Sandra L. Tunis

Medication Treatment Patterns following Initiation on Olanzapine versus Risperidone

ObjectiveTo compare medication treatment patterns for patients with schizophrenia following initiation on olanzapine versus risperidone.MethodsRetrospective analysis of a large, geographically diverse claims database of insured individuals identified 670 enrollees who: (1) were diagnosed with schizophrenia; (2) were initiated on olanzapine (n = 423) or risperidone (n = 247) monotherapy, and (3) had not been treated with olanzapine or risperidone during 1 year prior to initiation. Multivariate analyses were used to compare olanzapine and risperidone groups on treatment duration, the likelihood of receiving medication for at least 80% of days in the year post-initiation, the likelihood of receiving concomitant anti-Parkinsonian agents, and the likelihood of switching between medications of interest, by controlling for demographics, co-morbidities, and previous medication-use patterns.ResultsCompared with risperidone patients (mean dosage = 3.32 mg/day), patients treated with olanzapine (mean dosage = 10.45 mg/day) experienced a 29.4% increase in treatment duration (162 vs 213 days; p<0.0001), and a significantly higher probability of receiving medication for at least 80% of days in the year post-initiation (Odds Ratio [OR] = 2.057, p = 0.0002). Patients initiated on olanzapine versus risperidone were also found to be significantly less likely to use anti-Parkinsonian medications (OR = 0.639; p = 0.0284) and were significantly less likely to switch to risperidone than vice versa (OR = 0.275; p<0.0001).ConclusionsCompared with risperidone, patients initiated on olanzapine experienced more favourable medication-use patterns. Olanzapine patients had a significantly longer duration of pharmacotherapy, a significantly higher likelihood of receiving medication treatment for at least 80% of days in the year post-initiation, a significantly lower likelihood of concomitant use of anti-Parkinsonian agents, and a significantly lower probability of switching between medications of interest than risperidone patients. Findings that patients initiated on olanzapine had more favourable medication treatment patterns have important clinical and economic implications. Interruptions in antipsychotic therapy have been previously linked to increases in psychotic symptoms and increased use of costly acute-care services.

Cognitive and clinical predictors of success in vocational rehabilitation in schizophrenia

Cognitive impairments in schizophrenia appear to be associated with social problem solving, social and vocational functioning, and psychosocial skill acquisition. The present study examined the relationship of cognitive functioning, as well as clinical symptoms, to vocational outcomes among individuals with schizophrenia. One hundred and twelve participants with DSM-IV schizophrenia spectrum diagnoses underwent a comprehensive neuropsychiatric evaluation after enrolling in one of several employment programs. The neuropsychological evaluation examined verbal learning and memory, attention, speed of information processing, and executive functioning. Clinical symptoms were evaluated with the Positive and Negative Syndrome Scale (PANSS). Vocational outcomes were assessed 4 months after baseline assessment and included both measures of employment outcome (e.g., earnings) and of work performance as assessed by the Work Behavior Inventory (WBI). Negative symptoms, learning and memory performance, processing speed, and executive functioning were related to hours, weeks, and wages earned on the job. Stepwise multiple regression analyses found that among baseline clinical and cognitive predictors, only verbal learning and memory and cognitive disorganization symptoms were significant predictors of work behaviors 4 months later. Learning and memory were the only significant predictors of integrated employment at 4 months. These results suggest specific aspects of cognition may be modestly predictive of vocational outcomes.

Assessing the Value of Antipsychotics for Treating Schizophrenia: The Importance of Evaluating and Interpreting the Clinical Significance of Individual Service Costs

Schizophrenia is a serious and complex disorder, with treatment requiring a large number and wide range of health and social service resources. This paper addresses one challenge for assessing the direct costs of antipsychotic treatments — that of interpreting both cost and effectiveness implications of specific components of service use.Information collected on direct component costs has frequently been analysed and reported only in total. Results of several published studies provide evidence that the total direct medical costs associated with atypical antipsychotics appear to be at least equivalent to, and in some cases lower than, those associated with conventional agents. An important implication of this cost-equivalency finding is that treatment involving higher medication costs have led to offsets in certain medical service costs.Results from several studies demonstrate a shift of cost components, primarily from more expensive inpatient to less expensive outpatient care. Although the common inpatient versus outpatient dichotomy is useful, the complexities of schizophrenia and the heterogeneity of outpatient service provision are likely to warrant greater specificity.Published schizophrenia treatment guidelines can assist researchers to more fully understand and meaningfully interpret the possible relationship of antipsychotic effectiveness to the use of particular outpatient services. Because the disease requires comprehensive and continuous care, outpatient treatment costs may be better conceptualised as baseline or expectable costs necessary in the maintenance phase of treatment. Lack of expectable costs may represent poor patient outcomes and increased intangible costs. In contrast, reductions in acute outpatient service costs may provide important markers of treatment effectiveness. A small number of studies have examined the use of crisis services, but additional work is needed to differentiate treatments vis-à-vis the need for intensive (acute) interventions.The assessment and clinical interpretation of individual cost components may offer an important opportunity to build upon initial results focusing on total costs and tailor analyses to the complexities of the disorder and the treatment process. Research able to incorporate clinical acumen into cost analyses will enhance the ability of healthcare policy makers to make informed decisions regarding the value of different antipsychotic medications for the treatment of schizophrenia.

Antipsychotic Treatment of Behavioral and Psychological Symptoms of Dementia in Geropsychiatric Inpatients

Behavioral/psychological symptoms of dementia (BPSD) affect caregiver burden and transition from home to hospital or long-term care. The authors examined change in BPSD for dementia patients (from hospital admission to discharge) who were prescribed haloperidol (n= 289), olanzapine (n=209), or risperidone (n=500). Olanzapine was associated with significantly greater overall improvement in BPSD (based on the Psychogeriatric Dependency Rating Scale total score) than risperidone or haloperidol. Olanzapine was significantly superior on measures of active-, verbal-, and passive-aggression and delusions/hallucinations to risperidone or haloperidol, and, on manipulative behavior and noisiness, to risperidone. Results support the effectiveness of olanzapine in improving several BPSD in hospitalized dementia patients.

Cost-effectiveness of insulin detemir compared to NPH insulin for type 1 and type 2 diabetes mellitus in the Canadian payer setting: modeling analysis

ABSTRACT Objective: This study was conducted to quantify the long-term cost-effectiveness of insulin detemir (Levemir†) versus intermediate-acting neutral protamine Hagedorn (NPH) insulin for the treatment of type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) in Canada, and to assess the sensitivity of results to dis-utilities for hypoglycemic events. † Levemir is a trade name of Novo Nordisk, Princeton, NJ, USA Research design and methods: The web-based IMS-CORE diabetes model has a menu-driven interface programmed in hypertext markup language (HTML). It was used to project lifetime (60 years for T1DM and 35 years for T2DM) clinical and economic outcomes for patients on detemir vs. NPH. Cohort characteristics, utilities, and costs were derived from published literature. For T1DM, clinical trial data for HbA1c improvement (detemir −0.94% ± 1.07; NPH −0.82% ± 1.01) from baseline, and rates of hypoglycemic events (major events: 0.20 vs. 0.80 per patient-year for detemir vs. NPH, respectively) were modeled. For T2DM, observational study data for HbA1c improvement (detemir −0.18%) from baseline, and reductions in hypoglycemic events (major events: 0.0995 vs. 1.33 per patient-year for detemir vs. NPH, respectively) were modeled. Base-case hypoglycemia dis-utilities were −0.0118 for major and −0.0035 for minor events. Sensitivity analyses were conducted on discount rate and hypoglycemia dis-utility. Outcome measures: Outcomes included costs of treatment/management and costs (and incidence) of diabetes-related complications. Incremental cost-effectiveness ratios (ICERs) were calculated from differences in total costs and quality-adjusted life-years (QALYs). Results: Average total costs for T1DM were

Service utilization and costs of olanzapine versus divalproex treatment for acute mania: results from a randomized, 47-week clinical trial

CAN 83 622 ± 4585 for detemir and

An examination of factors affecting persistence with initial antipsychotic treatment in patients with schizophrenia.

CAN 72 016 ± 4593 for NPH. QALYs increased by 0.475 years with detemir, with an ICER of

Economic outcomes associated with switching individuals with schizophrenia between risperidone and olanzapine: findings from a large US claims database.

CAN 24 389/QALY. Average direct costs for T2DM were

Pioglitazone versus rosiglitazone treatment in patients with type 2 diabetes and dyslipidemia: cost-effectiveness in the US

CAN 74 919 ± 6391 (detemir) and

A cost-effectiveness analysis to illustrate the impact of cost definitions on results, interpretations and comparability of pharmacoeconomic studies in the US.

CAN 69 230 ± 6840 (NPH). QALYs increased by 0.305 years. The ICER was