Economic burden of atopic manifestations in patients with atopic dermatitis--analysis of administrative claims.

BACKGROUND: Atopic dermatitis (AD) has been associated with atopic manifestations (AMs), such as food allergies, asthma, allergic rhinitis, and allergic conjunctivitis. OBJECTIVES: To (1) compare the risk of developing AMs in patients with AD versus those without AD, (2) estimate the incremental costs attributable to AMs in patients with AD, and (3) examine the factors associated with incremental costs. METHODS: In this retrospective cohort study, the authors used MarketScan research databases containing medical and pharmacy claims with dates of service from January 1, 1999, to December 31, 2004. Patients were considered to have AD if they had at least 1 medical claim with a primary or secondary diagnosis of AD (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 691.8x) or contact dermatitis or other eczema of unspecified cause (ICD-9-CM codes 692.9x). To create comparable study cohorts, patients with AD were matched with non-AD patients using propensity scores that represented the likelihood of developing AD as predicted by logistic regression. After propensity score matching, the AD and non-AD cohorts did not statistically differ with respect to age, gender, geographic region, type of health insurance, Charlson Comorbidity Index, or baseline measures of medical and prescription drug utilization. The relative risks of developing AMs in the AD and non-AD cohorts were estimated using competing risk-survival analysis. AM was defined by ICD-9-CM codes for asthma (493.xx), allergic rhinitis (477.xx), allergic conjunctivitis (372.05 or 372.14), and food allergy (693.1x, 692.5x, 995.60). The annual incremental cost attributable to AMs in these AD patients was calculated from medical claims with AM and AD diagnosis codes and from pharmacy claims for prescription drugs used to treat asthma, allergic rhinitis, allergic conjunctivitis, or food allergy, and 95% confidence intervals (CIs) were calculated using the bootstrap method. RESULTS: Patients with AD were significantly more likely to develop AMs than patients without AD (21.8% versus 16.9%, adjusted relative risk [RR] = 1.33, 95% CI, 1.28-1.38). Among AD patients who developed AMs, allergic rhinitis was the most frequent manifestation (66.3%), followed by asthma (24.8%), allergic conjunctivitis (7.6%), and food allergy (1.8%). The incidence and adjusted RRs of developing AM for AD patients versus comparison patients were 5.3% versus 4.5% for asthma (RR = 1.20, 95% CI, 1.12-1.29), 14.6% versus 11.2% for allergic rhinitis (RR = 1.35, 95% CI, 1.29-1.41), 1.6% versus 1.1% for allergic conjunctivitis (RR = 1.50, 95% CI, 1.31-1.72), and 0.3% versus 0.1% for food allergy (RR = 2.35, 95% CI, 1.66-3.32). The annual AD + AM treatment costs for patients with AD increased substantially after they developed AMs. The additional financial burden attributable to AMs was estimated to be $482 per year, an almost 1.5-fold increase compared with AD cost alone (from $338 before AM development to $820 afterward, P < 0.001), with approximately equal distribution of costs between medical services ($243) and prescription drugs ($239). The largest incremental costs were observed in asthma ($973), followed by allergic rhinitis ($341). CONCLUSIONS: Patients with AD are significantly more likely to develop AM compared with patients without AD. The total treatment costs for AD patients who developed AMs were nearly 2.5 times the total treatment costs for patients with AD alone.

Administrative claims analysis of utilization and costs of care in health plan members with atopic dermatitis who had prior use of a topical corticosteroid and who initiate therapy with pimecrolimus or tacrolimus.

BACKGROUND: In the United States, pimecrolimus cream and tacrolimus ointment are approved as second-line therapy for short-term and intermittent noncontinuous long-term treatment of atopic dermatitis (AD) in nonimmunocompromised patients aged 2 years or older who have failed to respond adequately to other topical prescription treatments (e.g., topical corticosteroids), or when those treatments are not advisable; pimecrolimus is indicated for mild to- moderate AD and tacrolimus for moderate-to-severe AD. Comparative data on the effects of pimecrolimus versus tacrolimus on AD-related health care utilization and costs among similar patients seen in typical clinical practice are currently unavailable. OBJECTIVE: To compare utilization and costs of AD-related medical care in health plan members with AD who had prior use of a topical corticosteroid and who subsequently initiate therapy with pimecrolimus cream or tacrolimus ointment. METHODS: This was an observational, retrospective study using an administrative claims database with dates of service from August 1, 2000, through October 31, 2003, and representing approximately 2.5 million members in health maintenance organizations, preferred provider organizations, and Medicare and Medicaid plans mostly located in the cities of Chicago, Kansas City, and Phoenix and in the states of Kentucky, Florida, and Texas. The study sample included all members with 1 or more pharmacy claims for a topical corticosteroid and a diagnosis of AD (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 691.XX (excluding 691.0X), or 692.XX (excluding 692.0X-692.8X)] who subsequently had 1 or more pharmacy claims for pimecrolimus or tacrolimus. AD-related utilization and medical care costs (plan payments plus member cost share) over 12 months of follow-up were compared between the pimecrolimus and tacrolimus groups. Because information on disease severity was not available in the administrative claims data, propensity matching was used to control for differences between groups in baseline demographic and clinical characteristics and pretreatment utilization of AD-related medical care services. RESULTS: Before matching, compared with the tacrolimus group (n = 197), members in the pimecrolimus group (n = 197) were older (mean age of 38 vs. 32 years, P = 0.022), had fewer topical corticosteroid pharmacy claims (mean 2.08 vs. 3.01, P = 0.002), and had fewer grams of corticosteroids dispensed (mean 132 vs. 193, P = 0.029) in the 12 months prior to treatment. After matching, there were 157 members in each group with no statistically significant differences in pretreatment characteristics. During the 12-month follow-up period, the mean (median) number of pharmacy claims was 1.8 (1.0) for pimecrolimus versus 2.0 (1.0) for tacrolimus and the mean (median) grams of study medication were 102 (60) and 105 (60), respectively. Members in the pimecrolimus group received a lower average number of prescriptions for any topical corticosteroids (1.37 vs. 2.04, P = 0.021) and for high-potency topical corticosteroids (0.61 vs. 1.04, P = 0.023) and were less likely to initiate alternative therapy (5% vs. 17%, P <0.001) or receive antistaphylococcal antibiotics (16% vs. 27%, P = 0.014). Members in the pimecrolimus group had lower average (median) AD-related expenditures (75% to 78% attributable to AD drug cost) compared with matched tacrolimus members ($263 [$270] vs. $361 [$398], P = 0.012). CONCLUSIONS: In health plan members with AD who had previously received at least 1 topical corticosteroid prescription, the customary use of pimecrolimus or tacrolimus was 1 to 2 prescriptions in 12 months of followup and only a median of 60 grams of topical medication. The difference in AD-related utilization and costs between pimecrolimus and tacrolimus was small, less than $100 per year, but favored pimecrolimus. Further research using validated measures of disease severity to control for potential confounding is needed to confirm the results of this observational study.

Persistence, adherence, and risk of discontinuation associated with commonly prescribed antihypertensive drug monotherapies.

OBJECTIVE: To assess 1-year persistence and adherence with monotherapy using the most commonly dispensed individual agent in 4 antihypertensive drug classes: hydrochlorothiazide (HCTZ), amlodipine, lisinopril, or valsartan. DESIGN: Retrospective, longitudinal analysis of initial prescriptions during 2001 to 2002 from a nationwide administrative claims database representing 11 million covered lives in the United States. MEASUREMENTS: Drug utilization following initiation. Cox proportional hazards regression models controlled for demographics, case-mix, and concomitant treatments. RESULTS: Records for 60,685 subjects were included: HCTZ (n = 18,713), amlodipine (n = 11,520), lisinopril (n = 21,138), or valsartan (n = 9314). Over 1 year, 31% to 44% of subjects utilized no treatment for at least 60 days. Medication possession ratio (MPR) and adherence measures ranged from 73% to 90%. Valsartan was associated with significantly (P < .001) more favorable measures of persistence, length of therapy, time to discontinuation, MPR, and risk of discontinuation, compared with HCTZ, amlodipine, or lisinopril. The risk of discontinuation was 53%, 32%, and 14% greater for HCTZ, amlodipine, and lisinopril, respectively, versus valsartan (all comparisons P < .001). CONCLUSION: Among antihypertensive agents studied, valsartan was associated with the most favorable utilization patterns. Health care providers and systems should evaluate the use of antihypertensive drugs within their populations to identify and manage treatment discontinuation.

Patterns of psychotropic drug prescription for U.S. patients with diagnoses of bipolar disorders.

OBJECTIVE: Bipolar disorders are prevalent major illnesses with high rates of morbidity, comorbidity, disability, and mortality. A growing number of psychotropic drugs are used to treat bipolar disorder, often off-label and in untested, complex combinations. METHODS: To quantify utilization rates for psychotropic drug classes, this study used the 2002-2003 U.S. national MarketScan research databases to identify 7,760 persons with ICD-9 bipolar disorder subtypes. Survival analysis was used to estimate times until initial monotherapies were augmented, changed, or discontinued. RESULTS: The most commonly prescribed first drug class was antidepressants (50% of patients), followed by mood stabilizers (25%: anticonvulsants, 17%, and lithium, 8%), sedatives (15%), and antipsychotics (11%). At study midpoint only 44% of patients were receiving monotherapy. Those receiving monotherapy were ranked by initial drug prescribed and percentage of patients (bipolar I and bipolar II): antidepressants (55% and 65%), lithium (51% and 41%), antipsychotics (32% and 31%), anticonvulsants (28% and 29%), and sedatives (28%, 25%). Median time to adding another psychotropic was 2.5-times less than median time to changing the initial treatment (16.4 compared with 40.9 weeks), and stopping was rare. Median weeks until therapy was changed in any way for 25% of patients was as follows: lithium, 29 weeks; antidepressants, 13; anticonvulsants, 13; antipsychotics, 13; and sedatives, 9. CONCLUSIONS: Antidepressants were the first-choice agent twice as often as mood stabilizers. Lithium was sustained longer than monotherapy with other mood stabilizers. Time to augmentation was much shorter than time to change or discontinuation.

Impact of rivastigmine use on the risk of nursing home placement in a US sample.

INTRODUCTION: Although numerous studies have evaluated predictors of nursing home placement (NHP), few have focused on the effects of cholinesterase inhibitor (ChEI) use on NHP. The objective of this study was to compare the risk of NHP between rivastigmine patients versus no-ChEI patients (control group), and secondly, between rivastigmine versus donepezil patients. METHODS: A retrospective analysis of a large US medical claims database was performed. Eligible subjects were identified from those who had continuous medical coverage from 1 April 2000 to 30 June 2002. Rivastigmine and donepezil subjects were new users, defined as having received no ChEI treatment during the initial 6 months of the study. Control subjects were diagnosed with Alzheimer's disease (AD) at some point after the initial 6-month period. All subjects were followed from baseline (initiation of ChEI therapy or initial AD diagnosis) to the date of NHP or 30 June 2002, whichever occurred first. RESULTS: In the rivastigmine (n=1181), donepezil (n=3864), and control (n=517) groups, 3.7%, 4.4% and 11.0% of subjects, respectively, had an NHP (p <0.001 for rivastigmine versus control). A Cox proportional hazard model, controlling for age, gender, comorbidities and behavioural disorders, showed that the control subjects were almost 3-fold more likely to have NHP than rivastigmine subjects (hazard ratio [HR]=2.71; 95% CI 1.82, 4.03). The difference in the risk of NHP was not significant between the rivastigmine and donepezil groups (HR=1.23; 95% CI 0.89, 1.71). DISCUSSION: This study demonstrated that rivastigmine decreased the risk of NHP in a large insured population.