Patterns of care and costs of switching oral antipsychotic medications in patients with schizophrenia initiating monotherapy treatment: A US claims analysis

BACKGROUND

Antipsychotic medications are the mainstay of schizophrenia therapy but may need to be changed over the course of a patient's illness to achieve the desired therapeutic goals or minimize medication side effects. Investigations of real-world treatment patterns and economic consequences associated with antipsychotic changes, including switching, are limited.

OBJECTIVE

To describe treatment patterns among patients with schizophrenia who initiated oral antipsychotic medication (OAM) monotherapy and assess switching-related health care resource utilization (HCRU) and costs in US Medicare Advantage and commercially insured patients.

METHODS

Adults with at least 2 claims with a schizophrenia diagnosis who initiated (or reinitiated after ≥6 months) OAM monotherapy between January 1, 2015, and June 30, 2021, were identified in the Optum Research Database. A claims-based algorithm using timing of therapies and treatment gaps identified medication changes, specifically OAM monotherapy switches, among OAM initiators over a period of up to 7 years. Patients who switched from their initial OAM monotherapy to a second OAM monotherapy (initial OAM switchers) were matched based on clinical and demographic characteristics to OAM initiators who had not switched OAMs; switch-related HCRU and costs (incurred up to 3 months before and 3 months after the initial OAM switch) were compared between matched initial OAM switchers and nonswitchers.

RESULTS

Among 6,425 OAM monotherapy initiators, 1,505 (23.4%) had at least 1 OAM monotherapy switch at any time during follow-up, with a mean (SD) time to first switch of 209 (333) days (median, 67 days), a rate of 0.65 switches per person-year of follow-up, and 56% of first switches occurring within 3 months of OAM initiation. Of all OAM initiators, 947 (14.7%) were initial OAM switchers. Compared with 865 matched nonswitchers, 865 initial OAM switchers had greater mean counts of all-cause medical visits and greater mean counts of schizophrenia-related emergency and inpatient visits and longer inpatient stays per patient per month. Mean (SD) total schizophrenia-related costs per patient per month were $1,252 ($2,602) for switchers compared with $402 ($2,027) for nonswitchers (P < 0.001).

CONCLUSIONS

Changes to antipsychotic therapy in our sample of patients with schizophrenia were common, with nearly one-fourth switching OAMs, the majority within the first 3 months of therapy. Initial OAM switchers experienced greater HCRU and costs than nonswitchers. These findings highlight the importance of initiating OAM monotherapy that effectively maintains symptom control and minimizes tolerability issues, which would limit the need to switch OAMs and therefore prevent excess HCRU and treatment costs.

One-Year Medication Treatment Patterns, Healthcare Resource Utilization, and Expenditures for Medicaid Patients with Schizophrenia Starting Oral Atypical Antipsychotic Medication

Oral atypical antipsychotic (OAAP) medications are the most commonly prescribed treatment for the management of schizophrenia symptoms. This retrospective study, using Medicaid claims data (2016-2020), followed patients for 12 months after initiating OAAP therapy. Study outcomes included OAAP adherence, switching, augmentation, healthcare resource utilization (HRU), and expenditures. All-cause and schizophrenia-related HRU and expenditures were compared between adherent and nonadherent cohorts. Among 13,007 included patients (39.1 ± 12.8 years of age, 57.0% male, 36.1% Black, 31.8% White, 9.7% Hispanic), 25.7% were adherent to OAAPs (proportion of days covered [PDC] ≥ 0.8). During the 1-year follow-up period, Black individuals were in possession of an OAAP for an average of 166 days compared to 198 and 202 days for White and Hispanic patients, respectively. Approximately 16% of patients switched OAAP medications and 3.2% augmented therapy with an OAAP added to their index medication. Nearly 40% of patients were hospitalized during follow-up and 68.4% had emergency department (ED) visits. A greater proportion of nonadherent patients had all-cause inpatient (41.7% vs. 34.1%, p < 0.001) and ED visits (71.7% vs. 58.8%, p < 0.001) compared to adherent patients. Annual total healthcare expenditures were $21,020 per patient; $3481 higher for adherent versus nonadherent patients. Inpatient expenditures comprised 44.6% and 30.6% of total expenditures for nonadherent and adherent patients, respectively. Hospitalized patients' total expenditures were $23,261 higher compared to those without a hospitalization. Adherence to OAAP medication is suboptimal and associated with increased utilization of costly hospital and ED resources. Efforts to improve therapies and increase medication adherence could improve clinical and economic outcomes among individuals with schizophrenia.

A systematic review of the real-world effectiveness and economic and humanistic outcomes of selected oral antipsychotics among patients with schizophrenia in the United States: Updating the evidence and gaps

BACKGROUND

Schizophrenia is a chronic, relapsing, and burdensome psychiatric disorder affecting approximately 0.25%-0.6% of the US population. Oral antipsychotic treatment (OAT) remains the cornerstone for managing schizophrenia. However, nonadherence and high treatment failure lead to increased disease burden and medical spending. Cost-effective management of schizophrenia requires understanding the value of current therapies to facilitate better planning of management policies while addressing unmet needs.

OBJECTIVE

To review existing evidence and gaps regarding real-world effectiveness and economic and humanistic outcomes of OATs, including asenapine, brexpiprazole, cariprazine, iloperidone, lumateperone, lurasidone, olanzapine/samidorphan, paliperidone, and quetiapine.

METHODS

We conducted a literature search using PubMed, American Psychological Association PsycINFO (EBSCOhost), and the Cumulative Index of Nursing and Allied Health Literature from January 2010 to March 2022 as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. English-language articles describing adults with schizophrenia receiving at least 1 of the selected OATs and reporting real-world effectiveness, direct or indirect costs, humanistic outcomes, behavioral outcomes, adherence/persistence patterns, or product switching were identified.

RESULTS

We identified 25 studies from a total of 24,190 articles. Real-world effectiveness, cost, and adherence/persistence outcomes were reported for most OATs that were selected. Humanistic outcomes and product switching were reported only for lurasidone. Behavioral outcomes (eg, interpersonal relations and suicide ideation) were not reported for any OAT. The key economic outcomes across studies were incremental cost-effectiveness ratios, cost per quality-adjusted life-years, and health care costs. In studies that compared long-acting injectables (LAIs) with OATs, LAIs had a higher pharmacy and lower medical costs, while total health care cost was similar between LAIs and OATs. Indirect costs associated with presenteeism, absenteeism, or work productivity were not reported for any of the selected OATs. Overall, patients had poor adherence to OATs, ranging between 20% and 61% across studies. Product switching did not impact the all-cause health care costs before and after treatment.

CONCLUSIONS

Our findings showed considerable gaps exist for evidence on behavioral outcomes, humanistic outcomes, medication switching, and adherence/persistence across OATs. Our findings also suggest an unmet need regarding treatment nonadherence and lack of persistence among patients receiving OATs. We identified a need for research addressing OATs' behavioral and humanistic outcomes and evaluating the impact of product switching in adults with schizophrenia in the United States, which could assist clinicians in promoting patient-centered care and help payers understand the total value of new antipsychotic drugs.

Association Between Persistence with Oral Atypical Antipsychotic Medications and Hospital and Emergency Department Utilization in Medicaid Patients with Schizophrenia

Purpose

To examine 1-year persistence with oral atypical antipsychotics (OAAPs) for Medicaid patients with schizophrenia and assess the association between OAAP persistence and hospital and emergency department (ED) resource utilization.

Patients and Methods

Using 2016-2020 multi-state Medicaid claims data, this retrospective study followed patients diagnosed with schizophrenia for 12 months after initiating OAAP therapy. Patients started on an OAAP with no evidence of antipsychotic use in the previous 6 months were included if they had a diagnosis of schizophrenia, were not dually enrolled in Medicaid and Medicare, did not switch to a long-acting injectable antipsychotic, and were continuously eligible 6 months before and 12 months after the initial OAAP prescription (index date). OAAP persistence was measured allowing for a <60-day gap. All-cause and schizophrenia-related inpatient and emergency department (ED) resource utilization during the follow-up period were compared between OAAP persistent and non-persistent groups.

Results

The study sample of 13,007 had an average age of 39.1 years and 57.0% were male. Patients were persistent with their index OAAP for 135 days on average and 73.1% had a ≥60-day gap in antipsychotic therapy post-index. While 32.8% and 28.6% of patients who did not persist with their index OAAP restarted the index OAAP or switched to a different OAAP medication later in the year, respectively, a larger proportion (38.6%) had no further OAAP prescriptions. After adjustment for demographic and clinical variables, compared to non-persistent patients, persisting with OAAPs was significantly associated with fewer all-cause and schizophrenia-related hospitalizations (Incidence Rate Ratio [IRR]=0.742, p<0.001; IRR=0.823, p<0.001; respectively) and ED visits (IRR=0.759, p<0.001; IRR=0.773, p<0.001; respectively).

Conclusion

Non-persistence with OAAP medication is common among patients with schizophrenia and associated with negative outcomes including increased utilization of hospital and ED resources. Patient-centered interventions that improve antipsychotic persistence should be implemented to facilitate optimal outcomes in this population.

A Comprehensive Review of Methods to Measure Oral Oncolytic Dose Intensity Using Retrospective Data

BACKGROUND

Understanding the real-world use of oral oncolytics is essential to assess drug effectiveness. Retrospective analyses using medical and pharmacy claims data allow observation of drug use patterns and health outcomes. However, studies of medication adherence to oral oncolytics may not be sufficient in characterizing exposure because they typically measure refill frequency, not the administered dose or dose changes. Patients who appear fully adherent by traditional measures may be receiving different doses and experiencing differing effectiveness. Relative dose intensity (RDI) is a measure that has been used for intravenous drugs to capture the amount of a particular chemotherapeutic agent administered per unit of time (dose intensity), expressed as the fraction of the amount recommended in evidence-based guidelines. Such a measure would be useful for real-world studies of comparative effectiveness to characterize patient exposure to oral oncolytics.

OBJECTIVE

To identify studies that used administrative claims data to measure real-world oral oncolytic dose intensity, RDI, or similar constructs.

METHODS

Two health sciences librarians conducted a literature search (PubMed, January 1, 1809-February 6, 2018) including terms in each of the following concept areas: oncology drugs, dosage, and retrospective data sources. At least 2 reviewers scanned each title and abstract of publications retrieved from PubMed. Abstracts that indicated the study reported dose or related concepts and oral oncolytics using retrospective data sources were marked for full-text review. During full-text review, papers were excluded if they did not study oral oncolytics (i.e., only described intravenous chemotherapy); if they did not report drug dosage; or if the study was not retrospective. Resulting studies were included for full-text data extraction.

RESULTS

Of the 1,640 publications returned from the search, 41 were marked for full-text review. Full-text review established that 17 studies addressed a concept related to dose of oral oncolytics using retrospective data. Twenty-four studies were excluded: 11 did not measure dose; 9 did not study oral oncolytics; and 4 were not retrospective studies. Among the 17 articles marked for extraction, 5 articles reported dose intensity or RDI using medical records or electronic health record (EHR) data.

CONCLUSIONS

This study reveals not only the need for a claims-based measure of dose intensity for oral oncolytics, but also provides a basis for the development of such a measure based on previous EHR-based studies. While several claims data studies have characterized oral oncolytic dosing and duration, we found that no studies combined these dimensions into a single measure such as dose intensity. Methods using EHR data may be translatable to a claims data study. Future research is needed to develop and validate such measures.

DISCLOSURES

Novartis Pharmaceuticals provided funding for this study and is a manufacturer of oral onalytics, which is under study in this article. Arcona and Zacker are employees of Novartis. Slejko reports grants from PhRMA, PhRMA Foundation, and Takeda Pharmaceuticals and consulting fees from Pfizer, outside the submitted work. Stuart reports consulting fees from the University of Maryland during the study. The other authors have nothing to disclose. The preliminary findings of this study were presented in a poster at AMCP Nexus 2018, October 22-25, 2018, in Orlando, FL.

Share of Oncology Versus Nononcology Spending in Episodes Defined by the Centers for Medicare & Medicaid Services Oncology Care Model

PURPOSE

Performance-based payments to oncology providers participating in the Centers for Medicare & Medicaid Services (CMS) Oncology Care Model (OCM) are based, in part, on overall spending in 6-month episodes of care, including spending unrelated to oncology care. The amount of spending likely to occur outside of oncologists' purview is unknown.

METHODS

Following the OCM definition of an episode, we used SEER-Medicare data from 2006 to 2013 to identify episodes of cancer care for the following diagnoses: breast cancer (BC), non-small-cell lung cancer, renal cell carcinoma, multiple myeloma (MM), and chronic myeloid leukemia. Claims were categorized by service type and, separately, whether the content fell within the purview of oncology providers (classified as oncology, with all other claims nononcology). We calculated the shares of episode spending attributable to oncology versus nononcology services.

RESULTS

The percentage of oncology spending within OCM episodes ranged from 62.4% in BC to 85.5% in MM. The largest source of oncology spending was antineoplastic drug therapy, ranging from 21.8% of total episode spending in BC to 67.6% in chronic myeloid leukemia. The largest source of nononcology spending was acute hospitalization and inpatient physician costs, ranging from 6.6% of overall spending for MM to 10.4% for non-small-cell lung cancer; inpatient oncology spending contributed roughly similar shares to overall spending.

CONCLUSION

Most spending in OCM-defined episodes was attributable to services related to cancer care, especially antineoplastic drug therapy. Inability to control nononcology spending may present challenges for practices participating in the OCM, however.

Quantification of Economic Impact of Drug Wastage in Oral Oncology Medications: Comparison of 3 Methods Using Palbociclib and Ribociclib in Advanced or Metastatic Breast Cancer

BACKGROUND

Discarding unused drugs after dose changes or discontinuation can significantly affect pharmacy budgets. This is especially concerning for expensive oncology agents. However, few economic studies account for drug wastage, providing an inaccurate estimate of a drug's actual economic cost, cost-effectiveness, and value.

OBJECTIVES

To (a) compare the economic impact of drug wastage between ribociclib and palbociclib-clinically similar oral medications for metastatic breast cancer-using 3 approaches (Markov model, pharmacy acquisition cost model, and a retrospective claims analysis) and (b) compare the modeling results with a published estimate of drug wastage for palbociclib from a claims analysis.

METHODS

A Markov model and a pharmacy acquisitions cost model were developed to evaluate the economic impact of dose reductions for ribociclib and palbociclib over a 1-year time period. Data inputs were pharmacy costs (RED BOOK wholesale acquisition cost) and proportion of patients experiencing dose reductions from either ribociclib randomized clinical trials (MONALEESA-2, -3, or -7) or real-world observational data (Symphony Health retrospective claims analysis). The latter constituted the third approach for quantifying drug wastage. The economic impact of dose reductions for ribociclib and palbociclib in postmenopausal women with previously untreated HR-positive/HER2-negative advanced breast cancer was assessed. Drug wastage was defined as drug doses that could not be used by a patient following a dose reduction. The cost of drug wastage was defined as the cost associated with an unused drug resulting from a dose reduction. The predicted results from the 2 models were compared with a previously published claims analysis that estimated the effect of treatment costs and drug wastage for palbociclib based on the observed dosing patterns from the Symphony Health Solutions database.

RESULTS

In the Markov model, relative to ribociclib, palbociclib users experienced drug wastage of $112,382 total, or $1,124 per treated patient, per year due to dose changes. In the pharmacy acquisition cost model, relative to ribociclib, palbociclib usage was associated with an increased cost of $7,196 per patient per year (based on a mid-cycle dose reduction) comprising dosing-based cost differences and drug wastage cost for palbociclib of $3,727. The previously published claims analysis found that palbociclib users experiencing a dose reduction had drug wastage costs of $5,471 per patient.

CONCLUSIONS

In both models, dose reductions for ribociclib patients resulted in no wastage, since unused tablets could be administered in subsequent cycles, while dose reductions for palbociclib resulted in drug wastage and increased costs. The results from both models were consistent with previously published results from the claims analysis, demonstrating drug wastage costs for palbociclib.

DISCLOSURES

This study received financial support from Novartis Pharmaceuticals, which has products approved for treatment of breast cancer. Tang was employed by Novartis during this study; Zacker and Dalal are employed by Novartis and own company stock. Biskupiak, Brixner, and Oderda received payment from Novartis for this study. Brixner serves as a consultant for Millcreek Outcomes Group and also declares consulting fees from Abbvie, AstraZeneca, Abbott, Becton Dickinson, and Xcenda, unrelated to this study.

The Value of Progression-Free Survival in Metastatic Breast Cancer: Results From a Survey of Patients and Providers

Background. Value assessments and treatment decision making typically focus on clinical endpoints, especially overall survival (OS). However, OS data are not always available, and surrogate markers may also have some value to patients. This study sought to estimate preferences for progression-free survival (PFS) relative to OS in metastatic breast cancer (mBC) among a diverse set of stakeholders—patients, oncologists, and oncology nurses—and estimate the value patients and providers place on other attributes of treatment. Methods. Utilizing a combined conjoint analysis and discrete choice experiment approach, we conducted an online prospective survey of mBC patients and oncology care providers who treat mBC patients across the United States. Results. A total of 299 mBC patients, 100 oncologists, and 99 oncology nurses completed the survey. Virtually all patients preferred health state sequences with contiguous periods of PFS, compared with approximately 85% and 75% of nurses and oncologists, respectively. On average, longer OS was significantly (P < 0.01) preferred by the majority (75%) patients, but only 15% of nurses preferred longer OS, and OS did not significantly affect oncologists’ preferred health state. However, in the context of a treatment decision, whether a treatment offered continuous periods of stable disease holding OS constant significantly affected nurses’ treatment choices. Patients and providers alike valued reductions in adverse event risk and evidence from high-quality randomized controlled clinical trials. Conclusions. The strong preference for observed PFS suggests more research is warranted to better understand the reasons for PFS having positive value to patients. The results also suggest a range of endpoints in clinical trials may have importance to patients.

Drug Treatment Value in a Changing Oncology Landscape: A Literature and Provider Perspective

BACKGROUND

The U.S. health care system's transition to a value-based reimbursement model holds important implications for medical innovation, care delivery, and value-based assessments of therapeutic interventions. This transition has been especially noteworthy in oncology, with substantial ongoing changes to payer reimbursement and the provider landscape, as well as the introduction of value frameworks to guide drug treatment decision making. The implications of these changes for provider assessments of drug value and evidence needs remain unclear.

OBJECTIVES

To understand provider perspectives on drug value assessment and the utility of existing oncology value frameworks by identifying (a) key value-based trends in the evolving oncology landscape, (b) provider definitions of drug value, (c) the role of existing value frameworks in provider decision making, and (d) future provider evidence needs for making value-based treatment decisions.

METHODS

We conducted a literature review to identify existing oncology value frameworks and definitions of drug treatment value in oncology. Using a structured discussion guide informed by this literature review, we conducted 12 telephone-based in-depth interviews in November and December 2017 with U.S. oncology providers involved in organizational drug treatment and formulary decision making within their practices. Responses to interview questions were analyzed and reported as averages and percentages across participants.

RESULTS

Of 293 publications identified by keyword searches, 35 relevant articles were identified. Among these, the literature review identified no common definition for providers to assess drug value. Interview research participants described large ongoing changes in the oncology provider landscape, with economic pressures from payers as the foremost leading factor. Although 5 value frameworks were found in the literature, interviews found that in practice few providers consider these value frameworks to be key influences when evaluating treatment or formulary decisions. Furthermore, while 83% of participants' organizations employed some form of internal clinical pathways, only the minority (25%) with pathways integrated in their electronic medical record (EMR) systems saw these pathways as significantly affecting clinicians' drug treatment decision making. To aid the ongoing shift from volume-based to value-based care, we found that, rather than value frameworks, providers are looking for patient-level tools to make more appropriate drug decisions.

CONCLUSIONS

Payer reimbursement pressures are leading to radical changes in the oncology provider landscape, and there is a need for improved guidance for providers in assessing drug value. In particular, this study identifies the need for a timely and multifaceted summary of information required to assess the value of alternative treatment options for a given patient. Manufacturers also need to make significant strides to help generate and improve the dissemination of evidence to support the value of their therapies.

DISCLOSURES

Funding for this work was provided by Novartis Pharmaceuticals. The study sponsor was involved in study design, data interpretation, and data review. All authors contributed to the development of the manuscript and maintained control over the final content. Sasane, Howe, Wong, and Zacker were employees of Novartis at the time of this study. Frois, Jarvis, and Grice are or have been employed by Analysis Group, which received a grant from Novartis for this research. At the time of this study, Analysis Group received funding from multiple manufacturers with oncology products in their portfolio during this time period, including, but not limited to, Astellas and Genentech.

Modeling Episode-Based Payments for Cancer Using Commercial Claims Data

BACKGROUND

Innovative health care reimbursement models are gaining attention as a way to move away from a payment system that rewards quantity of service over quality of care. One such alternative payment model is episode-based payment, such as the Oncology Care Model (OCM) being piloted by the Center for Medicare & Medicaid Innovation.

OBJECTIVE

To adapt the OCM methodology to a commercially insured population to understand the challenges and potential implications of implementing an episode-based payment model in a commercial health plan.

METHODS

Administrative claims databases from 3 regional commercial health plans were used to identify continually eligible patients (aged ≥ 18 years) with breast cancer, lung cancer, melanoma, or chronic myelogenous leukemia (CML). Episode triggers were identified using the OCM methodology. In calculating the episode-based payments, adjustments to the OCM methodology were necessary to adapt the methodology to a commercial population, since not all Medicare data elements used in the OCM algorithm are available in commercial claims data.

RESULTS

The adapted OCM-like model was applied to data from 39,967 patients with 1 of 4 cancer types. Approximately 13% of patients had at least 1 episode per year and the average number of episodes per patient per year for patients with at least 1 episode ranged from 1.42 for patients with melanoma to 1.94 for patients with CML. The percentage of total annual costs included in episodes was 49%, 60%, 34%, and 52% for breast cancer, lung cancer, melanoma, and CML, respectively.

CONCLUSIONS

As health care financing shifts to alternative payment models, insurers may look to adopt episode-based payments for oncology, similar to the OCM. This study shows that implementing an OCM-like model in a commercial health plan is feasible but will require adjustments to the OCM algorithm to make it implementable and applicable to populations beyond Medicare.

DISCLOSURES

This study was conducted by Magellan Rx Management with funding contributed by Novartis. Zacker is an employee of Novartis. The other authors are employed by Magellan Rx Management and have nothing to disclose.

Cost variation and savings opportunities in the Oncology Care Model

OBJECTIVES

This study seeks to identify service categories that present the greatest opportunities to reduce spending in oncology care episodes, as defined by the CMS Oncology Care Model (OCM). Regional variation in spending for similar patients is often interpreted as evidence that resources can be saved, because higher-spending regions could achieve savings by behaving more like their lower-spending counterparts.

STUDY DESIGN

We used Surveillance, Epidemiology, and End Results Medicare data from 2006-2013 for this retrospective observational cohort study. Analysis focused on patients with non-small cell lung cancer, advanced (stage III or IV) breast cancer, renal cell carcinoma, multiple myeloma, or chronic myeloid leukemia.

METHODS

Episodes were identified for patients with the 5 included cancers, following the episode definition used in the OCM. We estimated standardized episode-level spending for a standard patient across subcategories of care for each hospital referral region (HRR) defined by the Dartmouth Atlas. The contribution of each subcategory to interregional variation in total spending reflects that subcategory's potential to yield savings.

RESULTS

Chemotherapy and acute inpatient hospital care tended to be the highest contributors to interregional variation. Imaging, nonchemotherapy Part B drugs, physician evaluation and management services, and diagnostics were negligible contributors to interregional variation for all 5 cancers.

CONCLUSIONS

Chemotherapy and inpatient hospital care offer the most potential to reduce spending within OCM-defined episodes. Other sources of savings differ by type of cancer. Assuming patient outcomes are not compromised, low-spending HRRs may be models for lowering cost in cancer care.

Greater Spending Associated with Improved Survival for Some Cancers in OCM-Defined Episodes

BACKGROUND

Previous research finds significant variation in spending and utilization across regions, with little evidence of differences in outcomes. While such findings have been interpreted as evidence that spending can be reduced without compromising patient outcomes, the link between spending variation and outcomes remains a critical question.

OBJECTIVE

To use evidence from geographic variations in spending and an individual-level survival analysis to test whether spending within oncology care episodes is associated with survival, where episodes are defined as in the Center for Medicare and Medicaid Innovation's Oncology Care Model (OCM).

METHODS

In this retrospective cohort analysis, patient data from the Surveillance, Epidemiology and End Results Medicare (SEER-Medicare) database for 2007-2013 were linked to hospital referral regions (HRRs) using ZIP codes. Patients in the SEER program are a part of selected population-based cancer registries throughout the United States whose records are linked to Medicare enrollment and claims data (93% of elderly registry patients were successfully linked to Medicare data). Episodes of cancer care were defined as in the OCM: 6 months following a triggering chemotherapy claim. We analyzed episodes of care for 5 tumor types: advanced breast cancer (BC), non-small cell lung cancer (NSCLC), renal cell carcinoma (RCC), multiple myeloma (MM), and chronic myeloid leukemia (CML). We removed the effects of differentials in Medicare payment rates, which were mostly geographic. Regression analysis was then used to calculate standardized spending levels for each HRR, that is, spending adjusted for differences in patient and episode characteristics. To examine the effect of spending during OCM-defined episodes on individual-level survival, we used Cox regression with patient characteristics and standardized HRR spending per episode as covariates. To address concerns that may arise from multiple comparisons across the 5 tumor types, we used the Benjamini-Hochberg procedure to control the false discovery rate.

RESULTS

Our analysis showed significant differences in standardized spending across HRRs. Compared with spending at the 20th percentile episode, spending at the 80th percentile ranged from 25% higher ($57,392 vs. $45,995 for MM) to 47% higher ($36,920 vs. $24,127 for RCC), indicating practice style variation across regions. The hazard of dying for patients with NSCLC and MM statistically significantly decreased by 7% (HR = 0.93, P = 0.006) and 13% (HR = 0.87, P = 0.019), respectively, for a $10,000 increase in standardized spending (in 2013 U.S. dollars). For the 3 other cancers, spending effects were not statistically significant. After using the Benjamini-Hochberg procedure with a 5% false discovery rate, the effects of increased spending on improved survival for NSCLC and MM remained statistically significant.

CONCLUSIONS

The association we found between spending and survival suggests caution may be warranted for physicians, pharmacists, other health care professionals, and policymakers involved in efforts to reduce across-the-board spending within OCM-defined episodes for at least 2 of the 5 cancers studied.

DISCLOSURES

Funding for this research was provided by Novartis Pharmaceuticals to Precision Health Economics in support of research design, analysis, and technical writing services. The funder provided input on study design and comments on the draft report. Baumgardner, Shahabi, and Linthicum are employees of Precision Health Economics (PHE), a health care consultancy to the insurance and life science industries, including firms that market oncology therapies. Vine was an employee of PHE at the time of this research. Zacker is an employee of and shareholder in Novartis Pharmaceuticals. Lakdawalla is a consultant to PHE and holds equity in its parent company, Precision Medicine Group.

Placement of selected new FDA-approved drugs in Medicare Part D formularies, 2009-2013

OBJECTIVES

To assess formulary decisions by Part D plans for selected newly approved drugs.

STUDY DESIGN

Retrospective cohort study.

METHODS

Formulary placement and restrictions were identified for 33 drugs in 8 therapeutic classes (antihyperglycemics, anticoagulants, antiplatelets, disease-modifying agents for multiple sclerosis [MS] and rheumatoid arthritis [RA], chronic obstructive pulmonary disease [COPD] drugs, antiepileptics, and antipsychotics) in 863 Part D plans with continuous CMS contracts between 2009 and 2013. Multivariable models estimated the impact of drug characteristics and Part D plan characteristics on probability of drug adoption and, for adopters, evaluated factors associated with months to adoption and requirements for prior authorization (PA) or step therapy (ST).

RESULTS

First Part D formulary placements varied from 2 to 14 months post FDA approval. On average, 56.7% of plans placed each drug within 6 months and 64.1% placed within 1 year of the National Drug Code assignment date. The most rapid adoption was for antipsychotics and antiepileptics. The slowest was for COPD drugs. More than 90% of disease-modifying agents for MS and RA were subject to PA. ST was uncommon except for antihyperglycemic agents. In adjusted analyses, enhanced benefit plans had a 4% higher probability of formulary placement (P <.01), and each additional star in the CMS star rating system increased the probability of adoption by 4% (P <.01). Overall, Medicare Advantage prescription drug plans had higher placement rates due to greater reliance on enhanced plan offerings and higher star ratings.

CONCLUSIONS

We found significant heterogeneity in formulary placement and restrictions for 33 new drugs in the Part D marketplace between 2009 and 2013. Further research is necessary to determine whether this pattern applies to other drug classes.

The impact of self- and physician-administered cancer treatment on work productivity and healthcare utilization

BACKGROUND

Lost productivity in the workplace represents a significant portion of the economic burden of cancer in the United States. Cancer treatments have historically been physician-administered, while recent innovations have led to the development of self-administered, usually oral, agents. Self-administered treatments have the potential to reduce healthcare utilization and time away from work, but the magnitude of these effects is unknown.

OBJECTIVE

To compare the effects of self- and physician-administered cancer treatment on work productivity and health care utilization.

METHODS

Cancer subtypes with self- and physician-administered treatment options were selected. Patients with female breast, or lung or bronchus cancer diagnosed in 2004-2013 were identified in the Truven Health Analytics Commercial Claims and Encounters and Health and Productivity Management databases. Using multivariate regression models, work productivity and healthcare utilization were compared for patients receiving self- versus physician-administered treatment in the 12 months after initial diagnosis. Work productivity outcomes included the number of sick days and short-term disability claims.

RESULTS

One month of self- versus physician-administered treatment significantly reduced cancer-related outpatient services, doctor visits, and infusions in the 12 months after initial diagnosis for both cancers of interest. In addition, breast and lung or bronchus cancer patients who received self-administered treatment were less likely to have short-term disability claims, and breast cancer patients with non-metastatic disease who received self-administered treatment had significantly fewer sick days.

CONCLUSIONS

Self-administered cancer treatment was associated with fewer cancer-related outpatient services and reduced time away from work compared to physician-administered cancer treatment.

Abstract P4-20-02: Value of cancer care for metastatic breast cancer patients and providers

Background: The landscape of treatment options and associated prognosis for patients with metastatic breast cancer (MBC) is rapidly evolving. In response to these advances in therapy, numerous organizations have invested considerable resources into developing evaluation frameworks seeking to clarify the value of new therapies. While some of these frameworks foster patient-provider shared decision making, others are more payer focused, and all are limited in their incorporation of patient perceptions of value and evidence on treatment aspects most meaningful to patients.

Objectives: 1) To identify the attributes of treatment that patients with MBC value most, and 2) to explore the alignment between patient valuation of treatment attributes and healthcare provider perceptions of what patients value.

METHODS: Four 90-minute focus groups were conducted: two with patients (aged &lt;50 years and aged ≥50 years) and two with healthcare providers (oncologists and oncology nurses) who treat patients with MBC. Using semi-structured discussion guides tailored to each participant group, patient and provider perceptions of the factors most important to patients when considering treatment were explored as well as various sources of perceived value in cancer care. Discussions were audio recorded and transcribed. Thematic analysis identified attributes patients with MBC consider when making treatment decisions, and concordance between patients and healthcare providers was assessed.

Results: A total of 24 patients and providers (n=5 patients &lt;50 years, n=5 patients ≥50 years, n=7 oncologists, and n=7 nurses) participated in four different focus groups. The factors of greatest importance to patients included: impact of treatment side effects on daily life, depth of treatment response, longevity of life, and the value of hope in traversing their illness and achieving survival landmarks and goals. In contrast, oncologists focused predominantly on clinical considerations, such as treatment effectiveness and managing side effects. Oncology nurses noted similar clinical factors as oncologists, but also aligned more closely with patients on humanistic elements informing treatment decision-making.

Conclusion: This analysis reveals that while patient and healthcare provider assessments of value in treating MBC are well-aligned with respect to clinical factors such as managing side effects and depth of treatment response; patients also prioritize emotional and psychological factors, -- like having hope and avoiding suffering -- in addition to clinical factors. Moving forward, patient-centered value frameworks for MBC will need to address this gap between what providers and payers value and patient goals and priorities.

Citation Format: May SG, Chung AH, Vania DK, Hou N, MacEwan J, Batt K, Kurian AW, Zacker C, Globe D, Goldman DP. Value of cancer care for metastatic breast cancer patients and providers [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-20-02.

A Systematic Review of the Effect of Cancer Treatment on Work Productivity of Patients and Caregivers

BACKGROUND

Cancer is a leading cause of death with substantial financial costs. While significant data exist on the economic burden of care, less is known about the indirect costs of treatment and, specifically, the effect on work productivity of patients and their caregivers. To examine the full effect of cancer and the potential value of new therapies, all aspects of care, including indirect costs and patient-reported outcomes, should be evaluated.

OBJECTIVE

To perform a systematic review of the literature examining the effect of cancer treatment on work productivity in patients and their caregivers.

METHODS

Articles, abstracts, and bibliographies were searched in MEDLINE, Cochrane, Scopus, CINAHL, and conference lists from the American Society of Clinical Oncology, International Society for Pharmacoeconomics and Outcomes Research, and Academy of Managed Care Pharmacy up to January 2016. The PRISMA guidelines were used. Controlled search terminology included individual pharmacologic therapies for cancer and terms related to patient and caregiver work productivity. Citations were included if they evaluated the effect of cancer treatment on work productivity, used and described productivity assessments and instruments, and were written in English. Studies that reported only clinical outcomes or assessed only nonpharmacological treatments were excluded. Identified studies were screened and extracted for study inclusion by 2 independent reviewers, with adjudication by 2 secondary reviewers during the final eligibility phase.

RESULTS

Of 978 potential citations, 62 articles or abstracts were included. Forty-six studies (74.2%) evaluated patient-related productivity; 10 studies (16.1%) focused on caregivers, and 6 studies (9.7%) were a combination. Sixteen countries contributed literature, including 26 studies (41.2%) conducted in the United States. The most commonly studied cancer was breast cancer (53.2%). Nearly 22% of the studies were conducted on multiple types of cancer. The significant diversity of study methodologies and measurements rendered a single unifying conclusion difficult. A variety of metrics were used to quantify productivity (hours lost, return to work, change of status, and activity impairment). The Work Productivity and Activity Impairment questionnaire was the most commonly used standardized tool (n = 9; 14.5%). Factors found to be associated with impairment in productivity included disease- and treatment-related effects, such as disease progression and severity, cognitive and neurological impairments, poor physical and psychological status, receipt of chemotherapy, and time and expenses required to receive therapy.

CONCLUSIONS

This review highlights the considerable variety of studies that have assessed work productivity for cancer treatment and the multifaceted reasons affecting patients and caregivers. With increasing emphasis being given to understanding the value that patients assign to various aspects of cancer treatment, more streamlined information on productivity may be important to patients as they play a greater role in selecting treatment goals through shared decision making with their providers.

DISCLOSURES

This study was funded by Novartis Pharmaceuticals, which provided the concept, general oversight, and research collaboration on the project. Covvey and Kamal received research funding from Novartis Pharmaceuticals and the College of Psychiatric and Neurologic Pharmacists. Zacker is employed by, and owns stock in, Novartis Pharmaceuticals. A related poster abstract was presented at the Academy of Managed Care Pharmacy April 2016 Annual Meeting and published as Kamal KM, Covvey JR, Dashputre A, Ghosh S, Zacker C. A conceptual framework for valuebased oncology treatment: a societal perspective. J Manag Care Spec Pharm. 2016;22(4 Suppl A):S28. A publication-only abstract was presented at the American Society of Clinical Oncology 2016 Annual Meeting and published as Covvey JR, Kamal KM, Dashputre A, Ghosh S, Zacker C. The impact of cancer treatment on work productivity of patients and caregivers: a systematic review of the evidence. J Clin Oncol. 2016;34(Suppl):e18249. Study concept and design were contributed by Zacker, Kamal, and Covvey. Dashputre and Ghosh took the lead in data collection, along with Kamal and Covvey, and data interpretation was performed primarily by Shah and Bhosle, along with Ghosh, Dashputre, Covvey, and Kamal. The manuscript was written by Kamal, Covvey, Shah, and Bhosle and revised primarily by Zacker, along with Shah, Bhosle, Kamal, and Covvey.

Results of the CAPPS: COPD--assessment of practice in primary care study

OBJECTIVE

Since many patients with COPD in the US are managed by primary care physicians, we evaluated adherence to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines in a primary care setting.

METHODS

A cross-sectional study was conducted using a random sample of patients (n=50-150 per site) aged 40-89 years with diagnosed COPD. Patients were identified for study inclusion (N=1517) from 11 US primary care sites. Demographic and clinical information was extracted from primary care medical records via retrospective chart review. The main outcome measures were adherence to GOLD primary care guidelines, assessed via three components as follows: 1. Is there a current diagnostic spirometry test measurement available within the patient's medical record during the prior calendar year? 2. Are comorbid conditions, if present, being treated appropriately? 3. Are adequate risk reduction measures being taken?

RESULTS

Mean patient age was 67.2 (SD±11.3) years, 54% were female, and 34% were current smokers. Overall, 19% of patients had comorbid asthma, 66% hypertension, 61% dyslipidemia, 30% cardiovascular disease, and 28% diabetes. Mean duration of COPD was approximately 4.8 years. Only 27% of patients had a spirometry test result documented within the past year. More than half (52%) of patients did not have a documented COPD stage; 20% were classified as stage I, 13% stage II, 12% stage III, 3% stage IV. About 63% of patients met at least one guideline component, while only 3% of patients met all components; 27% met diagnostic, 25% comorbid conditions management, and 32% met risk reduction criteria.

LIMITATIONS

The retrospective design of our study did not allow evaluation of some possible covariates or causal assessment, and spirometry measurements were unavailable for many patients.

CONCLUSIONS

Results suggest that treatment per COPD primary care guidelines was not consistently applied among participating practices (range 0.0%-8.7% for meeting all three components). Educational initiatives may increase primary care providers' knowledge of and adherence to COPD treatment guidelines and recommended patient management strategies.

Does an increase in non-antihypertensive pill burden reduce adherence with antihypertensive drug therapy?

Objectives

Hypertensive patients often are prescribed multiple medications for their hypertension as well as for other chronic conditions. Poor adherence has been both positively and negatively associated with increasing numbers of medications or required daily doses. We sought to determine whether adherence with antihypertensive drugs changes in response to a change in non-antihypertensive pill burden.

Methods

This retrospective cohort analysis used 2006–2007 US MarketScan Medicare Supplemental and Coordination of Benefits administrative data. The study sample comprised 471 359 beneficiaries diagnosed with hypertension. We measured monthly proportion of days covered (PDC) with antihypertensive medications and average number of daily doses with non-antihypertensive drugs (pill burden). We assessed the effect of changes in pill burden on subsequent changes in antihypertensive PDC using difference equations with sensitivity tests for the sign and magnitude of monthly change in pill burden and the presence of physician visits.

Key findings

Changes in monthly non-antihypertensive pill burden had essentially no impact on antihypertensive adherence rates for Medicare beneficiaries in retiree health plans. A monthly addition of one non-antihypertensive pill/day resulted in a statistically significant reduction in the following month's antihypertensive medication PDC of approximately one percentage point (−0.98). Similar results were obtained in a 3-month lag model (−0.88). These findings were insensitive to changes in model parameters.

Conclusions

while physicians should pay close attention to individual factors that may affect their patients' adherence to antihypertensive medications, our findings indicate that changes in medications used to treat concomitant diseases should have little short-term impact on antihypertensive adherence.

Perspectives on electronic medical records adoption: electronic medical records (EMR) in outcomes research

Health information technology (HIT) is engineered to promote improved quality and efficiency of care, and reduce medical errors. Healthcare organizations have made significant investments in HIT tools and the electronic medical record (EMR) is a major technological advance. The Department of Veterans Affairs was one of the first large healthcare systems to fully implement EMR. The Veterans Health Information System and Technology Architecture (VistA) began by providing an interface to review and update a patient's medical record with its computerized patient record system. However, since the implementation of the VistA system there has not been an overall substantial adoption of EMR in the ambulatory or inpatient setting. In fact, only 23.9% of physicians were using EMRs in their office-based practices in 2005. A sample from the American Medical Association revealed that EMRs were available in an office setting to 17% of physicians in late 2007 and early 2008. Of these, 17% of physicians with EMR, only 4% were considered to be fully functional EMR systems. With the exception of some large aggregate EMR databases the slow adoption of EMR has limited its use in outcomes research. This paper reviews the literature and presents the current status of and forces influencing the adoption of EMR in the office-based practice, and identifies the benefits, limitations, and overall value of EMR in the conduct of outcomes research in the US.

Lessons learned: who didn't enroll in Medicare drug coverage in 2006, and why?

The law that created Medicare's prescription drug benefit, Medicare Part D, also established extra help for low-income seniors in the form of a subsidy. This study, the first in-depth analysis of Part D enrollment among Medicare beneficiaries without prior drug coverage, finds that 63 percent of all eligible seniors and 69 percent of low-income beneficiaries were enrolled in Part D in 2006. However, only 29 percent of low-income beneficiaries were enrolled in the subsidy program, leaving millions without coverage. Many reported that premiums were too costly, enrollment too difficult, and information too hard to obtain for enrollment. Additionally, provisions of the recently enacted Patient Protection and Affordable Care Act may have the perverse impact of reducing enrollment in Part D for certain beneficiaries. Our findings emphasize the need to expand eligibility and improve policies to foster enrollment.

Effect of cardiometabolic risk factors on hypertension management: a cross-sectional study among 28 physician practices in the United States

OBJECTIVE

This cross-sectional study sought to determine the prevalence of cardiometabolic risk factor clusters (CMRFCs) and their effect on BP control among hypertensive patients from 28 US physician practices.

METHODS

Each participating practice identified a random sample of 150-300 adults aged >or= 18 years diagnosed with hypertension. The primary outcome variable was BP control (BP < 140/90 mmHg for non-diabetic and <130/80 mmHg for diabetic patients). CMRFCs included hypertension in addition to obesity, dyslipidemia, and diabetes.

RESULTS

Overall, 6,527 hypertensive patients were identified for study inclusion. More than half (54.3%) were female, and mean age was 64.7 years. Almost half (48.7%) were obese (BMI >or= 30 kg/m2). About 1 in every 4 patients (25.3%) had diabetes, and 60.7% had dyslipidemia. Mean blood pressure was 132.5/77.9 mmHg, and 55.0% of all patients had controlled BP; 62.4% of non-diabetic patients, and 33.3% of diabetic hypertensive patients, had BP controlled to recommended levels. Most (81.7%) hypertensive patients had >or= 1 cardiometabolic risk factor, and 12.2% had all 3 risk factors. As compared to hypertensive patients without additional risk factors, adjusted odds ratios for BP control were significantly lower for all combinations of CMRFCs (ORs 0.15-0.83, all p < 0.04), with the exception of patients who had only dyslipidemia in addition to hypertension (OR = 1.09, p = NS). Prescriber adherence to recommended hypertension treatment guidelines for patients with diabetes, heart failure, or prior myocardial infarction was high. Although patients with risk factors were prescribed more antihypertensive medications than those without, hypertensive patients with all 3 risk factors were prescribed a mean of 2.4 antihypertensive medications compared to 1.7 for those with no risk factors; odds of BP control in these patients, however, was 0.23 [95% CI 0.19-0.29] that of patients with no other CMRFCs.

CONCLUSIONS

Across 28 US practices, only 18% of hypertensive patients did not have any additional cardiometabolic risk factors. The high prevalence of CMRFCs presents a challenge to effective hypertension management.

Factors associated with first-fill adherence rates for diabetic medications: a cohort study

BACKGROUND

Little is known about first-fill adherence rates for diabetic medications and factors associated with non-fill.

OBJECTIVE

To assess the proportion of patients who fill their initial prescription for a diabetes medication, understand characteristics associated with prescription first-fill rates, and examine the effect of first-fill rates on subsequent A1c levels.

DESIGN

Retrospective, cohort study linking electronic health records and pharmacy claims.

PARTICIPANTS

One thousand one hundred thirty-two patients over the age of 18 who sought care from the Geisinger Clinic, had Geisinger Health Plan pharmacy benefits, and were prescribed a diabetes medication for the first time between 2002 and 2006.

MEASUREMENTS

The primary outcome of interest was naïve prescription filled by the patient within 30 days of the prescription order date.

RESULTS

The overall first-fill adherence rate for antidiabetic drugs was 85%. Copays < $10 (OR 2.22, 95% CI 1.57-3.14) and baseline A1c > 9% (OR 2.63, 95% CI 1.35, 5.09) were associated with improved first-fill rates while sex, age, and co-morbidity score had no association. A1c levels decreased among both filling and non-filling patients though significantly greater reductions were observed among filling patients. Biguanides and sulfonylureas had higher first-fill rates than second-line oral agents or insulin.

CONCLUSIONS

First-fill rates for diabetes medication have room for improvement. Several factors that predict non-filling are readily identifiable and should be considered as possible targets for interventions.

Use of health-related quality of life information in managed care formulary decision-making

BACKGROUND

The extent to which the increased volume of available health-related quality of life (HRQOL) information and heightened education has increased the acceptance and use of HRQOL remains unclear. Likewise, the value of HRQOL information in the formulary decision-making process continues to be undefined.

OBJECTIVE

To investigate the perceptions and use of HRQOL by managed care decision-makers in the formulary development process.

METHODS

A mail survey was sent to a nationwide sample of 108 Academy of Managed Care Pharmacy (AMCP) members who were involved in formulary management. Survey candidates were identified according to their job titles listed in the 1999-2000 AMCP membership directory. The survey process began in May 2000 and ended in August 2000. The main outcome measures included (a) managed care formulary decision-makers' assessment of HRQOL as a treatment outcome, (b) the existing role and future use of HRQOL information in formulary decisions, and (c) the level of understanding of HRQOL concepts and the benefits attributable to favorable HRQOL results.

RESULTS

A response rate of 51.9% was obtained. Most of the respondents (>70%) believed that patients consider HRQOL as an important treatment outcome. Fewer respondents (43%) felt that payers view HRQOL outcomes as an important quality indicator. Most respondents (95%) considered HRQOL data in making formulary decisions, and many (73%) believe that HRQOL outcomes will play a more important role in future formulary decisions. Respondents indicated a better understanding of disease-specific and generic HRQOL measurements than utility measurement and interpretation of results. A minority of respondents (34%) would be willing to pay a higher price for a product with better HRQOL outcomes. When asked which factors would lead to increased use of HRQOL information, respondents indicated that health care cost savings and increased productivity were considered important (77% and 65%, respectively).

CONCLUSIONS

A drug product with better HRQOL outcomes alone will not command a favorable listing on managed care formularies. HRQOL information needs to be made more applicable to managed care decision-making. Future studies should focus on the link between positive HRQOL outcomes, health care cost savings, and increased productivity.

Correlates of hypertension control in a primary care setting

BACKGROUND

Numerous clinical trials have demonstrated reduction in cardiovascular events as a result of lowering blood pressure (BP). Despite these findings, BP control rates, especially in primary care settings, remain suboptimal. This study describes hypertension control and its predictors, using data from a sample of 631 adult patients drawn from an established primary care practice.

METHODS

Data were obtained through chart review and patient survey during a 3-month period. The BP control was the outcome in a logistic regression model identifying demographic and clinical predictors of control.

RESULTS

Compared to patients with low Framingham Risk Scores (FRS), individuals with moderate and high scores had reduced odds of achieving control (69% reduction, 95% confidence interval [CI] 0.19-0.65; 82% reduction, 95% CI 0.10-0.36, respectively). Being female reduced the odds of control by 61% (95% CI 0.26-0.66). Having diabetes mellitus (DM) (95% CI 0.21-0.79) or impaired fasting glucose (IFG; fasting glucose >109 but <126 mg/dL) (95% CI 0.10-0.40) reduced the odds of control by 64% and 82%, respectively. For each additional point on a physician-rated patient knowledge scale, the odds of having controlled BP increased 78% (95% CI 1.44-2.56). Each additional co-morbid condition positively associated with control (34% increase in odds, 95% CI 1.15-1.86). Age (95% CI 0.98-1.02) and body mass index (BMI) (95% CI 0.97-1.04) had no effect.

CONCLUSIONS

Higher FRS, female sex, DM, and IFG negatively correlated with control. Patient knowledge and number of co-morbid conditions correlated positively. Age and BMI did not correlate with control. The most disturbing finding in our study was that higher risk patients who stand to benefit most from BP control were least likely to be controlled, despite being on more antihypertensive medications. These findings may be helpful to primary care providers in reaching patient hypertension control goals.

Absenteeism among employees with irritable bowel syndrome

Patterns of illness or disability-related work absence six months before and six months after a diagnosis of irritable bowel syndrome (IBS) were assessed from medical claims and absenteeism databases and were compared with a sample of patients with no gastrointestinal (GI) disorders. The records of 630 patients with IBS were compared with those of 1,260 persons without GI conditions. Mean monthly IBS-related absences increased by 69% (from 0.96 to 1.62 days) from the beginning of the six-month period before diagnosis to the month of diagnosis. With multivariate regression analysis, the incremental effect of an IBS diagnosis on six-month absenteeism was estimated to be 3.27 absences greater for persons with IBS.

Health-related quality of life associated with irritable bowel syndrome: comparison with other chronic diseases

BACKGROUND

Despite the rapidly growing body of literature on health-related quality of life (HRQoL). placing the results in a context that is meaningful to clinicians and patients is often overlooked.

OBJECTIVE

This study sought to quantify the impact of irritable bowel syndrome (IBS) on HRQoL by comparing the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) scores of IBS patients with normative US data and with the scores of patients having other chronic gastrointestinal (GI) and non-GI disorders.

METHODS

Two IBS reference groups were identified from the published literature: a largely untreated community sample of health maintenance organization (HMO) members (N = 92) and a sample of patients with IBS recruited through clinics and in the community (N = 140). SF-36 scores for these groups were compared with published US population norms (N = 2474) and with published scores for 3 other IBS samples (N = 464); a sample with other chronic GI disorders (dyspepsia [N = 126], gastroesophageal reflux disease [GERD] [N = 516]); and samples with other chronic episodic disorders (asthma [N = 375], migraine [N = 303], panic disorder [N = 73], rheumatoid arthritis [N = 693]).

RESULTS

The scores of patients in both IBS reference groups were significantly lower on several SF-36 domains than those of the US normative population (P < 0.003). Scores on several SF-36 scales were also significantly lower in the IBS reference groups compared with the GERD, asthma, and migraine samples (P < 0.003). Depending on the IBS sample used, scores did not differ or were higher compared with those in the sample with dyspepsia. Relative to the samples with panic disorder and rheumatoid arthritis, the IBS groups had significantly higher scores on most SF-36 domains (P < 0.003). Scores for the HMO reference group were generally higher than those for the clinic/community reference group.

CONCLUSIONS

Based on the results of this analysis, IBS is associated with impairment of HRQoL relative to US population norms and to populations with GERD, asthma, or migraine. HRQoL appears to be greater in patients with IBS than in those with panic disorder or rheumatoid arthritis, although the relative symptom severity in these samples was not known.

A microcosting analysis of zoledronic acid and pamidronate therapy in patients with metastatic bone disease

Our goal was to calculate resource use associated with administration of zoledronic acid, compared with pamidronate, as palliative care for patients with metastatic bone lesions. We conducted a time-and-motion study of therapy administration at each of three outpatient chemotherapy infusion sites participating in clinical trials of zoledronic acid and pamidronate. We developed a data-collection instrument to record all staff effort and patient resource use in drug administration. The main outcome measures were (a) direct costs of therapy administration per patient and (b) opportunity benefits expressed as the availability of resources gained per year. The average visit time for patients receiving the study dose of zoledronic acid, 4 mg, was 1 h, 6 min, compared to 2 h, 52 min for patients receiving a 90-mg dose of pamidronate. Infusion time accounted for much of the difference. In the base-case analysis, total direct costs per patient were $728 for zoledronic acid and $776 for pamidronate. The opportunity benefit for infusion of zoledronic acid vs pamidronate in the base case was 1.8 chairs per day, or 426 chairs per 240-workday year. Results were sensitive to changes in infusion facility size, days of operation, and average number of patients treated. Shorter infusion time associated with the administration of zoledronic acid, compared with pamidronate, yields substantial time savings for patients, as well as opportunity benefits for outpatient oncology facilities.

Irritable bowel syndrome: toward a cost-effective management approach

OBJECTIVE

To examine the economic implications of current irritable bowel syndrome (IBS) management practices and formulate recommendations based on these implications.

METHODS

Relevant English-language research publications in which the direct and indirect costs of IBS were examined, identified using a search of records contained in Medline.

RESULTS

Review of the identified publications indicates that in Western nations, IBS management is associated with high direct costs (particularly for diagnostic testing, office visits, pharmacotherapy, and emergency department visits). Indirect costs, associated with lost wages and decreased productivity, account for the largest proportion of the IBS economic burden. Moreover, rapid projected growth in IBS disease-related costs indicates a need for more focused attention toward improved treatment of IBS. More cost-effective management might be achieved by diagnosing and instituting nonpharmacologic and pharmacologic management earlier in the disease process. Under such an approach, patients are classified based on symptoms and a therapeutic trial is begun. More extensive, expensive diagnostic testing is reserved for patients refractory to treatment or for whom serious disease must be ruled out.

CONCLUSION

IBS is a condition with high direct and indirect costs. Management strategies should be evaluated both on their clinical efficacy and on their cost effectiveness. As new, IBS-specific pharmacotherapies become available, the ability to diagnose and manage the condition in a cost-effective manner can be improved.

The impact of pamidronate on inpatient and outpatient services among metastatic breast cancer patients

Our goal was to evaluate the impact of pamidronate therapy on medical resource utilization for treatment of bone metastases among patients with breast cancer. In this 12-center retrospective study, inpatient and outpatient resource utilization was abstracted from the medical charts of 295 patients with breast cancer who were diagnosed with bone metastases between July 1996 and April 1999. Data were abstracted from the time of bone metastasis diagnosis (baseline) to the present. The analysis compared non-pamidronate patients against pamidronate patients, who were stratified on the basis of whether their pamidronate therapy had been initiated within 3 months (early pamidronate group) or more than 3 months (late pamidronate group) after diagnosis. Resource utilization was compared among groups using multivariate regression analyses. A total of 101 early pamidronate, 72 late pamidronate, and 122 non-pamidronate patients were included in the analysis. The results showed that the early pamidronate group was roughly one-half as likely to have unplanned office visits attributable to bone metastases as the late pamidronate and non-pamidronate groups. The groups had a similar likelihood of ever being hospitalized for bone-related conditions; however, among those hospitalized, there were roughly one-half as many bone-related hospitalizations in the late pamidronate group as in the non-pamidronate group. Also, the mean length of stay was approximately 50% shorter in both pamidronate groups than in the non-pamidronate group. We conclude that pamidronate therapy may be associated with less medical resource utilization, particularly among patients hospitalized for bone-related conditions.

Community pharmacist knowledge and behavior in collecting drug copayments from Medicaid recipients

Community pharmacists' knowledge and behavior regarding the collection of copayments for prescription drugs from Medicaid recipients were studied. In fall 1998 a questionnaire was mailed to a random sample of 1465 community pharmacists (one pharmacist per drugstore) in Maryland, Pennsylvania, and West Virginia. The objectives were to determine the extent to which these pharmacists waived copayments for prescription drugs for Medicaid recipients, to document the pharmacists' knowledge of federal policies on Medicaid copayments, and to evaluate the factors associated with pharmacist copayment collection and knowledge of federal copayment policies. A total of 543 pharmacists (37%) responded. Most respondents indicated that they collected copayments for over 90% of drugs dispensed to Medicaid patients subject to copayment policies. Pharmacists most likely to waive Medicaid copayments practiced in drugstores with a high volume of Medicaid-related prescriptions and a large percentage of customers who were elderly Medicaid recipients. Pharmacists least likely to waive copayments believed that doing so would have a negative financial impact on the pharmacy. Nearly three fourths of the pharmacists exhibited fair or good knowledge of federal Medicaid copayment policies, but this varied widely by state. Many said that they would collect copayments in at least some situations even if this opposed federal policy. Pharmacists in Maryland, Pennsylvania and West Virginia had highly variable behavior patterns and knowledge with respect to the collection of drug copayments from Medicaid recipients.

The consequences of diarrhea occurring during chemotherapy for colorectal cancer: a retrospective study

PURPOSE

Diarrhea is one of the dose-limiting toxicities associated with chemotherapy agents in treatment regimens for colorectal cancer. The objectives of this study were to analyze the impact of all grades of diarrhea on clinical decisions for patients receiving treatment for colorectal cancer by characterizing the diarrhea that occurred, quantifying changes in chemotherapy treatment, identifying methods to treat diarrhea, and determining the economic impact. Patients and Methods. We retrospectively reviewed the treatment of 100 consecutive patients with colorectal cancer who experienced diarrhea during the course of chemotherapy. The diarrhea was documented in the progress notes and graded according to National Cancer Institute Common Toxicity Criteria. Changes in chemotherapy treatment and resource utilization associated with diarrhea were recorded.

RESULTS

The 100 patients received 673 chemotherapy cycles, of which 45% +/- 2% were associated with diarrhea. Approximately 52% of patients experienced diarrhea of grades 3 or 4, and 56 patients underwent 66 modifications in their chemotherapy treatment, such as dose reductions (22), delays in therapy (8), discontinuations of therapy (15), or multiple changes (11). Thirty-seven patients consumed resources beyond oral antidiarrheals to control diarrhea: 14 patients received emergency outpatient treatment, 23 patients were hospitalized, 21 patients received intravenous fluids, and one death due to dehydration was reported. Discussion and Conclusion. Diarrhea was a significant consequence of colorectal chemotherapy, with the majority of patients experiencing grades 3 or 4 diarrhea and 56% of all patients also modifying their chemotherapy treatment. Even mild diarrhea of grades 1 and 2 was associated with changes in treatment in 11% of patients; thus, diarrhea of all grades should be recognized and treated appropriately to maintain full-dose chemotherapy.

The reliability and validity of the impact on lifestyle questionnaire in patients with acromegaly

OBJECTIVES

Treatments for acromegaly, a growth hormone disorder, can be burdensome to patients, often requiring multiple self-administered injections daily. We developed the Impact on Lifestyle Questionnaire (ILQ) to measure the impact on patient's lifestyle imposed by the burden of injectable treatments for acromegaly. The primary objective of this study was to establish the reliability and validity of the ILQ.

METHODS

The ILQ consists of the SF-12 and 30 additional questions. Thirty-four patients, from two sites, completed the ILQ and scales measuring related concepts. Fourteen patients also completed a retest survey 4 weeks later. Survey sample data were combined with ILQ data from another 56 patients with acromegaly for a factor analysis. Reliability was assessed with Cronbach's alpha and test-retest. Zero-order correlations were examined between ILQ subscales and symptoms, depression, SF-12 mental and physical components, a measure of self-care burden, appraisal of illness, and single-item measures of quality of life and satisfaction.

RESULTS

The preconceived subscale structure was supported by factor analysis. These factors were internally consistent and stable over time. Good convergent validity was demonstrated between the Burden and Disruption scales with other measures of the burden of treatment. Patients indicated that they were generally compliant with therapy, and that treatment was not particularly burdensome or disruptive. Results based on the ILQ were consistent with other scales and qualitative responses.

CONCLUSIONS

The ILQ has three subscales, Burden, Lifestyle Disruption, and Compliance, that are reliable and demonstrate preliminary evidence of construct validity.

Cost of treating an episode of variceal bleeding in a VA setting

OBJECTIVES

The specific aims of this study were to develop a demographic description of a sample of patients presenting with bleeding esophageal varices and determine the direct health care costs of variceal bleeding.

METHODS

This was a retrospective evaluation of patients who underwent esophagogastroduodenoscopy at the Portland VA Medical Center between January 1993 and May 1997. Data sources included both electronic databases and patient medical charts. The primary unit of analysis was an episode of care, defined as an index bleed plus 6 months of follow-up or death, whichever came first.

RESULTS

The total inpatient direct cost was $1,566,904 and outpatient direct cost was $104,611, for a total of $1,671,515 for 100 bleeding episodes in 79 patients. Episodes of care for patients receiving < or =2 units of packed red blood cells were approximately a third as costly as those receiving >2 units of packed red blood cells (n = 17, $6,470 and n = 83, $17,553). The difference in costs was statistically significant (p < 0.05), and primarily attributable to hospital bed costs.

CONCLUSIONS

There is a substantial financial burden associated with this illness, primarily attributable to inpatient costs. In addition to severity of bleeding, Child's class, endoscopic findings, and the timing of pharmacological therapy seem to influence the overall cost of managing esophageal varices.

Who bears the burden of Medicaid drug copayment policies?

This DataWatch examines the impact of Medicaid prescription drug copayment policies in thirty-eight states using survey data from the 1992 Medicare Current Beneficiary Survey. Findings indicate that elderly and disabled Medicaid recipients who reside in states with copay provisions have significantly lower rates of drug use than their counterparts in states without copayments. After controlling for other factors, we find that the primary effect of copayments is to reduce the likelihood that Medicaid recipients fill any prescription during the year. This burden falls disproportionately on recipients in poor health.

Drug use and prescribing problems in four state Medicaid programs

In this article the authors present population-level prevalence rates for 61 specific drug-related problems occurring in three State Medicaid programs (Maryland, Iowa, and Washington) from 1989 through 1996 and a fourth (Georgia) from 1994 through 1996. The findings represent the first application of a consistent drug utilization review (DUR) screener program to Medicaid data across States. The study finds major differences in DUR failure rates among the four States with the lowest rates in Georgia and the highest in Washington. Only Iowa showed any population-level reduction in DUR failure rates during the study period, however, rates for community-dwelling elderly fell in most States.

An economic evaluation of energy-absorbing flooring to prevent hip fractures

An economic evaluation of energy-absorbing flooring designed to prevent hip fractures revealed a payback period of 10 1/2 years if only direct costs avoided were evaluated and just over 11 months when direct and indirect costs were included. Cost-effectiveness ratios of less than $0 per hip fracture prevented and life year saved were also estimated.