Luke Boulanger

Evaluation of cardiovascular morbidity associated with adherence to atorvastatin therapy.

Long-term adherence to statins is poor. We assessed the relationship between cardiovascular (CV) risk and atorvastatin adherence in primary- and secondary-prevention patients, adjusting for healthy-adherer bias by incorporating preventive service use into the model. Medical and pharmacy claims from employee-based plans from 2002 to 2008 were analyzed for patients who initiated atorvastatin in 2003–2004. Adherent patients were defined as having ≥60% of days covered in the year after atorvastatin initiation and were required to have pill coverage in months 10–12. CV events were identified as hospitalizations with a primary CV diagnosis and assessed from month 13 after atorvastatin initiation until the end of follow-up (≤36 months). Cox proportional hazards models were used to examine the association between atorvastatin adherence and CV event risk, adjusting for covariates including preventive service use. The study included 94,287 atorvastatin users (79,010 primary- and 15,277 secondary-prevention patients). In both populations, nearly one-half of the patients discontinued atorvastatin after 1 year. During follow-up, ∼2% of primary-prevention and ∼9% of secondary-prevention patients experienced CV events. After adjusting for covariates, adherent patients in the primary-prevention population had a significantly lower risk of CV events compared with nonadherent patients (hazard ratio, 0.82; 95% confidence interval, 0.74–0.91). In the secondary-prevention population, adherence to atorvastatin was also associated with lower CV risk (hazard ratio, 0.74; 95% confidence interval, 0.66–0.82). Atorvastatin discontinuation rates were high 1 year after treatment initiation. Patients who adhered to atorvastatin treatment were at lower CV risk. Quality-of-care interventions should target improvements to therapy persistence.

Changes in opioid use and healthcare costs among U.S. patients with diabetic peripheral neuropathic pain treated with duloxetine compared with other therapies

Abstract Objective: To examine changes in opioid use and healthcare costs among commercially insured patients with diabetic peripheral neuropathic pain (DPNP) who initiated duloxetine versus other standard of care (SOC) medications (tricyclic antidepressants, venlafaxine, gabapentin, pregabalin). Research design and methods: Using an administrative claims database, patients with DPNP aged 18–64 who initiated duloxetine or SOC between March 1, 2005 and December 31, 2005 were identified. Initiation was defined as a 90-day clean period without the available study medication. Selected patients had 12 months of continuous enrollment before and after the index date, and at least one opioid dispensed in the prior 90 days. Duloxetine and SOC patients were further classified into continuous and non-continuous users based on whether the medication possession ratio was ≥0.8. Total opioid days, number of opioid prescriptions dispensed, and cumulative morphine equivalents were examined over the 12-month pre- and post-index periods. Multivariate regressions were applied to assess the changes (pre-index minus post-index) in opioid use (total, short-acting vs. long-acting) and healthcare costs, controlling for demographic and clinical characteristics. Results: The study sample included 1281 patients: 98 duloxetine continuous, 243 duloxetine non-continuous, 195 SOC continuous, and 745 SOC non-continuous users. Controlling for demographic and clinical characteristics, duloxetine non-continuous and SOC (continuous and non-continuous) patients had significantly less reduction in total opioid days (−24.4, −23.7, −18.5, respectively, all p < 0.05) from the 12-month pre-index to the post-index period than duloxetine continuous patients. Compared with duloxetine non-continuous, SOC continuous, and SOC non-continuous users, duloxetine continuous users had a greater reduction in short-acting hydrocodone use (difference between the 12 month pre-index and post-index periods) in terms of the total number of prescriptions dispensed (adjusted differences: 1.5, 1.7, 1.7, respectively, all p < 0.05), total supply days (adjusted differences: 28.1, 27.3, 29.7, respectively, all p < 0.05), and morphine equivalent dosage (adjusted differences: 1290 mg, 1132 mg, 1127 mg, respectively, all p < 0.05). Duloxetine non-continuous patients had significantly higher adjusted total (

Opioid use and healthcare costs among patients with DPNP initiating duloxetine versus other treatments

12,729, p < 0.05) and inpatient costs (

Estimated medical cost reductions associated with apixaban in real-world patients with non-valvular atrial fibrillation.

14,993, p < 0.05) than duloxetine continuous patients. Limitations: Due to the use of a retrospective administrative claims database, this study is subject to selection bias between study cohorts, misidentification of DPNP and/or other comorbidities, and an inability to confirm adherence to therapy or assess indirect costs and costs of over-the-counter medications. Conclusions: Among commercially insured patients with DPNP, continuous treatment with duloxetine was associated with a reduction in opioid use between the 12-month pre- and post-index periods compared with treatment with SOC or non-continuous treatment with duloxetine. Duloxetine continuous patients also incurred lower subsequent healthcare costs than non-continuous duloxetine patients.

Application of randomized clinical trial data to actual practice: apixaban therapy for reduction of stroke risk in non-valvular atrial fibrillation patients.

Abstract Objective: To compare opioid utilization and healthcare costs over a 1-year period following the initiation with duloxetine versus other standard of care (SOC) treatments among patients with diabetic peripheral neuropathic pain (DPNP). Methods: This retrospective cohort study assessed commercially-insured DPNP patients between 18 and 64 years old who initiated duloxetine or other SOC treatments (tricyclic antidepressants, venlafaxine, gabapentin, pregabalin) between 3/1/2005 and 12/31/2005. Initiation was defined as a 90-day period without available study medication. The first dispense date of the study medication was denoted as the index date. Selected patients had no opioid pill coverage during the 90 days prior to initiation. Duloxetine and SOC patients were matched via propensity scoring (1:1 ratio), controlling for demographics, comorbidities, prior healthcare utilization and costs, and prior medication history. Opioid utilization and healthcare costs over the 12-month post-index period were compared between study cohorts. Results: The matched sample included 117 patients in each of the duloxetine and SOC cohorts. Compared with SOC-treated patients, duloxetine-treated patients were less likely to use any opioids (52.1 vs. 84.6%, p < 0.05) over the 12-month post-index period. Duloxetine-treated patients, on average, had two fewer opioid prescriptions dispensed, 27 fewer days on opioids, 121 days greater delay in subsequent opioid use, and 1815 mg lower morphine equivalent dosage than SOC-treated patients (all p < 0.05). Also, duloxetine-treated patients had significantly lower total (

Economic impact of using inhaled corticosteroids without prior exacerbation among elderly patients with chronic obstructive pulmonary disorder.

18 623 vs. 30 602, p < 0.05) and outpatient costs (

Average daily dose, medication adherence, and healthcare costs among commercially-insured patients with fibromyalgia treated with duloxetine

7371 vs. 15 343, p < 0.05). Due to the use of a retrospective administrative claims database, limitations of this study include the potential for selection bias between study cohorts, and inability to measure unobservable confounding and disease severity and/or duration. Conclusions: Among commercially-insured DPNP patients, duloxetine-treated patients had delayed and reduced opioid use and lower healthcare costs than SOC-treated patients.

Caregiver assistance among Medicare beneficiaries with atrial fibrillation and factors associated with anticoagulant treatment.

Abstract Objective: The Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial demonstrated that apixaban was effective in reducing the risk of stroke and major bleeding in non-valvular atrial fibrillation (NVAF) patients. Medical cost avoidance studies for oral anticoagulants have used warfarin event rates from clinical trials, which may not reflect the real-world (RW) setting. This study aimed to estimate the difference in medical costs associated with apixaban instead of warfarin in RW NVAF patients. Methods: This study selected patients with NVAF diagnosis during 2007–2010 from a Medco population of US commercial and Medicare health plans. Stroke and major bleeding excluding intracranial hemorrhage (MBEIH) were identified using diagnosis codes. Pharmacy claims were used to define warfarin exposure periods. Rates of stroke and MBEIH were calculated during warfarin exposure. To estimate the absolute risk reduction (ARR) between warfarin and apixaban in RW, the relative risk reductions (RRR) from ARISTOTLE were multiplied by the event rates observed in RW during warfarin exposure. Medical cost reductions associated with apixaban were calculated by applying the ARR to the 1-year incremental cost for each event. Stroke and MBEIH costs were obtained from the literature and adjusted to 2011 levels. Results: During a patient year, the use of apixaban instead of warfarin resulted in medical cost reductions of

Factors associated with pain medication selection among patients diagnosed with diabetic peripheral neuropathic pain: a retrospective study

493 for stroke and

INCIDENCE RATES OF DEATH AND MAJOR CARDIOVASCULAR EVENTS AMONG HOSPITALIZED PATIENTS WITH ACUTE CORONARY SYNDROME – AN ANALYSIS OF A NATIONAL REPRESENTATIVE MEDICARE POPULATION

752 for MBEIH and