How patient cost-sharing trends affect adherence and outcomes: a literature review.

OBJECTIVE: We sought to assess the relationship between patient cost sharing; medication adherence; and clinical, utilization, and economic outcomes. METHODOLOGY: We conducted a literature review of articles and abstracts published from January 1974 to May 2008. Articles were identified using PubMed, Ovid, medline, Web of Science, and Google Scholar databases. The following terms were used in the search: adherence, compliance, copay, cost sharing, costs, noncompliance, outcomes, hospitalization, utilization, economics, income, and persistence. RESULTS: We identified and included 160 articles in the review. Although the types of interventions, measures, and populations studied varied widely, we were able to identify relatively clear relationships between cost sharing, adherence, and outcomes. Of the articles that evaluated the relationship between changes in cost sharing and adherence, 85% showed that an increasing patient share of medication costs was significantly associated with a decrease in adherence. For articles that investigated the relationship between adherence and outcomes, the majority noted that increased adherence was associated with a statistically significant improvement in outcomes. CONCLUSION: Increasing patient cost sharing was associated with declines in medication adherence, which in turn was associated with poorer health outcomes.

Quality of care associated with common chronic diseases in a 9-state Medicaid population utilizing claims data: an evaluation of medication and health care use and costs.

The objective of this cross-sectional, retrospective study was to utilize claims data to establish a quality-of-care benchmark in a large multistate Medicaid population overall and by race. Quality of care and medication adherence (persistence and compliance) per national treatment guidelines, and health care costs/utilization were assessed across common chronic conditions in a large, 9-state Medicaid population. Overall, quality of care was suboptimal across conditions. Over 15% of asthma patients had ≥ 1 asthma-related emergency room/hospital event and 12% of chronic obstructive pulmonary disease patients had a Level II or III exacerbation. Only 36% of depression patients filled any antidepressant medication within 90 days of new episode. Only 45% of diabetes patients received ≥ 2 A1c tests. Patients who filled a prescription for any acceptable pharmacotherapy ranged from 35% (depression) to 83% (heart failure [HF]). Persistence for those filling any acceptable medication ranged from 16% (asthma) to 68% (HF). Compliance for patients filling ≥ 2 prescriptions ranged from 27% (asthma) to 75% (HF). Blacks had the lowest medication compliance and persistence for all conditions except hyperlipidemia. The results highlight the need to assess and improve quality across the spectrum of care, both overall and by race.

Adherence to treatment guidelines and therapeutic regimens: a US claims-based benchmark of a commercial population.

The objective of this cross-sectional, retrospective study assessing commercially insured patients was to provide a useful benchmark to US health care payers and decision makers to assess quality of care, medication use and adherence, and health care resource utilization/costs associated with common chronic diseases. Measures of quality of care were suboptimal and substantial numbers of patients were not using any pharmacotherapy considered acceptable according to treatment guidelines. The widespread nature of undertreatment, poor medication adherence, and substantial health care costs highlights deficits and points to the need for comprehensive, multifaceted strategies to improve clinical and economic outcomes for chronic diseases.

Quality of care for veterans with chronic diseases: performance on quality indicators, medication use and adherence, and health care utilization.

This study was conducted to assess and benchmark the quality of care, in terms of adherence to nationally recognized treatment guidelines, for veterans with common chronic diseases (ie, asthma, chronic obstructive pulmonary disease [COPD], coronary artery disease [CAD], diabetes, heart failure, hyperlipidemia [HL]) in a Veterans Health Administration (VHA) system. Patients with at least 1 of the target diagnoses in the period between January 2002 and mid-year 2006 were identified using electronic medical records of patients seen at the James A. Haley Veterans' Hospital in Tampa, Florida. The most common diseases identified were HL (34%), CAD (21%), and diabetes (19%). The percentage of patients filling a prescription for any guidelines-sanctioned pharmacotherapy ranged from 28% (heart failure) to 91% (asthma). Persistence to medication ranged from 21% (HL) to 63% (asthma), while compliance ranged from 49% (COPD) to 85% (CAD). Most patients with diabetes (88%) had at least 1 A1c test in a year, but only 47% of patients had A1c values <7%. This study found that quality of care was generally good for conditions such as cardiovascular disease and diabetes, but quality care for conditions that have not been a primary focus of previous VHA quality improvement efforts, such as asthma and COPD, has room for improvement.

Employee health and frequency of workers' compensation and disability claims.

OBJECTIVE: To assess the relationship between self-assessed employee health risk status and future workers' compensation (WC) and short-term disability (STD) claims. METHODS: A historical cohort study linking Health Risk Assessment (HRA) survey data with subsequent WC and STD claims. HRA participants who developed a WC or STD claim in the subsequent 12 months were identified as cases and compared with HRA participants who did not develop a claim in the subsequent 12 months. RESULTS: High-risk participants had higher odds of filing a WC claim, when compared with low-risk participants (OR: 2.99, 95% CI: 1.22 to 7.32) despite adjustment for demographic factors including job type. Medium-risk participants had 1.5 times higher odds, when compared with low-risk participants to file for STD (OR: 1.45, 95% CI: 1.15 to 1.82). Other relationships trended similarly but did not reach statistical significance. CONCLUSION: Self-assessed personal health risk does impact future lost productivity in WC and STD claims even after adjustment for demographic, health factors, and job type (WC only). Employers wishing to reduce the impact of lost productivity should consider a worker's personal health risks as predictors of future lost productivity and may want to address this in broad risk reduction programs.

Two double-blind, multicenter, randomized, placebo-controlled, single-dose studies of sumatriptan/naproxen sodium in the acute treatment of migraine: function, productivity, and satisfaction outcomes.

OBJECTIVE: To describe return to normal function, productivity, and satisfaction of patients with moderate or severe migraine attacks treated with combined sumatriptan/naproxen sodium, sumatriptan alone, naproxen sodium alone, or placebo. PATIENTS, DESIGN, AND SETTING: Patients in 2 identical, US, phase 3, randomized, double-blind, parallel-group, placebo-controlled, single-dose, multicenter studies treated a single moderate or severe migraine attack with sumatriptan/naproxen sodium (85 mg sumatriptan formulated with RT Technology and 500 mg naproxen sodium in a single-tablet formulation), sumatriptan, naproxen sodium, or placebo. MAIN OUTCOME MEASURES: Ability to function (not impaired, mildly impaired, severely impaired, or required bed rest) was collected in diary cards completed immediately prior to treatment, every 30 minutes for the first 2 hours, and hourly from 2 to 24 hours while awake. Patients completed the Productivity Assessment Questionnaire (PAQ) 24 hours after study drug administration. The Patient Perception of Migraine Questionnaire (PPMQ) was administered at screening and 24 hours post treatment to capture patient satisfaction. RESULTS: Compared with the other groups, the sumatriptan/naproxen sodium group reported significantly higher levels of normal or mildly impaired functioning as early as 2 and 4 hours after dosing. They also demonstrated greater reductions in workplace productivity loss compared with placebo in both studies, and were consistently more satisfied with their treatment compared with patients in other treatment groups and compared with their usual medications. CONCLUSIONS: Treatment with sumatriptan/naproxen sodium allowed significantly more subjects to return to normal or mildly impaired functioning more quickly, and sumatriptan/naproxen sodium patients were significantly more satisfied with their treatment compared with other treatment groups. Overall productivity loss was significantly reduced following use of sumatriptan/naproxen sodium.

Direct economic effect following mupirocin therapy failure among patients with uncomplicated skin and skin-structure infections in a large population-based cohort.

The goal of the study was to derive initial costs associated with failure of initial mupirocin therapy among patients diagnosed with uncomplicated skin and skin-structure infections (uSSSIs). A retrospective observational analysis of medical, pharmacy, and enrollment records was conducted using data from the National Managed Care Benchmark Database. Patients were classified as failing treatment with mupirocin if they either filled a second antibiotic commonly used to treat uSSSIs five to 30 days after their index mupirocin prescription fill or experienced a uSSSI-related hospitalization within 30 days after the index mupirocin prescription fill. Among 12,650 failure episodes, 11,867 (93.8%) required a second antibiotic contributing a mean cost of $62 per prescription. Approximately 4,782 (37.8%) had an associated outpatient encounter resulting in a mean cost of $221 per encounter. Nine percent of failures required a hospitalization with a mean cost of $6,597 per hospitalization. These medical, hospital, and pharmacy costs translated into an expected cost of $735.45 per mupirocin failure among patients with uSSSIs. The management of uSSSIs is costly in terms of health care resource use and direct health care expenditures when initial therapy with mupirocin fails.

Factors that affect adherence to bipolar disorder treatments: a stated-preference approach.

BACKGROUND: Medication nonadherence is high among patients with bipolar disorder, and may lead to poor clinical outcomes, decreased quality of life, and increased resource utilization. OBJECTIVE: To investigate the factors associated with nonadherence and to assess the effect of patient-stated preferences on stated adherence to hypothetical medications. RESEARCH DESIGN: A choice-format stated-preference Web survey was administered. In each choice question, patients were asked to choose among 2 or 3 different hypothetical medications. Each choice question was followed by a question asking patients about their likely adherence to the selected medication alternative. SUBJECTS: Patients (N = 469) with self-reported bipolar disorder completed the survey which was programmed and administered to members of a chronic-illness Web panel. MEASURES: Factors associated with stated adherence to current treatment were identified. The effects of socioeconomic characteristics and medication attributes on stated adherence to hypothetical medications were assessed. RESULTS: Patient socioeconomic characteristics affect patients' adherence. Being white and having more education has a significant positive effect on adherence. Self-reported current adherence is a strong factor in predicting adherence for better medications. Medication outcome attributes, especially severity of depressive episodes, strongly influence patients' stated adherence to treatment. Weight gain and cognitive effects of a medication most significantly affected patients' likely adherence to medications for bipolar disorder. CONCLUSIONS: Patients are the final health care decision makers; their satisfaction with a medication is likely to affect whether or not they adhere to the medication prescribed by their physician. In the case of bipolar disorder, this study suggests patients are likely to be more adherent to medications that reduce the severity of depressive episodes and do not cause weight gain or cognitive side effects. By understanding the factors that improve adherence, health care providers can optimize prescribing patterns, which may ultimately lead to more effective management and improvement in the patient's condition.

Migraine: a better way to recognize and treat it.

Consider using the Headache Assessment Quiz, which 76% of providers in this study said enabled patients to adequately convey headache severity/symptoms, compared with just 20% of providers at baseline who thought patients communicated clearly. Use the quiz also to better understand the impact of migraine on a patient's life, and to help determine which patients need migraine-specific therapy.

The cost-effectiveness of lamotrigine in the maintenance treatment of adults with bipolar I disorder.

OBJECTIVE: To present an economic model and cost-effectiveness estimates for lamotrigine in maintenance treatment of bipolar I disorder (BD-I) using outcomes from the pivotal lamotrigine trials. The main comparator treatments in the pivotal trials were lithium and .no maintenance. (acute-only) treatment. A comparison with olanzapine was included as an indirect analysis following publication of data during the course of our research. METHODS: A Markov model was built around the 3 health states of euthymia, mania, and depression. The base-case model simulates a cohort of 1,000 patients with BD-I who have recently stabilized after resolution of a bipolar mania episode. The cohort was modeled for a period of 18 months. Resource-use estimates were derived from best available published data, treatment guidelines, a physician survey, and published unit cost data. Outputs were measured in terms of costs per acute mood episode avoided, costs per euthymic day gained, and costs per quality-adjusted life-years (QALYs). Direct health care payer costs are used in the analyses. RESULTS: The base-case model for patients with a recent manic episode indicated that lamotrigine is the most effective treatment for avoiding both acute depression episodes and all types of acute episodes (depression and mania). It is also the most effective treatment in terms of number of euthymic days achieved (309 days per patient per year). Olanzapine is most effective for avoiding acute mania episodes. Total direct costs of treatment are lowest for the lithium treatment arm (Dollars 8,710 per patient for the 18-month period). All maintenance therapies were cost effective compared with the no-maintenance (acute-only treatment) arm. In the base case, lamotrigine had incremental cost-effectiveness ratios of Dollars 30 per euthymic day and Dollars 2,400 per acute episode avoided compared with lithium. A QALY analysis indicated that lamotrigine is cost effective in patients with a recent manic episode at Dollars 26,000 per QALY. The base-case model indicated that lamotrigine dominates olanzapine, (that is, lamotrigine costs less and is more effective than olanzapine) in patients with a recent manic episode. In a sensitivity analysis using outcomes from the pivotal trial of recently depressed patients, lamotrigine, in comparison with lithium, was not shown to be as cost effective as in the recently manic patients, but it was still cost effective compared with no maintenance treatment. CONCLUSIONS: For a defined cohort of patients with BD-I, the pharmacoeconomic model indicated that prevention of mood episodes with lithium and lamotrigine is cost effective in patients with a recent manic, mixed, or hypomanic episode. The conclusions with respect to the indirect comparison with olanzapine should be validated if and when direct trial data become available. Cost-effectiveness of maintenance treatments for patients with BD-I (recently depressed as well as recently manic) are likely to improve in models with a broader costing perspective and that take a longer time frame. Further research into the outcome implications of health-related quality of life and other BD subgroups are recommended.

The economic impact of opioids on postoperative pain management.

STUDY OBJECTIVE: To evaluate the consequences of opioid use for postoperative pain management and the degree to which these consequences may be reduced or minimized with opioid-sparing or opioid-replacement techniques. DESIGN: Literature review relating to the economics of postoperative pain management. Comparisons between opioids and opioid-sparing techniques were identified and selected for study. MEASUREMENTS AND MAIN RESULTS: Studies evaluating overall economic impacts or surrogate outcomes (e.g., resource use or recovery milestones) showed benefits with opioid-sparing therapies. CONCLUSIONS: Opioids will likely remain an integral part of postoperative pain management, but side effects increase the costs of care. The challenge is to identify situations where opioid-sparing techniques improve surrogate economic measurements and decrease overall hospital costs.

The validity and clinical utility of symptom monitoring in advanced lung cancer: a literature review.

Symptom monitoring and quality-of-life (QOL) evaluation in lung cancer patients might improve care. Brief, valid, and responsive tools are available to measure symptoms and their effect on QOL. Instruments available for use in lung cancer patients can be classified into 3 categories: generic, cancer-specific, and lung cancer symptom-specific. These instruments might assist clinicians in assessing and interpreting treatment outcomes from the patient perspective. They also can assist in treatment decision making, symptom palliation, and they might even be prognostic of survival. Over the past 20 years, these brief evaluations have been used in clinical trials to evaluate patient-reported outcomes. Now, with the advent of less toxic, targeted molecular therapies such as gefitinib (Iressa) in non-small-cell lung cancer, these instruments' value in showing symptomatic improvement from tumor control or regression might be further enhanced. To date, however, such assessments are not widely implemented in routine clinical practice. To better understand benefits of such assessments, we review existing evidence surrounding the instruments' use, evaluate their success, and highlight recent developments. We hope to encourage clinicians to incorporate these evaluations in clinical practice.