Transcript Trends in utilization and costs of services associated

Trends in utilization of services
associated with introduction of drug
coverage for Cholinesterase
Inhibitors (ChEI)
Malcolm Maclure, ScD, Professor
Wendy Smith and
Colin Dormuth, Assistant Professor
Dept Anesthesiology, Pharmacology and
Thereapeutics, UBC
Disclosures
• Dr. Maclure is a half-time employee of BC Ministry
of Health: Co-Director of Research and Evidence
Development in Pharmaceutical Services Division.
• Dr. Dormuth receives partial funding support from
Pharmaceutical Services Division.
Relation among ADTI studies
• Utilization & Cost Study cohort
– 76,094 new ADRD dx: Nov 1, 2002 to Oct 31, 2009
– Ever-users of ChEI in cohort: 14,327 (19%)
• Clinical Epidemiology cohort: Nov 2007-Sep 2011
– >18,000 patients approved for Special Authority
Contacts: 2254 Triage for eligibility: 1124
• Caregiver Appraisal Study: 1071 enrolled
• Seniors Medication Study: 198 indeterminate
• CLIMAT: ~100
Utilization Cohort Study Design
Policy
began
AFTER
BEFORE
Cohort entry
ADTI before
exclusion
period
HC* before
CONTROL BEFORE
May 1, 2000
Nov 1,
2002
May 1,
2004
Nov 1,
2005
ADTI after
HC* after
AFTER
Nov 1,
2007
Oct 31,
2009
* HC - Historical Control
Note: Cohort entry period begins before analysis period to allow time for the cohort to stabilize.
Note: Analysis does not begin until May 2004 to minimize the effect of Fair PharmaCare implementation.
Policy impact: Use of ChEIs up 13%
Cholinesterase Inhibitor Utilization
Daily Dose per Patient Month
Daily Dose per Patient Month
4.5
4
3.5
3
2.5
2
Historical Control
ADTI
1.5
ADTI began
1
0.5
0
0
6
12
18
Month
Policy
began
24
30
36
Coinciding drop in use of antipsychotics
Antipsychotic Utilization
Daily Dose per Patient Month
Daily Daily Dose per Patient Month
3.5
3
2.5
2
ADTI began
Historical Control
1.5
ADTI
1
0.5
0
0
6
12
18
Month
Policy
began
24
30
36
No impact on use of MD services
Physician Utilization:
Physician Visits per Patient Month
by Patients with an ADRD diagnosis
Physician visits per patient month
6
5
4
3
Historical Control
ADTI
2
ADTI began
1
0
May
Nov
May
Nov
Month
May
Policy
began
Nov
May
No impact on rate of entry to LongTerm or Palliative Care
Patients entering care per 1,000 patient months
Entries into Long-Term Care or Palliative Care
per 1,000 Patient Months
(Patients have ADRD diagnosis)
16
14
12
10
8
Historical Control
6
ADTI
ADTI began
4
2
0
May
Nov
May
Nov
May
Policy
Month
began
Nov
May
Probably no reduced mortality
Deaths per 1,000 Patient Months
(Patients have ADRD diagnosis)
Deaths per 1,000 Patient Months
16
14
12
10
8
Historical Controls
6
ADTI
ADTI began
4
2
0
May
Nov
May
Nov
May
Month
Policy
began
Nov
May
No reduction in hospital admissions
Hospital separations per 1,000 Patient Months
Hospital Utilization
Hospital Separations per 1,000 Patient Months
by Patients with an ADRD diagnosis
200
180
160
140
120
100
Historical Control
80
ADTI
ADTI began
60
40
20
0
May
Nov
May
Nov
May
Month
Policy
began
Nov
May
Incident Patients per 1,000 population
Policy increased AD diagnosis rate
Alzheimer's Disease and Related Dementias
(ADRD)
Incidence Rate per 1,000 population, by Age
(British Columbia)
100
90
80
70
60
50
40
30
20
10
0
85+
80 to 84
75 to 79
70 to 74
65 to 69
60 to 64
2002
2003
2004
2005
2006
Year
2007
2008
Policy
began
2009
Incident Patients per 1,000 population
Drug use trends are greatly
influenced by marketing
ChEI Recipient Incidence Rate
per 1,000 population
(Filled Prescriptions, BC Residents
60 years of age and older)
18
ADTI began
16
14
12
85+
10
80 to 84
8
75 to 79
6
70 to 74
4
65 to 69
2
60 to 64
0
1999
2001
2003
2005
Year
2007
Policy
began
2009
Drug use trends are greatly
influenced by marketing
Incident Recipients per 1,000 population
Memantine Recipient Incidence Rate
per 1,000 population
(BC Residents, 60 years of age and older)
4
ADTI began
3.5
3
2.5
85+
80 to 84
2
75 to 79
1.5
70 to 74
1
65 to 69
0.5
60 to 64
0
2004
2005
2006
2007
Year
2008
Policy
began
2009
Fairly stable incidence rate of
new users before policy
Incident Recipients per 1,000 population
Alzheimer's Disease Drug Recipient
Incidence Rate per 1,000 population
(ChEI and Memantine, BC Residents,
60 years and older)
6
5
4
ADTI began
3
Memantine on
the market
2
1
0
1999
2001
2003
2005
Year
2007
Policy
began
2009
Incident Recipients per 1,000 population
Incidence rate of ADRD drug
initiation, by age group
Alzheimer's Disease Drug Recipient
Incidence Rate per 1,000 population
(ChEI and Memantine, BC Residents
60 years and older)
25
ADTI began
20
85+
15
80 to 84
75 to 79
10
70 to 74
65 to 69
5
60 to 64
0
1999
2001
2003
2005
Year
Policy
began
2007
2009
Not
zero
Incident Recipients per 1,000 population
Antipsychotic incidence rate was
declining for other reasons
Antipsychotic Recipient Incidence Rate
per 1,000 population
(BC Residents 60 years and older)
15
ADTI began
14.5
14
13.5
Health Canada advisory re
atypical antipsyhotics and
dementia; increased
mortality
13
12.5
12
1999
2001
2003
2005
Year
2007
Policy
began
2009
Antipsychotic incidence rate was
declining for other reasons
Incident Recipients per 1,000 population
Antipsychotic Recipient Incidence Rate
per 1,000 population
(BC Residents 60 years of age and older)
45
ADTI began
40
35
30
85+
25
80 to 84
20
75 to 79
15
70 to 74
65 to 69
10
60 to 64
5
0
1999
2001
2003
2005
Year
2007
Policy
began
2009
Preliminary conclusions
• The Alzheimer’s Drug Therapy Initiative has
not yet been found to be associated with an
overall reduction in healthcare utilization
• Trend analysis, comparing the Policy Cohort
with Historical Controls, is made more difficult
by surges in marketing of new drugs
• Drug marketing and drug insurance policy
changes seem to influence rate of diagnosis of
Alzheimer’s Disease.