Cost-Effectiveness Modeling of Prostate-Specific Membrane Antigen Positron Emission Tomography with Piflufolastat F 18 for the Initial Diagnosis of Patients with Prostate Cancer in the United States

BACKGROUND AND OBJECTIVES

Piflufolastat F 18 is a novel prostate-specific membrane antigen (PSMA)-targeted positron emission tomography (PET) radiotracer that is superior to standard of care (SOC) imaging for the initial staging of prostate cancer and the detection of biochemical recurrence. As piflufolastat F 18 has been approved in the United States (US) for this indication, this modeling study assessed the cost effectiveness of piflufolastat F 18 versus fluciclovine F-18, gallium68-PSMA-11 (PSMA 11), and SOC imaging (a mix of bone scans, computed tomography, and magnetic resonance imaging) for the diagnosis and staging of prostate cancer from a US healthcare system perspective.

PERSPECTIVE

A US third-party payer perspective was used, which for this population reflects a mix of commercial and Medicare, considering only direct healthcare costs.

SETTING

This study utilized a tertiary healthcare setting.

METHODS

A decision tree was used to map the diagnostic/treatment pathway, consisting of the proportion of patients with local, regional, distant, or no disease; prostate-specific antigen (PSA) ≤ 1.0 or > 1.0; and accuracy of imaging modalities. A Markov model predicted the long-term outcomes of disease progression according to treatment decisions. Inputs to the model were informed by data from the OSPREY and CONDOR clinical trials, public data, and the literature. Treatment mix included active surveillance, radiation therapy, prostatectomy, androgen deprivation therapy (ADT), and radiation therapy + ADT, informed by expert opinion. Outcomes included life-years (LY), quality-adjusted life-years (QALY), and the incremental cost-effectiveness ratio (ICER). All costs were reported in 2021 US dollars, using the US Bureau of Labor Statistics Consumer Price Index. A willingness-to-pay (WTP) threshold of $150,000 was considered cost effective, consistent with the upper range used as the standard for price benchmarks by the Institute for Clinical and Economic Review. The robustness of the base-case results was assessed in deterministic and probabilistic sensitivity analyses.

RESULTS

Over a lifetime horizon, piflufolastat F 18 had the greatest effectiveness in terms of LYs (6.80) and QALYs (5.33); for the comparators, LYs ranged from 6.58 (SOC) to 6.76 (PSMA 11) and QALYs ranged from 5.12 (SOC) and 5.30 (PSMA 11). Piflufolastat F 18 was more cost effective compared with fluciclovine F 18, PSMA 11, and SOC, with ICERs of $21,122, $55,836, and $124,330 per QALY gained, respectively. Piflufolastat F 18 was associated with the greatest net monetary benefit ($627,918) compared with the other options at a WTP threshold of $150,000. The results of the deterministic and probabilistic sensitivity analyses supported the robustness of the base-case results.

CONCLUSIONS

This study suggests that piflufolastat F 18 is a cost-effective diagnostic option for men with prostate cancer in the US, with higher associated LY, QALY, and greater net monetary benefit than fluciclovine F 18, PSMA 11, and SOC imaging.

Implications of Delayed Testosterone Recovery in Patients with Prostate Cancer

To assess the clinical impact of delayed testosterone recovery (TR) following the discontinuation of medical androgen deprivation therapy (ADT), a retrospective, longitudinal analysis was conducted in adult males with prostate cancer using the Optum® de-identified Electronic Health Record data set and Optum® Enriched Oncology Data (2010-2021). Of 3875 patients who initiated and discontinued ADT, 1553 received one or more testosterone-level tests within the 12 mo following discontinuation and were included in this study. These 1553 patients were categorized into two cohorts: 25% as TR (testosterone levels >280 ng/dl at any test within 12 mo following ADT discontinuation) and 75% as non-TR. At baseline, non-TR patients were older, had lower testosterone levels, and were more likely to have diabetes, hyperlipidemia, and hypertension, but less likely to have sexual dysfunction. After adjustment for baseline characteristics, the TR cohort had a lower risk of new-onset diabetes (hazard ratio [HR] 0.47; 95% confidence interval [CI] 0.27-0.79), trended toward a lower risk of new-onset depression (HR 0.58; 95% CI 0.33-1.02), and had a higher likelihood of seeking treatment for sexual dysfunction (HR 1.33; 95% CI 0.99-1.78) versus the non-TR cohort. These findings support monitoring testosterone levels after ADT discontinuation to manage potential long-term comorbidities in patients with prostate cancer.

Patient summary

This real-world analysis of males with prostate cancer who were treated with medical androgen deprivation therapy (ADT) found that most patients did not have their testosterone level checked in the 12 mo after stopping ADT. Of those who did, 75% did not achieve normal testosterone levels (>280 ng/dl), and these patients were more likely to experience new-onset diabetes than those who achieved normal testosterone levels. These results suggest that to ensure effective clinical decision-making, physicians should check patients' testosterone levels after stopping ADT.

The experience of a severe hypoglycaemic event from the perspective of people with diabetes and their caregivers: "What am I going to do?"

AIMS

Among people with diabetes using insulin, severe hypoglycaemia (SH) can be a life-threatening complication, if untreated. The personal experiences during an SH event from the perspectives of people with diabetes and their caregivers are not well-characterized. This study assessed the perceptions of the event and the decision making processes of people with diabetes (T1D n = 36; T2D n = 24) and their caregivers during SH events.

METHODS

In-depth one-on-one telephone interviews were conducted with dyads of people with diabetes and caregivers in the United States (n = 120). An initial synopsis and inductive codebook schema were used to analyse the data with two independent coders (kappa = 0.87-0.89). Themes were developed from the codes, and codes were re-mapped to the themes.

RESULTS

Four themes were formed: (1) Caregivers scramble to do the right thing and support people with diabetes in treating SH; (2) Decision making capacity is impaired during an SH event, often a panicked time; (3) People learn to manage SH events through their own experiences and frequently make lifestyle changes to prevent and treat future events; and (4) Discussion with healthcare providers about SH, and particularly SH treatment, is limited.

CONCLUSIONS

SH events are stressful and often evoke emotional reactions that can impair decision making. Thus, advance treatment planning of SH events needs to occur. Much of the knowledge about SH treatment derives from prior experience rather than healthcare provider guidance, suggesting a need for healthcare providers to initiate proactive discussions about SH treatment.

Outcomes and resource use of patients with large hemispheric infarction and cerebral edema: analysis of real-world data

OBJECTIVE

Large hemispheric infarction (LHI) is associated with a high likelihood of the evolution of life-threatening edema. Few studies have assessed real-world clinical outcomes and management strategies among patients with LHI. The objective of this study was to describe the management, in-hospital outcomes, and direct healthcare resource burden of patients with LHI, as well as those of patients with subsequent cerebral edema.

METHODS

This observational, retrospective cohort study analyzed de-identified data from US adult patients using the IBM MarketScan Hospital Drug Database (Q4-2015 to Q4-2017). Patients were included in the "Possible LHI" or the "Other Ischemic Strokes" cohorts using ICD-10 diagnosis codes. Patients with possible LHI were further categorized into "LHI with Edema" and "LHI without Edema" subgroups using diagnosis and procedure codes. Select clinical and economic outcomes were compared between cohorts and subgroups using multivariable regressions.

RESULTS

Of 79,201 eligible encounters with ischemic strokes, 11,772 unique patients were assigned to the Possible LHI cohort while 67,429 were assigned to the Other Ischemic Strokes cohort. Among patients with possible LHI, 869 (7%) were assigned to the LHI with Edema subgroup and 10,903 (93%) were assigned to the LHI without Edema subgroup. Patients in the Possible LHI cohort had longer hospital stays (mean difference [MD] [95%CI] = 2.6 [2.4;2.8] days), higher total facility charges (MD [95%CI] = $28,656 [26,794;30,524]), and higher odds of death (odds ratio [95%CI] = 2.2 [2.0;2.4]) than the Other Ischemic Strokes cohort. Among patients with possible LHI, the incremental clinical and resource burden was further exacerbated in the subgroup of patients with edema (hospital days: MD [95%CI] = 5.0 [3.9;6.2] days; total facility charges: MD [95%CI] = $59,585 [50,816;67,583]; mortality: odds ratio [95%CI] = 10.3 [8.5;12.4]).

CONCLUSIONS

Among patients with ischemic strokes, LHI was associated with increased clinical management and direct healthcare resource burden in real-world hospital settings. The burden was substantially increased among patients who developed cerebral edema.

Cost-per-remitter with esketamine nasal spray versus standard of care for treatment-resistant depression

Aim: Estimate the cost-per-remitter with esketamine nasal spray plus an oral antidepressant (ESK + oral AD) versus oral AD plus nasal placebo (oral AD + PBO) among patients with treatment-resistant depression. Patients & methods: An Excel-based model was developed to estimate the cost-per-remitter for ESK + oral AD versus oral AD + PBO over 52 weeks from multiple US payer perspectives. Clinical end points and cost inputs were derived from clinical trials and the literature, respectively. Results: Under the base-case scenario, the cost-per-remitter for ESK + oral AD and oral AD + PBO were as follows: Commercial: US$85,808 versus US$100,198; Medicaid: US$76,236 versus US$96,067; Veteran's Affairs: US$77,765 versus US$104,519; and Integrated Delivery Network: US$103,924 versus US$142,766. Conclusion: The findings suggest that ESK + oral AD is a cost-efficient alternative treatment for treatment-resistant depression compared with oral AD + PBO.

Disease severity at the time of initial cognitive assessment is related to prior health-care resource use burden

INTRODUCTION

Research has shown increased health-care resource use (HRU) among patients with Alzheimer's disease and related disorders (ADRD) well before diagnosis, but the degree to which HRU is correlated with disease severity at the time of initial assessment is not well documented.

METHODS

Retrospective analysis of linked medical records and claims data for three cohorts: mild ADRD (first [index] Mini-Mental State Examination [MMSE] ≥20), moderate/severe ADRD (index MMSE < 20), controls without cognitive impairment. HRU during the pre-index year was compared using multivariate regressions.

RESULTS

ADRD cohorts had significantly (P < .01) higher HRU than controls. Compared to mild ADRD patients, moderate/severe ADRD patients had higher rates of hospitalizations (relative risk [RR]: 1.57), emergency department visits (RR: 1.36), potentially avoidable hospitalizations (RR: 1.72), and accidental falls (RR: 1.58).

DISCUSSION

HRU before initial assessment increases with disease severity at the time of assessment, highlighting the need for timely evaluation and improved management in the earliest stages of ADRD.

Abstract WP370: Inpatient Outcomes and Resource Utilization Among Patients With Large Hemispheric Infarction Who Developed Cerebral Edema: An Analysis of U.S. Real-World Data

Introduction: Patients with large hemispheric infarction (LHI) may suffer from life-threatening complications, including cerebral edema. Published data among these patients in real-world settings are limited. This study describes inpatient outcomes and resource utilization associated with cerebral edema among hospitalized patients with LHI.

Methods: A retrospective cohort study was conducted using the MarketScan Hospital Drug Database (2015Q3-2017Q4). As infarct volume is not captured in the data, patients were included based on diagnosis codes for infarction of the middle cerebral artery or carotid artery, which are most closely associated with LHI. Within this group, cerebral edema was determined based on a diagnosis code of cerebral edema (ICD-10-CM G93.6) or herniation (G93.5), or a craniectomy procedure. Logistic regressions, comparing patients with edema vs. those without edema, were used to estimate the odds ratio of death, ICU admission, and tracheostomy/intubation during the hospital stay. Linear regression models were used to estimate the mean difference in length of hospital stay, length of ICU stay, and hospital charges. All models controlled for age, sex, and admission type.

Results: A total of 11,772 patients were designated as likely LHI cases; 869 (7%) were identified with cerebral edema. Table 1 compares inpatient outcomes and resource utilization in patients with vs. without cerebral edema. Patients with cerebral edema had significantly higher odds of death, ICU admission and tracheostomy/intubation. They also had longer hospital stays, longer stays in the ICU, and higher hospital charges.

Conclusion: This study provides evidence in a real-world setting, highlighting the substantial clinical and economic burden associated with cerebral edema among patients hospitalized with LHI. Given the unmet needs, management strategies and interventions focusing on reducing cerebral edema among patients with LHI are warranted.

Temporal and Geographic Variation in the Incidence of Alzheimer's Disease Diagnosis in the US between 2007 and 2014

OBJECTIVES

Our aim was to describe the incidence of Alzheimer's disease (AD) in the United States, overall and by geographic region.

DESIGN

We conducted retrospective analyses of administrative claims data for a 5% random sample of US Medicare beneficiaries aged 65 years or older. AD incidence, defined as a diagnosis for AD (International Classification of Disease, Ninth Revision, Clinical Modification code 331.0×) in a given year, with no AD diagnosis in the beneficiary's entire medical history, was estimated for each calendar year between 2007 and 2014. Beneficiaries were required to be enrolled in Medicare for the calendar year of evaluation as well as the preceding 12 months. In addition, a cross-sectional assessment of geographic variation in AD incidence was conducted for 2014. For each population area (specifically, core-based statistical area, as defined by the US Census Bureau), AD incidence was estimated overall, as well as adjusted for differences in underlying patient demographics and metrics of access to care and quality of care. Changes in AD incidence from 2007 were also estimated.

SETTING

US fee-for-service Medicare.

PARTICIPANTS

US Medicare beneficiaries aged 65 years or older with no history of AD.

RESULTS

Overall, the diagnosed incidence of AD decreased over time, from 1.53% in 2007 to 1.09% in 2014; trends were similar for most population areas. In 2014, the rates of AD incidence ranged from 0% to more than 3% across population areas, with the highest observed incidence rates in areas of the Midwest and the South. Statistical models explain little of the geographic variation, although following adjustment, the incidence rates increased the most (in relative terms) in rural areas of western states.

CONCLUSION

Our findings are consistent with previously reported estimates of incidence of AD in the United States and its recent declining trend. Additionally, the study highlights the considerable geographic variation in the incidence of AD in the United States and suggests that further research is needed to better understand the determinants of this geographic variation. J Am Geriatr Soc 68:346-353, 2020.

Trends in health service use and potentially avoidable hospitalizations before Alzheimer's disease diagnosis: A matched, retrospective study of US Medicare beneficiaries

INTRODUCTION

This study evaluates rates of all-cause emergency department visits, all-cause hospitalizations, potentially avoidable hospitalizations, and falls in 3 years preceding Alzheimer's disease (AD) diagnosis.

METHODS

Patients with AD and controls with no cognitive impairment were identified from the Medicare claims data. Patients were required to be aged ≥ 65 years and have continuous Medicare enrollment for ≥4 years before the index date (AD cohort: first AD diagnosis in 2012-2014; controls: randomly selected medical claim). Outcomes for each preindex year were compared among propensity score-matched cohorts.

RESULTS

Each year, before index, patients with AD were more likely to have all-cause emergency department visits, all-cause hospitalizations, potentially avoidable hospitalizations, and falls (P < .05 for all comparisons) than matched controls (N = 19,679 pairs). Increasing absolute and relative risks over time were observed for all outcomes.

DISCUSSION

The study findings highlight the growing burden of illness before AD diagnosis and emphasize the need for timely recognition and management of patients with AD.

Economic and clinical benefits of early identification of acute kidney injury using a urinary biomarker

Purpose: To evaluate the budget impact of adding a diagnostic test of tissue inhibitor of metalloproteinase 2 and insulin-like growth factor binding protein 7 ([TIMP-2]·[IGFBP7]), which identifies patients at risk of moderate-to-severe acute kidney injury (AKI), to the current standard of care (SOC) in a hospital setting.Materials and methods: A budget impact model (2017 USD) was developed from the perspective of a hypothetical US hospital system serving 10,000 inpatients annually. The model estimated the impact of assessing the risk of AKI using SOC vs a combination of SOC and the US Food and Drug Administration-approved assay [TIMP-2]·[IGFBP7] over a 1-year period. Potential cost implications were assessed using estimates for payer mix among patients, diagnostic efficacy, and patient healthcare resource utilization. The model also considered provider adoption rates and the estimated costs of [TIMP-2]·[IGFBP7].Results: Compared to SOC alone, adding [TIMP-2]·[IGFBP7] to SOC was associated with a $1,855 reduction in uncompensated care per patient tested, which, after accounting for the additional costs of the test ($277), resulted in net savings of $1,578 per patient tested. The findings were robust to input parameter variations, as demonstrated by deterministic and probabilistic sensitivity analyses. In the probabilistic sensitivity analyses, net cost savings to the hospital ranged from $50,308-$3,971,514, or $101-$7,943 per tested patient (mean = $1,710; 95% confidence interval = $1,691-$1,729).Conclusions: The introduction of [TIMP-2]·[IGFBP7] as a novel tool in the identification of AKI risk may result in considerable cost savings from a hospital perspective under this model's base-case assumptions. Further prospective studies are needed to confirm these findings in a real-world setting.Key points for decision makersAn economic model was constructed to determine the budget impact of adding a diagnostic test ([TIMP-2]·[IGFBP7]), which identifies patients at risk of moderate-to-severe acute kidney injury, to the current standard of care (SOC) in a hospital setting.According to the present model, the use of [TIMP-2]·[IGFBP7] to identify acute kidney injury risk may reduce costs for hospitals by ∼$1,578 per patient tested.

Disease severity and minimal clinically important differences in clinical outcome assessments for Alzheimer's disease clinical trials

Introduction

This study estimated the minimal clinically important difference (MCID) for Mini Mental State Examination, Clinical Dementia Rating Scale sum of boxes, and Functional Activities Questionnaire across the Alzheimer's disease (AD) spectrum.

Methods

Retrospective analysis of the National Alzheimer's Coordinating Center Uniform Data Set (9/2005-9/2016) and MCID for clinical outcomes were estimated using anchor-based (clinician's assessment of meaningful decline) and distribution-based (1/2 baseline standard deviation) approaches, stratified by severity of cognitive impairment.

Results

On average, a 1-3 point decrease in Mini Mental State Examination, 1-2 point increase in Clinical Dementia Scale sum of boxes, and 3-5 point increase in Functional Activities Questionnaire were indicative of a meaningful decline. The MCID values generally increased by disease severity; the effect size and standardized response mean for those with meaningful decline were consistently in the acceptable ranges for MCID.

Discussion

These findings can inform design and interpretation of future clinical trials.

Procalcitonin guidance in patients with lower respiratory tract infections: a systematic review and meta-analysis

Although effective for bacterial lower respiratory tract infections (LRTIs), antibiotic treatment is often incorrectly prescribed for non-bacterial LRTIs. Procalcitonin has emerged as a promising biomarker to diagnose bacterial infections and guide antibiotic treatment decisions. As part of a regulatory submission to the U.S. Food and Drug Administration, this systematic review and meta-analysis summarizes the effects of procalcitonin-guided antibiotic stewardship on antibiotic use and clinical outcomes in adult LRTI patients. PubMed and the Cochrane Database of Systematic Reviews were searched for English-language randomized controlled trials published between January 2004 and May 2016. Random and fixed effects meta-analyses were performed to study efficacy (initiation of antibiotics, antibiotic use) and safety (mortality, length of hospital stay). Eleven trials were retained, comprising 4090 patients. Procalcitonin-guided patients had lower odds of antibiotic initiation (odds ratio: 0.26; 95% confidence interval [CI]: 0.13-0.52) and shorter mean antibiotic use (weighted mean difference: -2.15 days; 95% CI: -3.30 to -0.99) compared to patients treated with standard care. Procalcitonin use had no adverse impact on mortality (relative risk: 0.94; 95% CI: 0.69-1.28) and length of hospital stay (weighted mean difference: -0.15 days; 95% CI: -0.60 to 0.30). Procalcitonin guidance reduces antibiotic initiation and use among adults with LRTIs with no apparent adverse impact on length of hospital stay or mortality.

The Economic Burden of Abuse of Prescription Opioids: A Systematic Literature Review from 2012 to 2017

BACKGROUND

Abuse of prescription opioids [opioid use disorder (OUD), poisoning, and fatal and non-fatal overdose] is a public health and economic challenge that is associated with considerable morbidity and mortality in the USA and globally.

OBJECTIVE

To systematically review and summarize the health economics literature published over the last 5 years that describes the economic burden of abuse of prescription opioids.

METHODS

Findings from searches of databases including MEDLINE, Embase, and Cochrane CENTRAL as well as hand searches of multiple conference abstracts were screened against predefined inclusion criteria to identify studies reporting cost and healthcare resource utilization (HRU) data associated with abuse of prescription opioids.

RESULTS

A total of 49 unique studies were identified. Most of the studies examined direct costs and HRU, which were substantially higher for abusers of prescription opioids than non-abuser controls in several matched cohort analyses (US$20,343-US$28,718 vs US$9716-US$14,079 for mean direct combined annual healthcare costs reported in 6 studies). Although only a small number of studies reported indirect costs, these findings suggest a high societal burden related to productivity losses, absenteeism, morbidity, and mortality among those who abuse opioids. Studies of medication-assisted treatment demonstrated that factors such as adherence, dose, formulation (film or tablet), and relapse during treatment, were associated with direct costs and HRU among treated patients.

CONCLUSIONS

This systematic literature review shows that abuse of prescription opioids is characterized by substantial direct healthcare costs, medical utilization, and related societal costs. Future research should further investigate the indirect costs of opioid abuse.

Time to Treatment Intensification After Monotherapy Failure and Its Association With Subsequent Glycemic Control Among 93,515 Patients With Type 2 Diabetes

OBJECTIVE

The goal of this study was to evaluate the association between the timing of treatment intensification and subsequent glycemic control among patients with type 2 diabetes in whom monotherapy fails.

RESEARCH DESIGN AND METHODS

This retrospective analysis of the U.K. Clinical Practice Research Datalink database focused on patients with type 2 diabetes and one or more HbA_1c measurements ≥7% (≥53 mmol/mol) after ≥3 months of metformin or sulfonylurea monotherapy (first measurement meeting these criteria was taken as the study index date). Baseline (6 months before the index date) characteristics were stratified by time from the index date to intensification (early: <12 months; intermediate: 12 to <24 months; late: 24 to <36 months). Intensification was defined as initiating after the index date one or more noninsulin antidiabetes medication in addition to metformin or a sulfonylurea. Association between time to intensification and subsequent glycemic control (first HbA_1c <7% [<53 mmol/mol] after intensification) was evaluated using Kaplan-Meier analyses and Cox proportional hazard models that accounted for baseline differences.

RESULTS

Of the 93,515 patients who met the study criteria (mean age 60 years; ∼59% male; 80% taking metformin), 23,761 (25%) intensified <12 months after the index date; 11,908 (13%) intensified after 12 to <24 months; and 7,146 (8%) intensified after 24 to <36 months. Patients who intensified treatment ≥36 months after the index date (n = 9,638 [10%]) and those with no evidence of treatment intensification during the observable follow-up period (n = 41,062 [44%]) were not included in further analyses. The median times from intensification to control were 20.0, 24.1, and 25.7 months, respectively, for the early, intermediate, and late intensification cohorts. After adjustment for baseline differences, the likelihood of attaining glycemic control was 22% and 28% lower for patients in the intermediate and late intensification groups, respectively, compared with those intensifying early (P < 0.0001).

CONCLUSIONS

Earlier treatment intensification is associated with shorter time to subsequent glycemic control, independent of whether patients initiate first-line treatment with metformin or a sulfonylurea.

The Economic Burden of Abuse of Prescription Opioids: A Systematic Literature Review from 2012 to 2017

BACKGROUND

Abuse of prescription opioids [opioid use disorder (OUD), poisoning, and fatal and non-fatal overdose] is a public health and economic challenge that is associated with considerable morbidity and mortality in the USA and globally.

OBJECTIVE

To systematically review and summarize the health economics literature published over the last 5 years that describes the economic burden of abuse of prescription opioids.

METHODS

Findings from searches of databases including MEDLINE, Embase, and Cochrane CENTRAL as well as hand searches of multiple conference abstracts were screened against predefined inclusion criteria to identify studies reporting cost and healthcare resource utilization (HRU) data associated with abuse of prescription opioids.

RESULTS

A total of 49 unique studies were identified. Most of the studies examined direct costs and HRU, which were substantially higher for abusers of prescription opioids than non-abuser controls in several matched cohort analyses (US$20,343-US$28,718 vs US$9716-US$14,079 for mean direct combined annual healthcare costs reported in 6 studies). Although only a small number of studies reported indirect costs, these findings suggest a high societal burden related to productivity losses, absenteeism, morbidity, and mortality among those who abuse opioids. Studies of medication-assisted treatment demonstrated that factors such as adherence, dose, formulation (film or tablet), and relapse during treatment, were associated with direct costs and HRU among treated patients.

CONCLUSIONS

This systematic literature review shows that abuse of prescription opioids is characterized by substantial direct healthcare costs, medical utilization, and related societal costs. Future research should further investigate the indirect costs of opioid abuse.

Reliability of coded data to identify earliest indications of cognitive decline, cognitive evaluation and Alzheimer's disease diagnosis: a pilot study in England

OBJECTIVES

Evaluate the reliability of using diagnosis codes and prescription data to identify the timing of symptomatic onset, cognitive assessment and diagnosis of Alzheimer's disease (AD) among patients diagnosed with AD.

METHODS

This was a retrospective cohort study using the UK Clinical Practice Research Datalink (CPRD). The study cohort consisted of a random sample of 50 patients with first AD diagnosis in 2010-2013. Additionally, patients were required to have a valid text-field code and a hospital episode or a referral in the 3 years before the first AD diagnosis. The earliest indications of cognitive impairment, cognitive assessment and AD diagnosis were identified using two approaches: (1) using an algorithm based on diagnostic codes and prescription drug information and (2) using information compiled from manual review of both text-based and coded data. The reliability of the code-based algorithm for identifying the earliest dates of the three measures described earlier was evaluated relative to the comprehensive second approach. Additionally, common cognitive assessments (with and without results) were described for both approaches.

RESULTS

The two approaches identified the same first dates of cognitive symptoms in 33 (66%) of the 50 patients, first cognitive assessment in 29 (58%) patients and first AD diagnosis in 43 (86%) patients. Allowing for the dates from the two approaches to be within 30 days, the code-based algorithm's success rates increased to 74%, 70% and 94%, respectively. Mini-Mental State Examination was the most commonly observed cognitive assessment in both approaches; however, of the 53 tests performed, only 19 results were observed in the coded data.

CONCLUSIONS

The code-based algorithm shows promise for identifying the first AD diagnosis. However, the reliability of using coded data to identify earliest indications of cognitive impairment and cognitive assessments is questionable. Additionally, CPRD is not a recommended data source to identify results of cognitive assessments.

Excess Costs Associated with Possible Misdiagnosis of Alzheimer's Disease Among Patients with Vascular Dementia in a UK CPRD Population

BACKGROUND

Prior diagnosis of Alzheimer's disease (AD) among patients later diagnosed with vascular dementia (VaD) has been associated with excess costs, suggesting potential benefits of earlier rule-out of AD diagnosis.

OBJECTIVE

To investigate whether prior diagnosis with AD among patients with VaD is associated with excess costs in the UK.

METHODS

Patients with a final VaD diagnosis, continuous data visibility for≥6 months prior to index date, and linkage to Hospital Episode Statistics data were retrospectively selected from de-identified Clinical Practice Research Datalink data. Patients with AD diagnosis before a final VaD diagnosis were matched to similar patients with no prior AD diagnosis using propensity score methods. Annual excess healthcare costs were calculated for 5 years post-index, stratified by time to final diagnosis.

RESULTS

Of 9,311 patients with VaD, 508 (6%) had prior AD diagnosis with a median time to VaD diagnosis exceeding 2 years from index date. Over the entire follow-up period, patients with prior AD diagnosis had accumulated healthcare costs that were approximately GBP2,000 higher than those for matched counterparts (mostly due to higher hospitalization costs). Cost differentials peaked particularly in the period including the final VaD diagnosis, with excess costs quickly declining thereafter.

CONCLUSION

Potential misdiagnosis of AD among UK patients with VaD resulted in substantial excess costs. The decline in excess costs following a final VaD diagnosis suggests potential benefits from earlier rule-out of AD.

Patient Characteristics and Outcomes Associated with Receiving an Earlier Versus Later Diagnosis of Probable Alzheimer's Disease

BACKGROUND

Effectiveness of Alzheimer's disease (AD) treatments may depend critically on the timeliness of intervention.

OBJECTIVE

To compare characteristics and outcomes of patients diagnosed with probable AD (prAD) based on time elapsed from first onset of cognitive decline.

METHODS

Patients with ≥1 prAD diagnosis and ≥1 follow-up visit were selected from the National Alzheimer's Coordinating Center (NACC) Uniform Data Set (UDS; 9/2005-6/2015) and stratified based on the time between the perceived onset of cognitive decline at baseline and first prAD diagnosis (i.e., earlier versus later diagnosis). Characteristics at baseline and prAD diagnosis, clinically meaningful progression, and medication use following prAD diagnosis were compared.

RESULTS

Median time from perceived onset of cognitive decline to prAD diagnosis was 4.5 years (earlier diagnosis: ≤3.46; later diagnosis: >5.71). Earlier-diagnosed patients (n = 1,476) were younger at baseline (74.3 versus 76.3 years) and had better cognitive and functional scores than later-diagnosed patients (n = 1,474). At first prAD diagnosis, earlier-diagnosed patients had lower mean global Clinical Dementia Rating (CDR) score (0.8 versus 1.1), higher mean Mini-Mental State Examination (MMSE) (22.6 versus 20.0), and lower mean Functional Activities Questionnaire (11.6 versus 17.3). Earlier- and later-diagnosed patients experienced similar time to a decrease of ≥3 points in MMSE (median 23.2 versus 23.1 months, p = 0.83), but earlier-diagnosed patients had longer time to a CDR score of ≥2 points, and longer times to initiation of AD medication and antipsychotic agents (all p < 0.01).

CONCLUSION

Earlier prAD diagnosis in NACC data is associated with higher cognitive function and lower functional impairment at diagnosis.

Opioid Abuse: A Detailed Examination of Cost Drivers over a 24-Month Follow-up Period

BACKGROUND

Previous work has documented the considerable economic burden associated with opioid abuse, dependence, and overdose/poisoning (hereafter, "abuse"). Recent analyses have provided insights into the trajectory and drivers of the excess costs of abuse both before and after diagnosis, showing the important role of other substance abuse, mental health issues, and painful conditions.

OBJECTIVE

To build on the recently published study by Kirson et al. (2017) and extend its findings by (a) evaluating the trajectory of excess costs of abuse for an additional year after an incident abuse diagnosis and (b) exploring the diagnosis-level drivers of excess costs over time in greater detail.

METHODS

Using administrative medical and pharmacy claims, which included payment amounts, for beneficiaries covered by large self-insured companies throughout the United States, abusers were matched to controls using the same methods as in Kirson et al. Excess health care costs were assessed over a 24-month follow-up period, which comprised the 6 months before the initial abuse diagnosis and the 18 months after. Drivers of excess costs were then evaluated by diagnosis (grouped at the 3-digit ICD-9-CM level).

RESULTS

This study analyzed 9,345 matched pairs of abusers and non-abusers. Similar to the previous study, mean per-patient excess health care costs were found to rise considerably leading up to and shortly after the incident diagnosis of abuse, reaching $15,764 over the first half of the follow-up period. Over the newly extended follow-up period (months 6 to 18 after diagnosis), excess costs remained elevated ($7,346) and did not return to baseline levels. Over time, an increasing share of excess costs was observed for outpatient services and prescription drug use, relative to acute care settings. A detailed examination of cost drivers suggested elevated costs in several clinical categories (e.g., gastrointestinal, respiratory conditions) beyond those previously identified.

CONCLUSIONS

This research finds that the excess medical costs of abuse extend for at least 1 more year than previously documented, reflecting the need for considerable follow-up care over time. The identification of several other clinical categories with elevated excess costs suggests important areas for future research into the interaction of opioid abuse with the management of other conditions.

DISCLOSURES

This study was funded by Purdue Pharma. Howard was an employee of Purdue Pharma at the time that this study was conducted. Kirson, Scarpati, Jia, and Wen are employees of Analysis Group, which received funding from Purdue Pharma to conduct this study. Study concept and design were contributed by Kirson, Scarpati, and Howard, along with Jia and Wen. Jia and Wen took the lead in data collection, with assistance from Scarpati and Kirson. Data interpretation was performed by Scarpati, Kirson, and Howard, with assistance from Jia and Wen. The manuscript was written and revised by Scarpati, Kirson, and Howard.

Drivers of excess costs of opioid abuse among a commercially insured population

OBJECTIVES

To replicate and extend a recently published analysis of the drivers of excess costs of opioid abuse.

STUDY DESIGN

Retrospective data analysis using de-identified claims data from the Truven MarketScan Commercial Claims and Encounter database.

METHODS

Medical and prescription drug claims from beneficiaries covered by large self-insured US companies were used to select patients with incident diagnoses of opioid abuse between 2012 and 2015. Two cohorts, abusers and nonabusers, were matched using propensity score methods. Excess healthcare costs were estimated over a 6-month baseline period and 12-month follow-up period. Cost drivers were assessed by diagnosis (3-digit International Classification of Diseases, Ninth Revision, Clinical Modification groupings) and place of service.

RESULTS

The analysis included 73,714 matched pairs of abusers and nonabusers. Relative to nonabusers, abusers had considerably higher annual healthcare costs of $10,989 per patient, or $1.98 per member per month. Excess costs were similar, yet lower, than the previous analysis using another commercial claims database. In both analyses, a ramp-up in excess costs was observed prior to the incident abuse diagnosis, followed by a decline post diagnosis, although not to baseline levels. Key drivers of excess costs in the 2 studies included opioid use disorders, nonopioid substance misuse, and painful and mental health conditions. From 2010 to 2014, the prevalence of diagnosed opioid abuse doubled, with incidence rates exhibiting an increasing, though flatter, trend than earlier in the period.

CONCLUSIONS

Opioid abuse imposes a considerable economic burden on payers. Many abusers have complex healthcare needs and may require care beyond that which is required to treat opioid abuse. These results are robust and consistent across different data sources.

Basal Insulin Persistence, Associated Factors, and Outcomes After Treatment Initiation: A Retrospective Database Study Among People with Type 2 Diabetes Mellitus in Japan

INTRODUCTION

The objective of this study was to assess basal insulin persistence, associated factors, and economic outcomes for insulin-naïve people with type 2 diabetes mellitus (T2DM) in Japan.

METHODS

People aged at least 18 years with T2DM with first claim for basal insulin between May 2006 and April 2013 (index date), no insulin use before index date, and continuous insurance coverage for 6 months before (baseline) and 12 months after index date were selected from the Japan Medical Center Database. On the basis of whether there were at least 30-day gaps in basal insulin treatment, patients were classified as continuers (no gap), interrupters (at least one prescription after gap), and discontinuers (no prescription after gap). A multinomial logistic regression model identified factors associated with persistence. Annual healthcare resource use and costs in the year after initiation were compared between continuers and interrupters and between continuers and discontinuers using propensity score-based inverse probability weighting to adjust for baseline differences.

RESULTS

Of the 827 people included (mean age 50 years, ca. 71% male), 36% continued, 42% interrupted, and 22% discontinued basal insulin therapy in the year after initiation. Having at least one inpatient visit and using fewer classes of non-insulin antihyperglycemic medications during baseline were associated with lower likelihoods of continuing therapy. Relative to interrupters and discontinuers, continuers had lower hospitalization rates [continuers, 12.7%; interrupters, 25.4% (p < 0.001); discontinuers, 28.4% (p < 0.001)] and lower inpatient costs [continuers, ¥132,013; interrupters, ¥225,745 (p = 0.054); discontinuers, ¥320,582 (p = 0.036)], but higher pharmacy costs [continuers, ¥158,403; interrupters, ¥134,301 (p = 0.039); discontinuers, ¥121,593 (p = 0.002)] in the year after insulin initiation. Total healthcare costs were similar for the three cohorts.

CONCLUSIONS

Substantial proportions of people with T2DM in Japan interrupt or discontinue basal insulin within the year after initiation, and they have higher rates and costs of hospitalizations than patients who continue with their insulin therapy. Further research is needed to understand reasons behind basal insulin persistence and the implications thereof to help clinicians manage T2DM more effectively.

FUNDING

Eli Lilly and Company, Boehringer Ingelheim.

The Economic Burden of Opioid Abuse: Updated Findings

BACKGROUND

Opioid pain relievers can be highly effective in providing relief for patients suffering from pain. At the same time, prescription opioid abuse, dependence, overdose, and poisoning (hereinafter "abuse") have become a national public health concern. Opioid abuse is also costly: previous estimates of the annual excess costs of opioid abuse to payers range from approximately $10,000 to $20,000 per patient.

OBJECTIVES

To (a) provide a comprehensive, current estimate of the economic burden of opioid abuse to commercial payers and (b) explore the drivers of these excess costs of abuse.

METHODS

Administrative claims from beneficiaries covered by large self-insured companies throughout the United States were used to identify patients diagnosed with opioid abuse, dependence, and overdose/poisoning ("abuse") between 2012 and 2015. Sample selection criteria identified patients most likely to be misusing opioids. Abusers and nonabuser controls were matched using propensity scores. Excess health care costs were assessed over the 18-month study period. Drivers of excess costs were then evaluated by place of service and medical condition (identified as 3-digit ICD-9-CM groupings).

RESULTS

9,342 matched abuser/nonabuser pairs were analyzed. Relative to nonabusers, abusers had significantly higher annual health care resource utilization, leading to $14,810 in per-patient incremental annual health care costs. Excess costs began accumulating 5 months before the formal, incident diagnosis of abuse, driven by alcohol and nonopioid substance abuse. Major drivers of excess costs of abuse included opioid and other substance abuse disorders, mental health conditions, and painful conditions. Many patients had diagnoses for other substance abuse that predated their opioid abuse diagnoses.

CONCLUSIONS

Opioid abuse imposes a substantial economic burden on payers and often occurs in the context of other substance abuse. Poly-substance abuse often precedes the diagnosis of opioid abuse.

DISCLOSURES

This study was funded by Purdue Pharma. Mayne is an employee of Purdue Pharma. Kirson, Scarpati, and Birnbaum are employees of Analysis Group, which received funding from Purdue Pharma to conduct this study. Enloe and Dincer were employees of Analysis Group at the time this research was conducted. Study concept and design were contributed by Kirson, Birnbaum, Mayne, and Scarpati, along with Enloe and Dincer. Enloe and Dincer took the lead in data collection, along with Birnbaum and assisted by Kirson and Scarpati. Data interpretation was performed by all the authors. The manuscript was written and revised by Kirson and Scarpati, along with Mayne and Birnbaum.

Functional limitations and health care resource utilization for individuals with cognitive impairment without dementia: Findings from a United States population-based survey

Introduction

Little is known about functional limitations and health care resource utilization of people with cognitive impairment with no dementia (CIND).

Methods

Respondents with stable or progressive cognitive impairment (CI) after the first (index) indication of CIND in 2000–2010 were identified from the Health and Retirement Study (HRS). Respondents never exhibiting CI were identified as potential controls. Propensity score–based optimal matching was used to adjust for differences in demographics and history of stroke. Differences between cohorts were assessed accounting for HRS survey design.

Results

After matching, CIND respondents had more functional limitations (difficulty with ≥1 activities of daily living: 24% vs. 15%; ≥1 instrumental activities of daily living: 20% vs. 11%) and hospital stays (37% vs. 27%) than respondents with no CI (all P < .001). Seventy five percent of CIND respondents developed dementia in the observable follow-up (median time: ∼6 years).

Discussion

Even before dementia onset, CI is associated with increased likelihood of functional limitations and greater health care resource use.

Assessing the economic burden of Alzheimer's disease patients first diagnosed by specialists

Background

It is not known if there is a differential impact on Alzheimer’s disease (AD) diagnosis and outcomes if/when patients are diagnosed with cognitive decline by specialists versus non-specialists. This study examined the cost trajectories of Medicare beneficiaries initially diagnosed by specialists compared to similar patients who received their diagnosis in primary care settings.

Methods

Patients with ≥2 claims for AD were selected from de-identified administrative claims data for US Medicare beneficiaries (5 % random sample). The earliest observed diagnosis of cognitive decline served as the index date. Patients were required to have continuous Medicare coverage for ≥12 months pre-index (baseline) and ≥12 months following the first AD diagnosis, allowing for up to 3 years from index to AD diagnosis. Time from index date to AD diagnosis was compared between those diagnosed by specialists (i.e., neurologist, psychiatrist, or geriatrician) versus non-specialists using Kaplan-Meier analyses with log-rank tests. Patient demographics, Charlson Comorbidity Index (CCI) during baseline, and annual all-cause medical costs (reimbursed by Medicare) in baseline and follow-up periods were compared across propensity-score matched cohorts.

Results

Patients first diagnosed with cognitive decline by specialists (n = 2593) were younger (78.8 versus 80.8 years old), more likely to be male (40 % versus 34 %), and had higher CCI scores and higher medical costs at baseline than those diagnosed by non-specialists (n = 13,961). However, patients diagnosed by specialists had a significantly shorter time to AD diagnosis, both before and after matching (mean [after matching]: 3.5 versus 4.6 months, p < 0.0001). In addition, patients diagnosed by specialists had significantly lower average total all-cause medical costs in the first 12 months after their index date, a finding that persisted after matching ($19,824 versus $25,863, p < 0.0001). Total per-patient annual medical costs were similar for the two groups starting in the second year post-index.

Conclusions

Before and after matching, patients diagnosed by a specialist had a shorter time to AD diagnosis and incurred lower costs in the year following the initial cognitive decline diagnosis. Differences in costs converged during subsequent years. This suggests that seeking care from specialists may yield more timely diagnosis, appropriate care and reduced costs among those with cognitive decline.

Characteristics of High-Cost Patients Diagnosed with Opioid Abuse

BACKGROUND

Prescription opioid abuse is associated with substantial economic burden, with estimates of incremental annual per-patient health care costs of diagnosed opioid abuse exceeding $10,000 in prior literature. A subset of patients diagnosed with opioid abuse has disproportionately high health care costs, but little is known about the characteristics of these patients. 

OBJECTIVE

To describe the characteristics of a subset of patients diagnosed with opioid abuse with disproportionately high health care costs to assist physicians and managed care organizations in targeting interventions at the costliest patients.

METHODS

This retrospective claims data analysis identified patients aged 12 to 64 years diagnosed with opioid abuse/dependence in the OptumHealth Reporting and Insights medical and pharmacy claims database, Quarter 1 (Q1) 1999-Q1 2012. Inclusion criteria required that patients had a diagnosis of opioid abuse during or after Q1 2006, no prior diagnoses of opioid abuse, and continuous non-HMO coverage over an 18-month study period. The study period comprised a 12-month observation period centered on the date of the first opioid abuse diagnosis (index date) and a 6-month baseline period immediately preceding the observation period. Patients in the top 20% of total health care costs in the observation period were classified as "high-cost patients," and the remaining patients were classified as "lower-cost patients." Patient characteristics, comorbidities, health care resource use, and health care costs were compared between high-cost patients and lower-cost patients using chi-square tests for dichotomous variables and Wilcoxon rank-sum tests for continuous variables. In addition, multivariate regression was used to assess the relationship between patient characteristics in the baseline period and total health care costs in the observation period among all patients diagnosed with opioid abuse. 

RESULTS

9,291 patients diagnosed with opioid abuse met the inclusion criteria. The 20% of patients classified as high-cost patients accounted for approximately two thirds of the total health care costs of patients diagnosed with opioid abuse. Compared with lower-cost patients, high-cost patients were older (42.5 vs. 36.1; P  less than  0.001) and more likely to be female (55.9% vs. 42.9%; P  less than  0.001). They had a higher comorbidity burden at baseline, as reflected in the Charlson Comorbidity Index (0.8 vs. 0.2; P  less than  0.001), and rates of conditions such as chronic pulmonary disease (12.9% vs. 5.6%; P  less than  0.001) and mild/moderate diabetes (8.4% vs. 3.4%; P  less than  0.001). High-cost patients also had higher rates of nonopioid substance abuse diagnoses (12.4% vs. 8.9%; P  less than  0.001) and psychotic disorders (26.5% vs. 13.6%; P  less than  0.001). In the observation period, high-cost patients continued to have higher rates of nonopioid substance abuse diagnoses (53.0% vs. 47.2%; P  less than  0.001) and psychotic disorders (67.1% vs. 47.5%; P  less than  0.001). In addition, they had greater medical resource use across all places of service (i.e., inpatient, emergency department, outpatient, drug/alcohol rehabilitation facility, and other) compared with lower-cost patients. The mean observation period health care costs of high-cost patients was $89,177 compared with $11,653 for lower-cost patients (P  less than  0.001). High-cost patients had higher medical costs linked to claims with an opioid abuse diagnosis in absolute terms, but the share of total medical costs attributed to such claims was lower among high-cost patients than among lower-cost patients. While many baseline characteristics were found to have a statistically significant (P  less than  0.05) association with observation period health care costs, only 27.3% of the variation in observation period health care costs was explained by patient characteristics in the baseline period.

CONCLUSIONS

This study found that the costliest patients diagnosed with opioid abuse had high rates of preexisting and concurrent chronic comorbidities and mental health conditions, suggesting potential indicators for targeted intervention and a need for greater awareness and screening of comorbid conditions. Opioid abuse may exacerbate existing conditions and make it difficult for patients to adhere to treatment plans for those underlying conditions. Baseline patient characteristics explained only a small share of the variation in observation period health care costs, however. Future research should explore the degree to which other factors not captured in administrative claims data (e.g., severity of abuse) can explain the wide variation in health care costs among opioid abusers.

Basal insulin persistence, associated factors, and outcomes after treatment initiation among people with type 2 diabetes mellitus in the US

OBJECTIVE

To assess basal insulin persistence, associated factors, and economic outcomes for insulin-naïve people with type 2 diabetes mellitus (T2DM) in the US.

RESEARCH DESIGN AND METHODS

People aged ≥18 years diagnosed with T2DM initiating basal insulin between April 2006 and March 2012 (index date), no prior insulin use, and continuous insurance coverage for 6 months before (baseline) and 24 months after index date (follow-up period) were selected using de-identified administrative claims data in the US. Based on whether there were ≥30 day gaps in basal insulin use in the first year post-index, patients were classified as continuers (no gap), interrupters (≥1 prescription after gap), and discontinuers (no prescription after gap).

MAIN OUTCOME MEASURES

Factors associated with persistence - assessed using multinomial logistic regression model; annual healthcare resource use and costs during follow-up period - compared separately between continuers and interrupters, and continuers and discontinuers.

RESULTS

Of the 19,110 people included in the sample (mean age: 59 years, ∼60% male), 20% continued to use basal insulin, 62% had ≥1 interruption, and 18% discontinued therapy in the year after initiation. Older age, multiple antihyperglycemic drug use, and injectable antihyperglycemic use during baseline were associated with significantly higher likelihoods of continuing basal insulin. Relative to interrupters and discontinuers, continuers had fewer emergency department visits, shorter hospital stays, and lower medical costs (continuers: $10,890, interrupters: $13,674, discontinuers: $13,021), but higher pharmacy costs (continuers: $7449, interrupters: $5239, discontinuers: $4857) in the first year post-index (p < 0.05 for all comparisons). Total healthcare costs were similar across the three cohorts. Findings for the second year post-index were similar.

CONCLUSIONS

The majority of people in this study interrupted or discontinued basal insulin treatment in the year after initiation; and incurred higher medical resource use and costs than continuers. The findings are limited to the commercially insured population in the US. In addition, persistence patterns were assessed using administrative claims as opposed to actual medication-taking behavior and did not account for measures of glycemic control. Further research is needed to understand the reasons behind basal insulin persistence and the implications thereof, to help clinicians manage care for T2DM more effectively.

Estimating the health care burden of prescription opioid abuse in five European countries

Background

Opioid abuse, including abuse of prescription opioids (“RxOs”) and illicit substances like heroin, is a serious public health issue in Europe. Currently, there is limited data on the magnitude of RxO abuse in Europe, despite increasing public and scientific interest in the issue. The purpose of this study was to use the best-available data to derive comparable estimates of the health care burden of RxO abuse in France, Germany, Italy, Spain, and the United Kingdom (EU5).

Methods

Published data on the prevalence of problem opioid use and the share of opioid abuse patients reporting misuse of non-heroin opioids were used to estimate the prevalence of RxO abuse in the EU5 countries. The costs of RxO abuse were calculated by applying published estimates of the incremental health care costs of opioid abuse to country-specific estimates of the costs of chronic pain conditions. These estimates were input into an economic model that quantified the health care burden of RxO abuse in each of the EU5 countries. Sensitivity analyses examined key assumptions.

Results

Based on best-available current data, prevalence estimates of RxO abuse ranged from 0.7 to 13.7 per 10,000 individuals across the EU5 countries. Estimates of the incremental health care costs of RxO abuse ranged from €900 to €2,551 per patient per year. The annual health care cost burden of RxO abuse ranged from €6,264 to €279,927 per 100,000 individuals across the EU5 countries.

Conclusion

This study suggests that RxO abuse imposes a cost burden on health systems in the five largest European countries. The extent of RxO abuse in Europe should be monitored given the potential for change over time. Continued efforts should be made to collect reliable data on the prevalence and costs of RxO abuse in Europe to facilitate an accurate characterization of the extent of this potentially growing problem.

The Burden of Undiagnosed Opioid Abuse Among Commercially Insured Individuals

OBJECTIVES

Estimate the prevalence and healthcare costs of undiagnosed opioid abuse among commercially insured individuals.

STUDY DESIGN

Retrospective analysis of de-identified pharmacy and medical claims data and publicly-available survey data (no IRB approval required).

METHODS

This study focused on commercially insured individuals. Rates of prescription pain-reliever abuse/dependence ("abuse") among individuals ages ≥12 were calculated using National Survey on Drug Use and Health (NSDUH) public-use data for 2006-2011 and assumed to capture both diagnosed and undiagnosed opioid abuse. Rates of undiagnosed opioid abuse were calculated as the difference between NSDUH rates and published rates of diagnosed opioid abuse. OptumHealth Reporting and Insights claims data were used to estimate the healthcare costs of undiagnosed abuse. Diagnosed abusers ages 12-64 were identified using ICD-9-CM diagnosis codes for opioid abuse/dependence. Pre-diagnosis costs were assumed to be a proxy for undiagnosed opioid abuse costs. The ratio of undiagnosed to diagnosed abuse costs was calculated as the ratio of annual per-patient healthcare costs between pre-diagnosis and post-diagnosis periods.

RESULTS

While rates of diagnosed opioid abuse among commercially insured individuals increased from 0.07% in 2006 to 0.19% in 2011, rates of undiagnosed abuse decreased from 0.42% to 0.38% over the same time period. Annual per-patient healthcare costs of undiagnosed abusers were 69.2% of those of diagnosed abusers.

CONCLUSIONS

Per-patient healthcare costs of undiagnosed abusers among the commercially insured are estimated to be lower than those of diagnosed abusers. However, the higher prevalence of undiagnosed opioid abuse implies that undiagnosed abuse represents a substantial burden to commercial payers.

Sources of prescription opioids among diagnosed opioid abusers

OBJECTIVE

Diversion and abuse of prescription opioids are important public health concerns in the US. This study examined possible sources of prescription opioids among patients diagnosed with opioid abuse.

METHODS

Commercially insured patients aged 12-64 diagnosed with opioid abuse/dependence ('abuse') were identified in OptumHealth Reporting and Insights medical and pharmacy claims data, 2006-2012, and required to have continuous eligibility over an 18 month study period surrounding the first abuse diagnosis. We examined whether abusers had access to prescription opioids through their own prescriptions and/or to diverted prescription opioids through family members' prescriptions obtained prior to the abuser's first abuse diagnosis. For comparison, we examined access to prescription opioids of a reference population of non-abusers. Sensitivity analyses focused on patients initially diagnosed with opioid dependence and, separately, abusers not previously treated with buprenorphine.

RESULTS

Of the 9291 abusers meeting the selection criteria, 79.9% had an opioid prescription prior to their first abuse diagnosis; 20.1% of abusers did not have an opioid prescription prior to their first abuse diagnosis, of whom approximately half (50.8%) had a family member who had an opioid prescription prior to the abuser's first abuse diagnosis (compared to 42.2% of non-abusers). Similar results were found among patients initially diagnosed with opioid dependence and among abusers not previously treated with buprenorphine.

LIMITATIONS

The study relied on the accuracy of claims data to identify abusers, but opioid abuse is often undiagnosed. In addition, only prescription claims that were reimbursed by a health plan were included in the analysis.

CONCLUSIONS

While most abusers had access to prescription opioids through their own prescriptions, many abusers without their own opioid prescriptions had access to prescription opioids through family members and may have obtained prescription opioids that way. Given the study design and data source, this is likely a conservative estimate of prescription opioid diversion.

Medical resource use and costs among pain patients with potential opioid-tolerability issues

OBJECTIVE

To estimate excess medical resource use and costs associated with prescription opioid (RxO) tolerability issues.

DESIGN

This was an observational, retrospective analysis of deidentified administrative claims data.

SETTING

The study included commercially insured patients treated in different healthcare settings captured in the Truven MarketScan claims database.

PATIENTS

Patients aged 18-64 years initiating treatment with an RxO (index) and continuously treated with pain relievers over a 6-month period were selected. "Switchers" were patients who discontinued their index RxO and switched to non-RxO pain relievers < 30 days post-index, and whose last pain reliever in the 6-month follow-up period was not an RxO. Such switching was considered a proxy for RxO-tolerability issues. "Continuous RxO users" were patients who remained on the index RxO for the follow-up period. Switchers and continuous RxO users were matched 1:1 on propensity score, baseline medical costs, index RxO days supply, and short-/long-acting index RxO.

MAIN OUTCOME MEASURES

Six-month follow-up medical resource use and costs were compared between matched switchers and continuous RxO users.

RESULTS

A total of 10,704 pairs of switchers and continuous RxO users were matched. In the 6-month follow-up period, switchers had more outpatient (7.5 vs 6.8; p < 0.001) and inpatient (0.05 vs 0.04; p = 0.002) visits and longer inpatient stays (0.26 days vs 0.19; p = 0.006) compared to continuous RxO users. Switchers also had higher total medical costs ($4,522 vs $3,657; p < 0.001).

CONCLUSIONS

Switchers incur greater medical resource use and costs than similar patients continuously treated with their index RxO.

The economic burden of diagnosed opioid abuse among commercially insured individuals

The abuse of prescription opioids imposes a substantial public health and economic burden. Recent research using administrative claims data has substantiated the prevalence and cost of opioid abuse among commercially insured individuals. Although administrative claims data are readily available and have been used to effectively answer research questions about the burden of illness for many different conditions, an important issue is the reliability, replicability, and generalizability of estimates derived from different databases. Therefore, this study sought to assess whether the findings of a recently published study of opioid abuse in a commercial claims database (original analysis) could be replicated in a different commercial claims database. The original analysis, which analyzed the prevalence and excess health care costs of diagnosed opioid abuse in the OptumHealth Reporting and Insights Database, was replicated by applying the same approach to the Truven MarketScan Commercial Claims and Encounters Database (replication analysis). In the replication analysis, the prevalence of diagnosed opioid abuse increased steadily from 15.8 diagnosed opioid abusers per 10,000 in 2009, to 26.6 diagnosed opioid abusers per 10,000 in 2012. Although the prevalence of diagnosed opioid abuse was higher than reported in the original analysis, the trend of increasing prevalence over time was consistent across analyses. Additionally, diagnosed abusers had excess annual per patient health care costs of $11,376 in the replication analysis, which was consistent with the excess annual per patient health care costs of diagnosed abuse of $10,627 reported in the original analysis. The replication analysis also found an upward trend in the prevalence of diagnosed opioid abuse over time and substantial excess annual per patient health care costs of diagnosed opioid abuse among commercially insured individuals, suggesting that these findings are generalizable to other commercially insured populations.

Estimating the costs of opioid abuse and dependence from an employer perspective: a retrospective analysis using administrative claims data

BACKGROUND

Opioid abuse and dependence is problematic across many age groups, including the working-age population and their dependents. Little is known, however, about the economic costs of opioid abuse/dependence imposed on employers, who pay for a substantial portion of healthcare costs through their contributions to employer-sponsored health insurance and are also affected by indirect costs such as those due to disability and workplace absenteeism.

OBJECTIVE

To provide a comprehensive, current estimate of the economic burden of prescription opioid abuse/dependence to employers.

METHODS

Administrative claims from beneficiaries covered by large self-insured companies throughout the USA were used to identify patients, including employees and dependents, who were diagnosed with opioid abuse and/or dependence ('abusers') between 2006 and 2012. Healthcare and work-loss costs for abusers were assessed over a 12-month period and compared with those for patients not diagnosed with abuse ('comparison patients'), using propensity score matching.

RESULTS

7,658 matched pairs of abusers and comparison patients were analysed. Relative to comparison patients, abusers had significantly higher annual healthcare resource utilization, leading to US$10,627 in per-patient incremental annual healthcare costs. Additionally, abusers had US$1,244 in excess annual work-loss costs. Together, this implies an employer burden for diagnosed abuse of US$1.71 per member per month.

CONCLUSION

Opioid abuse/dependence impose a substantial economic burden on employers.

Use of prescription opioids with abuse-deterrent technology to address opioid abuse

OBJECTIVE

The development of new formulations of extended-release (ER) opioids with abuse-deterrent technology attempts to deter prescription opioid abuse while maintaining appropriate access to care for pain patients. This study examined the degree to which some patients may avoid switching to reformulated ER opioids with abuse-deterrent technology and the extent to which those patients are more likely to be abusers.

RESEARCH DESIGN AND METHODS

We analyzed Truven MarketScan pharmacy and medical claims data following the introduction of two reformulated ER opioids with abuse-deterrent technology. Adults aged 18-64 who were continuous users of extended-release oxycodone HCl (ER oxycodone) or extended-release oxymorphone HCl (ER oxymorphone) in a 6 month period prior to the introduction of the respective reformulations of those products were identified and categorized based on whether they switched to the reformulation, switched to other ER/long-acting (LA) opioids (without abuse-deterrent technology), or discontinued ER/LA opioid treatment in a 6 month post-reformulation period. Abusers were identified using ICD-9-CM diagnosis codes for opioid abuse/dependence. Pearson's chi-squared tests and Fisher's exact tests were then used to compare rates of abuse between patients who avoided switching to a reformulated ER opioid. Sensitivity analyses examined several definitions used in this analysis.

MAIN OUTCOME MEASURES

ER/LA opioid utilization; rates of diagnosed opioid abuse.

RESULTS

A total of 31%-50% of patients avoided switching to reformulated ER opioids. Rates of diagnosed opioid abuse were higher among these patients compared to patients who transitioned to the reformulated ER opioids.

LIMITATIONS

Due to the observational research design, caution is warranted in causal interpretation of the findings. The study was conducted among commercially insured continuous ER oxycodone or ER oxymorphone users; future research should consider additional patient populations, such as non-continuous users and those without commercial insurance (i.e., Medicare, Medicaid, uninsured).

CONCLUSIONS

Some patients switched to other ER/LA opioids without abuse-deterrent technology or discontinued ER/LA opioid treatment when their existing ER treatment was reformulated. Rates of opioid abuse were higher among patients who switched to other ER/LA opioids or discontinued ER/LA opioid treatment, suggesting that abusers may seek more easily abuseable alternatives such as prescription opioids without abuse-deterrent technology.

Medical cost savings associated with an extended-release opioid with abuse-deterrent technology in the US

OBJECTIVES

In the US, prescription opioids with technology designed to deter abuse have been introduced to deter drug abuse without hindering appropriate access for pain patients. The objective of this study was to estimate changes in medical costs following the introduction of a new formulation of extended-release (ER) oxycodone HCl (oxycodone) with abuse-deterrent technology in the US.

METHODS

Health insurance claims data were used to estimate changes in rates of diagnosed opioid abuse among continuous users of extended-release opioids (EROs) following the introduction of reformulated ER oxycodone in August 2010. This study also calculated the excess medical costs of diagnosed opioid abuse using a propensity score matching approach. These findings were integrated with published government reports and literature to extrapolate the findings to the national level. All costs were inflated to 2011 US dollars.

RESULTS

The introduction of reformulated ER oxycodone was associated with relative reductions in rates of diagnosed opioid abuse of 22.7% (p < 0.001) and 18.0% (p = 0.034) among commercially-insured and Medicaid patients, respectively. There was no significant change among Medicare-eligible patients. The excess annual per-patient medical costs associated with diagnosed opioid abuse were $9456 (p < 0.001), $10,046 (p < 0.001), and $11,501 (p < 0.001) for commercially-insured, Medicare-eligible, and Medicaid patients, respectively. Overall, reformulated ER oxycodone was associated with annual medical cost savings of ∼$430 million in the US.

LIMITATIONS

Because of the observational research design of this study, caution is warranted in any causal interpretation of the findings. Portions of the study relied on prior literature, government reports, and assumptions to extrapolate the national medical cost savings.

CONCLUSIONS

This study provides evidence that reformulated ER oxycodone has been associated with reductions in abuse rates and substantial medical cost savings. Payers and policy-makers should consider these benefits as they devise and implement new guidelines and policies in this therapeutic area.

Pre-diagnosis excess acute care costs in Alzheimer's patients among a US Medicaid population

BACKGROUND AND OBJECTIVES

Prior research has documented that Alzheimer's disease (AD) is associated with increased costs from comorbid conditions. However, little is known about medical resource utilization and costs among AD patients prior to the onset of cognitive symptoms. This study estimates excess acute care costs among Medicaid AD patients in the year prior to diagnosis.

STUDY DESIGN

Administrative claims data for New Jersey Medicaid patients over the period 1997-2010 were retrospectively analyzed. The study focused on non-institutionalized AD patients and examined their medical costs compared with matched controls with no dementia over the 12 months prior to their preliminary diagnosis. Costs reflect amounts reimbursed by Medicaid to medical service providers, reported in 2010 US dollars.

RESULTS

The study sample included 11,536 AD patients who were matched to controls. Average age was 76 years, and 76.2 % were female. Compared with matched controls, total medical costs over the 12-month pre-index period were US$ 5,549 higher among AD patients (US$ 14,977 vs. US$ 9,428, p < 0.001), of which US$ 3,321 (p < 0.001) was due to outpatient services. Home care and medical daycare services accounted for US $1,442 (p < 0.001) of the difference. Emergency department visits and inpatient care accounted for only a small fraction of the excess costs.

CONCLUSIONS

Compared with controls, Medicaid AD patients incurred higher acute care costs in the 12 months prior to their preliminary diagnosis, suggesting room for beneficial interventions and better disease management should earlier diagnosis become possible. These findings may be especially relevant in light of new criteria facilitating earlier diagnosis of AD.

Efficacy and effectiveness of depot versus oral antipsychotics in schizophrenia: synthesizing results across different research designs

OBJECTIVE

Nonadherence is a major challenge in schizophrenia treatment. While long-acting (depot) antipsychotic medications are often recommended to address adherence problems, evidence on the comparative effectiveness of depot versus oral antipsychotics is inconsistent. We hypothesize that this inconsistency could be due to systematic differences in study design. This review evaluates the effect of study design on the comparative effectiveness of antipsychotic formulations. The optimal use of different antipsychotic formulations in a general clinical setting depends on better understanding of the underlying reasons for differences in effectiveness across research designs.

DATA SOURCES

A PubMed literature review targeted English-language studies (2000-2011) with information on relapse, hospitalization, or all-cause discontinuation for depot and oral antipsychotic treatment arms in schizophrenia. The time frame was chosen to reflect research focused on the newer generation of antipsychotic agents. The search required at least 1 term from each of the following categories: (1) schizophrenia; (2) inject, injection, injectable, injectables, injected, depot, long-acting; and (3) iloperidone, fluphenazine, haloperidol, paliperidone, risperidone, olanzapine, asenapine, flupentixol, flupenthixol, lurasidone, clopenthixol, fluspirilene, zuclopentixol, zuclopenthixol.

STUDY SELECTION

Thirteen relevant studies were identified by 2 independent reviewers; these studies included information on 19 depot-oral comparisons.

DATA EXTRACTION

Age- and gender-adjusted risk ratios (RRs) (depot/oral) were calculated for the identified endpoints and pooled by study design (randomized controlled trial [RCT], prospective observational, and retrospective observational). Meta-analysis with random effects was used to estimate the pooled RRs, by study design. Average conversion factors between study designs were calculated as the ratios of pooled RRs.

RESULTS

Meta-analysis of adjusted endpoints showed no apparent benefit of depot over oral formulations in RCTs, with an RR of 0.89 (P = .416). In contrast, there was a significant advantage for depot formulations in other study designs (prospective RR = 0.62 [P < .001]; retrospective RR = 0.56 [P < .001]). These imply conversion factors of 1.43 and 1.59 between RCTs and prospective and retrospective designs, respectively.

CONCLUSIONS

The comparative effectiveness of antipsychotic formulations is sensitive to research design. Depot formulations displayed significant advantages in nonrandomized observational studies, whereas in RCTs no difference was observed. The estimated conversion factors may facilitate comparison across studies.

Matching-adjusted indirect comparison of adalimumab vs etanercept and infliximab for the treatment of psoriatic arthritis

OBJECTIVES

No head-to-head trial has compared the efficacy of adalimumab vs etanercept and infliximab for psoriatic arthritis (PsA). This study implements a matching-adjusted indirect comparison technique to address that gap.

METHODS

Patient-level data from a placebo-controlled trial of adalimumab (ADEPT) were re-weighted to match average baseline characteristics from pivotal published trials of etanercept and infliximab. ADEPT patients were re-weighted by odds of enrollment in comparator trials, estimated using logistic regression. Matched-on characteristics included PsA duration, age, gender, severity, active psoriasis, and concomitant treatment. After matching, placebo-adjusted treatment arms were compared at weeks 12 (or 14) and 24. Outcomes included ACR20/50/70, PsARC, HAQ, and modified TSS. PASI50/75/90 were compared for patients with active psoriasis. Cost per responder (CPR) was assessed in the US and Germany using matching-adjusted end-points and drug list prices. Statistical significance was assessed using weighted t-tests.

RESULTS

After matching, adalimumab-treated patients had greater placebo-adjusted rates of ACR70 and PASI50/75/90 at week 24 compared with etanercept (all p < 0.05). Adalimumab patients had a higher placebo-adjusted rate of ACR70 than infliximab at week 14 (p = 0.034). Adalimumab treatment had lower CPR for ACR70 and PASI50/75/90 compared with etanercept at week 24, in both the US and Germany (all p < 0.02). Adalimumab had lower CPR than infliximab for all outcomes at week 24 (all p < 0.05).

CONCLUSION

Adalimumab is associated with higher ACR70 and PASI50/75/90 response rates than etanercept at week 24 and a higher ACR70 response rate than infliximab at week 14. Adalimumab has significant advantages over etanercept and infliximab in CPR across multiple end-points.

KEY LIMITATIONS

The matching-adjusted indirect comparison method cannot account for unobserved differences in patient characteristics across trials, and only a head-to-head randomized clinical trial can fully avoid the limitations of indirect comparisons. CPR findings are limited to the US and German markets, and may not be generalizable to other markets with different relative pricing.

Direct and indirect costs of patients treated with extended-release oxymorphone HCl or controlled-release oxycodone HCl

OBJECTIVE

Compare direct and indirect costs of oxymorphone extended-release ('oxymorphone') and oxycodone controlled-release ('oxycodone') users.

METHODS

Patients, aged 18+, with ≥1 claim for oxymorphone/oxycodone, Q2:2006-Q4:2009, were selected from a de-identified private payer claims database and observed from the first such claim ('index date') until the earliest of: use of comparator drug; end of continuous eligibility; 12 months ('study period'). Patients with claims for any formulation of the comparator drug during the first 30 days of the study period were excluded. Direct (medical and drug) costs paid by private insurers were reported for patients aged 18-64 (n = 8354) and 65+(n = 3515), as well as sub-sets without cancer (n = 7090 and n = 2444, respectively). Indirect costs (medically-related absenteeism and disability) were reported for all employees, aged 18-64 (n = 1313), and employees without cancer (n = 1146). Multivariate models were used to estimate risk-adjusted costs controlling for patient characteristics.

RESULTS

Oxymorphone users, aged 18-64, had lower drug costs ($693 vs $763, p = 0.0035) and similar medical costs ($1875 vs $1976, p = 0.3570) per patient-month compared with oxycodone users (mean follow-up 236 and 280 days, respectively). Indirect costs were not different ($662 vs $670, p = 0.9370). Oxymorphone users, aged 65+, had similar Medicare supplemental drug costs ($533 vs $588, p = 0.0840) and lower medical costs ($459 vs $747, p < 0.0001). Results were comparable for subsets without cancer.

LIMITATIONS

Patients with concomitant use of oxymorphone and oxycodone were excluded.

CONCLUSIONS

Oxymorphone users incur lower risk-adjusted costs in several cost categories, compared with oxycodone users, and no higher costs in any of the examined categories.

Excess costs associated with patients with chronic thromboembolic pulmonary hypertension in a US privately insured population

BACKGROUND

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and potentially fatal disease. Little is known about the economic burden associated with CTEPH patients in the US.

OBJECTIVES

The objective of this study was to estimate excess direct costs associated with privately insured patients with CTEPH in the US.

METHODS

From a privately insured claims database (>8 million beneficiaries, 2002-7), 289 CTEPH patients were identified using the criteria: two or more claims for pulmonary hypertension (PH), International Classification of Diseases, ninth edition, clinical modification (ICD-9-CM) code 416.0 or 416.8; one or more claim for pulmonary embolism (ICD-9-CM: 415.1, V12.51; ICD-9 procedure: 38.7; Current Procedural Terminology [CPT]-4 code: 36010, 37620, 75825, 75940; Healthcare Common Procedure Coding System [HCPCS] code: C1880) within 12 months prior or 1 month after the initial PH claim (index date); one or more claim for right heart catheterization (RHC) within 6 months prior to any PH claim or one or more claim for echocardiogram within 6 months prior to a specialist-diagnosed PH claim; aged 18-64 years. Patients with CTEPH were matched demographically to controls without PH. Patients were followed as long as continuously eligible; mean follow-up in CTEPH patients was 21.5 months. Chi-squared tests were used to compare baseline co-morbidities. Wilcoxon rank-sum tests were used to compare direct (medical and pharmaceutical) patient-month costs to insurers.

RESULTS

The average age for CTEPH patients was 52.2 years, and 57.1% were women. Compared with controls, CTEPH patients had significantly higher baseline rates of co-morbidities (e.g. essential hypertension, congestive heart failure and chronic pulmonary disease) and a higher mean Charlson Co-morbidity Index score. Mean direct patient-month costs (year 2007 values) were $US4782 for CTEPH patients and $US511 for controls (p < 0.0001). Sensitivity analysis restricting the sample to patients diagnosed following RHC yielded a 15% increase in excess costs relative to the original sample. Regarding cost drivers, inpatient services accounted for 54%, outpatient and other services for 33% and prescription drugs for 11% of total direct healthcare costs per patient-month in CTEPH patients. Circulatory-/respiratory-related patient-month costs were $US2496 among CTEPH patients and $US128 among controls (p < 0.0001).

CONCLUSIONS

CTEPH patients had substantially higher costs and co-morbidity than matched controls, with circulatory-/respiratory-related costs accounting for 55% of excess costs. The high burden of illness suggests opportunities for savings from improved management.

Excess costs associated with patients with pulmonary arterial hypertension in a US privately insured population

BACKGROUND

Pulmonary arterial hypertension (PAH) is a rare but fatal disease. Little is known about the economic burden associated with PAH patients in the US.

OBJECTIVES

The objective of this study was to estimate excess direct costs associated with privately insured PAH patients in the US.

METHODS

From a privately insured claims database (>8 million beneficiaries, 2002-7), 471 patients with PAH were identified using the criteria: two or more claims for primary pulmonary hypertension (PH), International Classification of Diseases, ninth edition, clinical modification (ICD-9-CM) code 416.0; no left heart disease, lung diseases, chronic thromboembolic PH or miscellaneous PH diagnoses within 12 months prior or 1 month after the initial PH claim (index date); one or more claim for right heart catheterization (RHC) within 6 months prior to any PH claim or one or more claim for echocardiogram within 6 months prior to a specialist-diagnosed PH claim; aged 18-64 years. Patients with PAH were matched demographically to controls without PH. Patients were followed as long as continuously eligible; mean follow-up of PAH patients was 24.8 months. Chi-squared tests were used to compare baseline co-morbidities. Wilcoxon rank-sum tests were used to compare direct (medical and pharmaceutical) patient-month costs to insurers.

RESULTS

The average age for PAH patients was 52.2 years, and 55.8% were women. Compared with controls, PAH patients had significantly higher baseline rates of co-morbidities (e.g. essential hypertension, diabetes mellitus and congestive heart failure) and a higher mean Charlson Co-morbidity Index score. Mean direct patient-month costs (year 2007 values) were $US2023 for PAH patients and $US498 for controls (p < 0.0001), yielding excess costs of $US1525. Sensitivity analysis restricting the sample to patients diagnosed following RHC yielded a 64% increase in excess costs relative to the original sample. Regarding cost drivers, inpatient services accounted for 45%, outpatient and other services for 38% and prescription drugs for 15% of total direct healthcare costs per patient-month in PAH patients. Circulatory/respiratory system-related patient-month costs were $US724 among PAH patients and $US114 among controls (p < 0.0001).

CONCLUSIONS

Patients with PAH had substantially higher costs and co-morbidity than controls, with circulatory/respiratory system-related costs accounting for 40% of excess costs. The high burden of illness suggests opportunities for savings from improved management.

Prevalence of pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension in the United States

BACKGROUND

The prevalence of pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) in the US is largely unknown. Prior research has estimated PAH prevalence in Europe at ∼15-52 per million.

METHODS

Using a privately insured claims database (1999-2007) for the under age 65 population and a Medicare claims database for the 65+ population, and following the current clinical classification of PH, CTEPH patients were identified as having: ≥2 claims for pulmonary hypertension (PH) [ICD-9-CM: 416.0, 416.8]; ≥1 claim for pulmonary embolism (PE) ≤12 months prior or 1 month after the initial PH claim (index date). PAH patients were identified: ≥2 claims for primary PH [416.0]; no left heart disease, lung diseases, CTEPH, or miscellaneous PH diagnoses ≤12 months prior or 1 month after the index date. Both cohorts were required to have ≥1 claim for right heart catheterization ≤6 months prior to any PH claim, or ≥1 claim for echocardiogram ≤6 months prior to a specialist-diagnosed PH claim. Age- and gender-standardized prevalence rates per million individuals (PMI) were calculated using appropriate population weights.

RESULTS

Prevalence rates (95% CI) of CTEPH were estimated at 63 (34-91) PMI among the privately insured (<65), and 1007 (904-1111) PMI among the Medicare population (≥65). The corresponding estimates for PAH were 109 (71-146) PMI among the <65 population, and 451 (384-519) PMI for Medicare.

LIMITATIONS

Identification of PAH and CTEPH patients in administrative claims data is challenging, due to lack of specific ICD-9-CM codes for the conditions and risk of misdiagnosis.

CONCLUSIONS

Prevalence rates of CTEPH and PAH increase with age, and are higher among women. The increased risk of PE may explain the sharp age gradient for CTEPH prevalence. The estimated US prevalence of PAH is higher than existing estimates.