Concetta Crivera

Medication Adherence and Hospitalization Among Patients With Schizophrenia Treated With Antipsychotics

OBJECTIVE This analysis assessed rates of medication adherence and predictors of nonadherence and hospitalization among patients treated with long-acting injectable and oral antipsychotic therapies. METHODS Data were from a retrospective analysis of Florida Medicaid recipients with schizophrenic disorder (ICD-9-CM code 295.XX) who received a prescription for an antipsychotic between July 1, 2004, and June 30, 2005. Patients were required to have filled one additional antipsychotic prescription during follow-up. Adherence measures included medication possession ratio (MPR), medication persistence, medication consistency, and maximum gap in treatment. Multivariate logistic regression models identified predictors of nonadherence and hospitalization. RESULTS Patients were considered adherent if they had an MPR ≥ .8. A total of 12,032 patients met selection criteria. The mean ± SD MPR was .79 ± .23, medication persistence was 94.1% ± 16.4%, medication consistency was 83.3% ± 16.4%, and the maximum gap in treatment was 29.7 ± 41.4 days. Thirty-seven percent of patients were hospitalized for any cause, and 32% had a psychiatric hospitalization. Predictors of nonadherence included newly starting treatment; younger age; a substance abuse diagnosis; use of a mood stabilizer, antidepressant, anxiolytic, or anticholinergic; and receipt of long-acting first-generation antipsychotics. Receipt of long-acting second-generation therapy or receipt of both first- and second-generation medications was associated with lower likelihood of nonadherence. Predictors of hospitalization risk included a diagnosis of other psychoses or substance abuse, anticholinergic use, and nonadherence to therapy. CONCLUSIONS Results document rates of antipsychotic adherence and predictors of nonadherence and hospitalization. Findings may be useful to health plan administrators, formulary decision makers, and physicians.

Effectiveness of injectable risperidone long-acting therapy for schizophrenia: data from the US, Spain, Australia, and Belgium

BackgroundBecause wide variations in mental health care utilization exist throughout the world, determining long-term effectiveness of psychotropic medications in a real-world setting would be beneficial to physicians and patients. The purpose of this analysis was to describe the effectiveness of injectable risperidone long-acting therapy (RLAT) for schizophrenia across countries.MethodsThis was a pragmatic analysis of data from two prospective observational studies conducted in the US (Schizophrenia Outcomes Utilization Relapse and Clinical Evaluation [SOURCE]; ClinicalTrials.gov registration number for the SOURCE study: NCT00246194) and Spain, Australia, and Belgium (electronic Schizophrenia Treatment Adherence Registry [eSTAR]). Two separate analyses were performed to assess clinical improvement during the study and estimate psychiatric hospitalization rates before and after RLAT initiation. Clinical improvement was evaluated using the Clinical Global Impressions-Severity (CGI-S) and Global Assessment of Functioning (GAF) scales, and change from baseline was evaluated using paired t tests. Psychiatric hospitalization rates were analyzed using incidence densities, and the bootstrap resampling method was used to examine differences between the pre-baseline and post-baseline periods.ResultsThe initial sample comprised 3,069 patients (US, n = 532; Spain, n = 1,345; Australia, n = 784; and Belgium, n = 408). In all, 24 months of study participation, completed by 39.3% (n = 209), 62.7% (n = 843), 45.8% (n = 359), and 64.2% (n = 262) of patients from the US, Spain, Australia, and Belgium, respectively, were included in the clinical analysis. Improvements compared with baseline were observed on both clinical assessments across countries (P < 0.001 at all post-baseline visits). The mean improvement was approximately 1 point on the CGI-S and 15 points on the GAF. A total of 435 (81.8%), 1,339 (99.6%), 734 (93.6%), and 393 (96.3%) patients from the US, Spain, Australia, and Belgium, respectively, had ≥1 post-baseline visit and were included in the analysis of psychiatric hospitalization rates. Hospitalization rates decreased significantly in all countries regardless of hospitalization status at RLAT initiation (P < 0.0001) and decreased significantly in the US and Spain (P < 0.0001) when the analysis was limited to outpatients only.ConclusionsRLAT in patients with schizophrenia was associated with improvements in clinical and functional outcomes and decreased hospitalization rates in the US, Spain, Australia, and Belgium, despite differences in health care delivery systems.

The Impact of Topiramate on Health‐Related Quality of Life Indicators in Chronic Migraine

Background.— Chronic migraine is a disabling primary chronic daily headache disorder that significantly impacts the daily activities of patients with this disorder. To our knowledge, this is the first report of a large, randomized, double‐blind, placebo‐controlled trial that assessed the impact of topiramate on the daily activities, emotional distress, headache‐related disability, and global impression of change in patients with chronic migraine.

Adherence to non-vitamin-K-antagonist oral anticoagulant medications based on the Pharmacy Quality Alliance measure

Abstract Background: CMS Star Ratings help inform beneficiaries about the performance of health and drug plans. Medication adherence is currently weighted at nearly half of a Part D plan’s Star Ratings. Including the adherence to non-vitamin-K-antagonist oral anticoagulants (NOACs) as a measure in the Star Ratings program may increase a plan’s incentives to improve patient adherence. Objective: To assess the adherence to medication of patients who used the NOACs rivaroxaban, dabigatran, or apixaban in 2014 based on the Pharmacy Quality Alliance (PQA) adherence measure. Methods: Healthcare claims from the Humana database between July 2013 and December 2014 were analyzed. Adult patients with ≥2 dispensings of NOAC agents in 2014, at least 180 days apart, with >60 days of supply, and ≥180 days of continuous enrollment prior to the index NOAC were identified. The PQA measure was calculated as the percentage of patients who had a proportion of days covered (PDC) ≥0.8. Multivariate logistic regression analyses were also conducted adjusting for baseline confounders. Results: A total of 11,095 rivaroxaban, 6548 dabigatran, and 3532 apixaban users were identified. Based on the PQA adherence measure (PDC ≥0.8), a significantly higher proportion of rivaroxaban users (72.7%) was found to be adherent compared to dabigatran (67.2%: p < 0.001) and apixaban (69.5%: p < 0.001) users. Compared to apixaban users, the adjusted likelihood of being adherent was significantly higher for rivaroxaban users (unadjusted OR [95% CI]: 1.17 [1.08–1.27], p < 0.001; adjusted OR [95% CI]: 1.20 (1.10–1.31), p < 0.001) and significantly lower for dabigatran users (unadjusted OR [95% CI]: 0.90 [0.82–0.98], p = 0.019; adjusted OR [95% CI]: 0.85 [0.77–0.93], p < 0.001). Limitations: Limitations of the study are potential inaccuracies in claims data, possible change in patterns over time, and the impossibility of knowing whether all supplied tablets were taken. Conclusion: Using the PQA’s adherence measure, rivaroxaban users were found to have significantly higher adherence compared to apixaban and dabigatran users.

Evaluation of US prescription patterns: Are treatment guidelines for cancer-associated venous thromboembolism being followed?

INTRODUCTION Venous thromboembolism (VTE) is a common complication of cancer. Clinical practice guidelines recommend low-molecular-weight heparin (LMWH) for treatment of cancer-associated VTE, but it is unclear how frequently these are followed. This study assessed anticoagulation treatment patterns for VTE in newly diagnosed cancer patients in the United States. MATERIALS AND METHODS MarketScan® claims records of more than 80 million insured members between January 1, 2009 and July 31, 2014 were retrospectively analyzed. Subjects were included if they were 18years of age or older, and had a diagnosis of cancer (9 solid tumor types) and VTE. Data were included for LMWH, warfarin, and other anticoagulants (fondaparinux and direct oral anticoagulants [DOACs]). Patients with anticoagulant treatment prior to cancer diagnosis were excluded. RESULTS VTE developed in 6.2% of cancer patients (median, 181days after cancer diagnosis). VTE rates were highest for pancreatic (17.5%) and lung (12.6%) cancer and lowest for breast (4.2%) and prostate (4.1%) cancer. For patients for whom outpatient prescription data were available, warfarin was most commonly used (50.0%), followed by LMWH (40.0%) and other anticoagulants (10.0%). Over 6months, 13% of patients who initiated injectable anticoagulants remained on them compared with 30% of those who initiated oral anticoagulants. More patients switched from LMWH to warfarin and other anticoagulants (44%) versus those who switched from warfarin (28%). CONCLUSIONS Warfarin was the most utilized anticoagulant for cancer-associated VTE despite guideline recommendations for LMWH. More patients remained on oral versus injectable agents, which may be related to self-injection burden and costs.

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.

Pharmacy quality alliance measure: adherence to non-warfarin oral anticoagulant medications

Abstract Background: The Pharmacy Quality Alliance (PQA) recently endorsed adherence to non-warfarin anticoagulant agents as a new performance measure, but the Medicare Part D Star Ratings program has not yet adopted the measure. The current study aims to assess the real-world adherence to medication of patients who used non-vitamin-K-antagonist oral anticoagulants (NOACs) based on the PQA’s adherence measure. Methods: Healthcare claims from the Humana database during the year of 2013 were analyzed. Patients older than 18 with ≥2 dispensings of NOAC agents, at least 180 days apart between two NOAC dispensings in 2013 (a criterion to include chronic users), with ≥60 days of supply, and ≥180 days of continuous enrollment prior to the index NOAC were identified. The PQA measure on the index therapy was calculated as the percentage of patients who had a proportion of days covered (PDC) ≥0.8 during their follow-up. Results: A total of 9948 NOAC users (rivaroxaban: n = 4194, dabigatran: n = 5489, apixaban: n = 265) were identified. For rivaroxaban users, the proportion of patients with a PDC ≥0.8 (PQA measure) at 75.4% was significantly higher compared to dabigatran users (67.6%; P < 0.001) and higher compared to apixaban users (70.6%; P = 0.076). When allowing switches to other NOAC agents in the PQA measure, rivaroxaban users had a significantly higher PQA measure at 76.9% compared to both dabigatran (72.9%; P < 0.001) and apixaban (71.3%; P = 0.037) users. Multivariate logistic regression analyses corroborated the findings that rivaroxaban had a significantly higher adherence compared to the other NOAC agents. Limitations: Claims data may have contained inaccuracies, possible change in patterns over time, and the impossibility of knowing whether all supplied tablets were taken. Conclusion: Based on the PQA’s adherence measure, rivaroxaban users were found to have a higher adherence compared to dabigatran and apixaban users. Healthcare providers may want to consider the impact of anticoagulation selection on their ability to achieve quality metrics.

Resource utilization in patients with schizophrenia who initiated risperidone long-acting therapy: results from the Schizophrenia Outcomes Utilization Relapse and Clinical Evaluation (SOURCE)

BackgroundSchizophrenia is a chronic mental health disorder associated with increased hospital admissions and excessive utilization of outpatient services and long-term care. This analysis examined health care resource utilization from a 24-month observational study of patients with schizophrenia initiated on risperidone long-acting therapy (RLAT).MethodsSchizophrenia Outcomes Utilization Relapse and Clinical Evaluation (SOURCE) was a 24-month observational study designed to examine real-world treatment outcomes by prospectively following patients with schizophrenia initiated on RLAT. At baseline visit, prior hospitalization and ER visit dates were obtained for the previous 12 months and subsequent hospitalization visit dates were obtained at 3-month visits, if available. The health care resource utilization outcomes measures observed in this analysis were hospitalizations for any reason, psychiatric-related hospitalizations, and emergency room (ER) visits. Incidence density analysis was used to assess pre-event and postevent rates per person-year (PY).ResultsThe primary medical resource utilization analysis included 435 patients who had a baseline visit, ≥1 postbaseline visits after RLAT initiation, and valid hospitalization dates. The number of hospitalizations and ER visits per PY declined significantly (p < .0001) after initiation with RLAT. A 41% decrease (difference of -0.29 hospitalizations per PY [95% CI: -0.39 to -0.18] from baseline) in hospitalizations for any reason, a 56% decrease (a difference of -0.35 hospitalizations per PY [95% CI: -0.44 to -0.26] from baseline) in psychiatric-related hospitalizations, and a 40% decrease (-0.26 hospitalizations per PY [95% CI: -0.44 to -0.10] from baseline) in ER visits were observed after the baseline period. The percentage of psychiatric-related hospitalizations decreased significantly after RLAT initiation, and patients had fewer inpatient hospitalizations and ER visits (all p < .0001).ConclusionThe results suggest that treatment with RLAT may result in decreased hospitalizations for patients with schizophrenia.Trial RegistrationClinicalTrials.gov: NCT00246194

Clinical and economic outcomes among hospitalized patients with acute coronary syndrome: an analysis of a national representative Medicare population.

Objective To evaluate the clinical and economic burden of acute coronary syndrome (ACS), a common cardiovascular illness, in the Medicare population. Methods Data from the Medicare Current Beneficiary Survey were analyzed. Patients with incident hospitalization for ACS without similar events during the 6 months prior were included. Outcomes evaluated included inpatient mortality, 30-day mortality and readmission, subsequent hospitalization events, and total direct health care costs. Sample population weights were applied, accounting for multistage sampling design to obtain nationally representative estimates for the US Medicare population. Results Between March 1, 2002 and December 31, 2006, we identified 795 incident ACS patients (mean age 76 years; 49% male) representing 2,542,211 Medicare beneficiaries. The inpatient mortality rate was 9.71% and the 30-day mortality ranged from 10.96% to 13.93%. The 30-day readmission rate for surviving patients was 18.56% for all causes and 17.90% for cardiovascular disease (CVD)-related diagnoses. The incidence of death since admission was 309 cases per 1000 person–years. Among patients discharged alive, the incidence was 197 for death, 847 for CVD-related admission, and 906 for all-cause admission. During the year when the ACS event occurred, mean annual total direct health care costs per person were US

Assessment of effectiveness measures in patients with schizophrenia initiated on risperidone long-acting therapy: the SOURCE study results

50,458, with more than half attributable to inpatient hospitalization (