Health care resource use and cost differences by opioid therapy type among chronic noncancer pain patients.

The study assessed 12-month chronic pain (CP)-related health care utilization and costs among chronic noncancer pain (CNCP) patients who initiated various long-term opioid treatments. Treatments included monotherapy with long-acting opioids (mono-LAOs), mono-therapy with short-acting opioids (mono-SAOs), both LAOs and SAOs (combination), and opioid therapy initiated with SAO or LAO and switched to the other class (switch). Using MarketScan® claims databases (2006-2012), we identified CNCP patients with ≥90 days opioid supply after pain diagnosis and continuous enrollment 12 months before pain diagnosis (baseline period) and 12 months after opioid start (post-index period). Outcomes included CP-related health care utilization and costs. Among CNCP patients (n=21,203), the cohort distribution was 74% mono-SAOs, 22% combination, 2% mono-LAOs, and 2% switch. During follow-up, the average daily morphine equivalent dose was highest in mono-LAO patients (96.4 mg) compared with combination patients (89.8 mg), switch patients (64.3 mg), and mono-SAO patients (36.2 mg). After adjusting for baseline differences, the mono-LAO cohort had lower total CP-related costs ($4,933) compared with the mono-SAO ($8,604), switch ($10,470), and combination ($15,190) cohorts (all: P<0.05). Mono-LAO patients had greater CP-related prescription costs but lower medical costs than the other cohorts during the follow-up period, including lower CP-related hospitalizations (1% vs 11%-20%), emergency department visits (4% vs 11%-18%), and diagnostic radiology use (21% vs 54%-61%) (all: P<0.001). Use of pain-related medications and other treatment modalities was also significantly lower in the mono-LAO cohort relative to the other cohorts. CNCP patients using long-term monotherapy with LAOs had the lowest CP-related total health care costs in the 12 months after opioid initiation compared with mono-SAO, switch, or combination patients despite higher opioid daily doses and higher prescription costs. Future research accounting for severity and duration of pain would aid in determining the optimal long-term opioid regimen for CNCP patients.

Long-term patterns of use and treatment failure with anticholinergic agents for overactive bladder.

BACKGROUND: Overactive bladder (OAB) involves a complex set of symptoms with a lifetime prevalence of any symptom in ~30% of women and 20% of men. Anticholinergic agents are associated with poor medication persistence in OAB treatment. OBJECTIVE: This study evaluated the long-term patterns of use and treatment failure in patients prescribed anticholinergic agents for OAB. METHODS: This was a nonexperimental, retrospective cohort study. Medical, pharmacy, and eligibility data from the IMS LifeLink Health Plans Claims Database were used. Men and women aged ≥18 years were eligible for inclusion with an International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis of OAB in any field during the patient study period from January 2005 to June 2010. First documentation of a prescription filled between July 2005 and June 2008 for an anticholinergic agent was defined as the index prescription. Other inclusion criteria were: ≥1 pharmacy claim for an anticholinergic drug between July 2005 and June 2008; continuous enrollment 6 months before the index date, during which no anticholinergic drugs were filled; and 24 months of follow-up from the index prescription. Study outcomes were treatment failure, discontinuation, switch, reinitiation, and adherence. Treatment failure was defined as having a treatment discontinuation (ie, treatment gap of ≥45 days) or switching anticholinergic therapy. RESULTS: The analytic cohort comprised 103,250 patients with a mean age of 58.7 years. A majority were female (73%) and privately insured (75%). The vast majority of patients (91.7%) failed to meet their treatment goals with their index anticholinergic agent over the 24-month follow-up period. Of these, 5.8% switched, 51.3% permanently discontinued all anticholinergic agents, and 34.6% reinitiated treatment sometime after 45 days. The mean (SD) time to treatment failure was 159 (216.0) days, with a mean of 1.3 (0.5) unique anticholinergic agents per patient. Forty-eight percent of patients demonstrated appropriate adherence as determined by a medication possession ratio ≥80%. CONCLUSIONS: This study provides real-world data on treatment patterns over 2 years in a large cohort of patients diagnosed with OAB. Despite the potential for better adherence with some anticholinergic agents, these analyses suggest that such benefits have not yet been realized, and many patients end up without effective pharmacotherapy. Thus, there is a need for new therapies and strategies to increase persistence and adherence to improve outcomes in OAB.

Clinical and economic outcomes associated with low-dose fluticasone propionate versus montelukast in children with asthma aged 4 to 11 years.

OBJECTIVE: Inhaled corticosteroids (ICS) are preferred first-line controller agents for adults and adolescents with asthma. There is limited effectiveness data comparing ICS to leukotriene receptor antagonists (LTRA) in children with asthma aged 4 to 11 years. METHODS: A retrospective, matched cohort study was conducted using medical and pharmacy claims data. Asthma patients (ICD-9, 493.xx) naïve to any asthma controller therapy, and having ≥1 dispensing of fluticasone propionate 44 mcg (FP44), an ICS, or montelukast any dose (MON), an LTRA, were identified. Drug cohorts were matched (1:2) using propensity scores. Outcomes during follow-up included asthma-related ED visits, composite measure of asthma-related ED/hospital visit, asthma-related costs per month, and monthly rescue medication use. Statistical differences between cohorts were evaluated using multivariate regression models. RESULTS: The final matched sample included 6,636 patients (FP44=2,212; MON=4,424). During follow-up, the FP44 cohort had a 29% significantly lower risk of an asthma-related ED visit (Hazard ratio (95% CI) =0.71 (0.52, 0.96)) compared to the MON cohort. Monthly asthma-related costs were significantly reduced on average by 36% in the FP44 compared to the MON cohort ($48 vs $75, p<0.05). Use of short-acting beta-agonists per month were similar between cohorts but monthly adjusted number of oral corticosteroid prescriptions were significantly lower in the FP44 compared to the MON cohort (0.03 vs 0.04, p<0.001). CONCLUSION: Initiation of FP44 versus MON in children with asthma aged 4 to 11 years is associated with a significant reduction in asthma-related ED visits, costs, and oral corticosteroid use.