CHARACTERISTICS & OUTCOMES OF INSURED
PATIENTS TREATED WITH EXTENDEDRELEASE NALTREXONE (XR-NTX) OR ORAL
ALCOHOL DEPENDENCE MEDICATIONS
TAMI L. MARK, PHD, MBA
ACADEMY HEALTH ANNUAL MEETING
JUNE 29, 2010
AUTHORS
Tami L
L. Mark PhD
PhD, MBA1
Leslie Montejano1
Henry R
R. Kranzler
Kranzler, MD2
David R. Gastfriend, MD3
Mady Chalk, PhD4
1 Thomson
2
Reuters,
Reuters Inc
Inc.
University of Connecticut School of Medicine
3 Alkermes,
Inc.
4 Treatment
Research Institute, Inc.
2
FINANCIAL DISCLOSURE
This study was funded through a contract from
Alkermes to Thomson Reuters.
3
OBJECTIVES
• Compare the association between use of any
alcoholism medication and no medication on
utilization outcomes
• Compare the differences among the four
alcoholism medications in terms of adherence and
utilization outcomes
4
ALCOHOLISM MEDICATIONS
Product
Introduced in
US. Market
Disulfiram (Antabuse®)
1940s
Naltrexone (ReVia®)
1995
Acamprosate (Campral®)
2004
Extended-Release
E
t d dR l
N lt
Naltrexone
(Vivitrol®)
2006
5
PRESCRIPTIONS, 2007
XR-Naltrexone,
XR
Naltrexone,
15,000
Disulfiram,
179,000
Acamprosate,
306 000
306,000
Oral
Naltrexone,
221,000
Total Alcoholism Rx Prescriptions: 720,000
Total Antidepressant prescriptions: 226 million
T t l persons with
Total
ith alcohol
l h l dependence:
d
d
7.9
7 9 million
illi
6
METHODS
7
DATA SOURCE
• Thomson Reuters’
Reuters MarketScan® commercial
claims
• E
Enrollment
ll
t iinformation
f
ti and
d medical
di l and
d
prescription drug claims from large self-insured
employers and regional health plans
plans.
• A parallel analyses with MarketScan Multi-State
Medicaid Database
Database, however
however, the sample size of
XR-NTX was small in this database
8
SAMPLE SELECTION
MarketScan
Jan 2006 – Dec 2008
XR – NTX
NTX
Acamprosate
Disulfiram
(295)
(2,064)
(5,068)
(2,076)
Alcohol Dependence Dx
No Rx
(17,632)
Alcohol Use Disorder
In the Pre-period
Any Rx
(4,047)
Alcohol Use Disorder
In Pre-period
No Rx
(4,730)
9
INCLUSION CRITERIA
• 6 months of continuous enrollment pre
pre-index
index
• 6 months of continuous enrollment post-index
• 18 years or older
• Alcoholism medication claim for medication group
• Alcohol use disorder diagnosis in pre-period (only
for Any Rx vs.
vs no Rx comparison)
10
OUTCOME MEASURES: PERSISTENCE
• XR-NTX:
XR NTX: Unique dates of service x 30
30.5
5 days
• Oral Agents: days supplied summed
• Expressed as a percent of 182.5 days
11
OUTCOME MEASURES: INPATIENT
UTILIZATION
• Measured 6 months post index:
• Percent with inpatient admission:
– detoxification admission (ICD
(ICD-9-CM
9 CM Proc for
Detoxification)
– alcohol-related admission (ICD-9-CM Alcohol Principal Dx)
– admission
d i i ffor other
th reasons
• Total inpatient days:
– iinpatient
ti t d
detoxification
t ifi ti d
days
– alcohol-related inpatient days
– all other inpatient
p
days
y
12
OUTCOME MEASURES: VISITS
• Alcohol-related
Alcohol related ED visit
• Visit with primary MHSA Dx
• Visit with primary SA Dx
13
OUTCOME MEASURES: CHARGES
• Charge per day
• For detoxification hospitalization
• For alcohol hospitalization
• Based on HCUP
HCUP-NIS
NIS data for 2007
14
PROPENSITY SCORE MATCHING OR
WEIGHTING
• Demographics: age,
age gender
gender, region
region, employee type
• Neighborhood characteristics: household income,
poverty,
p
y African American, College
g Graduate
• Clinical
–
–
–
–
Drug abuse Dx
% with psychiatric Dxs
Charlson-Deyo Comorbidity index
Chronic Disease Score
• Pre-Period Utilization
– % with detoxification admission
– % with alcohol-related admission
– % with alcohol-related ED visit
• Pre
Pre-Period
Period Copayments
15
RESULTS
NO
O RX VS.
S ANY RX
16
UNADJUSTED SAMPLE DESCRIPTION
Category
Male
Age Group
18-34
35-44
45-54
55 64
55-64
Median household income
Below poverty level
African American
College graduate
Any Alcohol
Medication
59 8%
59.8%
15.0%
27.3%
37.7%
20 0%
20.0%
$51,314
8.9%
9.3%
27.5%
No Alcohol
Medication
66 8%
66.8%
21.0%
22.4%
32.9%
23 7%
23.7%
$49,976
6.9%
16.4%
14.7%
17
UNADJUSTED SAMPLE DESCRIPTION
Pre-Period Utilization
50.0%
45.0%
40 0%
40.0%
35.0%
30.0%
25 0%
25.0%
20.0%
15.0%
10 0%
10.0%
5.0%
0.0%
Detoxification
Admission
Alcohol-Related
Alcohol
Related
Non Alcohol
Non-Alcohol
Alcohol Related
Alcohol-Related
Admission
related Admission
ED Visit
Any Alcohol Medication
Psychiatrist Visit
No Alcohol Medication
18
PERCENT WITH HOSPITAL EVENTS
(DURING 6 MONTHS POST INDEX)
16.0%
%
14.0%
***
13.4%
***
11 2%
11.2%
12 0%
12.0%
11.4%11.6%
**
10.3%
10.0%
8.7%
8 0%
8.0%
8.3%
6.8%
6.0%
4 0%
4.0%
2.0%
0.0%
Detoxification
Admission
Alcohol-Related
Admission
Alcohol Rx
Non-Alcohol
Admission
No Alcohol Rx
Emergency Room
Visit
*** P < 0.01
** P < 0.05
19
INPATIENT DAYS PER 1,000 PATIENTS
1,400
***
1,163
Days per 1,0
000 Patients
s
1,200
***
1,086
967
1,000
862
800
706
650
600
400
200
0
Detoxification
Alcohol-Related Inpatient
Other Inpatient
*** P < 0.01
Alcohol Rx
No Alcohol Rx
20
PERCENT WITH SUBSTANCE ABUSE OR
MENTAL HEALTH VISIT
120.0%
***
***
100.0%
97.3%
94.9%
80.8%
80.0%
62.8%
60.0%
40.0%
20.0%
0.0%
SA Visit
MHSA Visit
Alcohol Rx
*** P < 0.01
No Alcohol Rx
21
AVERAGE NUMBER OF VISITS
12
***
***
10
9.0
7.7
8
6
10.5
5.4
4
2
0
SA Visit
MHSA Visit
*** P < 0.01
Alcohol Rx
No Alcohol Rx
22
RESULTS: COMPARISON
RESULTS
OF ALCOHOL
MEDICATIONS TO
XR NALTREXONE
XR-NALTREXONE
(VIVITROL)
23
UNADJUSTED SAMPLE COMPARISON
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Detoxification
Admission
Alcohol-Related
Admission
XR-naltrexone
Non-Alcohol
related
Admission
Oral naltrexone
Alcohol-Related
ED Visit
Disulfram
Psychiatrist
y
Visit
Acamprosate
24
Percent of Day
ys Covered
d
PERSISTENCE: PERCENT OF TIME
OVER 6 MONTHS WITH MEDICATION
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
41%
37%
37%
***
34%
XR-naltrexone
(n=295)
Oral naltrexone
(n=2,064)
Disulfiram
(n = 2,076)
Acamprosate
(n = 5,068)
***P < 0.001
25
PERCENT WITH DETOXIFICATION
ADMISSION (COMPARED TO XR-NTX)
10.0%
9.0%
8.0%
*
7.0%
6.5%
6.0%
5.0%
5.7%
5.8%
Oral naltrexone
(n=2,064)
Disulf iram
(n=2,076)
4.1%
4.0%
3.0%
2.0%
1.0%
0.0%
XR-naltrexone
(n=295)
Acamprosate
(n=5,068)
* P< 0.1
** P< 0.05
***P < 0.01
26
PERCENT WITH PRINCIPAL ALCOHOL
ADMISSION (COMPARED TO XR-NTX)
5.0%
5
0%
*
4.4%
4.5%
**
4.5%
4.0%
3.5%
3.1%
3.0%
2 5%
2.5%
2 3%
2.3%
2.0%
1.5%
1.0%
0.5%
0.0%
XR-naltrexone
(n=295)
Oral naltrexone
(n=2,064)
Disulfiram
(n=2,076)
Acamprosate
(n=5,068)
* P< 0.1
** P< 0.05
***P < 0.01
27
DETOXIFICATION DAYS PER 1,000
,
PATIENTS (COMPARED TO XR-NTX)
600
***
***
Days per 1,000
0 patients
500
*
400
300
200
100
0
XR-naltrexone
(n=295)
oral naltrexone
(n=2,064)
disulfiram ((n =
2,076)
acamprosate
p
((n =
5,068)
* P< 0.1
** P< 0.05
***P < 0.01
28
PRINCIPAL ALCOHOL DX INPATIENT DAYS
PER 1,000 PATIENTS (COMPARED TO XR-NTX)
600
Days per 1,0
D
000 patients
s
500
***
***
400
300
200
100
0
XR-naltrexone
(n=295)
oral naltrexone
(n=2,064)
disulfiram
(n = 2,076)
acamprosate
(n = 5,068)
* P< 0.1
** P< 0.05
***P < 0.01
29
EMERGENCY DEPARTMENT,, SUD AND
MENTAL HEALTH & SUD VISITS
90 0%
90.0%
80.0%
***
70.0%
***
***
60.0%
50.0%
***
40.0%
***
***
30.0%
***
20 0%
20.0%
10.0%
0.0%
XR-naltrexone
(n=295)
Oral naltrexone
(n=2,064)
Emergency Department Visits
Disulfiram (n =
2,076)
SA Visit
Acamprosate (n =
5,068)
MHSA Visit
***P < 0.01
30
CHARGES FOR DETOXIFICATION DAYS
PER 1,000
,
PATIENTS (COMPARED
(
TO XRNTX)
***
$1 600 000
$1,600,000
***
$1,400,000
$1 200 000
$1,200,000
*
$1,000,000
$800,000
$
,
$600,000
$400,000
$200,000
$0
XR-NALTREXONE
ORAL
NALTREXONE
DISULFIRAM
ACAMPROSATE
* P< 0.1
** P< 0.05
***P < 0.01
31
CHARGES FOR PRINCIPAL ALCOHOL DX
INPATIENT DAYS PER 1,000
,
PATIENTS
(COMPARED TO XR-NTX)
$1 400 000
$1,400,000
***
$1,200,000
***
$1,000,000
$800,000
$600,000
$400,000
$200,000
$0
XR-NALTREXONE
ORAL
NALTREXONE
DISULFIRAM
ACAMPROSATE
* P< 0.1
** P< 0.05
***P < 0.01
32
LIMITATIONS & STRENGTHS
• May be unmeasured differences between
populations (e.g., motivation to quit)
• Only focus is on utilization outcomes,
outcomes not other
domains
• Real-world effectiveness analysis across insurers
• Largest health econ analysis of XR-NTX
XR NTX to date
• First study to analyze all Alc Dep Rxs and No Rx
• Severity
S
it off illness
ill
bi
bias lik
likely
l tto work
k against
i t XR
XR-NT
NT
33
CONCLUSIONS
• Alcoholism medications are associated with
significantly and substantially lower detoxification
and hospitalization
p
utilization rates relative to
similar patients who received no medication
34
CONCLUSIONS CONTINUED
• XR
XR-NTX
NTX shows significant & substantial
advantages in reduced detoxification and
hospitalization
p
days
y over oral alcoholism
medications
• XR
XR-NTX
NTX shows
h
a pattern
tt
off ffewer d
days off iintensive
t
i
(i.e., inpatient) services with increased outpatient
service utilization
35
FUTURE WORK
• Findings need to be replicated with larger samples
samples,
in populations with different types of insurance (e.g.
Medicaid)) and in p
pragmatic
g
clinical trials
36
THANK YOU!!
• Tami.Mark@Thomsonreuters.com
• (301) 214 - 2211
37