Comparative Effectiveness Of Smoking Cessation Medications Among Schizophrenic Smokers

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comorbidities, and the associated cost of treatment (e.g the cost of hospitalisations due to exacerbations). Furthermore, the indirect costs associated with loss of productivity, absenteeism and impaired patient’s and caregiver’s work pose an additional burden on individuals and economies.  Conclusions: The substantial burden of COPD warrants active management and development of new classes of COPD medications that reduce the symptoms and exacerbations associated with the severity of the disease, improve patient’s HRQoL and consequently contribute to minimising the overall economic burden. PRS52 B.E.S.T. Asthma Program (Breathe easy. Start today.®): A Primary Care-Based Program For Dispensing Asthma Medication and Devices Reduces Acute Hospitalization and Expenditures in Medicaid Subjects Higgins YL, Keleti D, Shera D, Varma R, Odeleye A, Donia T, Michael KE, Gelzer AD Keystone First, Philadelphia, PA, USA

Objectives: To determine whether primary care-based dispensing of asthma supplies and hands-on education to Medicaid subjects with asthma reduces asthmarelated acute hospitalization and expenditures. Methods: Keystone First (a Medicaid managed care organization) and a pharmacy services supplier deliver secured cabinets stocked with asthma medication and devices to participating providers and support reimbursable provider-led education, allowing dispensation and training in the use of asthma supplies at the member’s point of service. Home delivery of asthma supplies was arranged by pre-refill calls made to the member 4–5 days prior to the refill due date. Provider and medication rates (utilization per member per year and expenditures per member per month) were calculated from subject claims pre- and post-engagement.  Results: In 2014, 23 participating practices used secured asthma cabinets to dispense 12,822 asthma medications and supplies to more than 6,000 members. Subjects were primarily African American males living in Philadelphia, both children and adolescents (50% and 85% were ≤ 6 and ≤ 12 years old, respectively). About 400–500 pre-refill calls are made weekly to members to arrange home delivery of medications. A one year pre/post analysis of all participating members in 2014 (N= 2,962) demonstrated: 1) decreases in inpatient admissions and outpatient visits (−19.5% and -4.3%; p=0.01) and corresponding expenditures (35.2% and -5.5%; p=0.01); 2) decreases in potentially preventable emergency department visits and expenditures (23.8% and -26.7%); 3) no significant change in potentially preventable readmissions and expenditures (+4.2% and +4.7%; p>0.9); 4) increases in prescription utilization and expenditures (+20% and 59.4%); 5) slight increases in medication adherence (PDC, 0.04; MPR, 0.11; SD, 0.42 and 0.37, respectively; and 6) significant expenditures savings (-20.2% and -10% with and without prescription, respectively; p>0.05).  Conclusions: Point-of-service dispensing of asthma supplies for Medicaid subjects with asthma significantly increases outpatient and prescription-related utilization and expenditures, but significantly reduces asthma-related acute hospitalization and expenditures. PRS53 Association Between Access-To-Care Factors And Health Care Resource Utilization Among Adults With Chronic Obstructive Pulmonary Disease Kim M1, Ren J1, Tillis W2, Asche CV1, Kim IK3, Kirkness CS1 of Illinois College of Medicine at Peoria, Peoria, IL, USA, 2OSF Saint Francis Medical Center, Peoria, IL, USA, 3Battelle Memorial Institute, Atlanta, GA, USA

1University

Objectives: One of barriers to obtaining good care may be the limited accessibility to health care. Few studies have been reported investigating the association between availability of access-to-care factors and chronic obstructive pulmonary disease (COPD)-hospitalizations. The objective of this study is to estimate the association between access-to-care factors and healthcare utilization including hospital/ emergency department (ED) visits and primary care physician (PCP) office visits among adults with COPD utilizing a nationally representative survey data.  Methods: We conducted a pooled cross-sectional analysis based upon a bivariate probit model, utilizing datasets from the 2011-2012 Behavioral Risk Factor Surveillance System linked with the 2014 Area Health Resource Files among adults with COPD. Dichotomous outcomes were hospital/ED visits and PCP office visits. Key covariates were county-level access-to-care factors including the population-weighted numbers of pulmonary care specialists, PCPs, hospitals, rural health centers and federally qualified health centers.  Results: Among a total of 9,332 observations, proportions of hospital/ED visits and PCP office visits were 16.2% and 44.2%, respectively. Results demonstrated that access-to-care factors were closely associated with hospital/ED visits. An additional pulmonary care specialist per 100,000 persons serves to reduce the likelihood of a hospital/ED visit by 0.4 percentage points (pp) (p= 0.028). In contrast, an additional hospital per 100,000 persons increases the likelihood of hospital/ED visit by 0.8 pp (p= 0.008). However, safety net facilities were not related to hospital utilizations. PCP office visits were not related with access-to-care factors.  Conclusions: Pulmonary care specialist availability was a key factor in reducing hospital utilization among adults with COPD. The findings of our study implied that an increase in the availability of pulmonary care specialists may reduce hospital utilizations in counties with little or no access to pulmonary care specialists, and that since availability of hospitals increases hospital utilization, directing COPD patients to pulmonary care specialists may decrease hospital utilizations. PRS54 Embracing Patient Heterogeneity Using Agent-Based Modeling And Preemptive Care Pathways Allows For Improved Care In The Treatment Of Bronchiolitis Obliterans Syndrome Zia A1, Weimersheimer P2, Mesa OA3, Peters C4, Jones C5 1University of Vermont, Burlington, VT, USA, 2University of Vermont College of Medicine, Burlington, VT, USA, 3Therakos, Inc., Wokingham, Berkshire, UK, 4Therakos, Inc., a Mallinckrodt Company, West Chester, PA, USA, 5University of Vermont - College of Medicine, Burlington, VT, USA

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Objectives: Existing BOS models predict survival rates and effectiveness of interventions but they lack the ability to provide pre-emptive high intensive care. These care pathways are sequential, rather than pre-emptive, and create as a consequence a downward spiral of path dependency and severity. In this study, our goal was to build an Agent Based Model (ABM) that could provide a transparent mechanism to compare existing path dependency with preemptive high intensity treatment including extracorporeal photophoresis (ECP) for patients who may have very different circumstances, tolerances and comorbidities.  Methods: Using recent data, we developed an ABM that captures patient heterogeneity and simulates an alternative scenario using what we call pre-emptive care pathways (PCPs). We compared this scenario with a usual care scenario using measures of health status, costs and treatment effects according to the guidelines established by International Society for Heart and Lung Transplantation (ISHLT).  Results: From 10,000+ experimental simulations in the ABM, we found that earlier introduction of ECP for patients with specific age, gender and underlying disease dynamics could increase the survival rates as compared with a scenario in which ECP was not introduced. Modeling changes from baseline in forced expiratory volume (FEV) per second, as per ISHLT guidelines, and their respective quality of life measures for patients in different stages of BOS, the proposed ABM with PCPs can predict and match an optimal individualized care pathway and the timing of treatment intervention for a specific patient conditional upon her/his disease characteristics.  Conclusions: We identified a new utility for ABMs to power PCPs in the context of confounding patient and treatment heterogeneity. It is anticipated that this tool will aid decision makers with clearer treatment pathways for BOS that are more aligned with individual circumstances, especially in maximizing chances of survival with respect to improved quality of life. PRS55 Relationship Between Severity And Acute Inhaler Use In Chronic Obstructive Pulmonary Disease Hur P1, Albrecht J2, Huang T3, Simoni-Wastila L3, Moyo P3, Khokhar B3, Harris I4, Wei Y5 1University of Maryland, School of Pharmacy, Baltimore, MD, USA, 2Univeristy of Maryland, School of Medicine, Baltimore, MD, USA, 3University of Maryland, School of Pharmacy, Baltimore, MD, USA, 4Impaq International, Columbia, MD, USA, 5University of Florida College of Pharmacy, Gainesville, FL, USA

Objectives: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommends maintenance inhaler use based on disease severity but offers limited guidance for acute inhaler use. The study aims to examine the relationship between chronic obstructive pulmonary disease (COPD) severity and acute inhaler use, alone or in conjunction with maintenance medications.  Methods: Using 5% sample of Medicare administrative claims from Chronic Condition Data Warehouse from 2006-2011, beneficiaries diagnosed with COPD were followed for two years. Individuals with at least 1 COPD-related inpatient visit, COPD-related emergency department visit, or supplemental oxygen claim during first six months of follow-up were categorized with moderate-severe COPD; otherwise, subjects were classified with mild COPD. Severity cohorts were compared on acute and maintenance inhaler use. Acute inhaler use per year was categorized into six groups (> 0 to ≤ 2, > 2 to ≤ 4, > 4 to ≤ 6, > 6 to ≤ 8, > 8 to ≤ 10, and > 10 to ≤ 12).  Results: 25,268 beneficiaries met inclusion criteria; of these beneficiaries, 81% had mild COPD. For acute inhaler use per year, there was a bimodal distribution for both cohorts, with highest peak use at > 0 to ≤ 2 and > 2 to ≤ 4 acute inhalers per year, and a second peak use at > 10 to ≤ 12 acute inhalers per year. Differences in median (interquartile range) acute inhaler use per year between mild (4.2 (5.9)) and moderate-severe (4.8 (6.4)) COPD cohorts were statistically significant (p< 0.001). Similar findings were found for maintenance inhalers.  Conclusions: The bimodal distribution for acute inhalers may indicate a group of patients with suboptimal use and a group with overuse of acute inhalers. Higher use of acute inhalers for moderate-severe COPD patients may indicate suboptimal use of and/or adherence to maintenance inhalers, overuse of acute inhalers, and/or insufficient control of COPD. Thus, it may be important for clinicians to be sensitive to patients’ COPD inhaler use patterns. PRS56 Comparative Effectiveness Of Smoking Cessation Medications Among Schizophrenic Smokers Wu I1, Chen H2, Bordnick P1, Essien EJ2, Johnson ML2, Peters RJ3, Wang X2, Abughosh S2 of Houston, houston, TX, USA, 2University of Houston, Houston, TX, USA, 3University of Texas Health Science Center at Houston, houston, TX, USA 1University

Objectives: To compare short term and long term smoking abstinence with different cessation medications among schizophrenia patients.  Methods: A retrospective cohort study was conducted using General Electric (GE) medical records database (1995 – 2011). The cohort consisted of adult smokers with a diagnosis of schizophrenia who newly initiated cessation medication (NRT, Bupropion or Varenicline). Cessation outcome was abstinence. It was measured at 12 weeks and 1 year following the initiation of cessation medications. Logistic regression models were carried out to determine the predictors of short term and long term abstinence.  Results: Of the 3,976 patients identified, majority used nicotine replacement therpapy (NRT) (n= 2,590, 65.14%) followed by Bupropion SR (n= 89, 2.24%) and Varenicline (n= 1,164, 29.28%). Although unadjusted analysis showed that abstinence rate was the highest for Varenicline across all cessation regimens (21.04%) in both the short term (21.04%) and the long term follow up (20.07%) among all cessation regimens, statistically significant difference was not detected in the multivariate analysis. Older age (OR= 1.02, 95% CI= 1.01 – 1.03), white race (OR= 1.83, 95% CI= 1.04 – 3.20), western household locations (OR= 2.18, 95% CI= 1.39 – 3.41) and receiving counseling (OR= 0.67, 95% CI= 0.49 – 0.92) were significantly associated with abstinence at week 12. Patients who had a 2nd exposure were less likely to quit compared to those without the 2nd exposure at one year (OR= 0.26, 95% CI= 0.13–0.55). No significant differences were found between cessation medications.  Conclusions: There were no statistically significant differences in quitting with type of cessation medication. Predictors of better abstinence identified included older age, white race, western

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household location, which can help identify subpopulations among schizophrenic patients that are more likely to succeed in quitting. These predictors should be considered when designing future interventions for schizophrenic population as this minority population may need more tailored approaches to achieve a successful cessation outcome. PRS57 Trends In Oral Glucocorticoid Utilization Among Older Adults With Respiratory Disease Amiche MA1, Lévesque LE2, Gomes T1, Adachi JD3, Cadarette SM1 Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada, 2Institute for Clinical Evaluative Sciences, Toronto, ON, Canada, 3McMaster University, Hamilton, ON, Canada

1Leslie

Objectives: Oral glucocorticoids (GC) are critical anti-inflammatory agents, yet increase the risk for osteoporosis, myopathy, hyperglycemia, and hypertension. The management of respiratory disease (asthma and chronic obstructive pulmonary disease) with oral GCs has changed over time, with an aim to reduce oral GC exposure and preference for inhaled GCs and bronchodilators. We describe changes in prescribing patterns of chronic oral GCs over time among older adults with respiratory disease.  Methods: We identified community-dwelling adults, aged 66+ years with respiratory disease initiating chronic oral GC therapy (e.g. new users) in Ontario using healthcare claims data, 1998/01-2012/12. Chronic oral GC use was defined as ≥ 450 mg prednisone equivalent and ≥  2 prescriptions over a 6-month period. Oral GC duration and cumulative dose, dispensing of inhaled GCs and bronchodilators, and prescriber specialties were described by calendar year. Spline regressions were used to describe quarterly trends in oral GC utilization.  Results: We identified 80,770 chronic oral GC users with respiratory disease (45% men, mean age= 75.0 years, SD= 6.6). Age and sex were similar over time. We observed a downward linear trend over time, representing a reduction of 93% in the median days of exposure to GC from 1998 to 2012 (58 days [IQR:93] in 1998 to 30 days [IQR:63] in 2012), yet only 17% (linear trend) reduction in the GC cumulative dose (median 1080 mg [IQR:1250] to 925 mg [IQR:1110]). The concomitant use of bronchodilators showed a convex curve with an initial decrease, followed by increase after 2007. Oral GC prescriber specialty changed little over time (overall: 10.7% respirologists, 6.1% rheumatologists, and 68.6% general practitioners).  Conclusions: Duration of oral GC use among older adults with respiratory disease decreased over time, yet the cumulative dose remained similar. These results suggest that patients are receiving higher GC doses for shorter duration despite recent efforts to reduce the total exposure. PRS58 Antibiotics Use Pattern And Appropriateness Among Children In The Treatment Of Cough/Cold And Diarrhea Ahmad A1, Khan MU1, Mohanta GP2, Parimalakrishnan S2, Patel I3 University, Kuala Lumpur, Malaysia, 2Annamalai University, Chidambaram, India, 3Shenandoah University, Winchester, VA, USA

1UCSI

Objectives: The objective of this study was to evaluate the prescription pattern of antibiotic utilization during the treatment of cough/cold and/or diarrhoea in pediatric patients.  Methods: A cross sectional descriptive study was conducted for the period of 6 months in pediatric units of a tertiary care hospital of south India. Children under 5 years of age presenting with illness related to diarrhea and/ or cough/cold were included in this study. Data were collected by reviewing patient files and then assessed in view of standard treatment guidelines. Descriptive and chi square analysis was conducted to assess the data.  Results: A total of 303 patients were studied during the study period. Mean age of the patients was 3.5±0.6 years. The majority of children were admitted mainly due to chief complaint of fever (63%) followed by cough and cold (56.4%). However, the appropriateness of antibiotic prescription was high in bloody and watery diarrhea (83.3% and 82.6%; p< 0.05). Cephalosporins and penicillins were the most commonly prescribed antibiotics (46.2% and 39.9%), though the generic prescriptions of these drugs were the lowest (13.5% and 10%). The seniority of prescriber was significantly associated with the appropriateness of prescriptions (P< 0.05). Antibiotics prescription was higher (93.5%) in Cold/cough and diarrhea in comparison to Cough/cold (85) or diarrhea (75%) alone.  Conclusions: The study observed high rate of antibiotic prescription. Their appropriateness with the standard guidelines was also below par. Not many drugs given in National List of Essential Medicine (NLEM) were prescribed in this study, moreover, the generic prescription of these drugs were also poor. Appropriate measures need to be taken to seal the knowledge gaps to enhance appropriateness of antibiotics. PRS59 Patient-Centered Outcomes Associated With Initial Maintenance Therapy Use Behavior Among Chronic Obstructive Pulmonary Disease Patients With Employer Sponsored Insurance Patel J1, Dalal A2, Stanford R3, Aparasu R1, Abughosh S1, Johnson ML1 1University of Houston, Houston, TX, USA, 2Novartis, US Health Economics and Outcomes Research, East anover, NJ, USA, 3GlaxoSmithKline, Research Triangle Park, NC, USA

Objectives: Medications in COPD can be effective in improving health outcomes and reducing costs if they are used appropriately by patients. Only 40 – 60% of individuals with COPD adhere to pharmacotherapy. The goal of this study is to describe medication use behavior and estimate exacerbation risk and healthcare expenditure among newly diagnosed COPD patients.  Methods: Using the Truven commercial and claims encounter database, this retrospective longitudinal study included 17,785 COPD patients newly initiating maintenance therapy (index date) between January, 2011 to Dec, 2011. Medication adherence was assessed using proportion of days covered (PDC). PDC values ranged from 0 to 1 which were calculated yearly over a two year rolling index follow-up period. The association of adherence with exacerbations and healthcare expenditure were estimated using logistic regression and gamma generalized linear models, respectively, adjusting for socio-demographics, comorbidities, comedication use and proxy measures of disease severity.  Results: Only 58% of newly diagnosed COPD patients were adherent (PDC> 0.80) in the first

year of maintenance medication use and the adherence rates decreasedto 28% (PDC> 0.80) during the second year. After controlling for baseline exacerbation rates and healthcare expenditure, patients with PDC < 0.80 exhibited higher risk of exacerbations (OR =  1.55, 95% CI: 1.35 – 1.79) and higher total healthcare ($784.06) and pharmacy expenditure ($543.12) driven by cost of short acting medications, compared with patients with PDC ≥ 0.80. Medical expenditure was similar across adherent and non-adherent patients with a new diagnosis of COPD.  Conclusions: Only 1 in 4 COPD patients remained adherent to maintenance medication treatment during the second year. Improved adherence in the first year of maintenance therapy use was significantly associated with reduced risk of exacerbation and lower healthcare expenditure. Being adherent to long acting medications reduced co-medication costs associated with short acting medications. PRS60 Assessment Of Medicare Advantage Prescription Drug Coverage Gap Among Copd Patients: Analysis Of Hospitalization Use Bhansali A1, Sansgiry SS2, Serna O3, Fleming ML4, Abughosh S4, Kamdar M5, Stanford R6 1University of Houston College of Pharmacy, Houston, TX, USA, 2The University of Houston, Houston, TX, USA, 3Cigna HealthSpring, Houston, TX, USA, 4University of Houston, Houston, TX, USA, 5Glaxo Smith Kline, Research Triangle Park, NC, USA, 6GlaxoSmithKline, Research Triangle Park, NC, USA

Objectives: More than a third of chronic obstructive pulmonary disease (COPD) patients enter Medicare coverage gap or donut hole every year increasing the cost sharing burden. This analysis assessed the association of falling into the coverage gap on number of hospitalization, ER visit/s and time to hospitalization among COPD patients.  Methods: A retrospective cross-sectional cohort study was conducted using Cigna-HealthSpring Medicare Advantage database, which captures members in south eastern Texas. Subjects were included if they had ≥  ICD-9 code (491.XX, 492.XX, 496.XX) for COPD, from their medical claims between January 1, 2011 and December 31, 2013. Three cohorts were compared: 1) patients not in coverage gap 2) patients in the gap and 3) those in gap with catastrophic coverage. Cohorts were matched 1:1 based on their propensity score calculated on age, plan type, index year, and Charlson Co-morbidity Index (CCI). Chi-square was used to compare resource utilization, and Cox proportional hazards model was used to compare time to hospitalization across the matched cohorts.  Results: A total of 3,142 COPD patients were identified with 79% in no gap, 10% in gap and 11% in gap with catastrophic coverage. Matched COPD patients who fall in gap (54%) compared to those not in gap (48%) differed significantly (p< .01) in total hospitalization and ER visits. Patients within gap (HR: 1.35, p < .001) and gap with catastrophic coverage (HR: 1.44, p< .001) have a likelihood of being hospitalized compared to patients in no gap while controlling for CCI, age and sex.  Conclusions: COPD patients who fall into the coverage gap have higher resource utilization than those that do not reach the gap. Patients in coverage gap and those in gap with catastrophic coverage were more likely to be hospitalized than those in no gap. Those that reach the coverage gap may be at greater risk of hospitalization. PRS61 Burden Of Respiratory Illness In A Multicentric Hospital Registry: The Argentine-Health Care Cost And Utilization Study Insua J Hospital Universitario Austral, Argentina, Argentina

Objectives: To measure the burden of respiratory illness (RI) among adults in a multicentric hospital outcome, utilization and cost study in Argentina (A-HCUPs).  Methods: data of 1 year output of 3 university hospitals, used CCS primary diagnosis (Dx1) (Software-level CCS-SL, 2009 Clinical classification,HCUPs (USA.), (CCS # mean [descriptive term]), total costs (CT $), (mean $) and median cost per discharge ($, 25P-75P-percentiles), in $I (1Arg $ =  1,608 PPP, 2008). Hospital Mortality, 30 day (30 day ReH) re-admissions obtained. RI was defined as #CCS SL: #122: Pneumonia ; 123: Influenza; 124: tonsillitis; 125: bronchitis; 126: Other infections; 127: bronchiectasis, COPD; 128: Asthma; 129: Aspiration Pn.; 130: pleurisy; pneumothorax; Pul. collapse; 131: Respiratory failure; insufficiency; arrest (adult); 132: RIL, external agents; 133: Other inferior RI; 134: Other upper tract RI.  Results: 45,466 discharges ≥  19 years of age, RI prevalence was 3,169 disch. (6.97%, 6.74 to 7.20) with CCS 122-134 Total: 1,628 women (51.05%) and 1,541 men (48 , 95%). Most frequent CCS was # 122 =  1359 (2.98, 95CI 2.83 -3.15). Ranking for men was CCS 122 (1), CCS 127 (2), CCS 133 (3) and CCS 130 (4); while women CCS 133 (2) and CCS classified 127 (3). CCS 133 lower respiratory ill-defined conditions are prevalent. The case fatality rate for RI was 12.33% (11.23 to 13.52) (range 33.12%,Aspiration pneumonia (CCS 129) to 0% (CCS 123,124,125,126, 128).Using CCS SL 1 Dx TC$ PPP = R $ 2,642,522; average (I $) =  14,559; Median =  $ 2,385 (=  $ 1,299 25P, 75P =  $ 5,583). Re H 365 days for CCS 122-134 are equal to 1722 (3.78%, 3.61 to 3.96) and 30 days ReH =  625 (1.37%, 1.27 to 1.49).  Conclusions: Mortality, readmissions and costs of respiratory CCS codes obtained show significant burden in 1Dx of minimum discharge data set. PRS62 Analysis Of Relationship Between Temperature Differences And Asthma Using Claims Database Matsuyama S Milliman, Tokyo, Japan

Objectives: According to the Asthma and Allergy Foundation of America, about 25.9 Million Americans have asthma and it has been increasing. Although children had higher prevalence of asthma compare with elderly people, the mortality was highest for the patients aged 65 or older. Many possible factors for asthma are reported including smoking, air pollutions, and climate. However, quantitative observation is not enough especially for elderly people. We analyzed the relationship between disorder and climate.  Methods: The Medicare data and the data of National Centers for Environmental Information from 2010 to 2013 were employed. Patients with asthma were identified by ICD9 codes and we extracted the patients with asthma in Miami by county. The climate data in the region was obtained from