Depression in Managed Care: Costs of Selective Serotonin Reuptake Inhibitors

s from Poster Presentations ABSTRACTS T The following poster presentations have been prepared for the Academy of Managed Care Pharmacy’s 13th Annual Meeting & Showcase, April 18–21, 2001 in Tampa, Florida. For more information about the studies described below, please contact the corresponding authors, indicated by an asterisk (*), whose addresses are listed in full. The names of individuals who are scheduled to present at the meeting are underlined. nnRisk of myocardial infarction with dihydropyridine calcium channel blockers in hypertensive diabetics Alabi R and Anderson RJ* Mercer University Southern School of Pharmacy, 3001 Mercer University Drive, Atlanta, GA 30341 OBJECTIVE: The primary objective of this study was to determine if there was an increased risk of myocardial infarction (MI) in a high-risk hypertensive diabetic population maintained on dihydropyridine calcium channel blockers (CCBs). METHODS: A retrospective population-based case-controlled study design was used to determine the relative risk of MI versus the prescribed antihypertensive drug regimen. Diabetic patients with hypertension were identified from the Kaiser Permanente data warehouse, and the date of the MI in the study patients was used as an index date to match controls. Patients in both groups were matched for continuous enrollment, age, gender, vital signs, lab tests, and compliance. High-risk patients were defined as those with a medical history of previous MI and/or angina pectoris or those who had undergone a coronary artery bypass graft (CABG) and/or an angioplasty procedure. A chi-squared analysis was used in a 2X2 design to test for differences. The odds ratio (OR) and confidence interval (CI) were determined for each antihypertensive drug regimen. RESULTS: During 1997–1999, 6,096 diabetics with hypertension were identified. The 135 “high-risk” study patients who suffered an MI were compared to an equally matched sample. Of these, 57 patients were on a calcium channel blocker (CCB) combination including 36 patients maintained on dihydropyridines (DHPs). The OR for all CCBs was determined to be 0.502 (95% confidence limit, 0.3095–0.8145). The relative risk of MI in the subset populations on either DHPs (OR=0.577 [0.3303–1.008]) or non-DHPs (OR=0.423 [0.2227–0.8038]) was also less than 1.0. CONCLUSIONS: No increase in the relative risk of MI could be determined with the use of dihydropyridine CCBs in this population. LEARNING OBJECTIVES: Audience participants will: 1. understand the advantages and limitations of a retrospective population-based case-control study design in a managed care setting; 2. discuss the relative risk of MI of various CCBs in a high-risk diabetic hypertensive population; 3. interpret the results using chi-square and OR as statistical analyses; and 4. identify the importance of medication compliance to risk of MI and its implications to pharmacy in a managed care population. nnMigraine program impacts coordination of patient care Andreasen C,* Esser D, and Krawcyk K United Healthcare of the Midlands, 2717 North 118th Street, Omaha, NE 68164 OBJECTIVE: To develop and implement a program to help coordinate care for members with migraines. The goal was to educate and provide the physicians with resources to help treat and manage these members as well as other patients with migraines. METHODS: The study population includes commercial, Medicare, and Medicaid managed care members continuously enrolled for 12 months; pharmacy and medical claims data from September 1, 1998 through February 28, 1999 were used. The target population was 177 members. The health plan developed an intervention that included a letter describing the program, member profile(s), an abbreviated treatment guideline, an educational booklet for members, and a physician feedback survey. The intervention was sent to every physician who either prescribed one of the abortive medications or had an office visit or encounter with the member. RESULTS: The 177 members had an average age of 43; there were 34 males and 143 females. The following results are from June 1, 1999 through November 30, 1999. The average number of abortive prescriptions per member decreased from 18.25 to 16.02 (p<.01). The average number of facility visits per member decreased from 2.00 to 1.34 (p<.05). The percentage of members who saw four or more health care providers decreased from 40% to 16% (p<.001). The average paid per member per month decreased from $426 to $290 (p<.001). The physicians’ response based on both the written survey and the telephone dialogue was very positive. CONCLUSION: A disease-management program can successfully coordinate migraine patients’ care. The program was repeated in 2000. LEARNING OBJECTIVES: Audience participants will: 1. recognize the importance of managing migraine costs; 2. learn how to implement a simple migraine disease-management program; and 3. understand how to measure outcomes for migraine disease-management programs. nnCost-minimization analysis of three nitroglycerin drug-treatment strategies Bell CF,* Semroc GN, Stephens JM, Klingman D, and Dever M Abt Associates Clinical Trials, 4800 Montgomery Lane, Suite 600, Bethesda, MD 20814-5341 (research performed at PAREXEL International Medical Marketing Services, Inc.) OBJECTIVE: To examine the economic implications of drug stability and potency issues with certain sublingual nitroglycerin (NTG) formulations when compared with lingual NTG spray in treating stable angina. METHODS: Using an economic model that projects patients’ angina frequency and prescription-refill pattern over time, the analysis estimates the cost difference between sublingual NTG tablets and NTG lingual spray. Vol. 7, No. 2 March/April 2001 JMCP Journal of Managed Care Pharmacy 123 Abstracts from Poster Presentations at AMCP’s 13th Annual Meeting & Showcases from Poster Presentations at AMCP’s 13th Annual Meeting & Showcase The model’s perspective is that of the third-party payor (e.g., managed care organization or formulary decision maker) and includes patients with stable angina who are eligible for NTG therapy and are not immediate candidates for invasive treatments (PTCA/CABG). Clinical and economic data were obtained from published sources and via expert panel. RESULTS: For mild angina patients (defined as those experiencing, on average, one angina episode per week), the model indicated that the twoyear prescription cost of treating 100,000 patients with sublingual NTG tablets ranged from $7.5 million to $16.4 million (100-tablet and 4X25 tablet formulations, respectively). Treating mild angina patients with NTG lingual spray resulted in a two-year prescription cost of $3.3 million. CONCLUSIONS: This study has demonstrated that although the initial cost of NTG lingual spray is greater than sublingual NTG tablets, a substantial savings can be achieved by prescribing NTG lingual spray. Subsequent analyses should be performed to demonstrate the economic implications (beyond prescription costs) of patients’ self-administering subpotent sublingual NTG tablets, which could have a significant impact on hospital emergency department utilization. The results and implications of this analysis should be verified, prospectively, in typical care settings. LEARNING OBJECTIVES: Audience participants will learn to: 1. provide an introduction to cost-minimization analyses to evaluate alternative medical interventions; 2. illustrate, with a practical example, how modeling exercises can be used to demonstrate the economic implications of alternative medical interventions; 3. detail the potential economic implications associated with NTG drug therapy for patients with stable angina, especially in light of the storage, stability, and potency issues with certain sublingual NTG formulations; and 4. raise the awareness of patients, health care providers, and decision makers regarding the appropriate use of NTG formulations to treat stable angina. nnAdherence to National Cholesterol Education Panel (NCEP) guidelines in a managed care outpatient clinic Bello C,* and Alvarez M Humana Inc., 440 W 49 Street, Hialeah, FL 33012 OBJECTIVE: To assess prescribing patterns and measure treatment outcomes in relation to National Cholesterol Education Panel (NCEP) guidelines among patients taking HMG CoA reductase inhibitors in a managed care outpatient clinic. METHODS: Patients receiving an HMG CoA reductase inhibitor were selected from a pharmacy claims database. Demographic and clinical data were collected by medical-chart review during November 1999 and September 2000. Data were collected from 118 patients. Mean age was 71.4 years; 64% were female; 35% of the patients were being treated for secondary prevention and 65% for primary prevention. Data analysis showed that 42% of patients achieved the low-density lipoprotein cholesterol (LDL-C) goal recommended by NCEP guidelines; 60% of patients achieved their NCEP goal of lower than 160 mg/dL, 50% reached their goal of lower than 130 mg/dL, and only 28% attained their LDL goal of 100 mg/dL or less. CONCLUSION: The majority of patients studied are not reaching NCEP LDL target levels. The study results will be shared with the medical staff and will serve as a benchmark for a continuous quality improvement program for the treatment of hyperlipidemia. LEARNING OBJECTIVES: Audience participants will: 1. understand the NCEP guidelines and the importance of treating to LDL–C goals; 2. understand current physician compliance rates to NCEP guidelines; and 3. understand how an Access database can be used to analyze clinical data. nn Utilization factors related to the pharmacologic management of overactive bladder disease Boccuzzi SJ,* Roehm JB, Kreilick C, Bookhart B, and Williamson T The Institute for Effectiveness Research L.L.C., Merck-Medco Managed Care L.L.C., A Merck Company, 520 US Highway 22 East Bridgewater, NJ 08807; and Pharmacia Corporation, Peapack, NJ OBJECTIVES: Urinary incontinence (UI) is associated with adverse physical, psychological, and economic outcomes affecting approximately 13 million Americans. UI is underreported and frequently untreated. Firstline therapy includes agents decreasing incontinence frequency. This study characterizes utilization and cost of Detrol (DE), Ditropan XL (DI), and generic oxybutynin (OX). METHODS: Drug markers associated with UI management in the Merck-Medco pharmacy claims database (N=60+M) were used to construct a continuously eligible new-therapy cohort from February 1, 1999 through August 31, 1999. Key utilization and drug-cost measures were evaluated through March 31, 2000. RESULTS: Sixty-one percent of patients (N=64,284) were 65 years old or older; 74% were female. DE was first-line in 66% of patients, followed by OX (20%) and DI (14%). Drug titration occurred in 5% of DE, 11% of DI, and 8% of OX patients; lower DE titration frequency reflected higher starting doses. Six-month persistence was higher for DE & DI (29%) than OX (19%). Primary-care physicians and obstetrician/gynecologists were more likely to prescribe DE, while DI prescriptions were higher among urologists. Average therapy cost/day (based on average wholesale price and average number of pills per day) was $0.88 for OX, $2.51 for DE, and $2.76 for DI. CONCLUSION: UI pharmacologic management appears suboptimal, with opportunity to improve utilization. While branded agents may cost more than generics, this study demonstrated 34% higher persistence for these agents. Among branded agents, DE may afford incremental savings ($0.25/day lower than DI). Additional studies are needed to characterize utilization and economic factors regarding management of UI. LEARNING OBJECTIVES: Audience participants will learn: 1. to characterize the utilization factors related to pharmacologic management of overactive bladder disease; 2. to evaluate the economic factors related to drug therapy with the currently available agents; and 3. to generate research hypotheses to guide further study in this ther-