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ABSTRACT: Objective: Patients with Alzheimer disease (AD) show a high incidence of behavioural and psychological symptoms of dementia, which often lead to the prescription of antipsychotics. Our study sought to assess the impact of the initiation of memantine or cholinesterase inhibitors (ChEIs) on the use of antipsychotics. Method: A retrospective cohort study was conducted using data from the Quebec provincial health plan database. Patients included in our study had received a diagnosis of AD and were initial users of memantine or ChEIs. The proportion of patients who used antipsychotics was estimated using prescription data dating back to 1 year before and to 1 year after the first prescription of memantine or ChEIs. The difference between the slopes corresponding to the periods pre- and postmemantine or ChEIs was analyzed using an interrupted time series design. Results: The percentage of antipsychotic users increased by 118.3% before and by 68.3% after initiation of a ChEI, and increased by 68.6% before and by 7.0% after initiation of memantine. Antipsychotic trends pre- and post-ChEI initiation were not statistically different (P = 0.89), while a statistical difference was observed when comparing the antipsychotic trends pre- and postmemantine initiation (P < 0.001). Conclusions: The initiation of memantine, unlike ChEIs, has a notable stabilization effect on the prescription of antipsychotics in patients with AD.
Canadian journal of psychiatry. Revue canadienne de psychiatrie 04/2013; 58(4):195-200. · 2.42 Impact Factor
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ABSTRACT: BACKGROUND: Although high non-adherence to medication has been noticed for ulcerative colitis (UC), little is known about adherence to mesalamine treatments and determinants that can predict adherence. The objective of this study was to assess adherence and persistence to mesalamine treatments and their potential determinants in mild to moderate UC patients in a real-life setting in Quebec, Canada. METHODS: A retrospective prescription and medical claims analysis was conducted using a random sample of mesalamine users with UC. For inclusion, patients were required to initiate an oral mesalamine treatment between January 2005 and December 2009. Patients with a diagnosis of Crohn's disease were excluded. Treatment adherence (medication possession ratio [MPR]) and persistence were evaluated over a 1-year period after the index prescription using the Kaplan-Meier method with log-rank test and stepwise regression to identify potential determinants. RESULTS: A sample of 1,681 of the new oral mesalamine users (mean age = 55.3) patients was obtained. Overall, the percentage of patients with a MPR of 80% or greater at 12 months was 27.7%, while persistence was 45.5%. Among patients treated with mesalamine delayed/extended-release tablets (Mezavant(R)), adherence and persistence were 40.9% and 71.9%, respectively. Predictors of high adherence included, male gender (OR=1.3; 95% confidence interval [CI]=1.1--1.6), older age (>60 years; OR=1.6; 95% CI=1.3--2.0) and current use of corticosteroids (OR=1.4; 95% CI=1.1--1.8). Predictors of high persistence included male sex (OR=1.4; 95% CI=1.1--1.7), current use of corticosteroids (OR=1.4; 95% CI=1.1--1.7) and presence of hypertension or respiratory diseases (OR=1.2; 95% CI=1.01--1.55). CONCLUSIONS: The majority of patients with UC exhibited low adherence and persistence to mesalamine treatments. Various determinants of improved adherence and persistence were identified.
BMC Gastroenterology 01/2013; 13(1):23. · 2.42 Impact Factor
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ABSTRACT: To understand attention-deficit/hyperactivity disorder (ADHD) treatment patterns and estimate adherence and persistence in Quebec, Canada.
This cross-sectional, retrospective prescription claims analysis used a random sample of 15 838 patients with ADHD from a Quebec database (Régie de l'assurance maladie du Québec [RAMQ]) to assess treatment patterns, adherence (1-year medication possession ratio in new users), and persistence (proportion persistent at 3, 6, and 12 months after index prescription).
The mean patient age was 14 years; 72.6% were male. During the 5-year study period (2004-2009), 416 646 ADHD prescriptions were filled. Short-acting (SA) medications declined from 72.8% to 26.4% of all claims, while stimulant and nonstimulant long-acting (LA) medications increased from 27.2% to 73.6%. Approximately half of the patients used both SA and LA medications (either concomitantly or subsequently), and the others used only SA (30%) or LA (19%) drugs. Among patients using both, switching from SA to LA was the most frequent (27.9%) treatment pattern. More patients on LA methylphenidates (6.4%) compared with LA amphetamines (1.9%; P < 0.01) required augmentation with an SA drug. Fewer patients on SA stimulants (39.4%) were ≥ 80% adherent compared with LA stimulants (63%; P < 0.001) and LA nonstimulants (60.2%; P < 0.001). More patients on LA stimulants (81.1%) were persistent at 12 months compared with LA nonstimulants (61.7%; P < 0.001) and SA stimulants (59.6%; P < 0.001). Similar trends were observed at all time points measured.
Switching from SA to LA medications and treatment augmentation are common in ADHD management, with implications for patient care and health care resource use. This analysis found poor adherence in ADHD treatment, although adherence and persistence were improved with LA stimulant formulations.
Postgraduate Medicine 05/2012; 124(3):139-48. · 1.78 Impact Factor
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ABSTRACT: Dexmedetomidine is an α(2)-receptor agonist administered by continuous infusion in the intensive care unit (ICU) for sedation of critically ill patients who are undergoing mechanical ventilation following intubation. Relative to ICU patients receiving midazolam (a γ-aminobutyric acid agonist) for sedation, those receiving dexmedetomidine spent less time on ventilation, had fewer episodes of delirium, and had a lower incidence of tachycardia and hypertension.
To assess the economic impact, in a Canadian context, of dexmedetomidine, relative to midazolam, for sedation in the ICU.
This economic evaluation was based on a cost-consequences analysis, from the perspective of the Canadian health care system. The selected time horizon was an ICU stay (maximum 30 days). Clinical data were obtained from a previously published prospective, randomized, double-blind trial comparing dexmedetomidine and midazolam. This evaluation considered the costs of the medications, mechanical ventilation, and delirium episodes, as well as costs associated with adverse events requiring an intervention. All costs were adjusted to 2010 and are reported in Canadian dollars.
The average cost of the medication was higher for dexmedetomidine than midazolam ($1929.57 versus $180.10 per patient), but the average costs associated with mechanical ventilation and management of delirium were lower with dexmedetomidine than with midazolam ($2939 versus $4448 for ventilation; $2127 versus $3012 for delirium). The overall cost per patient was lower with dexmedetomidine than with midazolam ($7022 versus $7680). Deterministic sensitivity analysis confirmed the robustness of the difference.
The use of dexmedetomidine was, in most contexts, a more favourable strategy than the use of midazolam, in terms of clinical consequences and economic impact. Dexmedetomidine was less expensive than midazolam and was associated with lower occurrence of delirium and shorter duration of mechanical ventilation.
The Canadian journal of hospital pharmacy 03/2012; 65(2):103-10.
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ABSTRACT: An observational study showed that combining memantine with a cholinesterase inhibitor (ChEI) treatment significantly delayed admission to nursing homes in patients with Alzheimer disease (AD). Our study aimed to evaluate the economic impact of the concomitant use of memantine and a ChEI, compared with a ChEI alone, in a Canadian population of patients with AD.
A cost-utility analysis using a Markov model during a 7-year time horizon was performed according to a societal and Canadian health care system perspective. The Markov model includes the following states: noninstitutionalized, institutionalized, and deceased. The model includes transition probabilities for institutionalization and death, adjusted with mortality rates specific to AD. Utilities associated with institutionalization and noninstitutionalization were included. For the health care system perspective, costs of medication as well as costs of care provided in the community and in nursing homes were considered. For the societal perspective, costs of direct care and supervision provided by caregivers were added.
From both perspectives, the concomitant use of a ChEI and memantine is a dominant strategy, compared with the use of a ChEI alone. On a per patient basis, there was a gain of 0.26 quality-adjusted life years with the treatment including memantine and cost decreases of Can$21 391 and Can$30 512, respectively, for the societal and health care system perspective.
This economic evaluation indicates that institutionalization is the largest cost component in AD management and that the use of memantine, combined with a ChEI, to treat AD is a cost-effective alternative, compared with the use of a ChEI alone.
Canadian journal of psychiatry. Revue canadienne de psychiatrie 10/2011; 56(10):596-604. · 2.42 Impact Factor
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ABSTRACT: Risk of morbidity and mortality in patients with severe heart failure (HF) is reduced by blockade of aldosterone receptors with spironolactone. However, benefits of spironolactone are potentially limited by treatment compliance and adverse events profile. The aim of this study was to estimate use of spironolactone by patients with HF, incidence of key adverse events, and patient compliance.
This study was performed using data from the Quebec provincial medical and drug plans (Régie de l'Assurance Maladie du Québec, RAMQ) for patients who had a diagnosis of HF. Relative incidence of gynecomastia and hyperkalemia was estimated for users and non-users of spironolactone. Treatment adherence was estimated for users of spironolactone and compared to adherence with angiotensin converting enzyme (ACE) inhibitors, beta-blockers (β-blockers), and angiotensin receptor blockers (ARBs).
RAMQ data were obtained for a total of 82,018 patients with a diagnosis of HF. Of these patients, 59.9% used an ACE inhibitor, 59.5% used a beta-blocker, 28.4% used an ARB, and 15.1% (n = 12,344) used spironolactone. Despite underestimation due to limitation of the database, the documented incidence of hyperkalemia (3.3% versus 1.4%) and gynecomastia (1.8% versus 0.7%) was significantly higher in spironolactone users than non-users (p < 0.001). Treatment compliance was significantly lower with spironolactone compared to ACE inhibitors, β-blockers, and ARBs (45.6% versus 56.1%, 59.7%, and 57.0%, respectively; p < 0.001). Persistence to treatment over a one-year period was also lower with spironolactone compared to ACE inhibitors, β-blockers, and ARBs (50.7% versus 64.5%, 70.4%, and 66.3%, respectively; p < 0.001).
Use of spironolactone is associated with an incidence of adverse events, which may have an impact on treatment compliance.
BMC Clinical Pharmacology 01/2011; 11:4. · 1.36 Impact Factor
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ABSTRACT: To assess the cost-utility of posterior lamellar keratoplasty (PLK) techniques, including deep lamellar endothelial keratoplasty, Descemet stripping endothelial keratoplasty, and Descemet stripping automated endothelial keratoplasty, in the treatment of corneal endothelial diseases.
Cost-utility analysis based on a Markov model.
Cohort of 100 patients waiting for corneal graft.
This cost-utility analysis was performed from a Canadian health system perspective over a lifetime period. A Markov model was constructed to compare the cost per quality-adjusted life-year (QALY) associated with penetrating keratoplasty (PK) and PLK techniques. The model included all major health states relevant to patients scheduled for corneal transplant: waiting for transplant, surviving graft with or without complications, irreversible failure, noneligibility, and death. Transition probabilities among health states were obtained from published clinical trials. Costs considered were those associated with surgery, patients' follow-up, and postsurgical complications. Number of QALYs was estimated presurgery and postsurgery using the Brown and Sharma conversion chart.
PLK proved to be more effective, providing more QALYs (+13 QALYs/100 patients), and it was less costly (-$68,792/100 patients) compared with PK. Deterministic and probabilistic sensitivity analyses confirmed the robustness of the base-case results.
From a clinical and an economic standpoint, PLK in the management of patients waiting for corneal graft represents a preferred strategy compared with PK only.
Canadian Journal of Ophthalmology 06/2010; 45(3):243-51. · 1.47 Impact Factor
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ABSTRACT: Fibromyalgia syndrome (FMS) is a chronic disorder defined by widespread muscle pain and multiple tender points. The objectives of this study were to estimate prevalence of comorbidities, healthcare resources utilization, and costs associated with FMS.
A retrospective cohort study was conducted using data from the Quebec provincial health plans (RAMQ) for a random sample of patients with diagnoses of FMS and a control cohort of patients without FMS, matched for age and gender. Prevalence of comorbidities was estimated. Healthcare resources consumed by FMS and non-FMS patients were identified in terms of visits to physicians, physician's interventions, pain-related medications, nonpain-related medications, and hospitalizations.
A total of 16,010 patients with 2 diagnoses of FMS were identified, and control patients were randomly selected with a ratio of 1:1. Incidence of most comorbidities was significantly higher in the FMS group and the chronic disease score (3.8 vs. 2.8; ANOVA P <0.001). The proportion of patients with at least 1 comorbidity was 87.4% in the FMS group and 60.1% in the control group (chiP<0.001). The annual number of visits to physician and physician's interventions was 25.1 for FMS and 14.8 for non-FMS patients. The amount paid by the RAMQ was significantly higher for patients with FMS ($4065) compared with patients without FMS ($2766) (ANOVA P<0.001).
Results of this analysis of the RAMQ database illustrate the high prevalence of comorbidities among patients with a diagnosis of FMS and strongly indicate that the economic burden of FMS is substantial.
The Clinical journal of pain 05/2010; 26(4):284-90. · 3.01 Impact Factor
