Variation in the use of pulmonary vasodilators in children and adolescents with pulmonary hypertension: a study using data from the MarketScan® insurance claims database

Michael L O'Byrne; Jennifer A Faerber; Hannah Katcoff; David B Frank; Alex Davidson; Therese M Giglia; Catherine M Avitabile

doi:10.1177/2045894020933083

Variation in the use of pulmonary vasodilators in children and adolescents with pulmonary hypertension: a study using data from the MarketScan® insurance claims database

Pulm Circ. 2020 Oct 27;10(3):2045894020933083. doi: 10.1177/2045894020933083. eCollection 2020 Jul-Sep.

Authors

Michael L O'Byrne^{1

2

3

4}, Jennifer A Faerber³, Hannah Katcoff³, David B Frank¹, Alex Davidson¹, Therese M Giglia¹, Catherine M Avitabile¹

Affiliations

¹ Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
² Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
³ Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.
⁴ Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia, PA, USA.

Abstract

Despite progress in pharmacotherapy in pediatric pulmonary hypertension, real-world patterns of directed pulmonary hypertension therapy have not been studied in the current era. A retrospective observational study of children (≤18 years) with pulmonary hypertension was performed using data from the MarketScan® Commercial and Medicaid claims databases. Associations between etiology of pulmonary hypertension and pharmaceutical regimen were evaluated, as were the associations between subject social and geographic characteristics (insurance-type, race, and/or census region) and regimen. Annualized costs of single- and multi-class regimens were calculated. In total, 873 subjects were studied, of which 94% received phosphodiesterase-5 inhibitors, 31% endothelin receptor antagonist, 9% prostacyclin analogs, and 7% calcium channel blockers. Monotherapy was used in 72% of subjects. Phosphodiesterase-5 inhibitors monotherapy was the most common regimen (93%). Subjects with idiopathic pulmonary hypertension, congenital heart disease, and unclassified pulmonary hypertension receive more than one agent and were more likely to receive both endothelin receptor antagonist and prostacyclin analogs than other forms of pulmonary hypertension. Compared to recipients of public insurance, subjects with commercial insurance were more likely to receive more intense therapy (p = 0.003), which was confirmed in multivariable analysis (OR: 1.4, p = 0.03). Receipt of commercial insurance was also associated with increased annual costs across all subjects (p < 0.001) and for the most common specific regimens. The majority of children with pulmonary hypertension receive phosphodiesterase monotherapy, followed by phosphodiesterase-endothelin receptor antagonist two drug regimens, and finally the addition of prostacyclin analogs for three-drug therapy. However, even after adjustment for measurable confounders, commercial insurance was associated with higher intensity care and higher costs (even within specific classes of pulmonary vasodilators). The effect of these associations on clinical outcome cannot be discerned from the current data set, but patterns of treatment deserve further attention.

Keywords: drug therapy; outcomes research; pediatric cardiology.