Cumulative burden of oral corticosteroid adverse effects and the economic implications of corticosteroid use in patients with systemic lupus erythematosus.

BACKGROUND: Corticosteroids (CSs) are used to treat patients with systemic lupus erythematosus (SLE) and are associated with potential adverse events (AEs). However, few data are currently available on the risk of AEs in CS users in an SLE population. OBJECTIVE: To examine AEs related to CS use and costs of treating CS-related AEs in patients with SLE. METHODS: In a retrospective cohort study using claims data (study period: January 1, 2000-June 30, 2010), patients aged ≥18 years having ≥2 SLE-related (International Classification of Diseases, Ninth Revision, Clinical Modification code 710.0x) outpatient or ≥1 inpatient/emergency department claim were identified with an index diagnosis date deemed as the date of first SLE diagnosis. Receipt of CS therapy was assessed within 6 months of the index diagnosis date. Cox models were used to evaluate risk of AEs in CS users and nonusers. Associated costs were computed for AEs where risk was significantly different among the cohorts. RESULTS: Of 2717 patients with SLE, 989 received CSs and 1728 did not. Users of CSs were ~1.5 times more likely to develop chronic AEs (sleep disturbances, migraines, cataracts, hypertension, and type 2 diabetes mellitus) and ~2 times more likely to develop acute AEs (pneumonia, herpes zoster, fungal infections, and nausea/vomiting) compared with CS nonusers. The mean annual cost for managing AEs was $4607 and was highest for diabetes mellitus ($9764), hypertension ($8773), and sleep disturbances ($5599). Applying differences in 1-year event rates (CS user: 58.1%; CS nonuser: 75.1%) to cost estimates yielded an additional $784 per year per CS user to manage known CS-related AEs compared with CS nonusers. CONCLUSIONS: Although CSs are prescribed to control SLE symptoms, these results highlight potential risks and costs associated with their use, which providers/payers should consider when making treatment decisions.

Longitudinal changes in functional disability in Alzheimer's disease patients.

BACKGROUND: Functional impairment is a core symptom of Alzheimer's disease (AD) often measured by loss of ability to perform activities of daily living (ADL). The objective is to describe the progressive loss of specific ADL functional capabilities expressed by AD patients' cognitive ability. METHODS: Data are from ELN-AIP-901, an observational study of cognitive progression in participants aged 50-85 with AD (n = 196), mild cognitive impairment (n = 70), or cognitively normal (n = 75). Participants were evaluated using the Mini-Mental Status Exam (MMSE) and the Disability Assessment for Dementia (DAD) every six months for ≤2 years. Hierarchical regression was used to estimate annual change in DAD and MMSE; first, by individuals' rate of change using linear regression, then controlling for baseline diagnosis. RESULTS: Over a two-year period, in AD participants, a 1-point change in MMSE was associated with a 3-point change in DAD (2.79, 95% CI: 1.97-3.63); DAD items within the finance, medication, and outings subdomains were impacted earlier than other subdomains; a hierarchy of functional impairment was observed, with instrumental ADL generally impaired prior to basic ADL. CONCLUSIONS: ADL are impacted in a progressive and hierarchical manner associated with cognitive decline, but substantial variability remains among individuals, as well as in the relative order of items affected.

Burden of Alzheimer's disease and association with negative health outcomes.

OBJECTIVE: To examine the association of Alzheimer's disease (AD) with common chronic conditions, acute care events, and risk of hospitalization. STUDY DESIGN: Retrospective matched cohort analysis. METHODS: Community-dwelling subjects with a diagnosis of and/or medication for AD were matched to subjects without AD based on age, sex, and geographic region. Administrative claims from commercially insured health plans for medical and pharmacy services provided from January 1, 2000, to March 31, 2006 (inclusive) were analyzed. The Deyo Charlson Index (DCI) was used to assess the number of chronic conditions. The outcomes of interest were risk of fractures and hospitalization. RESULTS: Among 5396 persons with AD and a matched cohort of 5396 persons without the condition, subjects with AD were more likely to have a diagnosis for any of the DCI components, had a higher rate of fractures (17.7% vs 7.9%, P <.00) and other urgent medical events (eg, pneumonia 14.0% vs 6.3%, P <.00), and were more likely to be hospitalized (odds ratio = 1.7; 95% confidence interval = 1.5, 1.9). There were significant differences in the medication use between the 2 groups, with the use of psychotics/tranquilizers 9-fold higher among persons with AD. CONCLUSION: Persons with AD have higher odds of experiencing a fracture, being hospitalized, and requiring other acute care medical services than those without AD. The disease also is associated with a higher prevalence of common chronic conditions.

Characteristics, drug therapy, and outcomes from a database of 500,000 hospitalized patients with a discharge diagnosis of heart failure.

Knowledge related to acute heart failure (HF) and its management in "real-world" clinical practice is limited. The authors delineated characteristics and drug therapy for hospitalized HF patients and their association with clinical and economic outcomes. The NDCHealth (National Data Corporation, Atlanta, GA) database, containing billing data from a geographically diverse sample of approximately 300 hospitals, was screened for admissions in 2003 of either a primary or secondary discharge diagnosis of HF. Of 2.5 million admissions screened, 496,534 patients (19.7%) had a primary (131,057) or secondary (365,477) discharge diagnosis of HF. Mean age was 73.1+/-13.9 years, and 55.4% were women. Mean length of hospital stay was 8.7+/-28.6 days, and in-hospital mortality was 7.1%. Mean hospital cost per admission was dollars 18,667. Admissions with HF as a secondary diagnosis were associated with a worse prognosis. HF commonly exists in hospitalized patients and is associated with significant morbidity, mortality, and economic burden, irrespective of whether it is the primary diagnosis or a secondary comorbidity.

Pharmacy and medical costs associated with switching between venlafaxine and SSRI antidepressant therapy for the treatment of major depressive disorder.

BACKGROUND: While much has been published on utilization of antidepressants and associated resource use, surprisingly little information is available on the relationship between a change in antidepressant agent and health care utilization. Given that many patients will not respond to initial therapy (and therefore would be candidates for switching treatment) and the array of antidepressant medications on the market, information on the impact of switching would be beneficial to both providers and policymakers. OBJECTIVE: To explore patterns of antidepressant drug use and depression-related and all-cause medical costs for patients who switched therapy between 2 drug classes, selective serotonin reuptake inhibitors (SSRIs) and the selective norepinephrine reuptake inhibitor (SNRI) venlafaxine. METHODS: Using an administrative claims database of 36 million members from 61 health plans, this retrospective cohort analysis examined patients who had (1) a diagnosis of major depressive disorder (MDD, International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 296.2x for MDD single episode, 296.3x for MDD recurrent episode, 300.4 for dysthymic disorder, and 311 for depressive disorder not elsewhere classified) and (2) a newly prescribed antidepressant during the year 2002. Costs were defined as amounts paid by health plans for all inpatient, outpatient, physician and pharmacy services (i.e., allowed charges after subtraction of member cost-share). Depression-related costs were defined using (1) medical claims with primary diagnosis of depression and (2) pharmacy claims for antidepressants. Using an index date of the first antidepressant claim, 12 months of pre-index and postindex data were available for all eligible patients. Switching was defined as occurring between the SSRIs and venlafaxine (i.e., patients who switched within the SSRI drug class across different SSRIs were treated as non-switchers until they switched to venlafaxine), and there was no minimum or maximum gap in therapy. The SSRIs included fluoxetine, citalopram, sertraline, and paroxetine; the only SNRI on the market at the time was venlafaxine. Multivariate regression analyses determined predictors of switching and factors influencing overall and depression-related costs, while controlling for confounding factors. For the 12-month period following the index date (fixed length of follow-up), the study compared per-patient per-year (PPPY) costs for (1) patients who switched versus those who did not switch and (2) patients with single versus multiple trials of SSRI for the subgroup of patients who switched from an SSRI to venlafaxine. For the time periods before versus after the switch (variable lengths of follow-up), per-patient means and medians of monthly cost averages (with follow-up periods <1 month set to 1 month for 16.5% [n=272] of SSRI-to-venlafaxine switchers and 14.1% [n=103] of venlafaxine-to-SSRI switchers) were calculated for the subgroup of patients who made a switch. RESULTS: A total of 48,950 patients were included in the study, with 43,653 (89.2%) treated first with SSRIs and 5,297 (10.8%) treated first with venlafaxine. Of the initial SSRI users, 1,645 (3.8%) switched to venlafaxine, and of the initial venlafaxine users, 733 (13.8%) switched to an SSRI. Mean (standard deviation [SD]) 12-month total (medical plus pharmacy) depression-related costs in 2002-2003 dollars were 118.0% higher for SSRI switchers ($1,225 [$3,438] vs. $562 [$2,153], P<0.001) and 18.4% higher for venlafaxine switchers ($863 [$1,503] vs. $729 [$1,185], P=0.021) as compared with non-switchers. From the pre-switch to post-switch periods, depression-related mean monthly medical costs declined by 66.4% among switchers from SSRIs ($113 [$912] vs. $38 [$347], P=0.001) and by 61.1% among switchers from venlafaxine ($54 [$299] vs. $21 [$138], P=0.005). Monthly mean depression-related pharmacy costs increased by 62.2% following a switch from an SSRI to venlafaxine (from $45 [$38] to $73 [$62], P<0.001) and declined by 17.3% following a switch from venlafaxine to an SSRI (from $52 [$45] to $43 [$38], P<0.001). After adjustment for multiple covariates including demographic characteristics, 10 selected comorbidities, and physician specialty, general linear models with log-transformed costs as the dependent variables demonstrated significant associations between switching and total costs (both all-cause and depression-related) in both the SSRI and the venlafaxine cohorts. CONCLUSIONS: Although relatively few patients switched antidepressant drug classes, patients who made a switch had higher all-cause health care costs and higher depression-related costs than patients who did not switch. Switching drug classes was associated with lower mean monthly depression-related health care costs following the switch. For those patients switching from an SSRI to venlafaxine, mean medical cost reductions offset higher pharmacy costs; for patients switching from venlafaxine to an SSRI, mean medical and pharmacy costs declined.

The economic effect of switching from sildenafil to another phosphodiesterase type 5 inhibitor.

Patients who could benefit from additional education about treatments for erectile dysfunction (ED) may prematurely discontinue or switch ED medications, resulting in unnecessary resource utilization. In a retrospective cohort study using a large, aggregated health claims database, the costs associated with switching from sildenafil to another phosphodiesterase type 5 (PDE-5) inhibitor were compared with those for patients refilling sildenafil. Of the 15,584 patients with an index sildenafil claim, 10,863 had a second PDE-5 inhibitor prescription (10,137 for sildenafil, 726 for vardenafil or tadalafil). Erectile dysfunction-attributable costs in the six-month preindex period were similar (P = .72), but postindex six-month ED costs were higher in patients who initially switched from sildenafil (dollar 173.38) versus patients who refilled sildenafil (dollar 131.51; P < .001). Regression analysis estimated that corrected ED-attributable and overall costs were 41% (P < .001) and 43% (P < .001) higher for patients who switched versus those who refilled sildenafil, respectively.

The use of rhinitis medications in children receiving initial controller therapy for asthma.

BACKGROUND: Due to common features of asthma and allergic rhinitis, a single therapeutic approach to treating both of these conditions has been proposed. OBJECTIVE: To compare and contrast the use of rhinitis medications in a group of children initiating various controller therapies for asthma. METHODS: A retrospective, observational study using an integrated managed care database of children aged 4-17 years with an initial medical claim for asthma and an initial pharmacy claim for fluticasone propionate (FP) and salmeterol in a single inhaler (FSC), FP alone, montelukast (MON), or combination FP + MON. Outcomes included the percentage of children initiating controller asthma therapy with prescriptions for non-sedating antihistamine (NSA) and intranasal corticosteroids (INCS) and the mean number of prescriptions for NSA and INCS. RESULTS: A total of 5247 children were included. The percentage of children who filled prescriptions for NSA or INCS and the mean number of prescriptions dispensed was similar among children treated with FSC, FP, MON, and FP + MON. There were no significant differences in the relative risk of dispensing either a NSA or INCS across cohorts. Observational studies are limited by their use of administrative data and lack of access to patient records. CONCLUSIONS: Children started on common asthma controller therapy are frequent users of rhinitis medications. The quantity and frequency of these medications is not different between dispensed asthma regimens.

Impact of adherence to concomitant gastroprotective therapy on nonsteroidal-related gastroduodenal ulcer complications.

BACKGROUND & AIMS: The clinical impact of nonadherence to gastroprotective agents (GPAs) coprescribed with anti-inflammatory therapies has not been evaluated. In a large, commercial, managed-care database, we retrospectively characterized the use of GPAs among patients receiving nonselective nonsteroidal anti-inflammatory drugs (ns-NSAIDs) or cyclooxygenase-2-selective inhibitors (coxibs) and determined the impact of nonadherence on the likelihood of gastroduodenal ulcer complications. METHODS: Analyses identified the populations of patients with concomitant histamine-2 receptor antagonist or proton pump inhibitor (PPI) therapy and determined adherence with the prescribed therapy with respect to the duration of anti-inflammatory treatment. Multivariate regression analyses modeled the association between adherence with concomitant protective therapy and the likelihood of upper gastrointestinal (GI) complications including peptic ulcer disease, ulcer, and/or upper-GI bleed. RESULTS: Among 144,203 patients newly prescribed anti-inflammatory therapies, 1.8% received concomitant GPA treatment (ns-NSAIDs, 1.4% vs coxibs, 2.6%; P < .0001). The likelihood of GPA use increased with the presence of risk factors: age older than 65 years (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.3-1.5) and prior history of peptic ulcer disease (OR, 2.5; 95% CI, 1.8-3.3), esophagitis/gastroesophageal reflux (OR, 3.8; 95% CI, 3.5-4.1), ulcer/upper-GI bleed (OR, 1.4; 95% CI, 1.2-1.5), or gastritis (OR, 2.5; 95% CI, 2.2-2.8). Of patients receiving concomitant PPI therapy, 68% had adherence rates of 80% or more. A significantly higher risk of upper-GI ulcers/complications was observed in ns-NSAID patients with adherence rates of less than 80% compared with adherence rates of 80% or more (OR, 2.4; 95% CI, 1.0-5.6), but no such relationship was observed among patients who took coxibs. CONCLUSIONS: Few patients receive concomitant GPA therapy when prescribed anti-inflammatory treatment, although use increased with the presence of risk factors. Adherence to concomitant therapy is paramount to reducing GI events among ns-NSAID users and educational efforts should be undertaken to promote use of and adherence to GPA therapy among these patients.

Overlap of anxiety and depression in a managed care population: Prevalence and association with resource utilization.

OBJECTIVE: To characterize the diagnosis of anxiety and depression within a large managed care population and to measure the impact of having both of these conditions on treatment patterns, health care utilization, and cost. Further, to compare the impact of having both conditions with having neither or either condition alone. METHOD: A retrospective, cross-sectional analysis of population-level anxiety-related and depression-related utilization over a 12-month study period was conducted. Data were from the PharMetrics Patient-Centric database, which is composed of medical and pharmaceutical claims for approximately 36 million patients from 61 health plans across the United States. Patients 18 years and older were included as cases in the analysis if they had a diagnosis of depression or anxiety during 2002. Four groups were identified based on the presence of anxiety and/or depression diagnosis: anxiety only, depression only, anxiety and depression, and controls. Controls were matched to the anxiety and depression cohort using a 4:1 ratio, based on patient age, gender, and similarity of health coverage. Cohorts were compared with respect to patient demographics, comorbid diagnoses, medication use, specialist care, utilization of health care services, and treatment costs, using both univariate and multivariate statistics. RESULTS: Significant differences in comorbid diagnoses, medication use, health care utilization, and treatment costs existed between the study groups. Specifically, patients with both anxiety and depression tended to have more somatic complaints such as abdominal pain, malaise, or chest pain than patients with either condition alone or the control group. Antidepressant use was highest among the anxiety and depression cohort, while anxiolytic use was as prevalent in the anxiety and depression cohort as in the anxiety only cohort. Patients in the anxiety only, depression only, or anxiety plus depression groups had a higher number of anxiety- and/or depression-related visits as well as visits not related to depression or anxiety than the control group, with the anxiety and depression cohort incurring the highest utilization of medical services. Similarly, in terms of cost, the disease cohorts incurred significantly higher cost than their control counterparts, with the anxiety and depression cohort incurring higher cost than those with either condition alone, even after accounting for differences in patient characteristics. CONCLUSIONS: Combination of anxiety and depression is fairly common in a managed care population as evidenced by diagnosis and treatment. The combination of both diagnoses appears to increase the complexity of these patients with respect to comorbid conditions as well as increases the economic cost to payers.

The economic impact of children dispensed asthma medications without an asthma diagnosis.

OBJECTIVE: To compare the resource utilization and healthcare costs of children with a diagnosis of asthma, children dispensed asthma medications but without a diagnosis of asthma, and control children. STUDY DESIGN: Children 0 to 17 years old were identified from an integrated managed-care database during calendar year 2001. They were compared on the basis of the presence of a medical claim for asthma (Dx cohort); a prescription for an asthma controller or reliever medication (excluding oral corticosteroids) but without an asthma diagnosis (Rx cohort), and control children. Using medical and pharmacy claims, resource utilization and costs were compared across cohorts. RESULTS: Children in both the Dx and Rx cohorts had significantly greater nonasthma and total all-cause annual healthcare costs compared with control children. The Dx and Rx cohorts had higher rates of nonasthma emergency department visits and hospitalizations. The risk of an oral corticosteroid dispensed was 14-fold and 7-fold greater for the Dx and Rx cohorts, respectively, compared with the control children. These findings were consistent in infant, toddler, school-age, and adolescent groups. CONCLUSIONS: Children dispensed asthma medications but lacking an asthma diagnosis have considerable morbidity and incur high healthcare resource utilization. This study suggests that better recognition of pediatric asthma is warranted.

Addition of dexmedetomidine to standard sedation regimens after cardiac surgery: an outcomes analysis.

STUDY OBJECTIVE: To characterize inpatient use of intravenous sedatives in the real-world setting, and to evaluate clinical and economic outcomes when dexmedetomidine was used with midazolam and propofol for select cardiovascular procedures. DESIGN: 12-month retrospective analysis. DATA SOURCE: An administrative claims database of operational data from a nationally representative sample of 250 medical and surgical hospitals. PATIENTS: Patients who received midazolam plus propofol (9996 patients) or dexmedetomidine, midazolam, plus propofol (356 patients) after cardiac valve or vessel surgery. MEASUREMENTS AND MAIN RESULTS: The source of patient demographics (e.g., age, sex, Charlson Comorbidity Index) and outcomes (e.g., charges, length of stay, mortality rate) was the hospital billing claim form. Patients in the dexmedetomidine-midazolam-propofol cohort tended to be younger and male and to have fewer comorbidities than those midazolam-propofol cohort. The primary outcomes for the three-drug cohort showed significant reductions in total charges/patient (approximately $18,000, p<0.05), total hospital length of stay (0.6 days, p<0.0001), days in the intensive care unit or cardiac care unit (3.87 days, p<0.0001), and mortality (2%, p=0.0142). Although pharmacy charges were higher (approximately $4000/patient), lower charges for the intensive care or cardiac care unit, operating room, room and board, and respiratory services were observed in the dexmedetomidinemidazolam-propofol cohort compared with the two-drug cohort. Also, mechanical ventilation was shorter by approximately 0.5 day in the three-drug cohort (p<0.01). CONCLUSION: These initial findings of a real-world assessment of dexmedetomidine use with other agents suggest favorable clinical and economic outcomes. Further research through randomized clinical trials of dexmedetomidine is warranted to better understand its optimum patient population, dosage, and the causality of the results, and to confirm the potential clinical and economic benefits observed in our patients.

Impact of therapy initiation with amlodipine or losartan on hemodynamic endpoints and JNC-VI blood pressure stage.

The relative efficacy of long-acting calcium channel antagonists and angiotensin II receptor blocking agents has been described in clinical trials; however, their effectiveness in an actual practice setting has not been well studied. This study assessed the effectiveness of 2 commonly prescribed antihypertensives, amlodipine and losartan, either as monotherapy or as add-on for patients insufficiently controlled on beta-blocker or diuretic therapy. This was a retrospective, observational study that utilized electronic medical records. Hypertensive patients more than 40 years old who were new users of amlodipine or losartan were included in the study. Patients with congestive heart failure or those using antihypertensives other than diuretics or beta-blockers were excluded. Blood pressure (BP) readings were followed up to 6 months after enrollment. Univariate and multivariate regression models were used to assess the impact of amlodipine or losartan therapy on hemodynamic end points and on JNC-VI BP stage. A total of 346 patients met the entry criteria. Of these, 275 (79.5%) amlodipine and 71 (20.5%) were prescribed losartan. Mean changes in systolic and diastolic blood pressure were greater for patients receiving amlodipine in univariate and multivariate analyses (reduction of 20/8 and 11/4 mm Hg, respectively; P<0.05). Mean change in pulse pressure trended strongly in favor of amlodipine (11.8 mm Hg vs. 7 mm Hg, P = 0.08). Univariate analysis indicated that amlodipine-treated patients were more likely to move to a better JNC-VI BP stage, where as losartan-treated patients, on average, moved to a worse stage. Amlodipine therapy was superior to losartan therapy among this population of hypertensive patients.

Treatment patterns for pediatric asthma prior to and after emergency department events.

There are 2 million asthma-related emergency department (ED) events each year in the United States. Children share a disproportional burden of these events. This study was designed to describe the treatment patterns in children in the year prior to and 2 months after an ED event. This retrospective observational study utilized the PharMetrics Integrated Outcomes Database that contains administrative claims from over 20 managed-care plans across the United States. Children aged 1-17 years with at least one ED visit for asthma during 2001 were included. Patients were required to have data available 12 months prior to and 2 months following the ED visit. We identified 5,501 pediatric asthma-related ED admissions. In the year prior to the ED event, 19.4% of children received an inhaled corticosteroid (ICS), 31.4% an oral corticosteroid (OCS), and 58.3% a short-acting beta-agonist (SABA). Overall, there were 3.7 albuterol units for every ICS unit dispensed in the 12 months prior to the event. Ninety-four percent of the children had an office visit in the year prior to the ED visit. Prescriptions dispensed for ICS and OCS increased 2.9-fold and 8.2-fold, respectively, in the month after the ED event. However, the dispensing rates for both medications reverted to near baseline by the second month after the index event. In conclusion, this study demonstrates the dependence of children with asthma on the use of rescue medications. An ED event results in only an incremental and transient increase in ICS-containing controller treatment.

Daily cost of an intensive care unit day: the contribution of mechanical ventilation.

OBJECTIVE: To quantify the mean daily cost of intensive care, identify key factors associated with increased cost, and determine the incremental cost of mechanical ventilation during a day in the intensive care unit. DESIGN: Retrospective cohort analysis using data from NDCHealth's Hospital Patient Level Database. SETTING: A total of 253 geographically diverse U.S. hospitals. PATIENTS: The study included 51,009 patients >/=18 yrs of age admitted to an intensive care unit between October 1, 2002, and December 31, 2002. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Days of intensive care and mechanical ventilation were identified using billing data, and daily costs were calculated as the sum of daily charges multiplied by hospital-specific cost-to-charge ratios. Cost data are presented as mean (+/-sd). Incremental daily cost of mechanical ventilation was calculated using log-linear regression, adjusting for patient and hospital characteristics. Approximately 36% of identified patients were mechanically ventilated at some point during their intensive care unit stay. Mechanically ventilated patients were older (63.5 yrs vs. 61.7 yrs, p < .0001) and more likely to be male (56.1% vs. 51.8%, p < 0.0001), compared with patients who were not mechanically ventilated, and required mechanical ventilation for a mean duration of 5.6 days +/- 9.6. Mean intensive care unit cost and length of stay were 31,574 +/- 42,570 dollars and 14.4 days +/- 15.8 for patients requiring mechanical ventilation and 12,931 +/- 20,569 dollars and 8.5 days +/- 10.5 for those not requiring mechanical ventilation. Daily costs were greatest on intensive care unit day 1 (mechanical ventilation, 10,794 dollars; no mechanical ventilation, 6,667 dollars), decreased on day 2 (mechanical ventilation:, 4,796 dollars; no mechanical ventilation, 3,496 dollars), and became stable after day 3 (mechanical ventilation, 3,968 dollars; no mechanical ventilation, 3,184 dollars). Adjusting for patient and hospital characteristics, the mean incremental cost of mechanical ventilation in intensive care unit patients was 1,522 dollars per day (p < .001). CONCLUSIONS: Intensive care unit costs are highest during the first 2 days of admission, stabilizing at a lower level thereafter. Mechanical ventilation is associated with significantly higher daily costs for patients receiving treatment in the intensive care unit throughout their entire intensive care unit stay. Interventions that result in reduced intensive care unit length of stay and/or duration of mechanical ventilation could lead to substantial reductions in total inpatient cost.

Medication utilization behavior in patients receiving phosphodiesterase type 5 inhibitors for erectile dysfunction.

INTRODUCTION: A number of preference studies have been conducted with phosphodiesterase type 5 (PDE5) inhibitor medications demonstrating inconsistent findings. Additionally, limited information is available regarding real-world utilization patterns of PDE5 inhibitors. AIM: To evaluate treatment patterns using real-world data for patients initiating erectile dysfunction (ED) therapy with Viagra (sildenafil citrate), Levitra (vardenafil), or Cialis (tadalafil). METHODS: Patients with an initial prescription claim for sildenafil, vardenafil, or tadalafil were identified in NDCHealth's Intelligent Health Repository. Medication refills, medication switching, and dose titration were analyzed. Logistic regression on the odds of refilling initial PDE5 medications was conducted controlling for patient age, presence of common comorbidities, initial number of tablets, and copay. RESULTS: A higher percentage of patients receiving sildenafil (52%) refilled their ED medication during the study period than patients receiving vardenafil (30%) or tadalafil (29%) (P<0.001). A smaller percentage of patients in the sildenafil cohort (6.4%) switched medication than in the tadalafil (9.0%) or vardenafil (10.4%) cohorts (P<0.001); the difference between the tadalafil and vardenafil cohorts in switching medications was also significant (P<0.001). There were no statistically significant differences between cohorts in dose titration frequency, which was low in all three treatment cohorts. Using logistic regression, the odds of refilling initial PDE5 therapy was significantly lower for vardenafil (odds ratio [OR]: 0.39, 95% confidence interval [CI]: 0.38-0.40; P<0.0001) and tadalafil (OR: 0.38, 95% CI: 0.37-0.40; P<0.0001) compared with sildenafil. CONCLUSIONS: Patients who were initially prescribed sildenafil were significantly more likely to refill their medication and significantly less likely to switch medications during the study period compared with patients who were initially prescribed vardenafil or tadalafil. These findings may indicate greater treatment satisfaction in patients receiving sildenafil, although future prospective evaluation is required.

A claims analysis comparing citalopram with sertraline as initial pharmacotherapy for a new episode of depression: impact on depression-related treatment charges.

BACKGROUND: Citalopram, a selective serotonin reuptake inhibitor (SSRI) recently approved in the United States for treatment of depression, has similar efficacy to and a lower acquisition cost than other SSRIs. The impact of using citalopram (instead of other SSRIs) on total treatment costs has not been studied extensively. OBJECTIVE: The aim of this study was to compare depression-related treatment charges for the first 6 months of treatment among patients with newly diagnosed depression who received sertraline or citalopram. METHODS: This was a retrospective analysis of medical and pharmaceutical claims from 20 managed care organizations across the United States. This study population can be considered representative of a commercially insured US population. Patients aged >or= 18 years with newly diagnosed depression (ie, major depressive disorder, dysthymia, or depressive disorder not otherwise specified) who had a prescription claim for sertraline or citalopram (within 30 days of initial diagnosis) from July 1, 1998, through June 30, 1999, were included in the study. Patients with previous mental disorders and/or treatment with an SSRI (including patients diagnosed with an anxiety disorder before the first SSRI prescription) were excluded from the analysis. Log-transformed depression-related treatment charges for the first 6 months of therapy were compared across the 2 treatment cohorts with use of multivariate regression. Other outcomes measures included medication compliance and use of other antidepressant medications during the 6-month study period. Costs were measured in year-1999 US dollars. RESULTS: A total of 15222 sertraline and 3175 citalopram patients met the inclusion criteria. Mean disease-related medical charges were US dollars 931 per patient in the setraline group and US dollars 1035 in the citalopram group ( [P<0.001). The difference between groups may have been due to higher mean outpatient charges in the citalopram group (US dollars 414 vs US dollars 360; P<0.001). Citalopram patients had lower mean pharmacy charges than did sertraline patients (US dollars 255 vs Us dollars 267; 0.036). After the data were controlled for differences in age, sex, managed care plan, pretreatment history of resource use, physician specialty type, index prescription year, and switching/augmentation of the treatment drug, depression-related charges for the citalopram patients were 22% higher than those for the sertraline cohort (beta coefficient, -0.21925; P<0.001). CONCLUSION: Despite potential cost savings due to a lower acquisition cost, initial treatment of depression with citalopram was associated with higher depression-related charges than was sertraline in the population studied.

Impact of cotherapy with some proton pump inhibitors on medical claims among HMO patients already using other common drugs also cleared by cytochrome P450.

Adverse drug event (ADE) rates resulting from coadministration of proton pump inhibitors (PPIs) and other drugs with potential for interaction with PPIs (DPIs) are unknown. This retrospective study assesses the occurrence of such ADEs and their potential impact on medical care costs by reviewing integrated medical and pharmacy claims. Managed care patients receiving one or more DPIs were identified. Within this sample, those who were also prescribed omeprazole or lansoprazole (DPI + PPI) were included. A second cohort (DPI alone) was created, matching for age, gender, and DPI use. Rates of ADEs were followed for 6 months after entry. Among PPI users, 58% used one or more DPIs, whereas 7% of DPI subjects used a PPI. Among claims arising from ADEs occurring in more than 1% of patients, 14 occurred in the DPI + PPI group and 2 occurred in the DPI-alone cohort, respectively, a highly significant difference. Crude odds ratios for the risks of specific ADEs were significantly increased for cotherapy with a PPI and warfarin, clarithromycin, corticosteroids, carbamazepine, nifedipine, or diclofenac. After adjustment, the first three associations remained significant. Coprescription of a PPI with potentially interacting drugs was common in practice and associated with significantly increased claims for medical care.

Comparison of managed care charges among patients treated with selective serotonin reuptake inhibitors for premenstrual dysphoric disorder.

OBJECTIVE: To determine the impact on managed care charges of selecting citalopram, fluoxetine, paroxetine, or sertraline as first-line pharmacotherapy for newly diagnosed premenstrual dysphoric disorder (PMDD). METHOD: This retrospective study analyzed administrative claims data from 14 managed care plans in the United States. The study population was identified from an integrated outcomes database for the period Jan. 1, 1998, to Dec. 31, 1999. Patients aged 18 years or older, newly diagnosed with PMDD, and initiating therapy with a selective serotonin reuptake inhibitor (SSRI) within 30 days of the diagnosis were eligible for analysis. To date, there is no specific ICD-9 diagnosis code for PMDD; thus, patients were required to have an ICD-9 diagnosis of premenstrual tension syndrome (ICD-9 625.4). Patients with documented previous psychiatric disorders/treatment were excluded. All inpatient, outpatient, and pharmacy claims incurred by each patient during the study period were included in the analysis. PMDD-related treatment charges for the 6-month period following treatment initiation were compared using multivariate regression. RESULTS: A total of 1413 patients met the study criteria. Fluoxetine and sertraline were the most common agents selected as first-line therapy. After differences in age, managed care plan, pretreatment resource utilization, physician specialty, index prescription year, treatment charges, presence of mental health and nonmental health comorbid conditions, and changes in medication were controlled for, patients taking paroxetine and citalopram had significantly higher PMDD-related treatment charges than sertraline patients (paroxetine, p =.0430; citalopram, p =.0226). Fluoxetine patients also had higher treatment charges than sertraline patients, though statistical significance was not reached. CONCLUSIONS: Sertraline, as first-line therapy for PMDD, was associated with lower PMDD-related treatment charges compared with other SSRIs during the first 6 months after treatment initiation.