Abstract
Background
Maintaining continuity of care after schizophrenia-related hospitalization is challenging for patients and healthcare providers and systems. Prior evidence suggests that second-generation long-acting injectable antipsychotics (SGLAIs) may reduce the risk of treatment nonadherence and readmission versus oral atypical antipsychotics (OAAs). Therefore, quality measures were compared between patients initiated on SGLAIs and OAAs in the United States.
Methods
Adults newly initiated on an SGLAI or OAA during a schizophrenia-related inpatient stay were identified in HealthVerity databases (01/2015–12/2020); the index date was the hospital discharge date. Patients had continuous health insurance coverage for pharmacy and medical services for 6 months pre-admission and post-discharge from the inpatient stay and ≥1 pharmacy or medical claim (i.e. treatment as indicated by the observed insurance claims) for an antipsychotic other than the index SGLAI or OAA in the 6 months pre-admission. Antipsychotic use and adherence, and schizophrenia-related readmissions and outpatient visits were compared during the 6-month period post-discharge. Characteristics between cohorts were balanced using inverse probability weights.
Results
Post-discharge, only 36.9% and 40.7% of weighted SGLAI (N = 466) and OAA (N = 517) patients had ≥1 pharmacy or medical claim for the antipsychotic initiated during the inpatient stay, among whom SGLAI patients were 4.4 times more likely to be adherent to that antipsychotic compared to OAA patients (p < .001). Additionally, SGLAI patients were 2.3 and 3.0 times more likely to have a pharmacy or medical claim for and be adherent to any antipsychotic relative to OAA patients (including index antipsychotic; all p < .001). Within 7 and 30 days post-discharge, 1.7% and 13.0% of SGLAI patients and 4.1% and 12.6% of OAA patients had a readmission. Further, SGLAI patients were 51% more likely to have an outpatient visit compared to OAA patients (p = .044).
Conclusions
Less than half of patients initiated on antipsychotics during a schizophrenia-related inpatient stay continued the same treatment post-discharge. However, SGLAI patients were more likely to be adherent to the initiated antipsychotic and to have an outpatient visit, which may suggest improved continuity of care post-discharge relative to OAA patients.
Introduction
Schizophrenia is a chronic and severe psychiatric illness characterized by various symptoms, including periods of delusions, hallucinations, thought disorder, and catatonic behavior, which remit and recur over timeCitation1,Citation2. Diagnosis typically occurs during the late teen years and young adulthood prior to the age of 40 yearsCitation3. The prevalence of schizophrenia is estimated to range between 0.25% and 0.64%Citation4–6, with higher estimates ranging from 2.16% to 4.01% reported among Medicaid beneficiariesCitation7.
The American Psychiatric Association (APA) recommends that patients with schizophrenia be treated with antipsychotic (AP) medication as part of a person-centered treatment plan that includes both pharmacologic and non-pharmacologic therapyCitation8. Treatment goals include promoting and maintaining recovery, maximizing quality of life and adaptive functioning, and reducing or eliminating symptomsCitation8. For patients who have been hospitalized, poor outcomes including poor medication adherence, rehospitalization, and institutionalization, are common post-dischargeCitation9–11. Additionally, symptomatic relapse is common, with prior evidence demonstrating an average of about 1.6 relapses per year among newly treated Medicaid beneficiaries with schizophreniaCitation12. In 2012, more than one-fifth of patients with a schizophrenia-related inpatient admission in the US were readmitted for any cause within 30 days, the highest number reported among adult Medicaid beneficiariesCitation13,Citation14. Readmissions are associated with a substantial economic burden, with Medicaid cost estimates for all-cause 30-days readmissions among patients with schizophrenia-related inpatient admission reaching $302 million in 2011Citation15.
As such, quality of care measures aimed at reducing the risk of readmissions among patients with schizophrenia are evaluated by the Centers for Medicare and Medicaid Services (CMS) based on Healthcare Effectiveness Data and Information Set (HEDIS) performance measures, which include readmissions within 7 and 30 days after discharge, outpatient visits, an AP dispensing 2 days before or within 30 days after discharge, and AP adherenceCitation16. Adherence to APs has been established as a contributing factor to reducing the risk of schizophrenia-related relapseCitation17,Citation18. Given the improved treatment adherence and clinical outcomes associated with long-acting injectable (LAI) AP treatment for schizophrenia compared to oral APsCitation19,Citation20, LAIs are recommended for patients transitioning between settings (e.g. at inpatient discharge) when the risk of nonadherence may be increasedCitation8.
A prior claims-based analysis of patients who received oral APs or LAIs within 30 days post-discharge from a schizophrenia-related hospitalization found that within 6 months post-discharge, patients treated with second-generation LAI therapies (SGLAIs) were 68% less likely to be nonadherent to the initiated AP and 41% less likely to have a schizophrenia-related readmission relative to patients treated with oral APsCitation21. Notably, this study focused on patients who had poor adherence to oral APs during the 6 months prior to the index hospitalization, and the earlier data cut (2010–2013) resulted in a different breakdown of SGLAIs used (e.g. aripiprazole was not included)Citation21. Post-discharge continuity of care continues to pose challenges for patients as well as healthcare providers and systemsCitation22. Identifying barriers to care continuity among patients transitioning between settings should be prioritized to prevent disruptions in patient care. Therefore, the objective of this study was to provide an updated comparison of HEDIS-informed quality measures (AP use and treatment patterns, continuity of care, and healthcare resource utilization [HRU]) between patients initiated on SGLAIs and OAAs during a schizophrenia-related inpatient stay, regardless of prior adherence history.
Methods
Data source
Data were derived from the HealthVerity platform, which integrates medical and pharmacy claims, electronic medical records, and hospitalization data from several private sources. De-identified patient-level data from January 1, 2015 to December 31, 2020 from a large hospital inpatient database (named “Private Source 88”) were linked through a matching and tokenization process to a closed provider-identifiable payer administrative claims database (named “Private Source 20”). The hospital inpatient database includes data on hospital services, diagnosis, medication use, medical devices, procedures, equipment fees, supplies, and evaluations for nearly 400 major hospitals and health systems in the United States. The payer administrative claims database includes transaction-level medical and pharmacy claims from 150 unique payers in all 50 states in the United States, with a mix of patients covered by commercial insurance (∼56%), Managed Medicaid (∼39%), and Medicare Advantage (∼5%) plans. This database provides information on insurance enrollment dates, demographic characteristics (including state of residence), physician visits, hospitalizations, long-term care services, and prescription drugs and other services. Additional information can be found onlineCitation23.
Per Title 45 of Code of Federal Regulations, Part 46.101(b)(4), the analysis of this study is exempt from institutional review for the following reasons: (a) it is a retrospective analysis of existing data with no patient intervention or interaction, and (b) no patient identifiable information is included in the datasetsCitation24.
Study design and patient selection
A retrospective longitudinal cohort design was used to compare patients newly initiated on an SGLAI (SGLAI cohort) or an OAA (OAA cohort) during an inpatient stay in the United States (Supplementary Figure 1). The index date was defined as the discharge date from a schizophrenia-related inpatient stay where the patient was newly initiated on an SGLAI or an OAA (i.e. index inpatient stay), to evaluate the continuity of care post-discharge. New initiation was defined as having no pharmacy or medical claims for the index SGLAI or OAA (i.e. no treatment with the index SGLAI or OAA based on observed insurance claims) in the 6 months prior to the start of the index inpatient stay. Study cohorts were mutually exclusive; patients meeting inclusion criteria for both cohorts (i.e. newly initiated on an SGLAI and an OAA during different schizophrenia-related inpatient stays; N = 11) were randomly assigned to either the SGLAI (n = 6) or OAA (n = 5) cohort using a uniform distribution. The baseline period was defined as the 6-month period prior to the index date, while the follow-up period spanned the 6-month period following the index date.
Inclusion criteria
Study inclusion and exclusion criteria details are reported in Supplementary Figure 2. Adults (aged 18 to 64 years) with a schizophrenia-related inpatient stay (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM]: 295.xx [excluding 295.7x]; International Classification of Diseases, 10th Revision, Clinical Modification [ICD-10-CM]: F20.xx, F21) were included. The first observed inpatient stay meeting the following criteria was defined as the index inpatient stay: ≥1 diagnosis for schizophrenia during the inpatient stay; no insurance claims with a diagnosis for bipolar disorder (ICD-9-CM: 296.4x, 296.5x, 296.6x, 296.7, 296.80, 296.89; ICD-10-CM: F31.xx) during the inpatient stay; ≥1 pharmacy or medical claim (i.e. treatment as indicated by the observed insurance claims) for a newly initiated SGLAI (SGLAI cohort) or OAA (OAA cohort) during the inpatient stay that was not received during the 6 months prior to the start of the inpatient stay; ≥1 insurance claim with a diagnosis for schizophrenia any time during the study period, except for during the inpatient stay; ≥6 months of continuous health insurance coverage for pharmacy and medical services preceding the start of and following discharge from the inpatient stay; ≥1 pharmacy or medical claim for an AP other than the index SGLAI (SGLAI cohort) or OAA (OAA cohort) in the 6 months prior to the start of the inpatient stay. Therefore, included patients were newly initiated on their index SGLAI (SGLAI cohort) or OAA (OAA cohort), but were not naïve to AP treatment.
Exclusion criteria
Patients were excluded if they had: any insurance claims for the index SGLAI or OAA in the 6 months prior to the start of the index inpatient stay; ≥1 insurance claim for an LAI in the 6 months prior to the start of the index inpatient stay or during the index inpatient stay (prior to the initiation of the index SGLAI for the SGLAI cohort); >1 type of SGLAI agent used during the index inpatient stay (SGLAI cohort only); or ≥1 insurance claim for clozapine at any time during or before the index inpatient stay.
Study measures
Patient demographic and clinical characteristics during the baseline period were identified in Private Sources 20 and 88 and reported for the SGLAI and OAA cohorts. Index inpatient stay characteristics (length of stay, the total charged amount in 2020 US dollars, admission source, most common admitting diagnoses, and discharge status) were identified in Private Source 88 and were described for each treatment cohort. The following quality measures, informed by HEDIS performance measuresCitation16, were identified in Private Source 20, based on medical and pharmacy claims, and were compared between treatment cohorts during the follow-up period: AP use, including adherence (measured as the proportion of days covered [PDC] ≥ 0.80; PDC was defined as the sum of non-overlapping days of supply of the medication divided by 6 months) and persistence (no gap of >30 or >60 days); continuity of care, including schizophrenia-related outpatient visits and inpatient readmissions; monthly all-cause HRU, including inpatient admissions, emergency room (ER) visits, outpatient visits, and other services.
Statistical analysis
Baseline and inpatient stay characteristics in the SGLAI and OAA cohorts were balanced using inverse probability of treatment weighting (IPTW) to estimate the average treatment effect. Weights were calculated from propensity scores generated using probability estimates from a multivariable logistic regression model in which initiation of an SGLAI was the binary dependent variable and patient characteristics were considered predictors; characteristics included in the model are presented in and . The balance of baseline characteristics between cohorts after weighting was assessed with standardized differences (<10% considered well-balanced)Citation25. In addition, p-values were reported using t-tests for continuous variables and chi-square tests or ’Fisher’s exact tests for categorical variables.
Table 1. Patient characteristics evaluated during the 6-Month baseline period.
Table 2. Characteristics during the index inpatient stayTable Footnotea.
Quality measures were compared between the weighted SGLAI and OAA cohorts. For binary variables, a binomial distribution with a logit link was used to calculate odds ratios (ORs). For count variables, a Poisson distribution with a log link was used to calculate incidence rate ratios (IRRs). Nonparametric bootstrap procedures with 500 replications were used to calculate 95% confidence intervals (CIs) and p values associated with the ORs and IRRs. Multiplicity adjustments were not conducted.
Results
Baseline patient characteristics and index inpatient stay characteristics
A total of 180 patients diagnosed with schizophrenia were included in the SGLAI cohort and 803 patients in the OAA cohort (Supplementary Figure 2). After weighting, patient characteristics were well-balanced between the SGLAI (N = 466) and OAA cohorts (N = 517; ). In the SGLAI cohort, the mean age was 40.5 years, 35.6% of patients were female, and 87.0% had Medicaid coverage. In the OAA cohort, the mean age was 40.6 years, 34.2% of patients were female, and 86.1% had Medicaid coverage.
The average ± standard deviation (SD) length of index inpatient stay was 14.3 ± 20.7 days for the SGLAI cohort and 13.0 ± 29.7 days for the OAA cohort (). Most patients were admitted based on physician referral (56.9% in the SGLAI cohort and 59.7% in the OAA cohort). Although all patients analyzed had a diagnosis for schizophrenia during the index inpatient stay, among the SGLAI and OAA cohorts, the admitting diagnosis was schizophrenia in 42.6% and 37.8% of patients, psychoses in 20.1% and 15.9% of patients, and suicidal ideation in 6.9% and 6.2% of patients, respectively. Most patients in both cohorts were discharged to home or self-care (84.4% for the SGLAI cohort and 80.6% for the OAA cohort).
AP use
SGLAI patients were 2.3 times more likely to have a pharmacy or medical claim for any AP compared to OAA patients (82.7% vs 67.9%, respectively; p < .001; ) and 6.0 times more likely to have a claim for any LAI relative to OAA patients (44.8% vs 11.9%, respectively; p < .001; ) within 6 months of discharge. Additionally, SGLAI patients were 3.0 times more likely to be adherent to any AP and 4.4 times more likely to be adherent to the index AP based on a proportion of days covered ≥0.80 compared to OAA patients (41.5% vs 19.1% and 20.0% vs 5.4%, respectively; all p < .001). Among patients with ≥1 index AP pharmacy or medical claim after discharge (36.9% of the SGLAI cohort and 40.7% of the OAA cohort), SGLAI patients were 7.8 times more likely to be adherent to the index AP relative to OAA patients (54.3% vs 13.2%, respectively; p < .001). At 6 months after discharge, SGLAI patients were 2.3 and 1.5 times more likely to be persistent to the index AP compared to OAA patients, based on no gap >30 days (21.4% vs 10.8%; p < .001) and no gap >60 days (23.8% vs 17.3%; p = .044), respectively.
Figure 1. Weighted AP use during the 6-month post-discharge follow-up period1. Abbreviations. AP, antipsychotic; CI, confidence interval; OR, odds ratio; PDC, proportion of days covered; SGLAI, second-generation long-acting injectable; SGOAP, second-generation oral antipsychotic. 1Inverse probability weights were used to obtain a balanced sample. Weights were estimated using a multivariable logistic regression model, and baseline covariates included all demographic and clinical characteristics reported in . 2CIs and p values were estimated from a nonparametric bootstrap procedure with 499 bootstrap resamples. At each bootstrap resample, the inverse probability of treatment weights were re-estimated. 3PDC was calculated for any AP and for the index AP. PDC to any AP was calculated among all patients; PDC for the index AP was calculated among all patients and among patients with ≥1 claim for the index AP during the observation period. PDC was defined as the sum of nonoverlapping days of supply for any AP or for the index AP divided by 6 months. Among patients in the SGLAI cohort, PDC calculations incorporated days of supply for the index SGLAI during the index inpatient stay that overlapped with the follow-up period. 4Persistence was calculated among all patients defined as the proportion of patients with no gap in index AP treatment of >30 or >60 days. Treatment gaps were assessed at 6 months based on gaps from the date of discharge to the date of the next claim or end of the 6-month period and from the end of the days of supply of the previous claim to the date of the next claim or end of the 6-month period. Among patients in the SGLAI cohort with days of supply for the index SGLAI during the index inpatient stay that overlapped with the follow-up period, the first day of index AP supply was the date of discharge.
Healthcare resource utilization
During the 6-month follow-up period, patients initiated on an SGLAI had 26% fewer days with all-cause ER visits per month than patients initiated on an OAA (mean 0.43 days vs 0.58 days; p = .044; ). All-cause inpatient admissions and outpatient visits were similar among SGLAI and OAA cohorts, with nearly half of the patients having at least one inpatient admission (43.2% vs 46.6%; p = .357) and most patients having at least one outpatient visit (84.9% vs 84.6%; p = .846).
Figure 2. Weighted all-cause healthcare utilization during the 6-month post-discharge follow-up period1. Abbreviations. CI, confidence interval; IRR, incidence rate ratio; OAA, oral atypical antipsychotic; OR, odds ratio; SGLAI, second-generation long-acting injectable. 1Inverse probability weights were used to obtain a balanced sample. Weights were estimated using a multivariable logistic regression model, and baseline covariates included all demographic and clinical characteristics reported in . 2CIs and p values were estimated from a nonparametric bootstrap procedure with 499 bootstrap resamples. At each bootstrap resample, the inverse probability of treatment weights were re-estimated.
Continuity of care
Within 30 days after discharge, patients treated with SGLAIs were 51% more likely to have a schizophrenia-related outpatient visit compared to patients treated with OAAs (36.3% vs 27.4%, respectively; p = .044; ). A numerically higher proportion of patients in the SGLAI cohort versus the OAA cohort had a schizophrenia-related outpatient visit within 7 days (14.3% vs. 11.9%, respectively) and 14 days (22.8% vs. 17.6%, respectively) post-discharge. Schizophrenia-related inpatient readmissions were not statistically different between the treatment cohorts within 30 days post-discharge (13.0% in the SGLAI cohort and 12.6% in the OAA cohort). However, a numerically lower proportion of patients in the SGLAI cohort relative to the OAA cohort had readmissions within 7 days (1.7% vs. 4.1%, respectively) and 14 days (4.9% vs. 7.6%, respectively).
Figure 3. Weighted schizophrenia-related healthcare utilization during the 6-month post-discharge follow-up period1,2. Abbreviations. CI, confidence interval; ICD-9-CM/ICD-10-CM, International Classification of Diseases, 9th/10th Revision, Clinical Modification; IRR, incidence rate ratio; OAA, oral atypical antipsychotic; OR, odds ratio; SD, standard deviation; SGLAI, second-generation long-acting injectable. 1Inverse probability weights were used to obtain a balanced sample. Weights were estimated using a multivariable logistic regression model, and baseline covariates included all demographic and clinical characteristics reported in . 2Schizophrenia-related health resource utilization was defined as claims with an ICD-9-CM diagnosis of 295.xx [excluding 295.7x] or an ICD-10-CM diagnosis of F20.xx or F21. 3CIs and P values were estimated from a nonparametric bootstrap procedure with 499 bootstrap resamples. At each bootstrap resample, the inverse probability of treatment weights were re-estimated.
![Figure 3. Weighted schizophrenia-related healthcare utilization during the 6-month post-discharge follow-up period1,2. Abbreviations. CI, confidence interval; ICD-9-CM/ICD-10-CM, International Classification of Diseases, 9th/10th Revision, Clinical Modification; IRR, incidence rate ratio; OAA, oral atypical antipsychotic; OR, odds ratio; SD, standard deviation; SGLAI, second-generation long-acting injectable. 1Inverse probability weights were used to obtain a balanced sample. Weights were estimated using a multivariable logistic regression model, and baseline covariates included all demographic and clinical characteristics reported in Table 1. 2Schizophrenia-related health resource utilization was defined as claims with an ICD-9-CM diagnosis of 295.xx [excluding 295.7x] or an ICD-10-CM diagnosis of F20.xx or F21. 3CIs and P values were estimated from a nonparametric bootstrap procedure with 499 bootstrap resamples. At each bootstrap resample, the inverse probability of treatment weights were re-estimated.](/cms/asset/730e7f17-e683-4acc-a416-fea3a057ce97/icmo_a_2237833_f0003_b.jpg)
Discussion
In this retrospective study of patients newly initiated on an SGLAI or OAA during a schizophrenia-related inpatient stay, patients who were initiated on SGLAIs demonstrated improved adherence and persistence to the initiated AP post-discharge compared to patients who were initiated on an OAA. Patients initiated on SGLAIs were more likely than those initiated on OAAs to have an outpatient follow-up visit within 30 days post-discharge, and a numerically lower number of patients in the SGLAI cohort had schizophrenia-related readmission within 7 and 14 days relative to the OAA cohort.
The observed improvements in AP adherence and persistence for patients initiated on SGLAIs relative to OAAs are consistent with recent claims-based analyses evaluating outcomes post-discharge among patients with a recent schizophrenia-related hospitalizationCitation21,Citation26. However, after discharge, less than half of the patients in each cohort continued the same AP initiated during the schizophrenia-related inpatient stay. Reasons for treatment discontinuation are not available in the data source, but several factors associated with nonadherence have previously been documented, including lack of insight, medication side effects, lack of caregiver support or stable housing, dose frequency, and medication costsCitation11,Citation27–30. These results may also be indicative of a lack of transition planning or care coordination post-dischargeCitation22. Additionally, a change in reimbursement between inpatient and outpatient settings may be a contributing factor to patients not continuing the index AP (e.g. Medicare Part D drug coverage requires separate enrolment than Medicare Part A hospital insurance)Citation31, although additional studies are needed to support this hypothesis.
Patients treated with SGLAIs were more likely to have a schizophrenia-related outpatient visit within 30 days post-discharge. However, this represented just over one-third and one-quarter of patients in the SGLAI and OAA cohorts, respectively, which is lower than prior research on a 2003 national sample of Medicaid patients conducted by Olfson et al. In the prior study, 59.3% of patients with a schizophrenia-related inpatient admission had a schizophrenia-related outpatient visit within the same timeframeCitation32. In the current study, within 7 days post-discharge, a numerically higher proportion of patients in the SGLAI relative to the OAA cohort had a schizophrenia-related outpatient visit (14.3% vs. 11.9%). However, both of these values were similarly lower than that reported by Olfson et al. with more than one-third of patients (41.7%) with a schizophrenia-related hospitalization having a schizophrenia-related outpatient visit within 7 daysCitation32. Differences in study design, population, and study timeframes may explain the lower proportion of schizophrenia-related outpatient visits post-discharge observed in the current study relative to Olfson et al.Citation32. Irrespective of the reason for the discrepancy, given that outpatient visits post-discharge have been associated with a reduction in schizophrenia-related relapsesCitation33,Citation34, timely outpatient follow-up is critical to minimize readmissions and improve patient outcomes.
Within 30 days post-discharge, schizophrenia-related readmissions were similar across cohorts (13.0% and 12.6% of patients in the SGLAI and OAA cohorts, respectively), which is aligned with Healthcare Cost and Utilization Project data from 2012 that cited this proportion as 15.7%Citation13. However, relative to patients in the SGLAI cohort, a numerically higher proportion of patients in the OAA cohort had schizophrenia-related readmission within 7 and 14 days, while the average length of stay for the index inpatient stay was shorter. Given prior work has found that shorter lengths of stay are associated with a shorter time to readmissionCitation35, careful emphasis should be placed to ensure patients are not discharged prematurely and that continuity of care among patients transitioning between settings is prioritized.
Quality measures evaluating continuity of care post-discharge remain important elements for schizophrenia disease management and are critical objectives for CMS to reduce the economic burden associated with hospital readmissions. In 2011, inadequate care coordination resulted in between $25 billion and $45 billion in unnecessary spending, in part due to unnecessary hospital readmissionsCitation36. While not included as part of HEDIS quality metrics, alternative measures such as the use of transition coaches (e.g. nurses/social workers who meet patients in the hospital and follow up through home visits and phone calls for 4 weeks post-discharge) to promote the development of patients’ skills at managing medication and follow-up care have been found to reduce 30-days hospital readmissions by 30%Citation36. Furthermore, additional transition of care measures such as receipt of discharge information, post-discharge medication reconciliation, post-discharge patient engagement through home or telehealth visits, and relationship continuity with hospital staff membersCitation16,Citation37 were not evaluable in the current data source but warrant consideration in future analyses evaluating post-discharge continuity of care among patients with schizophrenia.
Taken together with the literature, results from this study suggest that while patients treated with SGLAIs demonstrated improved continuity of care relative to those treated with OAAs, a notable proportion of patients with schizophrenia did not receive care that is aligned with HEDIS-informed quality measures, including AP use, outpatient follow-up visits, and inpatient readmissions post-dischargeCitation16. Transitions of care from hospital to community services are critical for patients with schizophrenia; recommendations include patient engagement in discharge planning, education and promotion of medication self-management, organizing post-discharge outpatient services, and crisis planningCitation38. Special emphasis should be made on building and maintaining the therapeutic relationship, given that therapeutic alliance has been shown to contribute to higher patient satisfaction and better adherence to medicationCitation39. In addition, alternative interventions such as psychosocial education and electronic reminders should be considered to improve outcomes in this high-risk populationCitation34.
Limitations
This study is subject to limitations. First, as with all claims-based studies, billing inaccuracies and missing data may have occurred. Relatedly, information related to the past history of compliance and course of illness, as well as reasons for HRU (beyond diagnosis or procedure codes), were not available in the data. The use of a 6-month threshold to define new treatment initiation may have resulted in the inclusion of some patients who re-initiated the index SGLAI or OAA after >6 months of discontinuation. Additionally, although the matching used to link patient records across data sources has high precision, perfect accuracy for identifying all claims for a patient or all matches is not guaranteed. The current study evaluated outcomes among patients treated in a large hospital network with overlapping continuous insurance eligibility; thus, the results may not be generalizable to patients treated at hospitals outside the network or those without health insurance. Furthermore, prescription fills (i.e. observed insurance claims) do not account for whether the medication dispensed was taken as prescribed, which may potentially overestimate adherence. Mental health-related diagnoses may be underreported in the claims data due to stigma. Despite the use of IPTW, residual confounding due to unmeasured confounders may exist, and limitations inherent to retrospective studies, such as the lack of patient randomization and inability to determine causation, also apply. Moreover, requiring fixed 6-month follow-up period post-index may have led to immortal time bias, to the degree that patients with schizophrenia that were well-controlled may have been selected and more severe patients who were lost to institutionalization may have been excluded. Lastly, the size of the SGLAI cohort was relatively small, so further studies using larger sample sizes are warranted to confirm these findings.
Conclusions
Following the CMS HEDIS quality measures, patients initiated on SGLAIs during a schizophrenia-related inpatient stay demonstrated improved continuity of care relative to patients initiated on OAAs. More specifically, relative to patients initiated on OAAs, patients initiated on SGLAIs were more likely to have a schizophrenia-related outpatient visit within 30 days post-discharge, were more likely to be adherent and persistent to the index AP, and had fewer days with ER visits during the 6-month post-discharge period. The majority of patients in both cohorts had a claim for any AP post-discharge; however, less than half of patients continued the AP initiated during the inpatient admission. Further research is warranted to identify the reasons for AP discontinuation and to determine if improved AP persistence and continuity of care post-discharge translates to better short- and long-term clinical outcomes among patients with schizophrenia.
Transparency
Declaration of funding
Financial support for this research was provided by Janssen Scientific Affairs, LLC. The study sponsor was involved in several aspects of the research, including the study design, the interpretation of data, the writing of the manuscript.
Declaration of financial/other relationships
CP and CB are employees of Janssen Scientific Affairs, LLC and stockholders of Johnson & Johnson.
DP, LM, CH, MHL, and PL are employees of Analysis Group, Inc., a consulting company that has provided paid consulting services to Janssen Scientific Affairs, LLC, which funded the development and conduct of this study and manuscript. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.
Author contributions
All authors meet the 4 ICMJE criteria for authorship of this manuscript. DP, LM, CH, MHL, and PL contributed to study conception and design, collection and assembly of data, and data analysis and interpretation. CP and CB contributed to study conception and design, data analysis and interpretation. All authors reviewed and approved the final content of this manuscript.
Previous presentation
Part of the material in this manuscript was presented at Psych Congress 2022 from September 17-20 in New Orleans, LA.
CMRO-2023-FT-0161 - Supplementary Material - 05-12-2023.docx
Download MS Word (66.7 KB)Acknowledgements
Medical writing support was provided by Cody Patton, BSc, an independent consultant, and Analysis Group, Inc., a consulting company that has provided paid consulting services to Janssen Scientific Affairs, LLC., which funded the development and conduct of this study and manuscript.
Data availability statement
The authors declare that the data supporting the findings of this study are available within the article and its supplementary information files.
Data that support the findings of this study were used under license from HealthVerity. Restrictions apply to the availability of these data, which are not publicly available and cannot be shared. The data are available through request made directly to the data vendor, subject to the data vendor’s requirements for data access.
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