More than 60 million Americans suffer from atopic

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1 At a Glance Original Research Practical Implications e131 Author Information e137 Web Exclusive Preferred Drug Utilization: Treating Allergic Rhinitis With Less-Sedating Antihistamines Kirsten M. Kloepfer, MD; Mark E. Helm, MD, MBA; Tamara T. Perry, MD; Ping Hu, MS; Stacie M. Jones, MD; and Perla A. Vargas, PhD ABSTRACT Background: In 2005, Arkansas Medicaid initiated an evidencebased prescription drug program. Loratadine was selected as the preferred less-sedating antihistamine (LSA). Objectives: To examine the impact of using a preferred LSA for treatment of allergic rhinitis (AR) among children enrolled in Medicaid and the State Children s Health Insurance Program. Methods: LSA claims data for children (aged 2-17 years) diagnosed with AR alone were retrospectively extracted for 12 months before and after program implementation. Changes in pharmacy claims, healthcare utilization, and costs were analyzed. Results: We identifi ed 11,591 children with AR. After program implementation, loratadine claims increased (479 to 14,448; P <.001), while total LSA claims decreased (19,111 to 15,699; P <.001). A signifi cant increase was seen in claims for leukotriene modifi er (2341 to 3289; P <.001) and intranasal steroids (4614 to 5064; P <.001). There were signifi cantly fewer outpatient claims (49,824 to 43,162; P <.001) and emergency department claims (3886 to 3236; P <.001). LSA pharmacy costs for children with AR decreased ($993,410 to $268,853; P <.001). Prior authorization for a nonpreferred LSA was requested for only 3% of the patients. Conclusions: Implementation of a preferred drug program for LSA using loratadine resulted in a change in fi lling patterns and LSA and medical cost reduction, without evidence of increased healthcare utilization. No signifi cant change in overall pharmacy spending was observed, and a shift was seen in utilization of other therapies to treat AR. (Am J Pharm Benefi ts. 2012;4(5):e130-e137) More than 60 million Americans suffer from atopic disease, including asthma, allergic rhinitis (AR), and atopic dermatitis, and the prevalence is increasing every year. 1-6 The healthcare costs associated with the treatment of AR have been estimated to exceed US $11 billion annually. 7 This estimate does not include the indirect costs incurred such as time off from work and school Antihistamines are the first-line pharmacologic treatment for AR in children. 2 The second-generation, less-sedating antihistamines (LSAs) are favored over first-generation antihistamines due to their efficacy and reduced side effects, including less sedation. 12 In March 2005, Arkansas Medicaid and State Children s Health Insurance Program (SCHIP) initiated an evidencebased preferred drug program. 13 The category of LSAs, including cetirizine, desloratadine, fexofenadine, and loratadine, was the first group of medications reviewed. The potential toxicity and therapeutic roles of these agents in the treatment of seasonal AR, perennial AR, and chronic idiopathic urticaria were reviewed by a committee of Arkansas physicians and pharmacists. After review of clinical research evidence, the Arkansas Drug Review Committee concluded that cetirizine, fexofenadine, desloratadine, and loratadine do not differ in their ability to lower total symptom scores in adults. However, there was insufficient head-to-head data to determine the efficacy of the target LSA in children. The committee found there was no evidence showing that the 4 LSAs under consideration presented an increased risk relative to the others. Based on this safety profile and low cost of administration, loratadine was approved as the preferred LSA for children and a prior authorization (PA) policy for nonpreferred LSAs was established. Under the PA protocol, approval was required prior to dispensing a new nonpreferred LSA. Patients using a nonpreferred LSA before the program implementation were allowed to continue. Once the program began, patients were required to use the nonpreferred LSA regularly in order to e130 The American Journal of Pharmacy Benefi ts September/October 2012

2 LSA Use in Pediatric Medicaid Patients maintain their nonpreferred prescription status. Routine use was defined as 4 filled prescription claims within 6 months. Prior authorization requests for a nonpreferred LSA could be granted at a prescriber s request if contraindications or severe allergic disease was present. Alternatively, PA requests could be approved if the patient failed to achieve relief after a 1-month loratadine trial. Patients given PA for a nonpreferred LSA were allowed to continue the medication indefinitely as long as they met the prescription refill requirement of 4 filled prescription claims in 6 months. The purpose of this study was to examine the impact of using a preferred LSA for the treatment of AR among children enrolled in Medicaid and SCHIP on prescription patterns, healthcare utilization, and costs. We compared paid claims for pharmacy and healthcare services, and cost estimates for children with AR before and after the implementation of the LSA preferred drug program. METHODS This study is a retrospective analysis of Medicaid and SCHIP pharmacy and medical claims data. To assess the impact of the program we examined (1) changes in prescription refills for all medications used to treat AR, (2) changes in overall healthcare utilization, and (3) changes in Medicaid program cost for both pharmacy and medical services. These data include encrypted patient identifiers, age, sex, claims for medical services (ie, outpatient, emergency department [ED], hospital admissions), and dispensed prescription pharmacy claims. The medical service claims included Current Procedural Terminology codes indicating physician services, costs of services rendered, and International Classification of Diseases, Ninth Revision (ICD-9) codes for patient diagnoses. The pharmacy claims data included medication identifiers, quantities dispensed, mediation charges paid, and dates of dispensing. Claims data were linked using encrypted individual patient identifier codes. Additionally, PA requests and outcome (ie, approval or denial) were linked to the claims data. Study Period Implementation of the LSA drug program began in March Patients were allowed to fill prescriptions without restrictions for the first 3 weeks of that month; therefore, claims for March 2005 were excluded from analysis. Data were extracted for the 12 months before (March 1, 2004, to February 28, 2005) and the 12 months after (April 1, 2005, to March 31, 2006) program inception. PRACTICAL IMPLICATIONS Arkansas Medicaid implemented a preferred drug program and made loratadine the preferred less-sedating antihistamine (LSA) for treatment of allergic rhinitis. We examined medication refill rates, physician visits, and healthcare costs to determine whether there was a negative impact on patient care. n Most patients changed to loratadine or discontinued LSA use rather than obtain authorization to take a different LSA. n There was no observed increase in outpatient care, emergency department visits, or hospitalizations after implementation of the preferred drug program. n There was a significant decrease in LSA medication cost without a significant increase in overall pharmacy costs. Study Sample Total healthcare costs could be calculated only for those patients with continuous eligibility. Therefore, the sample was restricted to patients with at least 1 claim for an LSA who were continuously enrolled in the Arkansas Medicaid or SCHIP program throughout the study period (March 1, 2004, to March 31, 2006). Each pharmacy claim included 30 days worth of medication, with refills every 30 days. Study subjects were children aged 2 to 17 years. Children younger than 2 years (in the period after program implementation) were excluded because loratadine, the preferred LSA, is indicated only in patients 2 years and older. All patients with an LSA claim in the pre-implementation period were then classified by atopic diagnoses associated with any medical service claim during the study period using the ICD-9 codes for AR (codes , 995.0, 995.3), asthma (AS; codes , ), atopic dermatitis (AD; code 691.8), and/or food allergy (FA; codes 691.8, 692.0, 692.1, 692.3, 692.4, 692.5, 692.8, , , , , 692.9, 698.9, 708.0, 708.1, 708.3, 708.9), as shown in the Figure. To avoid confounding by other atopic comorbidities, all patients with any diagnosis other than any form of AR were excluded. Patients with at least 1 short-acting b-agonist or inhaled steroid claim were also excluded. Patients with pharmacy claims for a leukotriene modifier or an intranasal corticosteroid were not excluded from the study. To examine changes in prescription patterns after the implementation of the preferred drug program, the number of claims for all medications used for the treatment of AR (ie, loratadine, nonpreferred LSA, intranasal steroids, leukotriene modifiers, first-generation antihistamines, Vol. 4, No. 5 The American Journal of Pharmacy Benefits e131

3 n Kloepfer Helm Perry Hu Figure. Subjects Included in Analysis 46,769 patients with 1 claim for LSA or 1 claim with diagnosis of allergic rhinitis, asthma, atopic dermatitis, and/or food allergy 33,127 patients without diagnosis of allergic rhinitis or allergic rhinitis with other atopic diagnoses 13,642 patients with allergic rhinitis alone 1876 patients with at least 1 claim for short-acting β-agonist and/or inhaled corticosteroid 175 patients with incomplete claims 11,591 patients included in analysis LSA indicates less-sedating antihistamine. cough/cold medications, oral steroids) was analyzed. To examine changes in patterns of utilization of medical services, the number of claims for outpatient visits, ED visits, and hospitalizations was also analyzed. To evaluate the relative impact on treatment costs, LSA pharmacy costs, total pharmacy costs, and total healthcare costs were calculated for 12 months before and after program inception. All prescription costs were calculated based on the amount paid to pharmacies for product costs and dispensing fees by Arkansas Medicaid. Finally, to explore the effect of the PA policy on medication access, individual records were further classified based on their PA request status and AR medication use. Four groups were identified: (1) patients whose PA request was approved, including those on a nonpreferred LSA prior to program implementation; (2) patients whose PA request was denied; (3) patients who made no PA request and used loratadine in the post-implementation period; and (4) patients who made no PA request and did not use loratadine in the post-implementation period. The study was approved by the University of Arkansas for Medical Sciences Institutional Review Board. No personal identifiers were used; thus, informed consent was waived. Statistical Analysis Assumptions of distributional normality were tested using the Kolmogorov-Smirnov test (P <.01); the Anderson- Darling test (P <.005); and the Cramer-von Mises test (P <.005). The test statistics rejected the null hypothesis that the dependent variables were normally distributed. Therefore, pre-post comparisons of individual patient e132 The American Journal of Pharmacy Benefits September/October 2012

4 LSA Use in Pediatric Medicaid Patients records were performed using the Wilcoxon sum rank test. All data processing and statistical tests were performed using SAS version (SAS Institute, Inc, Cary, North Carolina). RESULTS Study Population A total of 46,769 patients aged 2 to 17 years were continuously enrolled in Arkansas Medicaid and SCHIP programs between March 1, 2004, and March 31, 2006, and had more than 1 prescription for an LSA (Figure). Of these patients, 13,642 had 1 or more prescription claims for an LSA and 1 or more health service claims for a diagnosis of AR only in the pre-implementation period. Patients (n = 1876) with 1 or more prescriptions for a short-acting β-agonist and/or inhaled steroid were excluded. Finally, data analysis was performed on a sample of 11,591 patients with AR after 175 patients with incomplete claims data were excluded. The patients were 49% male and 51% female with a median age of 10 years (range 3-17 years). Prescription Patterns As shown in Table 1, there was a significant increase (3025%) in loratadine claims following program implementation from a mean of 0.04 claims per patient per year (PPPY) to 1.25 claims PPPY (P <.001). As expected, claims for nonpreferred LSAs were significantly reduced by 55.7% during the 12-month post-implementation period (1.58 to 0.7 PPPY, P <.001). However, significant reductions in the total number of LSA claims (19%) (1.63 to 1.32 PPPY, P <.001) and claims for cough/cold medications (8.1%) (0.74 to 0.68 PPPY, P <.001) were also observed. Simultaneous to the decrease in total LSA claims, a significant increase in claims for other relevant medications was observed, specifically a 40% increase in claims for leukotriene modifiers (0.20 to 0.28 PPPY, P <.001), a 10% increase in claims for intranasal steroids (0.40 to 0.44 PPPY, P <.001), and a 9% decrease in claims for systemic corticosteroids (0.11 to 0.10 PPPY, P =.016). No significant change in pharmacy claims for first-generation antihistamines (0.29 to 0.31 PPPY, P =.077) was observed during this period. Healthcare Utilization Healthcare utilization claims were examined to determine whether limiting the choice of LSA had increased the number of outpatient visits, ED visits, and/or hospital admissions. We could not separate out claims based on diagnosis, so we analyzed the total number of claims to see whether there was an overall increase in healthcare utilization. In the 12 months after program implementation, the total numbers of outpatient and ED visits were reduced by about 13% (4.30 to 3.72 PPPY, P <.001) and 17% (0.34 to 0.28 PPPY, P <.001), respectively. As expected, hospital admissions were rare events in this population (0.074 to PPPY, P =.72), with no significant change observed. Cost Analysis The preferred drug program reduced LSA cost by 73% ($724,557) for the pediatric patients with a single diagnosis of AR ($86 to $23 PPPY, P <.001). Despite these savings on LSA, the overall pharmacy cost was not significantly reduced ($562 to $583 PPPY, P =.11). The overall savings for medical services in this group was $59 PPPY (P <.005) for a total savings of $679,788. Prior Authorization Protocol To observe the effect of the PA protocol, we looked at the number of patients with PA requests and their pattern of LSA prescription filling (Table 2). Prior authorization was requested for only 3.3% of the children with AR (n = 307), and 61% (n = 188) of the requests were approved. Group 1: Patients With Prior Authorization Approved. Children with an approved PA had the highest number of LSA claims before and after program implementation (4.02 vs 5.19 claims PPPY, respectively, P <.001). As shown in Table 2, there were also significant increases in claims for leukotriene modifiers (0.52 to 0.89 PPPY, P <.001) and intranasal steroids (0.90 to 1.37 PPPY, P <.001). Unlike the other 3 groups, LSA prescription costs per patient before and after program implementation were not significantly different. Because these children remained on a nonpreferred LSA, this cost was not expected to change. However, total pharmacy costs per patient in this group were significantly increased ($937 to $1166 PPPY, P <.001) (Table 3). There was not a significant increase in medical costs ($2372 vs $2382 PPPY, P = 0.96) for the patients in this group. Group 2: Patients With Prior Authorization Denied. A total of 119 patients with at least 1 nonpreferred LSA before implementation of the program were denied a PA request. While the patients whose PA request was denied did not have a change in the number of claims submitted after the preferred LSA program was implemented, the distribution of claims changed (Table 2). There was a significant increase in the use of loratadine (0 to 2.09 claims PPPY, P <.001) with a significant decrease in the use of nonpreferred LSA (2.54 to 0 claims PPPY, P <.001). The cost of total LSA claims decreased more Vol. 4, No. 5 The American Journal of Pharmacy Benefits e133

5 n Kloepfer Helm Perry Hu Table 1. Summary of Claims for Less-Sedating Antihistamines, Other Medications for Allergic Rhinitis Treatment, Healthcare Utilization, and Medicaid Costs Before and After Implementation of the Preferred Drug Program (N = 11,591) Before Drug Program Claims, PPPY After Drug Program Claims, PPPY % Change P Variable Before Drug Program After Drug Program Claims Preferred LSA , <.001 Nonpreferred LSA 18, <.001 Total LSA 19,111 15, <.001 Other treatments for atopic disease Leukotriene receptor antagonists <.001 Nasal steroid <.005 First-generation antihistamine NS Cough/cold <.001 Systemic steroids <.05 Services Outpatient visits 49,824 43, <.001 ED visits <.001 Admissions (hospital/icu) NS Cost LSA $993,410 $268,853 $86 $23 73 $63 PPPY <.001 Pharmacy (including LSA) $6,518,664 $6,753,720 $562 $ $21 PPPY NS Medical $18,841,774 $18,161,986 $1626 $ $59 PPPY <.005 Pharmacy and medical $25,360,438 $24,915,706 $2188 $ $38 PPPY <.001 ED indicates emergency department; ICU, intensive care unit; LSA, less-sedating antihistamine; NS, not significant; PPPY, per patient per year. than $100 PPPY from $129 to $28 (P <.001; Table 3). An increase in the use of nasal steroids was observed (0.48 to 0.82 claims PPPY, P <.001), while the use of leukotriene modifiers did not change. There was no significant change in overall medical costs (Table 3). Of 11,212 patients without a PA request, 57.87% (6488) were treated with loratadine (group 3) after the program implementation and 42.13% (4724) did not fill any LSA prescription (group 4). Group 3: No Prior Authorization Requested, Use of Loratadine in Post-Implementation Period. Group 3 showed a significant increase in claims for loratadine (0.04 to 2.10 PPPY, P <.001), leukotriene modifiers (0.19 to 0.32 PPPY, P <.001), and intranasal steroids (0.34 to 0.57 PPPY, P <.001) during the post-implementation period (Table 2), with a significant change observed in outpatient visits and total medical costs (Table 3). Group 4: No Prior Authorization Requested, No Use of Loratadine in Post-Implementation Period. No PA request was submitted for this group of 4724 children who had an average of 1.86 LSA claims PPPY before program implementation, and no utilization in the post-implementation period. As Table 2 shows, claims for nasal steroids decreased significantly during the post period (0.45 to 0.19 PPPY, P <.001) while there was no change in claims for leukotriene modifiers (0.20 to 0.19 PPPY, P =.48). Not only did group 4 show an expected significant reduction in LSA cost ($96 to $0 PPPY, P <.001) and total pharmacy costs ($588 to $440 PPPY, P <.001), this group also showed a significant decrease in overall medical costs ($1623 to $1352 PPPY, P <.001), including a significant decrease in ED visits (0.34 claims to 0.25 claims PPPY, P <.001) and outpatient visits (4.51 claims to 2.87 claims PPPY, P <.001) (Table 2). DISCUSSION With more than $11 billion being spent every year treating AR, new methods are being explored by thirdparty payers to lower ambulatory costs. 14,15 Preferred e134 The American Journal of Pharmacy Benefits September/October 2012

6 LSA Use in Pediatric Medicaid Patients drug programs have been one avenue taken to lower costs. Researchers have raised concerns about unintended outcomes of preferred drug programs, including decreased use of essential therapies; declines in health; substitution of less effective, more toxic, or more expensive medications; or increased use of more costly physician or institutional care. 16 The influence of a preferred LSA program on patient care and treatment cost has been studied in adult populations 17 ; however, the effect on total cost, utilization, and therapy attrition rates in pediatric patients has not been evaluated. In this study, the implementation of a preferred LSA medication program in pediatric patients with a single diagnosis of AR resulted in a $724,557 reduction in LSA pharmacy costs over 12 months, a 73% savings on total LSA costs. Claims for loratadine, the preferred LSA, increased significantly; however, an overall reduction in the number of claims for LSAs was observed. Another unforeseen effect of the preferred drug program was an increase in other treatments for AR, including intranasal steroids and leukotriene modifiers. Despite this increased use of alternative treatments for AR, a significant increase in overall pharmacy costs was not observed. These outcomes raise concerns regarding unintended reductions in appropriate treatment. One can only speculate as to the reasons for this reduction. The PA policy might have induced physicians who were avoiding the hassle of the PA protocol to not treat patients with AR. Alternatively, patients who received a prescription for a nonpreferred LSA without PA may not have been able to fill it at the pharmacy and may have gone untreated. It is also possible that patients confused or misinformed about the policy might have incurred out-of-pocket expenses by purchasing over-the-counter loratadine outside of pharmacy coverage. Overall, the pharmacy changes did not reflect negatively on patient care, as suggested by the lack of increased healthcare utilization. According to projections prepared to monitor the effect of preferred drug program implementation, annual LSA forecast expenditures for the post-implementation period were $6,650,590 and observed expenditures were $1,954,280 for all patients regardless of age. The expected Table 2. Pharmacy and Healthcare Utilization Claims per Patient per Year Before and After Preferred LSA Program Implementation Claims by Group a LSA claims Before Preferred LSA Program, PPPY After Preferred LSA Program, PPPY Change, PPPY Group <.001 Group NS Group <.001 Group <.001 Loratadine Group <.001 Group <.001 Group <.001 Group <.001 Nasal steroids Group <.001 Group <.003 Group <.001 Group <.001 Leukotriene modifiers Group <.001 Group NS Group <.001 Group NS Outpatient visits Group /05 NS Group NS Group <.002 Group <.001 ED visits Group NS Group <.05 Group NS Group <.001 ED indicates emergency department; LSA, less-sedating antihistamine; NS, not significant; PA, prior authorization; PPPY, per patient per year. a Group 1 consisted of patients with PA approved (n = 188); group 2 consisted of patients with PA denied (n = 119); group 3 consisted of patients who did not request PA and used loratadine in the post-implementation period (n = 6488); group 4 consisted of patients who did not request PA and did not use loratadine in the post-implementation period (n = 4724). P Vol. 4, No. 5 The American Journal of Pharmacy Benefits e135

7 n Kloepfer Helm Perry Hu Table 3. Costs of Preferred LSA Program per Patient per Year Before and After Preferred LSA Program Implementation Type of Cost by Group a Before Preferred LSA Program, $ After Preferred LSA Program, $ Change, $ P LSA cost Group NS Group <.001 Group <.001 Group <.001 Total pharmacy cost Group <.001 Group NS Group <.001 Group <.001 Total medical cost Group NS Group NS Group <.05 Group <.001 LSA indicates less-sedating antihistamine; NS, not significant. a Group 1 consisted of patients with PA approved (n = 188); group 2 consisted of patients with PA denied (n = 119); group 3 consisted of patients who did not request PA and used loratadine in the post-implementation period (n = 6488); group 4 consisted of patients who did not request PA and did not use loratadine in the post-implementation period (n = 4724). percent savings for the entire population was comparable to the savings in our sample of pediatric AR patients (71% and 73%, respectively). Approximately $993,410 was spent on LSA prescriptions for the 12 months before and $268,853 for the 12 months after program implementation. The savings is significant, but if physicians substitute more costly medications to treat AR (nasal steroids and leukotriene modifiers) in place of using loratadine or the PA program, overall pharmacy costs will increase. Recently, new studies have shown improvement in AR symptoms when desloratadine is used with a leukotriene modifier. 18,19 If this becomes a new standard of care, overall medication expenditure for AR will increase. With more physicians across the nation prescribing leukotriene modifiers, this increase may already be reflected in the slight increase in total pharmacy costs in the post-implementation period. Having a preferred nasal steroid and criteria for prescribing leukotriene modifiers could be a reasonable cost-containment strategy to explore in managing AR. In addition, these changes may reflect national trends in medication use, as seen with the decrease in cough and cold medication use around the time of this study. 20 To fully assess the preferred drug program s impact on overall perceived well-being, changes in patient symptom score, quality of life, and satisfaction need to be monitored. Maintenance of PA for a nonpreferred LSA in this program requires adherence to LSA therapy, defined as continued use at least 4 out of the most recent 6 months. A challenge for this program, and a point of contention, is that some patients have AR symptoms requiring treatment only seasonally. Patients prescribed an LSA for seasonal AR may experience symptoms only a few months during the year, making the overall prescription filling rate insufficient to maintain PA approval. Patients may benefit from a decrease in filling requirements to accommodate their seasonal symptoms. This study has the limitations associated with retrospective analysis of claims data including (1) possible selection bias due to limiting the sample to patients with continued enrollment and the use of ICD-9 codes to identify patients, (2) the assumption that physicians are diagnosing and prescribing appropriately and that the codes used for billing reflect their clinical practice, and (3) lack of patient-level data including symptom scores, quality of life, and satisfaction. Moreover, since no patient- level information was available, our analysis did not include adjustment for potential confounding variables. For example, although patients with documented comorbid atopic conditions (ie, asthma, atopic dermatitis, food allergy) were excluded, undiagnosed atopic conditions may require more medications, increasing pharmacy costs. Moreover, differences in medication treatment selection reflect the preferences and characteristics of both patients and providers. Further, patients discontinue or switch medications during an AR episode for a variety of reasons, personal (eg, misunderstanding of instructions, misperceptions, convenience) or medical (eg, treatment efficacy, side effects). 21,22 For personal reasons, patients may also choose to treat their AR with over-the-counter products. Patients not taking an LSA in the post-implementation period may represent a subgroup with less severe disease, with misdiagnosed AR resulting in discontinuation of unwarranted medication, or patients with poor access to medical care or difficulties adhering to treatment who e136 The American Journal of Pharmacy Benefits September/October 2012

8 LSA Use in Pediatric Medicaid Patients were further alienated by the program. Unfortunately, evaluating patients based on medical claims limited our ability to explain the reasons behind the discontinuation of treatment in this group. Further studies are needed to assess treatment failure in this population. As the preferred drug program continues, some of the barriers and unintended outcomes might be worked out by the providers, patients, and Medicaid administrators. Hopefully that will lead to improved patient care in the treatment of AR and other atopic conditions. Overall, the preferred LSA program had a significant impact on LSA cost reduction. Future studies should examine the effect of other factors such as diagnosis of seasonal versus perennial AR and quality of care. A longterm prospective study comparing patient satisfaction, medication use, and quality of life/symptom scores may help to further understand the impact of the preferred drug program on overall mental and physical health. Author Affiliations: From Department of Pediatrics (KMK, TTP, SMJ), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AK; Department of Social and Behavioral Sciences (PAV), New College of Arts and Sciences, Arizona State University, Glendale, AZ; College of Pharmacy (MEH, PH), University of Arkansas, Little Rock, AK. Funding Source: None. Author Disclosures: The authors (KMK, TTP, PH, SMJ, PAV) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. Authorship Information: Concept and design (SMJ, PAV); acquisition of data (MEH, PH); analysis and interpretation of data (KMK, TTP, SMJ, PAV); drafting of the manuscript (KMK, TTP, SMJ, PAV); critical revision of the manuscript for important intellectual content (KMK, TTP, SMJ, PAV); statistical analysis (PH); provision of study materials or patients (MEH, SMJ, TTP); obtaining funding (MEH, SMJ, PAV); administrative, technical, or logistic support (MEH, PV); and supervision (SMJ). Address correspondence to: Kirsten M. Kloepfer, MD, Section of Allergy, Pulmonary and Critical Care, University of Wisconsin Hospital and Clinics, K4/910 CSC #9988, 600 Highland Ave, Madison, WI kkloepfer@uwhealth.org. REFERENCES 1. Bloom B, Cohen RA. Summary health statistics for U.S. children: National Health Interview Survey, Vital Health Stat ;(234): Dykewicz MS. Management of rhinitis: guidelines, evidence basis, and systematic clinical approach for what we do. 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