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For Medicaid beneficiaries with schizophrenia, early initiation of long-acting injectable antipsychotics (LAIs) was associated with fewer inpatient stays and emergency room (ER) visits compared with patients who started LAI treatment after being nonadherent to oral antipsychotics (OAPs) or other interventions, a researcher reported.

In addition, fewer than 15% of patients were started on an LAI before showing evidence of OAP nonadherence or having a schizophrenia-related inpatient admission or ER visit, according to a retrospective, longitudinal cohort study of Medicaid data from six states presented by Dee Lin, PharmD, MS, of Janssen Scientific Affairs in Titusville, New Jersey, at Psych Congress 2021, held virtually and in San Antonio.

"LAIs are widely recommended across different treatment guidelines. However, LAI initiation practices vary considerably," Lin said in his poster presentation. "Little is known regarding the effect on clinical outcomes of different LAI initiation strategies."

To perform the analysis, the researchers classified patients into four groups of treatment sequencing strategies based on the clinical events observed between OAP initiation and either transitioning to LAI treatment or "censoring" -- i.e., if a patient was not started on an LAI:

• Strategy 1: Patients who were adherent to OAPs without a schizophrenia-related inpatient admission or ER visit

• Strategy 2: Patients who were nonadherent to OAPs without a schizophrenia-related inpatient admission or ER visit

• Strategy 3: Patients with exactly one schizophrenia-related admission or ER visit

• Strategy 4: Patients with two or more schizophrenia-related inpatient admissions or ER visits at least 30 days apart

Patients treated with strategy 1 had 53% (P=0.004) and 73% (P<0.001) fewer inpatient admissions compared to those in the strategy 3 and 4 groups, respectively.

And compared with strategies 2, 3, and 4, respectively, patients treated with strategy 1 had 43%, 69%, and 80% fewer days of inpatient stays (all P<0.05); and 57%, 59%, and 79% fewer ER visits (all P<0.05).

Patients treated with strategy 2, compared with strategies 3 and 4, respectively, had 27% and 59% fewer inpatient admissions (P<0.05), 42% and 64% fewer days of inpatient stays (P<0.05). Patients treated with strategy 2 also had 52% (P<0.05) fewer visits to the ER versus those in the strategy 4 group.

Regarding healthcare costs, patients treated with strategies 1 and 2 had lower or similar all-cause medical costs compared with those treated with strategies 3 and 4, according to the findings.

Years of Medicaid data were taken from Iowa, Kansas, Mississippi, Missouri, New Jersey, and Wisconsin, resulting in a total of 13,444 patient profiles.

• Strategy 1 included a total of 1,759 patients (13% of the total), 386 of whom were initiated on LAIs (21.9%) and 1,373 (78.1%) of whom were censored

• Strategy 2 included a total of 7,211 patients (54%), 4.3% of whom were later initiated on LAIs and 95.7% of whom were censored

• Strategy 3 included 2,111 patients (16%), 9.2% of whom were initiated on LAIs and 90.8% of whom were censored

• Strategy 4 included 2,363 patients (18%), 6.5% of whom were initiated on LAIs and 93.5% of whom were censored

Mean age of the patients was about 48 across all four strategies; 40-48% were female, and 27-38% were Black; strategy 1 had the lowest proportion of both female and Black patients.

At baseline, a lower proportion of patients treated with strategy 1 had an all-cause inpatient admission, in comparison with strategies 2 and 4 (13.8% vs 21.8-24.5%, P<0.0001) or an ER visit (25.3% vs 38.4-42.7%, P<0.0001); however, patients from strategy 1 had similar total healthcare costs at baseline ($1,255 vs $1,181-$1,199, P=0.7981).

Study limitations, the researchers said, were that the Medicaid data came from only six states, and that the findings may be subject to residual confounding due to unmeasured confounders.

"The findings from the current study may inform future guidelines pertaining to LAI use," Lin concluded.

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