Use and costs of ambulatory care services among Medicare enrollees with schizophrenia

Systematic review of racial disparities in clozapine prescribing

OBJECTIVE

To conduct a systematic review of published evidence on clozapine prescribing disparities across racial and ethnic categories, estimate the size of these disparities, and assess possible causes to inform future monitoring and intervention.

METHODS

Electronic databases (MEDLINE, Embase, PsycINFO, Web of Science) were searched for directly relevant studies. Three independent reviewers selected studies: (1) of US samples; (2) directly addressed ethnic and/or racial disparities in prescribing of antipsychotic medications; (3) identified specific ethnic and/or racial groups (e.g. White, Blacks, Hispanics, non-Hispanic etc.); (4) reported clozapine prescription rates and (5) reported relevant covariates (i.e. gender, age, co-morbidities etc.).

FINDINGS

16 studies met our eligibility criteria. All studies reported clozapine underutilization in ethnic and racial minority patients when compared to their white counterparts. These findings remained consistent despite different time periods, designs, data set types, and after controlling for relevant covariates such as: length of hospital stay, institutional setting, and disease severity.

CONCLUSION

The reasons for underutilization of clozapine in minority patients remain unclear. Various contributors can be categorized as: clinician-related factors (e.g. prescriber lack of experience), patient-related factors (e.g. distrust or suspicion of clinician), and institution-related factors (e.g. state operated facilities). Direct examination of these factors can help inform efforts to reduce clozapine prescription disparities.

Global economic burden of schizophrenia: a systematic review

BACKGROUND

Schizophrenia is one of the top 25 leading causes of disability worldwide in 2013. Despite its low prevalence, its health, social, and economic burden has been tremendous, not only for patients but also for families, caregivers, and the wider society. The magnitude of disease burden investigated in an economic burden study is an important source to policymakers in decision making. This study aims to systematically identify studies focusing on the economic burden of schizophrenia, describe the methods and data sources used, and summarize the findings of economic burden of schizophrenia.

METHODS

A systematic review was performed for economic burden studies in schizophrenia using four electronic databases (Medline, EMBASE, PsycINFO, and EconLit) from inception to August 31, 2014.

RESULTS

A total of 56 articles were included in this review. More than 80% of the studies were conducted in high-income countries. Most studies had undertaken a retrospective- and prevalence-based study design. The bottom-up approach was commonly employed to determine cost, while human capital method was used for indirect cost estimation. Database and literature were the most commonly used data sources in cost estimation in high-income countries, while chart review and interview were the main data sources in low and middle-income countries. Annual costs for the schizophrenia population in the country ranged from US$94 million to US$102 billion. Indirect costs contributed to 50%-85% of the total costs associated with schizophrenia. The economic burden of schizophrenia was estimated to range from 0.02% to 1.65% of the gross domestic product.

CONCLUSION

The enormous economic burden in schizophrenia is suggestive of the inadequate provision of health care services to these patients. An informed decision is achievable with the increasing recognition among public and policymakers that schizophrenia is burdensome. This results in better resource allocation and the development of policy-oriented research for this highly disabling yet under-recognized mental health disease.

Family intervention and health care costs for kansas medicaid patients with schizophrenia

Despite a number of studies investigating the effect of pharmacotherapy on treatment costs for schizophrenia patients, there has been little attention given to the effect of family intervention. In this study, data from the Kansas Medicaid system were used to analyze healthcare costs for 164 schizophrenia patients who had participated in family intervention. Structural equation modeling was used to test two competing views of the role of family intervention in treatment. The results showed that a model including direct and indirect effects of family intervention provided a better fit to the data. Family intervention had a significant indirect effect on general medical costs (through other psychological treatment) that showed a savings of $586 for each unit increase in the provision of these services. In addition, the total indirect effects for family intervention showed a $580 savings for general medical costs and $796 for hospitalization costs (for each unit increase).

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.

Individual versus family psychotherapy in managed care: comparing the costs of treatment by the mental health professions

In an effort to understand how psychotherapy is practiced in the "real world," outpatient claims data were examined to determine the cost of individual and family therapy provided by marital and family therapists, master's nurses, master's social workers, medical doctors, psychologists, or professional counselors. Claims for 490,000 unique persons over 4 years were obtained from CIGNA. Family therapy proved to be substantially more cost-effective than individual or "mixed" psychotherapy. Physicians provided care in the fewest sessions, marital and family therapists had the highest success (86.6%) and lowest recidivism rates (13.4%), and professional counselors were the least costly. Outcomes were overwhelmingly successful, with 85% of patients requiring only one episode of care.

Investigation of racial and ethnic disparities in service utilization among homeless adults with severe mental illnesses

OBJECTIVE

This study examined whether there are service disparities among homeless adults with severe mental illnesses, a vulnerable population with a high level of unmet need.

METHODS

Data were collected at baseline for 6,829 black, Latino, and non-Latino white participants in the Access to Community Care and Effective Services and Support study. Outcome variables were measures of utilization of psychiatric outpatient, housing, and case management services in the previous 60 days. The sample was divided into white-black and white-Latino cohorts. Within each cohort, participants were stratified into comparable groups by propensity scores that estimated log-odds of being black or Latino as a function of several confounding variables. White-black and white-Latino differences in mean number of visits (a measure of intensity) and in the mean probability of at least one visit (a measure of access) were subsequently estimated for each of the three services.

RESULTS

The composition of the sample was 50% black, 6% Latino, and 44% white. Service utilization was low for the three services regardless of race-ethnicity. On multivariate analyses of service utilization in the previous 60 days, blacks made fewer psychiatric outpatient visits than whites (mean difference=.46, 95% confidence interval [CI]=.10 to .81]), yet Latinos had more case management visits than whites (mean difference=-.51, CI=-1.03 to -.05]). Analyses of access did not reveal racial-ethnic disparities.

CONCLUSIONS

Whereas blacks used psychiatric outpatient services less frequently than whites, hence experiencing a service disparity, Latinos used case management services more than whites did. Possible contributors and clinical and methodological implications of these results are discussed.

Hepatitis C services and individuals with serious mental illness

Although individuals with serious mental illness have been shown to be at increased risk for hepatitis C viral (HCV) infection, there is growing concern regarding limited dissemination of recommended HCV related services to this population. This paper presents rates of receipt of HCV prevention services among a cohort of seriously mentally ill adults and reports rates of recommended follow-up care among the subset who tested HCV positive in a pilot study. Previous HCV screening was low and indicated medical follow-up among those who tested positive was also limited. Results stress the need for increased screening and counseling and delivery of preventive and follow-up medical services.

The role of treatment setting and high acuity in the overdiagnosis of schizophrenia in African Americans

Multiple studies have shown that significant disparities exist in the diagnosis of schizophrenia between African Americans (AAs) and Whites with severe mental illness. This phenomenon has been a topic in the literature for nearly three decades, yet it remains unclear what factors contribute most conclusively to the overdiagnosis of schizophrenia in AAs. The purpose of this article was to collectively examine the contributing factors identified in the literature and to discuss the role of acuity and treatment setting in overdiagnosis as well. A variety of client-level (higher rates of use of psychotomimetic substances in AAs) and care process-level (misinterpretation of cultural mistrust as paranoia, under detection of depression, similarities in diagnostic criteria between mood and psychotic disorders, provider bias, miscommunication between patient and provider, changes in diagnostic criteria, differences in diagnostic practice between providers, and a lack of sufficient data obtained) factors emerged as influential in overdiagnosis. However, in this review, it also emerged that AAs tendency to use emergency and acute care services, a systems level factor, could be related as well. It is possible that assessment at a time when symptom acuity is severe might increase the likelihood of a schizophrenia diagnosis in AAs.

Appendectomy for appendicitis in patients with schizophrenia

BACKGROUND

Anecdotal evidence suggests that schizophrenia patients who require surgery have a high rate of adverse outcomes. We searched the Department of Veterans Affairs national datasets to determine the clinical course of schizophrenia patients with appendicitis who underwent appendectomy.

METHODS

The Patient Treatment File (the nationwide inpatient database for the Department of Veterans Affairs) and the Beneficiary Identification and Records Location System were searched to identify all patients with International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes for schizophrenia or schizoaffective disorder diagnosed with appendicitis during fiscal years 1995 to 1999. Computer-based information was supplemented with chart-based data. We sought data on six common preoperative risk factors and 25 specific adverse outcomes, including death.

RESULTS

There were 55 patients identified. The mean age was 49, and 96% were men. The median time from symptom onset to diagnosis of appendicitis was 3 days. A history of substance abuse was obtained in 16 (29%). Disruptive behavior was documented in 16 (29%). Restraints were used in 9 (9%). The appendix was perforated in 36 (66%) and gangrenous in 9 (16%). Thirty-one (56%) had > or = 1 complication; there were 2 in-hospital deaths (4%).

CONCLUSIONS

This is the first report on this topic in the medical literature. Appendicitis is typically diagnosed late in schizophrenic patients. Adverse patient behaviors are frequent. The complication and death rates are high.

Diagnostic variability for schizophrenia and major depression in a large public mental health care system dataset

Administrative datasets can provide information about mental health treatment in real world settings; however, an important limitation in using these datasets is the uncertainty regarding psychiatric diagnosis. To better understand the psychiatric diagnoses, we investigated the diagnostic variability of schizophrenia and major depression in a large public mental health system. Using schizophrenia and major depression as the two comparison diagnoses, we compared the variability of diagnoses assigned to patients with one recorded diagnosis of schizophrenia or major depression. In addition, for both of these diagnoses, the diagnostic variability was compared across seven types of treatment settings. Statistical analyses were conducted using t tests for continuous data and chi-square tests for categorical data. We found that schizophrenia had greater diagnostic variability than major depression (31% vs. 43%). For both schizophrenia and major depression, variability was significantly higher in jail and the emergency psychiatric unit than in inpatient or outpatient settings. These findings demonstrate that the variability of psychiatric diagnoses recorded in the administrative dataset of a large public mental health system varies by diagnosis and by treatment setting. Further research is needed to clarify the relationship between psychiatric diagnosis, diagnostic variability and treatment setting.

Substance abuse and psychiatric disorders in HIV-positive patients: epidemiology and impact on antiretroviral therapy

There is a high prevalence of substance abuse and psychiatric disorders among HIV-infected individuals. Importantly, drug and alcohol-use disorders are frequently co-morbid with depression, anxiety and severe mental illness. Not only do these disorders increase the risk of contracting HIV, they have also been associated with decreased highly active antiretroviral therapy (HAART) utilisation, adherence and virological suppression. The literature evaluating the relationship between substance abuse and HIV outcomes has primarily focused on injection drug users, although there has been increasing interest in alcohol, cocaine and marijuana. Similarly, the mental health literature has focused largely on depression, with a lesser focus on severe mental illness or anxiety. To date, there is little literature evaluating the association between co-occurring HIV, substance abuse and mental illness on HAART uptake, adherence and virological suppression. Adherence interventions in these populations have demonstrated mixed efficacy. Both directly observed therapy and pharmacist-assisted interventions appear promising, as do integrated behavioural interventions. However, the current intervention literature has several limitations: few of these studies are randomised, controlled trials; the sample sizes have generally been small; and co-occurring substance abuse and mental illness has not specifically been targeted in these studies. Future studies examining individual substances of abuse, psychiatric disorders and co-occurring substance abuse and psychiatric disorders on HIV outcomes will inform targeted adherence interventions.

Determinants of health plan membership among patients in routine U.S. psychiatric practice

This study utilized a large clinical dataset of patients representative of those in routine U.S. psychiatric practice to assess the influence of sociodemographic variables and diagnostic class on health plan membership (public or private). Data on patients with schizophrenia or other psychotic disorders (n=288) and patients with mood or anxiety disorders (n=1304) were obtained from a cross-sectional practice-based survey conducted by the American Psychiatric Institute for Research and Education. The likelihood of health plan membership was lower among males and among those from a minority race/ethnicity. Health plan membership was also affected by educational attainment and employment status. Even after controlling for these sociodemographic determinants of health plan membership, individuals with schizophrenia/other psychotic disorders were significantly less likely to belong to a health plan than those with mood/anxiety disorders.

Cost-effectiveness of olanzapine as first-line treatment for schizophrenia: results from a randomized, open-label, 1-year trial

OBJECTIVES

This randomized, open-label trial was designed to help inform antipsychotic treatment policies. It compared the 1-year cost-effectiveness of initial treatment with olanzapine (OLZ) (n = 229) versus a "fail-first" algorithm on conventional antipsychotics (then olanzapine if indicated) (CON) (n = 214); and versus initial treatment with risperidone (RIS) (n = 221).

METHODS

Individuals with schizophrenia or schizoaffective disorder were recruited from May 1998 to September 2001. Clinical, functioning, and resource utilization data were collected at baseline and five postbaseline visits. Brief Psychiatric Rating Scale scores defined "clinical effectiveness;" Lehman Quality of Life Scale social relations scores defined "social effectiveness."

RESULTS

Requiring failure on less expensive antipsychotics before use of olanzapine did not result in total cost savings, despite significantly higher antipsychotic costs with OLZ. Total 1-year mean costs were 21,283 dollars for CON; 20,891 dollars for OLZ; and 21,347 dollars for RIS (pair-wise comparisons nonsignificant). Intent-to-treat effectiveness comparisons (nonsignificant) were augmented by analyses that adjusted for duration on initial antipsychotic treatment, and by comparisons of patients remaining on initial antipsychotic treatment versus those who required switching. When accounting for differential switching rates (OLZ 0.14 vs. CON 0.53, P < 0.0001; vs. RIS 0.31, P < 0.0001), OLZ was significantly more effective than CON on clinical (P = 0.025) and social (P = 0.043) measures, and significantly more effective than RIS on the social (P = 0.002) measure. Further, patients initiated on an antipsychotic from which they needed to switch required additional resources for hospitalization (P = 0.036) and crisis services (P = 0.029).

CONCLUSIONS

Approaches that integrate costs, effectiveness, and treatment patterns are important for providing optimal information regarding the value of first-line antipsychotic options for schizophrenia.

Hepatitis C virus and HIV co-infection in people with severe mental illness and substance use disorders

OBJECTIVES

The 5-7% of adults in the United States with severe mental illness (SMI), especially the 50% who are 'dually diagnosed' with co-occurring substance use disorders (SUD), are at an elevated risk of HIV and hepatitis C virus (HCV). However, little is known about HIV/HCV co-infection in this population. This paper examines the prevalence and correlates of HIV, hepatitis C, and HIV/HCV co-infection in a large, multisite sample of SMI clients.

DESIGN

We conducted a re-analysis of data on prevalence and correlates of blood-borne infections in a multisite sample of SMI clients.

METHODS

In 1997-1998, 755 SMI clients were tested for HIV, hepatitis B virus and HCV, and assessed for demographic, illness-related and other behavioral risk factors for blood-borne infections. The prevalence and correlates of co-infection were examined, as well as the knowledge, attitudes and risk behaviors of individuals with HCV mono-infection.

RESULTS

Of the 755 participants, 623 (82.5%) were negative for both HIV and HCV, 23 (3.0%) were positive for HIV, 109 (14.4%) were positive for HCV, and 13 (1.7%) were co-infected with HIV and HCV. Overall, 2.5% of dually diagnosed participants were co-infected, whereas only 0.6% of SMI participants without a comorbid SUD diagnosis were co-infected. Co-infection was associated with psychiatric illness severity, ongoing drug abuse, poverty, homelessness, incarceration, urban residence and minority status. HCV-mono-infected clients continued to engage in high levels of risk behavior for HIV.

CONCLUSION

In addition to efforts to identify and treat SMI patients with HIV/HCV co-infection, HCV-mono-infected clients should be targeted for prevention interventions.

Geographical variation in acute psychiatric admissions within New York City 1990-2000: growing inequalities in service use?

The paper analyses geographical variations in use of acute psychiatric inpatient services within New York City and how these have changed from 1990 to 2000. We review literature suggesting reasons for the variations observed. Data from the New York State Department of Health Statewide Planning Research and Cooperative System were combined with population census data to produce age standardized ratio indicators of admissions and of bed days, as measures of use of general hospitals for psychiatric conditions, by males aged 15-64, in Zip Code Areas of New York City, in 1990 and 2000. Geographical variations in hospital use were related to proximity to general hospitals with psychiatric beds and to socio-economic status of local populations (as recorded in the 1990 and 2000 population censuses). Areas close to psychiatric hospitals areas show high admission levels. Controlling for this, Zip Code Areas with higher concentrations of poverty, of African American residents or of persons living alone were associated with relatively high admission ratios. These relationships vary somewhat between diagnostic groups. Area inequalities in standardized admission ratios persisted and widened between 1990 and 2000, and the highest hospital admission ratios were increasingly concentrated where social and economic disadvantage was greatest. Various possible reasons for this trend are explored. We conclude that increasing intensity of poverty in disadvantaged areas is not likely to provide an explanation and that the trends are more likely to result from changes in hospital management and funding affecting access to hospital services.

Non-adherence to antipsychotic medication regimens: associations with resource use and costs

BACKGROUND

Several factors are thought to influence resource use and costs in treating schizophrenia.

AIMS

To assess the relative impact of non-adherence and other factors associated with resource use and costs incurred by people with schizophrenia.

METHOD

Secondary analyses were made of data from a 1994 national survey of psychiatric morbidity among adults living in institutions in the UK. Factors potentially relating to resource use and costs were examined using two-part models.

RESULTS

Patients who failed to adhere to their medication regimen were over one-and-a-half times as likely as patients who did adhere to it to report use of in-patient services. Non-adherence is one of the most significant factors in increasing external service costs, by a factor of almost 3. Non-adherence predicted an excess annual cost per patient of approximately 2500 British pounds for in-patient services and over 5000 British pounds for total service use.

CONCLUSIONS

Resource use and costs are influenced by various factors. Medication non-adherence consistently exhibits an association with higher costs. Further important factors are patient needs and the ability of the system to address them.

A longitudinal analysis of the impact of social and clinical characteristics on the costs of schizophrenia treatment

OBJECTIVE

The aim of the study was the longitudinal analysis of the influence of social and clinical factors on the mid-term costs of schizophrenia treatment.

METHOD

Treatment costs as well as clinical and social characteristics of 307 patients with the ICD-10 diagnosis of schizophrenia were assessed at five follow-ups over 2.5 years. Between and within effects of clinical and social characteristics on treatment costs were estimated by error component regression models.

RESULTS

Effects caused by differences between individuals were found for age, partnership, in-patient history, objective and subjective role functioning, life-events and psychotic relapse. Effects of idiosyncratic transitory changes of social and clinical characteristics were found for symptoms, psychotic relapse, and for social role-functioning.

CONCLUSION

Treatment costs can be reduced to a limited extent not only by the prevention of psychotic symptoms and relapse but also by the improvement of role-functioning capacities.

Olanzapine versus risperidone in the treatment of schizophrenia : a comparison of costs among Texas Medicaid recipients

OBJECTIVE

To examine both schizophrenia-related costs and total (schizophrenia plus non-schizophrenia) healthcare costs among Texas Medicaid recipients who had been diagnosed with a schizophrenic disorder and had been initiated on olanzapine or risperidone.

METHODS

Cost data for services and prescription use were retrieved for 2,885 patients with schizophrenia who were initiated on olanzapine or risperidone between 1 January 1997 and 31 August 1998. Each patient was followed for 1 year before and 1 year after initiation of therapy. Multivariate analysis was used to control for a wide range of factors (drug choice, patient demographics, pre-utilisation costs, region, health conditions, and treatment patterns) that may influence schizophrenia-related costs and total healthcare costs. Estimation was conducted via a two-stage instrumental variables model.

RESULTS

The mean unadjusted total schizophrenia-related cost per patient per year during the observation period was 4,892 US dollars, and the total unadjusted healthcare cost per patient was 7,101 US dollars. Results revealed significant regional variation in schizophrenia-related and total healthcare costs. Significantly higher total healthcare costs were found for patients with other (nonpsychiatric) diagnoses, such as HIV and diabetes mellitus. Although, on average, patients taking olanzapine stayed on therapy longer than those taking risperidone (248.2 days vs 211.1 days; p < 0.0001), multivariate analysis revealed no significant difference in schizophrenia-related costs between patients who received olanzapine and risperidone (123 US dollars lower with olanzapine; p = 0.6439). However, patients who received olanzapine compared with risperidone had significantly lower total medical costs (693 US dollars lower with olanzapine; p = 0.0311).

CONCLUSION

This naturalistic study used data from a Texas Medicaid population to examine the schizophrenia-related costs and total healthcare costs for patients who received olanzapine versus risperidone. Multivariate analysis revealed no significant differences in schizophrenia-related costs for patients receiving olanzapine compared with risperidone, although total medical costs were significantly lower for patients initiated on olanzapine.