Ambulatory Costs Research Articles

Does Coordinated Postpartum Care Influence Costs?

Questions under study:To investigate changes to health insurance costs for post-discharge postpartum care after the introduction of a midwife-led coordinated care model.Methods:The study included mothers and their newborns insured by the Helsana health insurance group in Switzerland and who delivered between January 2012 and May 2013 in the canton of Basel Stadt (BS) (intervention canton). We compared monthly post-discharge costs before the launch of a coordinated postpartum care model (control phase, n = 144) to those after its introduction (intervention phase, n = 92). Costs in the intervention canton were also compared to those in five control cantons without a coordinated postpartum care model (cross-sectional control group: n = 7, 767).Results:The average monthly post-discharge costs for mothers remained unchanged in the seven months following the introduction of a coordinated postpartum care model, despite a higher use of midwife services (increasing from 72% to 80%). Likewise, monthly costs did not differ between the intervention canton and five control cantons. In multivariate analyses, the ambulatory costs for mothers were not associated with the post-intervention phase. Cross-sectionally, however, they were positively associated with midwifery use. For children, costs in the post-intervention phase were lower in the first month after hospital discharge compared to the pre-intervention phase (difference of –114 CHF [95%CI –202 CHF to –27 CHF]), yet no differences were seen in the cross-sectional comparison.Conclusions:The introduction of a coordinated postpartum care model was associated with decreased costs for neonates in the first month after hospital discharge. Despite increased midwifery use, costs for mothers remained unchanged.

Evaluating the Economic Burden and Health Care Utilization Following First-Line Therapy for Diffuse Large B-Cell Lymphoma Patients in the US Medicare Population

Introduction: Diffuse Large B-Cell Lymphoma (DLBCL) is the most common sub-type of non-Hodgkin lymphoma. Despite advances in immunochemotherapy, a significant portion of individuals with DLBCL are refractory or relapse following initial treatment and eventually succumb to the disease. Real world studies on DLBCL treatment patterns beyond first-line therapy are limited, and the health care costs associated with relapsed DLBCL are unknown. Using 100% Medicare claims data, our study set out to measure health care utilization following completion of first-line therapy for DLBCL.Methods: This retrospective study used 100% Medicare claims data (Inpatient, outpatient, Part D, SNF, HHA, Hospice, DME) to identify older adults (≥65 years) diagnosed with DLBCL (ICD9-CM diagnosis code: 200.7x) between Jan 1st 2010 - June 30th2014. Individuals were required to have prescription claims for a DLBCL chemotherapy treatment regimen 90 days pre-, or up to 1 year post-initial DLBCL claim. To limit our initial cohort selection to treatment-naïve patients, we excluded those with a DLBCL claim or prescription for a DLBCL related treatment at any time prior to the initial diagnosis date or treatment initiation date. All included patients were required to have continuous medical enrollment for 12 months before treatment initiation and receive at least one full cycle of valid DLBCL regimen. We then created our post first-line therapy study cohort by defining the end of first-line treatment by a gap of ≥60 days in therapy. Beneficiaries who initiated a second-line regimen during the follow-up period composed our relapsed group, whereas, individuals who completed first-line therapy without initiating any other chemotherapy treatment composed our non-relapse group. The index date for our health care utilization analysis was defined as the first-line treatment end date plus 60 days. Beneficiaries in both groups were required to have continuous medical benefits ≥1 year after this date or until death. Our primary outcome of health care resource utilization following first-line therapy were calculated as per patient per month and compared between our relapse and non-relapse groups using the chi-square test and t-test.Results:We identified 5,909 Medicare beneficiaries who completed first-line treatment for DLBCL, of which 1,552 had claims indicating second-line therapy during follow up (relapsed group). The mean age for the relapsed group was 77 years compared to 76 years for the non-relapse group (p=0.006). Other baseline characteristics were similar between our relapsed versus non-relapsed cohort. Compared to the non-relapse group, patients in our relapsed cohort were less likely to receive R-CHOP as first-line therapy (56.3% vs 80.5%, p<0.001), but more likely to receive rituximab monotherapy (20.8% vs. 6.0%, p<0.001), bendamustine-rituximab (9.0% vs. 3.4%, p<0.001), and CVP regimens (7.9% vs. 4.9%, p<0.001). The mean (median) follow-up time after first-line therapy was similar between groups with 915 (863) and 929 (893) days for the relapsed and non-relapsed cohorts, respectively. In the period following first-line therapy, our relapsed cohort had higher healthcare utilization with more patients having claims for hospital admissions (60.7% vs. 41.1%, p<0.001), emergency room visits (51.7% vs. 43.0%, p<0.001), use of skilled nursing facilities (19.3% vs. 12.5%, p<0.001), home health agency (35.5% vs. 23.3%, p<0.001), and hospice services (19.9% vs. 6.3%, p<0.001) compared to non-relapse patients. Major cost drivers among relapsed patients were inpatient costs ($1,147 vs. $511, p<0.001), outpatient office visits ($3,036 vs. $691, p<0.001), and ambulatory costs ($1,730 vs. $343, p<0.001). Consequently, higher total all-cause health care costs per patient per month were observed in the relapse group ($6,566 vs. $1,951, p<0.001).Conclusions: Our analysis found a significant portion of Medicare beneficiaries treated for DLBCL receive therapy beyond the first-line setting. Complete Medicare claims allowed us to capture comprehensive health care utilization, including end-of-life and supportive care not typically included in cost estimates. Our data confirms the expectations of higher health care utilization with relapsed DLBCL and suggest that improvements in first-line DLBCL therapy in older adults may offer significant health care savings in addition to improved clinical outcomes. DisclosuresHuntington:Johnson & Johnson: Consultancy; Oncosec Medical: Equity Ownership; Geron: Equity Ownership; Exelixis: Equity Ownership; Celgene: Consultancy, Honoraria; Pharmacyclics: Honoraria. Keshishian:STATinMED Research: Employment. Xie:Celgene: Research Funding. Baser:STATinMED Research: Employment. McGuire:Celgene Corporation: Employment, Equity Ownership.

Cost effects of preterm birth: a comparison of health care costs associated with early preterm, late preterm, and full-term birth in the first 3years after birth.

Preterm birth is one of the main causes for infant morbidity and mortality. Apart from negative health outcomes, preterm birth also produces significant health care expenditures. This study evaluates the costs associated with preterm birth in different health sectors during the first 3years of infants' lives. In a retrospective observational study based on claims data from a German statutory health insurance company, average costs for medication, hospital treatment, ambulatory treatment, and non-medical remedies during the first 3years after birth were analyzed for early preterm, late preterm, and full-term births. Costs associated with preterm births were generally higher than for full-term births, with the highest costs for the hospital treatment of early preterm births. Cost differences tended to decrease in the second and third year after birth except for ambulatory treatment costs, which decreased for late preterm and full-term births but not for early preterm births. The study shows that preterm birth is associated with increased health care costs, particularly during the first year after birth, indicating that the implementation of adequate programs and policies for preventing preterm birth is not only desirable from a medical but also from a health economic perspective.

Latin American Clinical Epidemiology Network Series – Paper 4: Economic evaluation of Kangaroo Mother Care: cost utility analysis of results from a randomized controlled trial conducted in Bogotá

Background and ObjectiveAlthough kangaroo mother care (KMC) has been shown to be safe and effective in randomized controlled trials (RCTs), there are no published complete economic evaluations including the three components of the full intervention. MethodsA cost utility analysis performed on the results of an RCT conducted in Bogotá, Colombia between 1993 and 1996. Hospital and ambulatory costs were estimated by microcosting in a sample of preterm infants from a University Hospital in Bogotá in 2011 and at a KMC clinic in the same period. Utility scores were assigned by experts by means of (1) direct ordering and scoring discrete health states and (2) constructing a multi-attribute utility function. Ninety-five percent confidence intervals (CIs) for the incremental cost–utility ratios (ICURs) were computed by the Fiellers theorem method. One-way sensitivity analysis on price estimates for valuing costs was performed. ResultsICUR at 1 year of corrected age was $ −1,546 per extra quality-adjusted life year gained using the KMC method (95% CI $ −7,963 to $ 4,910). ConclusionIn Bogotá, the use of KMC is dominant: more effective and cost-saving. Although results from an economic analysis should not be extrapolated to different systems and communities, this dominant result suggests that KMC could be cost-effective in similar low and middle income countries settings.

BIOENERGETIC DIFFERENCES DURING WALKING AND RUNNING IN TRANSFEMORAL AMPUTEE RUNNERS USING ARTICULATING AND NON-ARTICULATING KNEE PROSTHESES.

Transfemoral amputation (TFA) patients require considerably more energy to walk and run than non-amputees. The purpose of this study was to examine potential bioenergetic differences (oxygen uptake (VO2), heart rate (HR), and ratings of perceived exertion (RPE)) for TFA patients utilizing a conventional running prosthesis with an articulating knee mechanism versus a running prosthesis with a non-articulating knee joint. Four trained TFA runners (n = 4) were accommodated to and tested with both conditions. VO2 and HR were significantly lower (p ≤ 0.05) in five of eight fixed walking and running speeds for the prosthesis with an articulating knee mechanism. TFA demonstrated a trend for lower RPE at six of eight walking speeds using the prosthesis with the articulated knee condition. A trend was observed for self-selected walking speed, self-selected running speed, and maximal speed to be faster for TFA subjects using the prosthesis with the articulated knee condition. Finally, all four TFA participants subjectively preferred running with the prosthesis with the articulated knee condition. These findings suggest that, for trained TFA runners, a running prosthesis with an articulating knee prosthesis reduces ambulatory energy costs and enhances subjective perceptive measures compared to using a non-articulating knee prosthesis.

Cellulitis: A Review.

Cellulitis is an infection of the deep dermis and subcutaneous tissue, presenting with expanding erythema, warmth, tenderness, and swelling. Cellulitis is a common global health burden, with more than 650,000 admissions per year in the United States alone. In the United States, an estimated 14.5 million cases annually of cellulitis account for $3.7 billion in ambulatory care costs alone. The majority of cases of cellulitis are nonculturable and therefore the causative bacteria are unknown. In the 15% of cellulitis cases in which organisms are identified, most are due to β-hemolytic Streptococcus and Staphylococcus aureus. There are no effective diagnostic modalities, and many clinical conditions appear similar. Treatment of primary and recurrent cellulitis should initially cover Streptococcus and methicillin-sensitive S. aureus, with expansion for methicillin-resistant S. aureus (MRSA) in cases of cellulitis associated with specific risk factors, such as athletes, children, men who have sex with men, prisoners, military recruits, residents of long-term care facilities, those with prior MRSA exposure, and intravenous drug users. Five days of treatment is sufficient with extension if symptoms are not improved. Addressing predisposing factors can minimize risk of recurrence. The diagnosis of cellulitis is based primarily on history and physical examination. Treatment of uncomplicated cellulitis should be directed against Streptococcus and methicillin-sensitive S. aureus. Failure to improve with appropriate first-line antibiotics should prompt consideration for resistant organisms, secondary conditions that mimic cellulitis, or underlying complicating conditions such as immunosuppression, chronic liver disease, or chronic kidney disease.

Can the choice of the local anesthetic have an impact on ambulatory surgery perioperative costs? Chloroprocaine for popliteal block in outpatient foot surgery

Study objectiveShort-acting regional anesthetics have already been successfully used for peripheral nerve blocks in an ambulatory surgery setting. However, the impact on direct and indirect perioperative costs comparing 2 different short-acting local anesthetics has not been performed yet. DesignObservational, prospective, case-control, cost-minimization study. SettingOperating room, regional hospital PatientsOne hundred adult American Society of Anesthesiologists status I-III patients scheduled for popliteal block after minor ambulatory foot surgery. InterventionsApplication of 30 mL chloroprocaine 3% or of 30 mL mepivacaine 1.5% for anesthesia. MeasurementsCost-minimization evaluation. Direct and indirect perioperative costs were calculated. Block success, onset time and block duration, patient satisfaction, and unplanned outpatient visits or readmissions after discharge were also assessed. Main resultsOnset time (sensory: 4.3 ± 2.4 vs 11.5 ± 3.2 minutes; motor: 7.1 ± 3.7 vs 18.4 ± 4.5 minutes) and block duration (sensory: 105 ± 26 vs 317 ± 46 minutes; motor: 91 ± 25 vs 216 ± 31 minutes) were significantly shorter (P < .001) when chloroprocaine 3% was used. This translated to P < .001, basically due to a faster discharge home 55 ± 1 vs 175 ± 2 minutes; P < .001) in favor of chloroprocaine 3%, without negatively affecting either block efficacy or patients satisfaction. There were no unplanned outpatient visits or readmissions and no complications in the follow-up at 6 weeks. ConclusionsWe conclude that the more expensive chloroprocaine 3% for ambulatory foot surgery can reduce total perioperative costs and reduce length of stay in outpatient patients. Moreover, the saved time and personal resources could be used for additional cases, further increasing the revenues of an ambulatory surgical center.

Healthcare use and costs associated with post-traumatic stress syndrome in a community sample of older adults: results from the ESA-Services study.

Studies have shown higher healthcare utilization and costs associated with post-traumatic stress syndrome (PTSS) in veterans and community adult populations. Given the aging population and the impact on health system resources, it is important to understand the economic consequences of PTSS. The data retained came from 1,456 older adults aged 65 years and over recruited in primary medical clinics in the province of Quebec. PTSS was measured with the PTSS scale. Healthcare services (outpatient, emergency department (ED) visits, and inpatient stay) and medication use were captured separately from provincial administrative databases. Healthcare costs incurred in the past year included costs related to outpatient and ED visits, physician fees, inpatient stay, and medication use. Costs were calculated using a healthcare system perspective. χ 2 and Mann-Whitney analyses were used to assess healthcare use. Generalized linear models (GLM) with a gamma distribution (Log Link) were used to evaluate the healthcare costs associated with PTSS. Results showed a significant difference in the number mental health outpatient visits, the number of total prescriptions and the use (presence of at least one prescription) of antidepressants (ADs) and benzodiazepines (BZDs). The multivariate analyses showed that costs associated with outpatient visits, ED visits, mental health inpatient stays, physician fees, and medication use were significantly associated with the presence of PTSS. The total adjusted healthcare cost difference between groups was significant and reached $838 CAN. Respondents with PTSS were more likely to be prescribed psychotropic medications and to have higher ambulatory costs but not inpatient services related costs, more research is required to better understand whether the mental health needs of individuals with a probable PTSS are being met.

Atención integral postaborto, en el Instituto Especializado Materno Perinatal. 1995 - 2004

OBJETIVOS. Evaluar la experiencia en la aplicación del modelo: manejo ambulatorio y atención integral del aborto. DISEÑO. Estudio clínico retrospectivo. LUGAR. Instituto Especializado Materno Perinatal (IEMP), hospital de enseñanza. PARTICIPANTES. Mujeres con aborto de menos de 12 semanas. INTERVENCIONES. Se analizó los casos de aborto atendidos en la institución, en la década 1995 a 2004. Se comparó los procedimientos efectuados, como legrado uterino instrumental y aspiración manual endouterina (AMEU), así como los diagnósticos que justificaron la intervención quirúrgica. Se evaluó las complicaciones presentadas con AMEU y legrado uterino, la consejería efectuada y los métodos de planificación familiar postaborto, aplicados como parte de la atención integral. PRINCIPALES MEDIDAS DE RESULTADOS. Tipo de atención quirúrgica y complicaciones del aborto, consejería postaborto y costos. RESULTADOS. Entre los años 1995 y 2004, se atendió en el IEMP 58 757 casos de abortos, de los cuales 19 295 (32,8%) fueron resueltos ambulatoriamente (47,3% en el 2004). El método más usado fue la AMEU (92,1%), habiéndose comunicado pocas complicaciones (1,87%), siendo estas por AMEU insuficiente, hematometra, endometritis postaborto y enfermedad inflamatoria pélvica. La analgesia utilizada fue el bloqueo paracervical con lidocaína o petidina endovenosa. Las pacientes permanecieron en emergencia un promedio de 2 a 4 horas, siendo el costo del manejo del aborto ambulatorio ampliamente ventajoso con relación a un aborto con hospitalización. En 81,1% de los casos se hizo consejería y 50,4% salió con un método anticonceptivo. CONCLUSIONES. La clásica atención del aborto con hospitalización en el IEMP ha pasado a ser atención ambulatoria integral en el Servicio de Emergencia. Este modelo, propuesto por el Ministerio de Salud y Pathfinder, para la atención integral postaborto, ha sido validado e institucionalizado por etapas; el proyecto concluyó en el año 2002 y su aplicación es vigente, con amplias ventajas para la paciente y la institución.

Cost of measles containment in an ambulatory pediatric clinic.

Measles is highly infectious; prompt containment of illnesses is necessary to prevent spread. In August 2013, a 13-year-old male with measles exposed patients and employees in a pediatric clinic. We studied containment costs to identify avoidable costs. Measles exposure was defined as in-person contact with or presence in the same room <2 hours after the measles patient. Costs were calculated retrospectively using published costs of measles-mumps-rubella vaccine, cost-to-charge ratios for inpatient care in urban Washington State and local emergency department charges for post-exposure immunoglobulin (IG). Personnel costs were calculated by multiplying hourly wages by time for employees who worked on the response; overhead was excluded. Fifty-two patients, 60 caretakers and 10 employees were exposed. Personnel time cost $1961. Exposed patients had a mean age of 9.6 years (range: 2 months-19 years); 34 (65%) were fully vaccinated, and 18 (35%) were <12 months of age and too young to be vaccinated. Five patients (10%) were <6 months of age and required IG; 13 infants (25%) 6-11 months of age required measles-mumps-rubella vaccination. Caretakers followed up with their physicians for evidence of immunity. One employee had documented evidence of immunity; 9 required measles antibody testing or vaccination. Management of exposed persons cost $3694; overall clinic costs were $5655. Responding to 1 measles case cost the pediatric clinic more than $5000, despite isolating the patient promptly after examination. Documentation of employee immunity, vaccination of eligible patients and strict infection control precautions might reduce ambulatory costs associated with measles containment.

Healthcare costs of acute and chronic tonsillar conditions in the pediatric population in the United States

ObjectiveTo determine the prevalence and healthcare costs associated with the diagnosis and treatment of acute and chronic tonsillar conditions (ACT) in children. DesignCross-sectional analysis of the 2006, 2008, and 2010 Medical Expenditure Panel Surveys. MethodsPediatric patients (age<18 years) were examined from the above mentioned database. From the linked medical conditions file, cases with a diagnosis of ACT were extracted. Ambulatory visit rates, prescription refills, and ambulatory healthcare costs were then compared between children with and without a diagnosis of ACT and acute versus chronic tonsillitis, with multivariate adjustment for age, sex, ethnicity, region, insurance coverage and comorbid conditions (e.g., asthma and otitis media). ResultsA total of 74.3 million children (mean age 8.55 years, 51% male) were sampled (raw N=28,873). Of these, 804,229 children (1.1±0.1%) were diagnosed with ACT annually (mean age 7.24 years, 49.1% male); 64.6±2.0% had acute tonsillitis diagnoses and 35.4±2.0% suffered from chronic tonsillitis. Children with ACT incurred an additional 2.3 office visits and 2.1 prescription fills (both p<0.001) annually compared with those without ACT, adjusting for demographic variables and medical comorbidities, but did not have an increase in emergency department visits (p=0.123). Children with acute tonsillar diagnoses carried total healthcare expenditures of $1303±390 annually versus $2401±618 for those with chronic tonsillitis (p=0.193). ACT was associated with an incremental increase in total healthcare expense of $1685 per child, annually (p<0.001). ConclusionThe diagnosis of ACT confers a significant incremental healthcare utilization and healthcare cost burden on children, parents and the healthcare system. With its prevalence in the United States, pediatric tonsillitis accounts for approximately $1.355 billion in incremental healthcare expense and is a significant healthcare utilization concern. Level of evidence2C

Direct medical costs and source of cost differences across the spectrum of cognitive decline: A population-based study

BackgroundObjective cost estimates and source of cost differences are needed across the spectrum of cognition, including cognitively normal (CN), mild cognitive impairment (MCI), newly discovered dementia, and prevalent dementia. MethodsSubjects were a subset of the Mayo Clinic Study of Aging stratified-random sampling of Olmsted County, MN, residents aged 70 to 89 years. A neurologist reviewed provider-linked medical records to identify prevalent dementia (review date = index). Remaining subjects were invited to participate in prospective clinical/neuropsychological assessments; participants were categorized as CN, MCI, or newly discovered dementia (assessment date = index). Costs for medical services/procedures 1-year pre-index (excluding indirect and long-term care costs) were estimated using line-item provider-linked administrative data. We estimated contributions of care-delivery site and comorbid conditions (including and excluding neuropsychiatric diagnoses) to between-category cost differences. ResultsAnnual mean medical costs for CN, MCI, newly discovered dementia, and prevalent dementia were $6042, $6784, $9431, $11,678, respectively. Hospital inpatient costs contributed 70% of total costs for prevalent dementia and accounted for differences between CN and both prevalent and newly discovered dementia. Ambulatory costs accounted for differences between CN and MCI. Age-, sex-, education-adjusted differences reached significance for CN versus newly discovered and prevalent dementia and for MCI versus prevalent dementia. After considering all comorbid diagnoses, between-category differences were reduced (e.g., prevalent dementia minus MCI (from $4842 to $3575); newly discovered dementia minus CN (from $3578 to $711)). Following the exclusion of neuropsychiatric diagnoses from comorbidity adjustment, between-category differences tended to revert to greater differences. ConclusionsCost estimates did not differ significantly between CN and MCI. Substantial differences between MCI and prevalent dementia reflected high inpatient costs for dementia and appear partly related to co-occurring mental disorders. Such comparisons can help inform models aimed at identifying where, when, and for which individuals proposed interventions might be cost-effective.

Cost-effectiveness modelling of percutaneous coronary interventions in stable coronary artery disease.

The objective of this study is to develop a cost-effectiveness model comparing drug eluting stents (DES) vs bare metal stent (BMS) in patients suffering of stable coronary artery disease. Using a 2-years time horizon, two simulation models have been developed: BMS first line strategy and DES first line strategy. Direct medical costs were estimated considering ambulatory and hospital costs. The effectiveness endpoint was defined as treatment success, which is the absence of major adverse cardiac events. Probabilistic sensitivity analyses were carried out using 10000 Monte-Carlo simulations. DES appeared slightly more efficacious over 2 years (60% of success) when compared to BMS (58% of success). Total costs over 2 years were estimated at 9303 € for the DES and at 8926 € for bare metal stent. Hence, corresponding mean cost-effectiveness ratios showed slightly lower costs (P < 0.05) per success for the BMS strategy (15520 €/success), as compared to the DES strategy (15588 €/success). Incremental cost-effectiveness ratio is 18850 € for one additional percent of success. The sequential strategy including BMS as the first option appears to be slightly less efficacious but more cost-effective compared to the strategy including DES as first option. Future modelling approaches should confirm these results as further comparative data in stable coronary artery disease and long-term evidence become available.

A Cost-Minimization Analysis Comparing Immediate Sequential Cataract Surgery and Delayed Sequential Cataract Surgery From the Payer, Patient, and Societal Perspectives in the United States

The cost difference is evaluated between delayed sequential cataract surgery (DSCS) and immediate sequential cataract surgery (ISCS) in the United States for patients covered by Medicare. To perform a cost-minimization analysis comparing ISCS with DSCS in the United States from the payer, patient, and societal perspectives for the West Tennessee region and nationally. A cost-minimization analysis using cataract surgery volume and eligibility estimates, 2012 Medicare reimbursement schedules, and actual or estimated patient cost data for the West Tennessee region and nationally was performed comparing ISCS with DSCS. The West Tennessee model was set in a mixed small city and rural private practice setting and was extrapolated to a national model. Ambulatory surgery center and hospital outpatient department setting costs were evaluated. West Tennessee and national Medicare payer costs per patient and the total national Medicare payer cost for DSCS and for ISCS, as well as West Tennessee and national Medicare patient (direct medical, travel, and lost wages) costs for DSCS and for ISCS. Nationally, Medicare was estimated to reduce costs by approximately $522 million with the switch from DSCS to ISCS in 2012. With a change to ISCS, a West Tennessee Medicare patient was estimated to reduce costs by $174 for direct medical costs, $40 for travel costs, and $138 for lost wages (total cost reduction range, $329-$649). The total Medicare-based societal cost reduction was $783 million. Payers and patients would benefit from an economic standpoint by switching from DSCS to ISCS. Patients and their families would benefit from fewer visits. This becomes important given the increasing number of future cataract surgical procedures that will be performed as the baby boomer generation ages, especially given the fact that Medicare is already financially strained. Further research is needed to evaluate the effect of switching to ISCS from the physician and surgical facility perspectives.

Health care expenditures attributable to smoking in military veterans.

The health effects of cigarette smoking have been estimated to account for between 6%-8% of U.S. health care expenditures. We estimated Veterans Health Administration (VHA) health care costs attributable to cigarette smoking. VHA survey and administrative data provided the number of Veteran enrollees, current and former smoking prevalence, and the cost of 4 types of care for groups defined by age, gender, and region. Cost and smoking status could not be linked at the enrollee level, so we used smoking attributable fractions estimated in sample of U.S. residents where the linkage could be made. The 7.7 million Veterans enrolled in VHA received $40.2 billion in VHA provided health services in 2010. We estimated that $2.7 billion in VHA costs were attributable to the health effects of smoking. This was 7.6% of the $35.3 billion spent on the types of care for which smoking-attributable fractions could be determined. The fraction of inpatient costs that was attributable to smoking (11.4%) was greater than the fraction of ambulatory care cost attributable to smoking (5.3%). More cost was attributable to current smokers ($1.7 billion) than to former smokers ($983 million). The fraction of VHA costs attributable to smoking is similar to that of other health care systems. Smoking among Veterans is slowly decreasing, but prevalence remains high in Veterans with psychiatric and substance use disorders, and in younger and female Veterans. VHA has adopted a number of smoking cessation programs that have the potential for reducing future smoking-attributable costs.

Abstract 305: Post-discharge Costs in Heart Failure: Kidney Disease Severity as a Key Contributor

Background: This study examined post-discharge costs among individuals hospitalized with heart failure (HF) by stage of chronic kidney disease (CKD). Methods: A retrospective claims-based study of medical and pharmacy data linked to laboratory results from a large US health plan (Jan2007-Sep2012) was conducted. Earliest inpatient stay with HF diagnosis was defined as index hospitalization. Post-index costs were calculated per-member-per-month (PMPM) for the subset of individuals with a post-discharge observation up to 6 months. Individuals were assigned to CKD stages 1-5 using the CKD-Epidemiology Collaboration Group equation. One-way ANOVA was used to examine differences in follow-up health care costs across CKD stages. Results: A total of 24,023 individuals hospitalized with HF (mean age 70 y, 51% female, 71% white, 65% Medicare Advantage) were included. Subjects with at least moderately reduced renal function (eGFR &lt;60 mL/min, stages 3-5) when compared to individuals with normal/mild reduction (eGFR ≥60 mL/min, stages 1-2) experienced higher follow-up ambulatory ($1,508 vs. $1,236) and inpatient ($3,725 vs. $3,152) all-cause costs. HF-related medical costs accounted for approximately 40% of all-cause medical cost for CKD stages 2-4 (table). Conclusion: Findings from this study suggest that medical costs following HF hospitalization increase by severity of CKD stage, with HF-related costs comprising a large portion of inpatient and outpatient costs.

A Model for Estimating the Economic Impact of Secondhand Smoke Exposure

This study estimated the economic cost of health services and premature loss-of-life costs from secondhand smoke (SHS) exposure in Indiana. Costs of SHS-related mortality and morbidity were estimated using national attributable risk values for diseases that are causally related to SHS exposure both for adults and children. Estimated direct costs included hospital inpatient costs, loss-of-life costs, and ambulatory care costs where available, based on the most currently available Indiana hospital discharge data, vital statistics, census data, and nationally published research. Attributable risk values were applied to the number of deaths and hospital discharges in Indiana in 2008 and 2010, respectively, to estimate the number of individuals impacted by SHS exposure. All cost estimates were adjusted to 2010 US dollar values. The direct cost of health care and premature loss of life in Indiana attributed to SHS was estimated to be $1.3 billion in 2010--$237.8 million in health care costs and $879.0 million in premature loss of life for adults and $89.4 million in health care costs and $98.6 million in premature loss of life for children. The estimated population for Indiana in 2010 was 6 483 802 resulting in SHS-related costs of $201 per capita. This study demonstrated a model that could be used to estimate the costs of health care and premature mortality from exposure to SHS at a state or local level. These data may be used to support the education of the public, community leaders, and state policy makers regarding the magnitude of the problem and the compelling need to implement interventions to better protect the health of citizens and their economic prosperity.

Costs of psychosis in 2010: Findings from the second Australian National Survey of Psychosis

To estimate the annual costs of psychosis in Australia from societal and government perspectives and assess whether average costs per person differ by principal service provider at time of census. Costs of psychosis encompassing health sector costs, other sector costs, and productivity losses were assessed for 2010 using a prevalence-based, bottom-up approach. Resource use data were obtained from the second Australian National Survey of Psychosis and unit costs were from government and non-government organization (NGO) sources. Costs to society were assessed by principal service provider at census: public specialized mental health services (PSMHS) and NGOs during the census month (current clients), and PSMHS in the 11 months preceding census (recent clients), and any differences were ascertained. The average annual costs of psychosis to society are estimated at $77,297 per affected individual, comprising $40,941 in lost productivity, $21,714 in health sector costs, and $14,642 in other sector costs. Health sector costs are 3.9-times higher than those for the average Australian. Psychosis costs Australian society $4.91 billion per annum, and the Australian government almost $3.52 billion per annum. There are significant differences between principal service providers for each cost category. Current PSMHS clients had the highest health sector costs overall, and the highest mental health ambulatory, inpatient, and antipsychotic medication costs specifically. NGO clients had the highest other sector costs overall and the highest NGO assistance, supported employment, and supported accommodation costs. Recent PSMHS clients had the lowest productivity losses for reduced participation and the highest costs for absenteeism and presenteeism. The costs of psychosis are broad ranging and very high. Development and implementation of cost-effective prevention, treatment, and support strategies is critical to maximizing the efficiency of service delivery. A needs-based framework based on principal service provider and recency of contact may facilitate this process.

Effect of Electronic Health Records on Health Care Costs: Longitudinal Comparative Evidence From Community Practices

The United States is aiming to achieve nationwide adoption of electronic health records (EHRs) but lacks robust empirical evidence to anticipate the effect on health care costs. To assess short-term cost savings from community-wide adoption of ambulatory EHRs. Longitudinal trial with parallel control group. Natural experiment in which 806 ambulatory clinicians across 3 Massachusetts communities adopted subsidized EHRs. Six matched control communities applied but were not selected to participate. 47,979 intervention patients and 130,603 control patients. Monthly standardized health care costs from commercial claims data from January 2005 to June 2009, including total cost, inpatient cost, and ambulatory cost and its subtypes (pharmacy, laboratory, and radiology). Projected savings per member per month (PMPM), excluding EHR adoption costs. Ambulatory EHR adoption did not impact total cost (pre- to postimplementation difference in monthly trend change, -0.30 percentage point; P = 0.135), but the results favored savings (95% CI, $21.95 PMPM in savings to $1.53 PMPM in higher costs). It slowed ambulatory cost growth (difference in monthly trend change, -0.35 percentage point; P = 0.012); projected ambulatory savings were $4.69 PMPM (CI, $8.45 to $1.09 PMPM) (3.10% of total PMPM cost). Ambulatory radiology costs decreased (difference in monthly trend change, -1.61 percentage points; P < 0.001), with projected savings of $1.61 PMPM (1.07% of total PMPM cost). Intervention communities were not randomly selected and received implementation support, suggesting that results may represent a best-case scenario. Confounding is possible. Using commercially available EHRs in community practices seems to modestly slow ambulatory cost growth. Broader changes in the organization and payment of care may prompt clinicians to use EHRs in ways that result in more substantial savings.

Rising Annual Costs of Dizziness Presentations to U.S. Emergency Departments

Dizziness and vertigo account for roughly 4% of chief symptoms in the emergency department (ED). Little is known about the aggregate costs of ED evaluations for these patients. The authors sought to estimate the annual national costs associated with ED visits for dizziness. This cost study of adult U.S. ED visits presenting with dizziness or vertigo combined public-use ED visit data (1995 to 2009) from the National Hospital Ambulatory Medical Care Survey (NHAMCS) and cost data (2003 to 2008) from the Medical Expenditure Panel Survey (MEPS). We calculated total visits, test utilization, and ED diagnoses from NHAMCS. Diagnosis groups were defined using the Healthcare Cost and Utilization Project's Clinical Classifications Software (HCUP-CCS). Total visits and the proportion undergoing neuroimaging for future years were extrapolated using an autoregressive forecasting model. The average ED visit cost-per-diagnosis-group from MEPS were calculated, adjusting to 2011 dollars using the Hospital Personal Health Care Expenditures price index. An overall weighted mean across the diagnostic groups was used to estimate total national costs. Year 2011 data are reported in 2011 dollars. The estimated number of 2011 US ED visits for dizziness or vertigo was 3.9 million (95% confidence interval [CI] = 3.6 to 4.2 million). The proportion undergoing diagnostic imaging by computed tomography (CT), magnetic resonance imaging (MRI), or both in 2011 was estimated to be 39.9% (39.4% CT, 2.3% MRI). The mean per-ED-dizziness-visit cost was $1,004 in 2011 dollars. The total extrapolated 2011 national costs were $3.9 billion. HCUP-CCS key diagnostic groups for those presenting with dizziness and vertigo included the following (fraction of dizziness visits, cost-per-ED-visit, attributable annual national costs): otologic/vestibular (25.7%; $768; $757 million), cardiovascular (16.5%, $1,489; $941 million), and cerebrovascular (3.1%; $1059; $127 million). Neuroimaging was estimated to account for about 12% of the total costs for dizziness visits in 2011 (CT scans $360 million, MRI scans $110 million). Total U.S. national costs for patients presenting with dizziness to the ED are substantial and are estimated to now exceed $4 billion per year (about 4% of total ED costs). Rising costs over time appear to reflect the rising prevalence of ED visits for dizziness and increased rates of imaging use. Future economic studies should focus on the specific breakdown of total costs, emphasizing areas of high cost and use that might be safely reduced.