Healthcare resource utilization, costs and treatment patterns in patients with bipolar disorder treated with lurasidone or cariprazine

Figures & data

Figure 1. Study design.

Table 1. Baseline demographics and clinical characteristics for patients in the lurasidone cohort and cariprazine cohort.

	Lurasidone cohort (N = 16,683)	Cariprazine cohort (N = 4,128)	p-Value
Age, mean (SD)	39.4 (14.4)	40.0 (13.6)	.015
Female, N (%)	11,791 (70.7%)	2,818 (68.3%)	.002
Payer type, N (%)
Commercial	16,054 (96.2%)	4,040 (97.9%)	<.001
Medicare	629 (3.8%)	88 (2.1%)	<.001
Geographic location, N (%)
Northeast	3,192 (19.1%)	682 (16.5%)	<.001
Midwest	3,629 (21.8%)	852 (20.6%)	.119
South	7,321 (43.9%)	2,142 (51.9%)	<.001
West	2,486 (14.9%)	445 (10.8%)	<.001
Unknown	55 (0.3%)	7 (0.2%)	.091
Average dose at treatment initiation, mg per day, mean (SD)	47.7 (75.2)	2.4 (2.6)	nr
Index medication pill strength
Lurasidone, N (%)
20 mg	6,206 (37.2%)		nr
40 mg	5,903 (35.4%)		nr
60 mg	1,990 (11.9%)		nr
80 mg	1,858 (11.1%)		nr
120 mg	593 (3.6%)		nr
Mixed	133 (0.8%)		nr
Cariprazine, N (%)
1.5 mg		2,237 (54.2%)	nr
3 mg		1,562 (37.8%)	nr
4.5 mg		188 (4.6%)	nr
6mg		94 (2.3%)	nr
Mixed		47 (1.1%)	nr
CCI score, mean (SD)	0.5 (1.1)	0.4 (1.0)	.238
Bipolar diagnosis type, N (%)
Bipolar depression	9,306 (55.8%)	2,093 (50.7%)	<.001
Bipolar mania	2,248 (13.5%)	674 (16.3%)	<.001
Bipolar mixed	1,183 (7.1%)	446 (10.8%)	<.001
Bipolar unspecified	3,946 (23.7%)	915 (22.2%)	.043
Psychiatric comorbidities, N (%)
Anxiety	9,231 (55.3%)	2,371 (57.4%)	.015
Major depressive disorder	7,526 (45.1%)	1,814 (43.9%)	.177
Substance abuse disorders	4,196 (25.2%)	958 (23.2%)	.010
Personality disorder	1,054 (6.3%)	227 (5.5%)	.050
Cardiometabolic comorbidities, N (%)
Hypertension	3,483 (20.9%)	896 (21.7%)	.243
Hyperlipidemia	2,935 (17.6%)	798 (19.3%)	.009
Obesity	2,876 (17.2%)	784 (19.0%)	.008
Type 2 diabetes mellitus	2,282 (13.7%)	568 (13.8%)	.892
Concomitant medication, N (%)
Antidepressants	11,382 (68.2%)	2,863 (69.4%)	.162
Mood stabilizers	10,069 (60.4%)	2,495 (60.4%)	.919
Atypical antipsychotics	9,802 (58.8%)	2,109 (51.1%)	<.001
Aripiprazole	2,605 (15.6%)	811 (19.7%)	<.001
Olanzapine	1,037 (6.2%)	317 (7.7%)	<.001
Quetiapine	2,910 (17.4%)	793 (19.2%)	.008
Risperidone	928 (5.6%)	249 (6.0%)	.242
Anxiolytics	8,100 (48.6%)	2,197 (53.2%)	<.001
All-cause HCRU and costs
Proportion of patients with ≥ 1 hospitalization, N (%)	3,584 (21.5%)	577 (14.0%)	<.001
Inpatient costs, mean (SD)	$5,041 ($19,346)	$3,397 ($22,088)	<.001
Total costs, mean (SD)	$15,143 ($27,229)	$12,432 ($30,076)	<.001
Psychiatric-related HCRU and costs
Proportion of patients with ≥ 1 hospitalization, N (%)	3,327 (19.9%)	522 (12.6%)	<.001
Inpatient costs, mean (SD)	$3,776 ($13,451)	$2,335 ($10,987)	<.001
Total costs, mean (SD)	$8,643 ($18,719)	$6,021 ($15,906)	<.001

Abbreviations. CCI, Charlson Comorbidity Index calculated using Quan method; HCRU, healthcare resource utilization; mg, milligram; N, number of patients; nr, not reported.

Table 2. All-cause and psychiatric-related healthcare resource utilization, unadjusted and adjusted difference-in-difference.

	Lurasidone cohort			Cariprazine cohort			Unadjusted DID	p-Value	Adjusted DID	p-Value
	6-Month pre-index	6-Month post-index	Pre-post difference	6-Month pre-index	6-Month post-index	Pre-post difference
All-cause
Inpatient hospitalization
Proportion of patients with ≥ 1 hospitalization, %	21.5%	16.2%	−5.3%	14.0%	11.4%	−2.5%	−2.8%	<.001	−1.9%	.014
Inpatient LOS, mean	2.41	1.88	−0.54	1.55	1.30	−0.25	−0.29	.029	−0.003	.985
Number of hospitalizations, mean	0.305	0.242	−0.062	0.196	0.163	−0.034	−0.029	.016	−0.015	.267
Overall outpatient visits (inclusive of ED visits, office visits, and other outpatient visits)
Proportion of patients with ≥ 1 outpatient visit, %	98.7%	98.9%	0.1%	99.1%	98.5%	−0.6%	0.7%	.004	0.7%	.003
Number of outpatient visits, mean	19.67	21.61	1.94	19.36	20.23	0.87	1.07	<.001	1.18	<.001
ED visits
Proportion of patients with ≥ 1 ED visit, %	31.0%	27.0%	−4.0%	28.1%	25.3%	−2.7%	−1.3%	.181	−0.4%	.713
Number of ED visits, mean	0.60	0.52	−0.08	0.49	0.45	−0.04	−0.04	.094	−0.01	.685
Office visits
Proportion of patients with ≥ 1 office visit, %	95.3%	96.2%	1.0%	96.0%	96.5%	0.5%	0.4%	.288	0.5%	.215
Number of office visits, mean	6.42	6.98	0.56	6.78	7.03	0.25	0.31	<.001	0.39	<.001
Other outpatient visits
Proportion of patients with ≥ 1 other outpatient visit, %	95.9%	95.6%	−0.3%	95.7%	94.5%	−1.2%	0.8%	.083	1.0%	.043
Number of other outpatient visits, mean	12.65	14.10	1.46	12.09	12.75	0.66	0.79	<.001	0.76	.002
Number of pharmacy prescriptions, mean	14.82	17.44	2.62	15.71	18.60	2.89	−0.27	.025	−0.01	.915
Psychiatric-related
Inpatient hospitalization
Proportion of patients with ≥ 1 hospitalization, %	19.9%	14.9%	−5.0%	12.6%	10.3%	−2.4%	−2.7%	<.001	−1.8%	.015
Inpatient LOS, mean	2.29	1.77	−0.52	1.48	1.22	−0.26	−0.27	.041	0.03	.883
Number of hospitalizations, mean	0.280	0.220	−0.060	0.177	0.145	−0.032	−0.028	.013	−0.013	.291
Overall outpatient visits (inclusive of ED visits, office visits, and other outpatient visits)
Proportion of patients with ≥ 1 outpatient visit, %	93.8%	94.0%	0.2%	95.4%	94.1%	−1.3%	1.5%	.001	1.6%	<.001
Number of outpatient visits, mean	11.43	11.45	0.02	11.23	10.18	−1.05	1.07	<.001	1.20	<.001
ED visits
Proportion of patients with ≥ 1 ED visit, %	17.4%	14.2%	−3.2%	15.3%	13.1%	−2.2%	−1.0%	.203	−0.1%	.854
Number of ED visits, mean	0.28	0.24	−0.04	0.22	0.20	−0.02	−0.02	.245	−0.003	.831
Office visits
Proportion of patients with ≥ 1 office visit, %	84.1%	87.2%	3.1%	88.2%	88.5%	0.3%	2.8%	<.001	3.1%	<.001
Number of office visits, mean	3.50	4.09	0.60	3.81	4.11	0.29	0.30	<.001	0.36	<.001
Other outpatient visits
Proportion of patients with ≥ 1 other outpatient visit, %	81.9%	80.7%	−1.2%	81.6%	79.2%	−2.5%	1.3%	.104	1.5%	.063
Number of other outpatient visits, mean	7.65	9.15	1.50	7.20	7.83	0.63	0.87	<.001	0.73	.001
Number of pharmacy prescriptions, mean	8.35	10.86	2.51	8.59	11.34	2.75	−0.25	.004	−0.05	.562

Abbreviations. DID, difference-in-difference; ED, emergency department; HCRU, healthcare resource utilization; LOS, length of stay; N, number of patients. Notes: The adjusted DID model controlled for age, sex, geographic region, payer type, bipolar disorder type, comorbidities, and atypical antipsychotic use during the 6-month baseline period.

Figure 2. Patient selection.

Figure 3. Proportion of patients with all-cause and psychiatric-related hospitalizations. Notes: ***Indicates significance at p<.001.

Table 3. All-cause and psychiatric-related healthcare costs, unadjusted and adjusted difference-in-difference.

	Lurasidone cohort			Cariprazine cohort			Unadjusted DID	p-Value	Adjusted DID	p-Value
	6-Month pre-index	6-Month post-index	Pre-post difference	6-Month pre-index	6-Month post-index	Pre-post difference
All-cause costs, mean
Inpatient costs	$5,041	$3,989	−$1,052	$3,397	$3,253	−$144	−$907	.033	−$848	.057
Outpatient costs	$6,734	$7,160	$426	$6,132	$6,193	$61	$365	.174	$335	.278
ED costs	$796	$700	−$96	$678	$622	−$57	−$39	.392	−$11	.839
Office costs	$746	$790	$43	$759	$761	$3	$41	.002	$46	<.001
Other outpatient costs	$5,192	$5,670	$478	$4,695	$4,810	$115	$363	.158	$299	.312
Pharmacy costs	$3,369	$7,408	$4,039	$2,903	$7,628	$4,725	−$685	<.001	−$670	<.001
Total costs	$15,143	$18,557	$3,413	$12,432	$17,074	$4,642	−$1,228	.022	−$1,183	.038
Psychiatric-related costs, mean
Inpatient costs	$3,776	$2,831	−$945	$2,335	$2,160	−$175	−$770	.002	−$618	.030
Outpatient costs	$3,180	$3,701	$522	$2,794	$3,033	$238	$283	.073	$205	.264
ED costs	$378	$277	−$100	$398	$255	−$144	$43	.134	$53	.105
Office costs	$346	$428	$82	$295	$407	$112	−$30	.274	−$14	.672
Other outpatient costs	$2,456	$2,996	$540	$2,101	$2,370	$270	$270	.077	$166	.350
Pharmacy costs	$1,687	$5,581	$3,894	$892	$5,345	$4,453	−$559	<.001	−$546	<.001
Total costs	$8,643	$12,114	$3,471	$6,021	$10,538	$4,517	−$1,046	<.001	−$959	.007

Abbreviations. DID, difference-in-difference; HCRU, healthcare resource utilization; LOS, length of stay; N, number of patients. Notes: The adjusted DID model controlled for age, sex, geographic region, payer type, bipolar disorder type, comorbidities, and atypical antipsychotic use during the 6-month baseline period.

Figure 4. Adjusted Kaplan Meier curve for time to discontinuation. Notes: Covariates in the model included age, sex, geographic region, payer type, bipolar disorder type, comorbidities, atypical antipsychotic use, number of patients with inpatient hospitalizations, number of patients with ER visits, and total costs during the 6-month baseline period.

Table 4. Lurasidone and cariprazine treatment patterns during 6-month post-index period.

	Lurasidone cohort (N = 16,683)	Cariprazine cohort (N = 4,128)	p-Value
Average dose while on index treatment, mg per day, mean (SD)	47.1 (51.2)	2.4 (1.2)	nr
Adherence
MPR, mean (SD)	71% (44%)	64% (42%)	<.001
MPR ≥ 75%, N (%)	8,140 (49%)	1,699 (41%)	<.001
MPR ≥ 80%, N (%)	8,101 (49%)	1,692 (41%)	<.001
PDC, mean (SD)	62% (33%)	57% (32%)	<.001
PDC ≥ 75%, N (%)	7,624 (46%)	1,564 (38%)	<.001
PDC ≥ 80%, N (%)	7,279 (44%)	1,475 (36%)	<.001
Patients who discontinued, N (%)	8,555 (51%)	2,403 (58%)	<.001
Time to discontinuation
Days, median (95% CI)	129 (125, 134)	96 (90, 104)	<.001
Adjusted hazard ratio	0.86	Reference	<.001
Patients who switched to lurasidone/cariprazine, N (%)	58 (0.3%)	172 (4.2%)	<.001

Abbreviations. CI, confidence interval; MPR, medication possession ratio; N, number of patients; nr, not reported; PDC, proportion of days covered; SD, standard deviation. Notes: Adjusted hazard ratio was estimated with Cox proportional hazards model with inverse probability of treatment weighting (IPTW). Median time to discontinuation was estimated as 50% of population discontinued the index treatment.