Rooting in deep regolith enables forests to withstand seasonal and annual precipitation shortfalls. Despite its ecological importance, spatial patterns in regolith thickness within forest ecosystems are scarcely documented. Regolith thickness was estimated at 66 sites throughout a 543‐ha watershed in the southern Sierra Nevada by hand auger to point of failure or a maximum depth of 7.5 m, describing a minimum thickness estimate. Regolith consists of 1–2 m of soil overlying thick and porous weathered granodiorite. Depth to auger failure ranged from 1.52 to an indeterminate depth beyond 7.5 m. A total of 27 points exceeded 7.5 m depth. Normal, lognormal, and gamma data distribution models were fitted to observations to extrapolate thickness across the watershed and estimate thicknesses beyond the measurement limitation. Predictions for the 95th percentile of regolith thickness varied substantially; 26.05 m for lognormal, 16.87 m for gamma, and 9.56 m for normal. Considering any best fit model, >55% of the watershed area was deeper than 5 m. Depth classes were formed to evaluate the extent to which topography is associated with spatial trends in regolith thickness. Spatial patterns were related to two covariate proxies (distance from stream channel and topographic wetness) with the general landscape trend of shallow depth classes (<3.3 m) in lowlands and deeper regolith classes (>7.5 m) in uplands. The normalized difference vegetation index signatures over the late stages of a 5‐year drought were greener in the lowlands. In contrast, upland forests displayed widespread tree die‐off, suggesting deep water storage does not maintain forests over long‐term drought.

Research agendas play valuable roles in clearly identifying high-priority topics that reflect potential to improve health care quality. The purpose of this report is to present work completed by the Academy of Managed Care Pharmacy (AMCP) and AMCP Foundation Joint Research Committee. This committee set forth to develop a research agenda for our 2 organizations that focuses on critical evidence needs in managed care pharmacy. This document reviews results from 2 surveys that were conducted to better understand unmet research needs within managed care pharmacy and to inform professional efforts of managed care pharmacists. The first survey collected qualitative data from key opinion leaders (KOLs) regarding the top evidentiary gaps in managed care pharmacy and barriers to closing those gaps. The second survey was sent to AMCP members and AMCP Foundation stakeholders, used a mixed methods quantitative-qualitative design, and incorporated concepts from initial KOL responses. The key outcome from these proceedings is the research agenda, which identifies and prioritizes 4 evidentiary gaps in managed care pharmacy: (1) real-world evidence to inform managed care pharmacy decision making, (2) value-based models in managed care pharmacy to address total cost of care, (3) impact of benefit design or utilization management strategies on patient outcomes, and (4) impact of direct patient care services provided by managed care pharmacy on patient outcomes. The agenda was intended to be broad and will evolve over time. AMCP and the AMCP Foundation hope that this research agenda inspires the AMCP membership, researchers, and funding agencies to close these gaps in knowledge and understanding.

Study objective: Muscular tone that inhibits anesthetic or surgical care characterizes insufficient neuromuscular block. The incidence of insufficient neuromuscular block is unknown, therefore we developed novel electronic search strategies to identify occurrences of insufficient neuromuscular block. Our primary goal was to determine the incidence of intraoperative insufficient neuromuscular block in abdominal and neurovascular surgery. Our secondary goal was to assess factors independently associated with insufficient block. Design: Retrospective cohort. Setting: Operating rooms in a tertiary care center. Patients: Adults having abdominal, laparoscopic, and interventional neurovascular procedures under general anesthesia with endotracheal intubation between April 2005 and February 2013. Measurements: An expert panel of anesthesiologists used a Delphi process to develop criteria to identify insufficient intraoperative neuromuscular block. 10 final criteria were agreed upon and used to determine the incidence of insufficient neuromuscular block. Main results: 48,315 surgeries met our inclusion requirements. Intraoperative insufficient neuromuscular block was identified in 13,538 cases, representing 28% (95% CI: 27.6%, 28.4%) of the operations. Younger age, male sex, type of surgery, longer duration of surgery, pre-existing conditions, and use of volatile anesthetics were independently associated with insufficient block after Bonferroni correction. Conclusion: Our results suggest that episodes of insufficient block occur in over a quarter of operations that are generally thought to require muscle relaxation. Without neuromuscular monitoring, it is difficult to separate inadequate anesthesia from inadequate neuromuscular block, and both presumably contributed in many cases.

The FAO-56 dual crop coefficient model was used to simulate site-specific irrigation management to quantify the green water resource (rainfall stored in soil) in five California perennial crops (alfalfa, almonds, grapes, pistachios, and walnuts), considering local soil water holding capacity and climate data from 2003 to 2018. We tested different rooting depths and irrigation management thresholds (allowable depletion) across 1.46 million hectares of cropland to determine how the size of the soil water reservoir affects green water utilization and, consequently, blue water demand (irrigation). The 13-year cumulative green water utilization ranged from 17 to 36 million km 3 out of a 57 km(3) rainfall input and 162-263 km(3) cumulative blue water demand. For a deep scenario (2 m rooting; 50% allowable depletion), green water met 12% of cumulative crop water demand. However, green water use was not uniform: 20% of the landscape met over 20% of its annual crop water demand. Deeper rooting or greater allowable depletion reduced blue water demand more than the increase in green water utilization, due to less frequent irrigations, which reduced soil evaporative loss. Compared to a 'business-as-usual' shallow irrigation management scenario (0.5 m rooting; 30% allowable depletion), a moderate scenario (1.0 m rooting; 50% allowable depletion) saved 30 km(3) blue water evaporation and increased green water use by 7 km(3) through 13 years. Such savings would fill California's largest reservoir, Shasta Lake, 6.6 times. This study demonstrates an opportunity for climate-smart management of soil water storage, by delayed spring irrigation, applying deeper irrigations less often, and ending fall irrigation early.

Core Ideas Water quality and stream flow have temporal and spatial trends in response to variable climate. Our work reveals how Sierra Nevada forests responded to and recovered from multiyear drought. Regolith thickness trends reveal water storage capacity differences with elevation. Monitoring shows deep‐water changes via plant utilization or capillary flow during drought. Sensor networks within the Southern Sierra Critical Zone Observatory (SSCZO) and Kings River Experimental Watersheds (KREW) document changes in the water cycle spanning the west slope of the southern Sierra Nevada in California. The networks were established to document water dynamics throughout the critical zone spanning profile, hillslope, catchment, and watershed scales at key locations that reflect systematic differences in bioclimatic conditions imposed by a strong elevation gradient. The critical zone observatory attempts to constrain the hydrologic budget via representative measurements of streamflow, eddy flux covariance, snow depth, meteorological conditions, and water content and water potential in soil and deep regolith. These measurements reveal the complexity of interactions among all aspects of the water balance (runoff, storage, evapotranspiration [ET], and precipitation) through daily, seasonal, and annual timescales. Multiyear drought, catastrophic wildfires, insect outbreaks, and disease have caused widespread tree mortality in the Sierra Nevada. These disturbances offer a window into the future for this region, which is expected to undergo significant change in response to global warming. This hydrological observatory provides valuable hydrometric attributes and fluxes across the stream–groundwater–vadose zone–soil–vegetation–atmosphere continuum.

BACKGROUND:Obstructive sleep apnea (OSA) is a prevalent condition that is associated with early postoperative respiratory complications (PRCs). As the majority of patients with OSA are undiagnosed, preoperative screening remains the most efficient method to identify suspected OSA. METHODS:This retrospective study was performed on patients undergoing anesthesia in a single academic medical center. We assigned OSA risk class retrospectively to all patients in the study by using the Perioperative Sleep Apnea Prediction (PSAP) score. We evaluated the relationship between PSAP categories and early postoperative invasive airway placement after adjusting for several preoperative and intraoperative factors (including surgical risk) previously associated with PRC occurrence. RESULTS:A total of 108,479 patients were included in the final analysis with an incidence of PRC was 0.3% (n = 280). High PSAP score was associated with postoperative intubation (adjusted odds ratio, 2.3; 95% confidence interval, 1.5-3.7). Several risk factors reflecting anesthetic agents, neuromuscular blocking agents, and opioids were also independently associated with early PRC. CONCLUSIONS:We report that suspected OSA based on the PSAP score is independently associated with increased risk of early PRC. Specific anesthetic agents are independently associated with early PRC, pointing to the potential for examining risk modification through these exposures in future studies.

Postoperative respiratory complications (PRCs) are associated with significant morbidity, mortality, and hospital costs. Obstructive sleep apnea (OSA), often undiagnosed in the surgical population, may be a contributing factor. Thus, we aimed to develop and validate a score for preoperative prediction of OSA (SPOSA) based on data available in electronic medical records preoperatively.

Introduction The clinical importance of postoperative episodic hypoxemia is still unclear, and therefore largely under-studied. As a result, there is limited understanding of its relationship with early postoperative respiratory complications (PRC, defined as intubation within three days of surgery) and hospital resource utilization. Materials and methods This single center study was performed using a retrospective observational design. We described population based definitions of desaturation from continuous SpO2 monitoring data captured in the post anesthesia care unit (PACU), namely median SpO2 in PACU, duration of desaturation below median, nadir desaturation, and length of oxygen therapy relative to PACU duration. These measures were evaluated against the occurrence of early PRC in logistic regression models. Measures that were independently associated with early PRC were accepted as the primary study exposures. Stratified logistic regression models were planned if significant interaction occurred with high risk surgical procedures. Models were adjusted by including several patient conditions, procedural, and anesthesia risk factors. Propensity matching on desaturation occurrence was planned to evaluate the relationship with postoperative resource utilization. Results Among 125,740 patients included in the univariate analyses, 351 patients (0.3%) developed early PRC. Nadir desaturation <89% [14.3% of patients; adjusted odds ratio 2.02; 95% CI 1.52, 2.68; p<0.001] and PACU oxygen therapy requirements greater than 60 min [adjusted odds ratio 1.92 (>60 min) to 3.04 (>90 min); p<0.001] were identified as independent predictors of early PRC occurrence. A modest interaction was observed between desaturation and higher surgical risk. Propensity matching for postoperative oxygen requirement was performed in 37,354 matched patients. Matched analysis demonstrated significant increase in day of surgery charges, respiratory charges, total charges, hospital length of stay, reintubation and use of invasive or non-invasive ventilatory support. Conclusions In summary, we report that prolonged PACU oxygen therapy and nadir desaturation <89% in PACU as captured in a retrospective database are independently associated with early PRC. This study describes resource implications of PACU desaturation in a large academic medical center in North America.

Introduction: Obstructive sleep apnoea (OSA), the most common type of sleep-disordered breathing, is associated with significant immediate and long-term morbidity, including fragmented sleep and impaired daytime functioning, as well as more severe consequences, such as hypertension, impaired cognitive function and reduced quality of life. Perioperatively, OSA occurs frequently as a consequence of pre-existing vulnerability, surgery and drug effects. The impact of OSA on postoperative respiratory complications (PRCs) needs to be better characterised. As OSA is associated with significant comorbidities, such as obesity, pulmonary hypertension, myocardial infarction and stroke, it is unclear whether OSA or its comorbidities are the mechanism of PRCs. This project aims to (1) develop a novel prediction score identifying surgical patients at high risk of OSA, (2) evaluate the association of OSA risk on PRCs and (3) evaluate if pharmacological agents used during surgery modify this association.Methods: Retrospective cohort study using hospital-based electronic patient data and perioperative data on medications administered and vital signs. We will use data from Partners Healthcare clinical databases, Boston, Massachusetts. First, a prediction model for OSA will be developed using OSA diagnostic codes and polysomnography procedural codes as the reference standard, and will be validated by medical record review. Results of the prediction model will be used to classify patients in the database as high, medium or low risk of OSA, and we will investigate the effect of OSA on risk of PRCs. Finally, we will test whether the effect of OSA on PRCs is modified by the use of intraoperative pharmacological agents known to increase upper airway instability, including neuromuscular blockade, neostigmine, opioids, anaesthetics and sedatives.Ethics and dissemination: The Partners Human Research Committee approved this study (protocol number: 2014P000218). Study results will be made available in the form of manuscripts for publication and presentations at national and international meetings.

Study Objective: We used electronic health record data to define frequency of inadequate intraoperative neuromuscular blockade (NMB).Design: Retrospective observational study using electronic health record data.Setting: Operating room in a tertiary care academic hospital.Patients: A total of 129,209 adult patients with American Society of Anesthesiologists physical status 1 to 5 undergoing general anesthesia in an outpatient or inpatient setting who received nondepolarizing NMB. We excluded patients intubated before arrival to the operating room, patients undergoing a liver transplant or cardiac surgery, and patients who remained intubated at the end of the operation.Interventions: None.Measurements: The primary outcomes were inadequate NMB defined by (1) documentation of patient movement and (2) documentation of surgical request for additional NMB, followed by NMB agent administration.Main Results: A total of 1261 patients (1.0%) demonstrated either intraoperative movement (369 or 0.29%) or prompted surgical request for additional NMB agent (921 or 0.71%). Trend analysis showed a variation in the annual rate of inadequate NMB, with an increase from 2004 to 2013 for criteria 1 and 2.Conclusions: Nearly 1% of all general anesthetic procedures involving NMB exhibit inadequate relaxation resulting in procedural interruption. These data suggest that current use of neuromuscular blocking drugs and NMB monitoring expose patients to inadequate blockade. The risk of this phenomenon warrants further study.(C) 2016 Elsevier Inc. All rights reserved.

Using electronic health record data, we hypothesized that larger reversal doses are used for patients with deeper levels of neuromuscular blockade (NMB) as evidenced by the last recorded TOF measurement. We also examined if dosing regimens reflect current practice guidelines of using ideal body weight (IBW) for NMB agents and total body weight (TBW) for neostigmine.

Background: Surgeons and anesthesiologists have shared but often-conflicting objectives for neuromuscular relaxation. While surgeons require neuromuscular relaxation to optimize surgical conditions, anesthesiologists must balance these requests for additional muscle relaxation with timely extubation and operating room efficiency. Methods: An internet based survey of anesthesiologists and surgeons was conducted between November 14th and December 4th, 2013. Respondents were asked a series of questions about pre-, intra- and post-operative communication regarding neuromuscular relaxation in open and laparoscopic procedures. Results: A total of 256 anesthesiologists and 254 surgeons completed the survey. The most common reason cited by surgeons for requesting more neuromuscular relaxation in open procedures was difficulty closing the incision (86%) and in laparoscopic procedures it was patients’ breathing or straining while intubated (89%). Anesthesiologists honor surgeon’s requests for additional neuromuscular relaxation 60% of the time via NMB, choosing alternate approaches the remainder of the time. Reasons cited by anaesthesiologists as to why they were unlikely to administer more NMB upon request were that it was too close to the end of surgery (48%) or that they felt the patient was sufficiently relaxed (38%). Conclusions: Surgeons’ requests for additional neuromuscular relaxation at the end of surgery appear to be in conflict with anesthesiologists’ desire for rapid reversal and timely extubation. Neuromuscular management approaches that provide surgeons with adequate muscle relaxation and optimal surgical conditions, while allowing anesthesiologists to provide timely extubation, should be explored.

The incidence rate of hepatic decompensation was higher in patients with human immunodeficiency virus (HIV)/hepatitis B virus (HBV)/hepatitis C virus (HCV) triple infection than in those with HIV/HCV coinfection (24.1 vs 10.8 events per 1000 person-years; hazard ratio [HR], 1.89; 95% confidence interval [CI], 1.12-3.18). Compared with HIV/HCV-infected patients, the rate of decompensation was increased among HIV/HBV/HCV-infected patients receiving no anti-HBV therapy (HR, 2.48; 95% CI, 1.37-4.49) but not among those who did receive such therapy (HR, 1.09; 95% CI, .40-2.97).

Impacts of land use on soil organic C (SOC) are of interest relative to SOC sequestration and soil sustainability. The role of aggregate stability in SOC storage under contrasting land uses has been of particular interest relative to conventional tillage (CT) and no-till (NT) agriculture. This study compares soil structure and SOC fractions at the 30-yr-old Horseshoe Bend Agroecosystem Experiment (HSB). This research is unique in comparing NT and CT with adjacent land concurrently undergoing forest succession (FS) and in sampling to depths (15-28 cm) previously not studied at HSB. A soil moving experiment (SME) was also undertaken to monitor 1-yr changes in SOC and aggregation. After 30 years, enhanced aggregate stability under NT compared to CT was limited to a depth of 5 cm, while enhanced aggregate stability under FS compared to CT occurred to a depth of 28 cm and FS exceeded NT from 5-28 cm. Increases in SOC concentrations generally followed the increases in stability, except that no differences in SOC concentration were observed from 15-28 cm despite greater aggregate stability. Land use differences in SOC were explained equally by differences in particulate organic carbon (POC) and in silt-clay associated fine C. Enhanced structural stability of the SME soil was observed under FS and was linked to an increase of 1 Mg SOC ha(-1) in 0-5 cm, of which 90% could be attributed to a POC increase. The crushing of macroaggregates in the SME soil also induced a 10% reduction in SOC over 1 yr that occurred under all three land uses from 5-15 cm. The majority of this loss was in the fine C fraction. NT and FS ecosystems had greater aggregation and carbon storage at the soil surface but only FS increased aggregation below the surface, although in the absence of increased carbon storage.

Aim: Sustained virologic response (SVR) can be attained with boceprevir plus peginterferon alfa and ribavirin (PR) in up to 68% of patients, and short duration therapy is possible if plasma HCV RNA levels are undetectable at treatment week 8 (TW8 response). We have developed predictive models for SVR, and TW8 response using data from boceprevir clinical trials.Methods: Regression models were built to predict TW8 response and SVR. Separate models were built for TW8 and SVR using baseline variables only, and compared to models with baseline variables plus HCV RNA change after 4 weeks of PR (TW4 delta). Predictive accuracy was assessed by c-statistics, calibration curves, and decision curve analyses. Nomograms were developed to create clinical decision support tools. Models were externally validated using independent data.Results: The models that included TW4 delta produced the best discrimination ability. The predictive factors for TW8 response (n = 856) were TW4 delta, race, platelet count and ALT. The predictive factors for SVR (n = 522) were TW4 delta, HCV-subtype, gender, BMI, RBV dose and platelet count. The discrimination abilities of these models were excellent (C-statistics = 0.88, 0.80 respectively). Baseline models for TW8 response (n = 444) and SVR (n = 197) had weaker discrimination ability (C-statistic = 0.76, 0.69). External validation confirmed the predictive accuracy of the week 4 models.Conclusions: Models incorporating baseline and treatment week 4 data provide excellent prediction of TW8 response and SVR, and support the clinical utility of the lead-in phase of PR. The nomograms are suitable for point-of-care use to inform individual patient and physician decision-making.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of invasive surgical site infection (SSI) in the USA. Antimicrobial prophylaxis for SSI typically includes a cephalosporin. Vancomycin is used to provide MRSA coverage, but the timing of administration is challenging. Linezolid is an attractive agent for SSI prophylaxis, particularly for the prevention of SSI due to MRSA. Methods: We developed a decision-analytic model to evaluate linezolid use for cardiothoracic SSI prophylaxis. A theoretical cohort of 10,000 cardiothoracic surgery patients was followed through 2 stages: (1) occurrence of SSI, and (2) mortality after SSI. All patients were administered cefuroxime, vancomycin, or linezolid between 1 and 180 min prior to surgical incision. SSIs were categorized into 3 pathogen categories: (1) methicillin-susceptible Gram-positive, (2) methicillin-resistant Gram-positive, and (3) other organisms. The most effective strategy resulted in the fewest SSIs. Assumptions for antibiotic effectiveness, impact of administration time, and pathogens were based on the published literature. Results: Compared with cefuroxime, there was a 1% increase in the total number of SSIs in the linezolid group (mean SSI increase = 7), while there was a 12% increase in the vancomycin group (mean SSI increase = 86). Linezolid prophylaxis resulted in fewer SSIs due to methicillin-resistant Gram-positive infections (n = 108) compared with cefuroxime (n = 200, 46% reduction in the linezolid group) and vancomycin (n = 119, 9% reduction in the linezolid group). Conclusions: This simulation indicates that linezolid may offer benefits for SSI prophylaxis over existing prophylactic agents, particularly for the prevention of SSI due to Gram-positive methicillin-resistant pathogens.

What is known and Objective: Warfarin is a potent anticoagulant with many drugdrug interactions, including antimicrobials. There is limited data on the frequency of prescription of high-risk antimicrobials to patients on warfarin. To examine the frequency of prescriptions for potentially interacting antimicrobials in ambulatory patients on warfarin and the impact of warfarin on the prescription of high-risk antimicrobials.Methods: A retrospective cohort study of patients with pharmacy benefits who had 1 claim for an oral antimicrobial between 1 January 2008 and 31 December 2008 was conducted, utilizing a pharmacy benefits database. Demographic data including age, gender, chronic disease score (CDS) and geographic location were determined. Warfarin users were defined as any patient with 1 claim for warfarin during the follow-up period. Antimicrobials considered high risk for potential interaction with warfarin based on existing literature included trimethoprim/sulfamethoxazole, levofloxacin, ciprofloxacin, metronidazole and fluconazole. Multivariate analysis was used to determine the impact of warfarin use and other factors on high-risk antimicrobial prescription.Results and Discussion: A total of 4 568 150 patients with 1 claim for antimicrobials during 2008 were analysed. Of them, 110 192 (2.4%) also had one or more claims for warfarin. Among all antimicrobial prescriptions in warfarin users, 42.6% were for high-risk antimicrobials. The mean number of antimicrobial prescriptions was 3 0 in warfarin users versus 2.4 in warfarin non-users (P-value < 0 001). After adjusting for age, gender, CDS and geography, the odds of exposure to high-risk antimicrobials was 42% lower (OR 0 58; P-value < 0 001) in warfarin users compared with warfarin non-users.What is new and Conclusions: A high percentage (42.6%) of antimicrobial prescriptions among warfarin users were for high-risk antimicrobials that carry excess bleeding risk. Although clinicians were somewhat less likely to prescribe high-risk antimicrobials to warfarin users compared with nonusers, the incidence of co-prescription remains high.

Forest succession (FS) and no-till (NT) agriculture are generally assumed to have a beneficial effect on surficial soil organic C (SOC) stocks compared with conventional tillage (CT) management; however, land use effects to depths >30 cm remain uncertain. In this research we compared SOC contents and composition to 2 m under CT, NT, and FS at the 30-year Horseshoe Bend agroecosystem experiment in Athens, Georgia, USA. Soils from 0 to 2 m were fractionated into particulate organic C (POC) (53‐2000 μm) and fine C (<53 μm) fractions, and bulk soil δ13C signatures were determined. Soils from 0 to 28 cm were dry- and wet-sieved to estimate aggregate stability. Soil solutions were also collected at 0, 15, and 100 cm for dissolved organic C (DOC) analysis. Full-profile (0–2 m) SOC storage is 52 Mg ha−1 in CT, 60 Mg ha−1 in NT, and 62 Mg ha−1 in FS. Significant differences are limited to 0–5 cm and are linked to enhanced aggregate stability under NT and FS. Increases in subsoil POC under FS and changes in soil δ13C and C/N ratio indicate that substantial subsoil C cycling has occurred. DOC fluxes at 0 cm were significantly greater under NT (200 kg ha−1 year−1) and FS (210 kg ha−1 year−1) than under CT (80 kg ha−1 year−1). DOC fluxes at 15 cm are estimated to be 20 kg ha−1 year−1 under CT and NT and 40 kg ha−1 year−1 under FS. At 100 cm, DOC fluxes are 2 kg ha−1 year−1, regardless of land use. An increase in FS POC of 2 Mg ha−1 from 15 to 100 cm outweighs cumulative differences in DOC input to this layer, implicating deep forest rooting and bioturbation as active mechanisms in subsoil C change. Whereas differences in SOC content were concentrated near the surface, dynamic changes in C cycling extend well below the plow layer.

BACKGROUND: Generic antidepressants offer significant prescription drug cost savings compared with brand-name antidepressants, but critics of managed care interventions promoting generic medication use suggest that some generic antidepressants are not as safe or effective as the brand alternatives.OBJECTIVE: To assess (a) rates of discontinuation of the initially dispensed medication and (b) disease-specific and total health care costs and pharmacy costs, comparing patients who initiated therapy with brand versus generic selective serotonin reuptake inhibitors (SSRI) or selective norepinephrine reuptake inhibitors (SNRI).METHODS: Antidepressant users aged 18 to 64 years with no pharmacy claims for an SSRI/SNRI in the 180 days prior to the start of SSRI/SNRI therapy (baseline) were identified in the Market Scan database between July 1, 2005, and June 30, 2007, and were followed for 180 days (follow-up). All study patients met the following criteria: (a) continuously eligible from baseline through follow-up; (b) at least 1 medical claim with a primary or secondary diagnosis of major depressive disorder (ICD-9-CM codes 296.2 or 296.3) in either the baseline or follow-up period; and (c) no pharmacy claims for antipsychotic medications in the baseline period. For brand versus generic antidepressant initiators, logistic regression was used to determine the odds of 6-month therapy discontinuation, defined as no medication refills or absence of a refill for the initially dispensed medication within 1.5 times the days supply dispensed, adjusted for important covariates. Costs were measured as total plan allowed charges including member cost share. Adjusted mean (least squares means holding covariates at mean values) all-cause medical costs, disease-specific (claims with a ICD-9-CM diagnosis code for major depressive disorder in the primary or secondary diagnosis field) medical costs, all-cause pharmacy costs, and SSRI/SNRI antidepressant costs were compared for brand versus generic initiators using generalized linear regression models, also adjusted for baseline covariates.RESULTS: Of 16,659 new SSRI/SNRI users, 47.8% (n=7,955) initiated a brand-name medication and 52.2% (n=8,704) initiated a generic product. Of the 7,955 who initiated a brand-name antidepressant, 46.8% (n=3,723) discontinued the initially dispensed drug within 180 days, compared with 44.2% (n=3,843) of the 8,704 who initiated a generic. The adjusted odds of discontinuation among generic and brand drug users did not significantly differ (odds ratio [OR]=1.09, 95% CI=0.98-1.22). Adjusted all-cause 6-month average health care costs in patients initiating therapy on a generic antidepressant were $3,660 (95% CI=$3,538-$3,787) compared with $4,587 (95% CI=$4,422-$4,757) for patients initiating on a brand-name antidepressant. Adjusted average 6-month SSRI/SNRI antidepressant costs were 43.7% lower in patients initiating on a generic drug ($174 vs. $309).CONCLUSIONS: The likelihood of discontinuation was similar for patients who initiated therapy with brand or generic antidepressants, and short-term health care costs and pharmacy costs were lower in patients starting a generic SSRI/SNRI. The results suggest that the use of generic antidepressants as first-line agents in the treatment of major depressive disorder is associated with continuation rates similar to initiation with brand antidepressants but with lower health care costs. J Manag Care Pharm. 2011;17(2):123-32 Copyright (C) 2011, Academy of Managed Care Pharmacy. All rights reserved.