Predicting antidepressant persistence by
patient and prescriber characteristics:
a Belgian medical claim database study AN TAMSIN & DIONA D’HONDT
PROMOTOR: PROF. DR. FRANK DE SMET
COPROMOTOR: PROF. DR. KOEN DEMYTTENAERE
Introduction
Aim of the study
Material and methods
Results
Discussion
Conclusion
Introduction
Belgium is a leading European country in terms of antidepressant use (AD)(1)
DDD doubled the last twenty years (40 to 77 DDD / 100 residents / day)(2) despite numerous
campaigns
National (3) and international guidelines: adequate treatment =
minimum 6 months following the resolution of symptoms (after four to six weeks)
prevents relapse and recurrence
Shorter treatment duration is not uncommon / Adherence to initial AD medication
decreases over months (4–6)
Inadequate treatment has psychopathological and psychosocial consequences, decreases work productivity and quality of life (9)
Aim of the study
Analyse which characteristics of
Patients
Prescribers
may predict the duration of antidepressant (AD) therapy
Material and methods
Data extractions and analyses
R&D Department of the National Alliance of Christian Sickness Funds (CM)
Study design
Nationwide retrospective cross-sectional study
Administrative claim database of CM:
(reimbursed procedure codes)
records for reimbursed, dispensed prescriptions
sociodemographic characteristics
clinical diagnoses were not available
M & M: selection of antidepressants
Anatomical Therapeutic Chemical (ATC): all SSRIs (except for sertraline), all SNRIs (except for venlafaxine), all TCAs, bupropion, agomelatine, mianserineand mirtazapine.
Not included: venlafaxine, sertraline, trazodone, dosages too low to be therapeutically of value in the treatment of depression
ADs delivered between 01.01.2005 and 31.12.2015
Information AD:
Total amount of reimbursed and dispensed packages
Number of packages per reimbursement
Price of a reimbursement
CNK code of package
M & M: estimation length of episode
Days prescribed =
1 package = 98 days
4 dispensed packages:
01/10/2009
20/01/2010
(grace period 13 days = ok)
10/04/2010
(overlap until 15/04 = not
counted)
01/01/2013
Total amount of days = 3 x 98
= 144 days
Length of episode =
139 days
10/04/2010 + 98 days =
17/07/2010
minus
01/10/2009
Flexible doses: the lowest daily dose was used
-Grace period: 30 days-Switching between different ADs = a continuous AD consumption
Material and methods
Episode selection and exclusion
Treatment periods ongoing on 01.01.2010
Exclusion:
(Episodes of) patients who were (at start of the treatment episode):
< 18 or > 65 years
nursing home residents
unknown or offshore address
During the episode: died or changed their membership to another insurance fund (per trimester)
Episodes started before 2005
Material and methods
Patient characteristics
age
gender
unemployment and disability
major coverage allowance
hospitalization during the episode
geographical categorization
first treatment episode in the study period
Prescriber characteristics
age
gender
medical specialty
number of consultations performed by a
physician during the first year of the study
period (i.e., 2005)
number of ADs prescribed days in 2005
Material and methods
Statistical methods
Multivariate ordinary least-squares regression with clustering at prescriber’s level
was performed using the above mentioned variables.
Exclusion censored data: 1432 patients
Results
Overall
180 003 reimbursements
50% presented only one package
Median refund cost of €23.26
After estimation of LoE
Minimum 1, maximum 56, median 3 treatment episodes
Results
After selection (treatment ongoing on 01.01.2010)
96 584 treatment periods
LoE
Ranged from 13 to 3828 days
Median 341 days
Mean 608 days
50% of patients were treated with ADs for almost one year
31.57% of patients had a length of treatment episode shorter than 180 days
Patient characteristics
96 584 patients
Mean age 47 years - median age 48 years
67% female
85% first treatment episode during the 10 year study
period
Non disability, employment, major coverage,
hospitalization during episode
Center, residential
Results
Results
Characteristics of (most prevalent) prescriber
one prescriber is responsible for prescribing: 50%
14443 unique prescribers
1 to 142 patients per prescriber
psychiatrist most prevalent prescriber: 28%
70% is male
mean and median year of birth = 1959
Results
Results
Discussion
Length of episode
Median 341 days
Mean 608 days
Patients with long-term treatment are more present than patients with
a short-term treatment
15% already had an earlier treatment episodes ↔ only first time users
31,75% discontinued treatment < 6 months = similar to most other
studies
Prescriber’s intention to treat with short courses: off-label, non-mental
health indications or sub-threshold disorders and minor depressive disorders (10) shorter LoE
Discussion
Length of episode
Dispensed daily dose: surrogate of PDD ↔ DDD
Unable to check the prescribed dose
Lowest daily dose in case of flexible dosages ↔ highest daily dose
Grace period of 30 days
Shorter might imply misclassification of consecutive episodes as new episodes
Longer grace period would have overestimated 6-month persistence (11)
Discussion
Patient characteristics
Gender
Population female (67%) = other studies
Being male reduced the LoE with 20 days ↔ indifference in literature
Age
For each year a patient gets older, the LoE increased with 4 days = other studies
Hospitalization
Hospitalization expanded LoE = other study however they used another definition and did not reach statistical significance (45.7% versus 54.7%, respectively, p = 0.053) (12).
Discussion
Patient characteristics
First time treatment
First time treatment shortened LoE = other studies (13) : 1/3 first-time users did not purchase an AD
Discussion
Prescriber characteristics
Specialty
Psychiatrist in 28% ↔ lower in France (8.6%) (18), Netherlands (9.5%) (19), USA (15%)(4)) or higher USA 35% (20)
Psychiatrist expand LoE = other studies (4,12,17,21) except for 2 studies proof association (20,22)
Age
Younger physician larger episode ↔ two studies no association (14,22)
Gender
No association between gender and AD persistence = other studies (14,22)
Discussion
Prescriber characteristics
Shorter LoE with higher general amount of AD prescribed days of the prescriber
= Hansen et al. (14)
Positive correlation workload and the LoE ↔ Hansen et al. no statistically
significant correlation despite same definition (14)
Strengths and limitations
Strengths
First to analyze duration of AD treatment in a large population (41%)
representative for Belgian population
Medical claims databases are common used and has several advantages
Huge sample size(23)
Patients and doctors unaware information bias avoided (14)
Strengths and limitations
Limitations
Observational study : causality of the correlations reported?
Dispensing data:
underestimation of the prescription data
intention to (comply with treatment) ?
Other variables (concomitant medications, comorbid illnesses, immigration background or
educational level (47)?
Exclusion venlafaxine and sertraline
Relationship between characteristics and whether the length of this treatment period is
adequate or not is beyond the aim of this study
Future research
Studies confirming or disclaiming the suggested explanations for the
correlations found in this and other studies are needed.
Investigating the correlation between characteristics and inadequate
treatment duration:
too short(< 180 days according to guidelines)
very long LoE (e.g., 75th percentile of LoE)
target campaigns for AD use in specific subpopulations and for specific
prescribers
Conclusion
Confirmation of earlier studied associations between persistence on AD and patient/prescriber characteristics
Following factors extend the LoE
Female, older patient
AD prescribed by psychiatrist, by physician with lower prescribing behavior
Additional findings
Following factors extend the LoE
being hospitalized, low socioeconomic status
young prescribers, higher workload physician
Following factors shortened LoE
first episode
Future research
References
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