Adjusted Cost Ratio Research Articles

In-hospital worsening heart failure and associations with mortality, readmission, and healthcare utilization.

BackgroundA subset of patients hospitalized with acute heart failure experiences worsening clinical status and requires escalation of therapy. Worsening heart failure is an end point in many clinical trials, but little is known about its prevalence in clinical practice and its associated outcomes.Methods and ResultsWe analyzed inpatient data from the Acute Decompensated Heart Failure National Registry linked to Medicare claims to examine the prevalence and outcomes of patients with worsening heart failure, defined as the need for escalation of therapy at least 12 hours after hospital presentation. We compared patients with worsening heart failure to patients with an uncomplicated hospital course and patients with a complicated presentation. Of 63 727 patients hospitalized with acute heart failure, 11% developed worsening heart failure. These patients had the highest observed rates of mortality, all‐cause readmission, and Medicare payments at 30 days and 1 year after hospitalization (P < 0.001 for all comparisons). The adjusted hazards of 30‐day mortality were 2.56 (99% CI, 2.34 to 2.80) compared with an uncomplicated course and 1.29 (99% CI, 1.17 to 1.42) compared with a complicated presentation. The adjusted cost ratios for postdischarge Medicare payments at 30 days were 1.35 (99% CI, 1.24 to 1.46) compared with an uncomplicated course and 1.11 (99% CI, 1.02 to 1.22) compared with a complicated presentation.ConclusionsIn‐hospital worsening heart failure was common and was associated with higher rates of mortality, all‐cause readmission, and postdischarge Medicare payments. Prevention and treatment of in‐hospital worsening heart failure represents an important goal for patients hospitalized with acute heart failure.

Abstract 109: In-Hospital Worsening Heart Failure is Associated With Poor Patient Outcomes and Increased Health Care Utilization

Background: A subset of patients hospitalized with acute heart failure (AHF) experiences worsening clinical status while hospitalized and require escalation of therapy. This phenomenon, termed in-hospital worsening heart failure (WHF), is an endpoint for many clinical trials but limited data exist on the prevalence of WHF in clinical practice and associated outcomes. Methods: We analyzed inpatient data from Acute Decompensated Heart Failure National Registry (ADHERE) linked to Medicare claims data to describe outcomes and health care utilization of patients that developed WHF. In-hospital WHF was defined by any of the following: use of inotropes or intravenous vasodilators &gt;12 hours after admission; initiation of mechanical circulatory support, hemodialysis, or ventilation after the first inpatient day; or transfer to the ICU after initial admission to a regular hospital ward. Patients with WHF were compared to those with an uncomplicated hospital course and those that had a complicated hospital presentation, defined as requiring the above advanced therapies on arrival. Results: The study population consisted of 63,727 patients hospitalized between 01/2001 and 12/2004. Of these, WHF developed in 7032 (11%), 15,361 (24%) presented with a complicated presentation and 41,334 (65%) with an uncomplicated hospital course. Observed mean length of stay was longest in the WHF cohort (10.0 days) followed by complicated presentation (6.3 days) and uncomplicated course (4.8 days). Patients with WHF also had higher observed rates of mortality and all-cause readmission at 30 days and 1 year after discharge (P&lt;0.001; Figure). The adjusted hazard ratio for 30-day mortality was 2.56 (99% CI 2.34-2.80) for WHF compared to an uncomplicated hospital course and 1.29 (1.17-1.42) compared to a complicated presentation. Medicare payments were also higher for patients with WHF with an adjusted cost ratio at 30 days of 1.35 (99% CI 1.24-1.46) for WHF compared to an uncomplicated hospital course and 1.11 (1.02-1.22) compared to a complicated presentation. Conclusion: In a large, multicenter registry, in-hospital WHF was common and associated with higher rates of mortality, all-cause readmission, and Medicare payments. Preventing and treating WHF represents an important therapeutic target among patients hospitalized with AHF.

Effects of an Acute Care for Elders Unit on Costs and 30-Day Readmissions

Providing high-quality care while containing cost is essential for the economic stability of our health care system. The United States is experiencing a rapidly growing elderly population. The Acute Care for Elders (ACE) unit interdisciplinary team model of care has been shown to improve outcomes in hospitalized older adults. The University of Alabama at Birmingham ACE unit incorporates evidence-based care processes. We hypothesized that the ACE model would also reduce costs. To examine variable direct costs from an interdisciplinary ACE compared with a multidisciplinary usual care (UC) unit. Retrospective cohort study. Tertiary care academic medical center. Hospitalists' patients aged 70 years or older spending the entirety of their hospitalization in either the ACE or UC unit in fiscal year 2010. Using administrative data, we analyzed variable direct costs for ACE and UC patients. We also conducted a subset analysis restricted to the 25 most common diagnosis related groups (DRGs) shared by ACE and UC patients. Generalized linear regression was used to estimate cost ratios and 95% confidence intervals adjusted for age, sex, comorbidity score, and case mix index (CMI). A total of 818 hospitalists' patients met inclusion criteria: 428 from the ACE and 390 from the UC unit. For this study group (all DRGs), the mean (SD) variable direct cost per patient was $2109 ($1870) for ACE and $2480 ($2113) for UC (P = .009). Adjusted cost ratios revealed significant cost savings for patients with low (0.82; 95% CI, 0.72-0.94) or moderate (0.74; 95% CI, 0.62-0.89) CMI scores; care was cost neutral for patients with high CMI scores (1.13; 95% CI, 0.93-1.37). Significantly fewer ACE patients than UC patients were readmitted within 30 days of discharge (7.9% vs 12.8%; P = .02). Subset analysis of the 25 most common DRGs revealed a significantly reduced mean (SD) variable direct cost per patient for ACE compared with UC patients ($1693 [$1063] vs $2138 [$1431]; P < .001); cost ratios for total (0.78; 95% CI, 0.70-0.87) and daily (0.89; 95% CI, 0.85-0.94) variable direct costs remained significant after adjustment. The ACE unit team model reduces costs and 30-day readmissions. In an era when improving care processes while reducing costs is a vital objective for the Medicare program and our nation as a whole, the ACE model meets these goals.

Comparative effectiveness of low‐molecular‐weight heparin versus unfractionated heparin for thromboembolism prophylaxis for medical patients

Both unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) are approved for venous thromboembolism (VTE) prophylaxis. Which agent is superior remains controversial. To compare the effectiveness, complications, and costs of UFH and LMWH as VTE prophylaxis for hospitalized medical patients. Retrospective cohort. Three hundred thirty-three acute care facilities in 2004-2005. Adults with 4 common medical diagnoses considered to carry moderate-to-high risk of VTE. Excluded were patients on warfarin or with hospital stays of ≤ 2 days. VTE prophylaxis was assessed from billing data. None. VTE, major bleeding or heparin-induced thrombocytopenia, mortality, and cost. Of 32,104 patients who received prophylaxis, 55% received LMWH and the remainder received UFH. The hospital where the patient obtained care was the strongest predictor of receiving LMWH. VTE was observed in 163 (0.51%) patients; complications, followed by stopping therapy, were rare (<0.2%). In analysis adjusted for the propensity for UFH and other covariates, patients treated with UFH had an odds ratio for VTE of 1.04 (95% confidence interval [CI] 0.76 to 1.43) compared to LMWH. In a grouped treatment model, the odds of VTE with UFH was 1.14 (95% CI 0.72 to 1.81). Adjusted odds of bleeding with UFH compared to LMWH were 1.64 (95% CI 0.50 to 5.33), adjusted odds of complications followed by stopping prophylaxis were 2.84 (95% CI 1.43 to 45.66), and adjusted cost ratio was 0.97 (95% CI 0.90 to 1.05). For VTE prophylaxis, the effectiveness and cost of LMWH and UFH are similar, but LMWH is associated with fewer complications.

Quantifying the effect of health status on health care utilization using a preference-based health measure

The purpose of this study was to quantify the effect of health status on current and future payments and number of visits to health professionals in a large, representative community sample in British Columbia, Canada. The study population was comprised of all respondents to the 1994/5 cycle of the Canadian National Population Health Survey (NPHS) who were 12 years of age or older and residing in the province of British Columbia (N=2084). Health status was measured with the Health Utilities Index (HUI). Two outcomes were defined for each subject: (a) the sum of all healthcare costs covered by the Medical Services Plan, incurred during a given fiscal year, and (b) the total number of visits to all health practitioners during the same year. Outcome data were obtained for a period 1994–1998. We examined the relationship between the HUI and healthcare use in a multivariate log-linear model. In the full sample, better health in 1994–1995 was associated with lower healthcare cost and lower number of visits from 1994 through 1998. The overall adjusted cost ratio was 0.89 (99% CI=0.85, 0.94) and the overall adjusted visit ratio was 0.91 (99% CI=0.87, 0.95). The effect of health status on the costs of care and on the number of visits was similar in men and women, was stronger in persons less than 45 years of age compared to those 45+, and was not different according to place of residence. We conclude that the HUI is a strong predictor of health services use over 5 years. A 0.1 improvement in health utility is associated with a 10% reduction in the costs of care and number of visits to health professionals.