Healthcare utilization and costs incurred by patients with major depression after being switched from escitalopram to another SSRI for non-medical reasons

Figures & data

Figure 1. Sample counts by selection criteria. MDD, major depressive disorder; SSRI, selective serotonin reuptake inhibitor.

Table 1.  Demographics, comorbidities, healthcare utilization and healthcare costs — 3-month baseline period switching from escitalopram to another SSRI.

Baseline characteristics^1	Switch to another SSRI (switching sample) [A]	Continue escitalopram (control sample)^2 [B]	Difference^3 [A]–[B] or [A]/[B]	p-value^4 [A] vs. [B]
Study sample (n)	2,805	2,805
Demographic characteristics
Age on index date (mean, SD)	45.9 (13.6)	45.9 (13.6)	0.0	1.0000
Female (%)	74.2	74.2	1.0	1.0000
Year of index date (%)				1.0000
Year 2003	15.3	15.3
Year 2004	32.3	32.3
Year 2005	36.5	36.5
Year 2006	16.0	16.0
Deyo-Charlson comorbidity index (mean, SD)	0.3 (0.91)	0.3 (0.89)	0.04	0.1236
Comorbidity profile (%)
Mental diseases
Schizophrenia	0.6	0.1	8.1	0.0010*
Other psychotic disorders	0.8	0.5	1.7	0.1282
Dementia	0.6	0.4	1.5	0.2393
Generalized anxiety disorder	4.8	4.7	1.0	0.9497
Phobia	1.4	1.1	1.3	0.3390
Panic disorder	2.1	1.9	1.2	0.4456
Obsessive-compulsive disorder	1.8	1.0	1.8	0.0139*
Posttraumatic stress disorder	2.0	2.1	1.0	0.9230
Alcohol abuse	2.1	2.1	1.0	0.8514
Drug abuse	3.3	2.5	1.3	0.0647
Sleeping disorder	2.4	2.0	1.2	0.2965
Eating disorder	1.0	0.9	1.1	0.7855
Other comorbidities
Cancer	2.8	2.9	1.0	0.7488
Renal disease	1.0	0.9	1.2	0.5862
Cardiovascular disease	8.1	6.6	1.2	0.0264*
Hypertension	12.8	10.6	1.2	0.0076*
Diabetes	5.6	5.6	1.0	0.9052
Parkinsonism	0.4	0.3	1.2	0.6374
Epilepsy	0.6	0.3	2.0	0.1025
Hyperlipidemia	12.3	11.6	1.1	0.3946
HIV	0.4	0.2	2.0	0.1967
Chronic obstructive pulmonary disease	7.2	5.6	1.3	0.0120*
Irritable bowel syndrome	1.8	1.1	1.6	0.0325*
Nausea	2.4	1.5	1.6	0.0147*
Malaise and fatigue	8.4	5.7	1.5	<0.0001*
Healthcare service utilization (%)
Inpatient visit	8.3	5.0	1.7	<0.0001*
Outpatient hospital visit	44.1	39.5	1.1	0.0004*
Professional services	91.9	89.4	1.0	0.0013*
ER visit	13.4	9.8	1.4	<0.0001*
Healthcare costs, $ (mean, SD)
Prescription drug	995.2 (1225.7)	795.1 (1209.3)	200.1	<0.0001*
Medical service	2496.0 (6183.2)	1953.3 (4470.6)	542.6	0.0002*
Total healthcare costs	3491.1 (6510.2)	2748.4 (4807.8)	742.8	<0.0001*

¹Baseline characteristics are measured over the 3-month pre-index period.

²Study and control samples are matched 1:1 on age, gender and index year.

³Relative risk is calculated for proportions; difference is calculated for continuous variables.

⁴Paired t-test is used for comparing continuous variables; McNemar test is used for comparing categorical variables.

*Significant at 95% level.

n, number of patients; SD, standard deviation; SSRI, selective serotonin reuptake inhibitor.

Table 2.  3-month healthcare utilization of MDD claimants by index therapy — switching from escitalopram to another SSRI.

Healthcare utilization	Switch to another SSRI (switching sample)	Continue escitalopram (control sample)^1	Relative risk [A]/[B]	p-value^2 [A] vs. [B]
	(n = 2,805)	(n = 2,805)
	[A]	[B]
Urgent care
3-month rate, any cause (%)	16.0	13.5	1.2	0.0075*
3-month rate, MDD-related (%)	4.0	2.4	1.7	0.0004*
1. Hospitalization
3-month rate, any cause (%)	8.3	6.1	1.4	0.0012*
3-month rate, MDD-related (%)	2.3	1.2	2.0	0.0012*
Hospitalization days, any cause (mean, SD)	0.7 (3.9)	0.7 (6.5)	1.0	0.9344
Hospitalization days, MDD-related (mean, SD)	0.2 (2.6)	0.2 (3.1)	1.5	0.3012
2. ER visit
3-month rate, any cause (%)	12.6	10.7	1.2	0.0266*
3-month rate, MDD-related (%)	2.4	1.5	1.6	0.0147*
Non-urgent care
3. Outpatient visit
3-month rate, any cause (%)	45.9	41.6	1.1	0.0012*
3-month rate, MDD-related (%)	8.7	5.9	1.5	<0.0001*
4. Professional services
3-month rate, any cause (%)	92.5	89.2	1.0	<0.0001*
3-month rate, MDD-related (%)	57.6	54.2	1.1	0.0093*

¹Study and control samples are 1:1 matched on age, gender and index year.

²Paired t-test is used for comparing continuous variables; McNemar test is used for comparing categorical variables.

*Significant at 95%.

ER, emergency room; MDD, major depressive disorder; SD, standard deviation; SSRI, selective serotonin reuptake inhibitor.

Table 3.  Effect of switching to another SSRI relative to continuing escitalopram on 3-month rate of urgent care and non-urgent care of MDD claimants.

Rate of care	Coefficient^1	Odds ratio or IRR^2	95% confidence interval	p-value
Urgent care
3-month rate, any cause^3	0.051	1.11	(0.949, 1.290)	0.1982
3-month rate, MDD-related^3	0.199	1.49	(1.085, 2.045)	0.0139*
1. Hospitalization
3-month rate, any cause^3	0.108	1.24	(1.002, 1.536)	0.0479*
3-month rate, MDD-related^3	0.265	1.70	(1.104, 2.618)	0.0160*
Hospitalization days, any cause^4	0.408	1.50	(1.074, 2.110)	0.0175*
Hospitalization days, MDD-related^4	1.185	3.27	(1.608, 6.661)	0.0009*
2. ER visit
3-month rate, any cause^3	0.049	1.10	(0.932, 1.307)	0.2517
3-month rate, MDD-related^3	0.160	1.38	(0.928, 2.041)	0.1125
Non-urgent care
3. Outpatient visit
3-month rate, any cause^3	0.055	1.12	(0.997, 1.248)	0.0571
3-month rate, MDD-related^3	0.193	1.47	(1.190, 1.818)	0.0004*
4. Professional services
3-month rate, any cause^3	0.169	1.40	(1.159, 1.698)	0.0005*
3-month rate, MDD-related^3	0.067	1.14	(1.026, 1.272)	0.0152*

¹A positive coefficient indicates higher risk (logistic regression) or higher likelihood of event occurrence (negative binomial regression) for claimants who switch to another SSRI.

²Odds ratio for logistic regression and IRR for negative binomial regression.

³Logistic regression is used to control for confounding factors, which include baseline healthcare utilization and comorbidities (schizophrenia, other psychotic disorders, dementia, generalized anxiety disorder, phobia, panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, alcohol abuse, drug abuse, cancer, renal disease, cardiovascular disease, hypertension, diabetes, parkinsonism, epilepsy, hyperlipidemia, HIV, chronic obstructive pulmonary disease, irritable bowel syndrome, nausea, malaise and fatigue).

⁴Negative binomial regression is used to control for confounding factors, which include baseline healthcare utilization and comorbidities.

*Significant at 95 percent level.

ER, emergency room; IRR, incidence rate ratio; MDD, major depressive disorder; SD, standard deviation; SSRI, selective serotonin reuptake inhibitor.

Table 4.  3-month healthcare costs of MDD claimants by index therapy switching from escitalopram to another SSRI.

Observed healthcare costs	Switch to another SSRI (switching sample)	Continue escitalopram (control sample)^1	Difference	p-value^2
	(n = 2,805)	(n = 2,805)	[A] – [B]	[A] vs. [B]
	[A]	[B]
Total medical cost ($)	2515	2408	108	0.6388
Total drug cost ($)	1168	1005	163	<0.0001*
Total costs ($)	3683	3413	270	0.2505

¹Study and control samples are 1 : 1 matched on age, gender and index year.

²Paired t-test is used for comparing continuous variables; McNemar test is used for comparing categorical variables.

*Significant at 95 percent level.

MDD, major depressive disorder; SSRI, selective serotonin reuptake inhibitor.

Table 5.  Multivariate regression¹ for 3-month healthcare costs of MDD claimants switching from escitalopram to another SSRI.

Estimated healthcare costs	Switch to another SSRI (switching sample)	Continue escitalopram (control sample)	Difference	p-value
	[A]	[B]	[A]–[B]	[A] vs. [B]
Total medical cost ($)	1756	1618	138	0.0084*
Total drug cost ($)	1120	971	149	<0.0001*
Total costs ($)	2808	2486	322	<0.0001*

MDD, major depressive disorder; SSRI, selective serotonin reuptake inhibitor.

[1] A generalized linear model (GLM) with a log-link function and gamma distribution was used to estimate each cost component. The model controlled for confounding factors such as selected baseline comorbidities and baseline healthcare utilization.

* Significant at 95 percent level.

Bloom BS. Prevalence and economic effects of depression. Manag Care 2004; 13: 9–16

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