Average Total Cost Of Care Research Articles

The impact of oral oncology drugs in the era of value-based care.

15 Background: Oncology drug expenditures are a significant contributor to increasing total cost of care (TCOC). Oral oncolytics (OO), such as small molecule inhibitors (CDK 4/6 inhibitors, tyrosine kinase inhibitors, etc.), and immunomodulators, have revolutionized the treatment landscape for many cancers. We evaluated the patterns of OO use and spend for Medicare patients over time at a large community oncology practice participating in the Center for Medicare and Medicaid Innovation (CMMI)’s Value-based care (VBC) Program, the Oncology Care Model (OCM), with a focus on the seven cancers that are part of a successor model, the Enhancing Oncology Model. Methods: Using CMMI claims for attributed 6-month OCM episodes, we evaluated drug use and expenditures by performance period (PP) from July 2016 – June 2022 (11 PPs), with an emphasis on OO drugs. We used Part D expenditures as a proxy for OO. Results: From 2016-22, average TCOC per PP increased by 15.5% in the 7 EOM diagnoses (breast, lung, colon, prostate cancer, myeloma, lymphoma, and chronic leukemia). Average drug expenditures per PP grew 33% percent and represented 71% of total cost by PP11, up from 61% in PP1. Average expenditures per episode increased by 11.7% for Part B and 82.6% for Part D drugs (p<0.01). Increase in Part D drug expenditures was partly due to an increase in the number of unique oral drugs which grew by 32% over the evaluation period. The greatest increases in Part D drug expenditures occurred in breast cancer (87%) and lymphoma (153.7%). Table reports average OO expenditures per PP, percent change from PP1 to PP11, and the change in the % Part D drugs contributed to TCOC. Conclusions: Increases in drug expenditures represent the greatest impact on TCOC for cancer patients. OO medicines have an increasing role in the treatment landscape and represent a growing focus in VBC models. Utilization and cost of OO medication have a significant bearing on VBC performance. Diagnosis Avg. OO Expenditures PP1 Avg. OO Expenditures PP11 Avg. OO Expenditures Change Contribution of OO to TCOC Change from PP1 - 11 Breast $4,208 $7,869 87.0% 9.9% Leukemia $25,334 $41,128 62.3% 19.9% CRC $1,206 $2,158 78.9% 3.1% Lung $3,650 $3,625 -0.7% -2.5% Lymphoma $4,193 $10,637 153.7% 13.0% Myeloma $25,109 $39,298 56.5% 6.7% Prostate $18,815 $20,114 6.9% 3.2% Total $8,291 $15,140 82.6% 10.8%

Average Length of Stay, Average Preventable Readmission Rates, and Average Total Cost of Care: Is there a Relationship?

Average Length of Stay (ALOS), Average Preventable Readmission Rates (APRRs), and Average Total Cost of Care (ATCc) were examined to see if any relationship exists among the variables. Secondary data from the Texas Hospital data collection database was used for the study. Out of 379 acute care hospitals in Texas, 65 hospitals were selected for analysis using a G*Power analysis. Demographic analysis, Spearman’s Rank correlation, and Regression Analyses were conducted to explore the relationship. The results of the Spearman’s Rho correlation showed a significant negative relationship between ALOS and ATCc [ALOS – ATCc (rs = - .271, p = .016)], and for APRRs and ATCc, there was no statistically significant relationship [APRRs – ATCc (rs = .065, p = .564)]. The multiple regression analysis showed there was no statistically significant relationship between the variables [ALOS – ARRs – ATCc (F (2,62) = 1.584, p = .211)]. The results showed that ALOS and APRRs do not necessarily predict ATCc. Consequently, based on the study results ATCc is not solely determined by ALOS and APRRs. The absence of a significant relationship between ALOS, APRRs, and ATCc does not necessarily indicate inefficiency in practice or lack of effectiveness. The results showed that there are other mediating factors impacting care that were not assessed in the study that need to be examined carefully which may have implications for practice, research, and methodology. Future research should be considered to determine these moderating factors to better understand the complex relationship between ALOS, APRRs, and ATCc. An understanding of these complex dynamics may inform managerial strategies and help with critical clinical and fiscal decisions in a healthcare setting.
 Keywords: Average Length of Stay, Average Preventable Readmission Rates, Average Total Cost of care

Analyzing the use and impact of elexacaftor/tezacaftor/ivacaftor on total cost of care and other health care resource utilization in a commercially insured population.

BACKGROUND: Cystic fibrosis (CF) is a rare, life-threatening disease that results in severe respiratory, digestive, and metabolic problems. Elexacaftor/tezacaftor/ivacaftor is an oral drug that was approved by the US Food and Drug Administration (FDA) on October 21, 2019, after demonstrating clinical improvements compared with previous CF transmembrane conductance regulator modulators. Use of CF transmembrane conductance regulator modulators has improved CF care, but their high costs exceed commonly used cost-effectiveness thresholds. The Institute for Clinical and Economic Review issued an access and affordability alert warning that these high costs could threaten sustainable access to high-value care. There exists little real-world evidence on the uptake of elexacaftor/tezacaftor/ivacaftor and the impact on total cost of care and other health care resource utilization. This exploratory study analyzed the uptake and total cost-of-care impact of elexacaftor/tezacaftor/ivacaftor using pharmacy and medical claims data in a commercially insured patient population. OBJECTIVE: To analyze the uptake of elexacaftor/tezacaftor/ivacaftor by members who qualified for treatment and to evaluate the differences in total cost of care and health care resource utilization in members who started treatment with elexacaftor/tezacaftor/ivacaftor. METHODS: Uptake and per-member per-month information was obtained from Prime Therapeutics databases using cystic fibrosis transmembrane conductance regulator (CFTR) modulator claims. The total cost-of-care and resource utilization analysis used pharmacy and medical claims from Prime Therapeutics and Blue Cross NC across approximately 1.34 million commercially insured members over 20 months. Members with CF were identified by 2 or more International Classification of Diseases, Tenth Revision codes (E84.xx) in any field at least 30 days apart or by a CFTR modulator claim. Only continuously enrolled members with CF with an elexacaftor/tezacaftor/ivacaftor pharmacy claim were included. The date of the first claim served as the index date. RESULTS: At 12 months after FDA approval, 77 (68%) Blue Cross NC members with CF were using elexacaftor/tezacaftor/ivacaftor. Of these, 33 had switched from a different CFTR modulator and 44 were naive to CFTR modulator therapy. Pharmacy and medical claims for 51 continuously enrolled members that initiated elexacaftor/tezacaftor/ivacaftor were analyzed. The average total cost of care increased by 52% (P < 0.00001). Hospitalizations decreased from an average of 7.7 (± 7.2) to 3.9 (± 5.5) (P < 0.00001). The sum and average number of Pseudomonas aeruginosa infections were numerically lower, but the results did not meet statistical significance. Use of other supportive medications was numerically lower, but no statistically significant differences were observed. CONCLUSIONS: The uptake of elexacaftor/tezacaftor/ivacaftor was rapid, and the total cost of care increased despite reductions in hospitalizations and nonpharmacy costs. Differences in use of other CF-related medications appeared to be minimally affected. DISCLOSURES: Dr Smith and Dr Borchardt have no financial conflicts of interest to report. Both authors are employed at BCBSNC at the time of writing. The project had no outside funding or sponsorship. The majority of the work and data analysis was completed as part of the requirements of the PGY1 Managed Care Pharmacy Residency program at BCBSNC during the 2020-2021 cycle year. This research does not meet the definition of human subject research as defined by the US Department of Health and Human Services at 45 C.F.R. § 46.102(f). According to definitions in section (e)(1), our research did not require either (i) information or biospecimens through intervention or interaction with any individuals or (ii) obtained, used, studied, analyzed, or generated private information or identifiable biospecimens. Therefore, institutional review board approval or a valid exemption is not required.

The Cost of Frailty in Complex Gastrointestinal Surgery.

Frailty is a syndrome characterized by decreased physiologic reserve related with aging; it has been associated with increased costs of health care. Factors driving its economic impact remain poorly understood. We examine the association between frailty, complications, and costs in complex gastrointestinal surgery. Retrospective review of a prospective database encompassing elective complex gastrointestinal operations from 2017 to 2018 at a tertiary care hospital. Patients were categorized into non-frail (NF): MFI 0, pre-frail (PF): MFI 1-2, and frail (FR): MFI >2 based on the 5-Factor Modified Frailty Index. Linear regression models were applied. 612 patients were included; 268 (44%) were NF, 325 (53%) were PF, and 19 (3%) were FR. The FR group had a longer length of stay (7.26days) compared to NF (5.05days) or PF (5.67days) (p = 0.031). The average total cost of care for all patients was $19,413.06 (CI 18,297.13-20,528.98). The cost for NF was $17,648.54 (CI 15,969.18-19,327.9), PF $20,435.70 (CI 18,911.01-21,960.4, p = .016), and FR patients was $26,809.36 (CI 20,511.9-33,106.81). A complication was observed in 91 patients (14.9%); of these, 76 (12.4%) were serious complications, as defined by NSQIP. There was no difference in incidence of complications (NF 14.93%, PF 14.46%, FR 21.05%, p = .734). On average, a complication added $12,656.67 regardless of frailty category. Frail patients are more costly and have a longer length of stay than their more robust counterparts. Complications were the major driver of costs after complex gastrointestinal surgery regardless of frailty status.

Cost Analysis of the Treatment of Severe Burn Injuries in a Tertiary Burn Center in Northern Iran

Introduction: One of the most expensive aspects of health care is providing care for burn victims. However, just a few burn cost analysis studies have been conducted in Iran. This study aimed to estimate the cost of treating severe burn patients in a burn center. Methods: This retrospective study was performed on the medical records of 143 severe burns patients who were referred to a specialized burn center between March 2020 and March 2021. The data were collected regarding the treatment costs and analyzed using SPSS software (version 16.0). Results: The mean±SD total per-patient cost was $US 5445.53±4742.45. Electrical burn patients had an average total cost of care and the length of stay higher than other burn patients. The bed charges (21.97%), surgeon’s salary (27.17%), and equipment and consumables (17.83%) were the main cost drivers. Conclusion: The results of this study can help hospital authorities and governments understand the direct costs of a burn center and the total budget that a country might need to cover the annual costs of treating burn victims. In addition, the cost of burn care in this study differed from that in other studies. The disparity in reported numbers can be attributed to variation in the used methodologies, costing viewpoints, study site, treatment procedures, hospitalization regulations, medications, surgeries, the health service providers' salary, nonclinical support, and indirect costs.

Direct Medical Cost Inpatient ACS-STEMI at Sardjito Hospital 2017-2018

&lt;p&gt;&lt;span lang="EN-US"&gt;Cardiovascular disease is the main cause of human death worldwide. This disease is also a major burden in health financing, due to direct costs of treatment and hospitalization. One type of cardiovascular disease is Acute Coronary Syndrome (ACS). The incidence of ACS in Indonesia is still the highest with a prevalence rate of 7.2% and continues to increase every year. This study aimed to determine the average direct medical costs of new ACS-STEMI patients who are hospitalized at Dr. Sardjito Hospital Yogyakarta period 2017-2018 and the factors that influence the cost of the treatment statistically. This research was an observational study with a descriptive retrospective research design using data from medical records and the finance (accounting) department. The sampling technique used in this study was purposive sampling based on patients who met the inclusion criteria. A total of 495 patients matched the inclusion criteria and the average of the components of direct medical costs incurred by inpatients was IDR48,926,665 with an average length of stay of 5 days. Statistical test results showed that the categories of gender, age, and payment method were not significantly associated with the average total cost of care for ACS-STEMI patients (&lt;em&gt;p&lt;/em&gt;&amp;gt;0.05). Meanwhile, the categories of length of stay and treatment regimen were significantly correlated to the average total cost of care for ACS-STEMI patients (&lt;em&gt;p&lt;/em&gt;&amp;lt;0.05). The average total cost of new ACS-STEMI patients undergoing inpatient treatment amounted to IDR48,926,665 which was significantly influenced by the category of the length of hospitalization and therapeutic regimen.&lt;/span&gt;&lt;/p&gt;

Cost-Consequence Analysis of Single-Dose Dalbavancin Versus Standard of Care for the Treatment of Acute Bacterial Skin and Skin Structure Infections in a Multisite Healthcare System.

Acute bacterial skin and skin structure infections (ABSSSIs) are common infectious diseases that cause a significant economic burden on the healthcare system. This study aimed to compare the cost-effectiveness of dalbavancin vs standard of care (SoC) in the treatment of ABSSSI in a community-based healthcare system. This was a retrospective study of adult patients with ABSSSI treated with dalbavancin or SoC during a 27-month period. Patients were matched based on age and body mass index. The primary outcome was average net cost of care to the healthcare system per patient, calculated as the difference between reimbursement payments and the total cost to provide care to the patient. The secondary outcome was proportion of cases successfully treated, defined as no ABSSSI-related readmission within 30 days after the initiation of treatment. Of the 418 matched patients, 209 received SoC and 209 received dalbavancin. The average total cost of care per patient was greater with dalbavancin vs SoC ($4770 vs $2709, P < .0001). The average reimbursement per patient was $3084 with dalbavancin vs $2633 SoC (P = .527). The net cost, calculated as revenue minus total cost, was $1685 with dalbavancin vs $75 with SoC (P = .013). The overall treatment success rate was 74% with dalbavancin vs 85% with SoC (P = .004). Dalbavancin was more costly than SoC for the treatment of ABSSSI, with a higher 30-day readmission rate. Dalbavancin does not offer an economic or efficacy advantage.

Preoperative Risk Factor Screening Protocols in Total Joint Arthroplasty: A Systematic Review

BackgroundPreoperative optimization protocols targeting potentially modifiable risk factors could prove beneficial in reducing the rate of complications in lower extremity total joint arthroplasty (LE-TJA). We aimed to summarize the evidence on preoperative screening protocols targeting modifiable risk factors to assess their effect on postoperative outcomes following primary LE-TJA. MethodsA literature search of MEDLINE, EMBASE, CINAHL, and Cochrane Library databases was performed in August 2019. The bibliographies of relevant publications were searched for further applicable studies. Included studies were required to report at least one outcome including prosthetic joint infection/surgical site infection (PJI/SSI), hospital length of stay (LOS), disposition, 90-day emergency department visits, or hospital readmissions after implementation of an evidence-based preoperative optimization protocol targeting modifiable risk factors. Methodological quality of included studies was assessed using the methodological index for non-randomized studies (MINORS) criteria. ResultsA total of 8 retrospective cohort studies including 9915 patients were reviewed. Implementation of preoperative optimization protocols were associated with reductions in SSI (0.56% vs. 2.60%; RR 0.21 [95% CI 0.12 to 0.37]; P < .00001), hospital LOS, mean cost of care, and hospital readmission rates. The mean MINORS score for comparative studies was 16.285. ConclusionsImplementation and compliance with evidence-based preoperative protocols for optimization of modifiable risk factors is associated with overall improved outcomes following LE-TJA. SSI, hospital LOS, average total cost of care, and hospital readmission rates were favorable in those cohorts subjected to a preoperative intervention protocol. Future prospective studies are necessary for further refinement of preoperative optimization protocols and referral algorithms, without compromising patients’ access to surgery. Level of EvidenceIII, Systematic Review;

Healthcare Utilization Patterns and Health Quality Indicators in Sickle Cell Disease Patients Transitioning from Pediatric to Adulthood

Introduction: Due to improvements in comprehensive medical care, data suggests that about 93% of children born with sickle cell disease (SCD) are now living past 18 years of age. Young adulthood is a high-risk time for clinical complications and progressive SCD-related organ damage. The majority of SCD-related deaths occur after 18 years of age and after transfer to an adult provider, which leaves this population particularly vulnerable to poor outcomes. In addition, current research suggests that this transition period is associated with increased health care utilization (HCU), and thus, highlights the need for proper care models for transitioning SCD patients. This study aims to describe the pattern of HCU and health quality indicators (HQI) in SCD patients at different ages of the transition period.Methods: A retrospective data analysis of health insurance claims from a single health plan for service dates 04/01/2016 through 03/31/2017 was conducted. Members meeting the claims-based definition of SCD (those with any sickle cell related ICD 9/10 CM diagnosis code on at least two separate encounters on distinct dates during the study period) with 12 months of continuous membership were included in the initial sample. Those within this sample that are 11-35 years old were selected and further stratified into three groups representing pre-transition (Group A: 11-18 yr.), transition (Group B: 19-26 yr.), and adult (Group C: 27-35 yr.). Data obtained include demographics, HCU patterns (emergency department (ED) visits, frequency of acute inpatient admissions and diagnosis, 30-day readmission rate and total cost of care), and HQI (hydroxyurea (HU) use, influenza (Flu) vaccination status, and total cost and number of visits for PCP and specialists). Two specific metrics of utilization included in the analysis were emergency department reliance ratio (EDR) and calculated HU medication possession ratio (MPR). EDR was calculated as the sum total of all ED visits divided by the total number of ambulatory visits. An EDR ≥ 0.33 was considered an indicator of excessive reliance. MPR was calculated as total days of HU prescription divided by the difference between the number of days of insurance enrollment and the number of days hospitalized. MPR of 1.0 was considered complete adherence.Results: A total of 144 members, 88 (61%) female, fit the inclusion criteria. Member number was similarly distributed in all groups: A: 50, B: 48, and C: 46. Medicaid was the primary insurance for 123 (85%) patients, followed by Commercial 15 (10%), and Medicare 6 (5%). While average total cost of care was similar in the three groups (A: $22,688; B: $25,525 and C: $25,873) average cost of ED visits was three times more for Group C: $2,153 as compared with A: $862 and B: $954. As shown in table 1, an increase in EDR, acute inpatient admission cost, and readmission rate was noted between groups A and B. Moreover, although Group C represented older patients, their ED utilization, EDR, and readmission rate were comparable with that of Group B. Analysis of HQI showed that almost half (44%) of the patients in Group A had no ED visits during the study period as compared to 29% of Group B and 26% of Group C. Of note, Group C had a higher number of 10 or more ED visits (n=9; range 10- 63 visits) compared to Group B (n=2; range 1-14) and Group A (n=1). More than 50% of patients in Groups B and C did not have a PCP or specialty visit within the study period vs. 25% in Group A. Group B had 13 visits to pediatric Heme/Onc providers, but no visits to adult Heme/Onc providers, even though the institutional maximum transition age is 21 years old. MPR was roughly 0.25 for each of the groups, and thus, consistent with poor adherence across all ages. Influenza vaccination was less frequent in the transition group (Group B) than in Groups A and C.Conclusion: Our data shows the vulnerability of SCD patients during their transition years (19-26 yr.) from pediatric to adulthood, thereby confirming the findings from prior studies. These patients demonstrated higher HCU patterns (i.e. EDR, acute inpatient admission cost and readmission rate) and lower HQI (i.e. lack of PCP and Heme/Onc visits, lower Flu vaccinations, and MPR). Thus, this study highlights the urgent need of improved protocols and systems in order to provide continuity and quality care during these critical transition years.“The last two authors of this abstract contributed equally.” [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

The economic burden of malignant and premalignant hematological diseases in Southern Nigeria.

Hematological malignancies are a significant cause of morbidity and mortality. They constitute an economic burden for the patients, their relatives, and the society because of the cost associated with their management, which is usually long term. We aimed to determine the total direct cost of managing patients with premalignant hematological disorders (PMHDs) and malignant hematological disorders (MHDs). A hospital-based retrospective study was carried out between 1997 and 2015. Data were retrieved from the case notes of adult patients diagnosed with either PMHD or MHD. The total cost of medical care was calculated as the sum of in-patient and out-patient direct cost associated with their management. Data were analyzed using Statistical Package for Social Sciences. There was a total of 129 patients; 74 (57.4%) males and 55 (42.6%) females with mean age of 45.7 ± 16.3 years and the majority (n = 76, 58.9%) being employed. Males were more affected than the females except in chronic lymphocytic leukemia, myelodysplastic syndrome, and paroxysmal nocturnal hemoglobinuria. The commonest MHD was chronic myeloid leukemia with 37 (28.7%) patients. Full blood count was the commonest investigation done, whereas free light chains were the least (n = 2; 1.6%). The total cost of care for the 129 patients was N30,041,900.00 ($82,306.58) with an average total cost of care per patient of N232,882.95 ($638.04). Patients with non-Hodgkin lymphoma had the highest mean cost of care per patient (N373,196.30; $1,022.46). The average monthly expenditure per patient was about N70,000 ($190). In our setting, management of CHDs constitutes an economic burden.

Current and projected patient and insurer costs for the care of patients with non-small cell lung cancer in the United States through 2040

Aims: The objective of this study was to quantify the current and to project future patient and insurer costs for the care of patients with non-small cell lung cancer in the US.Materials and methods: An analysis of administrative claims data among patients diagnosed with non-small cell lung cancer from 2007–2015 was conducted. Future costs were projected through 2040 based on these data using autoregressive models.Results: Analysis of claims data found the average total cost of care during first- and second-line therapy was $1,161.70 and $561.80 for patients, and $45,175.70 and $26,201.40 for insurers, respectively. By 2040, the average total patient out-of-pocket costs are projected to reach $3,047.67 for first-line and $2,211.33 for second-line therapy, and insurance will pay an average of $131,262.39 for first-line and $75,062.23 for second-line therapy.Limitations: Claims data are not collected for research purposes; therefore, there may be errors in entry and coding. Additionally, claims data do not contain important clinical factors, such as stage of disease at diagnosis, tumor histology, or data on disease progression, which may have important implications on the cost of care.Conclusions: The trajectory of the cost of lung cancer care is growing. This study estimates that the cost of care may double by 2040, with the greatest proportion of increase in patient out-of-pocket costs. Despite the average cost projections, these results suggest that a small sub-set of patients with very high costs could be at even greater risk in the future.

Chemotherapy treatment patterns, costs, and outcomes of patients with gastric cancer in the United States: a retrospective analysis of electronic medical record (EMR) and administrative claims data.

BackgroundThe aim of this study was to conduct a retrospective database analysis to describe the chemotherapy treatment patterns and outcomes of patients with gastric cancer.MethodsIndividuals diagnosed with gastric cancer were identified from the IMS Oncology Database, which contains electronic medical record (EMR) data collected from a variety of community practices, and the Truven Health MarketScan® Research database, an administrative claims database. Eligible patients were 18 years of age or older and had an ICD-9 code 151.0–151.9. Patients were excluded if they had evidence of cancer within 6 months of the index diagnosis.ResultsThere were 5257 eligible patients identified in EMR data: 1982 (37.7 %) of these patients also had data regarding chemotherapy treatments. Of the 1982 patients who received first-line therapy, 42.3 %, 18.1 %, and 7.9 % went on to receive a second, third, and fourth line of chemotherapy, respectively. There were 11891 eligible patients identified in the administrative database; 5299 (44.6 %) had data regarding chemotherapy. Of those initiating chemotherapy, 2888 (54.5 %) received a second line and 1598 (30.2 %) received a third line of treatment. The average total cost of care during first-line therapy was $40,811 [standard deviation (SD) = $49,916], which was incurred over an average of 53.5 (SD = 63.4) days. A similar pattern was evident in second-line treatment (mean/SD, $26,588/$33,301) over 41.2 (SD = 55.7) days.ConclusionsCosts and duration of care received vary among gastric cancer patients in the U.S. There is a need to understand which regimens may be associated with better health outcomes and to standardize treatment as appropriate.

Cost analysis of a randomized trial of early palliative care (PC) in patients with metastatic non-small cell lung cancer (NSCLC).

4 Background: Several randomized, controlled trials have shown that early, integrated palliative and oncology care improves quality of life, mood, and symptom burden in patients with advanced cancers. However, the degree to which early involvement of specialty PC in the ambulatory care setting impacts the cost of care remains unknown. We investigated the health care costs for patients with metastatic NSCLC enrolled in a clinical trial of early PC. Methods: For this secondary analysis, we examined data from a randomized trial of 151 patients with newly-diagnosed metastatic NSCLC from 06/2006 to 07/2009. Patients received either early PC integrated with standard care or standard care (SC) alone. We abstracted costs for emergency and inpatient care, outpatient visits, intravenous chemotherapy, and physician services from the hospital’s accounting system. Oral chemotherapy costs were estimated based on actual drug charges for patients. To estimate hospice costs, we used Medicare reimbursement rates. For each participant, we calculated the average total cost of care per day for the entire study period as well as the total cost of care for the final 30 days prior to death. Costs differences between groups were examined with the Wilcoxon Rank-Sum Test. Results: We analyzed health care costs of the 138 patients who died by 07/15/2013 (early PC N=68; SC N=70). The mean number of days on study was longer for patients assigned to early PC (M=397, SD=360) versus SC (M=299, SD=266). Over the study period, early PC was associated with a lower average total cost per day of $117 (SD=$436) compared to SC (p=.09). In the final 30 days of life, patients in the early PC group incurred higher total costs for hospice care (Mean difference=$1,053, SD=$3,162, p=.11), while expenses for chemotherapy were less (Mean difference=$757, SD=$2,143, p=.06). No cost differences between groups met the threshold for statistical significance. Conclusions: Although this secondary analysis was inconclusive due to the lack of statistical power to examine differences in cost outcomes, the delivery of early PC for patients with metastatic NSCLC does not appear to increase health care expenses over the course of disease or at the end of life. Clinical trial information: NCT01038271.

Epidemiology and Comorbidities of Polycystic Ovary Syndrome in an Indigent Population

BackgroundPolycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age. The aims of this study were to provide an estimate of the prevalence of PCOS...

Compliance with Antihypertensive Therapy in the Elderly

Treatment regimens that require fewer dosage units and less frequent dosing to decrease the complexity and cost of care are among the strategies recommended to improve compliance with antihypertensive therapy. Simplifying therapy may be particularly important for elderly patients, who are more likely to have co-morbid conditions and to be taking multiple medications. To determine rates of compliance with antihypertensive therapy and total costs of care among elderly Medicaid recipients treated with fixed-dose combination amlodipine besylate/benazepril versus a dihydropyridine calcium channel antagonist and ACE inhibitor prescribed as separate agents (free combination). A longitudinal, retrospective, cohort analysis of South Carolina Medicaid claims for ambulatory services, hospital services, Medicare crossover, and prescription drug for the years 1997-2002. Follow-up was 12 months from the index date, defined as the first prescription dispensing date for a study drug. South Carolina Medicaid beneficiaries aged >or=65 years. Outcomes variables included compliance defined as the medication possession ratio (MPR), which was the total days' supply of drug (excluding last prescription fill) divided by the length of follow-up (with number of hospital days subtracted from the numerator and denominator). We hypothesized that elderly individuals receiving fixed-dose combination amlodipine besylate/benazepril HCl would be more compliant with therapy than those receiving a dihydropyridine calcium channel antagonist and ACE inhibitor as free combination. There were 2336 individuals in the fixed-combination group and 3368 in the free-combination group. The mean age was 76.0 +/- 7.2 years, and 82.6% were female. Compliance rates were significantly higher with fixed-dose versus free-combination therapy (63.4% vs 49.0%; p < 0.0001). The average total cost of care for patients receiving the fixed-dose combination was $US3179 compared with $US5236 (2002 values) for the free-combination regimen. In multivariate regression analyses on the log of total cost of care, average total costs increased by 0.5% for each 1-unit increase in MPR, and for each additional co-morbidity (measured by the chronic disease score) there was an increase of 10.4%. However, average total costs were reduced by 12.5% for patients using fixed-dose versus free-combination therapy (p < 0.003). Use of fixed-dose amlodipine besylate/benazepril HCl by elderly Medicaid recipients was associated with improved compliance and lower healthcare costs compared with a dihydropyridine calcium channel antagonist and ACE inhibitor prescribed as separate agents.

Palliation Is Associated With Lower Hospitalization Costs

NASHVILLE, TENN. — Palliative care is clinically effective and is associated with lower hospitalization costs, according to an analysis of about 300 patients at one medical center. In a subset of 104 patients who were hospitalized for more than 4 days and received palliative care, the total cost of hospital care averaged $209 per day less than the cost for another series of patients matched by age, diagnosis, and vital status at discharge, Dr. Laura C. Hanson and her associates reported in a poster at the annual meeting of the American Academy of Hospice and Palliative Medicine. The cost savings were greater when palliative care was used for a longer period of time. In patients for whom palliative care was used for more than half the time hospitalized, the daily savings for total costs was $363, compared with matched controls, reported Dr. Hanson, a physician in the division of geriatrics at the University of North Carolina in Chapel Hill. The analysis began with the 395 seriously ill patients who were referred to the inpatient, palliative care consult service at the University's hospital during 2002–2004. The study focused on 304 patients who consented to participate. Their mean age was 66 years, and 61% had cancer as their primary diagnosis. The top reasons for their referral were pain (57%), dyspnea (45%), and delirium (38%); percentages totaled more than 100%. End-of-life decision making was used for 88%; and 43% of the patients died during the index hospitalization. At the time of patient referral, the mean symptom severity on the McCorkle symptom distress scale was 2.6 for pain, 2.3 for dyspnea, 2.2 for delirium, and 1.4 for nausea. These scores dropped steadily during the period of palliative care; after a week of care, the mean scores were 1.1 for pain, 1.0 for dyspnea, 1.0 for delirium, and 1.0 for nausea. The average total cost of hospitalization for the 304 patients was $1,242 per day during the 20 days prior to the start of palliative care, and $753 per day during the 20 days after palliative care began, an estimated cost saving of $489 per day per patient. A second economic analysis examined the total cost of hospitalization for several subsets of the patients treated with palliative care, compared with matched series of patients who did not receive palliative care. Although the patients who received palliative care did average longer lengths of stay in the hospital, those patients also had fewer days in the ICU and lower variable costs that led to overall cost savings. In the subset of 104 patients who received palliative care for more than 4 days, the average total cost of care was $1,888 per day compared with an average of $2,097 per day for the control patients, a $209 per day difference. In the 66 patients who received palliative care for more than 25% of their days hospitalized, the average saving in total costs was $203 per day. A final analysis looked at the costs for 55 patients who received palliative care and died while hospitalized, and compared these costs with the average cost during the final 10 days of hospitalization for a matched set of control patients. Once again, the average total costs per day were lower in the patients who received palliative care.

“Bridging” and Mechanical Heart Valves

Mechanical heart valves require anticoagulation to prevent valve-associated thrombosis and thromboembolic stroke. Oral vitamin K antagonists such as warfarin are prescribed universally; however, oral agents do not act immediately and usually require at least 5 days to achieve a therapeutic effect. Article p 564 Measurement of the prothrombin time, which is standardized by reporting the result as the international normalized ratio (INR), assesses the anticoagulant effect of warfarin. For most mechanical heart valves, the target INR ranges between 2.0 and 3.5. In the postoperative cardiac surgical setting, patients are usually started on low doses of warfarin because they tend to have impaired hepatic metabolism and suboptimal nutritional status. Even with low initial doses of warfarin, mechanical heart valve replacement patients are susceptible to excessively high INRs.1 This known exaggerated initial response to warfarin after heart valve replacement can lead to the habitual prescription of such low warfarin doses that warfarin as monotherapy may not achieve a stable and therapeutic INR for weeks after its initiation. To minimize the delay in achieving therapeutic anticoagulation, a “bridging” anticoagulant is prescribed. The “bridge” is administered parenterally, thereby providing an immediate anticoagulant effect. Traditionally, the “bridging” agent has been unfractionated heparin (UFH). More recently, physicians tend to select low-molecular-weight heparin (LMWH), even though few studies exist to validate the efficacy and safety of either LMWH or UFH in this setting. The rationale for shunning UFH has been to avoid the known perils and inconveniences of its use as a continuous peripheral intravenous infusion. UFH is rarely administered in an immediately therapeutic dose because of fear of precipitating bleeding complications. Especially in postoperative mechanical valve replacement patients, there is reluctance to follow the high dosing requirements for initial bolus and infusion regimens published in standardized nomograms. Instead, UFH is usually started in cautious small …

Using efficacy, safety, and cost data to support a formulary decision regarding thrombolytic therapy.

When urokinase was withdrawn from the market, alternative thrombolytics such as alteplase and reteplase needed to be evaluated for peripheral vascular disease (PVD). The efficacy, safety, and cost of these agents were evaluated formally by the Department of Pharmacy and presented to the Pharmacy and Therapeutics Committee. No published data support a difference in efficacy or safety between these agents. A cost analysis estimated the average total cost of care was higher for patients treated with reteplase ($4,556) compared with alteplase ($2,139). Therefore, alteplase was determined to be a more cost-effective thrombolytic agent to treat PVD.

Lifetime Cost of HIV Care in France during the Era of Highly Active Antiretroviral Therapy

To estimate the treatment and health care costs of HIV infection or AIDS in France during the era of highly active antiretroviral therapy (HAART). We used a clinical database of HIV-infected patients to calculate the resource use and cost of care for different stages of HIV infection. Costs were incorporated into a computer-based, probabilistic simulation model of the natural history and treatment of HIV infection to estimate the lifetime cost of treating patients with HIV disease. A northern France HIV clinical cohort. 1232 HIV-infected patients followed from January 1994 through July 1998. In the absence of an AIDS-defining event, the average total cost of care ranged from 670 euros (1 euro=US $1.19) per person-month in the highest CD4 stratum (>500/microl) to 1060 euros per person-month in the lowest CD4 stratum (< or = 50/microl). The mean cost of care was estimated at 3370 euros per person-month during the initial months around the occurrence of an AIDS-defining event; at 1750 euros per person-month during the period spanning from 2 months after the diagnosis of specific AIDS-defining event to 1 month prior to death; and at 13010 euros per person-month in the final month prior to death. If clinical management of HIV infection began at a CD4 cell count of 378/microl, as in this cohort, the discounted lifetime cost of treating an HIV-infected French patient was estimated at 214000 euros. The undiscounted costs were 309000 euros over a projected life expectancy of 16.4 years. The cost of HIV disease varies widely depending upon the stage of illness. These estimates of stage-specific and lifetime costs of HIV care will assist health policy planners in assessing the burden of disease in the era of HAART and projecting future resource requirements.

Length of stay has minimal impact on the cost of hospital admission

Background: Hospital cost containment, cost reduction, and alternative care delivery systems continue to preoccupy health care providers, payers, employers, and policy makers throughout the United States. The universal metric for gauging the success of these efforts is hospital length of stay (LOS). Reducing the LOS purportedly yields large cost savings. The purpose of this study is to assess precisely how much hospitals save by shortening LOS. Study Design: We reviewed the cost-accounting records of all surviving patients (n = 12,365) discharged from our academic medical center during fiscal year 1998 with LOS of 4 days or more. Actual costs were identified through the University of Michigan cost-accounting system. Individual patient costs were broken out on a daily basis and then decomposed further into variable direct, fixed direct, and indirect categories. The population was analyzed by determining the incremental resource cost of the last full day of stay versus the total cost for the entire stay. The data were also stratified by LOS and by surgical costs. An analysis of all trauma patients was then performed on all patients discharged from the hospital’s adult level I trauma center (n = 665). Costs were determined on specific days, including admission day, each ICU day, day of discharge from the ICU, and each of the last 2 days before the discharge day. Results: The incremental costs incurred by patients on their last full day of hospital stay were $420 per day on average, or just 2.4% of the $17,734 mean total cost of stay for all 12,365 patients. Mean end-of-stay costs represented only a slightly higher percentage of total costs when LOS was short (eg, 6.8% for patients with LOS of 4 days). Even when the data were stratified to focus on patients without major operations, the $432 average last-day variable direct cost was only 3.4% of the $12,631 average total cost of care. A focus on the trauma center helps to explain this phenomenon. For our trauma center, variable direct costs accounted for 42% of the mean total cost per patient of $22,067. The remaining 58% was hospital overhead (fixed and indirect costs). The median variable direct cost on the first day of admission is $1,246, and the median variable direct cost on discharge is $304. Approximately 40% of the variable costs are incurred during the first 3 days of admission. Conclusions: For most patients, the costs directly attributable to the last day of a hospital stay are an economically insignificant component of total costs. Reducing LOS by as much as 1 full day reduces the total cost of care on average by 3% or less. Going forward, physicians and administrators must deemphasize LOS and focus instead on process changes that better use capacity and alter care delivery during the early stages of admission, when resource consumption is most intense.