Antipsychotic Adherence, Resource Use, and Costs Before and After the Initiation of Once-monthly Paliperidone Palmitate Therapy Among Medicaid Beneficiaries With Prior Schizophrenia Relapse

Real-world outcomes and practice patterns among patients with schizophrenia when switched from oral antipsychotics to long-acting injectable formulations after hospitalization

This study compared rehospitalization and practice patterns among patients with schizophrenia in the United States prescribed oral antipsychotics (OAs), alone or with long-acting injectable antipsychotics (LAIs) at hospital discharge. Data came from a hospital-based payer database from December 2019-June 2021. At discharge, 23,336 (84 %) patients were prescribed OAs and 4293 (16 %) were prescribed LAIs±OAs (first-generation LAIs±OAs, 2990/4293 [70 %]; second-generation LAIs±OAs, 1303/4293 [30 %]). The most prescribed OA and LAI±OA were risperidone (26 %) and haloperidol (37 %), respectively. Significantly greater proportions of patients were rehospitalized within 30, 60, or 90 days after discharge with OAs (11 %, 15 %, and 18 %, respectively) vs LAIs±OAs (8 %, 12 %, and 15 %; numbers needed to treat [NNTs], 37, 35, and 38), and with first-generation (9 %, 13 %, 16 %) vs second-generation (7 %, 10 %, 13 %) LAIs (p < 0.05 for all). Significantly greater proportions prescribed LAIs dosed once every 2 weeks vs monthly were rehospitalized within 60 days (15 % vs 11 %, respectively; NNT 33) and 90 days (18 % vs 14 %; NNT 26) (p < 0.05 for all). Prescriptions were based on clinical characteristics at discharge; those prescribed LAIs±OAs may have had less favorable prognoses. However, these results suggest that prescribing second-generation LAIs±OAs with less frequent dosing at discharge may lower rehospitalization risk for patients with schizophrenia.

Clinician differences in attitudes and perceptions on the use of long-acting injectable antipsychotic agents in treating patients with schizophrenia: results from the US DECIDE survey

BACKGROUND

Long-acting injectable antipsychotics (LAIs) reduce relapses in schizophrenia; however, most clinicians reserve LAIs for nonadherence with oral antipsychotics (OAs) or severe disease.

METHODS

US psychiatric clinicians were surveyed regarding their schizophrenia management practices and use of LAIs. Respondents were grouped by LAI use (high [≥ 31% of patients using LAIs], low [≤ 14% using LAIs]; mid not analyzed) and mindset based on their response to "Which of the following best fits the current way you view your use of [LAIs] for your patients with schizophrenia?"

RESULTS

Respondents (n = 380) were distributed across LAI use (106 high, 130 low) and mindset (123 early-use, 88 severity-reserved, 113 adherence-reserved, 56 LAI-hesitant) subgroups. Across subgroups, clinicians estimated that OA nonadherence was lower for patients in their practice (21-52%) than for patients nationwide (50-56%). Compared with other subgroups, greater proportions with high LAI use or an early-use mindset were confident in key aspects of LAI treatment like dosing, managing side effects, and access (67-74% high LAI use, 59-70% early-use vs. 11-57% other subgroups; P < .05 each), agreed it was "worth [their] time to resolve issues with the insurance company" (42%, 45% vs. 16-30%; P < .05 each), and were optimistic they would be able to do so (23%, 20% vs. 2-11%; P < .05 each). Clinicians with high LAI use estimated the proportion of patients who initially accept LAIs to be higher (mean, 56%) than clinicians with low LAI use (45%, P < .01); there were no differences among mindsets (49-54%). Clinicians with high LAI use or early-use mindset were more likely to "use any means necessary to ensure that a patient is on an LAI" than clinicians in other subgroups (44% high LAI use, 51% early-use vs. 5-22% other subgroups; P < .01 each) or had used guardianship to assist with treatment (70%, 69% vs. 32-56%; P < .05 each).

CONCLUSIONS

These results indicate that multiple factors (e.g., environmental/demographic factors, access, attitudes, motivation, knowledge/confidence) combine to influence LAI use, and highlight the need to tailor educational materials aimed at improving patient outcomes through increased LAI use.

Clinical, Quality of Life, and Health Care Utilization Outcomes of Switching the Administration Route of Antipsychotic Medications Among People With Schizophrenia Spectrum Disorder: A Systematic Review and Meta-Analysis

BACKGROUND

Using long-acting injectable (LAI) antipsychotic medications can improve the outcomes of patients with schizophrenia, such as reducing symptom severity and hospitalization risk. However, the outcomes of switching from oral to LAI antipsychotic medications are unclear.

AIMS

The purpose of this review is to provide a summary of the clinical, quality of life, and health care utilization outcomes of switching from oral to LAI antipsychotics among patients with Schizophrenia Spectrum Disorder.

METHODS

We thoroughly searched the PubMed, Scopus, PsycInfo, and CINAHL databases. To conduct the meta-analysis, we used the Comprehensive Meta-Analysis Program.

RESULTS

Forty-one articles met our inclusion criteria. After switching to LAIs, symptom severity, the number of rehospitalizations, emergency department visits, and overall health care costs were reduced. Also, social functioning significantly improved. However, no differences were observed in the frequency of outpatient visits. Pharmacy costs were increased between pre- and post-LAI initiation.

CONCLUSION

Our findings support evidence that changing the route of administration of antipsychotic medications from oral to long-acting intramuscular injections can improve the clinical, quality of life, and health care utilization outcomes in people with schizophrenia. Health care practitioners might consider encouraging LAI use earlier during treatment for schizophrenia for better clinical outcomes and to reduce health care utilization associated with treatment.

Preferences for Selecting and Initiating Long-Acting Injectable Antipsychotic Agents for the Treatment of Patients With Schizophrenia: Results From the US DECIDE Survey

Background

Long-acting injectable antipsychotics (LAIs) improve adherence and reduce schizophrenia relapse rates. Data on which LAI attributes drive clinician preference are limited.

Methods

In the DECIDE survey, 380 psychiatric clinicians (psychiatrists, psychiatric nurse practitioners, and physician assistants) were surveyed regarding preferences when selecting and initiating LAIs for patients with schizophrenia. Responses were analyzed by clinician use of LAIs (high [≥ 31% of their patients using LAIs] or low [≤ 14% of their patients using LAIs]) and mindset toward LAI use (early, severity reserved, adherence reserved, and LAI hesitant).

Results

Overall and across subgroups, side effects were the most important consideration when selecting a particular LAI, with 33% of clinicians ranking this as most important (26%-46% across subgroups). Clinician preference for the molecule was most often ranked least important (47% overall; 39%-59% across subgroups). A significantly higher proportion of clinicians with high vs low LAI use ranked product attributes as the most important consideration (26% vs 13%; P < .01). Across subgroups, multiple injection site options, small/on par needle, and price made at least two-thirds of clinicians somewhat/much more likely to use a particular LAI, and 63%-82% of clinicians reported being somewhat/much more likely to select an LAI dosed once monthly or less often vs 6%-11% being somewhat/much more likely to select an LAI dosed once every 2 weeks.

Conclusions

Overall, results from DECIDE provide insight into the decision-making process of psychiatric clinicians when selecting an LAI and highlight opportunities to help clinicians deliver optimal care for patients with schizophrenia.

Budget impact of introducing once-every-6-months paliperidone palmitate in US health care plans

BACKGROUND: In the United States, most patients with schizophrenia have Medicaid coverage. Antipsychotic treatments are the cornerstone of schizophrenia management; most patients are treated with daily oral antipsychotics but struggle with medication adherence. Evidence suggests that medication adherence is inversely correlated with dosing frequency. Once-monthly paliperidone palmitate (PP) has been demonstrated to improve adherence compared with oral antipsychotics; transitioning to once-every-3-months PP (PP3M) further improved adherence. In 2021, once-every-6-months PP (PP6M) was approved by the US Food and Drug Administration to provide even longer between-dose intervals. Public health stakeholders who aim to improve medication adherence are interested in understanding how introducing PP6M to the formulary will impact the budget. OBJECTIVE: To evaluate the budget impact of introducing PP6M to the formulary from the perspectives of a hypothetical US multistate health care payer and state Medicaid programs using California, Georgia, and Ohio as examples. METHODS: The budget impact model was developed from a payer perspective, comparing the reference scenario (without PP6M in the market) with a new scenario (with PP6M). The study population included patients with schizophrenia who were eligible to receive PP6M. Market shares were assigned to the reference and new market scenarios. Efficacy was measured by the relative risk of relapse while receiving treatment. Adherence effects were included in the model and affected costs of treatment and relapse rates. A deterministic 1-way sensitivity analysis was performed. RESULTS: Base-case results for a multistate payer with 1 million members demonstrate that adding PP6M to the market results in total incremental plan-level costs ranging from $7,747 in year 1 to $11,501 in year 5. Increased drug costs were offset by administration and relapse cost savings ($105 and $881 in year 5, respectively). The average incremental cost per treated patient per year was stable at $180.06 for each year, and the incremental cost per member per month stayed below $0.01 for each year. The results of the model from the state-level Medicaid scenarios are broadly similar to those of the multistate base-case perspective. The 1-way sensitivity analysis demonstrated the model is most sensitive to the per-package costs of PP6M and PP3M, along with the proportion of patients fully adherent with PP3M. CONCLUSIONS: The budget impact of introducing PP6M as a treatment option is minimal. With the expected cost offsets from reduced administration and relapse costs due to adherence benefits, these results suggest that PP6M can be a viable treatment option from a clinical and a budgetary perspective. DISCLOSURES: This study was funded by Janssen Scientific Affairs, LLC. The study sponsor provided funds to Xcenda and ApotheCom for medical writing, editorial support, and submission of the manuscript. Hilary Phelps was an employee of Janssen Global Services, LLC, at the time of the development and finalization of the manuscript. Alex Keenan is an employee of Janssen Global Services, LLC, and holds stock in Johnson & Johnson, Inc. Dee Lin and Carmela Benson are employees of Janssen Scientific Affairs, LLC, and hold stock in Johnson & Johnson, Inc. Aditya Raju was an employee of Xcenda at the time of the development and finalization of the manuscript, and Danmeng Huang is an employee of Xcenda, a health care consulting firm that was contracted by Janssen Scientific Affairs, LLC. Chih-Yuan Cheng is an employee of Janssen NV.

The Effect of Longer Dosing Intervals for Long-Acting Injectable Antipsychotics on Outcomes in Schizophrenia

Medication nonadherence in schizophrenia can have serious implications including relapses and hospitalization. Long-acting injectable (LAI) antipsychotics require fewer administrations, while ensuring sustained medication coverage. In this review, we summarize the expected real-world benefits of longer dosing intervals in the management of schizophrenia. LAIs are associated with improved clinical outcomes of less frequent relapses and reduced functional impairment, encouraging patients to regain control of their lives. Aripiprazole lauroxil and paliperidone palmitate three-monthly (PP3M) LAIs have longer dosing intervals of 2-3 months and provide improved outcomes in patients with schizophrenia. Paliperidone palmitate six-monthly (PP6M) LAI provides the longest dosing interval, twice-yearly dosing, among existing LAIs. Decreasing the frequency of LAI administrations has the potential to reduce occurrence of serious outcomes associated with poor medication adherence. By eliminating the need for daily oral antipsychotic dosing, LAIs could increase the likelihood of patient acceptance, decrease stigma, and promote self-esteem. Longer intervals of medication coverage may be desirable for patients with higher risk of relapse including adults with recent-onset schizophrenia, those living in circumstances that may deprive them of regular access (eg, homeless), those that are in transitions between care settings or to reduce interpersonal contact during public health emergencies (eg, COVID-19 pandemic).

Systematic review of community pharmacist administration of long-acting injectable antipsychotic medications

BACKGROUND

Long-acting injectable antipsychotic (LAIA) medications offer an effective treatment option for patients with serious mental illness. Despite demonstrated clinical safety and efficacy as well as increased adherence and less frequent administration compared with daily oral regimens, LAIAs remain underutilized in clinical practice. With legislation allowing pharmacists to administer injectable medications in 48 U.S. states, community pharmacies are uniquely positioned to serve as an access point for patients with serious mental illnesses to receive LAIA injections.

OBJECTIVE

This study aimed to conduct a systematic review of the health and economic benefits and costs of community pharmacist administration of LAIA medications.

METHODS

A systematic search of the literature published from January 1996 to April 2022 was conducted across 3 databases (Embase, PubMed, and Scopus Plus). Publications describing pharmacist administration of LAIA medications in outpatient settings were included. Publications that examined the use of LAIAs but did not involve a pharmacist administering the medication were excluded.

RESULTS

Of 2261 publications reviewed, we identified 8 publications (4 articles and 4 abstracts) that met our inclusion criteria, of which only 7 included results. Four studies reported high medication adherence achieved by patients receiving pharmacist-administered LAIAs. Two publications surveyed patient satisfaction with pharmacist administration of LAIAs in community pharmacy settings. One study found pharmacists' mixed attitudes regarding LAIA administration and time and safety barriers to offering the service.

CONCLUSION

We found very little evidence on the impact of pharmacist administration of LAIAs on patient outcomes. This review highlights the need to generate greater evidence on the health and economic benefits as well as financial models for pharmacists to administer LAIA medications in outpatient and community pharmacy settings. Such evidence could support more community pharmacists to offer LAIA medications and contribute to the shift toward value-based care.

National and regional description of healthcare measures among adult Medicaid beneficiaries with schizophrenia within the United States

AIMS

Provide the first national description across the US of variations in healthcare measures in 2018 among Medicaid beneficiaries with schizophrenia.

MATERIALS AND METHODS

Adult beneficiaries with ≥2 diagnoses for schizophrenia, and continuous enrollment with consistent geographical data in all of 2018 were identified from Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF) data for 45 of 50 states. Antipsychotic (AP) utilization rates, including long-acting injectable APs (LAIs), quality metrics, and all-cause healthcare resource utilization and costs for claims submitted to Medicaid were reported nationally and by state. Pearson correlation evaluated associations between LAI utilization and total healthcare costs at state and county levels.

RESULTS

Across the US 688,437 patients with schizophrenia were identified. The AP utilization rate was 51% (state range: 24-77%), while the LAI utilization rate was 13% (range: 4-26%). The proportion of patients adherent to any AP was 56% (range: 19-73%). Within 30 days post-discharge from an inpatient admission, 22% (range: 8-58%) of patients had an outpatient visit, and 12% (range: 4-48%) had a readmission. The proportion of patients with ≥1 inpatient admission and ≥1 emergency room visit was 34% (range: 19-82%) and 45% (range: 20-70%). Per-patient-per-year total healthcare costs averaged $32,920 (range: $717-$93,972). At the county level, a weak negative correlation was observed between LAI utilization and total healthcare costs.

LIMITATIONS

This study included Medicaid beneficiaries enrolled with pharmacy and medical benefits, including beneficiaries dually eligible for Medicare; results cannot be generalized to the overall schizophrenia population or those with other payer coverage.

CONCLUSIONS

In 2018, half of beneficiaries with schizophrenia did not submit any claims for APs to Medicaid, nearly half had an emergency room visit, and one-third had an inpatient admission. Moreover, healthcare measures varied considerably across states. These findings may indicate unmet treatment needs for Medicaid beneficiaries with schizophrenia.

Effectiveness and Quality of Life with Paliperidone Palmitate 3-Monthly in Comparison with Other Long-Acting Drugs

PURPOSE

Antipsychotic long-acting injections (AP-LAIs) are indicated for patients affected by schizophrenia especially those with poor treatment adherence.

PATIENTS AND METHODS

To compare paliperidone palmitate 3-monthly (PP3M), paliperidone palmitate one-monthly (PP1M) and haloperidol decanoate (HAL-D) treatment, we enrolled 90 patients with schizophrenia treated in Mental Health Center with one of the three AP-LAIs for at least six months and followed them for another 6 months. At 6 and 12 months of treatment we administered Clinical Global Impression-Severity, Global Assessment of Functioning and World Health Organization Quality of Life-26 items (WHOQOL-BREF). At 1-year treatment, we evaluated relapses (psychiatric hospitalizations and urgent consultations), side effects and drop-outs.

RESULTS

We did not highlight any statistically significant difference among the three treatments in relapses and scale scores. Weight increase was significantly higher in PP1M and PP3M groups. Twelve patients (13.3%) discontinued AP-LAI. At 1-year AP-LAI treatment, 69% of patients rated quality of life as "good" or "very good" and 71% declared themselves to be "satisfied" or "very satisfied".

CONCLUSION

HAL-D, PP1M and PP3M 1-year treatments were similarly effective in preventing relapses and improving quality of life and health satisfaction. All discontinuations in the new 3-monthly antipsychotic treatment were caused by patient refusal to continue it.

Real-World Evidence of the Clinical and Economic Impact of Long-Acting Injectable Versus Oral Antipsychotics Among Patients with Schizophrenia in the United States: A Systematic Review and Meta-Analysis

BACKGROUND

Long-acting injectable (LAI) antipsychotics, compared with oral antipsychotics (OA), have been found to significantly improve patient outcomes, including reduced hospitalizations and emergency room (ER) admissions and increased medication adherence among adult patients with schizophrenia. In turn, the clinical benefits achieved may translate into lower economic burden. Real-world evidence of the comparative effectiveness of LAI is needed to understand the potential benefits of LAI outside of the context of clinical trials. This study aimed to provide a comprehensive synthesis of recent published real-world studies comparing healthcare utilization, costs, and adherence between patients with schizophrenia treated with LAI versus OA in the United States.

METHODS

In this systematic literature review, MEDLINE^® was searched for peer-reviewed, real-world studies (i.e., retrospective or pragmatic designs) published in English between January 1, 2010 and February 10, 2020. Comparative studies reporting hospitalizations, ER admissions, healthcare costs, or medication adherence (measured by proportion of days covered [PDC]) in adults with schizophrenia treated with LAI versus OA (or pre- vs post-LAI initiation) in the United States were retained. Random effects meta-analyses were conducted among eligible studies to evaluate the association of LAI versus OA use on hospitalizations, ER admissions, healthcare costs, and treatment adherence. A sensitivity analysis among the subset of studies that compared OA with paliperidone palmitate once monthly (PP1M), specifically, was conducted.

RESULTS

A total of 1083 articles were identified by the electronic literature search, and two publications were manually added subsequently. Among the 57 publications meeting the inclusion criteria, 25 provided sufficient information for inclusion in the meta-analyses. Compared with patients treated with OA, patients initiated on LAI had lower odds of hospitalization (odds ratio [OR] 0.62, 95% confidence interval [CI] 0.54-0.71, n = 7), fewer hospitalizations (incidence rate ratio [IRR] [95% CI] 0.75 [0.65-0.88], n = 9), and fewer ER admissions (IRR [95% CI] 0.86 [0.77-0.97], n = 6). The initiation of LAI was associated with higher per-patient-per-year (PPPY) pharmacy costs (mean difference [MD] [95% CI] $5603 [3799-7407], n = 6), which was offset by lower PPPY medical costs (MD [95% CI] - $5404 [- 7745 to - 3064], n = 6), resulting in no significant net difference in PPPY total all-cause healthcare costs between patients treated with LAI and those treated with OA (MD [95% CI] $327 [- 1565 to 2219], n = 7). Patients initiated on LAI also had higher odds of being adherent to their medication (PDC ≥ 80%; OR [95% CI] 1.89 [1.52-2.35], n = 9). A sensitivity analysis on a subset of publications evaluating PP1M found results similar to those of the main analysis conducted at the LAI class level.

CONCLUSIONS

Based on multiple studies with varying sub-types of patient populations with schizophrenia in the United States published in the last decade, this meta-analysis demonstrated that LAI antipsychotics were associated with improved medication adherence and significant clinical benefit such as reduced hospitalizations and ER admissions compared with OA. The lower medical costs offset the higher pharmacy costs, resulting in a non-significant difference in total healthcare costs. Taken together, these findings provide strong evidence on the clinical and economic benefits of LAI compared with OA for the treatment of schizophrenia in the real world.