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The American Journal of Managed Care December 2010
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Comparison of Healthcare Utilization Among Patients Treated With Alcoholism Medications

Tami L. Mark, PhD; Leslie B. Montejano, MA; Henry R. Kranzler, MD; Mady Chalk, PhD; and David R. Gastfriend, MD

Treatment of alcohol dependence with medications offered advantages in reduced healthcare utilization and costs compared with usual treatment without medications.

Inverse probability of treatment weighting (IPTW) was used to adjust for differences in the characteristics of the 4 alcoholism medication groups being compared. To estimate the IPTW, a multinomial logit model was used in which the dependent variable was the treatment group. The independent variables were the demographic, geographic region, and clinical factors already listed. The IPTW was calculated as the inverse of the predicted conditional probability of being in the particular treatment group. The IPTW was normalized by its mean and was applied to the data to generate a reweighted pseudopopulation. Adjusted Wald test was performed to test for the difference in weighted continuous characteristics across the treatment cohorts. Rao-Scott χ2 test was conducted to test for the difference in the distribution of discrete outcomes across groups. STATA 9.2 MP (StataCorp LP, College Station, Texas) was used in the analyses.

RESULTS

Comparison of Groups Receiving Any vs No Alcoholism Medication

A total of 27,135 eligible adults were identified in the commercial database. Table 1 gives characteristics of 2977 matched patients in the group receiving any alcoholism medication and the group receiving no alcoholism medication. Approximately 60 percent of patients were male, with a mean age of 45 years. During the preperiod, 19% had a drug abuse or dependence diagnosis, 8% to 9% had a bipolar disorder diagnosis, 37% to 38% had a depression diagnosis, and 12% to 13% had an anxiety disorder diagnosis. Preperiod alcoholism-related healthcare utilization was high, with 22% to 24% of patients having a detoxification admission, 19% having a hospital admission with a principal diagnosis of alcohol dependence, and 21% having an alcoholism-related ED visit in the 6 months before medication initiation.

Among the prematched sample, patients receiving any alcoholism medication were slightly older, more likely to be female, and more likely to live in areas with more college graduates, a higher median household income, and less poverty (eAppendix B). Patients prescribed any alcoholism medication were more likely to have a preperiod diagnosis of depression, anxiety disorder, or bipolar disorder. In the preperiod, the group receiving any alcoholism medication had higher percentages of patients with a detoxification admission, an alcoholism-related admission, or an alcoholism-related ED visit.

Table 2 gives utilization outcomes and postperiod psychiatric comorbidities in the 2 groups after propensity score matching. The group receiving no alcoholism medication had a higher percentage of patients with a detoxification admission after the index date (13% vs 9%, P <.001) and more inpatient detoxification days per 1000 patients (1163 vs 706, P <.001) than the group receiving any alcoholism medication. Inpatient detoxification days translated to costs of $1,890,822 per 1000 patients treated  with any alcoholism medication and $3,113,389 per 1000 patients treated with no alcoholism medication.

The group receiving no alcoholism medication also had a higher percentage of patients with an inpatient admission for a  principal diagnosis of alcohol dependence (11% vs 7%, P <.001) and more alcoholism-related inpatient days (1086 vs 650, P <.001) (Table 2). Total charges for alcoholism-related inpatient days were estimated at $1,818,292 per 1000 patients treated with any alcoholism medication and $3,037,374 per 1000 patients treated with no alcoholism medication. There was no difference in the non-AUD inpatient admission rates. Finally, compared with groups receiving any alcoholism medication, the group receiving no alcoholism medication had a higher percentage of patients with alcoholism-related ED visits (10% vs 8%, P = .007) and had more alcoholism-related ED visits per 1000 patients (171 vs 127, P = .005).\

The pattern of greater healthcare utilization among the group receiving no alcoholism medication was also true for outpatient visits. Compared with the group receiving any alcoholism medication, the group receiving no alcoholism medication was more likely to have an outpatient visit with a substance abuse diagnosis (95% vs 63%, P <.001) and had more substance abuse visits (7.7 vs 5.4, P <.001) (Table 2). The percentages of patients with schizophrenia, bipolar disorder, or anxiety disorder during the  postperiod did not differ between the 2 study groups. The group receiving any alcoholism medication had a higher percentage of patients with a depression diagnosis than the group receiving no alcoholism medication (37% vs 33%, P <.001).

Comparisons Among 4 Alcoholism Medication Groups

Table 3 gives the characteristics of the 4 alcoholism medication groups after propensity score weighting. The characteristics were balanced across the groups. Differences among the 4 groups before weighting are given in eAppendix C.

Table 4 gives differences in outcomes after propensity score weighting across the 4 alcoholism medication groups. Patients receiving naltrexone XR had more time with filled prescriptions than patients receiving acamprosate (41% vs 34% of days covered in a 6-month period, P = .001).

Differences in percentages with detoxification admissions among the 4 alcoholism medication groups did not reach statistical significance at conventional levels. On average, the naltrexone XR group also had fewer inpatient detoxification days than the oral naltrexone group (P = .003) and the acamprosate group (P <.001) (Table 4). Fewer inpatient days translated to significantly lower inpatient costs per 1000 patients treated. Differences in percentages of patients with an alcoholism-related hospital admission did not reach statistical significance at conventional levels. On average, the naltrexone XR group had fewer alcoholism-related inpatient days than the disulfiram (P = .004) and acamprosate (P < .001) groups, which translated into lower inpatient costs per 1000 patients ($382,460 for naltrexone XR, $1,040,749 for disulfiram, and $1,214,881 for acamprosate).

A significantly higher percentage of patients receiving naltrexone XR (69%) had an outpatient visit for substance abuse treatment than patients receiving oral agents (38% for oralnaltrexone, 40% for disulfiram, and 40% for acamprosate; P <.001) (Table 4). Similar results were found for the category of combined substance abuse and mental health visits. The difference in the mean number of outpatient substance abuse or mental health visits did not reach statistical significance.

There were no statistically significant differences among the 4 alcoholism medication groups in the percentages of patients diagnosed as having anxiety disorder, schizophrenia, bipolar disorder, depression, or any psychiatric diagnosis. Similarly, there were no significant differences in the numbers of psychiatric diagnoses.

DISCUSION

In this retrospective claims analysis of matched commercially insured individuals, patients who received any alcoholism medication had fewer detoxification admissions, alcoholism-related inpatient care, alcoholism-related ED visits, and substance abuse outpatient visits in the 6 months following medication initiation than patients who received no alcoholism medication. Among the 4 groups of alcoholism medication users, naltrexone XR users were found to utilize more medication than acamprosate users. Furthermore, naltrexone XR use was associated with fewer inpatient detoxification days than oral naltrexone or acamprosate use and was associated with fewer inpatient days for a principal diagnosis of alcohol dependence than disulfiram or acamprosate use.

The data also reveal an inverse utilization pattern among 4 groups of alcoholism medication users relative to inpatient vs outpatient services. The naltrexone XR group had significantly less inpatient utilization, but significantly more patients in the naltrexone XR group had at least 1 outpatient substance abuse visit compared with patients receiving oral alcoholism agents. Higher outpatient services utilization may be an indication of better engagement, which may have contributed to lower inpatient services utilization. Notably, patients who used no alcoholism medication had greater outpatient services utilization than patients who used any alcoholism medication; however, there was no corresponding decline in inpatient services utilization. This finding suggests that engagement in outpatient treatment should be associated with better utilization outcomes, but perhaps only if that treatment is comprehensive in addressing both psychosocial and biologic aspects of alcohol dependence. Indeed, this conclusion is consistent with guidelines published by the National Institute on Alcohol Abuse and Alcoholism  stating that psychosocial approaches and medication use are complementary and “share the same goals while addressing different aspects of alcohol dependence: neurobiological, psychological, and social.”4

This study must be understood in light of its limitations. First, the observed associations may not be causal. Without randomization, there may be unmeasured confounding factors such as differential motivation and illness severity that underlie the observed differences in utilization. This risk may have been mitigated by baseline propensity score matching and weighting for relevant demographic, baseline clinical, and utilization variables. Furthermore, the results derive from a range of practices, settings, and provider types in community settings, which enhances external validity. Second, the study examined only commercial claims; therefore, the results may not generalize to other populations such as Medicaid beneficiaries. However, in parallel analyses among a limited number of Medicaid patients, results were consistent with the findings presented herein,  providing further support for their external validity. Third, study outcomes were utilization measures that, while important, did not include alcohol consumption patterns. However, intensive healthcare services utilization (eg, the number of subsequent inpatient detoxification days) may be a reasonable proxy for drinking behavior. Fourth, because of the recent introduction of naltrexone XR, the sample of 295 users of naltrexone XR was small, which may have limited the statistical power, and should be expanded in future analyses. Fifth, the inclusion criteria required continuous enrollment for 1 year, and individuals with continuous enrollment may have differed from those without continuous enrollment (eg, because of job loss) in severity, adherence, and outcomes. Sixth, comparisons across products did not attempt to control for the extent to which patients filled an “adequate” course of the medication, as the study intent was to focus on the effect of outcomes of the “usual” treatment patterns; however, this would be a useful follow-up study. Seventh, adherence was measured according to filled paid claims,  and while naltrexone XR is administered by a health professional and persists over 1 month, patients receiving oral agents may not have taken them as prescribed.

 
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