models compared the outcomes between cohorts, controlling for baseline differences.

Results

The sample included 238,372 patients (61,399 DPP-4i, 134,961 SU, 42,012 TZD). During 1-year follow-up, 47.3% of DPP-4i initiators, 41.2% of SU initiators, and 36.7% of TZD initiators were adherent. Adjusted odds of adherence were significantly greater among DPP-4i initiators than SU (adjusted odds ratio [AOR] = 1.678, P < 0.001) and TZD initiators (AOR = 1.605, P < 0.001). During 1-year follow-up, 55.0% of DPP-4i initiators, 47.8% of SU initiators, and 42.9% of TZD initiators did not discontinue therapy. Adjusted hazards of discontinuation were significantly greater for SU (adjusted hazard ratio [AHR] = 1.390, P < 0.001) and TZD initiators (AHR = 1.402, P < 0.001) compared with DPP-4i initiators. Saxagliptin initiators had significantly better adherence (AOR = 1.213, P < 0.001) compared with sitagliptin initiators, and sitagliptin initiators had significantly greater hazard of discontinuation (AHR = 1.159, P < 0.001). Results were similar over a 2-year follow-up.

Conclusions

US adults with T2DM who initiated DPP-4i therapy, particularly saxagliptin, had significantly better adherence and persistence compared with patients who initiated SUs or TZDs.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-014-0171-3) contains supplementary material, which is available to authorized users.

A review of real-world data on the effects of aripiprazole on weight and metabolic outcomes in adults

BACKGROUND

Metabolic abnormalities observed with atypical antipsychotic treatment may be specific to each antipsychotic medication. The association between atypical antipsychotics and risk factors for cardiovascular disease prompted the American Diabetes Association (ADA) and the American Psychiatric Association (APA) to issue a consensus statement that categorized aripiprazole and ziprasidone as atypical antipsychotics with a lower likelihood of metabolic abnormalities.

OBJECTIVE

The aim of the current systematic review was to evaluate real-world studies (i.e. observational/naturalistic and open-label studies) assessing the risk for weight gain, dyslipidemia, glucose abnormalities, and diabetes mellitus in adult patients receiving treatment with atypical antipsychotics, with a specific focus on aripiprazole.

METHODS

A systematic PubMed search for articles published between 1 January 2000 and 4 October 2011 was performed using the following search terms in the title and abstract: aripiprazole, atypical, glucose, insulin, cholesterol, triglycerides, diabetes, hemoglobin A1c, weight, body mass index, and hyperlipidemia.

RESULTS

Twenty-two peer-reviewed articles were found that assessed the metabolic effects associated with aripiprazole treatment, including studies from small observational trials to large databases (n = 15 to n > 1,700,000). Thirteen articles reported observational or naturalistic studies, and nine were open-label trials evaluating weight gain, dyslipidemia, glucose abnormalities, and the risk of developing diabetes in adult patients receiving treatment with aripiprazole. Compared with other atypical antipsychotics, aripiprazole was either less likely to have an impact or had a comparable impact on weight gain and dyslipidemia; the degree of effect appeared to be dependent on study design. In addition, there was less risk of diabetes mellitus with aripiprazole compared with most other atypical antipsychotic agents.

CONCLUSIONS

Consistent with data from randomized controlled studies, the current review of observational/naturalistic and open-label studies suggests aripiprazole may be associated with a lower risk than other commonly used atypical antipsychotics for metabolic adverse events in adults, consistent with the ADA/APA consensus statement.

Formulary restrictions on atypical antipsychotics: impact on costs for patients with schizophrenia and bipolar disorder in Medicaid

OBJECTIVES

To measure the impact of state Medicaid formulary policies on costs for patients with schizophrenia and bipolar disorder.

STUDY DESIGN

Retrospective analysis of medical and pharmacy claims for patients diagnosed with schizophrenia or bipolar disorder in 24 state Medicaid programs.

METHODS

We combined information on formulary restrictions in Medicaid with the medical and pharmacy claims of 117,908 patients with schizophrenia and 170,596 patients with bipolar disorder in Medicaid who were single-eligible, and newly prescribed a second-generation antipsychotic from 2001 to 2008. We tested the impact of formulary restrictions on the medical costs and utilization of patients in the 12 months after the index prescription. To capture social costs in addition to medical expenditures in Medicaid, we estimated the incremental costs of incarcerating patients with schizophrenia and bipolar disorder associated with formulary restrictions.

RESULTS

Patients with schizophrenia subject to formulary restrictions were more likely to be hospitalized (odds ratio 1.13, P <.001), had 23% higher inpatient costs (P <.001), and 16% higher total costs (P <.001). Similar effects were observed for patients with bipolar disorder. Our estimates suggest restrictive formulary policies in Medicaid increased the number of prisoners by 9920 and incarceration costs by $362 million nationwide in 2008.

CONCLUSIONS

Applying formulary restrictions to atypical antipsychotics is associated with higher total medical expenditures for patients with schizophrenia and bipolar disorder in Medicaid. Combined with the other social costs such as an increase in incarceration rates, these formulary restrictions could increase state costs by $1 billion annually, enough to offset any savings in pharmacy costs.

Incidence of cardiovascular outcomes and diabetes mellitus among users of second-generation antipsychotics

OBJECTIVE

To examine the risk of cardiovascular outcomes and diabetes mellitus in patients prescribed second-generation antipsychotics.

METHOD

From the MarketScan claims database, nondiabetic adults prescribed aripiprazole between July 2003 and March 2010 were propensity score-matched with patients prescribed olanzapine, quetiapine, risperidone, and ziprasidone. Patients were followed through the claims for International Classification of Diseases, Ninth Revision codes indicating myocardial infarction, stroke, heart failure, coronary bypass/angioplasty procedures, and incident diabetes. Incidence rates of each outcome were calculated and compared between aripiprazole and the other second-generation antipsychotics using Cox models.

RESULTS

Aripiprazole initiators were matched 1:1 to 9,917 olanzapine, 14,935 quetiapine, 10,192 risperidone, and 5,696 ziprasidone initiators. Increased risk was found with olanzapine for stroke (hazard ratio = 1.43; 95% confidence interval, 1.05-1.95) and any cardiovascular event (1.28; 1.05-1.55); with quetiapine for stroke (1.58; 1.19-2.09), heart failure (1.55; 1.15-2.11), and any cardiovascular event (1.50; 1.25-1.79); and with risperidone for stroke (1.54; 1.12-2.12), heart failure (1.43; 1.02-1.99), and any cardiovascular event (1.49; 1.21-1.83). Ziprasidone showed no significant difference in risk from aripiprazole for any outcome. Incidence of diabetes ranged from 18 to 21 events per 1,000 person-years in each cohort and did not differ significantly between second-generation drugs.

CONCLUSIONS

This analysis of real-world data found lower risk of some cardiovascular events with aripiprazole than with olanzapine, quetiapine, or risperidone, but no differences were found with ziprasidone. There were no significant differences in risk of diabetes. Limitations include use of claims data and inability to adequately control for differential prescribing of second-generation antipsychotics to patients at higher risk of diabetes.

Medical costs and hospitalizations among patients with depression treated with adjunctive atypical antipsychotic therapy: an analysis of health insurance claims data

BACKGROUND

Depression is frequently debilitating. The American Psychiatric Association recommends adjunctive atypical antipsychotics as a treatment option when response to antidepressants is inadequate.

OBJECTIVE

To compare medical costs and hospitalizations among patients with depression treated with adjunctive aripiprazole, olanzapine, or quetiapine.

METHODS

This retrospective analysis used medical and pharmacy claims data and enrollment information from a large US health plan. Patients were adult members of a commercial health plan who were diagnosed with depression (ie, ICD-9-CM 296.2x, 296.3x, or 311) and who received an antidepressant with adjunctive atypical antipsychotic therapy (aripiprazole, olanzapine, or quetiapine) between January 1, 2004, and January 31, 2010. Patients were continuously enrolled for 6-month pre- and 12-month postaugmentation periods. Those with schizophrenia or bipolar disorder were excluded. Postaugmentation outcomes were total and mental health-related medical costs and hospitalizations. Costs and hospitalizations were modeled with generalized linear models (ie, gamma distribution, log link) and logistic regression, respectively. Regressions controlled for dose, demographics, and general and medical health-related health status.

RESULTS

A total of 10,292 patients were identified across atypical antipsychotic cohorts: 3849 used aripiprazole, 1033 used olanzapine, and 5410 used quetiapine. Mean (SD) age was 44.1 (11.6) years and 70.3% were female. Compared with patients in the aripiprazole cohort, those in the olanzapine cohort had higher total medical costs (cost ratio [CR] 1.22, 95% CI 1.07-1.39) and higher mental health-related medical costs (CR 1.33, 95% CI 1.11-1.59), as well as higher odds of any (total) hospitalization (OR 1.58, 95% CI 1.30-1.92) and any mental health-related hospitalization (OR 1.81, 95% CI 1.38-2.38). Similarly, the quetiapine cohort had higher total medical costs (CR 1.27, 95% CI 1.16-1.39) and higher mental health-related medical costs (CR 1.23, 95% CI 1.09-1.39), as well as higher odds of any (total) hospitalization (OR 1.65, 95% CI 1.44-1.90) and any mental health-related hospitalizations (OR 1.78, 95% CI 1.45-2.18), compared with the aripiprazole cohort.

CONCLUSIONS

Compared with adjunctive olanzapine or quetiapine, adjunctive aripiprazole was associated with lower mean total and mental health-related medical costs and with lower odds of total and mental health-related hospitalizations in patients with depression.

Medical costs and utilization in patients with depression treated with adjunctive atypical antipsychotic therapy

Objective

To compare total medical costs and utilization over a 12-month period in commercially insured patients receiving FDA-approved adjunctive atypical antipsychotics (aripiprazole, olanzapine, or quetiapine) for depression.

Methods

A retrospective claims analysis was conducted from 2005–2010 using the PharMetrics database. Subjects were adult commercial health-plan members with depression, identified using International Classification of Diseases codes and followed for 12 months after augmentation with an atypical antipsychotic. Outcomes included total medical costs, hospitalization, and ER visits. Generalized linear models and logistic regression were used to compare the total medical costs and the odds of hospitalization and ER visits between the treatment groups after adjusting for baseline demographic and clinical characteristics.

Results

A total of 9675 patients with depression were included in the analysis, of which 68.4% were female, with a mean age of 45.2 (±12.0) years. Adjusted 12-month total medical costs were higher for olanzapine ($14,275) and quetiapine ($12,998) compared to aripiprazole ($9,801; P < 0.05 for all comparisons with aripiprazole). When divided into inpatient and outpatient costs, olanzapine and quetiapine had significantly higher adjusted inpatient costs compared to aripiprazole ($6,124 and $4,538 vs $2,976, respectively; P < 0.05 for all comparisons with aripiprazole). Similar results were seen for adjusted outpatient costs. Adjusted odds of hospitalization for olanzapine (odds ratio [OR] = 1.73; 95% CI confidence interval [CI] = 1.42–2.10) and quetiapine (OR = 1.40; 95% CI = 1.21–1.60) were significantly higher than aripiprazole at 12 months. The adjusted odds of an ER visit for olanzapine (OR = 1.40; 95% CI = 1.18–1.65) and quetiapine (OR = 1.62; 95% CI = 1.44–1.81) were also significantly higher compared to aripiprazole at 12 months.

Conclusions

In commercially insured major depressive disorder patients, olanzapine and quetiapine were associated with higher total medical costs, the difference being primarily attributable to higher inpatient costs. Additionally, olanzapine and quetiapine were associated with significantly higher odds of hospitalization and ER visits compared to aripiprazole.

Clinical Outcomes in Measurement-based Treatment (Comet): a trial of depression monitoring and feedback to primary care physicians

BACKGROUND

Despite the availability of effective treatments for depression, many patients under the care of primary care physicians do not achieve remission. Clinical Outcomes in Measurement-based Treatment (COMET) was designed to assess whether communicating patient-reported depression symptom severity to primary care physicians affects patient outcomes at 6 months.

METHODS

Nine hundred fifteen patients (intervention: n = 503; control: n = 412) diagnosed with major depressive disorder were enrolled in a prospective trial in which physician practice sites were assigned to either the intervention or control study arm. Only patients who were prescribed an antidepressant by their physician were eligible, but medication type was independent of the study protocol. Intervention-arm physicians received monthly updates on their patients' depression severity, which was determined with the nine-item Patient Health Questionnaire (PHQ-9) administered during telephone interviews. Remission was defined as a PHQ-9 score <5 at 6 months; response was defined as a score reduction ≥50%.

RESULTS

Among patients with baseline PHQ-9 score ≥5, 45.0% achieved remission (46.7% intervention versus 42.8% control) and 63.9% responded (67.0% intervention versus 59.7% control) at 6 months. After adjusting for baseline demographic and clinical variables, odds of remission (odds ratio [OR], 1.59 [95% CI, 1.07-2.37]) or response (OR, 2.02 [95% CI, 1.36-3.02]) were significantly greater for the intervention group than for control patients.

CONCLUSIONS

This study demonstrated that regular patient symptom monitoring with feedback to physicians improved outcomes of depression treatment in the primary care setting. Determining reasons for the high observed nonremission rates requires further investigation.

Medical care costs and hospitalization in patients with bipolar disorder treated with atypical antipsychotics

BACKGROUND

A large proportion of costs associated with the treatment of bipolar disorder are attributable to patient hospitalization.

OBJECTIVE

To investigate medical care costs and hospitalization rates among patients with bipolar disorder who were managed with aripiprazole compared with olanzapine, quetiapine, risperidone, or ziprasidone.

METHODS

This retrospective cohort study assessed patients who were aged 18 to 64 years, diagnosed with bipolar disorder, and who were receiving therapy with aripiprazole, olanzapine, quetiapine, risperidone, or ziprasidone. This study was based on data from the PharMetrics claims database between January 1, 2003, and September 30, 2008. The study used a time-to-event framework. Cox proportional hazards models were used to assess the impact of each atypical antipsychotic on time to hospitalization, including all-cause and mental health-related reasons. Generalized linear models were used to compare costs per treated patient per month between the groups. Aripiprazole therapy was the reference group for all comparisons.

RESULTS

Aripiprazole therapy showed a significantly lower hazard ratio (HR) for all-cause hospitalizations compared with olanzapine (HR, 1.4), quetiapine (HR, 1.4), risperidone (HR, 1.2), and ziprasidone (HR, 1.7); and for mental health-related hospitalizations compared with olanzapine, quetiapine, risperidone (HR, 1.3 each), and ziprasidone (HR, 1.7). Ziprasidone had higher unadjusted all-cause medical costs (US $1151 ± $2928) and unadjusted mental health-related costs (US $711 ± $2263) than the other antipsychotics that were included in this study, whereas aripiprazole had the lowest all-cause (US $804 ± $2523) and mental health-related costs (US $475 ± $2145) compared with the other antipsychotics. Quetiapine had the highest all-cause costs (US $1221; 95% confidence interval [CI], 1180-1263), and ziprasidone had the highest mental health-related costs (US $823; 95% CI, 754-898). Adjusted inpatient and emergency department all-cause costs were significantly lower for aripiprazole compared with all other atypical antipsychotics (P <.05), except olanzapine; however, the adjusted inpatient and emergency department mental health-related costs were significantly lower for aripiprazole only when compared with ziprasidone (P <.05).

CONCLUSIONS

The costs of medical care for patients with bipolar disorder differ based on the type of medication used, which can affect the rate of hospitalization. Treatment with aripiprazole was associated with fewer hospitalizations, longer time to hospitalization, and therefore the lowest all-cause and mental health-related medical costs compared with olanzapine, quetiapine, risperidone, or ziprasidone. Therefore, aripiprazole may offer an economic advantage over other atypical antipsychotics in patients with bipolar disorder.

Comparison of health-related quality of life among patients using atypical antipsychotics for treatment of depression: results from the National Health and Wellness Survey

Background

Use of atypical antipsychotics (AA) in combination with an antidepressant is recommended as an augmentation strategy for patients with depression. However, there is a paucity of data comparing aripiprazole and other AAs in terms of patient reported outcomes. Therefore, the objective of this study was to examine the levels of HRQoL and health utility scores in patients with depression using aripiprazole compared with patients using olanzapine, quetiapine, risperidone and ziprasidone.

Methods

Data were obtained from the 2009, 2010, and 2011 National Health and Wellness Survey (NHWS), a cross-sectional, internet-based survey that is representative of the adult US population. Only those patients who reported being diagnosed with depression and taking an antidepressant and an atypical antipsychotic for depression were included. Patients taking an atypical antipsychotic for less than 2 months or who reported being diagnosed with bipolar disorder or schizophrenia were excluded. Patients taking aripiprazole were compared with patients taking other atypical antipsychotics. Health-related quality of life (HRQoL) and health utilities were assessed using the Short Form 12-item (SF-12) health survey. Differences between groups were analyzed using General Linear Models (GLM) controlling for demographic and health characteristics.

Results

Overall sample size was 426 with 59.9% taking aripiprazole (n = 255) and 40.1% (n = 171) taking another atypical antipsychotic (olanzapine (n = 19), quetiapine (n = 127), risperidone (n = 14) or ziprasidone (n = 11)). Of the SF-12 domains, mean mental component summary (MCS) score (p = .018), bodily pain (p = .047), general health (p = .009) and emotional role limitations (p = .009) were found to be significantly higher in aripiprazole users indicating better HRQoL compared to other atypical antipsychotics. After controlling for demographic and health characteristics, patients taking aripiprazole reported significantly higher mean mental SF-12 component summary (34.10 vs. 31.43, p = .018), bodily pain (55.19 vs. 49.05, p = .047), general health (50.05 vs. 43.07, p = .009), emotional role limitations (49.44 vs. 41.83, p = .009), and SF-6D utility scores (0.59 vs. 0.56, p = .042).

Conclusions

Comparison of patients taking aripiprazole with a cohort of patients using another AA for depression demonstrated that aripiprazole was independently associated with better (both statistically and clinically) HRQoL and health utilities.

Trends in combination antipsychotic use among persons with commercial insurance: a data snapshot

In this data snapshot, the IMS PharMetrics Database was examined to assess the prevalence of combination antipsychotic therapy for the years 2003 through 2009 among 122,349 commercially insured adult individuals with bipolar disorder, depression, or schizophrenia. Although all three diagnostic groups were associated with varying amounts of combination antipsychotic use that included aripiprazole, olanzapine, quetiapine, risperidone and ziprasidone, persons with schizophrenia exhibited the highest rates. These findings indicate that from the perspective of "practice-based evidence," providers see value in combination therapy.

Effect of communicating depression severity on physician prescribing patterns: findings from the Clinical Outcomes in MEasurement-based Treatment (COMET) trial

OBJECTIVE

In this secondary analysis from the Clinical Outcomes in MEasurement-based Treatment trial (COMET), we evaluated whether providing primary care physicians with patient-reported feedback regarding depression severity affected pharmacological treatment patterns.

METHOD

Intervention-arm physicians received their patients' 9-item Patient Health Questionnaire scores monthly. Odds of having no change in antidepressant treatment during the 6-month study period were calculated. Relationships between depression symptom status (partial or nonresponse) at month 3 and treatment changes in months 3 through 6 were assessed.

RESULTS

Among 503 intervention and 412 usual care (UC) patients with major depressive disorder, most received antidepressant monotherapy at baseline (79.4% UC vs. 88.4% intervention; P=.047). Few switched their baseline antidepressant (17.4%), increased their dose (12.4%) or augmented with a second medication (2%). Odds of having no change in antidepressant therapy did not differ significantly between study arms (odds ratio 1.21; 95% confidence interval 0.78-1.88; P=.392). Few month 3 partial or nonresponders had a regimen change over the following 3 months; the study arms did not differ significantly (partial responders: 4.1% UC vs. 7.7% intervention; P=.429; nonresponders: 14.6% UC vs. 15.9% intervention; P=.888).

CONCLUSIONS

Among depressed patients treated in primary care, little active management was observed. The lack of treatment modification for the majority of partial and nonresponders was notable.

Intent-to-treat analysis of health care expenditures of patients treated with atypical antipsychotics as adjunctive therapy in depression

OBJECTIVE

To compare health care utilization and expenditures in patients with depression whose initial antidepressant (AD) treatment was augmented with a second-generation antipsychotic.

METHODS

Claims data from January 1, 2001, through June 30, 2009, were used to select patients aged 18 to 64 years with depression treated with ADs augmented with aripiprazole, olanzapine, or quetiapine. Patients were required to have 6 months of continuous eligibility before the first AD prescription and 6 months after the second-generation antipsychotic augmentation (index) date. Utilization and expenditures were assessed for 6 months after the index date. Multivariate regression was used to estimate adjusted expenditures and risks for hospitalizations and emergency department visits.

RESULTS

A total of 483 patients treated with aripiprazole, 978 with olanzapine, and 2471 with quetiapine were selected. Mean adjusted expenditures for aripiprazole were significantly lower than those for olanzapine for each service category (all-cause, all-cause medical care, mental health-related, and mental health-related medical care) and were significantly lower than those for quetiapine for each category with the exception of mental health-related. The adjusted risks for hospitalization and emergency department visits were significantly higher for quetiapine than for aripiprazole.

CONCLUSIONS

Compared with patients treated with ADs and aripiprazole, those treated with ADs and olanzapine or quetiapine had greater utilization and higher expenditures.

Impact of ACE inhibitors on mortality and morbidity in patients with AMI: Does tissue selectivity matter?

OBJECTIVE

To examine the impact of tissue selectivity of angiotensin-converting enzyme (ACE) inhibitors on mortality and morbidity in patients following acute myocardial infarction (AMI).

METHODS

A retrospective cohort study using a Medicaid claims database was conducted. Patients hospitalized for an AMI and subsequently filling a prescription for an ACE inhibitor were followed longitudinally for the occurrence of cardiovascular-related hospitalizations and all-cause mortality. A subanalysis was also conducted to account for switching/discontinuation of ACE inhibitor therapy. Stepwise (forward conditional) Cox-proportional hazards models were used to analyze the effect of tissue selectivity on study outcomes.

RESULTS

The final study sample consisted of 689 AMI and the results indicated that tissue-selective ACE inhibitors had a protective effect against hospitalization due to stroke/transient ischemic attack (TIA) (hazard ratio [HR] = 0.265; 95% confidence interval [CI] = 0.101-0.698). A similar lower rate in hospitalizations due to heart failure was observed in the group using tissue-selective ACE inhibitors; however, the results were not statistically significant (HR = 0.681; 95% CI = 0.436-1.063). A protective effect was also observed on the combined outcome of hospitalization due to any cardiovascular condition (HR = 0.712; 95% CI = 0.536-0.945). Hospitalizations due to recurrent AMI, need for coronary revascularization procedures, and mortality were not significantly different between patients using tissue-selective and non-tissue-selective ACE inhibitors. The completer subanalysis provided similar findings regarding the impact of tissue selectivity on study outcomes.

CONCLUSION

Tissue-selective ACE inhibitors may have a protective effect against hospitalization due to stroke/TIA or heart failure when compared to non-tissue-selective ACE inhibitors for patients following AMI.

The impact of an immunization training certificate program on the perceived knowledge, skills and attitudes of pharmacy students toward pharmacy-based immunizations

Objective

To assess the impact of a national immunization training certificate program on the perceived knowledge, skills and attitudes of pharmacy students toward pharmacy-based immunizations.

Methods

The study design utilized a pre- and post-survey administered to pharmacy students before and after the American Pharmacists Association’s (APhA) Pharmacy-Based Immunization Delivery program. The primary outcome explored was a change in the perceived knowledge, skills, and attitudes of the pharmacy students. A five-point Likert scale (i.e. strongly agree = 5, strongly disagree = 1) was used for measuring the main outcomes, which was summated by adding the individual item scores in each section to form a composite score for each outcome.

Results

The certificate training program resulted in a significant improvement in knowledge (38.5% increase in score, p<0.001) and skills (34.5% increase in score, p<0.001), but not attitudes (1% increase in score, p=0.210).

Conclusions

The national immunization training certificate program had a positive impact on the perceived knowledge and skills of pharmacy students. However, no change was observed regarding students’ perceived attitudes toward pharmacy-based immunizations.

Impact of Visual Impairment on Health-Related Quality of Life in Multiple Sclerosis

The aim of this study was to evaluate the impact of visual impairment on health-related quality of life (HRQOL) in patients with multiple sclerosis (MS). Patients at an outpatient MS clinic were asked to complete a battery of patient-reported outcome questionnaires. Health-related quality of life was measured using the Hamburg Quality of Life Questionnaire for Multiple Sclerosis (HAQUAMS), while visual impairment was measured using the Visual Function Questionnaire (VFQ). Hierarchical regression was used to determine the relative contribution of visual impairment to HRQOL. Usable responses were obtained for 116 MS patients. Those with higher levels of visual impairment (lower scores on the VFQ) reported significantly lower HRQOL (β = –0.01, P = .0007). Visual impairment also explained an additional 4% variance in the HRQOL scores, independent of disability and depression (ΔR2 = 0.04, F7,108 = 36.58). Overall, disability was the strongest predictor of HRQOL, explaining over 60% of the variation in HRQOL scores. The model explained 70% of the total variance in HRQOL. Given the prevalence of visual impairment and its influence on overall HRQOL, MS patients should be routinely screened using standard ophthalmic examination procedures or self-administered questionnaires such as the VFQ.

My First Patient Program to introduce first-year pharmacy students to health promotion and disease prevention

OBJECTIVES

To implement and assess the effectiveness of a program to teach pharmacy students the importance of taking personal responsibility for their health.

DESIGN

The My First Patient Program was created and lectures were incorporated into an existing first-year course to introduce the concepts of health beliefs, behavior modification, stress management, substance abuse, and nutrition. Each student received a comprehensive health screening and health risk assessment which they used to develop a personal health portfolio and identify strategies to attain and/or maintain their personal health goals.

ASSESSMENT

Student learning was assessed through written assignments and student reflections, follow-up surveys, and course evaluations. Students' attainment of health goals and their ability to identify their personal health status illustrated the positive impact of the program.

CONCLUSION

This program serves as a model for colleges and schools of pharmacy and for other health professions in the instruction of health promotion, disease prevention, and behavior modification.

Economic effect of augmentation strategies in patients with type 2 diabetes initiated on sulfonylureas

This study aimed to assess the economic effect of adding either a thiazolidinedione (TZD) or metformin to the initial sulfonylurea therapy in patients with type 2 diabetes. Researchers identified patients newly diagnosed with type 2 diabetes who initiated therapy with a sulfonylurea during a four-year period from a Medicaid claims database. They then followed these patients after physicians added either a TZD or metformin to the regimen and assessed type 2 diabetes-related costs in the 12-month follow-up period. Multivariate results indicated that patients augmented with metformin incurred 33.3% lower total diabetes-related costs, compared with those augmented with a TZD (P < .001). The study results can aid in making formulary decisions and developing treatment algorithms for step-wise management of type 2 diabetes.

Economic impact of cardiovascular co-morbidity in patients with type 2 diabetes

OBJECTIVES

To evaluate the impact of cardiovascular co-morbidity on total and diabetes-related healthcare costs in patients with type 2 diabetes.

METHODS

Retrospective analysis of the West Virginia state Medicaid claims data was conducted in patients with type 2 diabetes (ICD-9 codes: 250.0x-250.9x, where x=0 or 2) in the year 2001. Patients > or =65 years of age or those with managed care coverage were excluded. Presence of cardiovascular co-morbidity in the year 2001 was identified. Semi-logarithmic regression models were used to estimate the impact of cardiovascular co-morbidity on total and diabetes-related healthcare costs in the year 2002.Two-part models were used to study the impact of cardiovascular co-morbidity on ER/hospitalization, outpatient, and prescription costs. Smearing estimates were used to interpret the results from the semi-logarithmic models.

RESULTS

Presence of cardiovascular co-morbidity had a significant impact on all categories of total and diabetes-related healthcare costs, except diabetes-related prescription drug costs. Type 2 diabetes patients with cardiovascular co-morbidity had significantly higher total healthcare costs (38.9%, $12,550 vs. $9031), total ER/hospitalization costs (239.8%, $4845 vs. $1426), total outpatient costs (35.3%, $3956 vs. $2925), and total prescription drug costs (15.1%, $4686 vs. $4071) compared to those without cardiovascular co-morbidity. Similarly, type 2 diabetes patients with cardiovascular co-morbidity had significantly higher total diabetes-related healthcare costs (59.7%, $4349 vs. $2724), ER/hospitalization costs (346.8%, $1911 vs. $428), and outpatient costs (17.4%, $740 vs. $631) compared to patients without cardiovascular co-morbidity.

CONCLUSIONS

Presence of cardiovascular co-morbidity in patients with type 2 diabetes had a significant impact on total and diabetes-related healthcare costs.

Utilization and costs for compliant patients initiating therapy with pioglitazone or rosiglitazone versus insulin in a Medicaid fee-for-service population

OBJECTIVE

To compare health care utilization and costs for type 2 diabetes patients initiating therapy with one of two thiazolidinediones (TZDs, pioglitazone or rosiglitazone) or insulin in a Medicaid population.

METHODS

The study used a retrospective cohort design and included type 2 diabetes patients who initiated therapy with TZDs or insulin treatment during the 3-year period (1999-2001). These patients were identified from a Medicaid administrative claims database for approximately 230,000 fee-for-service Medicaid recipients using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes: 250.0x-250.9x, where x = 0 or 2). The first pharmacy claim for a TZD or insulin was treated as an index pharmacy claim, and utilization and costs were assessed for each patient for a 12-month follow-up period after the index date of the first pharmacy claim. A 12-month preperiod without a pharmacy claim for a TZD or insulin confirmed that the patient was newly prescribed with these medications. Analysis was restricted to a compliant sample receiving at least 6 pharmacy claims for either TZD or insulin in the 12-month follow-up period. The propensity matching technique was used to control for selection bias and potential imbalances between these groups at baseline. Patients initiating therapy with insulin or TZD were matched on the basis of demographics, year of index pharmacy claim, presence of microvascular/macrovascular complications, comorbidity, type 2 diabetes-related medical utilization and costs in the 12-month preperiod, overall health care utilization and costs in the preperiod, and type of oral hypoglycemic agents/other medications in the preperiod. Nonparametric bootstrapping was used to estimate the impact of therapy on both overall and type 2 diabetes-related health care utilization and costs in the matched sample.

RESULTS

A total of 2,842 patients with type 2 diabetes patients met the inclusion criteria prior to exclusion of 881 patients (31.0%) who did not receive at least 6 pharmacy claims for either TZD or insulin in the 12 months following the index pharmacy claim, leaving 1,961 type 2 diabetes patients who initiated therapy with one of the two TZDs or insulin in the 3-year enrollment period (TZDs = 1,523; insulin = 438). Propensity matching eliminated 1,271 patients (64.8%), resulting in a final sample consisting of 690 patients.345 patients per treatment group.with comparable demographic and utilization parameters at baseline. In the 12-month follow-up period for the measures of overall utilization, patients initiated on TZDs did not differ significantly in the number of emergency room (ER)/hospitalization episodes and the number of pharmacy claims compared with the patients initiated on insulin, but they did have an average of 1.2 fewer physician office visits (9.3 vs. 10.5, P <0.05). Compared with the insulin group, the TZD group incurred 35% lower costs for ER visits/hospitalization (dollar 3,727 vs. dollar 5,793, P <0.01) and 18% lower total health care costs (dollar 12,737 vs. dollar 15,563, P <0.05). No significant differences were observed between the groups in overall outpatient and pharmacy costs. When the analysis was restricted to type 2 diabetes-related utilization and costs, patients initiating therapy with TZDs had 0.8 fewer physician office visits (3.6 vs. 4.4, P <0.05). However, TZD patients had 2.7 (14.1%) more diabetes pharmacy claims than patients initiating therapy with insulin (P <0.01), but there was no difference in the number of type 2 diabetes-related ER visits/hospitalizations between the groups. The TZD group had 53% higher type 2 diabetes-related pharmacy costs than the insulin group (dollar 1,678 vs. dollar 1,096, P <0.01). However, these costs were offset by lower costs for ER visits and hospitalization for the TZD group as compared with the insulin group (dollar 2,855 vs. dollar 5.090, P <0.01) resulting in 25% lower total type 2 diabetes-related costs for the TZD group compared with the insulin group (dollar 5,425 vs. dollar 7,255, P <0.05).

CONCLUSION

Medicaid fee-for-service patients initiated on either pioglitazone or rosiglitazone incurred higher diabetes-related pharmacy costs, which were offset by lower total type 2 diabetes-related medical costs, contributed primarily by lower costs for ER visits and hospitalizations in this 12-month analysis.

Stage of change and smoking cessation outcomes among adolescents

This study examined the association between stage of change and smoking cessation outcomes among youth receiving two interventions of varying intensity: a 10-min brief self-help smoking cessation intervention (BI) or the American Lung Association's 10-week, Not-on-Tobacco (N-O-T) smoking cessation program. At baseline, the participants were classified into three stages (e.g., precontemplation, contemplation, and preparation) based on their intention to change their smoking behavior. Smoking behavior, stage of change, self-efficacy, and beliefs about smoking were assessed at baseline and 3 months postbaseline. Results demonstrated that the relationship between stage of change and cessation outcomes varied by treatment intensity. Logistic regression analyses revealed that BI participants in the preparation stage were 25 times more likely to quit smoking at postbaseline than were participants in the contemplation or precontemplation stages. In contrast, N-O-T was effective for youth regardless of baseline stage. Additionally, N-O-T participants demonstrated greater forward stage movement from baseline to postbaseline than did BI participants.

Exploring the Relationship Between Mental Health and Smoking Cessation: A Study of Rural Teens

This study examined the association between mental health and smoking cessation among rural youth. Participants were 113 male and 145 female adolescents ages 14-19 from rural West Virginia and North Carolina. Participants were enrolled in the American Lung Association's 10-week Not On Tobacco (N-O-T) program or a 15-min single-dose brief intervention. Baseline and postprogram measures were completed on smoking status (i.e., quit, reduction), nicotine dependence, smoking history, and depression and anxiety. Results showed that more N-O-T participants quit and reduced smoking than did brief intervention participants. Intervention group, baseline smoking rate, and the Group x Gender, Group x Anxiety, and Group x Depression interactions were significant predictors of change in smoking behavior from baseline to postprogram. In conclusion, more N-O-T participants demonstrated favorable changes in smoking than did brief intervention participants. Approximately 1/3 of youth exhibited mental health pathology; more females than males. Levels of depression and anxiety improved from baseline to postprogram, overall. Although the extent of the impact of mental health on cessation outcomes was inconclusive, findings suggest that rural youth who smoke may be at risk for pathological depression and anxiety. Future cessation programming with rural youth should consider the inclusion of coping and stress management skills and mental health referral protocols as significant program components.

Adolescent nicotine dependence and smoking cessation outcomes

The purpose of the present study was to examine adolescent nicotine dependence and its impact on smoking cessation outcomes with two treatments of varying intensity: a brief, self-help intervention and an intensive, multisession, school-based cessation curriculum called Not On Tobacco (N-O-T). A majority (80%) of adolescent smokers in this study were moderately to highly nicotine-dependent, using the Fagerstrom Tolerance Questionnaire. Further, nicotine dependence was positively correlated with duration of smoking and number of cigarettes smoked daily (P<.05). Data showed that the more cigarettes teens smoked daily and the longer they had smoked, the more dependent they were. Some teens (20%), however, had low nicotine dependence despite years of smoking and high smoking rates. Results showed that the relationship between nicotine dependence and cessation outcomes varied by treatment intensity. The brief intervention was successful with only low-dependent smokers, whereas the intensive, multisession, N-O-T intervention was effective with smokers possessing a range of nicotine dependence, including high-dependent smokers.

Recruitment barriers and successes of the American Lung Association's Not-On-Tobacco Program

This paper explores recruitment barriers and successes with research involving Not-On-Tobacco, the American Lung Association's (ALA) teen smoking cessation program. Forty-six program facilitators across four N-O-T studies completed a questionnaire to assess recruitment methods used, effectiveness of chosen methods, and recruitment barriers. Facilitators reported the most effective recruitment methods were "one-on-one conversation with students" (53.3%) and interpersonal contact where students received lollipops and information about N-O-T (33.3%; "lick-the-habit table"). The most frequently reported barriers to recruitment were "students not interested" (60.9%) and "active parental consent" (28.3%). The greatest barrier to obtaining active parental consent, as reported by facilitators, was "students did not want to tell parents they smoked" (78.3%). Findings suggest that recruitment presented a challenge to N-O-T research partners, including investigators, ALA staff, and program facilitators. However, recruitment was effective when active recruitment techniques such as maximized interpersonal contact involving one-on-one conversation were used.

A 2-year efficacy study of Not On Tobacco in Florida: an overview of program successes in changing teen smoking behavior

BACKGROUND

Adolescent smoking has been an issue of major concern in the United States. This has led to a need for the development, evaluation, and dissemination of effective youth cessation programs. The purpose of this paper is to report the results of a 2-year demonstration study (1999-2000) of the American Lung Association's teen smoking cessation program, the Not On Tobacco (NOT) program.

METHODS

The study used a "matched" design wherein each NOT school was matched to a brief intervention (BI) school. The study consisted of 20 NOT and 20 BI Florida high schools encompassing 627 students. The primary outcome measures were carbon monoxide-validated quit and reduction rates for NOT and BI schools at 5.2 months postprogram.

RESULTS

NOT smoking cessation and reduction outcomes were significantly better than those of the brief intervention. Further, data indicate that NOT was more effective than the brief intervention for females compared with males; males showed successful quit attempts in both intervention groups. Overall, more NOT youth either quit or reduced smoking than did BI youth.

CONCLUSIONS

These positive smoking behavior changes suggest that NOT is an effective teen smoking cessation option.