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The American Journal of Managed Care December 2018
Feasibility of Expanded Emergency Department Screening for Behavioral Health Problems
Mamata Kene, MD, MPH; Christopher Miller Rosales, MS; Sabrina Wood, MS; Adina S. Rauchwerger, MPH; David R. Vinson, MD; and Stacy A. Sterling, DrPH, MSW
From the Editorial Board: Jonas de Souza, MD, MBA
Jonas de Souza, MD, MBA
Risk Adjusting Medicare Advantage Star Ratings for Socioeconomic Status
Margaret E. O’Kane, MHA, President, National Committee for Quality Assurance
Reducing Disparities Requires Multiple Strategies
Melony E. Sorbero, PhD, MS, MPH; Susan M. Paddock, PhD; and Cheryl L. Damberg, PhD
Cost Variation and Savings Opportunities in the Oncology Care Model
James Baumgardner, PhD; Ahva Shahabi, PhD; Christopher Zacker, RPh, PhD; and Darius Lakdawalla, PhD
Patient Attribution: Why the Method Matters
Rozalina G. McCoy, MD, MS; Kari S. Bunkers, MD; Priya Ramar, MPH; Sarah K. Meier, PhD; Lorelle L. Benetti, BA; Robert E. Nesse, MD; and James M. Naessens, ScD, MPH
Patient Experience During a Large Primary Care Practice Transformation Initiative
Kaylyn E. Swankoski, MA; Deborah N. Peikes, PhD, MPA; Nikkilyn Morrison, MPPA; John J. Holland, BS; Nancy Duda, PhD; Nancy A. Clusen, MS; Timothy J. Day, MSPH; and Randall S. Brown, PhD
Relationships Between Provider-Led Health Plans and Quality, Utilization, and Satisfaction
Natasha Parekh, MD, MS; Inmaculada Hernandez, PharmD, PhD; Thomas R. Radomski, MD, MS; and William H. Shrank, MD, MSHS
Primary Care Burnout and Populist Discontent
James O. Breen, MD
Currently Reading
Adalimumab Persistence for Inflammatory Bowel Disease in Veteran and Insured Cohorts
Shail M. Govani, MD, MSc; Rachel Lipson, MSc; Mohamed Noureldin, MBBS, MSc; Wyndy Wiitala, PhD; Peter D.R. Higgins, MD, PhD, MSc; Sameer D. Saini, MD, MSc; Jacqueline A. Pugh, MD; Dawn I. Velligan, PhD; Ryan W. Stidham, MD, MSc; and Akbar K. Waljee, MD, MSc
Medicare Advantage Control of Postacute Costs: Perspectives From Stakeholders
Emily A. Gadbois, PhD; Denise A. Tyler, PhD; Renee R. Shield, PhD; John P. McHugh, PhD; Ulrika Winblad, PhD; Amal Trivedi, MD; and Vincent Mor, PhD
Provider-Owned Insurers in the Individual Market
David H. Howard, PhD; Brad Herring, PhD; John Graves, PhD; and Erin Trish, PhD
Mixed Messages to Consumers From Medicare: Hospital Compare Grades Versus Value-Based Payment Penalty
Jennifer Meddings, MD, MSc; Shawna N. Smith, PhD; Timothy P. Hofer, MD, MSc; Mary A.M. Rogers, PhD, MS; Laura Petersen, MHSA; and Laurence F. McMahon Jr, MD, MPH

Adalimumab Persistence for Inflammatory Bowel Disease in Veteran and Insured Cohorts

Shail M. Govani, MD, MSc; Rachel Lipson, MSc; Mohamed Noureldin, MBBS, MSc; Wyndy Wiitala, PhD; Peter D.R. Higgins, MD, PhD, MSc; Sameer D. Saini, MD, MSc; Jacqueline A. Pugh, MD; Dawn I. Velligan, PhD; Ryan W. Stidham, MD, MSc; and Akbar K. Waljee, MD, MSc
Veterans with inflammatory bowel disease taking adalimumab appear to be more likely to remain on the drug 1 year after initiation than patients who are privately insured.
RESULTS

MarketScan Cohort

From 2009 to 2012, we identified 15,606 patients with IBD who were prescribed ADA. After applying exclusion criteria, 4252 were prescribed ADA as their only anti-TNF, and 3264 of those patients were given at least 3 months’ supply without other erroneous fill data and at least 1 year of follow-up.

VHA Cohort

In the VHA, 1900 patients were found to have IBD with a prescription for ADA, and 1765 were prescribed only ADA. After applying exclusion criteria, 1030 patients of the 1765 had at least 3 valid prescriptions of ADA in the study period with no other erroneous fill data and at least 1 year of follow-up from the date of anti-TNF initiation.

Cohort Comparisons

Table 1 outlines the different characteristics of the patients in each cohort. The VHA cohort included mostly men, and the mean (SD) age in this cohort was higher than that seen in MarketScan: 47.7 (15.6) years versus 41.1 (15.3) years, respectively. There was also a difference in the IBD phenotypes between the 2 cohorts. The VHA cohort had fewer patients with Crohn disease (VHA, 54.5% vs MarketScan, 81.1%) and more patients classified as having indeterminate colitis (VHA, 23% vs MarketScan, 0.6%), likely due to differences in classification of IBD phenotype. The VHA classification determines phenotype based on all the codes being consistent for that phenotype; it is indeterminate if there are any discrepancies. In a sensitivity analysis that used this VHA method as a unified diagnosis classification for the IBD phenotype between the 2 cohorts, there remained a difference in the diagnosis makeup of the cohort (eAppendix Table 2), primarily in the classification of patients with UC versus indeterminate colitis. The mean (SD) CCI score was higher among veterans than the MarketScan population: 0.7 (1.2) versus 0.2 (0.5), respectively. When examining the concomitant medications, veterans were less likely to be taking steroids (VHA, 25.7% vs MarketScan, 39.2%), but more likely to be using immunomodulators (VHA, 31% vs MarketScan, 22.9%) and narcotics (VHA, 27.5% vs MarketScan, 20.3%), at the time of ADA initiation.

The mean (SD) adherence, as calculated by cumulative MPR, was high in both the VHA and MarketScan cohorts, at 0.90 (0.16) and 0.96 (0.11), respectively. Despite the MarketScan population’s higher adherence, the rates of dose escalation within 1 year and hospitalization or new steroid prescription were similar between the 2 populations (Table 1).

Table 2 shows that the percentage of patients who were persistent on ADA at 1 year without a significant interruption was lower among the MarketScan population (MarketScan, 1800 [55.2%] vs VHA, 755 [73.3%]). Concomitant steroid use remained higher in the MarketScan population at the 1-year time point (MarketScan, 10.3% vs VHA, 3.8%), whereas concomitant narcotic use and immunomodulator use were similar in the 2 populations at 1 year.

Examining predictors of persistence at the 1-year time point in the MarketScan population, we found that men (OR, 1.38; 95% CI, 1.16-1.63; P <.01), patients with Crohn disease (vs UC) (OR, 1.27; 95% CI, 1.02-1.57; P = .03), patients who were adherent (OR, 1.83; 95% CI, 1.45-2.30; P <.01), and those who had a dose escalation (OR, 1.82; 95% CI, 1.42-2.33; P <.01) were more likely to remain on the drug at 1 year in multivariable analysis (Table 3). Patients who were on narcotics around the time of anti-TNF initiation (OR, 0.71; 95% CI, 0.58-0.88; P <.01) or those who had a hospitalization or new steroid use (OR, 0.04; 95% CI, 0.03-0.05; P <.01) were conversely less likely to be on the drug at the 1-year time point. Age, CCI score, immunomodulator use, and corticosteroid use at ADA initiation did not influence the continued use of ADA at the 1-year time point. In a sensitivity analysis using a consistent IBD phenotype definition with the VHA cohort, Crohn disease (vs UC) had a similar effect on persistence but was no longer a significant predictor of persistence due to sample size limitation (eAppendix Table 3). Altering the IBD phenotype category did not significantly change the effect of other predictors in the multivariable model.

Examining persistence through multivariable analysis with the same predictors in the VHA population, we found no effect for male gender (OR, 1.16; 95% CI, 0.74-1.81; P = .52), a comparable beneficial trend for patients with Crohn disease (vs UC) (OR, 1.34; 95% CI, 0.95-1.90; P = .22), but no benefit for those who had a dose escalation (OR, 1.04; 95% CI, 0.69-1.58; P = .85) (Table 3). No effect was observed for patients who were on narcotics (OR, 1.02; 95% CI, 0.74-1.40; P = .91), whereas a negative but not significant trend was seen for patients who were on steroids at ADA initiation (OR, 0.76; 95% CI, 0.55-1.06; P = .11). However, a significant negative effect was seen in those who had a hospitalization or new steroid use (OR, 0.50; 95% CI, 0.36-0.70; P <.01); these patients were 50% less likely to be on the drug at the 1-year time point. Age, CCI score, adherence, immunomodulator use, and corticosteroid use at ADA initiation did not influence the continued use of ADA at the 1-year time point in the VHA population.


 
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