Trent McLaughlin

Patient Dependence and Longitudinal Changes in Costs of Care in Alzheimer's Disease

Background/Aims: To examine the incremental effect of patients’ dependence on others, on cost of medical and nonmedical care, and on informal caregiving hours over time. Methods: Data are obtained from 172 patients from the Predictors Study, a large, multicenter cohort of patients with probable Alzheimer disease (AD) followed annually for 4 years in 3 University-based AD centers in the USA. Enrollment required a modified Mini-Mental State Examination score ≧30. We examined the effects of patient dependence (measured by the Dependence Scale, DS) and function (measured by the Blessed Dementia Rating Scale, BDRS) on medical care cost, nonmedical care cost, and informal caregiving time using random effects regression models. Results: A one-point increase in DS score was associated with a 5.7% increase in medical cost, a 10.5% increase in nonmedical cost, and a 4.1% increase in caregiving time. A one-point increase in BDRS score was associated with a 7.6% increase in medical cost, a 3.9% increase in nonmedical cost and an 8.7% increase in caregiving time. Conclusions: Both functional impairment and patient dependence were associated with higher costs of care and caregiving time. Measures of functional impairment and patient dependence provide unique and incremental information on the overall impact of AD on patients and their caregivers.

Dependence as a Unifying Construct in Defining Alzheimer's Disease Severity

This article reviews measures of Alzheimers disease (AD) progression in relation to patient dependence and offers a unifying conceptual framework for dependence in AD. Clinicians typically characterize AD by symptomatic impairments in three domains: cognition, function, and behavior. From a patients perspective, changes in these domains, individually and in concert, ultimately lead to increased dependence and loss of autonomy. Examples of dependence in AD range from a need for reminders (early AD) to requiring safety supervision and assistance with basic functions (late AD). Published literature has focused on the clinical domains as somewhat separate constructs and has given limited attention to the concept of patient dependence as a descriptor of AD progression. This article presents the concept of dependence on others for care needs as a potential method for translating the effect of changes in cognition, function, and behavior into a more holistic, transparent description of AD progression.

Evaluation of Erectile Dysfunction Therapy in Patients Previously Nonadherent to Long-term Medications: A Retrospective Analysis of Prescription Claims

Erectile dysfunction (ED) can lead to treatment noncompliance in patients taking medications for chronic health conditions. Using the Intelligent Health Repository, NDCHealths longitudinal, United States health care claims database, we examined the impact of treating ED on adherence to long-term therapies in previously nonadherent patients. Male patients ≥18 years of age were identified who received antidepressant (AD), antihypertensive (AH), oral hypoglycemic (OHG), or lipid-lowering (LL) agents and initiated therapy with sildenafil citrate (Viagra) between January and June 2003. Treatment adherence was determined using medication possession ratios (MPRs) for the 12 months before and after the first prescription of sildenafil. Prior to initiation of therapy for ED with sildenafil, 64% of patients with comorbid medications were not adherent (MPR <0.8). Among these patients, 728 (27%) received AD, 2112 (78%) received AH, 984 (18%) received OHG, and 1078 (40%) received LL agents, with 66% of patients receiving multiple therapeutic classes. During the 12-month period after the first sildenafil prescription, patients had a significant increase in medication adherence compared with the 12 months before the first prescription of sildenafil (P < 0.0001). The percentage of patients who became adherent (MPR ≥0.8) with medications after sildenafil treatment was from 22% to 36%. With the exception of the LL group, there was a significant relationship between ≥3 sildenafil prescriptions and change in MPR (P < 0.05). Patients aged ≥65 years had similar improvement in MPR as patients ≤65 years. Treatment of ED with sildenafil improved adherence in patients taking common long-term medications who were previously nonadherent.

Does synchronizing initiation of therapy affect adherence to concomitant use of antihypertensive and lipid-lowering therapy?

Although efficacious medications are available to treat hypertension and dyslipidemia, treatment adherence is often poor. This retrospective study evaluated adherence in patients newly initiating antihypertensive (AH) and lipid-lowering (LL) therapies simultaneously versus within 180 days of one another. Data were analyzed for US managed care plan enrollees initiating AH before LL (cohort 1; n = 7099), LL before AH (cohort 2; n = 3229), or AH/LL simultaneously (cohort 3; n = 5072). A multivariate model evaluated potential predictors of adherence (medication possession ratio ≥ 0.80 over a bimonthly period). Percentages of patients adherent to AH/LL at 2, 6, and 12 months were as follows: 59.4%, 32.7%, and 31.3% in cohort 1; 45.0%, 30.8%, and 31.0% in cohort 2; and 75.2%, 34.4%, and 34.0% in cohort 3, respectively. After adjustment for potential confounders, patients initiating AH before LL therapy, or LL before AH therapy, were less likely to be adherent than patients prescribed both agents simultaneously (odds ratios = 0.838 and 0.691, respectively; P < 0.0001). Synchronous initiation of AH and LL therapies is an important predictor of adherence.

Impact of cotherapy with some proton pump inhibitors on medical claims among HMO patients already using other common drugs also cleared by cytochrome P450.

Adverse drug event (ADE) rates resulting from coadministration of proton pump inhibitors (PPIs) and other drugs with potential for interaction with PPIs (DPIs) are unknown. This retrospective study assesses the occurrence of such ADEs and their potential impact on medical care costs by reviewing integrated medical and pharmacy claims. Managed care patients receiving one or more DPIs were identified. Within this sample, those who were also prescribed omeprazole or lansoprazole (DPI + PPI) were included. A second cohort (DPI alone) was created, matching for age, gender, and DPI use. Rates of ADEs were followed for 6 months after entry. Among PPI users, 58% used one or more DPIs, whereas 7% of DPI subjects used a PPI. Among claims arising from ADEs occurring in more than 1% of patients, 14 occurred in the DPI + PPI group and 2 occurred in the DPI-alone cohort, respectively, a highly significant difference. Crude odds ratios for the risks of specific ADEs were significantly increased for cotherapy with a PPI and warfarin, clarithromycin, corticosteroids, carbamazepine, nifedipine, or diclofenac. After adjustment, the first three associations remained significant. Coprescription of a PPI with potentially interacting drugs was common in practice and associated with significantly increased claims for medical care.

Risk of recurrent emergency department visits or hospitalizations in children with asthma receiving nebulized budesonide inhalation suspension compared with other asthma medications.

ABSTRACT Objective: To examine whether nebulized budesonide inhalation suspension treatment reduces asthma-related emergency department visit/hospitalization recurrence risk in children compared with other asthma medications, particularly non-nebulized inhaled corticosteroids. Research design and methods: Longitudinal, retrospective claims analysis of data from a managed care organization database in the United States (July 1, 2000–June 30, 2002). Participants were children aged ≤ 8 years with an asthma diagnosis and asthma-related emergency department visit or hospitalization (index event). Asthma medication use, evaluated by asthma-related prescriptions ≤ 30 days after the index event, determined treatment groups. Main outcome measure: Emergency department visit/hospitalization recurrence risk from post-index day 31–180 across treatment groups. Results: Of 10 176 patients with an index event, 13% experienced a post-index recurrence. For patients receiving asthma prescriptions ≤ 30 days after the index event, those receiving budesonide inhalation suspension showed a significant reduction in emergency department visit/hospitalization recurrence risk compared with those not prescribed this treatment (adjusted hazard ratio, 0.71; 95% confidence interval, 0.57–0.89). For patients receiving asthma controller medication in the post-index period, those receiving budesonide inhalation suspension had a significantly lower recurrence risk than patients receiving prescriptions for other controller medications (hazard ratio, 0.71; 95% confidence interval, 0.52–0.97). Recurrence risk was significantly reduced (53%) in patients receiving budesonide inhalation suspension prescriptions compared with non-nebulized inhaled corticosteroid prescriptions (hazard ratio, 0.47; 95% confidence interval, 0.28–0.78). Conclusion: For children aged ≤ 8 years, budesonide inhalation suspension treatment after an asthma-related emergency department visit/hospitalization was associated with a significantly reduced risk of recurrence compared with other asthma medications and with non-nebulized inhaled corticosteroids. Because this was an observational study, results should be interpreted cautiously. However, this study allowed evaluation of treatment in real-world practice settings not often included in clinical trials.

Prevalence and Impact of Dementia-related Functional Limitations in the United States, 2001 to 2005

These analyses examined the relationship between dementia and comorbid conditions with respect to degree of functional impairment and emotional impact. Analyses were conducted using National Health Interview Survey (2001 through 2005) data from a subset of individuals aged ≥60 years with activity limitations attributed to dementia, senility, or Alzheimer disease compared with those whose limitations were attributed to other conditions. The mean number of limited activities was 6.84 (95% confidence interval: 6.48-7.20) for persons with dementia-related limitations and 4.87 (95% confidence interval: 4.81-4.93) for those with limitations not dementia related. Both groups reported similar prevalence of diabetes, acute myocardial infarction, heart disease, prostate cancer, breast cancer, angina, and emphysema; respondents with dementia-related functional limitations were more likely to report diabetes, depression or anxiety, and vision problems as being related to functional limitations. Persons with dementia-related functional limitations were also more likely than persons with non-dementia-related functional limitations to report feeling sad, hopeless, worthless, nervous, and that “everything is an effort.” Improving or maintaining functional independence in patients with dementia will likely require a multifaceted approach across disease states. Additional research will help define the impact of dementia on the development and progression of functional limitations related to comorbidities.

A Qualitative Assessment of the Concept of Dependence in Alzheimer’s Disease

Background: The Dependence Scale (DS) was designed to assess levels of patient need for care due to deficits typical of Alzheimer’s disease (AD). This study examined content validity of the DS based on input from patients, caregivers, and clinicians. Methods: Qualitative interviews with experts, patients, and caregivers were used to collect information on the concept of dependence and to assess content validity. Results: Nine clinicians rated item relevance ‘‘high’’ with consensus on the primacy of functional abilities and dependence in the measurement of AD progression. Twenty-two US, 11 UK, and 14 informal caregivers from Spain participated in focus groups; 18 patients participated in 3 separate focus groups. Discussion supported DS hierarchy of dependence, capture of mild-to-severe dependence, suitability of response options, and short recall time frame. Conclusions: Clinicians, caregivers, and patients support content validity of the DS in mild-to-moderate AD. The DS may be valuable to capture dependence within future clinical dementia trials.

Cognition in MCI and Alzheimer’s Disease: Baseline Data from a Longitudinal Study of the NTB

Baseline data are summarized from a study examining the psychometric properties of the Neuropsychological Test Battery (NTB) and its subtests, and correlating the NTB with other cognitive and functional assessments. A multicenter, longitudinal, non-interventional study included mild to moderate Alzheimer’s disease (AD, n = 196), mild cognitive impairment (MCI, n = 70), or normal cognition participants (NC, n = 75). The NTB, other cognitive assessment tools, functional/behavioral questionnaires, and health outcome assessments were administered. At baseline composite NTB, NTB memory, and NTB executive function z-scores were significantly lower for participants with AD compared with MCI, and for participants with MCI compared with NC. The composite NTB z-score had high test–retest reliability between screening and baseline. The results of this study suggest that NTB exhibits good reliability in patients with mild to moderate AD and MCI.

Relationship between patient dependence on others and caregiver burden in Alzheimer's Disease (AD)

ADRDA criteria. Cognitive functions were assessed using K-MMSE , KCDR and Seoul Neuropsychological Screening Battery. The frequency and severity of NPS were evaluated with of K-NPI. MRI or PET-CT of brain was applied to all patients. In general AD was classified as mild, moderate, severe and the corresponding K-MMSE scores are 20-24, 10-19, 0-9, the CDR scores are 0.5-1, 2-3, 4-5 But these are too wide range of scores in each group that might prevent which symptoms are frequent in exact phase or severity of disease, so we try to more subdivide into 6 groups, I(0-5), II(69), III (10-14), IV(15-19), V(20-24), VI (25<) in K-MMSE and I(0.5) , II(1), III (2), IV (3), V (4), VI (5) in CDR. We also evaluate correlation between ADL , Instrumental ADL and NPS. Results: Elation, euphoria were dominant in group IV in K-MMSE and group II in CDR. Delusion, apathy, indifference, aberrant motor behavior, sleep, night time behavior, appetite, eating change were high in group II in K-MMSE & III in CDR. Hallucination, agitation, aggression, depression, anxiety, disinhibition, irritability was frequent in group I in K-MMES & IV in CDR. Delusion, hallucination, disinhibition were high correlated with K-MMSE (p<0.05). Halluciantion, depression, dysphoria, disinhibition, irritability and aberrant behaviour were well related with CDR (p<0.05). Not only Barthel index was highly correlation with anxiety (r1⁄40.96), aberrant behavior (r1⁄40.86) but also instrumental ADL was related to CDR (r1⁄40.72). Conclusions: Although more than half of AD patients who visited to memory clinic are in mild stage of dementia, most of NPS of AD were common in group I & II in K-MMSE and III, IV in CDR except elation & euphoria. Subdivision of AD patient’s stage shows more detail status of NPI than previous reports.