Annual Excess Costs Research Articles

Association of Atopic Dermatitis With Bacterial, Fungal, Viral, and Sexually Transmitted Skin Infections.

Atopic dermatitis (AD) is associated with altered skin barrier, microbiome, and immune dysregulation that may increase risk of skin infections. The aim of the study was to determine whether AD is associated with skin infections and related outcomes. Data from the 2006 to 2012 National Emergency Department Sample were analyzed, including an approximately 20% sample of all US emergency department (ED) visits (N = 198,102,435 adults or children). Skin infections were increased in ED visits of adults (7.14% vs 3.76%) and children (5.15% vs 2.48%) with AD. In multivariable logistic regression models, AD was associated with significantly higher odds of skin infection in adults (adjusted odds ratio [95% confidence interval] = 1.93 [1.89-1.97]) and children (2.23 [2.16-2.31]). Pediatric and adult AD were associated with significantly higher odds of carbuncle/furuncles, impetigo, cellulitis, erysipelas, methicillin-resistant and methicillin-sensitive Staphylococcus aureus infections, molluscum contagiosum, cutaneous warts, herpes simplex and zoster viruses, eczema herpeticum, dermatophytosis, and candidiasis of skin/nails and vulva/urogenitals. Adults with AD had significantly higher odds of genital warts (1.51 [1.36-1.52]) and herpes (1.23 [1.11-1.35]). Skin infections were associated with US $19 million excess annual costs of ED care in persons with AD. Atopic dermatitis patients had higher odds of multiple bacterial, viral, fungal, and sexually transmitted skin infections.

Digital ulcers in systemic sclerosis: their epidemiology, clinical characteristics, and associated clinical and economic burden

BackgroundTo determine the frequency and clinical characteristics of systemic sclerosis-related digital ulcers, and associated direct health care costs, quality of life, and survival.MethodsDigital ulcers (DUs) were defined as an area with a visually discernible depth and a loss of continuity of epithelial coverage. DU severity was calculated based on the physician reported highest number of new DUs at clinical review (mild = 1–5 DUs, moderate 6–10 DUs, severe > 10 DUs). Healthcare use was captured through data linkage, wherein SSc clinical data captured prospectively in a dedicated clinical database were linked with health services databases to capture hospital admissions, emergency department (ED) presentations and ambulatory care (MBS) utilization and cost for the period 2008–2015. Healthcare cost determinants were estimated using logistic regression.ResultsAmong 1085 SSc patients, 48.6% experienced a DU over a mean follow-up of 5.2 ± 2.5 years. Those who developed DUs were more likely to have diffuse disease subtype (34.9% vs 18.2%, p < 0.001), anti-Scl-70 antibody (18.9% vs 9.3%, p < 0.001), and a younger age at SSc onset (43.6 ± 13.9 vs 48.8 ± 14.0 years, p < 0.001) in addition to reduced health-related quality of life (HRQoL) measured by the SF-36 but without a significant impact on survival. SSc patients with a history of a DU utilized significantly more healthcare resources per annum than those without a DU, including hospitalizations, ED presentation, and ambulatory care services. Total healthcare services, excluding medications, were associated with an annual excess cost per DU patient of AUD$12,474 (8574-25,677), p < 0.001, driven by hospital admission and ED presentation costs.ConclusionDUs place a large burden on the patient and healthcare system through reduced HRQoL and increased healthcare resource utilization and associated cost.

Economic Burden Of Inappropriate Empiric Antibiotic Therapy: A Report From Southern Iran.

IntroductionWidespread inappropriate antibiotic prescribing by healthcare professionals in the hospital setting is a great concern that may cause many undesirable consequences. Adherences to antibiotic guidelines have proven to be a simple and effective intervention to guide the choice of appropriate empiric antibiotic regimens and reduce the unnecessary variations in the practice among practitioners. The objective of this study was to evaluate the prescription patterns of empiric antibiotic therapy in relation to treatment guidelines and the economic burden of discordance with guidelines in a major referral Iranian university hospital.MethodHospital records of hospitalized patients with empiric antibiotic prescription, from September 2016 to February 2017 were reviewed. The process consisted of comparing empiric antimicrobial administration with institutional guidelines for each patient by a clinical pharmacist and an infectious disease specialist to evaluate the appropriate utilization of antibiotics. Adherence to guideline, the cost of antibiotics usage for each patient and the excess cost consequent from discordance with guideline was calculated.ResultsThe most inappropriate prescribed antibiotics were carbapenems and aminoglycosides. Overall guideline adherence was 27.8%. Frequency of antibiotic usage incompatibility with the guidelines on the basis of dosing interval, duration of therapy and drug indication were 31.46%, 29.44% and 19.36%, respectively. General surgery and internal medicine wards had the least and the most inappropriate antibiotic administration, respectively. Totally antibiotic usage cost was 578,959.39 USD (24,316,294,800 Iranian Rials, IRR) for 6 months, which the excess costs of inappropriate antibiotic prescribing, was 471,319.69 USD (19,795,427,225 IRR). The estimated annual excess cost is 942,639.38 USD (39,590,854,450 IRR).ConclusionIn this research, physicians’ adherence with guidelines for empiric antibiotic therapy was low which was led to 471,319.69 USD excess costs. These results urge institution policy makers to develop guidelines to ensure active dissemination and implementation of them to decrease inappropriate antibiotic usage.

The economic burden of systemic sclerosis related pulmonary arterial hypertension in Australia

BackgroundTo quantify the financial cost of pulmonary arterial hypertension (PAH) in systemic sclerosis (SSc).MethodsHealthcare use was captured through data linkage, wherein clinical data for SSc patients enrolled in the Australian Scleroderma Cohort Study were linked with hospital, emergency department (ED) and ambulatory care databases (MBS) for the period 2008–2015. PAH was diagnosed on right heart catheter according to international criteria. Determinants of healthcare cost were estimated using logistic regression.ResultsTotal median (25th–75th) healthcare cost per patient (including hospital, ED and MBS cost but excluding medication cost) for our cohort during 2008–2015 was AUD$37,685 (18,144-78,811) with an annual per patient healthcare cost of AUD$7506 (5273-10,654). Total healthcare cost was higher for SSc-PAH patients compared with those without PAH with a total cost per patient of AUD$70,034 (37,222-110,814) vs AUD$34,325 (16,093 – 69,957), p < 0.001 respectively with an annual excess healthcare cost per PAH patient of AUD$2463 (1973-1885), p < 0.001. The cost of SSc-PAH occurs early post PAH diagnosis with 89.4% utilizing a healthcare service within the first 12 months post PAH diagnosis with an associated cost per patient of AUD$4125 (0–15,666). PAH severity was the main significant determinant of increased healthcare cost (OR 2.5, p = 0.03) in our PAH cohort.ConclusionsDespite SSc-PAH being a low prevalence disease, it is associated with significant healthcare resource utilization and associated economic burden, predominantly driven by the severity of PAH.

The clinical and economic burden of systemic sclerosis related interstitial lung disease.

To quantify the burden of interstitial lung disease (ILD) in SSc. Clinical data for SSc patients enrolled in the Australian Scleroderma Cohort Study were linked with healthcare databases for the period 2008-2015. ILD was defined by characteristic fibrotic changes on high-resolution CT (HRCT) lung, while severity was defined by the extent lung involvement on HRCT (mild <10%, moderate 10-30%, severe >30%). Determinants of healthcare cost were estimated using logistic regression. SSc-ILD patients utilized more healthcare resources, including hospitalization, emergency department presentation and ambulatory care services, than those without ILD with a total cost per patient of AUD$48 368 (26 230-93 615) vs AUD$33 657 (15 144-66 905), P<0.001) between 2008-2015. Healthcare utilization was associated with an annual median (25th-75th) excess cost per SSc-ILD patient compared with those without ILD of AUD$1192 (807-1212), P<0.001. Increasing ILD severity was associated with significantly more healthcare utilization and costs with an annual excess cost per patient with severe ILD compared with mild ILD of AUD$2321 (645-1846), P<0.001. ILD severity and the presence of coexistent PAH were the main determinants of overall healthcare cost above median for this SSc-ILD cohort (OR 5.1, P<0.001, and OR 2.6, P=0.01, respectively). Furthermore, SSc-ILD patients reported worse physical HRQoL compared with those without ILD [34.3 (10.5) vs 39.1 (10.8), P<0.001], with a progressive decline with increasing ILD severity (P=0.002). SSc-ILD places a large burden on the healthcare system and the patient through poor HRQoL in addition to incremental healthcare resource utilization and associated direct cost.

Associations of pemphigus or pemphigoid with autoimmune disorders in US adult inpatients

The associations and predictors of the gamut of autoimmune conditions in pemphigus and pemphigoid have been examined in few large-scale controlled studies. To examine associations of pemphigus or pemphigoid with autoimmune disorders and related outcomes in adults. Data from the 2002-2012 National Inpatient Sample were analyzed, including an ∼20% sample of all US hospitalizations (n=72,108,077 adults). In multivariable logistic regression models, pemphigus (adjusted odds ratio 1.46, 95% confidence interval 1.30-1.63) and pemphigoid (adjusted odds ratio 1.35, 95% confidence interval 1.24-1.48) were associated with ≥1 autoimmune disorder. Pemphigus was associated with 9 of 29 and pemphigoid with 13 of 32 autoimmune disorders examined in bivariable models. Among pemphigus inpatients, unspecified autoimmune disease, vitiligo, eosinophilic esophagitis, and myasthenia gravis had the strongest effect sizes. Whereas, among pemphigoid inpatients, unspecified autoimmune disease, vitiligo, and chronic urticaria had the strongest effect sizes. There were significant differences of autoimmune comorbidities by age, sex, and race/ethnicity. The estimated excess annual costs of hospital care attributed to autoimmune disorders among inpatients with pemphigus was $2,286,588 and pemphigoid $4,301,681. Lack of treatment history data. Inpatients with pemphigus or pemphigoid had increased odds of multiple cutaneous, extracutaneous, and systemic autoimmune disorders, which were associated with a considerable cost burden.

Postoperative Critical Care for Adult Cardiac Surgical Patients

Cardiac operations represent one of the most common categories of surgery in developed countries with an annual cost in excess of $20 billion in the United States alone. Cardiac surgery is continuously evolving and modern practice has come to include minimally invasive, hybrid, and transcatheter techniques with the patient managed by “the heart team.” An increasing age and medical complexity of patients considered for cardiac surgical procedures mean that the critical care management needs to adapt to meet increasingly broad and elaborate needs. The second edition of Postoperative Critical Care for Adult Cardiac Surgical Patients remains edited by Dr Dabbagh, cardiac anesthetist, and Drs Esmailian and Aranki, both cardiac surgeons. Together they form an extensive body of professional expertise in all aspects of care of the adult cardiac surgical patient. They have supervised 26 chapter contributors representing anesthetic, critical care, and surgical departments mainly in Iran and the United States with a few Italian institutions represented as well. The book has an ambitious scope with the aim to cover all perioperative aspects of the cardiac surgical patient in 22 chapters totaling 670 pages with 60 tables and 97 illustrations, the majority in color. The format is conducive to a general discussion with a few aspects covered more in depth. All chapters are informative albeit some provide more guidance than others. The chapter of hemodynamic monitoring is detailed and includes an up-to-date overview of cardiac output monitors. A short final paragraph explains that transesophageal echocardiography is beyond the scope of this book and the reader is referred to other specialized resources. The chapter on postoperative coagulation and management of bleeding provides an excellent summary of point-of-care testing of coagulation in the intensive care unit with succinct presentations of both thromboelastography and rotational thromboelastometry. Interpretation and suggestions for actions based on results using both devices are presented and clearly summarized in table format. All relevant anticoagulants in current clinical practice and guidelines for their reversal are nicely presented. The chapter on “Postoperative Safety in Adult Cardiac Surgery Intensive Care Unit” includes a useful section on handoff protocols and also covers team huddles and team performance. In particular, the example multidisciplinary simulation scenario demonstrates the approach to building and improving teamwork along all facets of perioperative care, with a natural emphasis on postoperative complications. The chapter on cardiac anatomy is overly basic and lacking in terms of functional aspects and clinical implications. The chapter on cardiac physiology to some extent suffers from the same shortcomings and aspects of regulation of blood flow would seem to warrant a more comprehensive consideration. Some readers will surely be surprised that no references are made to the state-of-the-art research performed by Arthur Guyton. The pharmacology chapter provides a clinically orientated overview of most drugs likely to be encountered in a cardiac, or for that sake general, intensive care unit, while an approach of listing rather than categorizing by postoperative scenarios renders the text somewhat insipid. The chapter devoted to mechanical circulatory support includes rather extensive pharmacological and physiological considerations that are already covered in other chapters. This sidetracks the main theme of the text, in particular for the modality of venoarterial extracorporeal membrane oxygenation that has most relevance to cardiac intensive care practitioners. The chapter on renal complications focuses on basic principles, while renal replacement therapy is covered on less than 1 page. This appears cursory given the significance of dialysis-dependent renal failure on long-term clinical outcomes. Unfortunately, the presentation is at times distracted by a below-par English style and grammar that should have been addressed in a second revision. There is also a tendency for repetition and overlap between chapters, and a more effective use of cross-referencing would have been useful to the reader. An eBook edition is available but was not accessed for this review. The book navigates difficult waters between a preparatory text and a complete reference textbook. Those with some experience of general intensive care wanting to explore cardiac intensive care will likely find the book rewarding, while it is arguably a bit unwieldy to use as an introductory text. The fellow or specialist colleague with experience in a cardiac intensive care unit might find the text lacking in detail and depth compared to textbooks of cardiac surgery but still useful as a source for refreshing clinical knowledge. We recommend the advanced trainee or junior consultant looking for 1 manageable volume to cover the field to buy the book. Anders Aneman, MD, PhD, FCICMWilliam O’Regan, MD, FCICM, FANZCADepartment of Intensive CareLiverpool Hospital, South Western Sydney Local Health DistrictMacquarie University HospitalSydney, Australia[email protected]

Healthcare resource utilisation and costs of agitation in people with dementia living in care homes in England - The Managing Agitation and Raising QUality of LifE in Dementia (MARQUE) study.

BackgroundPeople with dementia living in care homes often experience clinically significant agitation; however, little is known about its economic impact.ObjectiveTo calculate the cost of agitation in people with dementia living in care homes.MethodsWe used the baseline data from 1,424 residents with dementia living in care homes (part of Managing Agitation and Raising QUality of lifE in dementia (MARQUE) study) that had Cohen-Mansfield Agitation Inventory (CMAI) scores recorded. We investigated the relationship between residents’ health and social care costs and severity of agitation based on the CMAI total score. In addition, we assessed resource utilisation and compared costs of residents with and without clinically significant symptoms of agitation using the CMAI over and above the cost of the care home.ResultsAgitation defined by the CMAI was a significant predictor of costs. On average, a one-point increase in the CMAI will lead to a 0.5 percentage points (cost ratio 1.005, 95%CI 1.001 to 1.010) increase in the annual costs. The excess annual cost associated with agitation per resident with dementia was £1,125.35. This suggests that, on average, agitation accounts for 44% of the annual health and social care costs of dementia in people living in care homes.ConclusionAgitation in people with dementia living in care homes contributes significantly to the overall costs increasing as the level of agitation increases. Residents with the highest level of agitation cost nearly twice as much as those with the lowest levels of agitation, suggesting that effective strategies to reduce agitation are likely to be cost-effective in this setting.

The Prevalence and Cost of Medicare Beneficiaries Diagnosed and At Risk for Opioid Abuse, Dependence, and Poisoning.

Reliance on prescription opioids to manage pain has been associated with increases in diversion, overdose, and addiction. Prevalence of misuse and abuse has been shown to be higher among government-insured populations than commercially insured populations. However, the prevalence and costs of misuse/abuse among the Medicare fee-for-service (FFS) population has not been studied. To (a) determine the prevalence and costs of prescription opioid misuse/abuse and (b) evaluate the prevalence and costs associated with those identified as at risk for opioid misuse/abuse in Medicare FFS beneficiaries. This retrospective case-control study used Medicare claims data for the calendar years of 2010 and 2011 and included Medicare beneficiaries aged at least 18 years. The index date was the date of first diagnosed misuse/abuse or at risk for abuse and had to occur between July 1, 2010, and June 30, 2011, and beneficiaries had to have at least 6 months continuous eligibility before and after the index date. Matching (1:1) was used for comparing opioid misusers/abusers with nonabuser controls, as well as comparing patients at risk for opioid abuse with controls not at risk for abuse. Controls were matched to cases by gender, age, disability, and geographic region. The index date of the control patient was set equal to the index date of the matched case. Prevalence of misuse/abuse in the Medicare FFS population was 13.1 per 1,000 persons, with the majority among patients receiving Medicare based on disability (76.2%). The prevalence of at risk for misuse/abuse was 117.4 per 1,000 persons. Approximately half of the Medicare FFS patients used an opioid. Overall total annual unadjusted mean costs of health care resources were significantly greater for abusers than for matched controls ($46,194 vs. $21,964; P < 0.0001), with a mean annual excess cost of $24,230. The overall total adjusted 6-month post-index mean costs of health care resources for abusers was significantly greater than that of matched controls ($33,942 vs. $10,754; P < 0.0001), with a mean excess cost of $23,188. The prevalence of diagnosed abuse among Medicare FFS population (13.1 per 1,000 persons) was higher than other payer groups studied using similar ICD-9-CM codes, and the majority of abuse was among those receiving Medicare based on disability (76.2%). The prevalence of at-risk abuse was 9 times higher than the prevalence of diagnosed abuse. As with other studies, health care resource utilization and costs were significantly greater for diagnosed abuse than matched controls. This study was sponsored by Pfizer. Roland is a Pfizer employee and stockholder and was involved in all aspects of the study as part of a mid-career fellowship in pharmacoeconomics with the University of Utah. Ye and Stevens are employees of University of Utah, and Oderda was an employee of University of Utah, which received financial support from Pfizer in connection with the development of this manuscript. Oderda also reports consulting fees from Pfizer, Trevena, and Pacira, unrelated to this study. The results of this study were presented at the Academy of Managed Care Pharmacy Nexus 2015; October 26-29, 2015; Orlando, FL, and the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2016; April 19-22, 2016; San Francisco, CA.

Correction: Excess direct hospital cost of treating adult patients with ventilator associated respiratory infection (VARI) in Vietnam.

[This corrects the article DOI: 10.1371/journal.pone.0206760.].

Excess direct hospital cost of treating adult patients with ventilator associated respiratory infection (VARI) in Vietnam

IntroductionVentilator associated respiratory infections (VARIs) are the most common hospital acquired infections in critical care worldwide. This work aims to estimate the total annual direct hospital cost of treating VARI throughout Vietnam.MethodsA costing model was constructed to evaluate the excess cost of diagnostics and treatment of VARI in Vietnam. Model inputs included costs for extra lengths of stay, diagnostics, VARI incidence, utilisation of ventilators and antibiotic therapy.ResultsWith the current VARI incidence rate of 21.7 episodes per 1000 ventilation-days, we estimated 34,428 VARI episodes in the 577 critical care units in Vietnam per year. The extra cost per VARI episode was $1,174.90 and the total annual excess cost was US$40.4 million. A 1% absolute reduction in VARI incidence density would save US$1.86 million annually. For each episode of VARI, the share of excess cost components was 45.1% for critical care unit stay and ventilation, 3.7% for diagnostics and 51.1% for extra antimicrobial treatment.ConclusionsAt the current annual government health expenditure of US$117 per capita, VARI represents a substantial cost to the health service in Vietnam. Enhanced infection prevention and control and antimicrobial stewardship programmes should be implemented to reduce this.

Association of vitiligo with hospitalization for mental health disorders in US adults.

Vitiligo has a complex bidirectional relationship with mental health (MH) disturbances. However, little is known about the relationship between vitiligo and MH emergencies. To examine the associations of vitiligo and MH hospitalizations in the United States. Data from the 2002 to 2012 National Inpatient Sample were analysed, including a ~20% sample of all US hospitalizations (n = 87 053 155 children and adults). Prevalence of hospitalization for MH disorders, their length of stay (LOS) and cost of care were determined for those with vitiligo compared to those without vitiligo. Hospitalization for MH disorders occurred more commonly in those with vitiligo compared to those without vitiligo (4.17% vs. 2.18%). In multivariable logistic regression models, vitiligo was associated with higher odds of admission for any MH disorder [adjusted odds ratio (95% confidence interval): 1.69 (1.61-1.78)], including 14 of 15 MH disorders examined. Associated MH disorders included anxiety, schizophrenia, depression, suicidal risk, personality disorder, ADD/ADHD and conduct disorder, substance use disorder, childhood and adolescent psychiatric illnesses, alcohol-related disorders, adjustment disorders, developmental disorders, impulse control disorders, history of mental health disorders and miscellaneous mental health disorders. Vitiligo patients hospitalized with any MH disorder had higher geometric-mean (95% confidence interval) cost of inpatient care [$10 992 ($10 477-$11 507) vs. $10 082 ($9728-$10 435)] and LOS [5.6 (5.3-5.8) vs. 4.8 (4.6-4.9); P < 0.0001] compared to those without vitiligo, with $10.5 million excess annual costs from hospitalization with MH disorders in persons with vitiligo. Persons with vitiligo had increased hospitalization for multiple MH disorders, which were associated with a considerable cost burden.

Association between atopic dermatitis and autoimmune disorders in US adults and children: A cross-sectional study

Little is known about the risk and predictors of autoimmune diseases in children and adults. To determine the prevalence, predictors, and excess costs of autoimmune disease in atopic dermatitis (AD) patients. Cross-sectional study of the 2002-2012 National Inpatient Sample, which includes a ∼20% sample of all US hospitalizations (n=87,053,155 adults and children). The prevalence of autoimmune disease was higher in adults with AD (7.9%, 95% confidence interval [95% CI] 7.3-8.5%) than without AD (5.7%, 95% CI 5.7%-5.8%) and higher in children with AD (2.0%, 95% CI 1.7%-2.3%) than without AD (1.0%, 95% CI 0.9%-1.1%). In multivariable logistic regression models controlling for sociodemographics, adult (adjusted odds ratio 1.45, 95% CI 1.32-1.58) and pediatric (adjusted odds ratio 2.08, 95% CI 1.73-2.50) AD were associated with any autoimmune disorder. In particular, AD was associated with 18 of 32 autoimmune disorders examined in adults and 13 of 24 examined in children, including disorders of the skin, endocrine, gastrointestinal, hematologic, and musculoskeletal systems. AD patients hospitalized with any autoimmune disorder had a higher cost of inpatient care, with $2.5-$50 million excess annual costs. Adults and children with AD had increased cutaneous and extracutaneous autoimmune disorders, which were associated with a considerable cost burden.

Health Care Costs Associated With Muscle Weakness: A UK Population-Based Estimate

Sarcopenia and muscle weakness are responsible for considerable health care expenditure but little is known about these costs in the UK. To address this, we estimated the excess economic burden for individuals with muscle weakness regarding the provision of health and social care among 442 men and women (aged 71–80 years) who participated in the Hertfordshire Cohort Study (UK). Muscle weakness, characterised by low grip strength, was defined according to the Foundation for the National Institutes of Health criteria (men < 26 kg, women < 16 kg). Costs associated with primary care consultations and visits, outpatient and inpatient secondary care, medications, and formal (paid) as well as informal care for each participant were calculated. Mean total costs per person and their corresponding components were compared between groups with and without muscle weakness. Prevalence of muscle weakness in the sample was 11%. Mean total annual costs for participants with muscle weakness were £4592 (CI £2962–£6221), with informal care, inpatient secondary care and primary care accounting for the majority of total costs (38%, 23% and 19%, respectively). For participants without muscle weakness, total annual costs were £1885 (CI £1542–£2228) and their three highest cost categories were informal care (26%), primary care (23%) and formal care (20%). Total excess costs associated with muscle weakness were £2707 per person per year, with informal care costs accounting for 46% of this difference. This results in an estimated annual excess cost in the UK of £2.5 billion.

Systematic Literature Review of the Economic Burden of Celiac Disease.

The prevalence of celiac disease (CD) has rapidly increased over recent decades, but costs related to CD remain poorly quantified. This systematic review assessed the economic burden of CD in North America and Europe. MEDLINE, EMBASE, EconLit, and the Cochrane Library databases were systematically searched to identify English-language literature from 2007 to 2018 that assessed costs, cost effectiveness, and health resource utilization for CD. Forty-nine studies met the inclusion criteria, of which 28 (57.1%) addressed costs of testing and diagnosis; 33 (67.3%) were from Europe. The cost per positive CD diagnosis of testing patients already undergoing esophagogastroduodenoscopy for other indications ranged from 1300 Canadian dollars ($Can) in Canada (2016 value) to €44,712 in the Netherlands (2013 value). Adding the CD test was cost effective when it combined diagnostic modalities (e.g., serology and biopsy). Direct annual excess costs to a US payer per diagnosed CD patient totaled $US6000 (2013 value) more than for a person without CD, chiefly due to outpatient care. Hospitalizations, emergency visits, and medication use were more common with CD. After initiating a gluten-free diet (GFD), patients visited primary care providers less often, used more medications, and missed fewer days from school and work. Most of the few available economic studies of CD assess testing and diagnosis costs, especially in Europe. Methods of testing generally are considered cost effective when they combine diagnostic modalities in symptomatic patients. Most costs to a payer of managing CD derive from outpatient care. Following GFD initiation, patients lose fewer days from work and school than pretreatment.

The cost of diabetes and obesity in Australia

Aims: To assess and compare the direct healthcare and non-healthcare costs and government subsidies by body weight and diabetes status.Methods: The Australian Diabetes, Obesity and Lifestyle study collected health service utilization and health-related expenditure data at the 2011–2012 follow-up surveys. Costing data were available for 4,409 participants. Unit costs for 2016–2017 were used where available or were otherwise inflated to 2016–2017 dollars. Age- and sex-adjusted costs per person were estimated using generalized linear models.Results: The annual total direct cost ranged from $1,998 per person with normal weight to $2,501 per person with obesity in participants without diabetes. For those with diabetes, total direct costs were $2,353 per person with normal weight, $3,263 per person with overweight, and $3,131 per person with obesity. Additional expenditure as government subsidies ranged from $5,649 per person with normal weight and no diabetes to $8,085 per person with overweight and diabetes. In general, direct costs and government subsidies were higher for overweight and obesity compared to normal weight, regardless of diabetes status, but were more noticeable in the diabetes sub-group. The annual total excess cost compared with normal weight people without diabetes was 26% for obesity alone and 46% for those with obesity and diabetes.Limitations: Participants included in this study represented a healthier cohort than the Australian population. The relatively small sample of people with both obesity and diabetes prevented a more detailed analysis by obesity class.Conclusion: Overweight and obesity are associated with increased costs, which are further increased in individuals who also have diabetes. Interventions to prevent overweight and obesity or reduce weight in people who are overweight or obese, and prevent diabetes, should reduce the financial burden.

Comparison of Medical Care Utilization and Costs Among Patients With Statin-Controlled Low-Density Lipoprotein Cholesterol With Versus Without Hypertriglyceridemia

High triglyceride (TG) levels are associated with higher medical costs, but the long-term impact of high TG on costs among patients with statin-controlled low-density lipoprotein cholesterol (LDL-C) is unclear. We compared medical utilization and costs over 6.5years between patients with high (200 to 400 mg/dl) versus normal (<150 mg/dl) TG levels, all of whom had established atherosclerotic cardiovascular disease (ASCVD). This was an observational cohort study of 17,183 patients with TG measured in 2010 and followed until death, disenrollment or the end of 2016. All patients had LDL-C levels between 40 and 100 mg/dl and were receiving statin therapy at the time of their TG measurement. We compared annualized medical utilization adjusted for differences between group in age, sex, race, and study site. We also compared annualized medical costs, further adjusting for baseline costs as a proxy for resource-intensive comorbidities. After multivariable adjustment, patients with high TG levels (n=2,702) had a mean of 13% more inpatient admissions per year (p<0.001). Despite adjustment for comorbidities such as diabetes and chronic kidney disease, total outpatient costs were 5% greater (p=0.035) among those with high TG, including emergency care costs (6% greater) and hospital ambulatory costs (25% greater). The overall difference in annual costs of $964 per patient in the high TG cohort totaled over $2.6million per year in excess annual costs and more than $13.5million over the mean follow-up of 5.2years.

PHS31 - Healthcare Resource Utilisation and Costs of Agitation in People with Demetia Living in Care Homes - The Managing Agitation and Raising Quality of Life in Dementia (MARQUE) Study

To compare the costs for care home residents with different levels of agitation measured by the Cohen-Mansfield Agitation Inventory (CMAI), and calculate the cost of agitation (over and above the cost of the care home) in residents with and without clinically significant symptoms of agitation using the CMAI as well as the excess costs associated with agitation. We used the baseline data from 1,424 residents with dementia living in care homes (part of Managing Agitation and Raising QUality of lifE in dementia (MARQUE) study) that had Cohen-Mansfield Agitation Inventory (CMAI) scores recorded. We investigated the relationship between residents’ health and social care costs and severity of agitation based on the CMAI. In addition, we assessed resource utilisation and compared costs of residents with and without clinically significant symptoms of agitation using the CMAI over and above the cost of the care home. The annual mean costs per resident with CMAI scores ≤45 and >45 were £2,410.21 (95% CI £2,158.74 to £2,661.67) and £2,800.66 (95%CI £2,451.74 to £3,149.58) respectively. Agitation defined by the CMAI was a significant predictor of costs. One point increase in the CMAI is associated with an increase of 0.5 percentage points (cost ratio 1.005, 95%CI 1.001 to 1.010) in annual costs. The excess annual cost associated with agitation per resident with dementia was £1,125.35. This suggests that, on average, agitation accounts for 44% of the annual health and social care costs of dementia in people living in care homes. Agitation in people with dementia living in care homes contributes significantly to the overall costs increasing as the level of agitation increases. Residents with the highest level of agitation cost nearly twice as much as those with the lowest levels of agitation, suggesting that effective strategies to reduce agitation are likely to be cost-effective in this setting.

Association between atopic dermatitis and serious cutaneous, multiorgan and systemic infections in US adults

BackgroundAtopic dermatitis (AD) is associated with barrier disruption, immune dysregulation, and immunosuppressing treatments that can increase the association with an unusual number of infections. ObjectiveTo determine whether adults with AD have an unusually large number of serious infections and related outcomes. MethodsData from the 2002 to 2012 National Inpatient Sample were analyzed, including an approximately 20% sample of all US hospitalizations (n = 72,108,077 adults). Prevalence of serious infections in hospitalized patients with vs without AD, length of stay, cost of care, and inpatient mortality secondary to serious infections were determined. ResultsThe prevalence of serious infections expressed as a percentage (95% confidence interval) was higher in adults hospitalized with than in those without AD (42.1% [41.6–42.6] vs 25.4% [25.2–25.6]; P = .0002). In logistic regression models with multiple predictors (multivariable logistic regression models), AD was associated with 32 of 38 infections examined. Associated cutaneous infections included eczema herpeticum (odds ratio [95% confidence interval] adjusted for other predictors: 67.93 [47.93–96.28]), erysipelas (11.15 [9.47–13.1]), and cellulitis (4.53 [4.42–4.64]). Associated respiratory infections included aspergillosis (1.51 [1.21–1.88]) and tuberculosis (1.57 [1.41–1.76]). AD was associated with extracutaneous, multiorgan, and systemic infections, including infectious arthropathy (2.01 [1.84–2.20]), endocarditis (1.25 [1.12–1.39]), encephalitis (1.65 [1.40–1.96]), and methicillin-resistant Staphylococcus aureus infections (3.29 [3.17–3.42]). Patients with AD hospitalized with vs without any serious infection had an increased geometric mean cost of inpatient care ($8,273 [8,126–8,423] vs $7,179 [7,052–7,307]) and length of stay (5.3 days [5.2–5.3] vs 3.9 [3.9–4.0]; P = .0002), with $11 to $228 million excess annual costs from hospitalization with serious infections in adults with AD. ConclusionAdults with AD had increased cutaneous, respiratory, multiorgan, and systemic infections, which were associated with a considerable cost burden.

Disease burden of knee osteoarthritis patients with a joint replacement compared to matched controls: a population-based analysis of a Dutch medical claims database.

On a population level, the incidence of knee prostheses (KPs) has increased, but excess health care costs per patient, compared to matched controls without a KP, in the years surrounding these procedures and their determinants are largely unknown. We therefore aimed to provide estimates of age- and sex-specific incidence of KPs, revision KPs, and prosthesis complications in patients with knee osteoarthritis (OA) and to determine excess health care costs in the years surrounding surgery compared with matched controls. All KPs in OA patients in the Achmea Health Database were identified as well as up to four controls. Incidence rates of KPs, revisions, and complications from 2006 to 2013 were determined. Annual health care cost and excess costs (over matched controls) preceding, during, and after surgery were calculated and their determinants were evaluated. The increased incidence of KPs, revisions, and complications was strongest in younger age categories and men. The average costs per patient were relatively stable between 2006 and 2012. KP patient's annual health care costs increased towards the year of surgery. After surgery, costs decreased, but remained higher as compared to costs prior to surgery. High post-surgery costs were mainly associated with subsequent revisions or additional KPs, but costs were also higher in females, lower age categories, and lower social economic status. These results underscore the increasing burden and medical need associated with end-stage OA, especially in younger age categories. Improvement of guidelines tailored to individual patient groups aimed at avoiding complications and revisions is required to counteract this increasing burden.