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Objective: To evaluate utilization and direct healthcare expenditures among psoriasis patients treated with systemic therapy and phototherapy in the United States., Design: Cohort study using retrospective administrative medical claims., Patients: Psoriasis patients treated with systemic therapy and phototherapy, as well as a matched cohort of non-psoriasis patients. All patients were covered by employer-sponsored insurance between 1 April 1996 and 31 December 2000., Main Outcome Measures: Estimated risk of hospitalization and total annual healthcare expenditures overall and by comorbidity status were compared for persons with psoriasis using systemic therapy or phototherapy and persons without psoriasis. Annualized utilization rates for hospitalizations, and use of emergency department, outpatient physician, outpatient laboratory, and outpatient pharmaceutical services were also compared across the two cohorts., Results: Seventeen percent of psoriasis patients were treated with systemic therapy or phototherapy. Patients with comorbid anemia, carcinoma, diabetes, depression, GI disorders, hepatotoxicity, hypertension, and nephrotoxicity had significantly higher expenditures than non-psoriasis patients with the same comorbidities (p < or =0.05). Elevated risk of hospitalization also contributed to higher expenditures in patients treated with systemic therapy or phototherapy. Limitations of this study include those inherent in using claims data such as dependence on diagnosis coding, the fact that psoriasis severity cannot be determined directly from claims data, confounding comorbidities, and the fact that only direct healthcare expenditures were considered in this analysis., Conclusion: Psoriasis patients treated with systemic therapies/phototherapies have significantly more comorbidities and higher mean total healthcare expenditures compared to non-psoriasis patients. Psoriasis patients with selected comorbidities have significantly higher mean total healthcare expenditures compared to non-psoriasis persons with the same comorbidities.

Purpose: Cancer accounts for 60.9 billion dollars in direct medical costs and 15.5 billion dollars for indirect morbidity costs. These estimates are derived primarily from national surveys or Federal databases. We derive estimates of the costs of cancer using administrative databases, which include claims and employment-related information on individuals insured by private or Medicare supplemental health plans., Methods: A retrospective matched-cohort control analysis was performed using 1998 to 2000 databases with information on insurance claims, benefits, and health productivity for 3 million privately insured employees, their dependents, and early retirees. Study patients had new diagnoses of one of seven types of cancer (n = 12,709). Controls without cancer were matched at a 3:1 ratio by demographics. A variable follow-up length was used (maximum of 2 years). Direct costs included health care costs for patients and deductibles and copayments for caregivers. Indirect costs of work absence and short-term disability (STD) were calculated for a subgroup of cancer patients and caregivers., Results: Mean monthly health care costs ranged from 2,187 dollars for prostate cancer to 7,616 dollars for pancreatic cancer, most often driven by hospitalization. Costs for controls were 329 dollars per month. Indirect morbidity costs to employees with cancer averaged 945 dollars, a result of a mean monthly loss of 2.0 workdays and 5.0 STD days., Conclusion: The economic burden of cancer is substantial. It is feasible to derive tumor-specific estimates of direct and indirect costs for large numbers of cancer patients using administrative databases. Policy makers charged with providing annual cost-of-cancer estimates should incorporate data obtained from a broad range of sources.

Objective: To obtain information on migraine and its impact on the family, particularly on the healthcare utilization and productivity of family members without migraine., Study Design: Retrospective study using linked medical and pharmacy claims data that allowed identification of families and individuals with migraine., Patients and Methods: Families with at least 1 migraineur were matched with up to 3 nonmigraineur families on employer, age of migraineur, number of family members, sex, and index date quarter. For a subset of employees, data on short- and long-term disability as well as absenteeism also were evaluated to determine the impact of migraine on these indirect costs., Results: The total healthcare costs of a family with a migraineur were 70% higher than those of the nonmigraine family, with most of the difference concentrated in outpatient costs. The impact of having a migraineur in the family persisted even after controlling for other disorders and demographics in a multivariate model. Total healthcare costs per family depended on which family member was the migraineur, and were about dollars 600 higher when the sole migraineur was a child versus a parent and almost dollars 2500 higher when both a parent and child were affected (compared with families in which the sole migraineur was a child). Work absence days, short-term disability, and workman's compensation days all were higher among migraine families than among families without a migraineur., Conclusion: Migraine families incur far higher direct and indirect healthcare costs than nonmigraine families, with variation depending on which family member is the clinically detected migraineur.

Background: Inhaled corticosteroids have been shown to reduce rates of hospitalization and emergency department use compared with leukotriene receptor antagonists., Objective: To examine differences in the probability of asthma-related hospitalizations, probability of switching or augmentin, with another therapy, and costs for patients treated with fluticasone propionate vs montelukast., Methods: The study involved a 24-month retrospective analysis of patients with claims for asthma treatment (primary diagnosis International Classification of Disease, Ninth Revision code of 493.xx) between January 1, 1997, and June 30, 2000, and at least I outpatient pharmaceutical claim for fluticasone propionate (44 microg) or montelukast (5 or 10 mg). Univariate and multivariate analyses were used to determine the probability of asthma-related hospitalizations and switching or augmenting to another therapy, asthma costs, and total health care costs. Sensitivity analyses were conducted by replicating all of the analyses by age strata (ages 4-17 years and > or = 18 years) and varying lengths of follow-up., Results: Patients receiving fluticasone propionate had a 62% lower risk of experiencing an asthma-related hospitalization within 1 year and a 44% lower risk of switching or augmenting to another asthma controller medication compared with montelukast. Asthma-related health care expenditures for montelukast patients were dollar 339 higher than for fluticasone propionate users (P < .001). Overall health care expenditures (asthma and nonasthma) were also dollar 1,197 higher in the montelukast group., Conclusions: Compared with montelukast-treated patients, patients treated with low-dose fluticasone propionate had a significantly lower risk of experiencing an asthma-related hospitalization, a lower risk of switching or augmenting with another controller, and significantly lower asthma and total health care costs.

Context: Treatment-resistant depression is a significant public health problem with profound effects on general medical and mental health-related health care costs., Objective: To describe health care costs of patients with treatment-resistant depression as their illness progresses, in terms of pharmaceutical and medical expenditures, and to identify factors associated with increasing degrees of treatment resistance., Data Sources: The MEDSTAT MarketScan Private Pay Fee for Service (FFS) Database, a medical and prescription claims database covering over 3.5 million enrollees, from 1995-2000., Design and Study Subjects: 7737 patients with depression (ICD-9) who had 2 or more unsuccessful trials of antidepressant medication at an adequate dose for at least 4 weeks from 1995-2000 were defined as treatment-resistant in this study. Demographic and clinical characteristics were assessed for these patients with treatment-resistant depression. The number of changes in depression medication treatment regimens was used as a proxy for increasing degrees of treatment resistance and its severity. MAJOR OUTCOME MEASURE: Differences in health care expenditures associated with increasing degrees of treatment-resistant depression., Results: Total depression-related and general medical health care expenditures increased significantly as treatment-resistant depression increased in severity. Multivariate analyses of patient demographic characteristics were not associated with ongoing treatment resistance. Disease severity, type of antidepressant at index, comorbid mental health disorders, and membership in a managed health care plan were associated with increasing degrees of treatment resistance., Conclusions: Depression and general medical health care expenditures increase with the degree of treatment-resistant depression. Disease management interventions for treatment-resistant depression that result in sustained remission early in the course of illness are most likely to be cost effective.

Patients with difficult-to-treat or suboptimally controlled asthma consume a disproportionate share of asthma health care resources. Treatment strategies that minimize exacerbations may decrease the need for unscheduled medical services, reduce emergency department visits, and minimize asthma-related hospitalizations. Clinical trial evidence indicates the immunoglobulin-E blocker omalizumab reduces the frequency of asthma exacerbations, minimizes symptoms, and improves lung function in patients with moderate-to-severe asthma that is inadequately controlled by inhaled corticosteroid therapy. Treatment with omalizumab of patients with suboptimally controlled asthma may reduce the clinical and economic burden of asthma.

The ratio of controller-to-reliever medication use has been proposed as a measure of treatment quality for asthma patients. In this study we examine the effects of plan-level mean out-of-pocket asthma medication patient copayments and other features of benefit plan design on the use of controller medications alone, controller and reliever medications (combination therapy), and reliever medications alone. The 1995--2000 MarketScan claims data were used to construct plan-level out-of-pocket copayment and physician/practice prescriber preference variables for asthma medications. Separate multinomial logit models were estimated for patients in fee-for-service (FFS) and non-FFS plans relating benefit plan design features, physician/practice prescribing preferences, patient demographics, patient comorbidities, and county-level income variables to patient-level asthma treatment patterns. We find that the controller-to-reliever ratio rose steadily over 1995--2000, along with out-of-pocket payments for asthma medications, which rose more for controllers than for relievers. After controlling for other variables, however, plan-level mean out-of-pocket copayments were not found to have a statistically significant influence on patient-level asthma treatment patterns. On the other hand, physician/practice prescribing patterns strongly influenced patient-level treatment patterns. There is no strong statistical evidence that higher levels of out-of-pocket copayments for prescription drugs influence asthma treatment patterns. However, physician/practice prescribing preferences influence patient treatment.

Background: There are no published studies that have compared the medical costs of patients with seasonal and perennial allergic rhinitis symptomatology., Objectives: The objectives of this study were to develop an algorithm for classifying patients into seasonal and perennial groups based on their patterns of allergy medication use and then compare the epidemiology and economics of the two groups., Methods: Data for the study were obtained from the 1996 to 1998 MarketScan databases containing linked inpatient, outpatient, and pharmaceutical claims for approximately 2 million covered lives annually. Patients were classified into seasonal allergic rhinitis (SAR) or perennial allergic rhinitis (PAR) groups based on their pattern of allergy medication use over the course of 1 year and then compared using descriptive methods., Results: Seventy-nine percent of the total study sample (80534 allergy patients) was classified as SAR and 21% as PAR. PAR patients were found to have higher mean levels of allergy-related outpatient payments (US dollars 568 vs. US dollars 471) and higher mean costs for second-generation antihistamines (US dollars 552 vs. US dollars 162). PAR patients also had higher levels of comorbidities (asthma, sinusitis, depression, and migraine), higher numbers of concomitant medications (multiple second-generation antihistamines, nasal steroids, other antihistamines, asthma medications, and ophthalmic decongestants), and more immunization encounters., Conclusions: Approximately 21% of allergic rhinitis patients have perennial symptoms as reflected in their patterns of medication use. Perennial patients have significantly higher allergy-related health-care costs and rates of comorbidities and greater use of concomitant medications. These distinct clinical and resource use profiles may have implications for therapy choices in the cost-effective management of perennial allergic rhinitis patients.

Crown discussed findings of a Medstat study probing the economic burden of psoriasis and the presence of comorbidity in psoriasis patients. He also discussed current economic issues in the marketplace, concluding with some thoughts on health economics and biologics--which are shifting the landscape of pharmacotherapy.

Introduction: Health-related retrospective databases, in particular claims databases, continue to be an important data source for outcomes research. However, retrospective databases pose a series of methodological challenges, some of which are unique to this data source., Methods: In an effort to assist decision makers in evaluating the quality of published studies that use health-related retrospective databases, a checklist was developed that focuses on issues that are unique to database studies or are particularly problematic in database research. This checklist was developed primarily for the commonly used medical claims or encounter-based databases but could potentially be used to assess retrospective studies that employ other types of databases, such as disease registries and national survey data., Results: Written in the form of 27 questions, the checklist can be used to guide decision makers as they consider the database, the study methodology, and the study conclusions. Checklist questions cover a wide range of issues, including relevance, reliability and validity, data linkages, eligibility determination, research design, treatment effects, sample selection, censoring, variable definitions, resource valuation, statistical analysis, generalizability, and data interpretation., Conclusions: For many of the questions, key references are provided as a resource for those who want to further examine a particular issue.

Advances in treatment technologies and development of evidence-based standards of care demand better methods for routine assessment of outcomes for schizophrenia in systems of care. This article describes the development and psychometrics of a new instrument to assess outcomes of routine care for persons with schizophrenia in service systems. Candidate items for the Schizophrenia Care and Assessment Program Health Questionnaire (SCAP-HQ) were drawn from existing measures. Domains covered include disease outcomes (symptoms, subjective medication effects, substance abuse), functional status, health status, quality of life, and public safety. A sample of 1,584 patients with schizophrenia or schizoaffective disorder who were recruited into a large prospective, naturalistic study on the course of treatment for schizophrenia completed the SCAP-HQ at baseline and 1 year later (n = 434), providing data for factor analysis, assessment of internal consistency, convergent validity, and responsiveness to change. A subsample of 121 patients completed a test-retest protocol. Fifteen scales were derived by factor analysis from 55 outcome items on the SCAP-HQ. These factors covered psychiatric symptoms, life satisfaction, instrumental activities of daily living, health-related disability, subjective medication side effects, vitality, legal problems, social relations, mental health-related disability, suicidality, drug and alcohol use, daily activities, victimization, violence, and employment. For most scales, standard psychometric parameters, including internal consistency and test-retest reliability, convergent validity, and responsiveness to change, were acceptable for application to large sample evaluations of care systems. This new measure represents an advance in the development of outcome measures for schizophrenia for use in large-scale studies of routine care.

Background: Approximately 50% of patients diagnosed with major depressive disorder will experience a recurrent or chronic course of illness for which long-term treatment is recommended. Moreover, at least 20% of patients diagnosed with depression do not respond satisfactorily to several traditional antidepressant medication treatment trials. Very little is known about the health care costs of patients with treatment-resistant depression., Method: Based on medical claims data (MarketScan Research Database, The MEDSTAT Group, Cambridge, Mass.) from January 1, 1995, to June 30, 2000, a naturalistic, retrospective analysis was conducted to study the characteristics and health care utilization of patients with treatment-resistant depression. All patients having an International Classification of Diseases, Ninth Revision (ICD-9), diagnosis code for unipolar or bipolar depression with specified antidepressant dosing and treatment durations were initially selected. Patients were then classified as "treatment resistant" if either they switched from or augmented initial antidepressant medication with other antidepressants at least twice (outpatient treatment-resistant group) or they switched from or augmented their initial antidepressant medication and also had a claim for either a depression-related hospitalization or suicide attempt (hospitalized treatment-resistant group). Those meeting the initial medication and diagnosis selection criteria but not meeting the treatment-resistance criteria constituted the comparison group. Members of the comparison group had comparatively stable antidepressant medication use patterns, consistent with an acceptable response to treatment. Patients were followed for a minimum of 9 months. Resource utilization was calculated from index date to last available claims data point and then annualized., Results: Treatment-resistant patients were more likely to be diagnosed with bipolar disorder or concurrent substance abuse or anxiety disorders than the comparison group (p <.001). Treatment-resistant patients were at least twice as likely to be hospitalized (general medical and depression related) and had at least 12% more outpatient visits (p <.02). Treatment resistance was also associated with use of 1.4 to 3 times more psychotropic medications (including antidepressants) (p <.001). Patients in the hospitalized treatment-resistant group had over 6 times the mean total medical costs of non-treatment-resistant depressed patients ($42,344 vs. $6512) (p <.001) and their total depression-related costs were 19 times greater than those of patients in the comparison group ($28,001 vs. $1455) (p <.001)., Conclusion: Treatment-resistant depression is costly and associated with extensive use of depression-related and general medical services. These findings underscore the need for early identification and effective long-term maintenance treatment for treatment-resistant depression.

In response to concerns about the cost burden of medical care in general and rising pharmaceutical costs in particular, a number of recent studies have examined trends in pharmaceutical expenditures. These studies have reached apparently disparate conclusions about factors responsible for rising pharmaceutical costs and the role that price and volume increases have played. In this paper, we examine methodological approaches that have been used to describe and analyze trends in medical and pharmaceutical expenditures using recent studies as examples. We present in detail one methodology for decomposing the factors of pharmaceutical spending and describe how variation in method can affect study findings. Finally, we consider some research extensions that we feel could considerably improve our understanding of the costs and benefits associated with pharmaceutical expenditures.

In this article, health care expenditures are assessed for patients diagnosed with depression who are being treated with either venlafaxine (immediate or extended release) or a selective serotonin-reuptake inhibitor (SSRI). Patients beginning treatment for a new depressive episode were identified retrospectively from 1994 to 1998. Before beginning therapy, patients prescribed venlafaxine (N = 353) had more nonmental illnesses (0.84 vs. 0.75 clinical events/patient, respectively; P < .01) and hospitalizations for mental illness (0.56 vs. 0.30 hospitalizations/patient; P = .06) than patients prescribed SSRIs (N = 7,330). In the six months after initiating treatment, venlafaxine was associated with lower hospitalization expenditures for nonmental illness than were SSRIs ($206 vs. $472, respectively; P = .02), but total health care expenditures were not significantly different.

Background: Although asthma and allergic rhinitis commonly occur together, the nature of the association has yet to be determined. Treatments for one condition could potentially alleviate the coexisting condition., Objective: Patients with both allergic rhinitis and asthma were studied to test the hypothesis that treating allergic rhinitis reduces health care utilization for co-morbid asthma., Methods: A retrospective cohort study was carried out with 1994-1995 MarketScan claims data. The cohort was limited to patients with both allergic rhinitis and asthma, aged 12 to 60 years, who were continuously enrolled and had no evidence of chronic obstructive pulmonary disease. Allergic rhinitis treatment and asthma-related events (hospitalizations and emergency department visits) were identified. An incidence density ratio (IDR) associated with exposure to allergic rhinitis treatment was calculated. A multivariate Poisson regression was estimated, and the parameter estimates were transformed into IDRs for each explanatory variable. An allergic rhinitis treatment indicator was included in all regressions., Results: The study sample population consisted of 4944 patients with allergic asthma, approximately 73% of whom were treated for their allergic rhinitis. Asthma-related events occurred more often for the untreated group compared with the treated group, 6.6% compared with 1.3%. An IDR of 0.49 for the treatment group (P =.001) indicates that the risk of an asthma-related event for the treated group was about half that for the untreated group., Conclusion: In summary, those who were treated for allergic rhinitis have a significantly lower risk of subsequent asthma-related events (emergency department visits or hospitalizations) than those who were not treated.

Background: Economic considerations increasingly play a role in the selection of antidepressant drugs and are often based on analyses from prospective and retrospective studies. However, the non-randomisation found in retrospective studies may result in significant selection bias., Aims: To highlight the use of statistical methods in non-randomised studies and the application of those methods to economic analyses., Method: The literature on the observational studies of economic outcomes with alternative antidepressants is reviewed and several statistical methodologies to control for biases that can occur in non-randomised study designs are described., Results: In comparisons of antidepressant drugs, differences in acquisition costs are consistently found to be at least offset by other components of care when broad measures of health care resource utilisation are considered., Conclusions: Economic evaluations of antidepressants should be based on broad measures of health care expenditure and can rely on data generated in real-world settings if appropriate statistical methods are used to control for the potential biases of non-randomisation.

Objectives: This paper examines three processes: SSRI antidepressant choice, adherence to treatment guidelines, and long-term health care expenditures associated with antidepressant treatment for patients with a diagnosis of depression., Methods: Patient records were abstracted from a medical claims database covering employer-provided health care plans. Treatment episodes required a 6-month antidepressant-free prior period; initial treatment with sertraline, paroxetine or fluoxetine; and data on direct medical costs over the 24 months following the initial prescription. The multivariate model of drug selection, patient adherence to antidepressant use guidelines, and cost was subjected to specification testing to rule out the possibility that nonrandom initial antidepressant selection might lead to sample selection bias. Further tests indicated that the results were free of bias due to a possible correlation between antidepressant selection and use of the medication, or because of the endogeneity of use patterns in the process driving cost. However, there was evidence of unobserved variables correlated with both achieving guideline adherent use and expenditures, which might have led to sample selection bias., Results: Subjects who met the study criteria included 796 initiating therapy with sertraline, 352 with paroxetine, and 882 with fluoxetine. Fluoxetine patients were significantly more likely than sertraline or paroxetine patients to achieve a use pattern that was consistent with guidelines for treating depressive disorder (p < .05). There were no statistically significant differences between the three treatment cohorts in total direct health care expenditures over the 2-year period (p < .05), and depression-related expenditures, other mental health expenditures, and non-mental health care expenditures did not show significant differences across the treatments (p < .05). Natural logged values of antidepressant drug expenditures were predicted to be highest for fluoxetine, followed by sertraline, then paroxetine (p < .01). Predicted log values of mental health expenditures were lower for sertraline relative to fluoxetine., Conclusions: Fluoxetine patients had the highest likelihood of using antidepressant medication according to treatment guidelines that were developed to assure quality care. This benefit was achieved without incurring greater total health care expenditures.

This study used data from the 1991-1993 MarketScan files, a large database of private sector inpatient, outpatient, and prescription drug medical claims, to identify a sample of 665 patients with schizophrenia. Descriptive and multivariate analyses were conducted on the subsamples with hospitalizations (N = 185) and without hospitalizations (N = 480) in the 1-year period following the initial diagnosis for schizophrenia observed in the 1991-1993 time period. After controlling for patient demographic characteristics, medical co-morbidities, and other factors, the cost of hospitalization itself was found to be $15,805.

Objective: To present national estimates of the prevalence and costs of inpatient admissions for aspiration pneumonia (AP) associated with percutaneous endoscopic gastrostomies (PEGs) inserted before or during an admission., Study Design: Retrospective analysis using medical claims., Patients and Methods: National estimates of the prevalence of inpatient admissions associated with AP and mortality rates were developed, using data from the Nationwide Inpatient Sample of the Hospital Cost and Utilization Project (HCUP-3) Database. The MEDSTAT Group's MarketScan Private Pay Fee-for-Service (FFS) and Medicare FFS databases were used to calculate the percentage of admissions for AP that were preceded by a PEG or that entailed a PEG placement. Associated statistics, such as average length of stay and mean payments for these admissions, also were estimated., Results: Approximately 300,000 inpatient admissions for AP took place in the United States in 1995, of which roughly 70,000 (23.9%) resulted in death. Approximately 10% of all AP admissions occurred after or entailed a PEG placement. After adjusting for differences in patients' age, gender, and health status, the total mean payments were estimated to be $26,618 per patient. This per-patient estimate translates into a national estimate of the cost of PEG-associated AP of approximately $808.2 million., Conclusion: The cost of PEG-associated AP is relatively high, as estimated in this study. The high inpatient mortality rates of AP imply that future efforts should be directed toward preventing AP.

Objective: To measure the cost of absenteeism and reduced productivity associated with allergic rhinitis., Methods: The National Health Interview Survey (NHIS) was used to obtain information on days lost from work and lost productivity due to allergic rhinitis. Wage estimates for occupations obtained from the Bureau of Labor Statistics (BLS) were used to calculate the costs., Results: Productivity losses associated with a diagnosis of allergic rhinitis in the 1995 NHIS were estimated to be $601 million. When additional survey information on the use of sedating over-the-counter (OTC) allergy medications, as well as workers' self-assessments of their reduction in at-work productivity due to allergic rhinitis, were considered, the estimated productivity loss increased dramatically. At-work productivity losses were estimated to range from $2.4 billion to $4.6 billion., Conclusion: Despite the inherent difficulty of measuring productivity losses, our lowest estimate is several times higher than previous estimates of the indirect medical costs associated with allergic rhinitis treatment. The most significant productivity losses resulted not from absenteeism but from reduced at-work productivity associated with the use of sedating OTC antihistamines.

Objective: To compare the economic outcomes associated with the tricyclic antidepressants (TCAs) and the selective serotonin reuptake inhibitors (SSRIs) in the treatment of depression., Method: A literature review of pertinent studies was performed. The advantages and disadvantages of clinical trials versus observational studies are described, and the breadth of the economic outcome measure chosen for the conclusions reached is discussed., Results: The inclusion and exclusion criteria of clinical trials, in combination with their strict provider and patient study protocols, limit their generalizability to naturalistic treatment settings. Retrospective studies of patients can provide valuable information about the experiences and costs incurred by patients in actual treatment. However, confounding factors (both observable and unobservable) limit the amount of confidence that can be placed in inferences about treatment effects. Randomized prospective studies with naturalistic follow-on may help to mitigate some of the concern about treatment confounders which has traditionally been associated with non-randomized observational studies., Conclusion: Retrospective studies and one randomized prospective study of the economic outcomes of TCA versus SSRI treatment have found the SSRIs to be less expensive than TCAs when total direct medical expenditures are considered. However, additional studies are needed to address this issue.

Background: A cascade of events follows initial antidepressant selection which includes the subsequent antidepressant use pattern, resultant clinical outcomes, and associated health care expenditures., Purpose: The purpose of this study using data from a clinical practice setting was to test whether the pattern of antidepressant use was correlated with patients' treatment response as measured by the score on the Clinical Global Impression-Improvement scale., Data and Methods: A retrospective dataset of patients who initiated therapy on fluoxetine, fluvoxamine, paroxetine, or sertraline in a primary care setting in Spain was used. A Cox proportional hazard analysis was used to predict the likelihood of treatment response based upon the pattern of initial antidepressant use, while minimizing the influence of other factors., Results: After controlling for other observed baseline characteristics including initial disease severity, (a) patients who remained on their initial antidepressant therapy for at least 2 months with no switching, augmentation, or upward dose titration were 1.63 times more likely to experience a treatment response than patients who had an adjustment to therapy; and (b) patients who initiated therapy on sertraline were 0.46 times as likely to experience a treatment response as patients who initiated therapy on the most common study antidepressant, fluoxetine., Conclusion: The pattern of antidepressant use is an important determinant of treatment response among patients initiating therapy on the newer antidepressants in clinical practice.

Objective: To assess if, in usual clinical practice, the patterns of use of new antidepressant are associated to different health resource utilisation., Design: Naturalistic, retrospective, observational study., Setting: Urban health center., Patients: DSM-IIIR diagnostic criteria of depressive disorder and treatment with a new antidepressant (n = 328)., Interventions: Information on resource utilisation was collected in those patients treated with fluoxetine (FLX), fluvoxamine (FLV) sertraline (SER), paroxetine (PAR) and venlafaxine (VLF). Direct, indirect and total costs were compared according to the different patterns of use (stable therapy, upward dose titration, switching or augmentation) and according to the initially prescribed antidepressant. The follow-up period was 6 months., Results: Direct and total daily costs of those patients with unestable therapy (upward dose titration, switching or augmentation) were 55% (p < 0.01) and 87% (p = 0.001) higher than for patients with stable therapy, respectively. Patients who initiated therapy on SER, VLF and PAR had 35% (p < 0.05), 80% (p < 0.05) and 37% (p < 0.05), respectively, higher average total costs per day than patients who initiated therapy with FLX. Regarding direct costs, patients who initiated therapy on SER and VLF had 48% (p < 0.001) and 58% (p < 0.05) higher average costs per day than patients who initiated therapy with FLX., Conclusions: New antidepressants show different patterns of use in a clinical practice setting, being FLX the agent more associated to a stable pattern of use. The pattern of use is associated to different health resource utilisation. Patients under stable therapy show lower health costs than those who need upward titration, switching or augmentation strategies. It is necessary to conduct randomized naturalistic studies to confirm these results.

Non-randomized studies of treatment effects have come under criticism because of their failure to control for potential biases introduced by unobserved variables correlated with treatment selection and outcomes. This paper describes the basic concepts of sample selection models--a technique used widely in the economics evaluation literature for nearly two decades--and discusses the potential role of these models in outcomes research. In addition, it presents a case study of the application of the sample selection modelling approach to evaluation of the effects of antidepressant therapies on medical expenditures for physician services. This case study presents empirical comparisons of alternative model specifications and discusses practical issues in evaluation of sample selection models. We demonstrate that, in this particular case, sample selection models yield very different conclusions regarding treatment effects than traditional ordinary least squares regression.

Administration of selective serotonin reuptake inhibitors (SSRIs) may increase plasma concentrations of concomitant medications that are also metabolized by the cytochrome P-450 system (CYP-450), in particular by the 2D6 and 3A4 isoenzymes. This may lead to side effects or other clinical events that might be expected to incur higher health-care expenditures. The purpose of this study was to assess whether there was a difference in expenditures during the first 90 days of SSRI therapy with paroxetine or sertraline versus fluoxetine in patients who were also receiving a stable dosage of a nonpsychiatric drug also metabolized by the CYP-450 2D6 or 3A4 isoenzyme systems. A sample of 2445 patients who initiated therapy with an SSRI while receiving a stable dosage of a nonpsychiatric drug was obtained from a private insurance claims database. Multivariate regression techniques were used to estimate total health-care expenditures in the first 90 days after receiving a prescription for an SSRI. After adjusting for nonrandom SSRI prescription patterns and controlling for observable and unobservable characteristics that might correlate with SSRI selection, total health-care expenditures were 95% higher for patients initiating SSRI therapy with sertraline or paroxetine compared with fluoxetine. Results suggest that there are cost differences between SSRIs during concomitant therapy with drugs also metabolized by the CYP-450 system. To determine whether there are additional differences in expenditures across SSRIs, future research should focus on (1) simultaneous initiation of SSRI therapy and a nonpsychiatric drug also metabolized by the CYP-450 enzyme system, and (2) addition of nonpsychiatric drug therapy to stable SSRI therapy. Relationships between additional expenditures, drug interactions, and clinical outcomes should also be assessed directly using medical records and patient interview data that are not available in claims-based files.

The purpose of this study was to evaluate whether 1-year total healthcare expenditures differed between patients who initiated therapy on a tricyclic antidepressant (TCA) or a selective serotonin reuptake inhibitor (SSRI) after controlling for initial antidepressant selection and antidepressant use pattern. A retrospective claims database covering a privately insured population in the US was used. Patients who initiated therapy in the outpatient setting (primary care or psychiatrist) were considered. Two-stage sample selection models were estimated that included controls for initial antidepressant selection and use pattern. The analyses indicated that: (i) self-selection due to initial antidepressant selection was a statistically significant determinant of expenditures for patients who initiated therapy on a TCA but not an SSRI; (ii) after controlling for initial antidepressant selection, antidepressant use pattern was a statistically significant and positive determinant of expenditures for both TCA and SSRI patients; and (iii) after controlling for initial antidepressant selection and use pattern, 1-year total direct healthcare expenditures were significantly lower for patients who initiated therapy on an SSRI than for patients who initiated therapy on a TCA.

Background: Providers and payers have an interest in the total health care costs following the initiation of antidepressant treatment in the real world of clinical practice. Analyses of these costs can help evaluate the economic consequences of patient management decisions associated with initial antidepressant selection., Objective: The purpose of this study was to assess the 1-year total direct health care costs for patients initiating therapy with one of the available tricyclic antidepressants (TCAs) or one of the three most often prescribed selective serotonin reuptake inhibitors (SSRIs) - paroxetine, sertraline, or fluoxetine., Method: A two-stage multivariate econometric model and data from fee-for-service private insurance claims between 1990 and 1994 were used to estimate the total direct health care costs following initial antidepressant drug selection for 2693 patients with a 'new' episode of antidepressant treatment. After controlling for both observed and unobserved characteristics, the 1-year total direct health care costs were found to be (1) statistically significantly lower for patients initiating therapy on fluoxetine than for patients initiating therapy on a TCA; (2) statistically significantly lower for patients who initiated therapy on fluoxetine than for patients initiating therapy on sertraline., Conclusions: Broadly considered, the findings in this study suggest that total direct health care costs differ across initial antidepressant selection after controlling for both observed and unobserved characteristics.

Asthma is a chronic inflammatory disorder of the airways that affects 10 to 17.5 million people and leads to more than $5 billion in treatment costs in the Unites States annually. This retrospective study is an initial step in understanding the beneficial economic outcomes of inhaled corticosteroid therapy by determining whether differences exist in healthcare utilization expenditures for three inhaled corticosteroids available for use in the United States: (1) beclomethasone dipropionate (Vanceril/Schering and Beclovent/Allan & Hanburys); (2) flunisolide (Aerobid/Forest); and (3) and triamcinolone acetonide (Azmacort/Rhône-Poulenc Rorer). This study was based on an analysis of 4,441 patients with at least one pharmaceutical claim for one of the study drugs, using inpatient, outpatient, and prescription drug claims data obtained from The MEDSTAT Group's MarketScan database for calendar years 1990 through 1993. We tested a null hypothesis for no differences in total asthma treatment costs, when drugs were excluded, using multivariate linear regression modeling controlling for patient demographic and clinical characteristics that might affect the study outcome. We found that, after excluding study drug payments and controlling for other contributing factors, total asthma healthcare expenditures to triamcinolone acetonide (Azmacort) users were higher than those for beclomethasone dipropionate (Vanceril and Beclovent) and flunisolide (Aerobid) users. When study drug costs were included in the expenditure measure, both triamcinolone acetonide (Azmacort) and flunisolide (Aerobid) users had higher expenditures than did beclomethasone dipropionate (Vanceril and Beclovent) users. No significant differences in expenditures were detected between Vanceril and Beclovent patients, a finding consistent with the fact that these drugs are the same type of inhaled corticosteroid. Other factors contributing to differences in total asthma healthcare costs included patient age, patterns of switching among and continuing with study drugs, prestudy asthma utilization or drug proxy severity, and comorbidities of precipitating illnesses.

Using data from the 1984 panel of the Survey of Income and Program Participation (SIPP), this article examines characteristics of the older population disaggregated by net-worth quintiles. The authors argue that income is not a sufficient measure of economic status for current policy discussions on issues such as changing Medicare co-payments, increasing the taxation of social security benefits, or means-testing under Medicaid. Net worth is a better measure of economic status, particularly for the elderly, because it represents the net value of assets accumulated over the life course. Their results indicate that there is considerable diversity in the economic status of the older population, which is masked by aggregate statistics (such as means and medians) typically used to summarize the economic status of population groups. Stereotypical views of the elderly based on such aggregates result in misdirected policy formulation. In the future, policymakers will need to formulate policies and programs using information on the distributions of income and assets among the older populations rather than relying on statistical aggregates.

This study uses data from the 1984 panel of the Survey of Income and Program Participation (SIPP) of the U.S. Bureau of the Census to develop new estimates of the potential market for private long-term care insurance. It found that this market is potentially significant--especially among individuals in the 65-69 age group who are willing to spend up to 50% of their discretionary income on such insurance--but considerably lower than previous estimates, such as those of Cohen and colleagues (1987).

We examined the direct and buffering effects of different dimensions of social support on the risk of being institutionalized over a 2-year period. Multivariate analyses indicated that specific aspects of social support, such as having a spouse or adult child caregiver, or having a caregiving relationship of at least 3 years' duration, moderated the impact of one type of stress (being highly dependent on others for care) on the risk of entering a nursing home. Networks that included a paid provider modestly offset the impact that multiple IADL impairments had on being admitted at least once to a nursing home.

This paper uses the 1980 Census data to estimate the size of the economic transfers associated with the 1985 to 1990 interregional migration of older persons. Total economic transfers are estimated by multiplying interregional migration flows of older persons by the average income of older persons in each migration stream. Assuming an average life expectancy of 15 years for elderly migrants and an expenditure multiplier of 2, the total redistribution of income as a result of 1985 to 1990 elderly migration is estimated to be over $600 billion. The South Atlantic and Mountain regions are the recipients of the largest positive net transfers; the East North Central and West North Central regions have the largest negative net transfers.

This paper examines one aspect of the economic impact of elderly migration, the transfer of income from state to state, a concern of policymakers, planners, and researchers. Using 1980 census microdata files it was determined that billions of dollars are transferred between states each year, some states (especially Florida) gaining and others losing. The 1980/1981 Consumer Expenditure Interview Survey was used to estimate the consumption patterns of the typical migrant household. These findings are discussed in the context of state economic development.