Comparative treatment patterns, resource utilization, and costs in stimulant-treated children with ADHD who require.
ABSTRACT Although not indicated for attention-deficit/hyperactivity disorder (ADHD), atypical antipsychotics (AAPs) are commonly prescribed for children with ADHD. The treatment patterns, resource utilization, and costs associated with AAPs relative to non-antipsychotic medications have not been evaluated for children with ADHD.
To compare treatment patterns, resource utilization, and costs to U.S. third party payers between stimulant-treated ADHD children who switch to or augment their stimulant treatment with AAPs (risperidone, aripiprazole, quetiapine, olanzapine, ziprasidone, paliperidone, and clozapine) compared with non-antipsychotic medications (atomoxetine, clonidine immediate-release (IR), guanfacine IR, dexmethylphenidate, mixed amphetamine salts, methylphenidate, lisdexamfetamine, and dextroamphetamine).
Patients with at least one ADHD diagnosis (ICD-9-CM codes 314.00 or 314.01) and at least one stimulant medication claim between January 1, 2005 and December 31, 2009, were identified from a large U.S. commercial medical/pharmacy claims database. Patients were classified into the AAP cohort if they had a claim for an AAP following a stimulant fill or into the non-antipsychotic cohort if they had a claim for a non-antipsychotic medication after a stimulant fill and no AAP claims. The index date was defined as the date of the first fill of the AAP or a randomly selected eligible non-antipsychotic medication. Patients were eligible for inclusion if they were aged 6-12 as of the index date and had at least 18 months of continuous eligibility. Patients were excluded if they had a psychiatric diagnosis for which AAPs were approved by the U.S. Food and Drug Administration (FDA) or commonly used. Patients in the non-antipsychotic group were matched 1:1 to patients in the AAP group using a propensity score generated from a logistic regression that included demographics, treatments, resource utilization, and comorbidities during the 6 months prior to the index date. All outcomes were measured during the 12 months following the index date. Treatment patterns were compared using Kaplan-Meier (KM) estimates and Cox proportional hazards models. Annual resource utilization was compared using McNemar's test and Poisson regression. Costs were estimated from the perspective of U.S. third-party payers and were adjusted to 2010 dollars using the medical component of the Consumer Price Index. Both all-cause and mental health-related costs were examined and compared using Wilcoxon signed-rank tests.
Of the 22,622 patients with ADHD identified to have used AAPs after a stimulant, 15,664 (69%) patients did not have a psychiatric diagnosis for which AAPs were FDA-indicated or commonly used. Among the 84,558 patients using non-antipsychotics after a stimulant, 81,397 (96%) did not have such psychiatric diagnoses. A total of 2,127 children in the AAP cohort and 16,508 children in the non-antipsychotic cohort met all of the study inclusion criteria. After propensity score matching, 1,857 children (358 switchers and 1,499 augmenters) were included in each of the matched cohorts. The baseline characteristics were well balanced between the matched cohorts. In the 12 months post-index date, children treated with AAPs were more likely to experience switching (KM: 17.2% vs. 10.4% at 12 months; HR = 1.75) and augmentation (KM: 43.4% vs. 22.4% at 12 months; HR = 2.62) than the non-antipsychotic group (both P less than 0.001). Rates of discontinuation were similar between groups (KM: 71.8% vs. 71.7% at 12 months; HR = 0.98, P = 0.600). The AAP cohort also had higher mean numbers of hospitalizations, emergency room visits, and outpatient visits (0.08 vs. 0.03, 0.34 vs. 0.25, 14.1 vs. 12.7 per patient, respectively; event rate ratios = 2.61, 1.33, and 1.11, respectively; all P less than 0.001). The AAP group also incurred higher all-cause mean medical, prescription drug, and total health care costs compared with the non-antipsychotic group ($3,090 vs. $2,238; $3,844 vs. $2,509; $6,934 vs. $4,748, respectively; all P less than 0.001). Patients in the AAP group also incurred higher mean total, medical, and drug costs related to mental health ($5,057 vs. $2,859; $1,555 vs. $964; $3,502 vs. $1,895, respectively; all P less than 0.001).
Stimulant-treated children with ADHD who switched to or augmented with AAPs versus non-antipsychotics had significantly greater rates of subsequent augmentation and health care resource utilization as well as higher total health care costs. Further research and/or drug utilization reviews may be warranted to fully evaluate the clinical and economic outcomes of pediatric ADHD patients who are receiving AAPs.
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ABSTRACT: Untreated attention-deficit/hyperactivity disorder (ADHD) can lead to substantial adverse social, economic, and emotional outcomes for patients. The effectiveness of current pharmacologic treatments is often reduced, due to low treatment adherence and medication discontinuation. This current systematic literature review analyzes the current state of knowledge surrounding ADHD medication discontinuation, focusing on: 1) the extent of patient persistence; 2) adherence; and 3) the underlying reasons for patients' treatment discontinuation and how discontinuation rates and reasons vary across patient subgroups. We selected 91 original studies (67 with persistence/discontinuation results, 26 with adherence results, and 41 with reasons for discontinuation, switching, or nonadherence) and 36 expert opinion reviews on ADHD medication discontinuation, published from 1990 to 2013. Treatment persistence on stimulants, measured by treatment duration during the 12-month follow-up periods, averaged 136 days for children and adolescents and 230 days for adults. Owing to substantial study heterogeneity, comparisons across age or medication type subgroups were generally inconclusive; however, long-acting formulations and amphetamines were associated with longer treatment duration than short-acting formulations and methylphenidates. The medication possession ratio, used to measure adherence, was <0.7 for all age groups and medication classes during a 12-month period. Adverse effects were the most commonly cited reason for discontinuation in all studies. Original research studies reported the lack of symptom control as a common discontinuation reason, followed by dosing inconvenience, social stigma associated with ADHD medication, and the patient's attitude. In summary, although there was a lack of consistency in the measurement of adherence and persistence, these findings indicate that drug adherence and persistence are generally poor among patients with ADHD. Clinicians may be able to help improve adherence and persistence to ADHD treatment by educating caregivers and patients on treatment goals, administering long-acting medications, and following-up with patients to verify if medication is still effective and well-tolerated.Neuropsychiatric Disease and Treatment 01/2014; 10:1543-69. DOI:10.2147/NDT.S65721 · 2.00 Impact Factor
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ABSTRACT: Abstract Objective: Stimulants are recommended as a first-line treatment for attention- deficit/hyperactivity disorder (ADHD); however, a subset of the patient population augments their stimulant treatment with other medications. The objective of this study was to estimate the 1 year period prevalence of concomitant psychotropic medication use among children and adolescents with ADHD during 2009. Methods: Patients 6-17 years of age with one or more primary ADHD diagnoses between July 1, 2008 and December 31, 2009 and one or more stimulant prescription fills during 2009 were identified from a large United States commercial claims database. Concomitant psychotropic medication use, defined as 30 days of continuous medication supply overlap between the augmenting agent and stimulant, was evaluated for 14 distinct psychotropic medication categories (6 with a United States Food and Drug Administration (FDA) approved indication for ADHD, 8 without an indication for ADHD). The 1 year period prevalence of concomitant psychotropic medication use (both overall and within each medication category) was calculated and compared between patients with and without psychiatric or neurologic comorbidities. Children (6-12 years) and adolescents (13-17 years) were evaluated separately. Results: A total of 71,201 children and 49,959 adolescents met the inclusion criteria. The 1 year period prevalence of concomitant psychotropic medication use among children and adolescents was 20.3% and 23.4%, with 5.7% and 6.7% augmenting with two or more medication categories, respectively. The most common concomitant medication categories were selective serotonin reuptake inhibitors (SSRIs) (children: 6.2%; adolescents: 11.4%), atypical antipsychotics (5.8%; 6.8%) and clonidine immediate release (5.4%; 2.9%). Children and adolescents with psychiatric or neurologic comorbidities had higher rates of augmentation than did those without comorbidities (all p<0.001). Conclusions: This epidemiologic study found that the prevalence of concomitant psychotropic medication use in children and adolescents ranged from 12.6% for noncomorbid ADHD to 41.7% for comorbid ADHD, in 2009. Future research is warranted to evaluate the rationale for, and clinical benefit of, concomitant psychotropic medication usage in patients with ADHD.Journal of child and adolescent psychopharmacology 05/2014; 24(5). DOI:10.1089/cap.2013.0107 · 2.59 Impact Factor