Greater need for treatment optimization in patients with epilepsy initiating adjunctive therapy: Results of a retrospective claims analysis of antiseizure medication drug load in the United States

BACKGROUND

This retrospective, observational study used US claims data to assess changes in antiseizure medication (ASM) drug load for a cohort of patients with epilepsy.

METHODS

Adults (≥18 years) with a diagnosis of epilepsy (ICD-10 code G40.xxx) who started new adjunctive ASM treatment with one of 4 branded (brivaracetam, eslicarbazepine, lacosamide, perampanel) or 4 unbranded (carbamazepine, lamotrigine, levetiracetam, topiramate) ASMs between January 1, 2016 and December 31, 2020 were identified from IBM MarketScan® research databases (primary study population). Patients must have been continuously enrolled 360 days before the start of the new ASM (eligibility period). Follow-up was from the start of new ASM until Day 540 (∼18 months). The primary endpoint was concomitant ASM drug load, which included all ASMs except the new (comparator) ASM. A sensitivity analysis population included adults with epilepsy who were continuously enrolled for ≥ 180 days during at least one calendar year in the study period (2016-2020), whether or not the comparator ASM was new or existing during that period. Total ASM drug load, which included comparator ASM and concomitant ASMs, was assessed in the sensitivity analysis population.

RESULTS

In total, 21,332 patients were included in the primary study population, of which 5767 initiated branded ASMs and 15,565 initiated unbranded ASMs. A total of 392,426 patients were included in the sensitivity analysis population during at least one calendar year 2016-2020. Concomitant ASM drug load increased in the 360 days prior to new ASM start and slightly declined thereafter. Mean concomitant ASM drug load for the primary population was 1.6 (SD 1.8) at new ASM start. Concomitant drug load was higher among those starting branded ASM comparators compared to those starting unbranded comparators. Mean total ASM drug load for patients increased over time and was approximately double for patients exposed to branded ASMs (mean range 2.1 to 2.7) compared to that of patients exposed to any unbranded ASM (mean range 1.0 to 1.3).

CONCLUSION

Concomitant ASM drug load increased prior to addition of new ASM, with higher increases observed among patients starting branded vs unbranded ASMs, followed by slight decreases thereafter. Total drug load increased linearly among all patients. These findings underscore the need for ongoing ASM regimen evaluation and treatment optimization in patients with epilepsy.

Incidence of mental health conditions by seizure control among adults with epilepsy in the United States

BACKGROUND

Mental health conditions (MHCs) are frequent comorbidities among people with epilepsy; however, the influence of seizure control on the incidence of MHCs is not well reported. This retrospective observational cohort study based on claims data evaluated the effects of indicators of poor seizure control on the incidence of MHCs among MHC-naïve people with epilepsy. We hypothesized that poor seizure control is associated with new-onset MHC diagnoses and/or new prescription drugs for MHCs.

METHODS

This study utilized a sample of patients from HealthVerity Marketplace, which includes more than 150 US commercial, Medicare, and Medicaid payers, to identify a cohort of adults (age ≥18 years) with prevalent epilepsy. Follow-up started on day 1 (January 1) after a 1-year eligibility assessment period occurring in calendar year 2017 or 2018. Patients were followed up until the occurrence of an incident MHC event (primary outcome), defined as a mental health diagnosis or psychotropic drug prescription. Time from follow-up to incident MHC diagnosis or to a drug prescription specific to depression or anxiety disorder was analyzed as a secondary outcome. Multivariate Cox proportional hazards regressions were estimated with time-varying covariates, measured in 6-month intervals during follow-up. Time-varying covariates were based on the occurrence of 4 variables used as indicators of poor seizure control in the prior period: epilepsy-related emergent care admissions, epilepsy-related inpatient admissions, epilepsy electroencephalography referrals, and exposure to one or more new antiseizure medications (ASMs).

RESULTS

From a random sample of 40,000 people with epilepsy, 2563 (mean age 46.1 years; 50.6% male) were included in the analysis. Incident MHC events were observed in 27.7% (incidence rate 24.4 events per 100 person-years over 2,915.7 total person-years of follow-up). Mean (standard deviation [SD]) time to event was 232.7 (186.3) days. Among the 4 variables, epilepsy-related emergent care admissions were associated with an increased risk of incident MHC events in the following 6-month period (hazard ratio [HR] = 1.676, 95% confidence interval [CI]: 1.386, 2.026, p < 0.001) as were prescriptions for new ASMs in the previous period (HR = 1.702, 95% CI: 1.359, 2.132, p < 0.001). Previous epilepsy-related emergent care admissions (HR = 1.650, 95% CI: 1.347, 2.021, p < 0.001) and new ASMs (HR = 1.632, 95% CI: 1.280, 2.081, p < 0.001) also predicted an increased risk of incident depression or anxiety in the following 6-month period.

CONCLUSIONS

Previous indicators of poor seizure control, including epilepsy-related emergent care admissions and new ASMs, predicted increased risk of new MHC events, including depression and anxiety, during the following 6-month interval in MHC-naïve patients with prevalent epilepsy. These data suggest that poor seizure control can increase the subsequent risk of new mental health diagnoses and treatment among people with epilepsy.

Indirect treatment comparison of cenobamate to other ASMs for the treatment of uncontrolled focal seizures

OBJECTIVE

The efficacy and safety of cenobamate relative to other antiseizure medications (ASMs) has not been evaluated. An indirect treatment comparison (network meta-analysis) was performed to determine if adjunctive cenobamate increases the odds ratio (OR) for ≥50% responder rate or for withdrawals due to treatment-emergent adverse events (TEAEs) leading to ASM discontinuation versus adjunctive therapy with other ASMs.

METHODS

A systematic literature review was conducted to identify randomized, double-blind, placebo-controlled trials (maintenance phase ≥ 12 weeks) assessing adjunctive ASMs in adults with uncontrolled focal seizures. Cenobamate was compared to a group of seven other ASMs, and to subgroups of branded (brivaracetam, eslicarbazepine acetate, lacosamide, and perampanel) and older (lamotrigine, levetiracetam, and topiramate) ASMs at FDA-recommended daily maintenance doses (FDA-RDMD), at all doses, and at maximum and minimum daily doses. Statistical significance was set at p < 0.05.

RESULTS

Twenty-one studies were eligible for analysis. The placebo-adjusted ≥ 50% responder rate for FDA-RDMD of cenobamate was superior (OR 4.200; 95% CI 2.279, 7.742) to FDA-RDMD of all seven assessed (OR 2.202 95% CI 1.915, 2.532; p = 0.044) and branded ASMs (OR 2.148; 95% CI 1.849, 2.494; p = 0.037). There was no significant difference for ≥50% responder rate between FDA-RDMD of cenobamate and FDA-RDMD of older ASMs (OR 2.617; 95% CI 1.767, 3.878; p = 0.202). No significant differences were identified for ≥50% responder rate when comparing all doses and maximum/minimum doses of cenobamate to all seven, branded, and older ASMs. Cenobamate demonstrated comparable TEAE withdrawal rates to all seven ASMs, branded ASMs, and older ASMs across each of the four dose ranges (all p > 0.05).

SIGNIFICANCE

Patients receiving FDA-RDMD of cenobamate were more likely to have ≥50% seizure reduction compared with FDA-RDMD of the seven assessed ASMs and branded ASMs, without an increase in treatment discontinuation due to TEAEs.

Thromboembolic events (TE) among patients with metastatic pancreatic ductal adenocarcinoma (mPDA) after chemotherapy (Chemo)

280

Background: Clinical trials suggest that patients with mPDA are at high risk of TE from both disease and treatment. TE rates and anticoagulant use among mPDA patients after first line chemo were investigated. Methods: Medicare beneficiaries enrolled in parts A, B, and D; diagnosed with mPDA; aged ≥ 65 years; and starting chemo between 1/1/2007 and 12/31/2012 were obtained from Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Eligible patients were enrolled from 12 months before chemo and followed until death, post-chemo disenrollment, or 12/31/2012. Arterial (ICD-9 410-411, 433-434), venous (ICD-9 415.1x, 453.4x, 453.8x, 453.9), and total TE were defined as ≥ 2 outpatient diagnoses ≥ 30 days apart, one inpatient diagnosis, or one outpatient diagnosis followed by outpatient anticoagulants within 90 days. Post-chemo TE incidence was calculated as the number of first events per 100 person-years (PY) for patients with and without TE 12 months before chemo. Time from chemo to first TE was estimated using the Kaplan-Meier (KM) method. Results: Among 1,308 eligible patients, mean age was 74 years [range 65-93]; 56% were female; 85% had no prior TE. Overall, 419 (32%) had a TE after chemo including 121 (9%) arterial and 363 (28%) venous TE. The table shows incidence, and time to TE for those with and without prior TE. Outpatient anticoagulants were prescribed for 276 (25%) patients with no prior TE and 110 (57%) patients with prior TE. Table. TE incidence and time to TE among mPDA patients after chemo Conclusions: mPDA patients face a substantial risk of TE after chemo, with nearly one-third of patients without prior TE and one-half of patients with prior TE experiencing events during treatment. These high rates of TE indicate the importance of conducting risk assessments for preventive measures early during a patients’ care.[Table: see text]

What Contributes Most to High Health Care Costs? Health Care Spending in High Resource Patients

BACKGROUND

U.S. health care spending nearly doubled in the decade from 2000-2010. Although the pace of increase has moderated recently, the rate of growth of health care costs is expected to be higher than the growth in the economy for the near future. Previous studies have estimated that 5% of patients account for half of all health care costs, while the top 1% of spenders account for over 27% of costs. The distribution of health care expenditures by type of service and the prevalence of particular health conditions for these patients is not clear, and is likely to differ from the overall population.

OBJECTIVE

To examine health care spending patterns and what contributes to costs for the top 5% of managed health care users based on total expenditures.

METHODS

This retrospective observational study employed a large administrative claims database analysis of health care claims of managed care enrollees across the full age and care spectrum. Direct health care expenditures were compared during calendar year 2011 by place of service (outpatient, inpatient, and pharmacy), payer type (commercially insured, Medicare Advantage, and Medicaid managed care), and therapy area between the full population and high resource patients (HRP).

RESULTS

The mean total expenditure per HRP during calendar year 2011 was $43,104 versus $3,955 per patient for the full population. Treatment of back disorders and osteoarthritis contributed the largest share of expenditures in both HRP and the full study population, while chronic renal failure, heart disease, and some oncology treatments accounted for disproportionately higher expenditures in HRP. The share of overall expenditures attributed to inpatient services was significantly higher for HRP (40.0%) compared with the full population (24.6%), while the share of expenditures attributed to pharmacy (HRP = 18.1%, full = 21.4%) and outpatient services (HRP = 41.9%, full = 54.1%) was reduced. This pattern was observed across payer type. While the use of physician-administered pharmaceuticals was slightly higher in HRP, their use did not alter this spending pattern.

CONCLUSIONS

Overall, expenditures in the HRP population are more than 10-fold higher compared with the full population. Managed care pharmacy can benefit from understanding what contributes to these higher costs, and managed care directors should consider an appropriately balanced assessment of the share of total spend by service and therapeutic category in HRP when devising drug usage and related cost-management strategies.

Use of a validated algorithm to estimate the annual cost of effective biologic treatment for rheumatoid arthritis

OBJECTIVES

To estimate biologic cost per effectively treated patient with rheumatoid arthritis (RA) using a claims-based algorithm for effectiveness.

METHODS

Patients with RA aged 18-63 years in the IMS PharMetrics Plus database were categorized as effectively treated if they met all six criteria: (1) a medication possession ratio ≥80% (subcutaneous) or at least as many infusions as specified in US labeling (intravenous); (2) no biologic dose increase; (3) no biologic switch; (4) no new non-biologic disease-modifying anti-rheumatic drug; (5) no new or increased oral glucocorticoid; and (6) ≤1 glucocorticoid injection. Biologic cost per effectively treated patient was defined as total cost of the index biologic (drug plus intravenous administration) divided by the number of patients categorized by the algorithm as effectively treated. Similar methods were used for the index biologic in the second year and for a second biologic after a switch.

RESULTS

Rates that the index biologic was categorized as effective in the first year were 31.0% etanercept (2243/7247), 28.6% adalimumab (1426/4991), 28.6% abatacept (332/1160), 27.2% golimumab (71/261), and 20.2% infliximab (474/2352). Mean biologic cost per effectively treated patient, per the algorithm, was $50,141 etanercept, $53,386 golimumab, $56,942 adalimumab, $73,516 abatacept, and $114,089 infliximab. Biologic cost per effectively treated patient, using this algorithm, was lower for patients who continued the index biologic in the second year and higher after switching.

CONCLUSIONS

When a claims-based algorithm was applied to a large commercial claims database, etanercept was categorized as the most effective and had the lowest estimated 1-year biologic cost per effectively treated patient. This proxy for effectiveness from claims databases was validated against a clinical effectiveness scale, but analyses of the second year or the year after a biologic switch were not included in the validation. Costs of other medications were not included in cost calculations.

Estimating effectiveness and cost of biologics for rheumatoid arthritis: application of a validated algorithm to commercial insurance claims

PURPOSE

The aim of this analysis was to implement a claims-based algorithm to estimate biologic cost per effectively treated patient for biologics approved for moderate to severe rheumatoid arthritis (RA).

METHODS

This retrospective analysis included commercially insured adults (aged 18-63 years) with RA in a commercial database, who initiated biologic treatment with abatacept, adalimumab, etanercept, golimumab, or infliximab between 2007 and 2010. The algorithm defined effectiveness as having all of the following: high adherence, no biologic dose increase, no biologic switching, no new nonbiologic disease-modifying antirheumatic drug, no increased or new oral glucocorticoid use, and no more than 1 glucocorticoid injection. For each biologic, cost per effectively treated patient was defined as total drug and administration costs (from allowed amounts on claims), divided by the number of patients categorized as effectively treated.

FINDINGS

Of 15,351 patients, 12,018 (78.3%) were women, and the mean (SD) age was 49.7 (9.6) years. The algorithm categorized treatment as effective in the first year for 30% (1899/6374) of etanercept, 30% (1396/4661) of adalimumab, 20% (560/2765) of infliximab, 27% (361/1338) of abatacept, and 29% (62/213) of golimumab treated patients. The 1-year biologic cost per effectively treated patient, as defined by the algorithm, was nominally lower for subcutaneously injected biologics than for infused biologics. The 1-year biologic cost per effectively treated patient, as defined by the algorithm, was lowest for etanercept ($49,952), followed by golimumab ($50,189), adalimumab ($52,858), abatacept ($71,866), and infliximab ($104,333).

IMPLICATIONS

Algorithm-defined effectiveness was similar for biologics other than infliximab. The 1-year biologic cost per effectively treated patient, as defined by the algorithm, was nominally lower for subcutaneously injected biologics than for infused biologics.

Treatment patterns following discontinuation of adalimumab, etanercept, and infliximab in a US managed care sample

OBJECTIVES

Because clinical guidelines do not offer clear recommendations for treatment options after discontinuing a tumor necrosis factor (TNF) blocker, this study evaluated treatment patterns within 360 days after discontinuation of TNF-blocker treatment.

METHODS

The IMS LifeLink Health Plan Claims database was used to identify patients diagnosed with rheumatoid arthritis, psoriasis, psoriatic arthritis, or ankylosing spondylitis who received etanercept, adalimumab, or infliximab between January 1, 2005 and March 31, 2009. Discontinuation from index (first) TNF blocker was defined as switching to a different TNF blocker or a >45-day gap in therapy. Patients were categorized into mutually exclusive groups in descending order: (a) restart of index TNF blocker; (b) switch to another TNF blocker; (c) switch to a different biologic; (d) switch to nonbiologic therapy; or (e) no new treatment.

RESULTS

Among 27,704 patients who initiated TNF-blocker therapy, 14,707 (53%) patients discontinued treatment over 1-3 years of follow-up. Within 360 days of discontinuing index TNF blocker, 53.4% of patients restarted index therapy: etanercept 59.9%, adalimumab 46.5%, and infliximab 43.1% (P < 0.001 for etanercept vs. adalimumab and infliximab). The majority of therapy restarts occurred within the first 3 months after discontinuation. Other patients switched to another TNF blocker: etanercept 17.1%, adalimumab 19.1% (P = 0.010 vs. etanercept), and infliximab 15.0% (P = 0.009 vs. etanercept). Switches from index TNF blocker to non-TNF-blocker biologic therapy were low: etanercept 1.9%, adalimumab 4.1%, and infliximab 10.7% (P < 0.001 for etanercept vs. adalimumab and infliximab). Switches from index TNF blocker to nonbiologic treatments were 5.4% for etanercept, 6.5% for adalimumab, and 6.9% for infliximab.

CONCLUSIONS

Restarting of index TNF-blocker therapy occurs frequently after discontinuation, suggesting that long gaps in TNF-blocker therapy may be common. A significantly higher proportion of etanercept patients restarted their index TNF blocker within 3 months of discontinuation, compared with adalimumab and infliximab patients.

Costs of tumor necrosis factor blockers per treated patient using real-world drug data in a managed care population

BACKGROUND

Several anti-inflammatory biologic medications are available in the United States for the treatment of moderate-to-severe rheumatoid arthritis, moderate-to-severe psoriasis, psoriatic arthritis, or ankylosing spondylitis. The tumor necrosis factor (TNF) blockers etanercept, adalimumab, and infliximab are approved for use in adults with any of these conditions, but predicting the annual costs of TNF-blocker treatment is complex due to differences in dosing schedules, treatment gaps, switching between TNF blockers, and dose escalation over time.

OBJECTIVES

To estimate the annual cost per treated patient from the payer perspective for etanercept, adalimumab, or infliximab in adults with rheumatoid arthritis, psoriasis, psoriatic arthritis, or ankylosing spondylitis.

METHODS

Adults in the IMS LifeLink Health Plan Claims Database were analyzed if they had at least 1 claim for etanercept, adalimumab, or infliximab between February 1, 2008, and July 5, 2010, and were continuously enrolled for at least 180 days before (pre-index period) through 360 days after the index claim (the first TNF-blocker claim after 6 months of continuous enrollment in the study period). Patients had a diagnosis of rheumatoid arthritis, psoriasis, psoriatic arthritis, or ankylosing spondylitis, or a combination of these conditions, in the pre-index period. Cost was based on dose and price using April 2012 wholesale acquisition cost. Costs of administration were included for the first subcutaneous dose (etanercept or adalimumab) for new patients and for every intravenous dose (infliximab). Total TNF-blocker drug and administration costs, including nonindex TNF-blocker costs among patients who switched treatments, were divided by number of patients to yield cost per treated patient for each index TNF blocker. Subgroup analyses included cost by condition and cost for patients who were new to TNF-blocker treatment (no index TNF-blocker claim in the pre-index period) or continuing TNF-blocker treatment.

RESULTS

Of the 30,107 patients in the analysis, the majority received etanercept (15,488 patients; 51.4%), followed by adalimumab (8,959 patients; 29.8%) and infliximab (5,660 patients; 18.8%). Approximately 2 in 3 patients (18,897 patients) were continuing TNF-blocker treatment, including 66.0%, 52.6%, and 70.0% of patients in the etanercept, adalimumab, and infliximab groups, respectively. Across all indications, the annual TNF-blocker cost per treated patient was lowest for etanercept, followed by adalimumab and then infliximab, respectively: overall ($17,767, $19,272, and $24,273); new patients ($17,270, $17,959, and $21,482); and continuing patients ($18,203, $20,453, and $25,468). Cost by condition among all patients ranged from $14,838 to $20,251 for etanercept, from $18,051 to $20,233 for adalimumab, and from $22,939 to $28,519 for infliximab. Cost by condition was 3% to 31% greater for adalimumab than for etanercept (relative cost, 103% to 131%), except among patients with psoriasis (relative cost, 94%), and was 26% to 72% greater for infliximab than for etanercept (relative cost, 126% to 172%). Approximately 9% to 11% of patients in each group switched TNF blockers in the first year, and the costs of nonindex TNF blockers comprised 16.8% of the total cost for etanercept, 13.4% for adalimumab, and 6.9% for infliximab.

CONCLUSIONS

In adult patients with rheumatoid arthritis, psoriasis, psoriatic arthritis, or ankylosing spondylitis, or some combination of these conditions, etanercept had a lower cost per treated patient than adalimumab or infliximab, except in patients with psoriasis alone. In these patients, adalimumab had a lower cost per treated patient than etanercept or infliximab.

Disability outcomes and dose escalation with etanercept, adalimumab, and infliximab in rheumatoid arthritis patients: a US-based retrospective comparative effectiveness study

INTRODUCTION

Rheumatoid arthritis (RA) is a chronic disease that if left untreated may substantially impair physical functioning. Etanercept, infliximab, and adalimumab are tumor necrosis factor (TNF) blockers whose FDA-approved indications in the US include moderate to severe RA. TNF-blocker dose escalation has been well documented in the literature; however, the comparative effectiveness of these agents remains uncertain.

OBJECTIVE

To compare the effectiveness and dose escalation rates of etanercept, adalimumab, and infliximab in US community settings. We hypothesized that etanercept would be equivalent to infliximab and adalimumab in patient-reported disability 9-15 months after therapy initiation, and that fewer etanercept patients would experience dose escalation.

METHODS

This is a retrospective analysis of the Arthritis, Rheumatism, and Aging Medical Information System (ARAMIS). Adult patients with no biologic use 6 months before TNF-blocker initiation (index) and with Health Assessment Questionnaire Disability Index (HAQ-DI) scores at index and 9-15 months after index were analyzed (218 etanercept, 93 infliximab, and 40 adalimumab).

RESULTS

HAQ-DI change scores at 9-15 months did not differ by treatment (-0.12, -0.10, and -0.08 points for etanercept, infliximab, and adalimumab, respectively; p = 0.52). Dose increases were observed in 1.4% of etanercept, 10.8% of infliximab (p < 0.001), and 12.5% of adalimumab patients (p = 0.004). HAQ-DI change was associated with pre-index HAQ-DI score (p < 0.0001) and disease duration (p = 0.001).

CONCLUSIONS

Fewer etanercept patients escalated dose than infliximab or adalimumab patients, but improvements in functional disability were similar. These differences may have been influenced by package labeling, mode of administration, or other factors. RA treatment with infliximab and adalimumab in community settings, characterized by dose escalation, did not yield greater disability improvements compared to etanercept, which remained at a relatively stable dose. Uncontrolled treatment selection in this observational design may have influenced outcomes, and prior methotrexate treatment may partly explain disability improvements smaller than typically observed in clinical trials.

Exenatide BID and liraglutide QD treatment patterns among type 2 diabetes patients in Germany

OBJECTIVES

This study evaluated patient and prescriber characteristics, treatment patterns, average daily dose (ADD), and glycemic control of patients initiating glucagon-like peptide 1 (GLP-1) receptor agonists in Germany.

METHODS

The LifeLink™ EMR-EU database was searched to identify patients initiating exenatide twice daily (BID) or liraglutide once daily (QD) during the index period (January 1, 2009-April 4, 2010). Eligible patients had ≥ 180 days pre-index history, ≥ 90 days post-index follow-up, and a pre-index type 2 diabetes diagnosis. Univariate tests were conducted at α=0.05.

RESULTS

Six hundred and ninety-two patients were included (exenatide BID 292, liraglutide QD 400): mean (SD) age 59 (10) years, 59% male. Diabetologists prescribed liraglutide QD to a larger share of patients (65% vs 35% exenatide BID) than non-diabetologists (51% vs 49%). GLP-1 receptor agonist choice was not associated with age (p=0.282), gender (p=0.960), number of pre-index glucose-lowering medications (2.0 [0.9], p=0.159), pre-index HbA1c (8.2 [1.5%], p=0.231) or Charlson Comorbidity Index score (0.45 [0.78], p=0.547). Mean (SD) ADD was 16.7 mcg (9.2, label range 10-20 mcg) for exenatide BID and 1.4 mg (0.7, label range 0.6-1.8 mg) for liraglutide QD. Among patients with post-index HbA1c tests, mean unadjusted values did not differ between cohorts. Exenatide BID patients were more likely than liraglutide QD patients to continue pre-index glucose-lowering medications (67.1% vs 60.3%, p=0.027) or to start concomitant glucose-lowering medications at index (32.2% vs 25.0%, p=0.013); exenatide BID patients were less likely to augment treatment with another drug post-index (15.8% vs 22.5%, p=0.027).

LIMITATIONS

Results may not be generalizable. Lab measures for clinical outcomes were available only for a sub-set of patients.

CONCLUSIONS

Results suggested that some differences exist between patients initiating exenatide BID or liraglutide QD, with respect to prescribing physician specialty and pre- and post-index treatment patterns. Both GLP-1 receptor agonists showed comparable post-index HbA1c values in a sub-set of patients.

Annual costs of tumor necrosis factor inhibitors using real-world data in a commercially insured population in the United States

OBJECTIVE

To calculate annual cost per treated patient of tumor necrosis factor (TNF) inhibitors etanercept, adalimumab, and infliximab for common approved indications, based on actual TNF-inhibitor use in clinical practice.

METHODS

Adults with ≥1 claim for etanercept, adalimumab, or infliximab between January 2005 and March 2009 were identified from the IMS LifeLink™ Health Plan Claims Database. Patients new to therapy or continuing therapy (i.e., a prior claim for a TNF-inhibitor) were analyzed separately. Included patients had been enrolled from 180 days before the first TNF-inhibitor claim (index date) through 360 days after the index date and had a diagnosis during the pre-index period for rheumatoid arthritis, psoriasis, psoriatic arthritis, or ankylosing spondylitis. Patients with Crohn's disease, ulcerative colitis, or juvenile idiopathic arthritis were excluded. Annual costs were calculated using wholesale acquisition costs for the TNF-inhibitor and Medicare Physician Fee Schedule for drug administration. Costs from restarting or switching TNF-inhibitor therapy during the first year were included.

RESULTS

A total of 27,704 patients (11,528 new, 16,176 continuing) had claims for etanercept, adalimumab, or infliximab, most commonly (65%) for treatment of rheumatoid arthritis. The most commonly used agent was etanercept (14,777 patients; 53%), followed by adalimumab (6862 patients; 25%) and infliximab (6065 patients; 22%). Annual cost per treated patient was etanercept $14,873, adalimumab $17,766, and infliximab $21,256 across all indications. Annual cost per treated patient by disease was (etanercept/adalimumab/infliximab): rheumatoid arthritis ($14,314/$17,700/$20,390), psoriasis ($17,182/$17,682/$23,935), psoriatic arthritis ($15,030/$18,483/$24,974), and ankylosing spondylitis ($14,254/$16,925/$23,056). New and continuing patients showed similar results, with etanercept having the lowest costs.

LIMITATIONS

This analysis is limited to three TNF-inhibitors and a US managed-care population.

CONCLUSIONS

Based on this analysis of real-world use of TNF-inhibitors among patients in nationwide clinical practice settings, the annual TNF-inhibitor cost per treated patient was lowest for etanercept across all indications.

Patient medication adherence: the forgotten aspect of biologics

The full benefit of biologic therapies isn't reached and quality of life is compromised if patients don't adhere to their medication regimen. Are adherence interventions in order?

Challenges for managing overactive bladder and guidance for patient support

OBJECTIVE

Describe challenges to improving management of overactive bladder (OAB) outcomes and summarize research findings on critical success factors for supporting OAB treatment.

STUDY DESIGN

A multidisciplinary team collected primary and secondary data, including an OAB-specific survey; a literature review; and an expert panel discussion.

METHODS

A US survey of patients who were prescribed antimuscarinics included topics related to OAB, such as reasons for medication discontinuation. The PubMed database was searched for articles published in the past 10 years on OAB treatment and adherence, and additional publications were reviewed related to health behavior change models. An expert panel reviewed findings and provided perspective.

RESULTS

The survey (n = 5392) showed that, among patients discontinuing OAB medications, 45.4% reported unmet treatment expectations as the reason for discontinuation. Literature review findings supported intervention at the beginning of OAB treatment, specific messages to increase treatment adherence, and involving the healthcare stakeholders most trusted by patients. Implications of OAB patient support were drawn from reviews of the Transtheoretical Model, the Health Belief Model, and social learning theory. The expert panel highlighted desirable attributes of OAB patient education delivered in the medical care setting.

CONCLUSION

Challenges to improving OAB symptom burden and outcomes include underdiagnosis, undertreatment, and patient nonadherence with medications. Patient support of medication adherence may be enhanced by simultaneously supporting the use of nonpharmaceutical lifestyle modifications and behavioral interventions. Healthcare providers acknowledge the need for patient education but lack the time and resources to deliver interventions or monitor patients' progress outside the medical office. Patient support may be achieved through external programs that complement patient-physician interactions.

Five-year routine cervical cancer screening rates and intervals in a US health plan

OBJECTIVE

Cervical cancer screening with liquid-based cytology or concurrent HPV screening may decrease positive predictive value and specificity of screening results. Following changes to leading guidelines for cervical cancer screening, policy-makers may benefit from more detailed statistics to improve management of routine screening intervals. This paper reports annual cervical cancer screening rates, intervals between routine screenings, population cost burden of routine screening, and concurrent HPV screening rates in the medical claims database of a large US health plan between 2000 and 2004.

RESEARCH DESIGN AND METHODS

Annual cervical cancer screening rates were reported for each calendar year between 2000 and 2004, plus intervals between routine screenings in a cohort enrolled for 5 years after a first routine screening. Interval estimates accounted for women not screened in the first year of the study period. Overall screening rates and intervals were adjusted to the US civilian female population, and costs were adjusted to 2004 dollars. This database research was exempt from IRB review.

RESULTS

Annual routine screening rates during the 5-year period ranged from 33.7 to 37.2 tests per 100 enrollees. Among females with routine screenings, 68.8% were re-screened within 3 years, and 26.8% were not re-screened within 5 years. Concurrent HPV screening was 1.9 tests per 1000 routine screenings in 2000, and 27.9 per 1000 in 2004. The cost of routine screening per 1000 females was $31,282.00 in 2000 and $38,515.07 in 2004.

CONCLUSION

More than a quarter of women with evidence of a routine cervical cancer screening were not re-screened within 5 years, while 43.4% were re-screened within a year. Triennial screening rates reported here are not comparable to traditional 3-year screening rates, and screening intervals were not reported separately by conventional and liquid-based cytology. Reducing rates of women receiving annual routine screening may offset the cost burden of newer screening technologies, but must be managed carefully to avoid decreasing 3-year screening rates. Clinicians should reinforce with their patients the need for routine screening at least triennially.

Characterizing substance abuse programs that treat adolescents

Few systematic studies have examined the characteristics of substance abuse treatment programs serving adolescents. An expert panel recently identified nine key elements of effective adolescent substance abuse treatment. We measured the percentage of treatment programs in the United States with at least 10 adolescent clients on a given day that reported these elements using data from the 2003 National Survey of Substance Abuse Treatment Services. This first look into the characteristics of facilities serving significant numbers of adolescents indicates that many facilities may be lacking in components considered important. The most significant measured potential areas for improvement occurred in the areas of including mental health as well as medical issues in comprehensive assessments and developing curricula to meet the developmental and cultural needs of clients. On a more encouraging note, many facilities were conducting discharge planning and providing aftercare, although the specifics of these services were not determined.