Mean Cost Difference Research Articles

Costs of U.S. Allopathic Medical Students Applying to Neurosurgery Residency: Geographic Considerations and Implications for the 2020–2021 Application Cycle

Although studies have evaluated the economic burden to medical students desiring a neurosurgery residency broadly, a detailed breakdown of costs has not been reported. Given that the Association of American Medical Colleges and Society of Neurological Surgeons have recommended neurosurgery residency programs for the 2021 residency application cycle cancel away rotations and in-person interviews, our objective was to evaluate cost savings to medical students applying during this time and the implications. Using the 2019-2020 Texas STAR Dashboard database, we queried responses from neurosurgery residency applicants. We recorded application costs, away rotation costs, interview costs, and total costs for medical school seniors applying to neurosurgery residency. Demographic information for applicants was also recorded. Mean and median costs were reported with percentile distributions and geographic comparisons. A Kruskal-Wallis H test was used to determine differences in mean costs by medical school region. Our cohort included 121 U.S. allopathic applicants to neurosurgery residency. Mean application costs were $1711, away rotation costs were $3840, interview costs were $6400, and total costs were $11,882. No significant difference was observed for mean total costs for applicants from schools in the central ($10,525/applicant), northeast ($11,311/applicant), south ($12,660/applicant) and west ($12,404/applicant) regions (P= 0.181). There was no significant difference in the mean application fees, away rotation costs, or interview costs among regions. In the COVID-19 era, neurosurgery residency applicants could save >$10,000 through the use of virtual interviews and lack of away rotations. There are potential geographic trends; however, further evaluation should be performed.

Resource Use by Hospital Type for Frequent Inpatient Pediatric Conditions.

Children's hospitals (CHs) deliver care to underserved, critically ill, and medically complex patients. However, non-CHs care for the majority of children with frequently occurring conditions. In this study, we aimed to examine resource use across hospitals where children receive care for frequent inpatient conditions. This was a cross-sectional, observational analysis of pediatric hospitalizations for 8 frequent inpatient conditions (pneumonia, asthma, bronchiolitis, mood disorders, appendicitis, epilepsy, skin and soft tissue infections, and fluid and electrolyte disorders) in the 2016 Kids' Inpatient Database. Primary outcomes were median length of stay (LOS) and median total cost. The primary independent variable was hospital type: nonchildren's, nonteaching; nonchildren's, teaching (NCT); and freestanding CHs. Multivariable linear regression was used to assess differences in mean LOS and costs. There were 354 456 pediatric discharges for frequent inpatient conditions. NCT hospitals cared for more than one-half of all frequent inpatient conditions. CHs and NCT hospitals cared for the majority of patients with higher illness severity and medical complexity. After controlling for patient and hospital factors, discharges for frequent inpatient conditions at CHs had 0.48% longer mean LOS and 61% greater costs compared with NCT hospitals (P < .01). CHs revealed higher estimated costs in caring for frequent inpatient conditions despite controlling for patient- and hospital-level factors but also cared for higher illness severity and medical complexity. Further research is warranted to explore whether we lack sufficient measures to control for patient-level factors and whether higher costs are justified by the specialized care at CHs.

Outcomes associated with comorbid diabetes among patients with COPD exacerbation: findings from the ACURE registry

BackgroundDiabetes is a common comorbidity among patients with exacerbation of chronic obstructive pulmonary disease (AECOPD). Diabetes has been reported to be associated with length of stay (LOS), death, and cost among AECOPD patients. However, most studies are retrospective or have small sample sizes. The association for cost has not been researched using diabetes as a main analytic factor. This study aimed to fill gaps mentioned above, to compare basic characteristics between the diabetic and non-diabetic group, and to detect associations between diabetes and clinical outcomes among patients hospitalized with AECOPD.MethodsA total of 5334 AECOPD patients, classified into diabetic and non-diabetic group, were included from a prospective multicenter patient registry study. Generalized linear regression and logistic regression were separately used for the association between diabetes and direct hospitalization cost and the association between diabetes and LOS.ResultsGenerally, diabetic patients had a more severe profile, including being older, more overweight or obese, having more former smokers, more emergency room visits in the past 12 months, and more comorbidities occurrence. Diabetic patients also had worse clinical outcomes, including higher cost and longer LOS. Additionally, the generalized linear regression indicated that the marginal mean cost difference between diabetic and non-diabetic patients was RMB (¥) 775.7.ConclusionsAECOPD patients with comorbid diabetes had a more severe profile and higher direct hospitalization cost. Diabetes screening and integrated care programs might help reduce the heavy comorbidity and economic burden. Moreover, corticosteroids and metformin could be considered in the treatment of these patients.Trial registration Clinicaltrials.gov with the identifier NCT0265752.

Cost Analysis of Medical Students Applying to Orthopaedic Surgery Residency: Implications for the 2020 to 2021 Application Cycle During COVID-19.

Introduction:Although studies have evaluated the economic burden to medical students desiring an orthopaedic residency broadly, no study has evaluated in detail the application costs, away rotation costs, interview costs, and total costs. Given that the Association of American Medical Colleges and the American Orthopaedic Association's Council of Orthopaedic Residency Directors have recommended orthopaedic surgery residency programs for the 2021 residency application cycle cancel away rotations and in-person interviews, our objective was to evaluate the cost savings to medical students applying during this time and the potential implications.Methods:Using the 2019 to 2020 Texas STAR Dashboard database, we queried responses from applicants applying to orthopaedic surgery residency. The dashboard was queried to record the application costs, away rotation costs, interview costs, and total costs for medical school seniors applying to orthopaedic surgery residency. Demographic information for applicants was also recorded. Mean and median costs were reported with percentile distributions and geographic comparisons. A Kruskal-Wallis H test was used to determine whether there were statistically significant differences in mean costs by medical school region.Results:The 2019 to 2020 Texas STAR Dashboard database had 473 responses from applicants to orthopaedic surgery residency. The mean application costs were $1,990, away rotation costs were $3,182, interview costs were $3,129, and total costs were $8,205. The mean total costs for applicants from Midwest schools were significantly less than Western schools ($7,410/applicant vs. $9,909/applicant) (p = 0.008). There was no significant difference between the mean application fees between regions. Away rotation costs for applicants from schools in the Midwest ($2,413/applicant) were significantly less compared with Northeast ($3,279/applicant), South ($3,343/applicant), and West ($3,913/applicant) (all p < 0.002). Interview costs for applicants from schools in the Northeast ($2,891/applicant) were less than applicants from Western US schools ($3,831/applicant) (p = 0.038).Conclusion:In the COVID-19 era, orthopaedic residency applicants could save on average $6,311 through the use of virtual interviews and lack of away rotations. There are geographic implications, with applicants from Western US medical schools potentially saving most.

The cost-effectiveness of sequential versus standard triple therapy for Helicobacter pylori eradication in Saudi Arabia.

Background:The utilization rate of different treatment regimens for Helicobacter pylori infection is believed to be high; however, the cost-effectiveness of these regimens has not been examined before. Therefore, the aim of this study was to examine the cost-effectiveness of the two commonly prescribed treatments for H. pylori infection.Methods:The data of an open-label, single-center, randomized trial that compared the efficacy of sequential therapy (SQT) (i.e., esomeprazole 20 mg twice daily for 10 days, amoxicillin 1000 mg twice daily for 5 days, then clarithromycin 500 mg and tinidazole 500 mg twice daily for 5 days) to standard triple therapy (STT) (i.e., esomeprazole 20 mg, amoxicillin 1000 mg, and clarithromycin 500 twice daily for 14 days) in the eradication of H. pylori, as confirmed by the negative urea breath test (UBT), were used. Propensity score matching bin bootstrapping, with 10,000 replications and bias correction was conducted to generate the 95% confidence limits. Moreover, probabilistic sensitivity analysis was conducted by varying both the eradication rates and the costs of treatment regimens.Results:There were 82 and 88 patients who were on SQT and STT, respectively. Patients' mean age was 47 years, and approximately 55% of them were females. The mean treatment costs were SAR 2,075.51 (USD 553.47) and SAR 2,629.26 (USD 701.14) for SQT and STT, respectively. The mean eradication rates for SQT and STT were 63.41% and 67.05%, respectively. The mean difference in costs and eradication rates for SQT versus STT were SAR − 550.75 (95% CI: −563.84- −537.69) and − 3.64% (95% CI: −6.98- 5.88). The use of SQT was more likely to be cost saving and more effective with 56.25% confidence level, in comparison to STT.Conclusion:The use of SQT in the treatment of H. pylori seems to be more cost-effective than STT.

Excess healthcare costs in patients with autosomal dominant polycystic kidney disease by renal dysfunction stage

Aim To build upon previous outdated studies by comprehensively assessing the direct healthcare burden of autosomal dominant polycystic kidney disease (ADPKD). Materials and methods Patients with ≥2 diagnoses for ADPKD (ADPKD cohort) were identified in the US fee-for-use IBM Truven Health Analytics MarketScan Commercial Claims and Encounters and IBM Truven Health Analytics MarketScan Medicare Supplemental databases (01 January 2015–31 December 2017) and matched (1:3) to controls without ADPKD (non-ADPKD cohort). The index date was the last calendar date followed by 12 months continuous enrollment (study period). Patients with ADPKD were stratified into one of seven mutually exclusive groups based on chronic kidney disease (CKD) stages (I–V), end-stage renal disease requiring renal replacement therapy (ESRD-RRT), and unknown stage. Results During the 12-month study period, patients with ADPKD incurred significantly higher total healthcare costs than those without ADPKD (mean cost difference = $22,879 per patient per year [PPPY]; p < .001). Besides CKD stages I and II, total healthcare cost differences increased as patients progressed beyond CKD stage III, with the greatest difference observed among patients with ESRD-RRT. Total healthcare cost differences between cohorts were more pronounced in subgroups of patients with hypertension ($29,347) and with high risk of rapid progression ($39,976). Similar results were observed in the Medicare Supplemental population, with a total mean cost difference of $42,694 PPPY (p < .001); cost difference was also higher in the hypertension ($46,461 PPPY) and high risk of rapid progression ($45,708 PPPY) subgroups. Limitations Results may not be representative of the overall ADPKD US population; CKD stage was based on diagnosis and procedure codes; criteria used to identify ADPKD at risk of rapid progression did not rely on laboratory values; there may be billing inaccuracies and omissions in health insurance claims data. Conclusions This study demonstrated the substantial healthcare costs associated with ADPKD, which increased as patients progressed through more severe CKD stages.

Femtosecond laser-assisted cataract surgery compared with phacoemulsification: the FACT non-inferiority RCT.

Cataract surgery is one of the most common operations. Femtosecond laser-assisted cataract surgery (FLACS) is a technique that automates a number of operative steps. To compare FLACS with phacoemulsification cataract surgery (PCS). Multicentre, outcome-masked, randomised controlled non-inferiority trial. Three collaborating NHS hospitals. A total of 785 patients with age-related cataract in one or both eyes were randomised between May 2015 and September 2017. FLACS (n = 392 participants) or PCS (n = 393 participants). The primary outcome was uncorrected distance visual acuity in the study eye after 3 months, expressed as the logarithm of the minimum angle of resolution (logMAR): 0.00 logMAR (or 6/6 if expressed in Snellen) is normal (good visual acuity). Secondary outcomes included corrected distance visual acuity, refractive outcomes (within 0.5 dioptre and 1.0 dioptre of target), safety and patient-reported outcome measures at 3 and 12 months, and resource use. All trial follow-ups were performed by optometrists who were masked to the trial intervention. A total of 353 (90%) participants allocated to the FLACS arm and 317 (81%) participants allocated to the PCS arm attended follow-up at 3 months. The mean uncorrected distance visual acuity was similar in both treatment arms [0.13 logMAR, standard deviation 0.23 logMAR, for FLACS, vs. 0.14 logMAR, standard deviation 0.27 logMAR, for PCS, with a difference of -0.01 logMAR (95% confidence interval -0.05 to 0.03 logMAR; p = 0.63)]. The mean corrected distance visual acuity values were again similar in both treatment arms (-0.01 logMAR, standard deviation 0.19 logMAR FLACS vs. 0.01 logMAR, standard deviation 0.21 logMAR PCS; p = 0.34). There were two posterior capsule tears in the PCS arm. There were no significant differences between the treatment arms for any secondary outcome at 3 months. At 12 months, the mean uncorrected distance visual acuity was 0.14 logMAR (standard deviation 0.22 logMAR) for FLACS and 0.17 logMAR (standard deviation 0.25 logMAR) for PCS, with a difference between the treatment arms of -0.03 logMAR (95% confidence interval -0.06 to 0.01 logMAR; p = 0.17). The mean corrected distance visual acuity was 0.003 logMAR (standard deviation 0.18 logMAR) for FLACS and 0.03 logMAR (standard deviation 0.23 logMAR) for PCS, with a difference of -0.03 logMAR (95% confidence interval -0.06 to 0.01 logMAR; p = 0.11). There were no significant differences between the arms for any other outcomes, with the exception of the mean binocular corrected distance visual acuity with a difference of -0.02 logMAR (95% confidence interval -0.05 to 0.00 logMAR) (p = 0.036), which favoured FLACS. There were no significant differences between the arms for any health, social care or societal costs. For the economic evaluation, the mean cost difference was £167.62 per patient higher for FLACS (95% of iterations between -£14.12 and £341.67) than for PCS. The mean QALY difference (FLACS minus PCS) was 0.001 (95% of iterations between -0.011 and 0.015), which equates to an incremental cost-effectiveness ratio (cost difference divided by QALY difference) of £167,620. Although the measurement of outcomes was carried out by optometrists who were masked to the treatment arm, the participants were not masked. The evidence suggests that FLACS is not inferior to PCS in terms of vision after 3 months' follow-up, and there were no significant differences in patient-reported health and safety outcomes after 12 months' follow-up. In addition, the statistically significant difference in binocular corrected distance visual acuity was not clinically significant. FLACS is not cost-effective. To explore the possible differences in vision in patients without ocular co-pathology. Current Controlled Trials ISRCTN77602616. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 6. See the NIHR Journals Library website for further project information. Moorfields Eye Charity (grant references GR000233 and GR000449 for the endothelial cell counter and femtosecond laser used).

Costs of treatment change following first-line somatostatin analog monotherapy among patients with neuroendocrine tumors

Background This study describes treatment characteristics and healthcare costs prior to and following treatment change from somatostatin analog (SSA) monotherapy among a privately-insured NET patient population in the US. Methods Patients with newly diagnosed NET and treated with SSA monotherapy were retrospectively identified in IBM MarketScan claims between 1/1/2014 and 3/31/2019. NET treatment change was captured ≥30 days after the SSA start date (earliest new treatment = index date). Healthcare costs (reimbursed amount in 2019 dollars) were reported for 1, 3, and 6 months pre- and post-index intervals. Results A total of 305 patients were identified (mean age: 58 years; female: 52%; metastatic disease: 49%). Most patients started on octreotide (81%) vs. lanreotide (19%). Common treatment changes included alternate SSA (38%), targeted therapy (30%), or chemotherapy (23%). Total costs increased on average by $13,272 between the month preceding and following treatment change (p < .001), with the highest increase among patients changing to targeted therapy ($19,677, p < .001) vs. an alternate SSA ($10,240, p < .001) or chemotherapy ($4,057, p = .155). The trajectory in mean cost difference using a 1, 3, and 6-month time period followed an increasing trend for patients who changed to targeted therapy (Δ$19,677, Δ$34,856, Δ$58,387) but was flat for patients who changed to the alternate SSA (Δ$10,240, Δ$10,026, Δ$11,727). Conclusions Higher total healthcare costs were observed following treatment change from first-line SSA. Switching to the alternate SSA was associated with a fixed, one-time cost; whereas, switching to targeted therapy was associated with both an initial switching cost and a persistent monthly increase.

Health Economic Evaluation of Patients with Colorectal Liver Metastases Randomized to ALPPS or TSH - Analysis from the LIGRO Trial

Introduction: Two-staged hepatectomy (TSH), is an established method in advanced colorectal liver metastases (CRLM). Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has emerged providing improved resection rate and survival. The health care costs and health outcomes, combining health related quality of life (HRQoL) and survival into quality-adjusted life years (QALYs), of ALPPS and TSH have not previously been evaluated and compared. Methods: This is a pre-planned, health economic evaluation from the LIGRO trial. One hundred patients with CRLM and standardized FLR < 30 % were randomized to ALPPS or TSH. Costs and QALYs were compared from treatment start up to 2 years. Costs are estimated from resource use, including all surgical interventions, length of stay after interventions, diagnostic procedures and chemotherapy and applying Swedish unit costs. QALYs were estimated by combining survival and HRQoL data, the latter being assessed with EQ-5D 3L. Estimated costs and QALYs for each treatment strategy were combined into an incremental cost-effectiveness ratio (ICER). Non-parametric bootstrapping was used to assess the joint distribution of incremental costs and QALYs. Results: The mean cost difference between ALPPS and TSH was 12662€, (95% CI -10728-36051, p=0.283). Corresponding mean difference in life years and QALYs was 0.1296 (95% CI -0.12-0.38, p=0.314) and 0.1285 (95% CI -0.11-0.36, p=0.28), respectively. The ICER was 93186 and 92414 for QALYs and life-years as outcomes, respectively. Conclusion: Based on the two-year data, the cost-effectiveness of ALPPS is uncertain. Further research, exploring cost and health outcomes beyond 2 year is needed.

Economic burden of major bleeding events in commercially insured patients with von Willebrand disease based on claims data from the United States.

BACKGROUND: von Willebrand disease (VWD) can lead to serious, life-threatening bleeding events associated with substantial clinical and economic burden. OBJECTIVE: To estimate the prevalence, health care resource utilization (HCRU), and costs associated with major bleeding events in patients with VWD. METHODS: This was a retrospective analysis of the IBM MarketScan database (2008-2016). Selected patients had ≥ 2 VWD diagnoses, no diagnosis of acquired coagulation factor deficiency, and continuous health care plan enrollment for ≥ 12 months from eligibility start date. Prevalence was calculated as the proportion of eligible patients with ≥ 1 major bleeding event during the observation period (start to end of continuous eligibility). HCRU and costs in the 12-month continuous enrollment period following the first major bleeding event were compared with those from a comparable 12-month period for patients without major bleeding events. RESULTS: Of the 19,785 patients with VWD, 15% experienced ≥ 1 major bleeding event during a median follow-up of 4 years; 89% of these events were gastrointestinal bleeds. For the economic analysis, 773 patients with ≥ 1 major bleeding event and 4,285 patients without major bleeding events met the selection criteria. Controlling for baseline covariates, patients with major bleeding events had significantly (P < 0.0001) more inpatient admissions (incidence rate ratio [IRR] = 3.2; 95% CI = 2.78-3.77), longer inpatient stays (IRR = 3.9; 95% CI = 3.12-4.93), and more emergency department visits (IRR = 2.0; 95% CI = 1.77-2.27) and outpatient visits (IRR = 1.3; 95% CI = 1.19-1.34) than patients without major bleeding events. Annual health care costs were significantly higher (P < 0.01) for patients with major bleeding events than those without them (predicted mean cost differences: total = $20,890, pharmacy = $2,593, and medical = $18,293). CONCLUSIONS: Major bleeding events were associated with increased HCRU and costs, mostly inpatient costs. Therefore, optimizing therapy to prevent or reduce major bleeding events has the potential to reduce health care use and costs in patients with VWD. DISCLOSURES: This study was funded by Baxalta U.S. Inc., a Takeda company (Lexington, MA). The study sponsor was involved with the study design, analysis, and interpretation of data; writing of the manuscript; and the decision to publish the article. Lu, Wu, and Ewenstein are employees of Baxalta U.S. Inc., a Takeda company, and are Takeda stock owners. Farahbakhshian is an employee of Shire U.S. Inc., a Takeda company, and is a Takeda stock owner. Oladapo was an employee of Baxalta U.S. Inc., a Takeda company, at the time the analysis was completed and the manuscript developed, and is a Takeda stock owner.

Healthcare use and costs of adults with anorexia nervosa and bulimia nervosa in Taiwan.

This study aimed to examine the health service use and healthcare costs of adults with anorexia nervosa (AN) and bulimia nervosa (BN) in Taiwan. AN and BN cases between 2002-2013 were extracted from a national health insurance database. For each AN and BN case, we randomly selected 10 controls with no eating disorder, matched for sex, age, urbanization of residence, and year of medical visit. The percentage and frequency of health services use and costs in the year preceding and after the diagnosis of AN/BN were compared between groups. We used generalized linear models with gamma distribution and log link function to determine the effects of age, sex, and psychiatric comorbidities on the total cost adjusting for physical comorbidities and to calculate the mean cost difference between groups by using marginal and incremental effects. Both individuals with AN and BN had significantly elevated healthcare utilization and costs compared to controls during the baseline and one-year period after diagnosis. Patients with AN had more than three times higher total costs (US $792) and patients with BN had two times higher total costs (US $320) than individuals without eating disorders. Comorbidity of depressive disorder and older age significantly increased healthcare costs among both individuals with AN and BN. There are high medical and economic burdens of care for individuals with AN and BN. Early diagnosis and integrated care for eating disorders are important tasks to reduce disease burden in Taiwan.

Associations Between Quality Measures and Outcomes for Children Hospitalized With Bronchiolitis.

To use adherence to the Pediatric Respiratory Illness Measurement System (PRIMES) indicators to evaluate the strength of associations for individual indicators with length of stay (LOS) and cost for bronchiolitis. We prospectively enrolled children with bronchiolitis at 5 children's hospitals between July 1, 2014, and June 30, 2016. We examined associations between adherence to each individual PRIMES indicator for bronchiolitis and LOS and cost. Sixteen indicators were included, 9 "overuse" indicators for care that should not occur and 7 "underuse" indicators for care that should occur. We performed mixed effects linear regression to examine the association between adherence to each individual indicator and LOS (hours) and cost (dollars). All models controlled for patient demographics, patient complexity, and hospital. We enrolled 699 participants. The mean age was 8 months; 56% were male, 38% were white, and 63% had public insurance. Three indicators were significantly associated with shorter LOS and lower cost. All 3 indicators were overuse indicators and related to laboratory testing: no blood cultures (adjusted mean difference in LOS: -24.3 hours; adjusted mean cost difference: -$731, P < .001), no complete blood cell counts (LOS: -17.8 hours; cost: -$399, P < .05), and no respiratory syncytial virus testing (LOS: -16.6 hours; cost: -$272, P < .05). Two underuse indicators were associated with higher cost: documentation of oral intake at discharge ($671, P < .01) and documentation of hospital follow-up ($538, P < .05). A subset of PRIMES quality indicators for bronchiolitis are strongly associated with improved outcomes and can serve as important measures for future quality improvement efforts.

Healthcare resource utilization and costs associated with first-line ibrutinib compared to chemoimmunotherapy treatment among Medicare beneficiaries with chronic lymphocytic leukemia

Objective This retrospective observational study aimed to compare healthcare resource utilization and costs of Medicare beneficiaries with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) who received ibrutinib versus chemoimmunotherapy (CIT) in first line (1 L). Methods Fee-for-service (FFS) and Medicare Advantage (MA) claims data were used to identify adults with a CLL/SLL diagnosis initiating 1 L ibrutinib single agent or CIT between 4 March 2016 and 30 September 2017 (index date). HRU and costs (Medicare spending) were evaluated during 1 L Oncology Care Model (1 L OCM) episodes (the first six months post-index) and over the observed 1 L duration. Patients' baseline characteristics were balanced using inverse probability of treatment weighting. Mean monthly cost differences (MMCDs) obtained from ordinary least square regressions were used to compare costs between ibrutinib and CIT cohorts. Results In the Medicare FFS dataset (ibrutinib: n = 2014; CIT: n = 2050), ibrutinib patients incurred significantly higher monthly pharmacy costs (1 L OCM: MMCD = $4878, p < .0001; 1 L duration: MMCD= $4892, p < .0001) that were fully offset by lower monthly medical costs (1 L OCM: MMCD= -$8289, p < .0001; 1 L duration: MMCD=-$5888, p < .0001), yielding a monthly total healthcare cost reduction (1 L OCM: MMCD=-$3411, p < .0001; 1 L duration: MMCD=-$996, p < .0001) relative to CIT patients. In the MA dataset (ibrutinib: n = 293; CIT: n = 303), ibrutinib was also associated with a monthly total healthcare cost reduction (1 L OCM: MMCD=-$10,459; 1 L duration: MMCD=-$5492). Conclusions In Medicare patients with CLL/SLL, 1 L ibrutinib single agent was associated with total monthly cost savings relative to 1 L CIT, driven by lower monthly medical costs that fully offset higher monthly pharmacy costs.

Burden of Parkinson's Disease by Severity: Health Care Costs in the U.S. Medicare Population.

Current understanding of the health care costs of Parkinson's disease (PD) and the incremental burden of advanced disease is incomplete. The aim of this study was to assess the direct economic burden associated with advanced versus mild/moderate PD in a prevalent national sample of elderly U.S. Medicare beneficiaries with a PD diagnosis. Analyzing 100% fee-for-service Medicare claims from 2013, we defined advanced PD with a medication-based algorithm and calculated all-cause and PD-related costs for the overall sample and by disease severity. We measured primary PD-related costs (based on claims with a primary diagnosis of PD) and any PD-related costs (based on claims with PD in any diagnostic field). Generalized linear models were used to estimate risk-adjusted mean cost differences between the advanced and mild/moderate PD groups for the calendar year. The final sample (N = 144,703) had mean observed all-cause, primary PD-related, and any PD-related costs of $23,041 (SD, $34,045), $3429 (SD, $7431), and $9924 (SD, $22,140), respectively. Twenty percent of patients were classified as advanced PD. Costs varied substantially; any PD-related mean costs were $483 for the lowest patient decile (which included 1% of the advanced group) and $48,145 for the highest decile (which included 15% of the advanced group). Incremental risk-adjusted costs of advanced PD were $5818 (95% confidence interval [CI]: $5411-$6225) for all-cause costs, $3644 (95% CI: $3484-$3806) for primary PD-related costs, and $6088 (95% CI: $5779-$6398) for any PD-related costs. Elderly Medicare beneficiaries with PD had substantial variation in PD-related costs. Advanced PD was associated with a larger economic burden than mild/moderate PD. © 2020 International Parkinson and Movement Disorder Society.

Management of chronic headache with referral from primary care to direct access to MRI compared with Neurology services: an observational prospective study in London

ObjectivesTo evaluate the cost, accessibility and patient satisfaction implications of two clinical pathways used in the management of chronic headache.InterventionManagement of chronic headache following referral from Primary Care that differed...

S1361 Healthcare Resource Use and Associated Costs in the Three Years Following the Initial Diagnosis of Diabetic or Idiopathic Gastroparesis: A Retrospective Claims Analysis

INTRODUCTION: Diabetic gastroparesis (DG) and idiopathic gastroparesis (IG) are the two most common forms of gastroparesis (GP). Because of the limited treatment options, many patients (pts) have inadequate symptom control which may lead to increased healthcare resource use (HRU). This study aimed to quantify the economic burden in HRU and associated costs of DG/IG in the United States over the 3 years (yrs) after first GP diagnosis (dx). METHODS: Adults newly diagnosed with DG or IG were identified in Optum’s de-identified Clinformatics® Data Mart Database (Q1-2007 to Q1-2019). Pts were continuously enrolled for ≥1 yr before and ≥1 yr after their first GP dx (index date). For controls without GP dx, index dates were randomly selected. Pts with DG/IG were matched 1:1 to controls using a mixed approach of exact matching (i.e., age, sex, complete yrs of follow-up post-index) and propensity score matching (i.e., income, education, index yr, Charlson Comorbidity Index [CCI] comorbidities, diabetic complications [DG only]). All-cause HRU and direct healthcare costs per person-year (PPY) were compared between DG/IG cases and matched controls in the 3 yrs post index date. RESULTS: DG and IG cohorts included 18,015 and 14,305 pts (mean age: 62 and 54 yrs; 34% and 24% males), respectively. DG/IG pts had a high comorbidity burden at baseline (DG: 34% chronic pulmonary disease, 29% renal disease; IG: 28% chronic pulmonary disease). Demographics and CCI comorbidities were balanced between GP pts and controls (Table 1). DG/IG pts had significantly higher annual HRU compared to matched controls in the first 3 yrs post-index, with the highest gap observed in Yr 1 (Figure 1). Healthcare costs were also significantly higher for DG/IG pts vs. controls across all 3 yrs post-index (mean total cost differences PPY: DG Yr 1 $34,885, Yr 2 $28,071, Yr 3 $25,606; IG Yr 1 $23,176, Yr 2 $16,627, Yr 3 $14,396; see Figure 2 for Yr 1 cost breakdown by service setting). Patterns of disease burden did not change in a sensitivity analysis with additional adjustment for conditions associated with GP (e.g., anemia, anxiety disorder). CONCLUSION: This study showed a substantial economic burden of both DG and IG among adults, highest in the first yr after dx and persistent over 3 yrs. In the first yr after dx, DG and IG pts had healthcare costs approximately two-fold higher than for the matched controls, emphasizing the need for more effective treatments that may reduce the burden of illness.Table 1Figure 1Figure 2

Outpatient Cost-effectiveness Study of Hyperkalemia Management

Introduction Patiromer (PAT) is a sodium free, non-absorbed potassium (K+) binder approved for the treatment of hyperkalemia (HK). There is limited real-world evidence on the outpatient cost implications associated with PAT treatment of HK. Hypothesis To assess the cost-effectiveness of treating HK with PAT vs. no K+ binder in a Medicare Advantage population. Methods This retrospective, matched cohort study was conducted using Optum's de-identified Clinformatics® Data Mart Database from 1/1/16-12/31/18. Two HK cohorts were identified: PAT exposed/unexposed (NoPAT). Inclusion criteria included pre-index serum K+ ≥5.0 mEq/L, HK diagnosis (ICD-10 code) and ≥6 months insurance enrollment post-index. Propensity score matching and coarsened exact matching with baseline variables were used to identify the complete set of matching unexposed and exposed HK episodes. Follow-up began on the index date and ended at the first censoring event (insurance disenrollment, death, 12/31/18, sodium polystyrene sulfonate [SPS] or sodium zirconium cyclosilicate [SZC] initiation, PAT discontinuation [exposed only], PAT initiation [unexposed only]). A zero-inflated negative binomial regression model was performed on the outcomes. Outpatient outcomes were defined as any costs not identified as inpatient, ED or pharmacy. Outpatient cost outcomes were measured at 6 months post-index (mean US$ [CI 95%]). Results The study population included 2004 patients (1002 matched pairs), the mean age was 74 years and 60% were male. Patients had a mean of 5 comorbidities, most commonly diabetes mellitus (73%), congestive HF (35%), and end-stage renal disease (10%). At 6 months post-index, 300 (150 matched pairs) PAT and NoPAT patients remained uncensored and, of those, 299 had non-zero outpatient costs evaluated; total PAT outpatient mean cost difference (savings) was $4828 ($2205, $5833; P ≤0.004) for PAT vs. NoPAT patients. ConclusionS In a matched-cohort design of individuals with hyperkalemia covered with Medicare Advantage, patiromer usage was associated with a 35% reduction in outpatient costs over a 6-month period compared to those that were not treated with patiromer. Further study is warranted to replicate these findings in a large cohort.

The long-term costs and effects of tubal flushing with oil-based versus water-based contrast during hysterosalpingography

Research questionWhat are the long-term costs and effects of oil- versus water-based contrast in infertile women undergoing hysterosalpingography (HSG)? DesignThis economic evaluation of a long-term follow-up of a multicentre randomized controlled trial involved 1119 infertile women randomized to HSG with oil- (n = 557) or water-based contrast (n = 562) in the Netherlands. ResultsIn the oil-based contrast group, 39.8% of women needed no other treatment, 34.6% underwent intrauterine insemination (IUI) and 25.6% had IVF/intracytoplasmic sperm injection (ICSI) in the 5 years following HSG. In the water-based contrast group, 35.0% of women had no other treatment, 34.2% had IUI and 30.8% had IVF/ICSI in the 5 years following HSG (P = 0.113). After 5 years of follow-up, HSG using oil-based contrast resulted in equivalent costs (mean cost difference –€144; 95% confidence interval [CI] –€579 to +€290; P = 0.515) for a 5% increase in the cumulative ongoing pregnancy rate compared with HSG using water-based contrast (80% compared with 75%, Relative Risk (RR) 1.07; 95% CI 1.00–1.14). Similarly, HSG with oil-based contrast resulted in equivalent costs (mean cost difference –€50; 95% CI –€576 to +€475; P = 0.850) for a 7.5% increase in the cumulative live birth rate compared with HSG with water-based contrast (74.8% compared with 67.3%, RR 1.11; 95% CI 1.03–1.20), making it the dominant strategy. Scenario analyses suggest that the oil-based contrast medium is the dominant strategy up to a price difference of €300. ConclusionOver a 5-year follow-up, HSG with an oil-based contrast was associated with a 5% increase in ongoing pregnancy rate, a 7.5% increase in live birth rate and similar costs to HSG with water-based contrast.

12. Health care costs and characteristics of spinal fusion patients receiving concentrated bone marrow aspirate (BMAC), iliac crest autograft or bone morphogenic protein (BMP) therapy: a retrospective cohort study utilizing administrative claims

BACKGROUND CONTEXT To aid in fusion, surgeons may choose to use a biologic or other grafting agent in posterior lumbar spinal fusion procedures. This study explored the differences in cost and a variety of outcomes of bone marrow aspirate concentrate (BMAC), iliac crest autogenous bone grafting (autograft) and recombinant human bone morphogenetic proteins (rhBMP) -2 and -7. Autograft complications include pain, risk of infection and donor morbidity. BMP drawbacks are high cost and at risk of stimulating too much bone growth. While BMAC has been shown to promote bone and soft tissue healing, possible risks include bleeding and infection or nerve damage. PURPOSE A market assessment was conducted to explore the clinical value of each product. The study also looked at patient demographics, outcomes, and cost across the grafting products. STUDY DESIGN/SETTING Retrospective administrative claims data from the Optum Commercial and Medicare Advantage affiliated claims dataset between January 1, 2016 and December 31, 2017. PATIENT SAMPLE The final study cohort consisted of 14,668 patients (BMAC: n=3,181; autograft: n=11,085; BMP: n=402) in the US. 84.5% (n=12,683) of patients had only 1 index procedure product and 97.2% (n=14,251) had a successful fusion. The majority of patients were aged 65+ (n=7,581 /52%), female (n=8,122 /55%), and received Medicare coverage (n=8,639 /59%). OUTCOME MEASURES Data on select patient demographic and clinical characteristic measures were collected, including Charlson Comorbidity Index (CCI) score and top AHRQ comorbidities. Inpatient and outpatient hospital costs, length of stay (LOS) and mean standardized cost per patient by procedure were among the data collected to drive the cost analysis. METHODS Patients with >= 1 a CPT code for a procedure of interest for autograft or BMAC or an ICD-10-PCS code for BMP of interest were identified during the study time period. Patients were indexed at admission date of MS-DRG involving first observed instance of a procedure of interest and required to have 6 months pre-and 12 months post-index continuous medical and pharmacy coverage. Data were analyzed using descriptive statistics. The mean differences in costs were assessed using Student's t-test for statistical significance. RESULTS The average length of stay (BMAC=3.6 days; autograft=3.8 days; BMP=4.3 days [p-value: BMAC vs autograft= CONCLUSIONS Data from this study showcases the cost savings and potential impact on health outcomes which can be incurred through the implementation of BMAC as a biologic in treating spine fusion patients. Given the rising cost of spinal fusion procedures performed annually in the US, further research should focus on evaluating the cost-effectiveness of the various procedures. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Clinical Utility and Cost of Inpatient Transthoracic Echocardiography Following Acute Ischemic Stroke.

It is unclear whether it is clinically necessary or cost-effective to routinely obtain a transthoracic echocardiogram (TTE) during inpatient admission for ischemic stroke. We assessed consecutive patients presenting with acute ischemic stroke at a comprehensive stroke center from 2015 to 2017 who underwent TTE. We assessed for findings on TTE that would warrant urgent intervention including cardiac thrombus, atrial myxoma, mitral stenosis, valve vegetation, valve dysfunction requiring surgery, and low ejection fraction. Subsequent changes in management included changes in anticoagulation, antibiotics, or valve surgery. We calculated in-hospital resource utilization and associated costs for inpatient TTE using individual direct cost details within a case-costing system. Of 695 patients admitted with acute ischemic stroke, 516 (74%) had a TTE and were included in our analysis. TTE findings were potentially clinically significant in 30 patients (5.8%) and changed management in 17 patients (3.3%). Inpatient admission was prolonged to expedite TTE in 24 patients, while TTE occurred after discharge in 76 patients. After correcting for the cost of TTE, the mean difference in cost to prolong an admission for TTE was $555.52 (USD), or $16 832 per change in management. Given the low clinical utility of inpatient TTE after acute ischemic stroke and the costs associated with prolonging admission, discharge from hospital should not be delayed solely to obtain TTE.