Adherence to oral second-generation antipsychotic medications in patients with schizophrenia and bipolar disorder: physicians' perceptions of adherence vs. pharmacy claims.

OBJECTIVE: To compare physician-reported adherence of specific patients to oral second-generation antipsychotics vs. actual adherence rates determined from the patients' pharmacy claims. METHODS: Claims data from the HealthCore Integrated Research Database identified patients with schizophrenia or bipolar disorder with ≥ 1 oral second-generation antipsychotic prescription. The prescribing physicians were identified from the pharmacy claims and asked to complete an Internet survey assessing their perception of medication adherence for 1-2 of their patients and their beliefs regarding adherence to second-generation antipsychotics in general for a 1-year period. Adherence to second-generation antipsychotics was determined for each patient by pharmacy claims for the same period. Physician survey data were merged with patient claims data via unique patient identifiers, and physician-reported adherence rates were compared with claims-based rates as measured by the medication possession ratio. RESULTS: One hundred and fifty-three physicians responded to the survey, representing 214 patients (44 with claims for schizophrenia, 162 with bipolar disorder, 8 with claims for bipolar disorder and schizophrenia). Most physicians (60%) had no formal adherence training. More than two-thirds (68%) reported emphasising the importance of adherence and reported approximately 76% of their patients were adherent (≥ 71% of the time). In the schizophrenia group, 16 of 17 (94%) patients with low-to-moderate (≤ 70%) adherence levels had high (≥ 71%) physician-estimated adherence. In the bipolar disorder group, 62 of 92 (67%) patients with low-to-moderate adherence levels had high physician-estimated adherence. CONCLUSIONS/INTERPRETATION: These analyses suggest that, even when physicians are asked about specific patients in their practice, there is discordance between physician perceptions and adherence as measured through pharmacy claims. This disparity may delay appropriate interventions, potentially contributing to relapses.

Change in employment status over 52 weeks in patients with schizophrenia: an observational study.

BACKGROUND: The aim of this post-hoc analysis was to describe change in employment status over time in patients with schizophrenia. METHODS: Data were from three 52-week open-label extensions of the double-blind pivotal trials of paliperidone extended-release (ER) (trial numbers NCT00650793, NCT00210769 and NCT00668837). Employment status prior to trial entry was recorded at baseline of the open-label phase and change was measured at 4-week intervals. Patients were included if they were in the open-label, intent-to-treat analysis set (i.e., received at least one dose of the study medication and had a baseline and at least one post-baseline efficacy measurement) and had valid dates in the productivity data. Employment categories included full-time, part-time, casual, sheltered work, unemployed but seeking work, unemployed and not seeking work, retired, not employed outside the home and student. Change in employment status from baseline to post-baseline (last visit) was assessed using McNemar's test. RESULTS: Of the 1077 patients enrolled in the open-label extensions, 1012 (94.0%) met inclusion criteria. The average age was 37.7 years (SD 10.9) and 59.1% were male. At baseline, the largest percentage of patients was unemployed and not seeking work (56.8%), followed by retired (14.9%) and unemployed but seeking work (11.7%). Five different definitions of employment were created. Employment rates increased according to all five definitions (p < 0.0001), ranging from a 43% increase according to the definition most similar to that used by the US Bureau of Labor Statistics to an increase of 114% when only part-time and full-time employment were considered. CONCLUSION: In this uncontrolled population of patients with schizophrenia who were treated with paliperidone ER, the percentage of patients who were employed increased over time. By using multiple measures of employment, researchers can identify the nature of the employment status change.

Evaluation of health services use following the initiation of risperidone long-acting therapy among schizophrenia patients in the veterans health administration.

WHAT IS KNOWN AND OBJECTIVE: The introduction of long-acting injection antipsychotic agents has been associated with better treatment persistence and better subsequent patient outcomes. However, limited empirical data are available on patient outcomes resulting from the initiation of long-acting injectable antipsychotic agents. In this study, we assessed patterns of health-care utilization following the initiation of risperidone long-acting therapy (RLAT), the first and only second generation long-acting injectable antipsychotic agent, in schizophrenia patients within the Veterans Health Administration. METHODS: Patients were identified if they initiated RLAT between 1 October 2005 and 30 September 2006, were ≥ 18 years of age at the time of initiation, and had at least four injections following the initiation. Paired t-tests and McNemar tests were used to compare patterns of health services use during 12 months pre- and post-initiation. RESULTS AND DISCUSSION: Among 924 eligible study subjects, about 94% were male with mean age of 51·1 years and as high as 60% had >3 and 29% had >5 comorbid conditions. The initiators of RLAT had an average of 17·3 (SD ± 9·7) injections within the 12 months following the initiation, with an average of 14 days between injections. Between the pre- and post-initiation periods, although the number of psychiatric-related outpatient visits increased from 24·6 to 39·1 (P < 0·001), the number of psychiatric hospitalizations decreased from 1·4 to 1·0 (P < 0·001) with an average length of stay reducing from 20 to 14 days (P < 0·001). The percentage of patients who experienced at least one or two psychiatric-related hospitalizations decreased from 68·9% to 45·7% (P < 0·001) and from 34·9% to 24·4% (P < 0·001), respectively. WHAT IS NEW AND CONCLUSION: Despite the values of RLAT in treating patients with schizophrenia, RLAT is largely underutilized in routine clinical practice. This observation highlights the importance for future research to ascertain the cost-effectiveness of initiating RLAT, especially the extent to which medication adherence influences the prescription pattern of RLAT and subsequent costs of initiating RLAT.

Exploratory analysis of psychiatric-related utilization and costs associated with paliperidone ER compared with other oral atypical antipsychotics using pharmacy claims from an administrative database.

OBJECTIVE: To compare psychiatric-related healthcare resource utilization (inpatient facility admissions, emergency room visits and ambulatory visits) and costs (medical, pharmacy and total healthcare costs) in patients initiated on paliperidone extended release (ER), risperidone, aripiprazole, olanzapine, ziprasidone or quetiapine. METHODS: This exploratory, retrospective administrative claims analysis database compared patients from a large US commercial health plan who were initiated on their index oral atypical antipsychotics between January 1, 2007, and June 30, 2007. Cohorts were assigned by first antipsychotic claim and propensity score-matched by age, gender, US census division, race, household income, baseline antipsychotic use, co-morbid conditions and psychiatric-related utilization. Psychiatric-related healthcare resource utilization and costs were measured for 6 months post-initiation. Descriptive analyses compared paliperidone ER with the other cohorts. RESULTS: There were 562 patients in matched paliperidone ER (n = 95), risperidone (n = 94), aripiprazole (n = 94), olanzapine (n = 89), ziprasidone (n = 95) or quetiapine (n = 95) cohorts. The paliperidone ER cohort had fewer mean psychiatric-related ambulatory visits than the risperidone cohort (p = 0.05). The paliperidone ER cohort had significantly lower mean psychiatric-related medical costs than the olanzapine, quetiapine and ziprasidone cohorts (p < 0.05) and lower total costs than the ziprasidone and olanzapine cohorts (p = 0.02). No other outcomes were significantly different. LIMITATIONS: Small sample sizes and short post-index observation times due to the launch of paliperidone ER in January 2007, coupled with the inherent lag time with medical claims data, limit the generalizability of the study findings. CONCLUSION: Patients treated with paliperidone ER may have psychiatric-related utilization costs that are comparable to those of patients who initiated treatment with other oral atypical antipsychotics.

Hospitalisation and resource utilisation in patients with schizophrenia following initiation of risperidone long-acting therapy in the Veterans Affairs Healthcare System.

OBJECTIVE: To examine hospitalisation rates and resource utilisation following initiation of risperidone long-acting therapy (RLAT) among US veterans with schizophrenia. METHODS: Encounter data were analysed from the Ohio Veterans Affairs (VA) Healthcare System. Adult patients (schizophrenia or schizoaffective disorder) with ≥1 medical or hospital visits with a diagnosis code of 295.xx, continuous enrolment from January 2003 through January 2006, and ≥4 injections of RLAT were selected. Analyses compared psychiatric-related resource utilisation pre- and post-exposure to RLAT; each patient served as his/her own control. The pre-exposure and post-exposure periods defined were equal in duration (e.g., a 6-month post-exposure period was matched with a 6-month pre-exposure period). Descriptive and comparative analyses (paired t tests, McNemar's test) were performed. RESULTS: Patients (n=106) were 51.9 years old (+/-10.2), male (93%), white (73%) and received on average 14 RLAT doses (+/-9.7; range, 4-47 injections) over 309 days (+/-196; range, 42-737 days). Most experienced a psychiatric-related hospitalisation prior to initiation; less than half experienced hospitalisation after initiation (75% vs. 42%; p<0.001). Relative to pre-initiation, fewer psychiatric-related hospitalisations (mean [SD] change, -0.8 [2.0]; p<0.001), shorter length of stay (-25 [63.6] days; p<0.001), fewer inpatient days/month (-3.1 [7.2] days) and one (2.8) additional outpatient visit/month (p<0.001) occurred post-initiation. LIMITATIONS: The absence of a control group in this pre-/post comparison may have resulted in exposure to a regression to the mean effect. Also, this study evaluated only one cohort of patients in a VA healthcare setting. CONCLUSIONS: VA patients with schizophrenia and schizoaffective disorder treated with RLAT experienced fewer hospitalisations and psychiatric-related inpatient days following RLAT initiation. Further studies utilising a control group and in non-VA populations are warranted.

Effect of early addition of rosiglitazone to sulphonylurea therapy in older type 2 diabetes patients (>60 years): the Rosiglitazone Early vs. SULphonylurea Titration (RESULT) study.

AIM: To compare the efficacy, safety and tolerability of adding rosiglitazone (RSG) vs. sulphonylurea (SU) dose escalation in older type 2 diabetes mellitus (T2DM) patients inadequately controlled on SU therapy. METHODS: A total of 227 T2DM patients from 48 centres in the USA and Canada, aged > or =60 years, were randomized to receive RSG (4 mg) or placebo once daily in combination with glipizide 10 mg twice daily for 2 years in a double-blind, parallel-group study. Previous SU monotherapy was (1/4) to (1/2) maximum recommended dose for > or =2 months prior to screening with fasting plasma glucose (FPG) > or =7.0 and < or =13.9 mmol/l. Treatment options were individualized, and escalation of study medication was specifically defined. RESULTS: Disease progression (time to reach confirmed FPG > or =10 mmol/l while on maximum doses of both glipizide and study medication or placebo) was reported in 28.7% of patients uptitrating SU plus placebo compared with only 2.0% taking RSG and SU combination (p < 0.0001). RSG + SU significantly decreased HbA(1c), FPG, insulin resistance, plasma free fatty acids and medical care utilization and improved treatment satisfaction compared with uptitrated SU. CONCLUSIONS: Addition of RSG to SU in older T2DM patients significantly improved glycaemic control and reduced disease progression compared with uptitrated SU alone but without increasing hypoglycaemia. These benefits were associated with increased patient treatment satisfaction and reduced medical care utilization with regards to emergency room visits and length of hospitalization. Early addition of RSG is an effective treatment option for older T2DM patients inadequately controlled on submaximal SU monotherapy.

The use of health care services by people with diabetes in rural areas.

Current standards of health care support the view that diabetes can be managed in an outpatient setting, thereby preventing costly hospitalization. Yet, recent studies on access to care suggest that rural residents do not receive the same services for diabetes care as their urban counterparts. This study identifies differences in use for three types of services-hospital care, home health visits, and physician office visits--by geographical location. Using a sample of 6,698 Medicare beneficiaries, the authors performed multivariate analysis of variance to test the influence of geographical differences on each type of service use after controlling for the other types of service use and individual factors. Results showed significant differences among the geographical categories, with diabetic individuals in the most sparsely populated communities reporting fewer physician office visits and more home health visits than their urban counterparts. Because this pattern may have a negative impact on health outcomes, additional research is needed to determine the optimal array of services necessary to manage chronic diseases, such as diabetes, in rural areas.

Profiles of hospital, physician, and home health service use by older persons in rural areas.

Using data from the Medicare Current Beneficiary Survey, we identify differences in hospital days, home health visits and physician office visits across five geographical categories. After controlling for individual characteristics and availability of health care providers, we find significant differences in service use. Results show greater use of home health care and less use of physician office visits and hospital care in rural areas. Because service use exhibits patterns of substitution and complementarity, future research on the use of health services needs to move beyond modeling the use of single services to modeling the range of services used.