5-year Cumulative Costs Research Articles

Abstract 4137810: Association of Sociodemographic Characteristics on Costs of Care in Patients with Obstructive Hypertrophic Cardiomyopathy

Introduction: No evidence exists on the impact of sociodemographic characteristics on costs of care for obstructive hypertrophic cardiomyopathy (oHCM). Therefore, we evaluated 5-year cumulative costs by age, sex, and race/ethnicity. Methods: Retrospective cohort study of adults diagnosed with oHCM (January 2013 to December 2021) using Optum claims and electronic medical record data. Patients with ≥2 claims for HCM (ICD-9 and-10) at least 30 days apart (index date = earliest oHCM claim) with ≥1 additional oHCM claim or septal reduction therapy, 6-months pre-index and 5-year post-index continuous enrollment were included. HCM-related cumulative costs (2022 CPI adjusted) were reported for medical (ambulatory [AB]: office [OV] visits, outpatient [OP] visits); emergency room [ER] visits; inpatient admissions (IP); and pharmacy (Rx). Results: Among 5,129 patients with oHCM, 52% were female (mean age 63.9 ± 14.3 years; 77.6% non-Hispanic White; 40% Medicare). Compared to females (Table), male patients had greater costs including total ($71,581 vs $63,710, p= 0.014), medical ($70,395 vs $62,455, p= 0.013), ambulatory ($16,024 vs $10,776, p<0.001), OV ($1,906 vs $1,573, p<0.001), and OP ($14,118 vs $9,202, p<0.001). Compared with White patients, Black patients had significantly greater IP costs ($54,572 vs $42,686, p= 0.01), Hispanic patients had greater ER costs ($1,724 vs $791, p<0.001), and Asian patients had greater OV costs ($2,094 vs $1,800, p<0.001). Patients aged 18-39 years had greater costs across all categories (p<0.001; IP=NS), except Rx. Patients aged 40-54 years had the highest Rx costs ($1,557, p<0.001), followed by 18-39, 55-64, 65-74, 75+ years ($1,528; $1,329; $1,197; $867), respectively. Conclusions: For oHCM patients , being male and age 18-39 years was associated with increased HCM-related healthcare costs. Differences in cost across race/ethnicity exist, including greater IP and ER costs for Black and Hispanic patients, respectively. Future research is required to understand the source of these differences among oHCM patients.

Costs Attributable to Clostridioides difficile Infection Based on the Setting of Onset.

Although hospital-onset Clostridioides difficile infection (CDI) is associated with significant healthcare costs, the economic burden of CDI with onset in other facilities or the community has not been well studied. Incident CDI cases were identified using 2011-2017 Medicare fee-for-service data. Controls were randomly selected in a 4:1 ratio matching to the CDI case surveillance definition. Inverse probability of exposure weights were used to balance on measured confounders. One-, 3-, and 5-year cumulative costs attributable to CDI were computed using a 3-part estimator (parametric survival model and pair of 2-part models predicting costs separately in intervals where death did and did not occur). A total of 60 492 CDI cases were frequency-matched to 241 968 controls. One-, 3-, and 5-year adjusted attributable costs were highest for hospital-onset CDI at $14 257, $18 953, and $21 792, respectively, compared with hospitalized controls and lowest for community-associated CDI compared with community controls at $1013, $3161, and $6454, respectively. Adjusted 1-, 3-, and 5-year costs attributable to community-onset healthcare facility-associated CDI were $8222, $13 066, and $16 329 and for other healthcare facility-onset CDI were $5345, $6764, and $7125, respectively. Economic costs attributable to CDI in elderly persons were highest for hospital-onset and community-onset healthcare facility-associated CDI. Although lower, attributable costs due to CDI were significantly higher in cases with CDI onset in the community or other healthcare facility than for comparable persons without CDI. Additional strategies to prevent CDI in the elderly are needed to reduce morbidity and healthcare expenditures.

Does bariatric surgery reduce future hospital costs? A propensity score-matched analysis using UK Biobank Study data.

To estimate the hospital costs among persons with obesity undergoing bariatric surgery compared with those without bariatric surgery. We analysed the UK Biobank Cohort study linked to Hospital Episode Statistics, for all adults with obesity undergoing bariatric surgery at National Health Service hospitals in England, Scotland, or Wales from 2006 to 2017. Surgery patients were matched with controls who did not have bariatric surgery using propensity scores approach with a ratio of up to 1-to-5 by year. Inverse probability of censoring weighting was used to correct for potential informative censoring. Annual and cumulative hospital costs were assessed for the surgery and control groups. We identified 348 surgical patients (198 gastric bypass, 73 sleeve gastrectomy, 77 gastric banding) during the study period. In total, 324 surgical patients and 1506 matched control participants were included after propensity score matching. Mean 5-year cumulative hospital costs were €11,659 for 348 surgical patients. Compared with controls, surgical patients (n = 324) had significantly higher inpatient expenditures in the surgery year (€7289 vs. €2635, P < 0.001), but lower costs in the subsequent 4 years. The 5-year cumulative costs were €11,176 for surgical patients and €8759 for controls (P = 0.001). Bariatric surgery significantly increased the inpatient costs in the surgery year, but was associated with decreased costs in the subsequent 4 years. However, any cost savings made up to 4 years were not enough to compensate for the initial surgical expenditure.

Bariatric surgery is expensive but improves co-morbidity: 5-year assessment of patients with obesity and type 2 diabetes.

Bariatric surgery can be effective in weight reduction and diabetes remission in some patients, but is expensive. The costs of bariatric surgery in patients with obesity and type 2 diabetes mellitus (T2DM) were explored here. Population-based retrospectively gathered data on patients with obesity and T2DM from the Hong Kong Hospital Authority (2006-2017) were evaluated. Direct medical costs from baseline up to 60 months were calculated based on the frequency of healthcare service utilization and dispensing of diabetes medication. Charlson Co-morbidity Index (CCI) scores and co-morbidity rates were measured to compare changes in co-morbidities between surgically treated and control groups over 5 years. One-to-five propensity score matching was applied. Overall, 401 eligible surgical patients were matched with 1894 non-surgical patients. Direct medical costs were much higher for surgical than non-surgical patients in the index year (€36 752 and €5788 respectively; P < 0·001) mainly owing to the bariatric procedure. The 5-year cumulative costs incurred by surgical patients were also higher (€54 135 versus €28 603; P < 0·001). Although patients who had bariatric surgery had more visits to outpatient and allied health professionals than those who did not across the 5-year period, surgical patients had shorter length of stay in hospitals than non-surgical patients in year 2-5. Surgical patients had significantly better CCI scores than controls after the baseline measurement (mean 3·82 versus 4·38 at 5 years; P=0·016). Costs of glucose-lowering medications were similar between two groups, except that surgical patients had significantly lower costs of glucose-lowering medications in year 2 (€973 versus €1395; P = 0.012). Bariatric surgery in obese patients with T2DM is expensive, but leads to an improved co-morbidity profile, and reduced length of hospitalization.

Editors' Note: Three-Month Modified Rankin Scale as a Determinant of 5-Year Cumulative Costs After Ischemic Stroke: An Analysis of 11,136 Patients in Korea

Using their pooled, prospective multicenter registry of over 11,000 Korean stroke survivors, Dr. Kim et al. reported the estimated direct healthcare costs in the years after acute ischemic stroke. Unsurprisingly, the estimated direct costs of care (including costs of inpatient and outpatient visits, prescription medications, and long-term care) were significantly greater in the year after stroke than the year before (mean $38,152 USD vs $8,718 USD), with a 5-year cumulative poststroke cost estimated at $117,576 USD. Importantly, there was considerable variation in the 5-year cumulative healthcare costs based on 3-month disability using the modified Rankin Scale (mRS). Compared with patients with no disability (mRS 0), patients dependent on others for ambulation and for activities of daily living (mRS 4) incurred considerably greater costs over the same period ($279,188 vs $53,578). Because healthcare administrators and policy makers determine healthcare reimbursement rates for various conditions and treatments, it is critical that any independent benefit of acute stroke intervention (e.g., reperfusion therapies) be evaluated thoroughly—as pointed out by Drs. Ganesh and Varma. In this analysis, recanalization therapies were strongly associated with better 3-month functional outcomes but paradoxically increased inpatient and outpatient care costs in the final multivariable model. It seems that the long-term functional disability (3-month mRS) was the principal driver of the cost effect, and after adjustment for this variable, any cost savings from recanalization could be negated. To clarify whether (and to what degree) acute recanalization therapies may mediate the long-term cost savings in stroke survivors, the investigators are exploring ways to model this in a follow-up analysis. Using their pooled, prospective multicenter registry of over 11,000 Korean stroke survivors, Dr. Kim et al. reported the estimated direct healthcare costs in the years after acute ischemic stroke. Unsurprisingly, the estimated direct costs of care (including costs of inpatient and outpatient visits, prescription medications, and long-term care) were significantly greater in the year after stroke than the year before (mean $38,152 USD vs $8,718 USD), with a 5-year cumulative poststroke cost estimated at $117,576 USD. Importantly, there was considerable variation in the 5-year cumulative healthcare costs based on 3-month disability using the modified Rankin Scale (mRS). Compared with patients with no disability (mRS 0), patients dependent on others for ambulation and for activities of daily living (mRS 4) incurred considerably greater costs over the same period ($279,188 vs $53,578). Because healthcare administrators and policy makers determine healthcare reimbursement rates for various conditions and treatments, it is critical that any independent benefit of acute stroke intervention (e.g., reperfusion therapies) be evaluated thoroughly—as pointed out by Drs. Ganesh and Varma. In this analysis, recanalization therapies were strongly associated with better 3-month functional outcomes but paradoxically increased inpatient and outpatient care costs in the final multivariable model. It seems that the long-term functional disability (3-month mRS) was the principal driver of the cost effect, and after adjustment for this variable, any cost savings from recanalization could be negated. To clarify whether (and to what degree) acute recanalization therapies may mediate the long-term cost savings in stroke survivors, the investigators are exploring ways to model this in a follow-up analysis.

Reader Response: Three-Month Modified Rankin Scale as a Determinant of 5-Year Cumulative Costs After Ischemic Stroke: An Analysis of 11,136 Patients in Korea.

We congratulate Drs. Kim et al.1 on their article. Their sample was nearly 8-fold higher than preceding work from the Oxford Vascular Study, cited by the authors2; in addition, they included invaluable data on the use of recanalization therapies. It was surprising, however, that recanalization therapies did not decrease the poststroke costs but rather increased the costs in their models. We know that recanalization therapies such as thrombolysis3 and thrombectomy improve the 3-month mRS,4 which is the main driver of poststroke costs as confirmed in this study. If the association of recanalization therapy with costs is estimated from a model adjusted for 3-month mRS, we suspect that any decrease in the cost from this therapy would likely be “adjusted out.” Did the authors include an interaction term in their model for the interaction between 3-month mRS and recanalization therapies? Because this high-quality data set is likely to influence the perceptions of policy makers and future cost-effectiveness analyses, it would be helpful to further clarify this point.

Author Response: Three-Month Modified Rankin Scale as a Determinant of 5-Year Cumulative Costs After Ischemic Stroke: An Analysis of 11,136 Patients in Korea.

We thank Drs. Ganesh and Varma for the thoughtful comments on our article.1 In relation to the role of recanalization and costs after stroke, it is reasonable that the cost for patients who received recanalization therapy was increased compared with those who did not when recanalization therapy and 3-month modified Rankin Scale (mRS) were included as independent variables in the same model. As Drs. Ganesh and Varma mentioned, the cost-reducing effect of recanalization therapy seemed to vanish by adjustment for 3-month mRS.

Economic burden of epilepsy in children: A population-based matched cohort study in Canada.

The economic burden of childhood epilepsy to the health care system remains poorly understood. This study aimed to determine phase-specific and cumulative long-term health care costs in children with epilepsy (CWE) from the health care payer perspective. This cohort study utilized linked health administrative databases in Ontario, Canada. Incident childhood epilepsy cases were identified from January 1, 2003 to June 30, 2017. CWE were matched to children without epilepsy (CWOE) on age, sex, rurality, socioeconomic status, and comorbidities, and assigned prediagnosis, initial, ongoing, and final care phase based on clinical trajectory. Phase-specific, 1-year and 5-year cumulative health care costs, attributable costs of epilepsy, and distribution of costs across different ages were evaluated. A total of 24411 CWE were matched to CWOE. The costs were higher for prediagnosis and initial care than ongoing care in CWE. Hospitalization was the main cost component. The costs of prediagnosis, initial, and ongoing care were higher in CWE than CWOE, with the attributable costs at $490 (95% confidence interval [CI] = $352-$616), $1322 (95% CI = $1247-$1402), and $305 (95% CI = $276-$333) per 30 patient-days, respectively. Final care costs were lower in CWE than CWOE, with attributable costs at -$2515 (95% CI = -$6288 to $961) per 30 patient-days. One-year and 5-year cumulative costs were higher in CWE ($14776 [95% CI = $13994-$15546] and $39261 [95% CI = $37132-$41293], respectively) than CWOE ($6152 [95% CI = $5587-$6768] and $15598 [95% CI = $14291-$17006], respectively). The total health care costs were highest in the first year of life in CWE for prediagnosis, initial, and ongoing care. Health care costs varied along the continuum of epilepsy care, and were mainly driven by hospitalization costs. The findings identified avenues for remediation, such as enhancing care around the time of epilepsy diagnosis and better care coordination for epilepsy and comorbidities, to reduce hospitalization costs and the economic burden of epilepsy care.

Three-month modified Rankin Scale as a determinant of 5-year cumulative costs after ischemic stroke: An analysis of 11,136 patients in Korea.

Stroke is a devastating and costly disease; however, there is a paucity of information on long-term costs and on how they differ according to 3-month modified Rankin scale (mRS) score, which is a primary outcome variable in acute stroke intervention trials. We analyzed a prospective multicenter stroke registry (Clinical Research Collaboration for Stroke in Korea) database through linkage with claims data from the National Health Insurance Service with follow-up to December 2016. Healthcare expenditures were converted into daily cost individually, and annual and cumulative costs up to 5 years were estimated and compared according to the 3-month mRS score. Between January 2011 and November 2013, 11,136 patients were enrolled in the study. The mean age was 68 years, and 58% were men. The median follow-up period was 3.9 years (range 0-5 years). Mean cumulative cost over 5 years was $117,576 (US dollars [USD]); the cost in the first year after stroke was the highest ($38,152 USD), which increased markedly from the cost a year before stroke ($8,718 USD). The mean 5-year cumulative costs differed significantly according to the 3-month mRS score (p < 0.001); the costs for a 3-month mRS score of 0 or 5 were $53,578 and $257,486 USD, respectively. Three-month mRS score was an independent determinant of long-term costs after stroke. We show that 3-month mRS score plays an important role in the prediction of long-term costs after stroke. Such estimates relating to 3-month mRS categories may be valuable when undertaking health economic evaluations related to stroke care.

Home Dialysis Is Associated with Lower Costs and Better Survival than Other Modalities: A Population-Based Study in Ontario, Canada.

Background:How and where to initiate dialysis are policy challenges with enormous economic and health consequences. Initiating with home hemodialysis (HD) or peritoneal dialysis (PD) may reduce costs and improve outcomes but evidence is conflicting.Methods:We conducted a population-based study in patients aged ≥ 18 years who initiated chronic dialysis in the province of Ontario, Canada from 2006 to 2014 (N = 12,691) using linked administrative data. Patients were grouped by initial modality: facility HD, facility short daily or slow nocturnal (SD/SN) HD, PD, home HD. We estimated publicly-paid healthcare costs (2015 Canadian dollars; 1 = 0.947 US dollar) and survival, from dialysis initiation to March 2015.Results:By 5 years after dialysis initiation, mean 30-day costs (as-treated) for patients receiving PD and home HD were 50% and 64% lower, respectively, than for facility HD patients ($11,011). Approximately 50% of costs were unrelated to dialysis, reflecting high comorbidity in these patients. With covariate adjustment, mean 5-year cumulative costs were similar for initiators of home HD and PD ($304,178 and $349,338) and higher for facility HD initiators ($410,981). The highest 5-year unadjusted survival was for home HD patients (80%), followed by PD (52%), SD/SN HD (50%), and facility HD (42%).Conclusions:This study in a large cohort over 9 years provides new population-based evidence suggesting that initiating dialysis at home is cost-effective, with lower costs and better survival, than starting with facility HD. Survival differences persisted after adjustment for baseline characteristics but we could not adjust for functional status or severity of comorbidities.

Impact of Abuse Deterrent Formulations of Opioids in Patients With Chronic Pain in the United States: A Cost-Effectiveness Model

ObjectiveOpioid abuse is a significant public health problem in the United States. We evaluate the clinical effectiveness and economic impact of abuse-deterrent formulations (ADF) of opioids relative to non-ADF opioids in preventing abuse. MethodsWe developed a cost-effectiveness model simulating 2 cohorts of 100 000 noncancer, chronic-pain patients newly prescribed either ADF or non-ADF extended-release (ER) opioids and followed them over 5 years, tracking new events of opioid abuse and opioid-related overdose deaths in addition to tracking 5-year cumulative costs of therapeutic use and abuse of ADF and non-ADF opioids. Patients in each cohort entered the model for therapeutic opioid use from where they could continue in that pathway, discontinue opioid use, or abuse opioids or die of opioid overdose-related or unrelated causes. In addition, one-way sensitivity and scenario analysis were conducted. ResultsOver a 5-year time period, using ADF opioids prevented an additional 2300 new cases of opioid abuse at an additional cost of approximately $535 million to the healthcare sector. Threshold analyses showed that a 40% decrease in ADF opioid costs was required to attain cost neutrality between the 2 cohorts, whereas a 100% effectiveness in abuse reduction still did not result in cost neutrality. A 43% decrease in diversion with ADFs relative to non-ADFs was required to attain cost neutrality. Including a societal perspective produced results directionally similar to the base-case analysis findings. ConclusionADF opioids have the potential to prevent new cases of opioid abuse, but at substantially higher costs to the health system.

Determinants of Medicare Costs for Elderly Patients With Oral Cavity and Pharyngeal Cancers.

In the United States, nearly 8400 patients die each year from oral cavity and pharynx cancers, most of whom are 65 years and older; however, the costs attributable to these cancers are not well described. To identify the primary determinants of cost in patients with oral and pharyngeal cancer. In this retrospective cohort analysis of data from Medicare and Surveillance, Epidemiology, and End Results hospitals (January 1, 1995, through December 31, 2005), we studied patients 66 years and older with newly diagnosed oral cavity (n = 6724) and pharyngeal (n = 3987) cancers. Five-year cumulative costs, defined as Medicare Parts A and B payments, were estimated using inverse probability weighting. Linear regression analysis with inverse probability weighting was used in multivariate analyses of costs to estimate the effects of covariates on cumulative costs. In multivariate analyses, costs were significantly increased by demographics, comorbidities, and treatment selection. Compared with white patients, African Americans accumulated $11,450 (95% CI, $1320-$22,299) and $25,093 (95% CI, $14,917-$34,985) more in costs for oral cavity and pharyngeal cancers, respectively. The presence of 1 or 2 comorbidities increased the mean 5-year cumulative costs by $13,342 (95% CI, $6248-$19,186) and $14,139 (95% CI, $6009-$22,217) for patients with oral cavity and pharyngeal cancers, respectively. For 3 or more comorbidities, the mean 5-year cumulative costs increased by $22,196 (95% CI, $15,319-$28,614) and $27,799 (95% CI, $19,139-$36,702) for patients with oral cavity and pharyngeal cancers, respectively. Patients who received chemotherapy accumulated a mean of $26,919 (95% CI, $18,309-$35,056) and $37,407 (95% CI, $29,971-$44,644) more in costs by 5 years for oral cavity and pharyngeal cancers, respectively. Oral and pharyngeal cancer is burdensome to elderly patients from a Medicare cost perspective. Several factors were associated with 5-year costs, including some modifiable factors that may be potential targets for interventions to reduce overall costs.

Economic evaluation of medication, laser trabeculoplasty and filtering surgeries in treating patients with glaucoma in the US

ABSTRACTObjective: Despite the significant clinical and economic burden associated with glaucoma, studies evaluating the long-term costs of existing treatments are limited. This study compared the 5-year costs of three treatment strategies: medication, laser trabeculoplasty, and filtering surgeries in managing patients with primary open-angle glaucoma whose intra-ocular pressures were not adequately controlled by two medications.Research design and methods: A Markov model was developed to simulate the transition of treatment progression over a 5-year period to evaluate the total treatment costs associated with each strategy. In the medication arm, medications were the only available treatment, whereas in the laser trabeculoplasty and surgery arms, patients would receive concomitant medications both at the time of the procedure and in subsequent years. Treatment states were determined by the rate of success in controlling patients’ intra-ocular pressure in each year. The distribution of treatment states and the transition probabilities between these states were derived from published literature, adjusted or supplemented by the authors’ own treatment experiences. Costs assessed in the model included treatment, complications associated with each treatment, and physician office visits obtained from published literature and standardized fees and schedules.Results: The 5-year cumulative costs were approximately $6571, $4838 and $6363 for patients in the medication, laser trabeculoplasty, and filtering surgery arms, respectively. Costs of third-line medication, first-line medication following laser trabeculoplasty, and post-surgery complications had the greatest impact on the model results in the medication, laser trabeculoplasty, and filtering surgery arms, respectively. Probabilistic sensitivity suggested the results were statistically significant ( p < 0.001), favoring the use of laser trabeculoplasty.Conclusions: Over 5 years laser trabeculoplasty was associated with the lowest total costs compared to treatment by medication alone or by filtering surgery for patients who were not adequately controlled by two medications. Future development of glaucoma treatment should focus on reducing the need for post-procedure medical therapy as well as lowering the rate of post-procedure complications. Limited by the availability of the transition probabilities in published literature, the model results need to be validated by prospective or retrospective observational studies.

Cancer Patient Care in Clinical Trials Sponsored by the National Cancer Institute: What Does It Cost?

“What does it cost?” This has been the refrain reiterated with increasing intensity over the last decade on the issue of financial coverage of patient care for patient’s enrolled in clinical trials sponsored by the National Cancer Institute (NCI). In the past, the answer to this question, to the frustration of health care payers and providers, has been, “We don’t know.” In recent years, the financial coverage of patient care in clinical trials has become an urgent question because implicit subsidies available for support of clinical research in the past have been suppressed by various measures aimed at achieving global health care cost containment (1). The NCI, through its Office of Clinical Research Promotion, has been in the forefront of addressing this problem by negotiating agreements in principle and in practice with such organizations as Medicare and the American Association of Health Plans for coverage of patient care in clinical trials sponsored by the National Institutes of Health (NIH) (2). Legislation mandating coverage of patient care costs for specific cancer clinical trials has been enacted in Maryland, Rhode Island, and Georgia (3) and is under consideration in several other states. A similar mandate is also under consideration at the federal level as part of the proposed Patient’s Bill of Rights Act of 1998 (4). These proposals must be “costed out,” by such agencies at the Congressional Budget Office (5) as they are considered, and many of these proposals and agreements contain requirements for continued evaluation of the economic impact of clinical trial coverage as the programs go into effect (4–6). Until now, the entities responsible for “costing out” the financial impact of coverage proposals have had to operate in the absence of empiric information. Because predicting financial exposure into the future is always risky business, these analyses have tended to err on the high side. Now, with the data provided by Wagner et al. (7) in this issue of the Journal, it will be possible to begin to place more realistic and, as it turns out, lower ceilings on these estimates. What can we learn from this study? Wagner et al. (7) examined the patient care cost of 61 cancer patients enrolled in NCI-sponsored phase II or phase III clinical trials at the Mayo Clinic from 1988 through 1994 and compared these costs with the 61 “control” patients receiving standard care in Olmsted County, MN. The 61 control patients were carefully pairmatched with the clinical trial patients on the basis of age, sex, site of primary cancer, stage of cancer, date of diagnosis, and clinical trial eligibility. Total cumulative medical care costs, for each case and control patient, were tracked at 1 month, 3 months, 6 months, 1 year, and 5 years after the date of diagnosis. In the analysis of 5-year cumulative costs, statistical methods were used that take the effects of censoring into account. The study found that trial participants experienced only slightly higher costs compared with control patients and that this difference was not statistically significant. At 1 year after diagnosis, the average cost for trial enrollees was $24 645 compared with $23 964 for comparable patients receiving standard care. The respective costs at 5 years were $46 424 and $44 133. These results should be considered preliminary because of the small size of this study and the notoriously high variance of medical cost data (8), as can be seen in Fig. 1 of Wagner et al. (7). Nevertheless, the results of this study and other preliminary work presented at a NCI-sponsored symposium in July 1998 (9) strongly suggest that, until more definitive