The Effects of Antidepressant Step Therapy Protocols on Pharmaceutical and Medical Utilization and Expenditures
Abstract
Objective:
Method:
Results:
Conclusions:
Method
Results
Sample Description
Characteristic | Step Therapy Plan Subjects (N=15,552) | Comparison Plan Subjects (N=45,244) | Analysis | ||
---|---|---|---|---|---|
N | % | N | % | p | |
Age group (years) | |||||
0–17 | 1,464 | 9.4 | 4,584 | 10.1 | <0.001 |
18–34 | 3,093 | 19.9 | 8,878 | 19.6 | 0.138 |
35–44 | 3,734 | 24.0 | 9,030 | 20.0 | <0.001 |
45–54 | 5,033 | 32.4 | 16,356 | 36.2 | <0.001 |
55–64 | 2,228 | 14.3 | 6,396 | 14.1 | 0.685 |
Gender | |||||
Female | 11,200 | 72.0 | 30,030 | 66.4 | <0.001 |
Male | 4,352 | 28.0 | 15,214 | 33.6 | <0.001 |
Relationship to Employee | |||||
Employee | 11,621 | 74.7 | 22,661 | 50.1 | <0.001 |
Spouse | 2,276 | 14.6 | 15,432 | 34.1 | <0.001 |
Child/other | 1,655 | 10.7 | 7,151 | 15.8 | <0.001 |
Mean | SD | Mean | SD | p | |
Age (years) | 40.62 | 13.40 | 40.58 | 13.96 | 0.764 |
Median household income in residential zip code (U.S. dollars)a | 39,143.00 | 12,598.00 | 47,861.00 | 13,984.00 | <0.001 |
College graduates in residential zip code (%)a | 0.21 | 0.13 | 0.23 | 0.13 | <0.001 |
Deyo-Charlson Comorbidity Index rating | 0.29 | 0.78 | 0.27 | 0.74 | 0.005 |
Chronic Disease Score rating | 2.85 | 3.00 | 2.44 | 2.80 | <0.001 |
ICD-9 count | 6.90 | 5.18 | 6.98 | 5.58 | 0.263 |
Variable | Step Therapy Plan Subjects | Comparison Plan Subjects | Analysis | ||
---|---|---|---|---|---|
Mean | SD | Mean | SD | p | |
Enrollees receiving antidepressant medicationa | |||||
Utilization | |||||
Days antidepressant medication suppliedb | 35.3 | 38.6 | 39.5 | 39.5 | <0.0001 |
Antidepressant discontinuation rateb | 0.03 | 0.018 | 0.03 | 0.18 | 0.6864 |
All prescriptions filledb | 6.58 | 6.62 | 7.05 | 7.15 | <0.0001 |
Emergency room visitsb | 0.11 | 0.42 | 0.09 | 0.37 | <0.0001 |
Outpatient office visitsb | 1.39 | 1.71 | 1.25 | 1.76 | <0.0001 |
Inpatient admissionsb | 0.034 | 0.21 | 0.028 | 0.19 | <0.0001 |
Expenditures (U.S. dollars) | |||||
Prescription drugs | 498.00 | 943.00 | 629.00 | 1,008.00 | <0.0001 |
Emergency room visits | 115.00 | 1,864.00 | 70.00 | 436.00 | <0.0001 |
Inpatient admissions | 409.00 | 4,615.00 | 363.00 | 3,769.00 | 0.0502 |
Outpatient medical visits | 948.00 | 3,788.00 | 1,053.00 | 3,171.00 | <0.0001 |
All enrolleesc | |||||
Antidepressant initiation rate (per enrollee per year) | 0.007 | 0.08 | 0.006 | 0.08 | 0.0082 |
Days antidepressant medication supplied (per enrollee) | 8.27 | 23.91 | 8.78 | 24.84 | <0.0001 |
Multivariate Model
Variable | Enrollees Receiving Antidepressant Medicationa | Enrollees Receiving Antidepressant Medicationa | All Enrollees | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Antidepressant Days | Generic Antidepressant Days | Brand Antidepressant Days | Number of Prescriptions | Antidepressant Daysb | |||||||||||
Coefficient | SD | p | Coefficient | SD | p | Coefficient | SD | p | Coefficient | SD | p | Coefficient | SD | p | |
Step therapy plan/non-step therapy plan (reference=non-step therapy plan) | −0.103 | 0.010 | <0.001 | 0.020 | 0.027 | 0.455 | −0.155 | 0.015 | <0.001 | −0.074 | 0.008 | <0.001 | −0.080 | 0.015 | <0.001 |
After step therapy plan implementation (reference=before implementation/non-step therapy plan) | −0.054 | 0.009 | <0.001 | 0.052 | 0.024 | 0.030 | −0.189 | 0.018 | <0.001 | −0.011 | 0.006 | 0.055 | −0.048 | 0.011 | <0.001 |
Time after step therapy plan implementation | 0.015 | 0.002 | <0.001 | 0.032 | 0.005 | <0.001 | −0.002 | 0.004 | 0.682 | 0.007 | 0.001 | <0.001 | 0.012 | 0.002 | <0.001 |
Quarter | 0.067 | 0.001 | <0.001 | 0.195 | 0.004 | <0.001 | 0.035 | 0.002 | <0.001 | 0.016 | 0.001 | <0.001 | 0.059 | 0.002 | <0.001 |
Quarter2 | −0.003 | 0.000 | <0.001 | −0.008 | 0.000 | <0.001 | −0.002 | 0.000 | <0.001 | −0.001 | 0.000 | <0.001 | −0.003 | 0.000 | <0.001 |
Age (years) | 0.015 | 0.000 | <0.001 | 0.018 | 0.001 | <0.001 | 0.012 | 0.000 | <0.001 | 0.024 | 0.000 | <0.001 | 0.041 | 0.000 | <0.001 |
Female | 0.122 | 0.008 | <0.001 | 0.181 | 0.021 | <0.001 | 0.188 | 0.013 | <0.001 | 0.084 | 0.007 | <0.001 | 0.626 | 0.013 | <0.001 |
Deyo-Charlson Comorbidity Index rating | −0.003 | 0.002 | 0.210 | −0.002 | 0.006 | 0.800 | 0.003 | 0.004 | 0.434 | 0.020 | 0.002 | <0.001 | −0.009 | 0.004 | 0.016 |
Diagnoses | 0.017 | 0.000 | <0.001 | 0.008 | 0.001 | <0.001 | 0.020 | 0.001 | <0.001 | 0.014 | 0.000 | <0.001 | 0.029 | 0.001 | <0.001 |
College graduates in residential zip code (%)c | 0.273 | 0.039 | <0.001 | 0.040 | 0.097 | <0.001 | 0.250 | 0.059 | <0.001 | −0.043 | 0.030 | 0.158 | 0.384 | 0.060 | <0.001 |
Median income in residential zip codec | 0.000 | 0.000 | 0.895 | −0.002 | 0.001 | 0.100 | 0.001 | 0.001 | 0.304 | 0.000 | 0.000 | 0.130 | −0.001 | 0.001 | 0.018 |
Constant | 2.851 | 0.017 | <0.001 | 0.773 | 0.045 | <0.001 | 2.415 | 0.025 | <0.001 | 1.377 | 0.013 | <0.001 | 0.964 | 0.024 | <0.001 |
Variable | Outpatient Visits for All Diagnoses | Outpatient Mental Health-Related Visits | Inpatient Admissions for All Diagnoses | Inpatient Mental Health-Related Admissions | Emergency Room Visits for All Diagnoses | Emergency Room Visits for Mental Health-Related Diagnoses | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Coefficient | SD | p | Coefficient | SD | p | Coefficient | SD | p | Coefficient | SD | p | Coefficient | SD | p | Coefficient | SD | p | |
Step therapy plan (reference=non-step therapy plan) | 0.099 | 0.007 | <0.001 | −0.964 | 0.031 | <0.001 | 0.063 | 0.026 | 0.017 | −0.329 | 0.099 | <0.001 | −0.642 | 0.024 | <0.001 | 0.001 | 0.080 | 0.994 |
After step therapy plan implementation (reference=before implementation/non-step therapy plan) | 0.045 | 0.008 | <0.001 | 0.166 | 0.037 | 0.000 | 0.150 | 0.041 | <0.001 | 0.184 | 0.129 | 0.15 | 0.267 | 0.025 | <0.001 | 0.185 | 0.121 | 0.127 |
Quarter after step therapy plan implementation | 0.001 | 0.002 | 0.387 | 0.010 | 0.007 | 0.158 | 0.009 | 0.008 | 0.264 | 0.010 | 0.023 | 0.68 | 0.050 | 0.004 | <0.001 | −0.020 | 0.021 | 0.344 |
Quarter | 0.014 | 0.001 | <0.001 | 0.031 | 0.004 | <0.001 | 0.041 | 0.008 | <0.001 | 0.188 | 0.028 | <0.001 | 0.120 | 0.006 | <0.001 | 0.070 | 0.022 | 0.002 |
Quarter2 | −0.001 | 0.000 | <0.001 | <0.001 | 0.000 | −0.001 | −0.003 | 0.000 | <0.001 | −0.010 | 0.002 | <0.001 | −0.010 | 0.000 | <0.001 | −0.003 | 0.001 | 0.052 |
Age (years) | 0.003 | 0.000 | <0.001 | −0.024 | 0.001 | <0.001 | −0.002 | 0.001 | 0.007 | −0.045 | 0.003 | <0.001 | 0.001 | 0.001 | 0.466 | −0.044 | 0.003 | <0.001 |
Female | 0.148 | 0.007 | <0.001 | −0.070 | 0.020 | <0.001 | −0.135 | 0.021 | <0.001 | −0.637 | 0.082 | <0.001 | −0.008 | 0.024 | 0.732 | −0.551 | 0.068 | <0.001 |
Deyo-Charlson Comorbidity Index rating | 0.043 | 0.003 | <0.001 | −0.044 | 0.007 | <0.001 | 0.086 | 0.008 | <0.001 | −0.116 | 0.050 | 0.02 | 0.005 | 0.010 | 0.617 | −0.077 | 0.036 | 0.031 |
Diagnoses | 0.029 | 0.000 | <0.001 | 0.034 | 0.001 | <0.001 | 0.069 | 0.001 | <0.001 | 0.071 | 0.005 | <0.001 | 0.041 | 0.002 | <0.001 | 0.072 | 0.005 | <0.001 |
College graduates in residential zip code (%)b | 0.203 | 0.028 | <0.001 | 1.409 | 0.098 | <0.001 | −0.641 | 0.092 | <0.001 | 0.401 | 0.332 | 0.23 | −0.153 | 0.114 | 0.181 | 0.023 | 0.261 | 0.931 |
Median income in residential zip codeb | 0.001 | 0.000 | <0.001 | 0.001 | 0.001 | 0.319 | −0.002 | 0.001 | 0.047 | −0.006 | 0.003 | 0.06 | −0.003 | 0.001 | <0.001 | 0.000 | 0.003 | 0.907 |
Constant | −0.432 | 0.013 | <0.001 | −0.897 | 0.039 | <0.001 | −4.130 | 0.045 | <0.001 | −6.196 | 0.154 | <0.001 | −2.334 | 0.045 | <0.001 | −6.074 | 0.148 | <0.001 |
Variable | Outpatient Expenditures | Inpatient Expenditures | Emergency Room Expenditures | Prescription Drug Expenditures | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Coefficient | SD | p | Coefficient | SD | p | Coefficient | SD | p | Coefficient | SD | p | |
Step therapy plan (reference=non-step therapy plan) | −0.206 | 0.012 | <0.001 | −0.180 | 0.062 | 0.004 | −0.135 | 0.033 | <0.001 | −0.219 | 0.014 | <0.001 |
After step therapy plan implementation (reference=before implementation/non-step therapy plan) | 0.074 | 0.018 | <0.001 | 0.129 | 0.086 | 0.131 | 0.205 | 0.051 | <0.001 | −0.022 | 0.010 | 0.039 |
Quarter after step therapy plan implementation | 0.007 | 0.003 | 0.032 | 0.031 | 0.013 | 0.013 | 0.044 | 0.010 | <0.001 | 0.005 | 0.002 | 0.033 |
Quarter | 0.034 | 0.003 | <0.001 | 0.096 | 0.016 | <0.001 | 0.078 | 0.008 | <0.001 | 0.044 | 0.001 | <0.001 |
Quarter2 | −0.001 | 0.000 | <0.001 | −0.005 | 0.001 | <0.001 | −0.003 | 0.001 | <0.001 | −0.002 | 0.000 | <0.001 |
Age (years) | 0.014 | 0.000 | <0.001 | 0.011 | 0.002 | <0.001 | −0.008 | 0.001 | <0.001 | 0.024 | 0.000 | <0.001 |
Female | 0.022 | 0.010 | 0.023 | −0.352 | 0.038 | <0.001 | −0.250 | 0.023 | <0.001 | −0.064 | 0.012 | <0.001 |
Deyo-Charlson Comorbidity Index rating | 0.134 | 0.007 | <0.001 | 0.171 | 0.013 | <0.001 | 0.071 | 0.012 | <0.001 | 0.045 | 0.005 | <0.001 |
Diagnoses | 0.060 | 0.001 | <0.001 | 0.092 | 0.003 | <0.001 | 0.070 | 0.002 | <0.001 | 0.017 | 0.001 | <0.001 |
College graduates in residential zip code (%)b | 0.101 | 0.042 | 0.015 | −0.508 | 0.178 | 0.004 | −0.315 | 0.089 | <0.001 | 0.093 | 0.051 | 0.069 |
Median income in residential zip codeb | −0.001 | 0.000 | <0.001 | −0.003 | 0.002 | 0.072 | −0.002 | 0.001 | 0.008 | 0.001 | 0.001 | 0.033 |
Constant | 5.827 | 0.020 | <0.001 | 4.708 | 0.077 | <0.001 | 3.387 | 0.051 | <0.001 | 5.630 | 0.023 | <0.001 |
![](/cms/10.1176/appi.ajp.2010.09060877/asset/images/appi.ajp.2010.1202.jpeg)
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