Prakash Navaratnam

Physician adherence to the national asthma prescribing guidelines: evidence from national outpatient survey data in the United States.

BACKGROUND The Expert Panel 2 Guidelines for the Diagnosis and Management of Asthma (EPR-2 guidelines) were developed to improve medication prescribing for patients with persistent asthma and to control acute exacerbations of asthma. In addition, these guidelines also encourage physician-provided asthma education. Little is known about prescribing adherence to EPR-2 guidelines. OBJECTIVES To examine physician adherence to EPR-2 asthma medication prescribing guidelines and determine patient and physician factors associated with prescribing of asthma medications. METHODS This study was a cross-sectional retrospective analysis of National Ambulatory Medical Care Survey physician visit survey data from 1998 through 2004. Data were extracted on all patients with an International Classification of Diseases, Ninth Revision (ICD-9) code for asthma (493.XX) and reason for visit as asthma. The unit of analysis was individual patient visit. The dependent variables in analyses were specific type of drug class. The independent variables were various patient and physician factors. Logistic regression analysis was used to evaluate study objectives. RESULTS Asthma patients in 2002 had 3.3 times more odds of being prescribed controller medications compared with asthma patients in 1998. Findings in 2004 were not significant. Elderly patients had 54% less odds of receiving controller medication compared with those in the 35- to 64-year-old age group. Patients in the other race category are 40% as likely to receive controller asthma medication compared with white patients. Physicians in 2002 had 6.3 times more odds of prescribing long-acting beta-agonists compared with those in 1998. Physicians without ownership stake in their practice had 1.9 times more odds of providing asthma education to their patients compared with those who owned their practice. CONCLUSION Physician prescribing of asthma pharmacotherapy does not adequately comply with EPR-2 treatment guidelines.

Adherence and asthma control with mometasone furoate versus fluticasone propionate in adolescents and young adults with mild asthma

Introduction. Because adherence to asthma controller medication among adolescents and young adults is poor but critical for asthma control, strategies are needed to improve adherence. One strategy is to reduce the number of daily doses necessary to maintain adequate control. Mometasone furoate delivered through a dry powder inhaler (MF-DPI) is an inhaled corticosteroid (ICS) approved for once-daily dosing in most patients. Fluticasone propionate (FP) is an ICS approved for twice-daily dosing. A retrospective claims analysis was performed to assess treatment adherence and markers of asthma control in adolescent and young adult patients with mild asthma who began treatment with MF-DPI or FP. Methods. Data from approximately 37 million patients in an administrative insurance claims database in the United States were analyzed. Patients, 12–25 years, with mild asthma and previous asthma medication use were assigned an index date based on their first prescription fill of MF-DPI or FP between 1 January 2005 and 10 October 2008. Demographics, prescription claims, and health care utilization data were captured in the 365-day period before (preindex) and after (postindex) the index date. Patients from each cohort were propensity score-matched 1:1 based on preindex data. Adherence was measured by prescription fills and percentage of days covered (PDC); asthma control was measured by exacerbations and short-acting β2-agonist (SABA) canister claims. Bivariate and multivariate generalized linear model (GLM) analyses were conducted to determine differences in outcomes between the cohorts. Results. After matching, 692 patients per group (average age – 16 years) were analyzed. Adherence in the postindex period was significantly higher in the MF-DPI cohort compared with the FP cohort as measured by PDC (23.5% vs. 14.5%; p< .0001) and prescription fills (2.70 vs. 1.91; p< .0001). The mean number of postindex SABA canister claims was significantly lower in the MF-DPI cohort compared with the FP cohort (1.04 vs. 1.40; p< .0001). There was no significant difference in the mean number of postindex exacerbations between the cohorts. Conclusion. Adolescent/young adult patients with mild asthma who received MF-DPI had better postindex adherence and fewer SABA canister claims than patients receiving FP.

Frequency of high-risk patients not receiving high-potency statin (from a large managed care database).

We examined trends in low-density lipoprotein cholesterol (LDL-C) goal attainment in high-risk patients and use of high-potency statins (HPS) in a large, managed-care database from 2004 to 2012. The 2013 American Heart Association/American College of Cardiology prevention guidelines recommend that subjects with atherosclerotic cardiovascular disease (ASCVD) should be prescribed HPS therapy, irrespective of LDL-C levels. Previous guidelines recommend an LDL-C target <70 mg/dl. Patients diagnosed with ASCVD based on International Classification of Diseases, Ninth Revision codes with ≥1 LDL-C test from January 2004 to December 2012 were identified in the Optum Insight database. Patients were identified as treated if they received lipid-lowering therapy (LLT) within 90 days of the LDL-C measurement and untreated if they did not receive LLT treatment. LLT treated patients were stratified into HPS users or non-HPS LLT users. There were 45,101 eligible patients in 2004 and 40,846 in 2012. The proportion of high-risk patients who were treated with LLT increased from 61.4% (2004) to 70.5% (2008) then remained relatively constant until 2012 (67.9%). Mean LDL-C values in treated patients decreased from 103.7 ± 32.1 (2004) to 90.8 ± 31.4 mg/dl (2012). The proportion of patients treated with HPS increased from 13% in 2004 to 26% in 2012. Although the proportion of treated high-risk patients who achieve LDL-C <70 mg/dl levels has increased sharply from 2004, approximately 3 of 4 patients still did not meet this target. Only 1/4 of ASCVD patients are on HPS. In conclusion, our findings highlight the need for renewed efforts to support guideline-based LDL-C treatment for high-risk patients.

Asthma Pharmacotherapy Prescribing in the Ambulatory Population of the United States: Evidence of Nonadherence to National Guidelines and Implications for Elderly People

OBJECTIVES: To examine the level of physician adherence to the Expert Panel Report 2 (EPR‐2) pharmacotherapy guidelines of the asthma population, specifically in the elderly ambulatory patient population of the United States.

The national cost of asthma among school-aged children in the United States

BACKGROUND Recent research has quantified the national health care resource use (HCRU) and health care expenditure (HCE) burden associated with adult asthma; however, estimates specific to school-aged children are more than 2 decades old. OBJECTIVE To estimate the national HCRU and HCEs attributable to asthma among school-aged children in the United States. METHODS This was a cross-sectional retrospective analysis of school-aged children (aged 6-17 years) in the nationally representative 2007-2013 Medical Expenditure Panel Survey. All-cause HCRU and HCEs of school-aged children with asthma were compared with school-aged children without asthma, controlling for sociodemographics and comorbidities. HCRU encounters included emergency department (ED) and outpatient visits, hospitalizations, and prescriptions. Expenditures included total, medical, ED, inpatient, outpatient, and pharmacy. Negative binomial regression analyses were used for HCRU and Heckman selection with logarithmic transformation, and smearing retransformation was used for HCEs. RESULTS There were 44,320 school-aged children of whom 5,890 had asthma. Children with asthma incurred a higher rate of all-cause annual ED visits (incidence rate ratio [IRR], 1.5; P < .001), hospitalizations (IRR, 1.4; P < .05), outpatient visits (IRR, 1.4; P < .001), and prescription drugs (IRR, 3.3; P < .001) compared with school-aged children without asthma. They incurred US

A retrospective analysis of clinical characteristics, hospitalization, and functional outcomes in residents with and without Clostridium difficile infection in US long-term care facilities

847 (2015 dollars) more annually in all-cause expenditures (P < .001). Private insurance and Medicaid paid the largest share of expenditures. Pharmacy and outpatient costs represented the largest proportion of total expenditures. On the basis of the nationally representative Medical Expenditure Panel Survey sample weights from 2013, the total annual HCEs attributable to asthma for school-aged children in the United States was US

The cost-effectiveness of treatment with desloratadine in patients with persistent allergic rhinitis

5.92 billion (2015 dollars). CONCLUSION Childhood asthma continues to represent a prevalent and significant clinical and economic burden in the United States. More aggressive treatment and asthma management programs are needed to address this national financial and resource burden.

National Prevalence of Poor Asthma Control and Associated Outcomes Among School-Aged Children in the United States

Abstract Objective: Patients in long-term care (LTC) are at increased risk for acquiring Clostridium difficile infection (CDI). We compared the characteristics and outcomes of matched cohorts with and without CDI in the LTC setting. Methods: Using a retrospective cohort design, demographic characteristics, Minimum Data Set (MDS 2.0) assessments (years 2007–2010), and pharmacy records of residents were analyzed. Residents were required to have a CDI diagnosis, ≥1 MDS 2.0 assessment ≤120 days pre- and post-index event, and receipt of metronidazole (MET) or vancomycin (VAN) within ±7 days of index date. Baseline characteristics were compared between cases and controls matched 1:3 on age, gender, and index year. Cox regression (CR) analysis evaluated the relationship between CDI status, and post-index mortality and hospitalization. Results: A total of 1145 CDI residents were matched with 3488 non-CDI residents. A second sample used propensity score methods. CDI vs. non-CDI residents had a higher baseline comorbidity burden (Charlson score: 3.0 ± 1.9 vs. 2.2 ± 1.8, respectively), and were more likely to have had a recent hospitalization (63% vs. 9%, respectively) and shorter mean pre-index continuous length of stay (cLOS) in the LTC (386.4 d ± 536.3 d vs. 568.3 d ± 567.4 d, respectively), all P < 0.0001. CR analyses of both samples indicated that CDI was strongly associated with shorter times to hospitalization and mortality (hazard ratio (HR) = 1.3, P = 0.023 and 2.2, P < 0.0001, respectively; propensity-matched group). Pre-index LTC cLOS also remained an important variable in the CR analysis and was the strongest predictor of post-index hospitalization and mortality (HR = 0.999 and 0.996, respectively, P < 0.0001), indicating that residents with longer pre-index LTC cLOS had longer times to post-index hospitalization and mortality. Our reliance on the MDS records for case identification was our chief limitation; misclassification was mitigated by our requirement to include CDI treatment as part of our inclusion criteria. Conclusions: Understanding factors that put LTC patients at risk for CDI can help guide better management and improvement of patient outcomes.

Treatment with Inhaled Mometasone Furoate Reduces Short-Acting β2 Agonist Claims and Increases Adherence Compared to Fluticasone Propionate in Asthma Patients

Abstract Objectives: A new classification of persistent allergic rhinitis (PER) has been developed by the ARIA working group. Although the burden of AR is significant, treatment itself is also costly. It is unclear if treatment based on the new definition of PER is cost-effective. Methods: The current study simulated the cost-effectiveness of desloratadine compared to placebo in the treatment of PER from the French societal perspective. Decision analysis was used to model the costs, effectiveness and cost-effectiveness over 12 months. Costs included medical expenditures (physician visits and prescription drugs) attributable to PER and related comorbidities and lost productivity due to absenteeism and presenteeism. Prices, tariffs and national wages were estimated from French national sources. Measures of effectiveness included: symptom-based visual analogue scale (VAS), Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), Total 5 Symptoms Score (T5SS), categorical improvement in therapeutic response, interference with activities of daily living (ADL) and sleep outcomes. Mild or symptom-free days and ‘responders’ were also captured as outcomes. Univariate and second-order multivariate probabilistic sensitivity analyses were conducted. Results: Treatment with desloratadine dominated placebo (cost less and resulted in greater effectiveness) for all measures of effectiveness. Of the individuals taking desloratadine 46.8% were classified as ‘responders’ vs. 34.8% for placebo (p = 0.0012). Individuals taking desloratadine experienced mild/no symptoms for 57.6% of study days vs. 36.5% for placebo (p = 0.002). The expected annual cost of treatment with desloratadine (€1819) was less than placebo (€2618). Lost productivity was the most significant contributor to total cost. Results of the 10,000 Monte Carlo simulations showed that treatment was cost-saving in 99.6% of simulations. Conclusions: Treatment of PER with desloratadine resulted in improved effectiveness and significant savings. While the cost of drug treatment is greater than that of no treatment, the downstream costs associated with not treating PER significantly outweigh the cost of treatment. Key limitations include the comparison of desloratadine to placebo and the sources of cost and effectiveness measures. Future studies should examine the cost-effectiveness of all available treatments for PER. In addition, many utilization, productivity and effectiveness measures were taken from clinical trials and may not accurately reflect ‘real world’ treatment patterns and outcomes.

Association of persistent and transient worsening renal function with mortality risk, readmissions risk, length of stay, and costs in patients hospitalized with acute heart failure.

BACKGROUND The degree of asthma control among school-aged children (SAC) nationally is not well understood. OBJECTIVE The objective of this study was to characterize poor control among SAC (aged 6-17 years) in the United States. METHODS This was a retrospective analysis of the 2007-2013 Medical Expenditure Panel Survey. Indicators of poor control included exacerbation in previous year; use of >3 canisters of short-acting β-agonist (SABA) in 3 months; and asthma-specific (AS) emergency department (ED) or inpatient (IP) visits. Treatment indicators included daily controller medication and peak flow meter use. Negative binomial regression was used for health resource utilization (HRU); generalized linear models with log-link were used for health care expenditures. RESULTS There were 44,320 SAC, of whom 5,890 had asthma. The prevalence of poor control and treatment among SAC with asthma were as follows: exacerbation (59%), >3 canisters of SABA (4%), ED/IP visit (3%), daily controller (19%), peak flow (12%). In 2013, 3.4 million SAC had an asthma exacerbation and 200,000 had an AS ED/IP visit. SAC with asthma and an exacerbation had 18.9 times more annual AS ED visits (and 43.3 times more AS hospitalizations) than SAC with asthma but no exacerbation. SAC with asthma and an indicator of poor control incurred greater annual all-cause expenditures than SAC without asthma (