What happens next?: a claims database study of second-line pharmacotherapy in patients with major depressive disorder (MDD) who initiate selective serotonin reuptake inhibitor (SSRI) treatment

BACKGROUND: The objective of this research was to examine treatment patterns and health-care costs associated with second-step pharmacotherapy in patients with major depressive disorder (MDD) who initiated monotherapy with a selective serotonin reuptake inhibitor (SSRI) in 2010. METHODS: This claims database study analyzed patients diagnosed with MDD who were prescribed a monotherapy SSRI, with the first prescription identified as the index date. Patients were required to be ≥18 years old, to have continuous insurance coverage from 1 year prior (pre-index) through 1 year post (post-index) from the index date, and to have not received an antidepressant in the pre-index period. The analyses are descriptive of the patient characteristics, initial SSRI prescribed, most commonly prescribed second-step therapies, and annualized health-care costs. RESULTS: The identified patients (N = 5,012) were predominantly female (65.2%) with a mean age of 41.9 years. The most frequent index SSRIs were citalopram (30.1%) and sertraline (27.5%), and 52.9% of patients were prescribed a second-step pharmacotherapy during the post-index period. Add-on therapy occurred twice more frequently than switching treatments, with either anxiolytics (40.2%) or antidepressants (37.1%) as the most common classes of add-on pharmacological therapies. Patients who added a second medication or switched therapies had higher annualized medical costs compared with patients who continued their index SSRI or discontinued treatment. CONCLUSIONS: For patients who were initially treated with an SSRI therapy, approximately half were prescribed a second-step treatment. In this comprehensive claims analysis, many of these patients experienced the addition of second medication, rather than switching to a new therapy. Given the type of medications used, it is possible that second-step interventions were targeted toward resolution of residual symptoms; however, this work is limited by the use of claims data without information on dosing or clinical symptoms, side effects, or response. Findings from this study set the expectation that physicians and patients will most likely need to partner for additional interventions in order to achieve remission

The Allocation of a Prize (R)

Consider agents who undertake costly effort to produce stochastic outputs observable by a principal. The principal can award a prize deterministically to the agent with the highest output, or to all of them with probabilities that are proportional to their outputs. We show that, if there is suf cient dipersion in agents ' skills relative to the noise on output, then the proportional prize will on average elicit more output from the agents than the deterministic prize. Indeed, assuming agents know each others ' skills (the complete information case), this result holds when any Nash selection, under the proportional prize, is compared with any individually rational strategy selection under the deterministic prize. When there is incomplete information, the same result obtains but now we must restrict to Nash selections for both prizes. We also compute the optimal scheme — among a natural class of probabilistic schemes — for awarding the prize, namely that which elicits maximal effort from the agents for the least prize. In general the optimal scheme is a monotonic step function which lies "between" the proportional and the deterministic schemes. When the competition is over small fractional increments (a case that commonly arises in the presence of strong contestants whose base levels of production are high), the optimal scheme awards the prize according to the "log of the odds", where the odds are based on the proportional scheme

Methodologies used in cost-effectiveness models for evaluating treatments in major depressive disorder: a systematic review

<p>Abstract</p> <p>Background</p> <p>Decision makers in many jurisdictions use cost-effectiveness estimates as an aid for selecting interventions with an appropriate balance between health benefits and costs. This systematic literature review aims to provide an overview of published cost-effectiveness models in major depressive disorder (MDD) with a focus on the methods employed. Key components of the identified models are discussed and any challenges in developing models are highlighted.</p> <p>Methods</p> <p>A systematic literature search was performed to identify all primary model-based economic evaluations of MDD interventions indexed in MEDLINE, the Cochrane Library, EMBASE, EconLit, and PsycINFO between January 2000 and May 2010.</p> <p>Results</p> <p>A total of 37 studies were included in the review. These studies predominantly evaluated antidepressant medications. The analyses were performed across a broad set of countries. The majority of models were decision-trees; eight were Markov models. Most models had a time horizon of less than 1 year. The majority of analyses took a payer perspective. Clinical input data were obtained from pooled placebo-controlled comparative trials, single head-to-head trials, or meta-analyses. The majority of studies (24 of 37) used treatment success or symptom-free days as main outcomes, 14 studies incorporated health state utilities, and 2 used disability-adjusted life-years. A few models (14 of 37) incorporated probabilities and costs associated with suicide and/or suicide attempts. Two models examined the cost-effectiveness of second-line treatment in patients who had failed to respond to initial therapy. Resource use data used in the models were obtained mostly from expert opinion. All studies, with the exception of one, explored parameter uncertainty.</p> <p>Conclusions</p> <p>The review identified several model input data gaps, including utility values in partial responders, efficacy of second-line treatments, and resource utilisation estimates obtained from relevant, high-quality studies. It highlighted the differences in outcome measures among the trials of MDD interventions, which can lead to difficulty in performing indirect comparisons, and the inconsistencies in definitions of health states used in the clinical trials and those used in utility studies. Clinical outcomes contributed to the uncertainty in cost-effectiveness estimates to a greater degree than costs or utility weights.</p

Preferences related to attention-deficit/hyperactivity disorder and its treatment

Kate Van Brunt1, Louis S Matza1, Peter M Classi2, Joseph A Johnston21Center for Health Outcomes Research at United BioSource Corporation, Bethesda, MD, USA; 2Eli Lilly and Company, Indianapolis, IN, USAObjectives: A growing body of literature has highlighted the importance of considering patient preferences as part of the medical decision-making process. The purpose of the current review was to identify and summarize published research on preferences related to attention-deficit/hyperactivity disorder (ADHD) and its treatment, while suggesting directions for future research.Methods: A literature search identified 15 articles that included a choice-based assessment of preferences related to ADHD.Results: The 15 studies were grouped into four categories based on preference content: preference for a treatment directly experienced by the respondent or the respondent&amp;#39;s child; preference for general treatment approaches; preference for a specific treatment attribute or outcome; and preference for aspects of ADHD-related treatment. Preference assessment methods ranged from global single items to detailed choice-based procedures, with few studies using rigorously developed assessment methods. Respondents included patients with ADHD, clinicians, parents, teachers, and survey respondents from the general population. Factors influencing preference include treatment characteristics, effectiveness for specific symptoms, side effects, and respondent demographics. Minimal research has examined treatment preferences of adults with ADHD.Discussion: Because there is no dominant treatment known to be the first choice for all patients, ADHD is a condition for which individual preferences can play an important role when making treatment decisions for individual patients. Given the potential role of preferences in clinical decision-making, more research is needed to better understand the preferences of patients with ADHD and other individuals who are directly affected by the disorder, such as parents and teachers.Keywords: patient preference, ADHD, parent preference, utilit

Economic burden and comorbidities of attention-deficit/hyperactivity disorder among pediatric patients hospitalized in the United States

<p>Abstract</p> <p>Background</p> <p>This retrospective database analysis used data from the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) to examine common primary diagnoses among children and adolescents hospitalized with a secondary diagnosis of attention- deficit/hyperactivity disorder (ADHD) and assessed the burden of ADHD.</p> <p>Methods</p> <p>Hospitalized children (aged 6-11 years) and adolescents (aged 12-17 years) with a secondary diagnosis of ADHD were identified. The 10 most common primary diagnoses (using the first 3 digits of the ICD-9-CM code) were reported for each age group. Patients with 1 of these conditions were selected to analyze demographics, length of stay (LOS), and costs. Control patients were selected if they had 1 of the 10 primary diagnoses and no secondary ADHD diagnosis. Patient and hospital characteristics were reported by cohort (i.e., patients with ADHD vs. controls), and LOS and costs were reported by primary diagnosis. Multivariable linear regression analyses were undertaken to adjust LOS and costs based on patient and hospital characteristics.</p> <p>Results</p> <p>A total of 126,056 children and 204,176 adolescents were identified as having a secondary diagnosis of ADHD. Among children and adolescents with ADHD, the most common diagnoses tended to be mental health related (i.e., affective psychoses, emotional disturbances, conduct disturbances, depressive disorder, or adjustment reaction). Other common diagnoses included general symptoms, asthma (in children only), and acute appendicitis. Among patients with ADHD, a higher percentage were male, white, and covered by Medicaid. LOS and costs were higher among children with ADHD and a primary diagnosis of affective psychoses (by 0.61 days and $51), adjustment reaction (by 1.71 days and$940), or depressive disorder (by 0.41 days and $124) versus controls. LOS and costs were higher among adolescents with ADHD and a primary diagnosis of affective psychoses (by 1.04 days and$352), depressive disorder (by 0.94 days and $517), conduct disturbances (by 0.86 days and$1,330), emotional disturbances (by 1.45 days and $1,626), adjustment reaction (by 1.25 days and$702), and neurotic disorders (by 1.60 days and $541) versus controls.</p> <p>Conclusion</p> <p>Clinicians and health care decision makers should be aware of the potential impact of ADHD on hospitalized children and adolescents.</p

Patient characteristics, comorbidities, and medication use for children with ADHD with and without a co-occurring reading disorder: A retrospective cohort study

<p>Abstract</p> <p>Background</p> <p>Children and adolescents with attention-deficit/hyperactivity disorder (ADHD) often have a co-occurring reading disorder (RD). The purpose of this research was to assess differences between children with ADHD without RD (ADHD-only) and those with ADHD and co-occurring RD (ADHD+RD).</p> <p>Methods</p> <p>Using data from the U.S. Thomson Reuter Marketscan^®Databases for the years 2005 through 2007, this analysis compared the medical records--including patient demographics, comorbidities, and medication use--of children (age < 18) with ADHD-only to those with ADHD+RD.</p> <p>Results</p> <p>Patients with ADHD+RD were significantly younger, more likely to have received a procedure code associated with formal psychological or non-psychological testing, and more likely to have been diagnosed with comorbid bipolar disorder, conduct disorder, or depression. They were no more likely to have received an antidepressant, anti-manic (bipolar), or antipsychotic, and were significantly less likely to have received a prescription for a stimulant medication.</p> <p>Conclusions</p> <p>Relying on a claims database, there appear to be differences in the patient characteristics, comorbidities, and medication use when comparing children with ADHD-only to those with ADHD+RD.</p

Mapping inequalities in school attendance:The relationship between dimensions of socioeconomic status and forms of school absence

In this article, we investigated whether and to what extent various dimensions of socioeconomic background (parental education, parental class, free school meal registration, housing status, and neighborhood deprivation) predict overall school absences and different reasons for absenteeism (truancy, sickness, family holidays and temporary exclusion) among 4,620 secondary school pupils in Scotland. Students were drawn from a sample of the Scottish Longitudinal Study comprising linked Census data and administrative school records. Using fractional logit models and logistic regressions, we found that all dimensions of socioeconomic background were uniquely linked to overall absences. Multiple measures of socioeconomic background were also associated with truancy, sickness-related absence, and temporary exclusion. Social housing and parental education had the most pervasive associations with school absences across all forms of absenteeism. Our findings highlight the need to consider the multidimensionality of socioeconomic background in policy and research decisions on school absenteeism. A more explicit focus on narrowing the socioeconomic gap in absenteeism is required to close the inequality gap in educational and post-school outcomes

Analisis Pengaruh Panjang Serat Catgut Pada PLA/Hydroxyapatite/Catgut Terhadap Sifat Mekanik, Morfologi, dan Biodegradasi Untuk Aplikasi Bone Plate

Bone plate berbahan baja tahan karat dan titanium merupakan biomaterial paling popular digunakan dalam bedah ortopedi. Keunggulan dari baja tahan karat dan titanium adalah tahan terhadap korosi, biokompatibel, dan sifat mekanik yang sangat baik. Disamping keunggulan itu, ada kekurangan yaitu non-absorbable, dan membutuhkan operasi sekunder. Untuk mengatasi permasalahan tersebut, bahan pengganti tulang komposit yang dapat diserap tubuh menjadi solusi. Bahan bone plate yang digunakan berupa poly-lactic acid(PLA), Hidroksiapatit, dan serat Catgut Chromic 2.0 USP. Alasan memilih poly-lactic acid(PLA) sebagai matriks karena biopolimer yang berhasil meningkatkan bioaktivitas untuk perbaikan tulang, unggul terhadap sifat biokompatibilitas, biodegradability, sifat pemrosesan yang mudah, dan bioabsorbability yang baik. Sedangkan hidroksiapatit sebagai filler karena tidak beracun, bersifat ostekonduktif dan dapat menyatu dengan tulang sehingga meningkatkan proses regenerasi tulang. Sedangkan Catgut Chromic karena untuk meningkatkan performa dari sifat fully absorbable dari poly-lactic acid(PLA) karena catgut memiliki elastisitas dan tegangan tarik yang tinggi. Tujuan dari penelitian ini adalah untuk mengetahui pengaruh panjang serat Catgut/PLA/Hidroksiapatit terhadap sifat mekanik, morfologi, dan biodegradasi untuk aplikasi bone plate. Dengan dilakukan penambahan variasi panjang serat pada rasio matriks:filler sebesar 80:20 dapat memberikan sifat mekanik yang baik, morfologi, dan biodegradasinya untuk melihat kesesuaiannya untuk aplikasi pada tulang yang mengalami fraktur. Rasio filler Hidroksiapatit:Catgut adalah 5:15. Catgut chromic dengan variasi panjang 2, 4, 6, dan 8 mm. Analisis pengujian pada penelitian ini menggunakan uji Fourier Transform Infrared(FTIR), uji SEM, Uji Tekan, dan Uji Weight Loss. Dari hasil penelitian tidak menunjukkan perubahan signifikan terhadap molecular structure, morfologi, dan mekanik. Bahkan material ini belum bisa dikategorikan sebagai kandidat biokomposit degradable sebagai implan karena laju degradasi yang cukup kuat dan tidak bisa di kontrol. Meskipun pada.variasi panjang serat 2 mm memiliki compressive strength 10,40 MPa serta degradation time selama 31.8 bulan yang mendekati kriteria pengganti tulang mandibula. ============================================================================================================================== Stainless steel and titanium bone plates are the most popular biomaterials used in orthopedic surgery. The advantages of stainless steel and titanium are corrosion resistance, biocompatible, and excellent mechanical properties. Apart from these advantages, there are disadvantages, namely non-absorbable, and requiring secondary surgery. To overcome this problems, composite bone substitute materials that can be absorbed by the body are the solution. The bone plate materials used are poly-lactic acid (PLA), hydroxyapatite, and Catgut Chromic 2.0 USP fiber. The reason for choosing superior poly-lactic acid (PLA) as a matrix is because the biopolymer has succeeded in increasing bioactivity for bone repair, for its biocompatibility, biodegradability, easy processing properties, and good bioabsorbability. Meanwhile, hydroxyapatite is used as a filler because it is non-toxic, is osteoconductive and can blend with bone thereby increasing the process of bone regeneration. Whereas Chromic Catgut is due to improve performance from the fully absorbable nature of poly-lactic acid (PLA) because catgut has high elasticity and tensile stress. The purpose of this study was to determine the effect of Catgut/PLA/Hydroxyapatite fiber length on mechanical properties, morphology, and biodegradation for bone plate applications. By adding fiber length variations at a matrix:filler ratio of 80:5:15 it can provide good mechanical properties, morphology, and biodegradability to see its suitability for application to fractured bones. The filler ratio of Hydroxyapatite:Catgut is 5:15. Chromic catgut with length variations of 2, 4, 6 and 8 mm. Test analysis in this study used the Fourier Transform Infrared (FTIR) test, SEM test, compression test, and weight loss test. The results showed that the addition of fiber length at a ratio of 80:5:15 affected the mechanical properties, morphology and rate of degradation. Variation of fiber length of 2 mm is a specimen variation that is close to bone extraction, with a compressive strength of 10.40 MPa and a degradation time of 31.8 months