Andrew Howe

Risk of Arrest in Persons With Schizophrenia and Bipolar Disorder in a Florida Medicaid Program: The Role of Atypical Antipsychotics, Conventional Neuroleptics, and Routine Outpatient Behavioral Health Services

OBJECTIVE To examine (1) arrest outcomes for adults with schizophrenia and bipolar disorder who were treated with first-generation antipsychotics (FGAs) or second-generation atypical antipsychotics (SGAs) and (2) the interaction between medication class and outpatient services in a Florida Medicaid program. METHOD In a secondary data analysis, Florida Medicaid data covering the period from July 1, 2002, to March 31, 2008, were used to identify persons diagnosed with schizophrenia, schizoaffective disorder, and bipolar disorder and to examine antipsychotic medication episodes lasting at least 60 days. There were 93,999 medication episodes in the population examined (N = 36,519). Medication episodes were coded as (1) SGA-aripiprazole, clozapine, olanzapine, paliperidone, quetiapine, risperidone, risperidone long-acting therapy, or ziprasidone; or (2) FGA-any other antipsychotic medication. Outpatient services were defined as the proportion of 30-day periods of each medication episode with at least 1 behavioral health visit. Survival analyses were used to analyze the data, and they were adjusted for the baseline propensity for receiving an SGA. RESULTS Second-generation antipsychotic episodes were not associated with reduced arrests compared to FGA episodes; however, the interaction between outpatient services and SGA episodes was significant (hazard ratio [HR] = 0.68; 95% CI, 0.50-0.93; P = .02) such that an SGA episode with an outpatient visit during at least 80% of every 30-day period of the episode was associated with reduced arrests compared to SGA episodes with fewer outpatient services. There was no significant effect for concurrent FGA episodes and outpatient treatment (HR = 0.81; 95% CI, 0.60-1.10; P = .18). Substance use, poor refill compliance, and prior arrest increased risk of subsequent arrest. CONCLUSIONS The interaction between outpatient visits and treatment with SGAs was significantly associated with reduced arrests. These findings indicate the importance of concurrent antipsychotic medications and outpatient services to affect arrest outcomes for adults with schizophrenia and bipolar disorder.

Budget Impact Analysis of Tapentadol Extended Release for the Treatment of Moderate to Severe Chronic Noncancer Pain

BACKGROUND Opioids are commonly used to manage chronic pain. Although traditional μ-opioids are effective in reducing pain, they are often associated with opioid-induced side effects (OISEs) that can limit treatment effectiveness. Studies have shown that tapentadol extended release (ER) has a lower incidence of gastrointestinal adverse events than oxycodone controlled release (CR) at equianalgesic doses. OBJECTIVE A model was developed to estimate the budget impact of placing tapentadol ER on a hypothetical US health plan formulary of Schedule II long-acting opioids. METHODS We estimated annual direct health care costs for patients who received 6-month therapy with long-acting formulations of tapentadol, oxycodone, morphine, hydromorphone, oxymorphone, or fentanyl. Costs included medications, copayments, OISE management, and switching/discontinuation. Published estimates of incidence/prevalence, OISEs, and pain management resources and costs were used. The base case analysis assumed a 10% formulary share of tapentadol ER with a 10% decrease of oxycodone CR. The resulting per-member per-month (PMPM) formulary cost differences and results of a 1-way sensitivity analysis are reported. RESULTS In a health plan of 500,000 members, 2600 (0.52%) are estimated to experience chronic pain annually. Adding tapentadol ER to the formulary was associated with an annual budget savings of

Factors related to criminal justice expenditure trajectories for adults with serious mental illness

148,945 (

Risperidone Long-Acting Therapy Prescribing Patterns and Their Impact on Early Discontinuation of Treatment in a Large Medicaid Population

0.0248 PMPM). This savings was achieved through a decrease in both pharmacy costs (

Short-Term Impact of Preferred Drug List Changes on Health Care Use and Medicaid Costs: Injectable Risperidone

144,062;

PMH82 OUTCOMES OF SECOND GENERATION ATYPICAL ANTIPSYCHOTICS, FIRST GENERATION ANTIPSYCHOTICS AND ROUTINE OUTPATIENT BEHAVIORAL HEALTH SERVICES IN PREVENTING ARRESTS IN PERSONS WITH SEVERE MENTAL ILLNESS

0.0240 PMPM) and medical costs (

Characteristics and Experiences of Adults With a Serious Mental Illness Who Were Involved in the Criminal Justice System

4883;

Arrest trajectories of adult offenders with a serious mental illness

0.0008 PMPM). Cost decreases were driven by lower daily average consumption and fewer OISEs with tapentadol ER versus oxycodone CR, leading to reduced resource utilization over 6 months of treatment. Sensitivity analyses showed results were most sensitive to drug acquisition costs. CONCLUSIONS Our results suggest that replacing 10% of oxycodone CRs formulary share with tapentadol ER would decrease the overall budget of a health plan with 500,000 members. Placing tapentadol ER on a health plan formulary may result in a reduction in both pharmacy and medical costs.

PMH84 Validity of Administrative Claims Data for Calculating Adherence Measures for Long-Acting Injectable (Lai) Antipsychotic Therapies

BACKGROUND Criminal careers have been extensively studied in general population sample, but less is known about such patterns among people with major mental illness, and where so, criminal justice expenditure has not been taken into account. AIMS Our aim was to examine criminal justice system expenditure over time in one Florida county. Our main research question was whether treatment for mental disorders was related to a change in criminal offending and expenditure trajectory. METHODS We used the Pinellas County (Florida) Criminal Justice Information System to identify individuals under age 65 arrested between July 2003 and June 2004. Archival medical service, social and homeless services data were used to identify individuals with a serious mental illness. A two-step analysis was used to examine the data: first, we identified groups of people with similar patterns of criminal justice expenditures over 4 years (July 2002 to June 2006); second, we evaluated their demographic characteristics, diagnosis and treatment as potential predictors of group membership. RESULTS Three thousand seven hundred sixty-nine people with serious mental illness were identified in the Pinellas County jail population. Their average length of stay in jail was 151 days and in prison was 48 days. The trajectory analysis identified three groups of individuals with distinct trajectories of criminal justice expenditures: those with low stable, those with initially high but decreasing and those with initially high and sustained or increasing. Mental health treatment, whether acute or sustained, voluntary or mandatory, was associated with membership of the low stable group. CONCLUSION Review of criminal justice expenditure over time on individuals with major mental disorder may provide important indicators of unmet need for mental health services. Furthermore, it seems probable that improved provision of such services for them could reduce recidivism as well as improving health. Interventions may also be better focused if criminal justice expenditure trajectories are examined; programmes targeting re-offending as well as specific mental health problems may be most effective.

PSY12 A Budget Impact Analysis of Tapentadol Extended Release (ER) for the Treatment of Moderate to Severe Chronic Pain

OBJECTIVE Medicaid claims were examined to determine whether utilization of risperidone long-acting therapy (LAT) was consistent with manufacturers prescribing information recommendations and what factors were associated with early discontinuation. METHOD Florida Medicaid claims between July 1, 2003, and June 30, 2007, were used. Recipient demographics and diagnoses, provision of oral antipsychotic supplementation during the first 21 days, number of injections received, medication possession ratio, and augmentation/polypharmacy after the first 21 days were assessed. Logistic regression was used to identify factors associated with early discontinuation of risperidone LAT. RESULTS There were 3,364 individuals who received 4,546 episodes of risperidone LAT. Most recipients were between 18 and 64 years and had schizophrenia or schizoaffective disorder. Median episode length was 106 days. Median number of injections was 5. Supplementation with oral antipsychotic during the first 21 days was provided in 48% of episodes. Mean dosages were 25 mg or less for 28% of episodes and greater than 75 mg for 7% of episodes. Augmentation/polypharmacy after the first 21 days occurred in 43% of episodes. Early risperidone LAT discontinuation was associated with absence of oral supplementation during the first 21 days (P < .001), low (P = .045) or high (P < .001) initial doses of risperidone LAT, prior inpatient treatment (P < .001), having a substance use disorder (P = .001), and being male (P = .036). CONCLUSIONS Prescribing practices for risperidone LAT were compared with the recommended protocol. Risperidone LAT was typically used with recommended age and diagnostic groups. However, important discrepancies were identified that could have reduced perceived effectiveness and tolerability of risperidone LAT. Early discontinuation was less likely when the recommendations in the manufacturers prescribing information regarding dosage and supplementation with oral antipsychotics were followed.