Laura Joszt

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Two posters presented at the Academy of Managed Care Pharmacy annual meeting evaluated health care resource utilization (HCRU) among adult patients taking insomnia medications.

 looked at adult patients with hypertension and comorbid insomnia who were treated with older generation insomnia medications. These patients were compared with a matched cohort with hypertension and no sleep disorders.

The researchers used the IBM MarketScan Commercial and Medicare Supplemental Databases to identify eligible patients for the retrospective cohort study. Eligible patients had one or more prescriptions for zolpidem immediate release (IR), zolpidem extended release (ER), trazodone, or benzodiazepines.

They matched 81,502 patients with hypertension and insomnia (H+I) with the control cohort. The H+I patients had higher adjusted odds of emergency department (ED) visits, outpatient visits, and non-insomnia prescription drug use within 12 months of their earliest fill date for an insomnia medication. H+I patients had longer inpatient stays, although they did not have higher odds of inpatient visits, particularly for patients with trazodone, benzodiazepines, or zolpidem IR.

Adjusted total costs per patient per month (PPPM) for the H+I patients was higher relative to the matched cohort ($2,343 vs $1,013). Costs for outpatient, pharmacy, and the ED were higher for almost all H+I patients compared with the matched cohorts. H+I patients taking zolpidem ER were the only H+I patients who did not have higher inpatient costs compared with the control group.

“Results suggest differences by medication class and/or mechanism that warrant further research on the impact associated with newer dual orexin receptor antagonists,” the authors concluded.

, from the same authors and using the same databases, evaluated HCRU and costs associated with insomnia and the same older generation insomnia drugs in adult patients with depression. The 21,027 patients with depression and insomnia (D+I) were matched 1:1 with a control cohort with depression but no sleep disorders.

While the D+I patients in general had higher adjusted odds of ED visits, outpatient visits, and non-insomnia prescription drug use compared with the control, the mean length of stay was not longer for patients prescribed zolpidem ER. Adjusted total costs PPPM were $2,450 for D+I patients compared with $1,095 for the matched controls.

For both posters, the authors noted that since insomnia is underreported or underdiagnosed, some patients with insomnia may have been missed, and that the results may not be generalizable to a non–commercially insured population. For the second poster, the authors noted that a limitation of the study was that it did not control for whether depression was treated.

Articles

Treating insomnia with commonly prescribed, older generation medications increases health care resource utilization and costs in patients with comorbid conditions.

Understanding the Economic Burden of Insomnia Treatment in Patients With Comorbid Conditions

Early treatment of multiple sclerosis (MS) is associated with better physical outcomes. Now a Swedish study shows that early treatment may also be associated with better financial ones.

 of the Karolinska Institute and his colleagues divided 3,610 people with multiple sclerosis into two groups, those who started disease-modifying therapy (DMT) within two years of the onset of their disease (early treatment) and those who started DMT two years afterward (delayed treatment). They designed the study so a 95% decrease in annual earning was the main measure of financial outcome.

Multiple Sclerosis Journal — Experimental, Translational and Clinical

showed that patients in the delayed treatment group were more likely to reach that unfavorable financial threshold than the patients in the early treatment group.

Their findings were similar when they looked at slightly smaller group of people with MS and when they were likely to receive “social benefits,” such as a disability pension. Those in the delayed treatment group were more likely to receive social benefits than those in the early treatment group. More specifically, delayed treatment increased the “risk” of receiving benefits by 42%.

Kavaliunas and his colleagues said that this study was to their knowledge the first to examine the association between early and late treatment and the income of MS patients, although they have previously reported findings on early treatment and disability pensions, so the territory is not entirely uncharted. There is also a body of research that has shown an association between MS and lower income and early retirement.

In this study, the drugs that counted as disease-modifying therapy were interferon beta, glatiramer acetate, Tysabri (natalizumab), Gilenya (fingolimod), Rituxan (rituximab), Aubagio (teriflunomide), Lemtrada (alemtuzumab), mitoxantrone, and (Tecfidera) dimethyl fumarate.

“In conclusion, we confirm the benefits of early treatment initiation in the socioeconomic context using the novel and unbiased outcome, also support the idea that it can serve as a precise outcome measure and can be used as a proxy parameter of disability,” Kavaliunas and his co-authors concluded.

Earlier treatment of multiple sclerosis with disease-modifying therapy reduced the chances of a sharp decrease in income, according to Swedish researchers.

Study Shows Early DMT for Multiple Sclerosis Associated With Income Benefit 

Multiple sclerosis (MS) typically affects people in their prime working years, most often striking between the ages of 20 and 50. Rates of unemployment are high. As many as four out of every five people with the neurological condition that affects movement, gait and vision may be unemployed. 

 compares two groups of patients with MS to identify the factors that may influence their likelihood of holding a job.

“While much is known about the demographic and disease variables associated with 

unemployment in MS, less is known about the role of person-specific factors and one's engagement in health-related behaviors,” wrote author 

, Ph.D., senior research scientist at the Center for Neuropsychology and Neuroscience Research of the Kessler Foundation in East Hanover, New Jersey. The 

 funds research into people with disabilities and the employment issues they face.

Previous studies have examined MS and employment but were retrospective. The press release accompanying the publication of Strober’s findings says hers is the first to study the issue prospectively.

Strober’s study included 252 people with MS and divided them into two groups: “at risk” for leaving the workforce (n = 67) and “not at risk” (n = 185). The participants in the “at risk” group reported that they were considering reducing their hours or leaving the workforce altogether because of difficulties related to their MS.

Participants in the study were between the ages of 20 and 64 and were currently employed. They completed an online survey about a number of topics, including work status and history, disease symptoms, personality, coping, self-efficacy and disease management. Participants also completed the Symbol Digit Modalities Test (SDMT), which measures processing speed.

The “at risk” and “not at risk” groups were similar as far as age, gender, education, and disease duration were concerned. There was, though, a difference in disease course: A greater proportion of patients in the “at risk” group had a progressive course (13% vs 3%).

The “at risk” group also reported greater levels of fatigue, sleep disturbance, pain, depression and anxiety. Based on their survey responses, they also had greater levels of neuroticism; lower levels of extraversion, conscientiousness and agreeableness; lower MS self-efficacy; and a greater use of maladaptive coping.

In addition, they reported lower “locus of control” — how strongly people believe that they have power over situations and experiences that affect their lives. The “at risk” group was also less likely to engage in positive health-related behaviors, such as healthy eating, exercise and social/intellectual activities.

“What is perhaps is more novel and exciting about the present findings is the fact that engagement in health-related behaviors, specifically diet and exercise proved to be a significant predictor even when disease and person-specific factors were taken into account,” Strober wrote.

Among the limitations that she noted was almost all (94%) of the patients in the study had a relapsing-remitting course, which was likely because the individuals recruited were still working and at the early stage of being considered “at risk” for unemployment. The study also did not include a measure of disease severity, because it relied on medical information from the patients’ neurologists, many of which did not report something like the Expanded Disability Status Scale.

"Risk of unemployment is highest during the first three to five years after diagnosis, so we need to be able to intervene early to prevent job losses, and their subsequent impact on physical and mental health, as well as on personal and family finances. This study points to factors related to risk of unemployment that may be amenable to early intervention," Strober said in the 

. "While further research is needed, professionals who provide MS care should be aware of the potential impact of this diagnosis on future employment and be prepared to intervene before individuals leave the workforce."

People with MS who are at risk for joblessness have poorer health-related habits and lower “locus of control” scores, according to findings by Kessler Foundation researcher Lauren Strober.

Prospective Study Identifies Factors Associated With Unemployment Among People With MS

While the frequency of cancer diagnoses has increased among patients with multiple sclerosis over the past 30 years, the overall cancer risk among patients with MS and matched controls is similar, according to a study 

Researchers used the United Kingdom’s Clinical Practice Research Datalink, which has been collecting primary care data since 1987, to conduct a population-based nested case control study. They used the data to compare the occurrence of cancer between people with MS or clinically isolated syndrome (CIS), a single inflammatory demyelinating event that can turn into multiple sclerosis, and controls who do not have MS or CIS.

“It has been suggested that the abnormal immune response seen in MS could improve 

surveillance against malignancy,” wrote the authors, led by Chiara Zecca of the Neurocenter of Southern Switzerland in Lugano, Switzerland. “However, chronic inflammation also represents a recognized risk factors for cancer development.”

The study included 10,204 patients with MS who were matched with 39,448 controls. Some of those patients were excluded from the study for various reasons, so the researchers ended up analyzing data for 9,816 patients with MS and 37,901 controls. Almost three-quarter (71.6%) of the people in both groups were women; their  median age was 47. People with MS were followed up for 5.6 years after index date and the controls were followed up for 6.2 years.

Cancer was reported in 433 (4.41%) patients with MS and 2014 (5.31%) controls. Female gender was negatively associated with the risk of cancer, while age at index date and calendar year at index date were both positively associated with cancer risk. Zecca and her colleagues noted that disease status (MS vs control) was not at all associated with the risk of cancer.

The authors pointed out that a previous study in Norway had found patients with MS had an increased risk of cancer, particularly with involvement of the respiratory, urinary and central nervous system, but the MS cohort in this study did not show risk for any specific type of cancer. The findings are consistent with others from Northern Europe and Iran that found no differences in cancer risk between patients with MS and the general population. Research conducted in the United States, Canada, and Europe have found that people with MS have a lower risk of developing cancer.

The research team pointed out that while cancer risk was stable for the control group over time, the risk increased among MS patients by approximately 2% per calendar year. They hypothesized that the introduction of new therapeutic agents, changes in clinical care, standardized and regular cancer screening programs, and changes in lifestyle behaviors may explain the increase over time among patients with MS. However, they noted that this finding requires further investigation.

“While several explanations appear to be possible, including increasing surveillance and more careful cancer screening programs in MS patients, we believe the rapid and continuous evolution of MS care, treatments and related potential secondary effects, require maximal attention in routine neurological care,” Zecca and her colleagues concluded.

Study found that while  frequency of cancer among people with multiple sclerosis (MS) increased over time, the overall cancer risk is similar between patients with MS and the general population.

Laura Joszt

Articles

Understanding the Economic Burden of Insomnia Treatment in Patients With Comorbid Conditions

Study Shows Early DMT for Multiple Sclerosis Associated With Income Benefit

Prospective Study Identifies Factors Associated With Unemployment Among People With MS

Similar Cancer Risk Between Patients With MS, General Population in the UK, Study Finds