title: Utilization patterns of stimulants in ADHD in the Medicaid population: a retrospective analysis of data from the Texas Medicaid program.
abstract: BACKGROUND
  Some previously published research on treatment utilization patterns in patients with attention deficit/hyperactivity disorder (ADHD) has been focused on data from commercial health plans, whereas research in the Medicaid population is lacking. Thus, little is known about these utilization patterns in Medicaid populations, which typically have demographic and clinical characteristics that differ from those of employer-based groups.
  
  
  OBJECTIVE
  The objectives of the present retrospective data analysis were to evaluate the associations of medication groups (categorized by stimulant type [methylphenidate or amphetamine] and duration of action [short-acting (SA) or long-acting (LA)]) with measures of stimulant utilization patterns (adherence, persistence, and switching) in children, adolescents, and adults with ADHD enrolled in the fee-for-service delivery model within the Texas Medicaid Program.
  
  
  METHODS
  Texas Medicaid fee-for-service claims data were analyzed retrospectively. Data from enrollees with ADHD (6-63 years) were included if patients were newly initiated on medication from January 2006 to September 2007, had ≥1 medical claim with a code for ADHD, and had continuous Medicaid eligibility 6 months before and after treatment initiation. Adherence, persistence, and switching were compared by initial stimulant medication group (SA methylphenidate [SA-M], LA-M, SA amphetamine [SA-A], and LA-A). Rates were compared overall and by age group (children, adolescents, and adults). Multivariate models were used to control for demographic, clinical, and utilization covariates.
  
  
  RESULTS
  Of 15,055 eligible patients, mostly children, 71% were initiated on methylphenidate; 90% received LA formulations (LA-M, 65%; LA-A, 25%). Most children (66%) and adolescents (65%) were initiated on LA-M, followed by LA-A (23% and 29%, respectively). Among adults, 38% each were initiated on LA-M and LA-A. Overall adherence (measured using the days in possession ratio [DPR]) and persistence were significantly greater with the LA versus the SA formulations (mean DPR, 0.497-0.504 vs 0.407-0.418, respectively; mean persistence, 81 vs 66-67 days; both, P < 0.001), and the rates of switching were lower with the LA versus the SA formulations (12.3%-14% vs 27%-28%; P < 0.001). On multivariate analyses, the likelihoods of adherence and persistence were significantly greater with the LA formulations, and the likelihood of being switched was significantly greater with the SA formulations (P < 0.001). These analyses also showed that medication utilization was significantly related to demographic and clinical characteristics.
  
  
  CONCLUSIONS
  Based on the findings from this retrospective analysis, ADHD treatment utilization patterns varied by formulation in this Texas Medicaid population. Persistence at 180 days was poor regardless of the stimulant used. Consideration of stimulant formulations and demographic characteristics in patients in whom long-term ADHD management is being initiated may assist in optimum utilization, perhaps leading to better symptom control and more efficient resource utilization.
authors.affiliation: Center for Pharmacoeconomic Studies, College of Pharmacy, The University of Texas, Austin, TX 78712, USA. ken.lawson@austin.utexas.edu
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Lawson
authors.forename: Michael
authors.initials: M
authors.lastname: Johnsrud
authors.forename: Paul
authors.initials: P
authors.lastname: Hodgkins
authors.forename: Rahul
authors.initials: R
authors.lastname: Sasané
authors.forename: M Lynn
authors.initials: ML
authors.lastname: Crismon
mesh_terms: D000293:Adolescent; D000328:Adult; D001289:Attention Deficit Disorder with Hyperactivity / Q000188:drug therapy*; D000697:Central Nervous System Stimulants / Q000627:therapeutic use*; D002648:Child; D017723:Drug Utilization Review; D005260:Female; D006801:Humans; D008297:Male; D008484:Medicaid; D008875:Middle Aged; D010349:Patient Compliance; D012189:Retrospective Studies; D013781:Texas; D014481:United States; D055815:Young Adult
chemical_list: D000697:Central Nervous System Stimulants