An evaluation of health-related quality of life in patients with systemic lupus erythematosus using PROMIS and Neuro-QoL.

Systemic lupus erythematosus (SLE) is a multi-organ chronic autoimmune disease that can negatively affect patients' health-related quality of life (HRQOL). This study evaluated HRQOL of SLE patients using questionnaires from the Patient-Reported Outcomes Measurement Information System (PROMIS) and Quality of Life in Neurological Disorders (Neuro-QoL). Individuals with SLE completed an online survey consisting of the PROMIS-29 health profile, PROMIS Psychosocial Illness Impact-Negative, and Neuro-QoL Applied Cognition. PROMIS and Neuro-QoL scores have a mean of 50 in the US general population. Patients self-rated SLE disease severity as negligible, mild, moderate, or severe. Of the 333 participants (mean age 45 years; 92% female; 26% Black; mean SLE disease duration 12 years, 56% with SLE disease severity as moderate or severe), mean HRQOL scores were worse than those of the general population by ≥0.5 SD with the greatest deficits observed in the domains of fatigue, applied cognition, psychosocial illness impact-negative, pain interference, and physical function. Greater SLE disease severity was associated with worse mean HRQOL scores (all p < 0.05). Pain severity was also associated with worse HRQOL scores on all domains (p < 0.05) except for satisfaction with social role. Test-retest reliability exceeded 0.70 for all PROMIS and Neuro-QoL scores. PROMIS-29 and Neuro-QoL are valid tools to assess HRQOL in patients with SLE. These patients reported substantial deficits that correlated with their SLE disease severity, with pain being an important independent contributor. These deficits should be monitored in SLE patients during their routine clinical care and evaluated when investigating new therapies.

Health-Related Quality of Life in Patients with Idiopathic Pulmonary Fibrosis.

PURPOSE: Idiopathic pulmonary fibrosis (IPF) produces symptoms and activity limitations that impair health-related quality of life (HRQOL). The Patient-Reported Outcomes Measurement Information System(®) (PROMIS(®)) includes measures of self-reported health and HRQOL for a range of conditions. This study evaluated the HRQOL of individuals with IPF using PROMIS measures and examined associations between HRQOL and key symptoms or supplemental oxygen need. METHODS: Individuals who reported being told by a doctor that they have IPF completed an online battery of measures at baseline and 7-10 days later (for test-retest reliability). Measures included a brief survey of demographic and health-related questions, the PROMIS-29 profile, the Modified Medical Research Council Dyspnea Scale (MMRC), PROMIS dyspnea severity short form, A Tool to Assess Quality of life in IPF (ATAQ-IPF) and one cough item from the Functional Assessment of Chronic Illness Therapy (FACIT). RESULTS: 220 individuals were included in the final sample. Except for sleep disturbance, all PROMIS domain scores significantly (p < .01) differed by MMRC level. Supplemental oxygen users were more impaired than non-users in fatigue, physical function, and social role participation (p < 0.01). The test-retest reliability was acceptable to excellent (>0.7) for all scales, but was lower for sleep disturbance (0.64). CONCLUSIONS: People with IPF report substantial deficits in HRQOL across a range of PROMIS domains, and deficits vary by dyspnea and cough severity. These deficits warrant monitoring in clinical practice and consideration when investigating new therapies. Further research is required to further evaluate the psychometric performance of the PROMIS-29 in IPF.

Medication costs to private insurers of diversion of medications for attention-deficit hyperactivity disorder.

BACKGROUND: The diversion of prescription stimulants for misuse, particularly those used in the treatment of attention-deficit hyperactivity disorder (ADHD), is potentially a significant problem for public health and for healthcare funding and delivery. Most prior research on the diversion of prescription stimulants for misuse, particularly those used in the treatment of ADHD, has focused on the 'end users' of diverted medications rather than the suppliers. Furthermore, little is known about the direct costs of diversion for third-party insurance payers in the US. OBJECTIVES: The objectives of this study were to estimate the prevalence in the US of people whose private insurance paid costs for ADHD prescriptions that they gave or sold to another person (diversion), and to estimate medication costs of diversion to private insurers. METHODS: Estimates are from a cross-sectional survey of respondents from two Internet survey panels targeting individuals aged 18-49 years in the civilian, noninstitutionalized US population, principally for those who filled prescriptions for ADHD medications in the past 30 days that were covered by private health insurance. Analysis weights were post-stratified to control totals from the Current Population Survey and National Health Interview Survey. Weighted prevalence rates and standard errors for diversion are reported, as are the costs of diverted pills using drug prices reported in the 2008 Thomson Reuters RED BOOK™. Sensitivity analyses were conducted that varied the cost assumptions for medications. RESULTS: Among individuals aged 18-49 years whose private insurance paid some costs for ADHD medications in the past 30 days, 16.6% diverted medications from these prescriptions. Men aged 18-49 years for whom private insurance paid some costs of ADHD drugs in the past 30 days were more than twice as likely as their female counterparts to divert medications from these prescriptions (22.5% vs 9.1%; p = 0.03). After a pro-rated co-payment share was subtracted, the estimated value of diverted medications in a 30-day period was $US8.0 million. Lower- and upper-bound estimates were $US6.9 million to $US17 million, for a range of $US83 million to $US204 million annually. Overall, diversion accounted for about 3.6% of the total costs that private insurers paid for ADHD medications (range: 3.5-4.5%). The percentages varied by medication category, although relative differences were sensitive to inclusion of a pro-rated co-payment. A higher percentage of the costs of extended-release (XR) medications was lost to diversion compared with that for immediate-release (IR) medications. CONCLUSIONS: Costs of ADHD medications paid for by private insurers that were lost to diversion were small relative to the total estimated medication costs and relative to total estimated healthcare costs for treating ADHD. Nevertheless, there may be significant cost savings for insurers if diversion can be reduced, particularly for XR medications. These findings represent a first step to informing policies to reduce diversion both in the interest of public health and for direct and indirect cost savings to insurers.

Test-retest reliability of two patient-report measures for use in adults with ADHD.

AIMS: Childhood attention-deficit/hyperactivity disorder (ADHD) frequently persists into adulthood and continues to impair health-related quality of life (HRQL). Thus, it is important to have validated symptom and HRQL measures for assessing treatment outcomes in this population. The purpose of the current analysis was to assess test-retest reliability of two measures designed specifically for adults with ADHD: the Adult ADHD Self-Report Screener (ASRS) and the Adult ADHD Quality of Life Measure (AAQoL). METHODS: Data were collected at a US clinic specializing in the treatment of adult ADHD. Patients completed the ASRS (six-item ADHD symptom screening version) and the AAQoL (a 29-item condition-specific HRQL measure) at two visits, two weeks apart. At the second visit, patients also completed a measure of symptom stability so that test-retest reliability could be examined in the stable population. Test-retest reliability was examined through intraclass correlations (ICC) and t-tests comparing scores from the two visits. RESULTS: A total of 74 participants were enrolled (62.2% male; mean age = 38.6 years), and 43 of these participants attended both visits and were stable between visits (65.1% male; mean age = 39.3 years). The ICC assessing the association between Visit 1 and Visit 2 ASRS scores was 0.86, and the ICCs for the AAQoL subscales were 0.88 (Life Productivity), 0.75 (Psychological Health), 0.74 (Life Outlook), 0.78 (Relationships), and 0.86 (total score). The t-tests found no statistically significant differences between Visit 1 and Visit 2 scores for the ASRS or AAQoL. CONCLUSIONS: The ASRS and AAQoL demonstrated good test-retest reliability. Findings add to previous results suggesting that these instruments are useful outcome measures for treatments of ADHD in adults.

Associations of nonrestorative sleep with insomnia, depression, and daytime function.

STUDY OBJECTIVES: Nonrestorative sleep (NRS) complaints are common but associations with insomnia, daytime function or depressive symptoms are not well-established. This study aims to (1) describe insomnia related symptoms and sleep quality in those with NRS compared to those with no NRS; (2) identify the independent associations between NRS, insomnia severity, and depression; and (3) identify the association between NRS and daytime function independent of insomnia severity and depression. DESIGN: Cross sectional survey of enrollees at a health plan in the Midwestern United States. MEASUREMENT: Respondents were surveyed about the presence and frequency of NRS complaints, depression, insomnia severity and related symptoms. Multivariate regression was used to examine the study's three research aims. PARTICIPANTS: Study sample consisted of 541 subjects with NRS and 717 who reported never experiencing any NRS symptoms. RESULTS: We found a statistically significant interaction between NRS and total sleep duration such that the association between sleep duration and sleep quality was attenuated in those with NRS compared to those without NRS (b=-0.26, SE=0.07, p<0.0001). In multivariate analysis, subthreshold, moderate and severe insomnia were associated with NRS (OR [95%CI]=5.93 [4.24-8.31], 9.22 [6.15-13.83] and 6.10 [3.34-11.14], respectively). NRS was independently associated with daytime physical function, cognitive function and emotional function OR [95%CI]=2.21 [1.59-3.08], 1.90 [1.37-2.64] and 1.71 [1.23-2.36], respectively. CONCLUSION: NRS is a complex concept that should be further defined and studied in the larger context of sleep quality, other insomnia related symptoms, daytime function and depression.

Structure and diagnosis of adult attention-deficit/hyperactivity disorder: analysis of expanded symptom criteria from the Adult ADHD Clinical Diagnostic Scale.

CONTEXT: Controversy exists about the appropriate criteria for a diagnosis of adult attention-deficit/hyperactivity disorder (ADHD). OBJECTIVE: To examine the structure and symptoms most predictive of DSM-IV adult ADHD. DESIGN: The data are from clinical interviews in enriched subsamples of the National Comorbidity Survey Replication (n = 131) and a survey of a large managed health care plan (n = 214). The physician-administered Adult ADHD Clinical Diagnostic Scale (ACDS) was used to assess childhood ADHD and expanded symptoms of current adult ADHD. Analyses examined the stability of symptoms from childhood to adulthood, the structure of adult ADHD, and the adult symptoms most predictive of current clinical diagnoses. SETTING: The ACDS was administered telephonically by clinical research interviewers with extensive experience in the diagnosis and treatment of adult ADHD. PARTICIPANTS: An enriched sample of community respondents. MAIN OUTCOME MEASURE: Diagnoses of DSM-IV /ACDS adult ADHD. RESULTS: Almost half of the respondents (45.7%) who had childhood ADHD continued to meet the full DSM-IV criteria for current adult ADHD, with 94.9% of these patients having current attention-deficit disorder and 34.6% having current hyperactivity disorder. Adult persistence was much greater for inattention than for hyperactivity/impulsivity. Additional respondents met the full criteria for current adult ADHD despite not having met the full childhood criteria. A 3-factor structure of adult symptoms included executive functioning (EF), inattention/hyperactivity, and impulsivity. Stepwise logistic regression found EF problems to be the most consistent and discriminating predictors of adult DSM-IV /ACDS ADHD. CONCLUSIONS: These findings document the greater persistence of inattentive than of hyperactive/impulsive childhood symptoms of ADHD in adulthood but also show that inattention is not specific to ADHD because it is strongly associated with other adult mental disorders. In comparison, EF problems are more specific and consistently important predictors of DSM-IV adult ADHD despite not being in the DSM-IV, suggesting that the number of EF symptoms should be increased in the DSM-V/ICD-11.

Stimulant formulation and motivation for nonmedical use of prescription attention-deficit/hyperactivity disorder medications in a college-aged population.

There is relatively little research examining motives for nonmedical use (NMU) of attention-deficit/hyperactivity disorder (ADHD) medications and predictors of motivation. We present results of a secondary analysis of an Internet-based epidemiological survey to explore the relationship between stimulant formulation and motivation for NMU of ADHD stimulant medications in a college-aged population. Demographic predictors of motivation to engage in NMU were also explored to investigate the potential correlates of recreational versus performance-enhancement motivations. Respondents scoring higher on the Adult ADHD Self-Report Scale were significantly more likely to engage in NMU of ADHD stimulant medications. Those using extended release (ER) stimulant formulations were less likely to endorse "staying awake" as a reason for NMU compared to those using immediate release (IR) stimulant formulations.

A retrospective claims analysis of combination therapy in the treatment of adult attention-deficit/hyperactivity disorder (ADHD).

BACKGROUND: Combination therapy in managing psychiatric disorders is not uncommon. While combination therapy has been documented for depression and schizophrenia, little is known about combination therapy practices in managing attention-deficit/hyperactivity disorder (ADHD). This study seeks to quantify the combination use of ADHD medications and to understand predictors of combination therapy. METHODS: Prescription dispensing events were drawn from a U.S. national claims database including over 80 managed-care plans. Patients studied were age 18 or over with at least 1 medical claim with a diagnosis of ADHD (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 314.0), a pharmacy claim for ADHD medication during the study period July 2003 to June 2004, and continuous enrollment 6 months prior to and throughout the study period. Dispensing events were grouped into 6 categories: atomoxetine (ATX), long-acting stimulants (LAS), intermediate-acting stimulants (IAS), short-acting stimulants (SAS), bupropion (BUP), and Alpha-2 Adrenergic Agonists (A2A). Events were assigned to calendar months, and months with combined use from multiple categories within patient were identified. Predictors of combination therapy for LAS and for ATX were modeled for patients covered by commercial plans using logistic regression in a generalized estimating equations framework to adjust for within-patient correlation between months of observation. Factors included age, gender, presence of the hyperactive component of ADHD, prior diagnoses for psychiatric disorders, claims history of recent psychiatric visit, insurance plan type, and geographic region. RESULTS: There were 18,609 patients identified representing a total of 11,886 months of therapy with ATX; 40,949 months with LAS; 13,622 months with IAS; 38,141 months with SAS; 22,087 months with BUP; and 1,916 months with A2A. Combination therapy was present in 19.7% of continuing months (months after the first month of therapy) for ATX, 21.0% for LAS, 27.4% for IAS, 23.1% for SAS, 36.9% for BUP, and 53.0% for A2A.For patients receiving LAS, being age 25-44 or age 45 and older versus being 18-24 years old, seeing a psychiatrist, having comorbid depression, or having point-of-service coverage versus a Health Maintenance Organization (HMO) resulted in odds ratios significantly greater than 1, representing increased likelihood for combination therapy in managing adult ADHD.For patients receiving ATX, being age 25-44 or age 45 and older versus being 18-24 years old, seeing a psychiatrist, having a hyperactive component to ADHD, or having comorbid depression resulted in odds ratios significantly greater than 1, representing increased likelihood for combination therapy in managing adult ADHD. CONCLUSION: ATX and LAS are the most likely drugs to be used as monotherapy. Factors predicting combination use were similar for months in which ATX was used and for months in which LAS was used except that a hyperactive component to ADHD predicted increased combination use for ATX but not for LAS.

Prevalence of nonmedical methamphetamine use in the United States.

BACKGROUND: Illicit methamphetamine use continues to be a public health concern in the United States. The goal of the current study was to use a relatively inexpensive methodology to examine the prevalence and demographic correlates of nonmedical methamphetamine use in the United States. METHODS: The sample was obtained through an internet survey of noninstitutionalized adults (n = 4,297) aged 18 to 49 in the United States in 2005. Propensity weighting methods using information from the U.S. Census and the 2003 National Survey on Drug Use and Health (NSDUH) were used to estimate national-level prevalence rates. RESULTS: The overall prevalence of current nonmedical methamphetamine use was estimated to be 0.27%. Lifetime use was estimated to be 8.6%. Current use rates for men (0.32%) and women (0.23%) did not differ, although men had a higher 3-year prevalence rate (3.1%) than women (1.1%). Within the age subgroup with the highest overall methamphetamine use (18 to 25 year olds), non-students had substantially higher methamphetamine use (0.85% current; 2.4% past year) than students (0.23% current; 0.79% past year). Methamphetamine use was not constrained to those with publicly funded health care insurance. CONCLUSION: Through the use of an internet panel weighted to reflect U.S. population norms, the estimated lifetime prevalence of methamphetamine use among 18 to 49 year olds was 8.6%. These findings give rates of use comparable to those reported in the 2005 NSDUH. Internet surveys are a relatively inexpensive way to provide complimentary data to telephone or in-person interviews.

Weight management using the internet a randomized controlled trial.

BACKGROUND: Most weight-loss research targets obese individuals who desire large weight reductions. However, evaluation of weight-gain prevention in overweight individuals is also critical as most Americans become obese as a result of a gradual gain of 1-2 pounds per year over many years. METHOD: This study evaluated the efficacy of an Internet-based program for weight-loss and weight-gain prevention with a two-group, prospective, randomized controlled trial. A military medical research center with a population of 17,000 active-duty military personnel supplied 446 overweight individuals (222 men; 224 women) with a mean age of 34 years and a mean BMI of 29. Recruitment and study participation occurred 2003-2005 and data were analyzed in 2006. Participants were randomly assigned to receive the 6-month behavioral Internet treatment (BIT, n=227) or usual care (n=224). Change in body weight, BMI, percent body fat, and waist circumference; presented as group by time interactions, were measured. RESULTS: After 6 months, completers who received BIT lost 1.3 kg while those assigned to usual care gained 0.6 kg (F((df=366))=24.17; I<0.001). Results were similar for the intention-to-treat model. BIT participants also had significant changes in BMI (-0.5 vs +0.2 kg/m(2); F((df=366))=24.58); percent body fat (-0.4 vs +0.6%; F((df=366))=10.45); and waist circumference (-2.1 vs -0.4 cm; F((df=366))=17.09); p<0.001 for all. CONCLUSIONS: Internet-based weight-management interventions result in small amounts of weight loss, prevent weight gain, and have potential for widespread dissemination as a population health approach. TRIAL REGISTRATION: NCT00417599.

The nonmedical use of prescription ADHD medications: results from a national Internet panel.

BACKGROUND: Emerging evidence suggests that nonmedical use (NMU) of prescription attention deficit/hyperactivity disorder (ADHD) medications is rising, but many previous investigations have used clinical or regionally based samples or limited their investigations to stimulants rather than to medications specifically used to treat ADHD. Using an Internet-based epidemiological survey, this paper advances understanding of the prevalence and correlates of NMU of medications used to treat ADHD, sources of diverted medications, motivations for use, and consumption patterns. METHODS: The study used a self-administered Internet survey of civilian, noninstitutionalized adults (N = 4,297) aged 18 to 49 in the United States. National-level estimates were created using propensity scoring methods and weighting procedures using data from three nationally representative probability surveys: a random-digit dialed telephone survey, the current U.S. Census, and the National Survey on Drug Use and Health (NSDUH). RESULTS: Past-year prevalence of NMU of ADHD medications was approximately 2%, with 4.3% reported among those aged 18 to 25 and 1.3% among those aged 26 to 49. Most respondents reporting NMU used on multiple occasions. Receipt of medications for ADHD was a significant correlate of past-year NMU, though most nonmedical users never had a prescription. Among persons who had never been prescribed medication to treat ADHD, friends or family members were the most common source. Productivity was the most frequently endorsed reason for NMU. Alcohol was the substance most commonly used in combination with ADHD drugs. CONCLUSION: Because most prescription ADHD medications currently are highly regulated, policy options for supply-side reduction of nonmedical use may include identifying those medications with lower abuse liability for inclusion on insurance formularies. Patient and physician education programs also may be useful tools to heighten awareness of intentional and unintentional diversion of ADHD medications for nonmedical purposes.

Validity of the World Health Organization Adult ADHD Self-Report Scale (ASRS) Screener in a representative sample of health plan members.

The validity of the six-question World Health Organization Adult ADHD Self-Report Scale (ASRS) Screener was assessed in a sample of subscribers to a large health plan in the US. A convenience subsample of 668 subscribers was administered the ASRS Screener twice to assess test-retest reliability and then a third time in conjunction with a clinical interviewer for DSM-IV adult ADHD. The data were weighted to adjust for discrepancies between the sample and the population on socio-demographics and past medical claims. Internal consistency reliability of the continuous ASRS Screener was in the range 0.63-0.72 and test-retest reliability (Pearson correlations) in the range 0.58-0.77. A four-category version The ASRS Screener had strong concordance with clinician diagnoses, with an area under the receiver operating characteristic curve (AUC) of 0.90. The brevity and ability to discriminate DSM-IV cases from non-cases make the six-question ASRS Screener attractive for use both in community epidemiological surveys and in clinical outreach and case-finding initiatives.

The relationship between quality of life and clinical efficacy from a randomized trial comparing olanzapine and ziprasidone.

OBJECTIVE: To examine treatment-specific changes in health-related quality of life (QOL) among patients with schizophrenia and to assess the association between clinical and QOL improvement. METHOD: This post hoc analysis used the findings of a 28-week, randomized, multicenter trial of patients with schizophrenia (DSM-IV) treated with olanzapine (10-20 mg/day) or ziprasidone (80-160 mg/day). Data were collected from August 2001 to December 2002. Efficacy was measured using the Positive and Negative Syndrome Scale (PANSS). Quality of life was assessed with the generic health self-administered Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36) and the disease-specific expert-administered Heinrichs-Carpenter Quality of Life Scale (QLS). Mixed-effects-repeated-measures and last-observation-carried-forward approaches were used to assess the effects of treatment on QOL and the association of clinical outcomes to QOL outcomes. RESULTS: Olanzapine- and ziprasidone-treated patients demonstrated similar improvement from baseline to endpoint on the SF-36 and QLS. All correlations between changes in PANSS scores and the SF-36 were significant (p < .001), ranging from -0.159 to -0.400. All correlations between changes in PANSS scores and the QLS were significant (p < .0001), ranging from -0.286 to -0.603. The correlations between the 2 QOL measures were generally significant but small to moderate in magnitude. CONCLUSIONS: The results of this study indicate that, in patients with schizophrenia, olanzapine and ziprasidone treatment are associated with significant QOL and clinical improvements. Further, the significant correlation between change scores on the PANSS and QOL measures suggests that treatment-related clinical improvements are associated with improved health-related and disease-specific QOL. CLINICAL TRIALS REGISTRATION: ClinicalStudyResults.org identifier 2347.

Decreased use of clonidine following treatment with atomoxetine in children with ADHD.

The objectives of the present study were to examine clonidine use before and after initiation of atomoxetine in a cohort of children with attention deficit/hyperactivity disorder (ADHD). For this purpose, medical and pharmaceutical claims data for patients from 75 managed health care plans across the United States were extracted to identify a cohort of patients aged 18 years and younger at the time of a first atomoxetine prescription. Clonidine users were characterized on the basis of demographics, comorbid conditions, medication use and provider types, and prescribing patterns before and after the index atomoxetine prescription assessed. Subgroups of patients switching from clonidine to atomoxetine were examined and predictors of ongoing or new clonidine use were assessed. Of patients filling a first prescription for atomoxetine, 9.6% received a prescription for clonidine at some time and 4.3% within the previous 2 months. Children identified with a hyperactive component to their ADHD, those with more complex diagnostic histories, and those with tics and sleep disorders were particularly likely to receive clonidine. More than a third of patients (36.5%) with recent clonidine use subsequently discontinued use, with the pattern of clonidine use before and after atomoxetine use being highly dependent upon the pattern of stimulant prescription. Atomoxetine, in some cases, seems to have replaced clonidine in the treatment of patients with ADHD complicated with comorbid psychiatric disorders. In others, atomoxetine has replaced both stimulant and clonidine in patients previously requiring this combination for the control of symptoms or for the management of stimulant-related adverse effects.

Factors associated with initiation with atomoxetine versus stimulants in the treatment of adults with ADHD: retrospective analysis of administrative claims data.

OBJECTIVE: To determine which factors are associated with use of atomoxetine (ATX) relative to stimulant medications (STIMs) for treatment initiation in adults with attention-deficit/hyperactivity disorder (ADHD). A similar exploratory analysis of the use of ATX versus STIMs in children has been published previously. METHODS: This was an exploratory analysis using a retrospective observational cohort design applied to administrative pharmacy and medical claims from an integrated managed care database. Patients were identified if they had at least 1 administrative claim with a diagnosis for ADHD. Treatment .initiation. was defined as a new prescription for an ADHD medication preceded by 3 months without similar therapy. Two separate analyses were done, one comparing medication starts for ATX with those of any STIM, the other comparing starts of ATX with long-acting stimulants (LA-STIMs). Logistic regression analyses of prior-year administrative claims were used to compare the frequencies of differential predictors of the use of medication. RESULTS: There were 10,359 patients aged >18 years who initiated ATX or a STIM between April and December of 2003 and had at least 1 claim with a diagnosis for ADHD (International Classification of Diseases, Ninth Revision, Clinical Modification codes 314.0x). Approximately one third (28 of 82) of the comparisons related to patient demographics, diagnostic history, and previous treatment history was found to be related to the use of ATX versus STIMs and/or LA-STIMs. Patients were more likely to have received ATX than a STIM if they had prior diagnoses of bipolar disorder (odds ratio [OR] 1.47; 95% confidence interval [CI], 1.16-1.87), alcohol dependence (OR 1.80; 95% CI, 1.26-2.58), anxiety (OR 1.21; 95% CI, 1.05-1.40), previous use of antipsychotic medication (OR 1.55; 95% CI, 1.22-1.96), or previous antidepressant use (OR 1.14; 95% CI, 1.01-1.28). Prior use of behavioral services greater than 12 visits was associated with the use of ATX relative to STIMs (OR 1.46; 95% CI, 1.20-1.77) but not for ATX relative to LA-STIMs. Conversely, ATX was used less often than STIMs for initiation in younger adults aged 18 to 24 years (OR 0.66; 95% CI, 0.58-0.74), female patients (OR 0.89, 95% CI, 0.80-0.99), patients with personality disorders (OR 0.53; 95% CI, 0.34-0.82), and those with prior use of STIMs (OR 0.62; 95% CI, 0.56-0.69). The majority of comparisons (54 of 82) related to demographics, diagnostic history, and previous treatment history did not show statistically significant associations. CONCLUSIONS: During the first year of ATX.s market introduction, some differences in the frequency of various clinical factors were found in adults treated with ATX compared with those patients who received STIMs. This association may suggest that STIMs and ATX are used to address different treatment needs in adults with ADHD. Future studies will need to determine the significance of the practice pattern differences inferred here and if they persist after ATX has been on the market longer.

Nonmedical use of prescription stimulants in the United States.

OBJECTIVE: This study estimated prevalences and correlates of stimulant diversion in the United States and examined relationships between diversion and measures of abuse or dependence. METHODS: We conducted descriptive and multivariate analysis of data from the National Survey on Drug Use and Health. Key measures were nonmedical use (misuse) of any prescription stimulant, any stimulant other than methamphetamine, and stimulants indicated for attention-deficit/hyperactivity disorder (ADHD). RESULTS: Lifetime stimulant misuse included some misuse of longer-acting ADHD drugs. The majority of past-year misuse involved drugs other than methamphetamine, particularly for youth aged 12-17. Past year misuse was more prevalent among persons aged 12-25, compared with older adults, and among Whites, compared with other groups. Prevalences in large metropolitan areas were lower than or similar to those in less populated areas. About 13% of past-year stimulant misusers met the survey criteria for dependence or abuse, as did about 10% of persons aged 12-25 who misused only nonmethamphetamine stimulants. CONCLUSIONS: Most stimulant misuse in the United States (particularly among youth) involved prescription drugs other than methamphetamine. The problem is not limited to metropolitan areas.

Predictors of selecting atomoxetine therapy for children with attention-deficit-hyperactivity disorder.

STUDY OBJECTIVE: To investigate predictors of beginning treatment with atomoxetine, a new attention-deficit-hyperactivity disorder (ADHD) drug, shortly after it was introduced into the marketplace compared with well-established stimulants for children in a managed care setting. DESIGN: Retrospective cohort analysis. DATA SOURCE: Managed care claims database. PATIENTS: A total of 45,144 patients aged 18 years or younger who filled a prescription for an ADHD-specific drug. MEASUREMENTS AND MAIN RESULTS: For each patient, the most recent start of therapy between April 1 and December 31, 2003, was categorized by drug: atomoxetine; any stimulant; or short-, intermediate-, or long-acting stimulant. The categories were based on the first use of the drug without use of a drug in that same category in the previous 3 months. Logistic regression analysis of past-year administrative claims was applied to determine predictors of the start of specific pharmacotherapy. Patients with a claim of ADHD with hyperactivity were 1.50 times more likely to begin therapy with atomoxetine than with any stimulant (95% confidence interval [CI] 1.42-1.58). Patients with a history of tics (odds ratio [OR] 3.11, 95% CI 2.54-3.82), anxiety (OR 1.35, 95% CI 1.24-1.48), pervasive developmental disorders (OR 2.00, 95% CI 1.69-2.37), or frequent use of behavioral care services (OR 1.34, 95% CI 1.21-1.48) were predisposed to starting treatment with atomoxetine relative to any stimulant, but patients with obesity were not (OR 0.68, 95% CI 0.53-0.87). A short-acting stimulant was specifically preferred for patients with narcolepsy or hypersomnolence (OR 0.33, 95% CI 0.20-0.56). Alcohol dependence, but not drug dependence or drug abuse, was predictive of the selection of atomoxetine over a short-acting stimulant (OR 2.98, 95% CI 1.25-7.09). CONCLUSION: Atomoxetine therapy was systematically preferred for patients with psychiatric comorbidities, contraindications to stimulants, or relatively heavy use of behavioral health care.

Impact of a statewide Medicaid managed care system on healthcare utilization and outcomes for people living with HIV.

BACKGROUND: Medicaid managed care (MMC) systems provide insurance for many persons living with HIV and AIDS (PLWH). This study sought to assess the impact of a statewide MMC system (TennCare) on healthcare utilization and outcomes for PLWH. METHODS: A retrospective longitudinal analysis of trends in population characteristics was performed. The study population included all Tennessee PLWH identified by State Health Department, enrolled for 1 year or longer in Medicaid (1992-1993) or TennCare (1994-1997). Main outcome measures included health care utilization, incidence of opportunistic infections, and mortality. RESULTS: From 1992 to 1997, the following decreased: average number of hospitalizations for HIV (0.72 to 0.37) and AIDS (1.27 to 0.52); emergency visits for HIV (1.70 to 1.12) and AIDS (1.65 to 1.02); outpatient visits for HIV (5.94 to 5.00) and AIDS (8.37 to 7.35), percentage of persons diagnosed with Pneumocystis carinii pneumonia for AIDS (10% to 6%) and percentage of persons diagnosed with community-acquired pneumonia for HIV (14% to 9%) and AIDS (27% to 12%), annual incidence of AIDS in the HIV population (33% to 10%), and annual mortality for HIV (3% to 1%) and AIDS (16% to 3%). The average number of antiretroviral medication prescriptions filled increased for HIV (1.27 to 2.45) and AIDS (1.31 to 3.34). CONCLUSIONS: This study documents improvements in utilization patterns, morbidity, and mortality in a statewide MMC system. These findings suggest that MMC patients are benefiting from recent advances in therapy.

Outpatient use of major antipsychotic drugs in ambulatory care settings in the United States, 1997-2000.

OBJECTIVE: To describe the prescription of antipsychotic agents in the United States and to investigate the association between demographic characteristics, clinical diagnosis, and antipsychotic prescribed. METHODS: Four years (1997-2000) of data from the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Care Survey (NHAMCS) were combined for analysis. Distributions for patient age, race, gender, primary diagnosis, and provider's medical specialty were assessed. Logistic regression models were developed to estimate the probability of receiving either (1) a second-generation vs a first-generation antipsychotic, or (2) olanzapine vs risperidone, given differences in gender, race, age, and primary diagnosis. RESULTS: Nearly 35.9 million ambulatory healthcare visits resulted in antipsychotic prescription during 1997-2000, or nearly 1% of all healthcare visits for the period. Nearly 30% of these visits were to nonpsychiatric physicians. The use of first-generation antipsychotics declined during this period, while the use of second-generation antipsychotics increased. Risperidone and olanzapine accounted for the majority of second-generation antipsychotic use. While the mean ages of patients using risperidone and olanzapine were similar, the age distributions differed, with risperidone showing more frequent use among the young (< 18 years) and the old (> 65 years). Patients of nonwhite race were more likely to receive olanzapine than risperidone. CONCLUSION: Results from this national survey indicate that second-generation antipsychotics are being used with increasing frequency and are widely used outside of the psychiatric specialty. Differences in age distribution, racial representation, and diagnostic representation are associated with drug selection, reinforcing the importance of accounting for case-mix factors when researching these antipsychotics in observational studies.

Improvements in access to care for HIV and AIDS in a statewide Medicaid managed care system.

BACKGROUND: Some experimental Medicaid managed care systems have expanded eligibility criteria for chronically ill persons, but these systems' impact on access to care remains unknown. OBJECTIVE: To determine whether initiating a statewide Medicaid managed care system (TennCare) guaranteeing universal access for persons living with HIV or AIDS (PLWHs) increased their enrollment in public sector insurance. DESIGN, SETTING, AND PARTICIPANTS: A retrospective longitudinal descriptive analysis of trends in population characteristics during the study period was performed. The study population included all PLWHs in Tennessee (1992-1997) identified by the State Health Department. These data linked with Medicaid/TennCare enrollment files identified percentages of Tennessee's HIV/AIDS population enrolled in Medicaid (1993) or TennCare (1994-1997) and eligi-bility/demographics changes during program initiation. MAIN OUTCOME MEASURE: Annual percentage of PLWHs enrolled in Medicaid/TennCare. RESULTS: Absolute numbers of PLWHs served by Medicaid/TennCare increased 475% from 1992 (n = 593) to 1997 (n = 2818). Similar increases in Tennessee's overall HIV-positive population occurred. Percentages of PLWHs enrolled in Medicaid/TennCare increased (1993 to 1997): HIV (28% to 34%) and AIDS (32% to 44%). The largest percentage of PLWHs added to the program were uninsured/uninsurable. CONCLUSIONS: Absolute numbers of PLWHs covered by Medicaid/TennCare substantially increased. Percentages of PLWHs covered increased more modestly, partly owing to large increases in overall numbers of HIV-positive Tennesseans during the study period. Increases in coverage were greatest for the AIDS population. Tennessee's broad expansion of eligibility for PLWHs resulted in improved access, but did not result in enrollment of most PLWHs. States contemplating similar Medicaid expansions should not expect all PLWHs to crowd into public sector insurance programs.