Medication selection, health services outcomes, and cost trajectories for Medicaid beneficiaries with infantile spasms

Jea Young Min; Kelly G Knupp; Anup D Patel; Reneé A Shellhaas; Manyao Zhang; Zachary M Grinspan

doi:10.1016/j.eplepsyres.2021.106733

Medication selection, health services outcomes, and cost trajectories for Medicaid beneficiaries with infantile spasms

Epilepsy Res. 2021 Oct:176:106733. doi: 10.1016/j.eplepsyres.2021.106733. Epub 2021 Jul 24.

Authors

Jea Young Min¹, Kelly G Knupp², Anup D Patel³, Reneé A Shellhaas⁴, Manyao Zhang¹, Zachary M Grinspan⁵

Affiliations

¹ Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA.
² Department of Pediatrics and Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
³ Nationwide Children's Hospital, Columbus, OH, USA.
⁴ Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.
⁵ Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA; Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA. Electronic address: zag9005@med.cornell.edu.

PMID: 34333373
DOI: 10.1016/j.eplepsyres.2021.106733

Abstract

Objective: There are three recommended first-line treatments for infantile spasms, adrenocorticotropic hormone (ACTH), oral corticosteroids, and vigabatrin, though non-standard treatments such as topiramate are sometimes selected. Is it uncertain how treatment selection influences health services outcomes.

Methods: We conducted a retrospective cohort study of Medicaid beneficiaries newly diagnosed with infantile spasms from 2009-2010. We included infants with a new diagnosis of infantile spasms between age 2-9 months who filled ACTH (reference), prednisolone, vigabatrin, or topiramate prescriptions. Multivariable Cox proportional hazards regression compared time to first emergency department (ED) visit or hospitalization across treatment groups during 2 years of follow-up. Monthly costs for each treatment were examined in 6-month intervals and compared in a multivariable generalized linear model.

Results: Among 256 children with infantile spasms, 116 received ACTH, 62 prednisolone, 15 vigabatrin, and 63 topiramate. The rate of ED visit or hospitalization per person-year did not differ significantly for prednisolone (0.9 [95 % CI 0.7-1.2]; adjusted hazard ratio [aHR] 0.84, 95 % CI 0.57-1.24), vigabatrin (0.8 [95 % CI 0.4-1.5]; aHR 0.91, 95% CI 0.45-1.84), or topiramate (1.7 [95 % CI 1.3-2.3]; aHR 1.15, 95 % CI 0.80-1.65), when compared to ACTH (1.1 [95 % CI 0.9-1.3]). The median payment for ACTH was $96,406 (interquartile range 70,742-138,476) during the first 6 months. The adjusted mean total payment in the first 6 months was 73% lower for prednisolone (95% CI -82, -61), 69% lower for vigabatrin (95% CI -84, -40), and 73% lower for topiramate (95% CI -82, -59). However, in subsequent 6-month intervals, costs associated with ACTH were not significantly different compared to other treatments.

Significance: Compared to other treatments for infantile spasms, use of ACTH was associated with greater cost in the first 6 months of treatment, but not with reduced ED visits or hospitalizations. The cost effectiveness of ACTH depends on its relative clinical efficacy, and merits additional research.

Keywords: Cost trajectories; Health services research; Infantile spasms; Treatment.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Anticonvulsants / therapeutic use
Child
Health Services
Humans
Infant
Medicaid
Retrospective Studies
Spasms, Infantile* / drug therapy
Treatment Outcome
Vigabatrin / therapeutic use

Substances

Anticonvulsants
Vigabatrin