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      Duloxetine treatment adherence across mental health and chronic pain conditions

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          Abstract

          Purpose

          This study applied a uniform methodology for measuring and comparing duloxetine adherence in the treatment of multiple chronic medical conditions.

          Materials and methods

          Study patients 18–64 years of age initiating duloxetine therapy during 2008 were identified from a large managed care database. The study was restricted to patients with continuous health plan eligibility for 12 months pre- and post-duloxetine initiation. Study patients had ≥1 medical claim with an inpatient or outpatient diagnosis of one (and only one) of the following conditions: major depressive disorder (MDD); generalized anxiety disorder (GAD); fibromyalgia, diabetic peripheral neuropathic pain; or chronic musculoskeletal pain, as established in studies in patients with osteoarthritis and chronic lower back pain (CLBP). Patients initiating duloxetine who had two or more of the six studied conditions were not included in this study, thereby avoiding the need to differentiate between primary and secondary diagnoses from the claims records. Adherence rate was defined as the percentage of patients with a 365-day medication possession ratio ≥0.8.

          Results

          A total of 20,490 patients initiated duloxetine treatment during 2008 with a diagnosis of one of the studied conditions during the study period. The adherence rate in our sample was 34.6% and was highest among patients with MDD (37.3%) and lowest for patients with CLBP (29.9%). In general, adherence among patients with MDD and GAD was greater than among those with a chronic pain condition.

          Conclusion

          Adherence among newly initiated duloxetine patients varied modestly across the medical conditions for which it was used. After adjusting for potential confounders, differences between the mental conditions (MDD and GAD) and the chronic pain conditions (CLBP, osteoarthritis, and diabetic peripheral neuropathic pain) were statistically significant. These results may be useful in the determination of expectations of adherence, and how it may differ for each of the conditions studied.

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          Most cited references25

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          Impact of medication adherence on hospitalization risk and healthcare cost.

          The objective of this study was to evaluate the impact of medication adherence on healthcare utilization and cost for 4 chronic conditions that are major drivers of drug spending: diabetes, hypertension, hypercholesterolemia, and congestive heart failure. The authors conducted a retrospective cohort observation of patients who were continuously enrolled in medical and prescription benefit plans from June 1997 through May 1999. Patients were identified for disease-specific analysis based on claims for outpatient, emergency room, or inpatient services during the first 12 months of the study. Using an integrated analysis of administrative claims data, medical and drug utilization were measured during the 12-month period after patient identification. Medication adherence was defined by days' supply of maintenance medications for each condition. The study consisted of a population-based sample of 137,277 patients under age 65. Disease-related and all-cause medical costs, drug costs, and hospitalization risk were measured. Using regression analysis, these measures were modeled at varying levels of medication adherence. For diabetes and hypercholesterolemia, a high level of medication adherence was associated with lower disease-related medical costs. For these conditions, higher medication costs were more than offset by medical cost reductions, producing a net reduction in overall healthcare costs. For diabetes, hypercholesterolemia, and hypertension, cost offsets were observed for all-cause medical costs at high levels of medication adherence. For all 4 conditions, hospitalization rates were significantly lower for patients with high medication adherence. For some chronic conditions, increased drug utilization can provide a net economic return when it is driven by improved adherence with guidelines-based therapy.
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            Comparison of drug adherence rates among patients with seven different medical conditions.

            To compare drug adherence rates among patients with gout, hypercholesterolemia, hypertension, hypothyroidism, osteoporosis, seizure disorders, and type 2 diabetes mellitus by using a standardized approach. Longitudinal study. Health care claims data from 2001-2004. A total of 706,032 adults aged 18 years or older with at least one of the seven medical conditions and with incident use of drug therapy for that condition. Drug adherence was measured as the sum of the days' supply of drug therapy over the first year observed. Covariates were age, sex, geographic residence, type of health plan, and a comorbidity score calculated by using the Hierarchical Condition Categories risk adjuster. Bivariate statistics and stratification analyses were used to assess unadjusted means and frequency distributions. Sample sizes ranged from 4984 subjects for seizure disorders to 457,395 for hypertension. During the first year of drug therapy, 72.3% of individuals with hypertension achieved adherence rates of 80% or better compared with 68.4%, 65.4%, 60.8%, 54.6%, 51.2%, or 36.8% for those with hypothyroidism, type 2 diabetes, seizure disorders, hypercholesterolemia, osteoporosis, or gout, respectively. Age younger than 60 years was associated with lower adherence across all diseases except seizure disorders. Comorbidity burden and adherence varied by disease. As comorbidity increased, adherence among subjects with osteoporosis decreased, whereas adherence among those with hypertension, hypercholesterolemia, or gout increased. Add-on drug therapies and previous experience with taking drugs for the condition increased adherence among subjects with hypertension, type 2 diabetes, hypothyroidism, or seizure disorders but not the other conditions. This uniform comparison of drug adherence revealed modest variation across six of seven diseases, with the outlier condition being gout.
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              Comparing Adherence and Persistence Across 6 Chronic Medication Classes

              BACKGROUND: The National Quality Forum recently endorsed the proportion of days covered (PDC)—a measure of medication adherence—as an indicator of quality in drug therapy management. OBJECTIVES: To inform initial efforts to improve the quality of drug therapy management, we compared PDC and persistence among new users of 6 commonly used chronic medication categories. METHODS: A retrospective analysis of pharmacy claims in a database of more than 64 million members enrolled in 100 health plans assessed persistence and adherence to drug therapy in 6 chronic conditions. Patients were included in the analysis if they initiated a prescription drug of interest in any of 6 drug classes—prostaglandin analogs, statins, bisphosphonates,oral antidiabetics, angiotensin II receptor blockers (ARBs), and overactive bladder (OAB) medications—between January 1 and December 31, 2005.The first claim for a drug of interest during this period was considered a patient’s index date. Patients were required to have a minimum of 12months of continuous enrollment both preceding and following their index date. New users of a treatment were identified by excluding patients who filled a prescription for any drug in the same class during the previous 12months and were followed for a minimum of 12 months. Nonpersistence was defined as discontinuation of the therapy class following an allowed gap between refills—30-, 60-, and 90-day refill gaps were used. Adherence was defined as a continuous measure of the proportion of days covered (PDC) during the 12-month post-index period. Logistic regression analyses predicted (a) nonpersistence during the 12-month post-index period and (b) adherence (PDC) of at least 80%, with drug class as the predictor variable of interest, controlling for demographic variables, insurance and plan type, history of hospitalization, Charlson comorbidity score,copayment for index medication, and number of medications at index. RESULTS: A total of 167,907 patients were identified across 6 cohorts.Using the 60-day gap, 6-month persistence rates were prostagl and in analogs 47%, statins 56%, bisphosphonates 56%, oral antidiabetics 66%,ARBs 63%, and OAB medications 28%. After the first 90 days of therapy,relative persistence was stable across cohorts, and rates declined consistently from 6 months post-index to study end. Logistic regression models showed that oral antidiabetic users had a 59%, 36%, 37%, and 79% decreased risk of nonpersistence in a 12-month follow-up period compared with patients taking prostaglandin analogs, statins, bisphosphonates, orOAB medications, respectively. Risk of nonpersistence decreased with increasing age. Mean (SD) 12-month adherence rates were: prostagl and in analogs 37% (26%), statins 61% (33%), bisphosphonates 60% (34%), oral antidiabetics 72% (32%), ARBs 66% (32%), and OAB medications 35%(32%). Logistic regression indicated that oral antidiabetic use was a significantpredictor of adherence (PDC) of at least 80% compared with other therapy classes. Adjusted odds ratios for oral antidiabetics were 17.60(95% confidence interval [CI]=15.38-20.14) versus prostaglandin analogs,2.06 (95% CI=1.99-2.12) versus statins, 1.92 (95% CI=1.83-2.02) versus bisphosphonates, 1.29 (95% CI=1.24-1.34) versus ARBs, and 5.77 (95%CI=5.38-6.19) versus OAB medications.
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                Author and article information

                Journal
                Clinicoecon Outcomes Res
                Clinicoecon Outcomes Res
                ClinicoEconomics and Outcomes Research: CEOR
                Dove Medical Press
                1178-6981
                2014
                11 February 2014
                : 6
                : 75-81
                Affiliations
                [1 ]Global Health Outcomes, Eli Lilly and Company, Indianapolis, IN, USA
                [2 ]Global Statistical Sciences, Eli Lilly and Company, Indianapolis, IN, USA
                Author notes
                Correspondence: Stephen L Able, Eli Lilly and Company, 1 Lilly Corporate Center, Indianapolis, IN 46285-0001, USA, Tel +1 317 276 3612, Fax +1 317 277 7444, Email able_stephen_l@ 123456lilly.com
                Article
                ceor-6-075
                10.2147/CEOR.S52950
                3930481
                24596469
                23e94481-4fd8-4706-994c-37b3960d86c8
                © 2014 Able et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License

                The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                History
                Categories
                Original Research

                Economics of health & social care
                adherence,duloxetine,major depressive disorder,generalized anxiety disorder,chronic lower back pain,diabetic peripheral neuropathic pain

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