Anderson, JR

Dodd, MA

Gupchup, GV

Shah, BM

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242 Abstracts
PMH39
BASELINE COMPARISON OF PATIENTS WITH
SCHIZOPHRENIA USING OLANZAPINE,
RISPERIDONE AND TYPICAL ANTIPSYCHOTICS
IN CALIFORNIA MEDICAID PROGRAM
Mulani P1, Gibson PJ2, McCombs J1
1University of Southern California, Los Angeles, CA, USA;
2Eli Lilly and Company, Indianapolis, IN, USA
OBJECTIVES: To assess the demographic, diagnostic and
cost differences at baseline among Medi-Cal patients with
schizophrenia using olanzapine, risperidone, or typical
antipsychotics.
METHODS: Ambulatory patients with schizophrenia,
who initiated antipsychotic drug therapy on olanzapine,
risperidone or typical antipsychotics, after a break of
more than 30 days from their previous antipsychotics,
were identiﬁed. Of these, patients with data available 
for at least six months prior to and 12 months following
the initiation date of these medications during March
1998-August 2001 were included. Baseline demographic,
diagnostic and cost variables were compared among these
three groups.
RESULTS: The ﬁnal sample comprised of 8022, 4909,
4867, olanzapine, risperidone and typical (O;R;T) patient
episodes respectively. The episodes for which typical
antipsychotics were initiated had the highest total costs
in the six months prior to drug initiation (mean (SE): O
= $4,224 (11,219); R = $4,339 (11,217); T = $5,403
(14,786); p < 0.0001). Patients initiated on olanzapine
had been more treatment resistant, as indicated by 
differences in use of more than two antipsychotics 
previously (O = 42.97%; R = 37.10%; T = 40.13%; p <
0.0001), prior clozapine use (O = 1.11%; R = 0.71%; T
= 1.07%; p < 0.07), prior use of depot antipsychotics (O
= 3.96%; R = 2.55%; T = 2.16%; p < 0.0001) and dose
of prior antipsychotic (mean chlorpromazine equivalents
(SE): O = 228.1 (662); R = 161.2 (494); T = 130.5 (474);
p < 0.0001). Patients with episodes treated with typical
antipsychotics had a higher proportion of comorbidities
including muskoskeletal system disorders, anxiety 
disorders, and circulatory system diseases. Olanzapine
had relatively few older and younger initiators (age <20
or age >65), compared to risperidone (O = 13.67%; R =
24.69%; T = 18.90%; p < 0.0001).
CONCLUSIONS: Signiﬁcant cost, demographic and
diagnostic differences at baseline existed among 
patients initiating risperidone, olanzapine, and typical
antipsychotics. Speciﬁcally, olanzapine was used for 
more treatment resistant patients with schizophrenia.
Non-randomized studies comparing treatment and cost
outcomes for these medications need to account for the
differences.
PMH40
THE IMPACT OF SECOND-GENERATION
ANTIPSYCHOTICS IN BIPOLAR PATIENTS IN
THE CALIFORNIA MEDICAID PROGRAM
Sterling KL, McCombs J
University of Southern California, Los Angeles, CA, USA
The California Medicaid program added second-
generation antipsychotic medications to its formulary in
October 1997.
OBJECTIVE: To investigate the impact of the formulary
expansion on antipsychotic drug selection. STUDY 
POPULATION: 52,389 antipsychotic-initiated patient
treatment episodes were separated into three groups, new:
no previous drug therapy history, restarters: restarted
drug therapy while not on active therapy, and aug-
menters: started a new drug while on active therapy.
METHODS: Time trend analysis was performed to deter-
mine the changes in the number of overall treatment
episodes initiated with an antipsychotic within each of the
three subgroups. Multivariate logistic regression models
of the selection of drug therapy were estimated separately
for the three subgroups. Independent variables included
patient demographics, prior use of services, and diagnos-
tic proﬁle.
RESULTS: The formulary expansion immediately but
temporarily increased the total number of restarter and
augmenter episodes, with a less apparent increase in the
total number of new episodes (access effect). Once at
steady state level within all three subgroups, second-
generation antipsychotics accounted for approximately
two-thirds of antipsychotic treated episodes. The formu-
lary expansion changed the clinical parameters that inﬂu-
enced the selection of antipsychotic therapy. Factors that
correlate with the use of second-generation antipsychotics
in the pre-period appear to have been attenuated by the
formulary expansion. The formulary expansion increased
access to the second-generation antipsychotics for minori-
ties, HIV+ persons, persons with history of alcohol abuse,
individuals in the long term care setting, and in urban
counties. Access to the second-generation antipsychotics
was less dependent on psychiatric hospital visits, visits to
psychiatrists, and having a previous diagnosis of schizo-
phrenia or depression in the medical history.
CONCLUSION: Future research should explore the
impact of the formulary expansion on the cost and
achievement of drug therapy outcomes of treating
patients with bipolar disorder, with consideration of
potential treatment selection bias.
PMH41
REDUCTION IN LONG-ACTING
BENZODIAZEPINE THERAPY AND ASSOCIATED
FRACTURES IN ELDERLY MEDICAID PATIENTS
Dodd MA, Shah BM, Gupchup GV,Anderson JR
The University of New Mexico, Albuquerque, NM, USA
OBJECTIVES: The objectives of this study were to
encourage the replacement of long-acting benzodi-
243Abstracts
azepines with appropriate doses of short-acting or 
intermediate-acting benzodiazepines or zolpidem and to
reduce the number of potentially associated fractures in
a population of elderly New Mexico Medicaid recipients.
METHODS: The New Mexico Medicaid fee-for-service
prescription claims database was reviewed to identify
patients 65 years and older with 2 or more claims for
long-acting benzodiazepines between October 1 and
December 31, 2000. Educational letters, response forms
and prescription proﬁles were mailed to the prescribers,
pharmacies and consultant pharmacists of these patients.
The database was reviewed from March 1 to May 31,
2001 to assess changes in prescribing patterns. Based on
a previous epidemiologic study and Medicare reimburse-
ment for hip fractures, a cost analysis was performed.
RESULTS: A total of 182 patients were included in the
intervention. Educational materials were mailed to 147
prescribers, 94 pharmacies and 12 consultant pharmacists
for these patients on January 31, 2001. Sixty-four pre-
scribers (44%), 30 pharmacies (32%) and 3 consultant
pharmacists (25%) responded for 103 (57%) patients.
Overall, 16% (n = 29) of the remaining eligible patients
were no longer receiving long-acting benzodiazepine
therapy in the 3-month post-intervention period. Based
on a previous epidemiologic study, 3 fractures were
potentially prevented resulting in a cost savings of
$24,256 to Medicaid/Medicare over a period of nine
years.
CONCLUSIONS: A change in patients’ therapy and 
a potential cost savings to the Medicaid/Medicare 
programs was observed after the intervention.
PMH42
FROM CONVENTIONAL ANTIPSYCHOTICS TO
ATYPICALS AND BACK: DYNAMIC PROCESSES
IN THE DIFFUSION OF NEW MEDICATIONS
Leslie DL, Rosenheck R
Yale University School of Medicine, West Haven, CT, USA
OBJECTIVES: Between 1994 and 1999, the Food and
Drug Administration approved three new antipsychotic
medications for the treatment of schizophrenia. This
study tracks antipsychotic prescription patterns in the
Department of Veterans Affairs to determine how these
new drugs have diffused in a national healthcare system.
METHODS: Pharmacy claims data were collected for all
patients with a diagnosis of schizophrenia in the Depart-
ment of Veterans Affairs (VA). Patients who were stable
on a pharmacotherapy regimen were followed over ﬁscal
year 2000 to determine how often patients switch to
another drug, how much time elapses before they switch,
the drug to which they switch, and whether they subse-
quently switch back.
RESULTS: Of the 21,873 patients with schizophrenia
who were stable for three months on their medication,
5,426 (24.8%) switched medications during the next 
year. However, half of these patients (2,708 or 49.9%)
switched back to their original therapy, usually within 30
days. Patients stable on clozapine were the least likely 
to switch (17.8%), while patients stable on quetiapine
were the most likely to switch (37.4%). When patients
switched medications, they were most likely to switch 
to olanzapine (35.1%) and least likely to switch to 
clozapine (0.7%) or quetiapine (14.0%).
CONCLUSIONS: Pharmacotherapy for schizophrenia is
a dynamic process. One quarter of patients who are stable
on an antipsychotic drug regimen change their medica-
tion within one year. Quetiapine was the least favored of
the newer drugs. Our results suggest that it is important
that all of these medications are included on formularies.
PMH43
THE IMPACT OF A FORMULARY EXPANSION TO
INCLUDE ADDITION OF SECOND-GENERATION
ANTIPSYCHOTIC MEDICATIONS ON THE
TREATMENT OF PATIENTS WITH
SCHIZOPHRENIA
Mulani P, McCombs J
University of Southern California, Los Angeles, CA, USA
The California Medicaid program added olanzapine 
and risperidone to its formulary in October 1997. This
resulted in an immediate but temporary increase in the
total number of patients initiating episodes of therapy
(access effect) and the substitution of second-generation
antipsychotics for older drugs.
OBJECTIVE: Model how the formulary expansion
altered drug selection decisions and then use these models
to match patients for the purpose of estimating the 
cost impact of the formulary expansion. STUDY 
POPULATION: 19,221 olanzapine, 25,252 risperidone
and 1,22,547 patient episodes using traditional drugs
were classiﬁed into three groups: patients with no previ-
ous antipsychotic use (new), patients re-starting drug
therapy and patients switching between antipsychotic
medications without a break in therapy.
METHODS: Multinomial logistic regression models of
the drug selection process were estimated then used to 
calculate propensity scores for olanzapine and risperidone
use using the post-expansion clinical decision criteria.
Health care costs were then compared within quintile bins
for these 3 treatment episode types.
RESULTS: The formulary expansion signiﬁcantly
improved access for minorities, women and urban 
residents. However, the propensity-score matching of
olanzapine and risperidone patients with patients using
traditional antipsychotics (quintile bins) did not result in
highly congruent patient populations. Patients using 
traditional antipsychotics consistently exhibited higher
levels of health care use prior to the start of the treatment
episode. Simple within-bin comparisons of health care
costs found lower costs for olanzapine and risperidone
patients. Differences based on multivariate cost models
within each quintile bin greatly reduced these differences.
However, continuous days of therapy were consistently
higher for risperidone and olanzapine patients.


PMH41 REDUCTION IN LONG-ACTING BENZODIAZEPINE THERAPY AND ASSOCIATED FRACTURES IN ELDERLY MEDICAID PATIENTS 

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PMH41 REDUCTION IN LONG-ACTING BENZODIAZEPINE THERAPY AND ASSOCIATED FRACTURES IN ELDERLY MEDICAID PATIENTS

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