Burden Of Health Care Expenditures Research Articles

Abstract 5314: A peripheral blood-based glycoproteomic predictor of checkpoint inhibitor treatment benefit in advanced non-small cell lung cancer

Abstract Background: Protein glycosylation is the most common and complex form of post-translational protein modification. Glycosylation profoundly affects protein structure, conformation, and function. The elucidation of the potential role of differential protein glycosylation as biomarkers has been limited by the technical complexity of generating and interpreting this information. We have recently established a novel, powerful platform that combines liquid chromatography-mass spectrometry with a proprietary artificial-intelligence-based data processing engine that allows, for the first time, highly scalable interrogation of the glycoproteome. Here we report the performance of this platform to predict likely benefit from immune-checkpoint inhibitor (ICI) therapy in advanced non-small cell lung cancer (NSCLC). Methods: Our platform was utilized to assess 532 glycopeptide (GP) and peptide signatures representing 75 serum proteins in pretreatment blood samples from a cohort of 123 individuals (54 females, 69 males, age range 30 to 88 years). Inclusion criteria were a diagnosis of unresectable stage 3 or 4 NSCLC, treatment with pembrolizumab monotherapy (26 patients), or treatment with combination pembrolizumab-chemotherapy (97 patients). Overall survival (OS) data were available for all patients. Results: An ensemble multivariable-model-based glycoproteomic classifier consisting of 7 GP and non-glycosylated peptide biomarker features selected from a generalized additive model for OS was developed using ≈2/3rds of the full cohort (n=88) and validated in the remainder of patients (n=35). The classifier yielded similar statistical significance in Cox regression analysis for separating patients who are likely to benefit from ICI therapy from those who are not, to accurately predict likely ICI benefit with a sensitivity of >95% while performing at a specificity of 33% to predict those who are unlikely to benefit. Results were further analyzed in patients with either non-squamous or squamous NSCLC with first-line therapy (n=98). The classifier yielded a hazard ratio (HR) for prediction of likely ICI benefit of 3.6 with median OS of 13.9 vs. 4.2 months, and of 3.5 with median OS of 13.5 vs. 4.5 months in the entire cohort and the first-line treated patients, respectively. Conclusions: The glycoproteomic classifier described here predicts with high sensitivity which patients are likely to benefit from ICI therapy. In addition to potentially reducing the use of ICIs in a safe manner in patients who would be unnecessarily subjected to possible adverse drug reactions, our classifier simultaneously has the potential of reducing the burden of health care expenditures. Our results indicate that glycoproteomics holds a strong promise as a predictor for ICI treatment benefit which appears to significantly outperform other currently pursued biomarker approaches. Citation Format: Klaus Lindpaintner, Chad Pickering, Alan Mitchell, Gege Xu, Xin Cong, Daniel Serie. A peripheral blood-based glycoproteomic predictor of checkpoint inhibitor treatment benefit in advanced non-small cell lung cancer. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5314.

Long-Term Health Care Utilization After Cardiac Surgery in Children Covered Under Medicaid

BackgroundUnderstanding the longitudinal burden of health care expenditures and utilization after pediatric cardiac surgery is needed to counsel families, improve care, and reduce outcome inequities. ObjectivesThe purpose of this study was to describe and identify predictors of health care expenditures and utilization for Medicaid-insured pediatric cardiac surgical patients. MethodsAll Medicaid enrolled children age <18 years undergoing cardiac surgery in the New York State CHS-COLOUR database, from 2006 to 2019, were followed in Medicaid claims data through 2019. A matched cohort of children without cardiac surgical disease was identified as comparators. Expenditures and inpatient, primary care, subspecialist, and emergency department utilization were modeled using log-linear and Poisson regression models to assess associations between patient characteristics and outcomes. ResultsIn 5,241 New York Medicaid-enrolled children, longitudinal health care expenditures and utilization for cardiac surgical patients exceeded noncardiac surgical comparators (cardiac surgical children: $15,500 ± $62,000 per month in year 1 and $1,600 ± $9,100 per month in year 5 vs noncardiac surgical children: $700 ± $6,600 per month in year 1 and $300 ± $2,200 per month in year 5). Children after cardiac surgery spent 52.9 days in hospitals and doctors’ offices in the first postoperative year and 90.5 days over 5 years. Being Hispanic, compared with non-Hispanic White, was associated with having more emergency department visits, inpatient admissions, and subspecialist visits in years 2 to 5, but fewer primary care visits and greater 5-year mortality. ConclusionsChildren after cardiac surgery have significant longitudinal health care needs, even among those with less severe cardiac disease. Health care utilization differed by race/ethnicity, although mechanisms driving disparities should be investigated further.

Policy transfer and health policymaking process: The case of social health insurance in Ghana

Since the introduction of the user fee system of healthcare financing in 1969 and its subsequent modifications, the burden of healthcare expenditure on residents of Ghana created health inequality. This system encouraged the poor and vulnerable to have limited access to essential drugs and services. Policy entrepreneurs contributed to raising awareness about the poor and vulnerable people in Ghana not having access to health due to the user fee system as a public policy problem. This awareness began to spread among political leaders, the masses, and professional groups, warranting the attention of policymakers. As significant public dissatisfaction and agitation against the user fee policy continued, the media continued to hold the government responsible for initiating the policy. The democratization process and election period between 1998 and 2000 provided a window of opportunity that led to the idea of health policy change. In 2003, Ghana established the National Social Health Insurance, a form of Social Health Insurance. This study examines the process of establishing the social health insurance scheme through policy transfer framework. First, the paper examines Ghana’s health policy after independence, the National Health Service, and the User Fee Policy that was implemented in 1985. Second, the paper accessed the policy transfer framework and applied it to the transfer of social health insurance. Third, the paper explains the radical change from the user fee policy to the social health insurance model. This essay uses time series analysis and comparative analysis to assess the impact of the social health insurance on the under-five mortality ratio, maternal mortality ratio and out-of-pocket expenditure. The assessment results show that the social health insurance scheme has a positive impact on under-five mortality, maternal mortality and out-of-pocket payment compared to Nigeria without social health insurance for the poor and other vulnerable groups. The paper concludes that policy transfer alone cannot be a single variable to explain radical health policy change, but when combined with other complementary perspectives, an empirically grounded account of policy change can be developed.

Contributions and challenges of healthcare financing towards universal health coverage in Ethiopia: a narrative evidence synthesis

BackgroundHigh burden of healthcare expenditure precludes the poor from access to quality healthcare services. In Ethiopia, a significant proportion of the population has faced financial catastrophe associated with the costs of healthcare services. The Ethiopian Government aims to achieve universal health coverage (UHC) by 2030; however, the Ethiopian health system is struggling with low healthcare funding and high out-of-pocket (OOP) expenditure despite the implementation of several reforms in health care financing (HCF). This review aims to map the contributions, successes and challenges of HCF initiatives in Ethiopia.MethodsWe searched literature in three databases: PubMed, Scopus, and Web of science. Search terms were identified in broader three themes: health care financing, UHC and Ethiopia. We synthesised the findings using the health care financing framework: revenue generation, risk pooling and strategic purchasing.ResultsA total of 52 articles were included in the final review. Generating an additional income for health facilities, promoting cost-sharing, risk-sharing/ social solidarity for the non-predicted illness, providing special assistance mechanisms for those who cannot afford to pay, and purchasing healthcare services were the successes of Ethiopia’s health financing. Ethiopia's HCF initiatives have significant contributions to healthcare infrastructures, medical supplies, diagnostic capacity, drugs, financial-risk protection, and healthcare services. However, poor access to equitable quality healthcare services was associated with low healthcare funding and high OOP payments.ConclusionEthiopia's health financing initiatives have various successes and contributions to revenue generation, risk pooling, and purchasing healthcare services towards UHC. Standardisation of benefit packages, ensuring beneficiaries equal access to care and introducing an accreditation system to maintain quality of care help to manage service disparities. A unified health insurance system that providing the same benefit packages for all, is the most efficient way to attain equitable access to health care.

THE SOCIAL CLASS VARIATION IN HEALTH CARE EXPENDITURE: A CASE STUDY OF KHALLIKOTE BLOCK, GANJAM DISTRICT, ODISHA

This objective carries the primary data collected through a questionnaire from my study area and analyses of the impact of health care on the socio-economic development and the level of living of the social class families compared to other families. This also focuses on the problems and preferences of the health care expenditure burden of social class families. This present study was undertaken to investigate the existing health problems and healthcare practice of the social class (SC, ST, and OBC) communities of Khallikote Block in Ganjam District based on the present scenario, which exists between the SC, ST, and OBC groups. The findings of the study indicated that the demographic profile, socioeconomic status, general health status, but still lack of knowledge as well as poor availability of medical institution people intended to use traditional herbal medicine. The housing status of the social class community households needs to be improved through the help of village Panchayat should be oriented by Indira Awas yojana, and help of the people of construct good houses. It is necessary to provide orientation to village Panchayat about healthy housing and sanitation in the tribal communities. The village must be connected with the provision of “Rural Drinking Water” facilities in the social class village area, and villages to have safe drinking water in the villages as well in the community. The study has the following limitations: The study has depicted the current situation of the Khallikote Block in Odisha; the result may not be relevant to other class of people. The study is limited to a cross-section sample of 348 households of the selected sample villages in Langaleswar and Khojapalli Panchayat. It has been assumed that the respondents are true and honest while filling the questionnaire and there is no bias. Due to time and resource limitations, a full-length survey is not possible with a wider representation of data. Insurgency problem in the state created a problem for data collection from interior parts of the state. Despite these limitations, an attempt has been made to make the study more scientific and reliable by testing the reliability of the primary data. KEYWORDS: Health care expenditure, Income, cross-section sample, Regression, demographic profile.

&lt;p&gt;The Impact of Air Pollution on Healthcare Expenditure for Respiratory Diseases: Evidence from the People’s Republic of China&lt;/p&gt;

BackgroundAir pollution is an important factor in health outcomes and health-care expenditure. It has become an important issue of global concern. The objective of this study was to explore the influence of air pollution on the economic burden of respiratory diseases using different levels of PM2.5.MethodsStarting from the demand side, we took the 3,546 patients in the Respiratory and Critical Care Department of a tertiary hospital in Beijing between 2013 and 2015 as examples, combining daily air-quality data using a generalized linear regression–analysis model to explore the impact of air pollution on health-care expenditure on a microindividual level.ResultsWe found that PM2.5 had a significant impact on health-care expenditure on respiratory diseases. It had a positive impact on total health-care expenditure, drug expenditure, and antibiotic expenditure. The impact of different levels of air pollution on the health care–expenditure burden of disease was heterogeneous. As the air-pollution index increased, health care–expenditure burden of respiratory diseases also gradually raised. The impact of PM10 and air-quality index had a positive impact on health-care expenditure for respiratory diseases. Air pollution had a significant impact on health care–expenditure burden of respiratory diseases. The effect of length of stay on various health-care expenditure was significantly positive.ConclusionThe impact of mortality-risk classification on various health-care expenditure is significant. Therefore, policy-making must take into account both the supply side and the demand side of health-care services. Furthermore, the government should strengthen environmental governance, pay attention to the heterogeneity of the health care–expenditure burden affected by environmental pollution, improve the medical insurance system, and improve the health of residents to reduce the health care–expenditure burden.

Marginal Health Care Expenditure Burden Among U.S. Civilian Noninstitutionalized Individuals with Multiple Sclerosis: 2010-2015.

Multiple sclerosis (MS) is a chronic neuroinflammatory disorder with significant health care burden. However, little is known about health care expenditures since the introduction of oral agents for MS after 2010. To analyze health care expenditures in individuals with MS using Medical Expenditure Panel Survey (MEPS) data from 2010-2015. This retrospective cross-sectional study included adults (≥ 18 years) with MS (Clinical Classification Code 080) and those without MS based on the 2010-2015 full year consolidated MEPS Household Component and Medical Provider Component data files. Descriptive weighted analyses were performed to compare health care expenditures between individuals with MS and without MS. The 2-part model involving probit and generalized linear models was used to estimate the marginal increase in total health care expenditures for MS patients. There were 0.61 million patients (95% CI = 0.50-0.72) diagnosed with MS annually, accounting for a prevalence of 0.25%. The 2-part model revealed that the marginal total health care expenditures in patients diagnosed with MS were $20,103.49 (95% CI = $14,516.24-$25,690.73) more compared with those without MS. Further, the mean adjusted prescription medication expenditures for the MS group were $13,092.16 (95% CI = $9,452.20-$16,732.12) higher than the non-MS group and accounted for 65.12% of total health care expenditures in MS. MS is an expensive neuroinflammatory disease with a majority of the burden attributable to prescription medications. High prescription expenditure burden can be a barrier to optimal patient care in MS. No funding was received for this study. Hutton reports grants from Adamas, Biogen, EMD Serono, Genzyme, Hoffman-LaRoche, MedImmune, Mallinckrodt, and Novartis and fees from Biogen, Celgene, Genzyme, Genentech, and Novartis, outside the submitted work. Aparasu reports grants from Novartis, Incyte, and Astellas, outside the submitted work. Earla and Thornton have nothing to disclose. Part of the study findings was presented at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) 2019 National Conference; May 18-22, 2019; New Orleans, LA.

Advancing alternative health care financing through effective community partnership: A necessity for universal health coverage in Nigeria

This paper sought to advance alternative health care financing for the attainment of universal health coverage (UHC) in Nigeria considering the widening inequality, dwindling government spending, and non-inclusive health insurance scheme in the country. An adoptive narrative review of existing literature and authors’ experiences and observations of health care financing system was used to develop an overview of health care financing system in Nigeria. The results showed that Nigeria has a long way to go in attaining universal health coverage considering her high burden of disease and low health care expenditure, especially in comparison with Africa and similar countries across the globe. The results further showed that out-of-pocket spending dominates health care expenditure in Nigeria, and that the only way to curb heavy reliance on unsustainable and inequitable health care financing is to encourage risk-pooling of resources. This article therefore argues that alternative health care financing through effective community partnership is a necessity to achieving health for all. This understanding could inform health policies by annexing necessary connections with the promise of extending primary health care to all, especially the vulnerable groups, in a rapidly changing but highly unequal society.

Health Care Expenditure Burden of Cancer Care in the United States.

Using nationwide data, this study estimated and compared annual health care expenditures per person between noncancer and cancer patients, and among patients with the 4 most common cancers. Two-part models were used to estimate mean expenditures for each group by source of payment and by service type. We found that cancer patients had nearly 4 times higher mean expenditures per person ($16 346) than those without cancer ($4484). These differences were larger among individuals aged 18 to 64 years than those ≥65 years. Medicare was the largest source of payment for cancer patients, especially among those ≥65 years. Among the 4 most common cancers, the most costly cancer was lung cancer. Ambulatory care visits accounted for the majority of health care expenditures for those with breast cancer, while for those with other cancers, inpatient services also contributed to a significant portion of expenditures especially among younger patients. This study demonstrates that cancer patients experience a substantially higher health care expenditure burden than noncancer patients, with lung cancer patients having the highest expenditures. Expenditure estimates varied by age group, source of payment, and service type, highlighting the need for comprehensive policies and programs to reduce the costs of cancer care.

Drug therapy problems among patients with cardiovascular disease admitted to the medical ward and had a follow-up at the ambulatory clinic of Hiwot Fana Specialized University Hospital: The case of a tertiary hospital in eastern Ethiopia.

Background:Pharmacotherapy is important in reducing morbidity and mortality related to cardiovascular diseases. However, these advantages are limited by drug therapy problems that can impact on a patient’s quality of life, prolong hospital stays, and increase the overall burden of healthcare expenditures. Therefore, this study was aimed to assess drug therapy problems among patients with cardiovascular diseases who were hospitalized and received follow-up at the ambulatory clinic of Hiwot Fana Specialized University Hospital.Methods:An institution-based cross-sectional study design was used to collect data from patients with cardiovascular diseases who were admitted to the medical ward and those who had received follow-up at the ambulatory clinic of Hiwot Fana Specialized University Hospital. The collected data were coded, entered, and analyzed using SPSS version 16. The associations of selected categorical variables were done using binary logistic and multivariate logistic regression analyses.Results:Out of 216 study participants, females accounted for 123 (57%), whereas 93 (43%) of them were males. Among cardiovascular diseases identified in the medical ward and ambulatory clinics of Hiwot Fana Specialized University Hospital, congestive heart failure 96 (44.4%) and hypertension 93 (43.1%) were the two most commonly diagnosed disorders. Of the total participants involved in the study, 131 (60.65%) had drug therapy problems. Among the seven classes of drug therapy problems assessed, the most commonly observed was the need for additional drug therapy 76 (58%); followed by cases related to unnecessary drug therapy and noncompliance both of which were estimated to be 16 (12.2%). In addition, of independent variables, only the use of more than three drugs was significantly associated in both binary logistic (crude odds ratio = 0.41, 95% confidence interval = 0.234–0.719, p = 0.002) and multivariate logistic regressions (adjusted odds ratio = 4.86, 95% confidence interval = 1.625–14.536, p = 0.005) as compared with those patients who were using less than three drugs.Conclusion:The findings of the study indicated that more than half of the study participants experienced drug therapy problems, for which 58% required additional drug therapy. The risk of drug therapy problem is found to increase with the use of more than three drugs. Since these problems are adversely affecting the treatment outcome of patients, this is an area which requires special attention and the cooperation of healthcare professionals to tackle it.

The national cost of asthma among school-aged children in the United States

BackgroundRecent research has quantified the national health care resource use (HCRU) and health care expenditure (HCE) burden associated with adult asthma; however, estimates specific to school-aged children are more than 2 decades old. ObjectiveTo estimate the national HCRU and HCEs attributable to asthma among school-aged children in the United States. MethodsThis was a cross-sectional retrospective analysis of school-aged children (aged 6–17 years) in the nationally representative 2007–2013 Medical Expenditure Panel Survey. All-cause HCRU and HCEs of school-aged children with asthma were compared with school-aged children without asthma, controlling for sociodemographics and comorbidities. HCRU encounters included emergency department (ED) and outpatient visits, hospitalizations, and prescriptions. Expenditures included total, medical, ED, inpatient, outpatient, and pharmacy. Negative binomial regression analyses were used for HCRU and Heckman selection with logarithmic transformation, and smearing retransformation was used for HCEs. ResultsThere were 44,320 school-aged children of whom 5,890 had asthma. Children with asthma incurred a higher rate of all-cause annual ED visits (incidence rate ratio [IRR], 1.5; P < .001), hospitalizations (IRR, 1.4; P < .05), outpatient visits (IRR, 1.4; P < .001), and prescription drugs (IRR, 3.3; P < .001) compared with school-aged children without asthma. They incurred US$847 (2015 dollars) more annually in all-cause expenditures (P < .001). Private insurance and Medicaid paid the largest share of expenditures. Pharmacy and outpatient costs represented the largest proportion of total expenditures. On the basis of the nationally representative Medical Expenditure Panel Survey sample weights from 2013, the total annual HCEs attributable to asthma for school-aged children in the United States was US$5.92 billion (2015 dollars). ConclusionChildhood asthma continues to represent a prevalent and significant clinical and economic burden in the United States. More aggressive treatment and asthma management programs are needed to address this national financial and resource burden.

BCG-unresponsive non-muscle-invasive bladder cancer: recommendations from the IBCG.

Intravesical immunotherapy with live attenuated BCG remains the standard of care for patients with high-risk and intermediate-risk non-muscle-invasive bladder cancer (NMIBC). Most patients initially respond, but recurrence is frequent and progression to invasive cancer is a concern. No established and effective intravesical therapies are available for patients whose tumours recur after BCG, representing a clinically important unmet need. Development and discovery of treatment options for BCG-unresponsive NMIBC is a high priority in order to decrease the morbidity, burden of health-care expenditures, and mortality related to bladder cancer. This Review of treatment options after BCG failure focuses on principles of optimal management emerging therapies, thus enabling a synthesis of recommendations for management for such patients.

Comparing Health Care Financial Burden With an Alternative Measure of Unaffordability.

Health insurance plans with high deductibles increase exposure to health care costs, raising concerns about how the growth in these plans may be impacting both the financial burden of health care expenditures on families and their access to health care. We find that foregoing medical care is common among low-income, privately insured families, occurring at a greater rate than those with higher incomes or Medicare coverage. To better understand the relationship between out-of-pocket (OOP) spending and access, we used the 2011-2014 Medical Expenditure Panel Survey (MEPS) data and a logistic model to analyze the likelihood of avoiding or delaying needed medical care based on health insurance design and other individual and family characteristics. We find that avoiding or delaying medical care is strongly correlated with coverage under a high-deductible health plan, and with depression, poor perceived health, or poverty. However, it is relatively independent of the percent of income spent on OOP costs, making the percent of income spent on OOP costs by itself a poor measure of health care unaffordability. Individuals who spend a small percentage of their income on health care costs may still be extremely burdened by their health plan when financial concerns prevent access to health care. This work emphasizes the importance of insurance design as a predictor of access and the need to expand the definition of financial barriers to care beyond expenditures, particularly for the low-income, privately insured population.

Inpatient and outpatient health care utilization and expenditures among older adults aged 50 years and above in India

Background: Social and economic inequality in utilization of health care services, as well as high out of pocket expenditures are prevalent in overall Indian population. The situation among older adults will be much more critical as they require long-term health care services. The objective of this study is to assess the utilization of outpatient and inpatient care among older adults and incurred out of pocket health expenditure. It also tried to explore the association between socioeconomic factors on receiving health care services and out of pocket health expenditure among older adults in India.Data source: The data from the Study on Global Ageing and Adult Health (SAGE) Wave 1 was used, which was conducted in 2007-08 in India. Respondents aged 50 and above are taken as older adult population. The final sample size was 7150 respondents aged 50 years and above.Results: The percentage of older adults aged 50 years and above receiving outpatient and inpatient health care service were 87.5% and 14.6% respectively. The use of private health facilities was high compared to government health facility. High utilization of outpatient among women and high use of inpatient care among men were found, which was insignificant after adjusting for other variables. Socioeconomic characteristics also play an important role in access to health care among older adults. Place of residence, marital status, caste, education and presence of morbidity were related to the utilization of health care services. Place of residence, education and wealth quintile were also significantly associated with health expenditures.Conclusion: Requirement of long-term health care among older adult population may result in increasing burden of health care expenditures. Socioeconomic characteristics also play an important role in access to health care among older adults. Developing quality and affordable health care services for older adults to ensure equity in accessibility and affordablility will be a major task for the public health system in India.

Operant Conditioning and the Practice of Defensive Medicine

n the United States, the enormous burden of health care expenditure on the national budget and the role of physiI cians in controlling these costs are under scrutiny. The Centers for Medicare and Medicaid Services estimates that national health care expenditure in 2014 accounted for 17.5% of the gross domestic product in the United States, reaching almost $3 trillion; although all aspects of medicine saw cost increases, the growth rate increase in expenditure on physician and clinical services nearly doubled. This situation dominates every budgetary discussion at federal, state, and local municipality levels. Cost reductions are a priority, as is a careful analysis of physician practices and resource utilization. Most, but not all, practicing physicians mature through a process of residency training and board certification. In the United States, national boards, such as the American Board of Neurological Surgery, assiduously ensure a high level and uniformity of physician competency. Certification is an arduous process, and it requires demonstration of knowledge, competency, and careful judgment; it provides a measure of physician excellence. However, the American Board of Neurological Surgery and other similar bodies have little control over the utilization of resources by physicians once they enter practice.

Healthcare Expenditure Burden Among Non-elderly Cancer Survivors, 2008-2012.

Introduction:There is increasing concern regarding the financial burden of cancer on patients and their families. This study presents nationally representative estimates of annual out-of-pocket (OOP) burden among non-elderly cancer survivors and assesses the association between high OOP burden and access to care and preventive service utilization.Methods:Using the 2008–2012 Medical Expenditure Panel Survey, 4,271 cancer survivors and 96,780 individuals without a history of cancer were identified, all aged 18–64 years. High annual OOP burden was defined as spending > 20% of annual family income on OOP healthcare costs. Associations between high OOP burden and access to care were evaluated with multivariable logistic regression. Analyses were conducted in 2015.Results:Compared with individuals without a cancer history, cancer survivors were more likely to report a high OOP burden (4.3% vs 3.4%, p=0.009) in adjusted analyses. High OOP burden was more common among cancer survivors who were poor (18.4%), with either public insurance (7.9%) or uninsured (5.7%), and not working (10.2%). Among cancer survivors, high OOP burden was associated with being unable to obtain necessary medical care (19.2% vs 12.5%, p=0.002), delaying necessary medical care (21.6% vs 13.8%, p=0.002), and lower breast cancer screening rates among age-appropriate women (63.2% vs 75.9%, p=0.02).Conclusions:High OOP burden is more common among adults with a cancer history than those without a cancer history. High OOP burden was associated with being unable to obtain necessary medical care, delaying necessary medical care, and lower breast cancer screening rates among women.

Abstract 645: Atheroprotective Mechanism of Chromium Picolinate in Streptozotocin-Induced Diabetic ApoE-/- Mice

Vascular disease accounts for increased morbidity and mortality in diabetes. Given the burden of health care expenditure in diabetics, relatively cost-effective strategies represent an attractive therapeutic approach. Trivalent chromium (Cr) is a mineral nutrient reported to have a beneficial role in glycemic and cardiovascular health. While previous studies suggest that Cr reduces vascular inflammation in diabetes, the precise mechanisms of Cr action in the large blood vessels in diabetes remain unknown. We showed earlier that Cr picolinate (CrP, a bioavailable form of Cr) in vitro downregulates a potent proatherogenic matricellular protein thrombospondin-1 (TSP-1) in glucose-stimulated vascular smooth muscle cells. The present study provides the first evidence of an atheroprotective mechanism of Cr in vivo in a mouse model of diabetic atherosclerosis. Briefly, hyperglycemia was induced in male ApoE -/- mice (6wks age) with 50mg/Kg/day streptozotocin (STZ), i.p. for 5 consecutive days. Hyperglycemic mice (blood glucose&gt;250mg/dl) on regular chow diet were treated with or without CrP (8μg/Kg) in drinking water starting at 8 wks of age and all mice were sacrificed at 18 wks of age. Using en face atherosclerotic lesion assay shown by Oil red O staining, we demonstrated that CrP in vivo significantly prevents development of lesion in aortic vessel walls of hyperglycemic STZ-ApoE -/- mice compared to untreated STZ-ApoE -/- mice. Consistently, high-frequency ultrasound imaging of common carotid artery revealed that CrP prevents development of vascular lesions in STZ-ApoE -/- mice while untreated mice showed more pronounced lesions with a significant reduction (20%) in carotid artery diameter. Importantly, atheroprotective effects of CrP were accompanied by a significant decrease (&gt;35%) in TSP-1 and PCNA (proliferation marker) expression in aortic vessels of STZ-ApoE -/- mice, shown by immunoblotting. Also, en face studies showed that knockout of TSP-1 protects STZ-induced hyperglycemic ApoE -/- mice against atherosclerosis. Together, our results suggest that CrP in vivo prevents diabetic atherosclerosis via downregulation of TSP-1 in the large blood vessel wall, underscoring TSP-1 as a novel therapeutic target in diabetic atherosclerosis.

Scelte di spesa e trend epidemiologici: un modello di simulazione

The Report Salute Italia 2028 aims at estimating the health needs of the Italian population by 2028 as a planning tool that can be used in the decision making process. The development of forecasts, trends and scenarios is helpful in identifying the actions to be taken with an evidence-based approach, in order to try to align the health services supply with the emerging health needs. The analysis is based on a set of indicators recognized at the national and international level. Most data derive from the Italian Observatory Healthcare Report and statistical models have been used to estimate future trends. An effort was made to develop a methodology able to link the trends emerged to the economic-financial and supply perspective. The report highlights which will be the peculiar needs of the Italian population and the main critical situations in the span time considered. Core indicators have been selected and analyzed regarding the following areas: demographic scenario, burden of disease (tumors, cardiovascular and infectious diseases, diabetes), institutional framework and health care expenditure. The financial crisis in Italy can affect substantially the crucial sector of the health care. The spending review process should avoid horizontal policies that can reduce the health expenditure in the short term, but resulting in the long term in a reduction of the health services covered and, thus, of the health status of the population.

Hypoxic locomotor rehabilitation for incomplete spinal cord injury

Neurorehabilitation is experiencing a paradigm shift toward treatments that are both effective and efficient, driven by increasing demands upon clinical practice and the staggering burden of health care expenditures. The impetus is toward finding ways to maximize the potential for recovery by targeting networks spared by the lesion. Residual networks can undergo reorganization with recovery, involving plasticity or improved efficiency at the level of preexisting synapses and sprouting from surviving fibers for creation of new circuits.1 Capitalizing on the potential for plasticity and employing methods that can augment this potential are the 2 driving themes in current rehabilitation research. In this issue of Neurology® , Hayes et al.2 present a study that sought to address both.

Growth in private payments for health care by Canadian households

IntroductionDespite first-dollar public coverage for hospital and physician services, Canadians spend more privately on health care than citizens of most other developed countries. We quantified recent growth in private payments by Canadian households for health care. MethodsUsing data from 163,081 respondents to Statistics Canada's annual Survey of Household Spending from 1998 to 2009, we calculated inflation-adjusted per-household spending on private health insurance premiums and out-of-pocket payments on six types of health care services. Further, we estimated the prevalence and some socio-economic determinants of households spending over 10% of after-tax income on health care using logistic regression. ResultsWe found that Canadian households spent $19.8 billion on private payments for health care in 2009. This represents an average of $1523 per household—a 37% increase over 1998. The top three spending categories in 2009 were private health insurance premiums ($5.9 billion), dental ($4.9 billion) and prescription drugs ($4.2 billion). Even after adjusting for inflation, expenditure on every category of health care spending increased between 1998 and 2009. The proportion of households spending more than 10% of after-tax income on health care increased by 56% (from 3.3% to 5.2%). Households including a senior, with a low income, and in British Columbia or the Atlantic Provinces were significantly more likely to reach this threshold. InterpretationOver the period studied, the burden of private health care expenditures increased substantially for Canadian households. As direct charges reduce the use of necessary health care services, investigation into the health consequences of these increases is warranted.