Predictors of Treatment Initiation with Tumor Necrosis Factor-α Inhibitors in Patients with Rheumatoid Arthritis
Predictors of Treatment Initiation with Tumor Necrosis Factor-α Inhibitors in Patients with Rheumatoid Arthritis
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DOI：
10.18553/jmcp.2014.20.11.1110
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发表时间：
2014-11-01
影响因子：
2.1
通讯作者：
Farley, Joel F.
中科院分区：
文献类型：
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作者：
Desai, Rishi J.;Rao, Jaya K.;Farley, Joel F.
背景技术背景：生物疾病缓解抗风湿药物（DMARDs）的引入彻底改变了类风湿关节炎（RA）患者的治疗。然而，由于生物制剂的成本比非生物制剂高得多，保险慷慨度较低的患者可能难以负担这些药物，这可能导致潜在的可及性差异。目的：确定影响RA患者肿瘤坏死因子（TNF）-α抑制剂生物制剂治疗开始的因素。来自Truven的市场扫描商业索赔和遭遇以及医疗保险补充和福利协调（2007-2010）的健康保险索赔数据用于进行回顾性队列研究。确定了两个独立的RA患者队列：（1）单药治疗非生物制剂DMARD使用者和（2）联合治疗非生物制剂DMARD使用者。主要结局是2008-2009年期间，在索引住院或门诊RA访视后12个月开始使用INF-α抑制剂。预测因素在指数前12个月进行测量，并根据Andersen行为模型分为易感因素、促成因素或需求因素。诱发变量包括年龄、性别和地理位置;使能变量包括与保险相关的因素，如人头费、支付者类型和保险慷慨度，这是使用前一年患者填写的处方中的费用分摊信息定义的;需求变量包括疾病相关因素，如RA的严重程度、疼痛控制药物的使用和其他合并症的存在。分层逻辑回归模型被用来获得估计的影响，个别predictors.Results：开始INF-α抑制剂的观察，在10.31%的单药治疗非生物DMARD用户（1,922 18,641）和13.09%的组合非生物DMARD用户（983 7,508）。在非生物制剂DMARD单药治疗使用者中，开始使用INF-α抑制剂与年龄等易感因素相关（OR = 0.98，95% CI =0.97-0.98，每年增加）和地理区域（中西部与南部OR =0.83，95% CI =0.73-0.93;东北部与南部OR =0.77，95% CI=0.64-0.92;西部与南部OR =0.86，95% CI=0.74-0.99）;访问风湿病学家的有利因素（1次访视vs.未访视OR =1.22，95% CI=1.01-1.46），健康保险类型（商业与医疗保险补充OR =0.79，95% CI =0.66-0.95），以及药物福利慷慨度（高于平均水平与较差OR =1.16，95%CI =1.01-1.34，最慷慨与较差OR =1.21，95%CI =1.05-1.40）;和RA严重程度的需要因素（基于索赔的RA严重程度指数ICIRASI每增加一个单位，OR =1.19，95% CI = 1.14-1.23），首次使用止痛药前（类固醇OR =1.81，95% CI = 1.622.02;非选择性非甾体抗炎药OR =1.17，95% CI =1.05-1.31;考克斯-2抑制剂OR =1.22，95% CI =1.05-1.41）和合并症（合并症指数每增加一个单位，OR =0.94，95% CI =0.90-0.99）。在基线时使用非生物类DMARD联合治疗的患者中，开始INF-α抑制剂治疗与年龄（OR =0.98，95% CI=0.97-0.99，每年增加）和地区（中西部vs.南部OR =0.81，95% CI =0.68-0.96）相关。与单药治疗非生物制剂DMARD使用者相比，在这些患者中观察到与某些需求因素的更强关联（CIRAS OR =1.28，每增加一单位的95% CI=1.21-1.35，类固醇使用OR =2.05，95% CI =1.73-2.42，非选择性NSAID使用OR =1.36，95% CI = 1.17 - 1.58）。然而，与单一治疗DMARD使用者组不同，在非生物DMARD联合治疗使用者中，健康保险类型和药物福利慷慨的有利因素与INF-α抑制剂的启动无关。在基线时接受DMARD单药治疗的RA患者中，在老年患者、美国特定地理区域的患者、以及那些没有那么慷慨的处方药福利的病人。虽然未来的研究应该检查这些差异对健康结果的影响，但付款人在做出处方决定时应该意识到这些RA患者群体中治疗不足的可能性。版权所有（C）2014年，管理护理药房学院。All rights reserved.
BACKGROUND: Introduction of biologic disease-modifying antirheumatic drugs (DMARDs) has revolutionized treatment in patients with rheumatoid arthritis (RA). However, due to substantially higher costs of biologics compared with nonbiologics, patients with less insurance generosity may have difficulty affording these agents, which may lead to potential access disparities.OBJECTIVE: To identify factors affecting treatment initiation with tumor necrosis factor (TNF)-alpha inhibitor biologics in patients with RA.METHODS: Health insurance claims data derived from Truven's Market Scan Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits (2007-2010) were used to conduct a retrospective cohort study. Two separate cohorts of RA patients were identified: (1) monotherapy nonbiologic DMARD users and (2) combination therapy nonbiologic DMARD users. The primary outcome was INF-alpha inhibitor initiation 12 months following an index inpatient or outpatient RA visit during 2008-2009. Predictors were measured 12 months pre-index and grouped into predisposing, enabling, or need factors based on Andersen's Behavior Model. Predisposing variables included age, sex, and geographic location; enabling variables included insurance-related factors such as capitation, payer type, and insurance generosity, which was defined using cost-sharing information from prescriptions filled by the patients in the previous year; and need variables included disease-related factors such as severity of RA, use of pain control medications, and presence of other comorbidities. Hierarchical logistic regression models were used to derive estimates of the impact of individual predictors.RESULTS: Initiation of INF-alpha inhibitors was observed in 10.31% of the monotherapy nonbiologic DMARD users (1,922 of 18,641) and 13.09% of combination nonbiologic DMARD users (983 of 7,508). Among monotherapy nonbiologic DMARD users, initiation with INF-alpha inhibitors was associated with the predisposing factors of age (OR = 0.98, 95% Cl =0.97-0.98 for each year increase) and geographic region (Midwest vs. South OR =0.83, 95% CI =0.73-0.93; Northeast vs. South OR =0.77, 95% CI=0.64-0.92; and West vs. South OR =0.86, 95% CI=0.74-0.99); enabling factors of visit to rheumatologists (1 visit vs. no visit OR =1.22, 95% CI=1.01-1.46), health insurance type (commercial vs. Medicare supplemental OR =0.79, 95% Cl =0.66-0.95), and drug benefit generosity (above average vs. poor OR =1.16, 95% CI=1.01-1.34 and most generous vs. poor OR =1.21, 95% CI=1.05-1.40); and need factors of RA severity (OR =1.19, 95% Cl= 1.14-1.23 for each unit increase in a claims-based RA severity index ICIRASI), pre-index pain reliever use (steroids OR =1.81, 95% Cl= 1.622.02; nonselective nonsteroidal anti-inflammatory drugs [NSAID] OR =1.17, 95% CI =1.05-1.31; COX-2 inhibitors OR =1.22, 95% CI =1.05-1.41), and comorbidities (OR =0.94, 95% CI =0.90-0.99 for each unit increase in a comorbidity index). Treatment initiation with INF-alpha inhibitors among patients with combination therapy nonbiologic DMARDs use at baseline was associated with age (OR =0.98, 95% CI=0.97-0.99 for each year increase) and region (Midwest vs. South OR =0.81, 95% CI =0.68-0.96). Stronger associations with some of the need factors were observed (CIRAS OR =1.28, 95% CI=1.21-1.35 for each unit increase, steroids use OR =2.05, 95% CI =1.73-2.42, and nonselective NSAID use OR =1.36, 95% CI = 1.171.58) in these patients compared with the monotherapy nonbiologic DMARD users. However, unlike the monotherapy DMARD user group, the enabling factors of health insurance type and drug benefit generosity were not found to be associated with INF-alpha inhibitor initiation among nonbiologic DMARD combination therapy users.CONCLUSIONS: Potential disparities in the initiation of INF-alpha inhibitors among RA patients on monotherapy DMARDs at baseline were noted among older patients, patients in certain geographic region of the United States, and patients with less generous prescription drug benefits. Although future research should examine the impact of these disparities on health outcomes, payers should be aware of the potential for undertreatment among these groups of RA patients when making formulary decisions. Copyright (C) 2014, Academy of Managed Care Pharmacy. All rights reserved.