Erik Muser

Predictors of medication nonadherence and hospitalization in Medicaid patients with bipolar I disorder given long-acting or oral antipsychotics

Abstract Purpose: To assess rates and predictors of medication nonadherence and hospitalization among patients with bipolar I disorder. Methods: This was a retrospective cohort analysis of Medicaid patients who were aged ≥18 years, had ≥1 inpatient or ≥2 outpatient medical claims indicating bipolar I disorder (ICD-9-CM codes 296.0x–296.1x, 296.4x–296.7x), and filled ≥1 prescription for antipsychotic medication between January 1, 2004, and December 31, 2006. Patients were followed for 1 year from the date of first (index) antipsychotic prescription. Patients were required to be continuously eligible for Medicaid without dual Medicare eligibility from 1 year before (baseline) through 1 year after (follow-up) index, and were required to receive ≥1 additional antipsychotic during follow-up. Descriptive statistics and predictors of medication nonadherence (medication possession ratio <0.8) and hospitalization were generated. Results: A total of 9410 patients met study eligibility criteria with a mean age of 38 years; 74% were female and 75% were white. Approximately 31% and 57% had baseline diagnoses of substance abuse and other psychiatric conditions, respectively. During follow-up, roughly 60% of patients were nonadherent and 40% of patients were hospitalized for any reason (37% psychiatric-related). Multivariate analysis showed that new antipsychotic starts, younger patients, those with a baseline concomitant substance abuse diagnosis, those taking a baseline antidepressant, and those with a baseline psychiatric hospitalization had significantly higher risk of nonadherence. Baseline psychiatric hospitalization, baseline substance abuse or other psychosis diagnosis, baseline use of an anxiolytic, anticholinergic, or anticonvulsant, and nonadherence to therapy in the follow-up period were significant predictors of increased risk of hospitalization. Limitations: This analysis did not attempt to evaluate the complex relationships among treatment type, adherence, hospitalization, and other variables. Conclusions: Study results showed that the risk of nonadherence is relatively high and confirmed that nonadherence is associated with a greater risk of hospitalization.

Patterns of relapse and associated cost burden in schizophrenia patients receiving atypical antipsychotics

Objective: To identify relapse in schizophrenia and the main cost drivers of relapse using a cost-based algorithm. Methods: Multi-state Medicaid data (1997–2010) were used to identify adults with schizophrenia receiving atypical antipsychotics (AP). The first schizophrenia diagnosis following AP initiation was defined as the index date. Relapse episodes were identified based on (1) weeks during the � 2 years post-index associated with high cost increase from baseline (12 months before the index date) and (2) high absolute weekly cost. A compound score was then calculated based on these two metrics, where the 54% of patients associated with higher cost increase from baseline and higher absolute weekly cost were considered relapsers. Resource use and costs of relapsers during baseline and relapse episodes were compared using incidence rate ratios (IRRs) and bootstrap methods.

Rates and predictors of antipsychotic non-adherence and hospitalization in Medicaid and commercially-insured patients with schizophrenia

Abstract Objective: To assess rates and predictors of antipsychotic non-adherence and hospitalizations among patients with schizophrenia in separate Medicaid and commercial populations. Methods: This retrospective analysis used the Thomson Reuters MarketScan Multi-State Medicaid and IMS LifeLink Health Plan claims databases. These analyses included patients with a diagnosis of schizophrenia (295.xx) who received a prescription for an antipsychotic between January 1, 2008, and June 30, 2009 (date of first claim in window defined as index). Patients were required to have one additional antipsychotic prescription in the 1 year following index. Rates of adherence and psychiatric and all-cause hospitalization were evaluated. Multivariate logistic regression models identified predictors of antipsychotic non-adherence and hospitalization. These analyses were not intended to compare outcomes between the Medicaid and commercial populations. Results: Patients, 20,710 Medicaid and 7528 commercial, met all inclusion criteria. Both populations were ∼47% male, with a younger mean ± SD age among the Medicaid population (42.6 ± 14.1 vs 47.9 ± 17.1 years). Mean ± SD MPR in follow-up was 0.77 ± 0.25 in the Medicaid population (37.5% non-adherent) and 0.73 ± 0.27 in the commercial group (44.6% non-adherent). Rates of all-cause and psychiatric hospitalizations were 28.6% and 27.2%, respectively, among Medicaid and 29.2% and 26.3% among commercial patients. Newly starting antipsychotics and being non-adherent to therapy at baseline were both found to significantly increase the likelihood of non-adherence 12-fold in the Medicaid population (both p < 0.001) and 8-fold in the commercial population (both p < 0.001). Medicaid patients with a baseline psychiatric hospitalization had a 3-fold increased likelihood of hospitalization (p < 0.001) and commercial patients had a 2-fold increase (p < 0.001). Limitations: These two populations were not compared statistically; no conclusions as to the cause of any observed differences in outcomes can be made. Conclusions: Previous non-adherence, newly starting antipsychotic therapy, and previous hospitalization were significant predictors of non-adherence and hospitalization in Medicaid and commercial populations.

The threshold rate of oral atypical anti-psychotic adherence at which paliperidone palmitate is cost saving

Abstract Objective: To identify, estimate, and compare ‘real world’ costs and outcomes associated with paliperidone palmitate compared with branded oral atypical anti-psychotics, and to estimate the threshold rate of oral atypical adherence at which paliperidone palmitate is cost saving. Methods: Decision analytic modeling techniques developed by Glazer and Ereshefsky have previously been used to estimate the cost-effectiveness of depot haloperidol, LAI risperidone, and, more recently, LAI olanzapine. This study used those same techniques, along with updated comparative published clinical data, to evaluate paliperidone palmitate. Adherence rates were based on strict Medication Event Monitoring System (MEMS) criteria. The evaluation was conducted from the perspective of US healthcare payers. Results: Paliperidone palmitate patients had fewer mean annual days of relapse (8.7 days; 6.0 requiring hospitalization, 2.7 not requiring hospitalization vs 17.8 days; 12.4 requiring hospitalization, 5.4 not requiring hospitalization), and lower annual total cost (

Comparative effectiveness of injectable paliperidone palmitate versus oral atypical antipsychotics: early postmarketing evidence

20,995) compared to oral atypicals (mean

Economic impact of psychiatric relapse and recidivism among adults with schizophrenia recently released from incarceration: a Markov model analysis

22,481). Because paliperidone palmitate was both more effective and less costly, it is considered economically dominant. Paliperidone palmitate saved costs when the rate of adherence of oral atypical anti-psychotics was below 44.9% using strict MEMS criteria. Sensitivity analyses showed results were robust to changes in parameter values. For patients receiving 156 mg paliperidone palmitate, the annual incremental cost was

Health care resource utilization and costs in a commercially insured population of patients with bipolar disorder type I and frequent psychiatric interventions.

1216 per patient (ICER = 

Characteristics, healthcare utilization and costs of bipolar disorder type I patients with and without frequent psychiatric intervention in a Medicaid population

191 per day of relapse averted). Inclusion of generic risperidone (market share 18.6%) also resulted in net incremental cost for paliperidone palmitate (

Impact of Paliperidone Palmitate Versus Oral Atypical Antipsychotics on Health Care Resource Use and Costs in Veterans with Schizophrenia.

120; ICER = 

Comparison of Medicaid spending in schizoaffective patients treated with once monthly paliperidone palmitate or oral atypical antipsychotics

13). Limitations of this evaluation include use of simplifying assumptions, data from multiple sources, and generalizability of results. Conclusions: Although uptake of LAIs in the US has not been as rapid as elsewhere, many thought leaders emphasize their importance in optimizing outcomes in patients with adherence problems. The findings of this analysis support the cost-effectiveness of paliperidone palmitate in these patients.