Trends in overall survival and costs of multiple myeloma, 2000-2014.

Little real-world evidence is available to describe the recent trends in treatment costs and outcomes for patients with multiple myeloma (MM). Using the Truven Health MarketScan Research Databases linked with social security administration death records, this study found that the percentage of MM patients using novel therapy continuously increased from 8.7% in 2000 to 61.3% in 2014. Compared with MM patients diagnosed in earlier years, those diagnosed after 2010 had higher rates of novel therapy use and better survival outcomes; patients diagnosed in 2012 were 1.25 times more likely to survive 2 years than those diagnosed in 2006. MM patients showed improved survival over the study period, with the 2-year survival gap between MM patients and matched controls decreasing at a rate of 3% per year. Total costs among MM patients have increased in all healthcare services over the years; however, the relative contribution of drug costs has remained fairly stable since 2009 despite new novel therapies coming to market. Findings from this study corroborate clinical data, suggesting a paradigm shift in MM treatment over the past decade that is associated with substantial survival gains. Future studies should focus on the impact on specific novel agents on patients' outcomes.

Quantifying the matrix of relationships between reduced vancomycin susceptibility phenotypes and outcomes among patients with MRSA bloodstream infections treated with vancomycin .

OBJECTIVES: Several phenotypic characteristics of Staphylococcus aureus have been identified as aetiological factors responsible for adverse outcomes among patients receiving vancomycin. However, characterization of the outcomes associated with these reduced vancomycin susceptibility phenotypes (rVSPs) remains largely incomplete and it is unknown if these features contribute to deleterious treatment outcomes alone or in concert. This study described the interrelationship between rVSPs and assessed their individual and combined effects on outcomes among patients who received vancomycin for a methicillin-resistant S. aureus (MRSA) bloodstream infection. METHODS: An observational study of adult, hospitalized patients with MRSA bloodstream infections who were treated with vancomycin between January 2005 and June 2009 was performed. The rVSPs evaluated included the following: (i) Etest MIC; (ii) broth microdilution MIC; (iii) MBC : MIC ratio; and (iv) heteroresistance to vancomycin by the Etest macromethod. Failure was defined as any of the following: (i) 30 day mortality; (ii) bacteraemia ≥ 7 days on therapy; or (iii) recurrence of MRSA bacteraemia within 60 days of therapy discontinuation. RESULTS: During the study period, 184 cases met the study criteria and 41.3% met the failure criteria. There was a clear linear exposure-response relationship between the number of these phenotypic markers and outcomes. As the number of phenotypes escalated, the incidence of overall failure increased incrementally by 10%-18%. CONCLUSIONS: The data suggest that rVSPs contribute to deleterious treatment outcomes in concert.

Association of provider and patient characteristics with HIV-infected women's antiretroviral therapy regimen.

OBJECTIVE: We explored the effect of patient and provider factors on the type of antiretroviral regimen among women receiving therapy. PATIENTS: Five hundred ninety-five New York State nonpregnant HIV+ women with full Medicaid eligibility and at least 1 month of a prescribed antiretroviral regimen in federal fiscal years (FFY) 1997-1998 and intervals in FFY 1997-1998, who had delivered a liveborn baby within 5 years. MEASUREMENTS: From pharmacy claims in 4 6-month intervals in FFY 1997-1998, data were extracted on (1) an acceptable > or = 2 antiretroviral combination regimen per expert guidelines; and (2) a highly active regimen, including a protease inhibitor or nonnucleoside analog (highly active antiretroviral therapy [HAART]). RESULTS: Of 1514 woman-6-month intervals with filled antiretroviral prescriptions, 82% had an acceptable regimen, and of 1246 woman-6-month intervals on acceptable antiretroviral therapy, half demonstrated the use of HAART. Adjusted odds ratios (AORs) of acceptable antiretroviral therapy were higher (p < .05) for HIV specialty care (AOR = 1.71 for one or two visits; AOR = 2.10 for 3+ visits) or HIV clinical trials site care (AOR = 1.43; 95% confidence interval [CI]: 1.01, 2.04). Among women on acceptable antiretroviral regimens, those aged older than 25 years (AOR = 1.69; CI: 1.13, 2.53) or who were high school graduates (AOR = 1.50; CI: 1.09, 2.06) had higher odds of HAART. Methadone-treated women had twofold and nearly threefold higher AORs of acceptable antiretroviral regimens and HAART, respectively, than current drug users. CONCLUSION: Provider HIV expertise is associated with receipt of an acceptable antiretroviral regimen in women, although receipt of HAART is affected more by age, education, and current drug abuse. Methadone treatment seems to improve access to acceptable antiretroviral regimens as well as to HAART.

Antiretroviral use and pharmacy-based measurement of adherence in postpartum HIV-infected women.

BACKGROUND: Antiretroviral treatment for HIV-infected women is standard during pregnancy to prevent vertical transmission, but data on postpartum therapy for the mother are lacking. OBJECTIVE: The objective of this study was to examine the impact of provider and patient characteristics on receipt of antiretroviral therapy and pharmacy-based measurement of adherence by postpartum HIV-infected women. RESEARCH DESIGN: This was a retrospective cohort study. SUBJECTS: The study included 2,648 New York State Medicaid-enrolled HIV-infected women who delivered from January 1993 through October 1996 and were followed up through September 1997. MEASURES: From Medicaid claims in the first postpartum year, the study examined any prescribed antiretroviral therapy and, among women treated >2 months, adherence, defined as > or =80% days covered by prescribed therapy from first to last antiretroviral prescription. RESULTS: Antiretroviral therapy was prescribed for 681 (26%) study women. Of 292 women treated >2 months, 28% were adherent on the basis of the pharmacy-based measure. The proportion of treated women was highest in 1996 (40%), and adherence was best in 1995 (44%) when most women took monotherapy. The adjusted odds ratios (AORs) of treatment were 1.67 (95% CI, 1.24 to 2.25) for women receiving HIV-focused services and 2.71 (95% CI, 1.99 to 3.69) for women with a provider in an HIV-related specialty. The AORs of adherence were greater for women with HIV-focused services (2.13; 95% CI, 1.05 to 4.30) and for former illicit drug users versus nonusers (2.40; 95% CI, 1.05 to 5.50). CONCLUSIONS: This population-based pharmacy analysis reveals improving antiretroviral use but continuing poor pharmacy-based adherence by postpartum HIV-infected women. Receipt of HIV-focused services appears to be particularly beneficial in increasing the likelihood of treatment and adherence.

Adherence to antiretroviral therapy by pregnant women infected with human immunodeficiency virus: a pharmacy claims-based analysis.

OBJECTIVE: To assess adherence to antiretroviral therapy with the use of Medicaid pharmacy claims data for human immunodeficiency virus (HIV)-infected pregnant women and to identify associated maternal and health care factors. METHODS: We retrospectively studied a cohort of 2714 HIV-infected women in New York State who delivered live infants from 1993-96. Among 682 women prescribed antiretroviral therapy in the last two trimesters, we studied 549 who started therapy more than 2 months before delivery. Adherence was defined as adequate if the supplied drug covered at least 80% of the days from the first prescription in the last two trimesters until delivery. Multivariable analyses were used to examine associations between maternal and health care factors and adherence. RESULTS: Only 34.2% of 549 subjects had at least 80% adherence based on pharmacy data, a rate that remained stable over time. The adjusted odds ratios (ORs) of adherence for black (OR 0.47, 95% confidence interval [CI] 0.30, 0.75) and Hispanic (OR 0.49, 95% CI 0.29, 0.82) women were nearly 50% lower than for white women. The OR of adherence was 0.32 (95% CI 0.12, 0.90) for teenagers compared with women aged 25-29 years and 0.56 (95% CI 0.34, 0.92) for women in New York City versus those residing elsewhere. Women on antiretroviral therapy before pregnancy were more likely to adhere (OR 1.55, 95% CI 1.02, 2.35). CONCLUSION: Teenagers, women of minority groups, and women living in New York City had greater risks of poor antiretroviral adherence, whereas women already prescribed antiretrovirals before pregnancy had better adherence. Our conservative pharmacy data-based measure showed that most HIV-infected women adhered poorly and adherence did not improve over the 4-year study.

Clinic HIV-focused features and prevention of Pneumocystis carinii pneumonia.

OBJECTIVE: To examine the association of clinic HIV-focused features and advanced HIV care experience with Pneumocystis carinii pneumonia (PCP) prophylaxis and development of PCP as the initial AIDS diagnosis. DESIGN: Nonconcurrent prospective study. SETTING: New York State Medicaid Program. PARTICIPANTS: Medicaid enrollees diagnosed with AIDS in 1990-1992. MEASUREMENTS AND MAIN RESULTS: We collected patient clinical and health care data from Medicaid files, conducted telephone interviews of directors of 125 clinics serving as the usual source of care for study patients, and measured AIDS experience as the cumulative number of AIDS patients treated by the study clinics since 1986. Pneumocystis carinii pneumonia prophylaxis in the 6 months before AIDS diagnosis and PCP at AIDS diagnosis were the main outcome measures. Bivariate and multivariate analyses adjusted for clustering of patients within clinics. Of 1,876 HIV-infected persons, 44% had PCP prophylaxis and 38% had primary PCP. Persons on prophylaxis had 20% lower adjusted odds of developing PCP (95% confidence interval [CI] 0.64, 0.99). The adjusted odds of receiving prophylaxis rose monotonically with the number of HIV-focused features offered by the clinic, with threefold higher odds (95% CI 1.6, 5.7) for six versus two or fewer such features. Patients in clinics with three HIV-focused features had 36% lower adjusted odds of PCP than those in clinics with one or none. Neither clinic experience nor specialty had a significant association with prophylaxis or PCP. CONCLUSIONS: PCP prevention in our study cohort appears to be more successful in clinics offering an array of HIV-focused features.

Association of maternal HIV infection with low birth weight.

We evaluated factors associated with low birth weight (LBW) in an HIV-infected cohort (n = 772) and a general sample (n = 2,377) of women delivering a live singleton in federal fiscal years 1989 and 1990 while enrolled in New York State Medicaid. The association of LBW and HIV infection was studied in logistic models, controlling for illicit drug use, demographic characteristics, adequacy of prenatal care, and medical risk factors. Overall, 29% of the HIV-infected women had a LBW infant compared to 9.3% of the general sample (p < 0.001). The adjusted odds of LBW for HIV-infected women were twofold higher than for uninfected women [odds ratio (OR) = 2.04 and 95% confidence interval (Cl) = 1.54, 2.69]. Odds of LBW were also increased for illicit drug users (OR = 2.16; 95% CI = 1.59, 2.94), cigarette smokers (OR = 1.81; 95% CI = 1.37, 2.39), and African-American versus non-Hispanic white women (OR = 1.89; 95% CI = 1.31, 2.72). Lower odds appeared for women with adequate prenatal care (OR = 0.54; 95% CI = 0.42, 0.68). Among only women with full-term deliveries, the association of HIV with LBW remained strong as we found nearly threefold greater odds of LBW for HIV-infected women. This study indicates that HIV-infected women have an increased risk of bearing a L.BW infant, even after adjusting for the effects of drug use, health care delivery, and other social and medical risk factors.

A population-based comparison of the clinical course of children and adults with AIDS.

OBJECTIVE: To examine the association of clinical complications and age at diagnosis with survival for a cohort of children and adults with AIDS. DESIGN: A population-based analysis of 734 children and 5584 adults diagnosed with AIDS from 1985 to 1990 in New York State. RESULTS: The initial AIDS-defining diagnoses for 68% of children were lymphoid interstitial pneumonitis or infections specified in the Centers for Disease Control and Prevention's (CDC) pediatric AIDS case definition but not the CDC's 1987 adult AIDS case definition. Of opportunistic infections in both case definitions, Pneumocystis carinii pneumonia (PCP) was the most common initial AIDS diagnosis, occurring in 53% of adults, 47% of children aged < 6 months at diagnosis (n = 122) and 14% aged > or = 6 months at diagnosis (n = 612). Median survival after AIDS diagnosis was 62 months for all children compared with 11 months for adults. For children initially diagnosed with conditions only in the pediatric case definition, median survival ranged from 27 to 62 months compared with less than 12 months for children and adults with PCP. Compared with children aged 6-54 months, the estimated hazards of death for younger and older children were 2.06 [95% confidence interval (CI), 1.48-2.86] and 1.54 (95% CI, 1.10-2.16), respectively. CONCLUSION: Children survived significantly longer than adults after AIDS diagnosis, but their survival varied by age at diagnosis. Differences in the types of common initial AIDS-defining diagnoses appear to contribute to the observed differences in survival.

Implications of generalists' slow adoption of zidovudine in clinical practice.

BACKGROUND: The lag time for adoption of new acquired immunodeficiency syndrome (AIDS) therapies into the clinical practices of different types of ambulatory care providers can be estimated from patient use of zidovudine therapy during the first few years after approval by the Food and Drug Administration. METHODS: We analyzed receipt of zidovudine therapy from April 1987 through March 1990 by 3643 patients with a diagnosis of AIDS. The study group was continuously enrolled in the New York State Medicaid program for at least 6 months after diagnosis. For each patient, the dominant providers of ambulatory care, receipt of zidovudine therapy, and consultation with a human immunodeficiency virus-AIDS specialist within 6 months after diagnosis were determined from Medicaid claims. AIDS specialists included physicians or clinics specializing in infectious disease or hematology/oncology or specific clinics within designated AIDS centers. RESULTS: In 1987, 55% of those who had an AIDS specialist as their dominant care provider received zidovudine therapy, compared with only 36% of patients with a primary care clinic as their dominant care provider. It was not until 1990, 3 years after approval by the Food and Drug Administration, that the percentage of patients receiving zidovudine therapy (77% to 78%) was comparable for patients of primary care clinics and AIDS specialists. In logistic regression analysis, zidovudine use did not differ between patients of AIDS specialists and patients with other types of dominant providers when the latter group had consulted with an AIDS specialist (adjusted odds ratio, 1.38; 95% confidence interval, 0.99 to 1.95). CONCLUSIONS: In our AIDS study population, there was at least a 3-year lag before patients of primary care clinics received zidovudine therapy at the same rate as patients of AIDS specialists. Conditions such as AIDS with rapid changes in treatment options may require a close relationship between generalists and specialists to increase access to new therapies.

Zidovudine's impact on resource use by patients with symptomatic HIV illness: a large sample analysis.

This study used a longitudinal data set of 4,957 patients and 39,455 patient-months of observation, drawn from 17 months of data on patients with symptomatic HIV disease identified from the New York State Medicaid Program. Multivariate regression analysis was used to evaluate the effect of AZT on the use of several medical services. The results show that AZT produced substantial reductions in resource use. Patients who took AZT were hospitalized fewer days per month and, including the cost of the drug, had Medicaid expenditures that were several hundred dollars lower per month. The reduction in total expenditures is largely accounted for by a reduction in inpatient expenditures and an increase in pharmacy expenditures. These effects were temporary, however, as the impact of the drug decreased with each month of use. There were no declines in expenditures and utilization after approximately 7 to 9 months of AZT use.

The epidemiology of AIDS in the New York and California Medicaid programs.

An epidemiological analysis of the impact of AIDS on the New York and California Medicaid programs was conducted for 1983-1986. The epidemic affected the New York and California Medicaid programs in several similar ways. The total number of cases grew rapidly over the study time period. In both states, the epidemic was mostly confined to the young adult (21-44 years) age group. Cases were geographically concentrated and highly localized even within counties, but evidence of geographic dispersion to counties outside of the urban centers was also evident. Some dramatic differences were also found between California and New York. Patients with claims histories of drug use were far more likely to be found in the New York population and the proportion of other adult males (our proxy for the homosexual risk group) was higher in California. A much higher proportion of New York's population was female (30 vs. 5%). New York also had many more pediatric cases. Most importantly, New York's raw number of cases was substantially higher than California, with approximately three times as many cases during the time period (1983-1986). There is also substantial evidence that transmission of the disease to heterosexual partners of drug users places heterosexual urban minorities at grave risk of contracting the disease through interaction with infected persons.

Consumer preference for personal drug information source: relationship to perceived importance of drug class.

The purposes of this study were to: (1) determine consumer preferences for personal drug information sources, and (2) determine if preference for information source is affected by perceived drug importance. A telephone survey of 204 metropolitan subjects was conducted using a systematic sampling design. Pharmacists and physicians were preferred over lay sources for all drug categories. Pharmacists and physicians were preferred equally for drugs perceived of low to moderate importance, but not for drugs perceived of highest importance. Perceived drug importance, which has not been examined previously, appears to be an important factor in consumers' preference for personal drug information sources.