Cost Disparity Research Articles

Measuring Disparities in Cost and Spending across Connecticut School Districts

Despite multiple court cases and repeated efforts at reform, there are still significant concerns about the equity and the adequacy in Connecticut’s public K–12 education funding. One vital component of any attempt to reform education finance is a methodologically rigorous evaluation of what it would cost school districts across the state to achieve target performance standards given their student characteristics. This report addresses that need, evaluating the equity and the adequacy of school spending in Connecticut based on education costs. Different from actual school expenditure, a district’s education cost is an estimation based on its cost factors that are outside the direct control of local officials at any given point in time; efficiency levels are held constant across school districts in the estimation. This report finds large disparities in education costs due to differences among school districts in cost factors. It also finds that, despite existing state aid programs, disparities in cost-adjusted spending across the state remain large. Spending in some districts is well below the levels needed to achieve common performance goals. Among the specific findings of this report is that in the last year for which data were analyzed, the average costs of school districts with the lowest socioeconomic status and highest level of student need were 62 percent greater than those of districts with the highest socioeconomic status and the lowest level of student need. When this report holds every district’s efficiency at the statewide average level, it finds that more than half of Connecticut’s public school students attended districts where spending was insufficient to meet the “predicted costs” to achieve the statewide average student test performance level. A direct, negative consequence of spending inadequacy is student underperformance relative to the common student performance target. This report recommends that the state consider adopting the cost measure as the basis of a new, scientifically grounded, equitable, and adequate formula that allocates more state aid to districts with higher costs. It also suggests that many districts need to increase their spending to meet their predicted costs and close the gap between student performance and the common goal. The exact amount of the additional spending needed partly depends on the state’s choices for the student performance target and the common level of district efficiency. For example, this report estimates that in the last year analyzed, with district efficiency held at the statewide average level, an additional $940 million, or an increase of 12.3 percent from statewide public K–12 school spending, would have been needed to fully fund the predicted costs required to achieve the statewide average student test performance level in every district. While the state and local governments now face great fiscal difficulties induced by the COVID-19 pandemic, they should remain committed to the investment in public education, because it will affect Connecticut’s economic growth in the long run.

Study of social disparities in pediatric laparoscopic appendectomy outcomes and cost.

Purpose:There is an increasing focus on racial and social disparities in health care. There have been several studies that have documented disparities in outcome between racial groups in the adult literature. Not much is known about disparities in outcomes after surgical procedures in children. The purpose of this study was to investigate the effect of race on complications (outcomes) and costs after laparoscopic appendectomy.Methods:This study is a single-center retrospective chart review of 248 pediatric patients who underwent appendectomies for uncomplicated acute appendicitis from 2015 to 2017. Patients were divided into minority (Africa American or Hispanic) and non-minority groups, and length of stay, preoperative and postoperative factors, and total costs were compared.Results:Of 185 eligible patients, 45.9% (n = 85) were of Hispanic or African American ethnicity and 54.1% (n = 100) were Caucasian. About 11.8% of minority patients had comorbidities and 12% of majority patients had comorbidities (p = 1). Readmission rate for minority group patients was 3.5% (n = 3) and 2% (n = 2) for majority patients (p = 0.7). The average cost of hospital stay for minority patients was $30,900 and for majority patients was $31,111 (p = 0.59).Conclusions:Standardization of care protocols has reduced social/racial disparities in surgical outcomes. In the most common pediatric surgery emergency procedure, laparoscopic appendectomy, there were no differences in outcomes or costs between minority (Hispanic/Africa American) and Caucasian ethnic groups.Level of evidence:Level IIIType of study:Clinical Study

The issue of school privatisation in Côte d'Ivoire

The Ivorian state has been involved in the construction of public schools given their importance for development. Since the 1980s, there has been a reduction in funding linked to the economic crisis and structural adjustment programmes. Thus, by a convention the State will concede the public service of education to the private sector.
 The results of this research on the conditions of access to private schools in the Abidjan district were analysed through a cross-sectional study with descriptive and analytical aims. This has led to disparities in costs between municipalities. 40,000 FCFA for minima and 1, 922,000 FCFA for maxima, a multiplication order of 48. In secondary school, the minimum is 43,000 FCFA and the maximum is 2, 706,000 FCFA, a multiplication order of 63. In higher education there are less disparities.
 In total, there are many differences in the costs of schooling from one school to another. While the public-private partnership has encouraged more children to attend school, it has also created a challenge to access because of the expensive costs of attending school.

Do safety-net hospitals provide equitable care after decompressive surgery for acute cauda equina syndrome?

IntroductionSafety-net hospitals provide care to a substantial share of disadvantaged patient populations. Whether disparities exist between safety-net hospitals and their counterparts in performing emergent neurosurgical procedures has not yet been examined. ObjectiveWe used the Nationwide Inpatient Sample (NIS), a national all-payer inpatient healthcare database, to determine whether safety-net hospitals provide equitable care after decompressive surgery for acute cauda equina syndrome (CES). MethodsThe NIS from 2002 to 2011 was queried for patients with a diagnosis of acute CES who received decompressive surgery. Hospital safety-net burden was designated as low (LBH), medium (MBH), or high (HBH) based on the proportion of inpatient admissions that were billed as Medicaid, self-pay, or charity care. Etiologies of CES were classified as degenerative, neoplastic, trauma, and infectious. Significance was defined at p < 0.01. ResultsA total of 5607 admissions were included in this analysis. HBHs were more likely than LBHs to treat patients who were Black, Hispanic, on Medicaid, or had a traumatic CES etiology (p < 0.001). After adjusting for patient, hospital, and clinical factors treatment at an HBH was not associated with greater inpatient adverse events (p = 0.611) or LOS (p = 0.082), but was associated with greater inflation-adjusted admission cost (p = 0.001). DiscussionEmergent decompressive surgery for CES performed at SNHs is associated with greater inpatient costs, but not greater inpatient adverse events or LOS. Differences in workflows at SNHs may be the drivers of these disparities in cost and warrant further investigation.

Social inequality in the homeschooling efforts of German high school students during a school closing period

ABSTRACT School closings have been a key policy measure worldwide for reducing the spread of corona-virus disease (COVID-19). In Germany, federal states closed schools in mid-March and started to reopen them in late April. This policy potentially increased parental obligations for supervision and support during homeschooling and, thus, might reinforce social inequality in educational opportunities. Therefore, this research note investigates social inequality in students’ homeschooling efforts. Moreover, it asks whether social disparities in home learning environments, social support, teacher support, and cost–benefit-related considerations account for the social differences in homeschooling efforts during the school closing period in Germany. To that end, we use data from an ongoing research project on high school students in their final years that were collected during the school closing period. Our results show pronounced differences in home schooling efforts by social background. Thus far, the mechanisms under study can explain only a moderate part of the social origin effect. In summary, the results show that school closings have the potential to exacerbate social inequality in educational opportunities. Therefore, future research should scrutinise the extent to which school closings reinforce inequality in educational opportunities.

INA-CBGs claim versus total hospital cost: A vaginal delivery investigation at Airlangga University Academic Hospital, Indonesia.

Background: Inadequate funding for vaginal delivery can be one of the barriers to reducing the maternal mortality rate. It could be therefore critical to compare the vaginal delivery cost between total hospital cost and INA-CBGs cost in national health insurance.Methods: This was a retrospective cross-sectional study conducted from October to December 2019 in Universitas Airlangga Academic Hospital. It collected data on primary diagnosis, length of stay, total hospital cost, INA-CBGs cost, and counted disparity. The data analyzed statistically using t-test independent sample (or Mann-Whitney test).Results: A total of 149 vaginal delivery claims were found, with the majority having a level II severity (79.87%) and moderate preeclampsia as a primary diagnosis (20.1%). There was a significant disparity in higher total hospital costs compared with government INA-CBGs costs (Rp. 9,238,022.09±1,265,801.88 vs 1,881,521.48±12,830.15; p<0.001). There was also an increase of LOS (p<0.001), total hospital cost (p<0.001), and cost disparity (p<0.01) in a higher severity level of vaginal delivery.Conclusion: Vaginal delivery costs in INA-CBGs scheme are underneath the actuarial value. There was also an increase in total hospital costs and a more significant disparity in the higher severity levels of vaginal delivery.Significance for public healthThe inadequate availability of funds for childbirth can be one of the administrative constraints that are directly or indirectly related to efforts to reduce maternal mortality. This study will give references to government, stakeholder, and researchers to highlight the urgency of vaginal delivery cost in a country.

Sources of regional and center-level variability in survival and cost of care for congenital diaphragmatic hernia (CDH)

PurposeEnormous variability in management and cost occurs in CDH care. The purpose of this study was to identify regional mortality and cost patterns underlying this variability. MethodsThis is a retrospective study of neonatal CDH patients at U.S. hospitals using data from the Pediatric Health Information System (PHIS) database (2015–2018). Patients were risk-stratified using CDH Study Group predicted survival (CDHSG-PS), and mortality and costs were assessed by region (East, West, Mid-West, and South) and center. ResultsHigher mortality and extracorporeal life support (ECLS) rates were found in the Mid-West and South (p<0.0001). Higher mortality was seen with ECLS among low-volume centers in the South (p=0.007). When broken down by CHDSG-PS, higher severity patients had higher mortality in the Mid-West and South (p=0.038). Cost was significantly lower for high severity nonsurvivors than survivors ($244,005 vs $565,487, p=0.0008). The East spent more on high-severity patients with lower mortality compared to other regions, but also spent 3.5 times more on low severity nonsurvivors than survivors. Costs were higher at high-volume centers for low- and medium-severity patients, but all centers spent the same on high-severity patients. ConclusionCenter volume, region, and patient severity all contribute to the complex survival and cost disparities that exist in CDH care. Standardization of care may improve survival and reduce cost variability. Type of studyRetrospective database study. Level of evidenceLevel II

Value for money in procurement of urban bus services – Competitive tendering versus negotiated contracts: Recent New Zealand experience

The new Public Transport Operating Model (PTOM) recently introduced by the New Zealand government for local public transport services involves a mix of competitively-tendered and negotiated bus contracts in the main metropolitan areas. Most features of the procurement procedures and almost all the contract terms and conditions are common to both types of contract. This has provided a rare opportunity internationally to compare the impacts of the alternative procurement methods on contract prices.The paper analyses the prices for the tendered and negotiated bus contracts in NZ's two largest metropolitan areas, Auckland (50 contracts, c.1100 buses) and Wellington (16 contracts, c.400 buses). Key findings are that: (i) for the tendered contracts, significant cost reductions were achieved compared with previous tendering rounds, reflecting the considerable increase in the number of bidders per contract; and (ii) for the negotiated contracts, (gross) costs averaged about 10–15% higher (Auckland) and 30–35% higher (Wellington) than the equivalent tendered costs.These cost disparities reflected the weak position of the regional councils in their contract negotiations with the operators, as a result of the councils not having recourse to tendering as a fallback negotiating position and coming under considerable time pressures to introduce the new services.

The U.S.–China trade imbalance and the theory of free trade: debunking the currency manipulation argument

ABSTRACT The U.S.–China trade imbalance is commonly attributed to a Chinese policy of currency manipulation. However, empirical studies failed to reach consensus on the RMB misalignment. We argue that this is not a consequence of poor measurement but of theory. At the most abstract level the conventional principle of comparative cost advantage suggests real exchange rates will adjust so as to balance trade. Therefore, the persistence of trade imbalances tends to be interpreted as arising from currency manipulation facilitated by foreign exchange interventions. By way of contrast, the absolute cost theory explains trade imbalances as the outcome of free trade among nations that have unequal real costs. We argue that a disparity in real costs is the root cause of the U.S.–China trade imbalance.

Disparities in inpatient costs and outcomes after elective anterior cervical discectomy and fusion at safety-net hospitals

IntroductionCharacterizing disparities that exist at safety-net hospitals is crucial for crafting national healthcare reform policies. Healthcare disparities in performing elective neurosurgical procedures like anterior cervical discectomy and fusion (ACDF) at safety-net hospitals have not yet been examined. ObjectiveWe use the National Inpatient Sample (NIS), a national all-payer healthcare database of inpatient admissions, to determine whether safety-net hospitals can provide equitable care after elective ACDF. MethodsThe NIS from 2002 to 2011 was queried for patients who received ACDF in the context of degenerative spine disease. Hospital safety-net burden was designated as low (LBH), medium (MBH), or high (HBH) based on the proportion of inpatient admissions that were billed as Medicaid, self-pay, or charity care. Significance was set at p < 0.001. ResultsA total of 219,433 admissions were included in this analysis. HBHs were more likely than LBHs to treat patients who were Black, Hispanic, on Medicaid, or had myelopathy (p < 0.001). After adjusting for patient, hospital, and clinical factors, treatment at an HBH was associated with greater in-patient inflation-adjusted log cost (p < 0.001), but not with greater length of stay (LOS) (p = 0.04) or odds of an inpatient adverse event like death, incidental durotomy, surgical site infections, deep vein thromboses and others (OR 95 % CI = 0.86−1.42, p = 0.43) compared to LBHs. DiscussionSafety net hospitals had greater inpatient costs, but no greater LOS or odds of inpatient adverse events after elective ACDF. These results demonstrate a need for policies that reduce the cost of performing ACDFs at SNHs.

Value of Anti–Vascular Endothelial Growth Factor Gene Therapy for Neovascular Age-Related Macular Degeneration

To use discounted cash flow (DCF) analysis to estimate the value creation associated with anti-vascular endothelial growth factor (VEGF) genetic therapy for neovascular age-related macular degeneration (nAMD). Economic analysis. Adults undergoing serial intravitreal anti-VEGF injections in 1 eye for nAMD. Discounted cash flow modeling with scenario analysis was used to derive a present value for a 1-time alternative treatment to lifelong anti-VEGF treatment for nAMD. Multiple sensitivity analyses were performed on the basis of patient age at time of first injection and frequency interval of intravitreal injection. Present values of DCF and scenario analyses. Discounted cash flow analysis of intravitreal anti-VEGF treatment for nAMD resulted in a base-case valuation of $208 420.61,$219 093.31, and $17 379.41 for a 1-time alternative treatment to aflibercept, ranibizumab, and bevacizumab, respectively. This figure covaried significantly with anti-VEGF agent according to the patient age at first injection ($78 323.19-$292 449.87) and frequency of injections ($148 422.91-$388 096.81). In addition, for bevacizumab, variability was driven by the hypothetical degree of clinical superiority of 1-time therapy to repeated intravitreal injections due to reduction in adverse events ($17 379.41-$18 250.79) or reduction in direct or indirect costs associated with age-related macular degeneration ($17 379.41-$657 406.55). Anti-VEGF gene therapy approaches can create significantly different value propositions based on the agent modeled, patient age at first injection, frequency of injections, and clinical profile of the medication. Although the use of aflibercept or ranibizumab as a comparative cost metric is logical from a bioequivalence perspective, the disparity in medication costs should not be the primary value driver in applied models. Instead, bevacizumab should be the base case ($17 379.41), with additional value driven from an improvement in quality of life through clinical superiority. A reduction in direct and indirect costs can be used to approximate the value from maintained visual acuity, which is elaborated in the DCF analysis approach described in this article. This model can serve as a basis for assessing the price ceiling of myriad gene therapy approaches. Given the high present values for these therapeutics, innovative costing and reimbursement mechanisms should be further explored, with contingencies for sustained efficacy.

Racial/Ethnic Disparities in Costs, Length of Stay, and Severity of Severe Maternal Morbidity

Research ObjectiveSimilar to maternal mortality, the United States has experienced increases in the rates of severe maternal morbidity (SMM) and has pronounced racial/ethnic disparities in SMM, with non‐Hispanic Black (NHB) women having twice the rate as non‐Hispanic White (NHW) women. This study further examined these racial/ethnic disparities, looking for differences in costs, lengths of stay (LOS), and severity of SMM.Study DesignSecondary data analysis was performed using the CDC definition of SMM, including readmissions up to 42 days postpartumAUTHOR: Please confirm if the edits made in the sentence ‘Secondary data analysis…up to 42 days postpartum’ convey the intended meaning.. GLM models with a gamma distribution and a log link, with and without hospital fixed‐effects, were used to estimate the effect of SMM on costs and LOS, controlling for race/ethnicity, cesarean delivery, type of insurance, parity, maternal age and BMI, multiple births, and an obstetric severity index.Population StudiedCalifornia linked birth certificate‐patient discharge data for 2009‐2011. About 200 000 were excluded for missing charge data (almost all insured by Kaiser Permanente). Cost‐to‐charge ratios were used to estimate costs (including readmissions) after adjusting for inflation to December 2017 dollars. Mean DRG‐specific reimbursement was used to estimate physician payments. The final N = 1 262 862.Principal FindingsSMM was observed in 1.34% of NHW and 2.62% of NHB. Adjusting for delivery method, among those deliveries with SMM, NHB women also had 38% longer LOS (5.1 vs 3.7 days) and 23% higher average costs per case ($19 507 vs $15 879) compared to NHW women. There were small racial/ethnic differences in the rates for the specific groups of diagnoses in the CDC definition of SMM, but NHB women had higher costs and LOS per case within almost all of these groups. Adjusting for risk, NHB women with SMM had costs that were 22% higher without and 17% higher with hospital fixed‐effects. For LOS, these were 21% and 20%, respectively. These effects were slightly smaller (15% and 12% for costs and 14% and 13% for LOS, respectively) when the different indicators of SMM were controlled for, indicating that NHB women were somewhat more likely to have more serious types of SMM. Asian women experienced added costs that were similar to NHB women in models without hospital fixed‐effects, but these differences were much smaller in the fixed‐effects models.ConclusionsThere are racial/ethnic disparities in the per‐case costs and LOS among patients with SMM. The moderation of these effects for NHB women in the fixed‐effects models indicates that some of the elevated costs and LOS are due to disparate quality of care at hospitals more likely to treat NHB women. This effect is even more pronounced for Asian women.Implications for Policy or PracticeThese results indicate a key policy role for facility‐based improvements and interventions. Additionally, the moderation of overall effects when the type of SMM is controlled for indicates that some of the added costs and LOS for NHB and Asian women are due to a higher prevalence of more serious types of SMM. This individual risk could also be shaped by broader social determinants of health as well as policies. Initiatives to reduce racial disparities in SMM should account for both individual risk (clinical complexity) and structural risk (hospital‐ and system‐level factors).Primary Funding SourceNational Institutes of Health.

Universal Drug Coverage and Socioeconomic Disparities in Health Care Costs Among Persons With Diabetes.

To examine whether neighborhood socioeconomic status (SES) is a predictor of non-drug-related health care costs among Canadian adults with diabetes and, if so, whether SES disparities in costs are reduced after age 65 years, when universal drug coverage commences as an insurable benefit. Administrative health databases were used to examine publicly funded health care expenditures among 698,113 younger (20-64 years) and older (≥65 years) adults with diabetes in Ontario from April 2004 to March 2014. Generalized linear models were constructed to examine relative and absolute differences in health care costs (total and non-drug-related costs) across neighborhood SES quintiles, by age, with adjustment for differences in age, sex, diabetes duration, and comorbidity. Unadjusted costs per person-year in the lowest SES quintile (Q1) versus the highest (Q5) were 39% higher among younger adults ($5,954 vs. $4,270 [Canadian dollars]) but only 9% higher among older adults ($10,917 vs. $9,993). Adjusted non-drug costs (primarily for hospitalizations and physician visits) were $1,569 per person-year higher among younger adults in Q1 vs. Q5 (modeled relative cost difference: 35.7% higher) and $139.3 million per year among all individuals in Q1. Scenarios in which these excess costs per person-year were decreased by ≥10% or matched the relative difference among seniors suggested a potential for savings in the range of $26.0-$128.2 million per year among all lower-SES adults under age 65 years (Q1-Q4). SES is a predictor of diabetes-related health care costs in our setting, more so among adults under age 65 years, a group that lacks universal drug coverage under Ontario's health care system. Non-drug-related health care costs were more than one-third higher in younger, lower-SES adults, translating to >$1 billion more in health care expenditures over 10 years.

Patient outcomes in myeloproliferative neoplasm-related thrombosis: Insights from the National Inpatient Sample

BackgroundPhiladelphia-negative myeloproliferative neoplasms (MPNs) – polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF) – often present with thrombosis. We aimed to determine the inpatient mortality, cost of care, and length-of-stay among individuals with Philadelphia-negative MPNs who had arterial or venous thrombosis associated with admission versus those who were admitted for non-thrombosis-related events. MethodsUsing ICD-10M coding, we identified 7,128,770 patients from the National Inpatient Sample (NIS) database who were hospitalized in 2016. 31,302 patients had a diagnosis of a Philadelphia-negative MPN. Mortality, length-of-stay, and cost of care were compared between patients who had thrombosis included among the top three diagnoses and those who were admitted for other reasons. Chi-squared test for categorical variables and t-test for continuous variables were used to compare baseline characteristics. Final multivariable models were constructed to determine predictors of outcomes. ResultsInpatient mortality was significantly higher among individuals with Philadelphia-negative MPN who had thrombosis associated with admission as compared to those who were hospitalized for other reasons (5.7% versus 3.1%, P < 0.001). Unadjusted cost of care was also significantly higher for patients with thrombosis as compared to those without thrombosis ($25,539.06 versus $19,002.72 USD, respectively, P < 0.001). Length-of-stay was longer among the former group as compared to the latter (8.26 versus 7.95 days, P = 0.0963). However, this finding did not reach statistical significance. ConclusionsHospitalization for MPN-related thrombotic events is associated with excess inpatient mortality and higher cost of care. However, thrombosis has no statistically significant effect on length-of-stay among this population. The underlying causes of mortality and cost disparities among patients with MPN-associated thrombosis warrant further investigation.

Office Cystoscopy Urinary Tract Infection Rate and Cost before and after Implementing New Handling and Storage Practices.

Based on 2010 American Urological Association recommendations our practice transitioned from sterile to high level disinfection flexible cystoscope reprocessing and from sterile to clean handling practices. We examined symptomatic urinary tract infection rate and cost before and after policy implementation. We retrospectively reviewed 30-day outcomes following 1,888 simple cystoscopy encounters that occurred from 2007 to 2010 (sterile, 905) and 2012 to 2015 (high level disinfection, 983) at the Malcom Randall Veterans Affairs Medical Center. We excluded veterans who had recent instrumentation, active or recent urinary tract infection, performed intermittent catheterization, or had complicated cystoscopy (dilation, biopsy etc). Patient/procedural factors and cost were collected and compared between groups. Both cohorts had similar age (mean 68 years), race (Caucasian, 82%), comorbidities (cancer history, 62%; diabetes mellitus, 36%; tobacco use, 24.5%), and cystoscopy procedural indications (cancer surveillance, 50%; hematuria, 34%). Urological complication rate was low between groups (1.43%) with no significant difference in symptomatic urinary tract infection events (0.99% sterile vs 0.51% high level disinfection, p=0.29) or unplanned clinic/emergency department visits (0.66% sterile vs 0.71% high level disinfection, p=0.91). Roughly 95% of the cohorts were given prophylactic antibiotics, most commonly fluoroquinolones (91%). High level disinfection was $82 cheaper per procedure than sterile with most cost disparity stemming from reprocessing. Total savings for our facility by switching to high level disinfection was more than $100,000 annually. In an older, morbid veteran population receiving centralized care and prophylactic antibiotics we found no difference in symptomatic urinary tract infection or unplanned visits between sterile or high level disinfection techniques. However, high level disinfection was associated with a sizable cost savings, improved clinic workflow, and reduced use of personal protective equipment.

Regional and income disparities in cost of living changes: evidence from Egypt

ABSTRACT Inflation has been rising in Egypt since 2007, and reached record levels in 2017. It was more pronounced in rural Egypt and likely hurt the poor proportionately more, since rising food prices were a major factor behind higher prices over this period. Moreover, rising prices, as measured by the Consumer Price Index (CPI), do not accurately measure changes in the cost of living. When inflation is high, people resort to substitution to hedge themselves against a declining standard of living. Regardless of price changes, habit formation and taste changes can also render the fixed basket of the CPI less representative over time. To accurately monitor changes in the cost of attaining a given utility level, I constructed True Cost of Living Indices (TCLI) and used them to examine the regional and income disparities in cost of living changes, and the extent of the bias in the CPI. Results confirmed that cost of living increases were higher in rural regions, and that there were far larger regional disparities in cost of living increases over time using the TCLI. The bias in the CPI was quite substantial, ranging from underestimating the change in cost of living by 1.86 percentage points, to overestimating it by 1.05 percentage points, depending on region. Finally, I found strong evidence that households at the bottom of the expenditure distribution fared much worse. Depending on region, cost of living increases were 2.8 to 4.1 percentage points higher per year for the poorest urban households than for the richest, during the period under study.

Disparities in Emergency Transport of Women with a Preterm Labor Diagnosis in Urban vs Rural Areas in the US.

ObjectiveThis study evaluated patterns of utilization and costs of emergency transport among women with a diagnosis of preterm labor in the US.MethodsThe IBM® Treatment Pathways® tool was used to interrogate a cohort randomly selected from the IBM’s MarketScan® dataset. Differences in costs and utilization patterns were assessed by the type of emergency transport service and geography.ResultsA cohort of 12,995 women between the ages of 16 and 45 met the inclusion criteria. About 1,029 (7.9%) of these women had evidence of emergency transport within a day of the preterm labor diagnosis. In this cohort, the median cost of emergency ground transportation was US$834; air transport had a median cost of US$22,922. Additionally, 3.1% (284) women out of a cohort of 8,728 women ages of 16 and 45 with a diagnosis of false labor required emergency transport within 7 days suggesting that they were discharged too soon.DiscussionThe prevalence of emergency transport for preterm labor in rural areas is significantly higher compared to non-rural areas. In addition, the disproportionate use of air transport in rural areas increases the costs of the preterm labor event. Moreover, disparities in both utilization rates and costs were identified for different parts of the country.

Abstract 315: The Prevalence of Cardiovascular Health Expenditure Disparities in Aging US Adults

Introduction: Cardiovascular disease is a leading cause of mortality among adults in the United States. Chronic diseases, and resultant higher medical expenditures for treatment and prescription medications, have increased steadily alongside cardiovascular disease diagnoses in recent years. Objective: To investigate the increased prevalence of cardiovascular disease diagnoses and possible association with increased medical expenditures in adults 65 or older. The increase in expenditures will be compared to medical costs for adults 64 and younger, based on type of health service utilized. Design, Setting, and Participants: A quantitative, deductive, retrospective cross-sectional study was conducted from January 2011 to December 2015. Data from the household component (medical conditions, socioeconomic and demographic characteristics, healthcare expenditures, and use of medical services) and the medical conditions component were obtained from the Medical Expenditure Panel Survey database and information was extracted for adults ≥ 18 years between 2011 and 2015. Analyses were conducted using binary logistic regression. Results/Findings: Older adults ≥ 65 years with cardiovascular disease incurred higher costs for outpatient (odds ratio 1.235; 95% CI, 1.227, 1.243), inpatient (odds ratio 2.142; 95% CI, 2.124, 2.161), and emergency room expenditures (odds ratio 1.063; 95% CI, 1.047, 1.079) when compared to adults aged 64 and younger. Conclusion and Relevance: Assessing the influences of cost disparities on chronic diseases can help address variations in health care expenditures, and can initiate tailored educational modules and evidence-based practice guidelines that can help older adults. While this study may inform and improve stakeholder collaboration between various components of the United States health care system, it also expresses a greater need for chronic disease prevention education, health care quality improvement and improved patient understanding for a rapidly aging adult population, especially among those with cardiovascular disease experiencing increased medical expenditures.

Racial/ethnic disparities in colorectal cancer treatment utilization and phase-specific costs, 2000-2014.

BackgroundOur study analyzed disparities in utilization and phase-specific costs of care among older colorectal cancer patients in the United States. We also estimated the phase-specific costs by cancer type, stage at diagnosis, and treatment modality.MethodsWe used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify patients aged 66 or older diagnosed with colon or rectal cancer between 2000–2013, with follow-up to death or December 31, 2014. We divided the patient’s experience into separate phases of care: staging or surgery, initial, continuing, and terminal. We calculated total, cancer-attributable, and patient-liability costs. We fit logistic regression models to determine predictors of treatment receipt and fit linear regression models to determine relative costs. All costs are reported in 2019 US dollars.ResultsOur cohort included 90,023 colon cancer patients and 25,581 rectal cancer patients. After controlling for patient and clinical characteristics, Non-Hispanic Blacks were less likely to receive treatment but were more likely to have higher cancer-attributable costs within different phases of care. Overall, in both the colon and rectal cancer cohorts, mean monthly cost estimates were highest in the terminal phase, next highest in the staging phase, decreased in the initial phase, and were lowest in the continuing phase.ConclusionsRacial/ethnic disparities in treatment utilization and costs persist among colorectal cancer patients. Additionally, colorectal cancer costs are substantial and vary widely among stages and treatment modalities. This study provides information regarding cost and treatment disparities that can be used to guide clinical interventions and future resource allocation to reduce colorectal cancer burden.

Geographic Variation in Costs of Transsphenoidal Pituitary Surgery in the United States

Geographic variations in health care costs have been reported for many surgical specialties. In this study, we sought to describe national and regional costs associated with transsphenoidal pituitary surgery (TPS). Data from the Truven-MarketScan 2010-2014 were analyzed. We examined overall total, hospital/facility, physician, and out-of-pocket payments in patients undergoing TPS including technique-specific costs. Mean payments were obtained after risk adjustment for patient-level and system-level confounders and estimated differences across regions. The estimated overall annual burden was $43 million/year in our cohort. The average overall total payment associated with TPS was $35,602.30, hospital/facility payment was $26,980.45, physician payment was $4685.95, and out-of-pocket payment was $2330.78. Overall total and hospital/facility costs were highest in the West and lowest in the South (both P < 0.001), whereas physician reimbursements were highest in the North-east and lowest in the South (P < 0.001). There were no differences in out-of-pocket expenses across regions. On a national level, there were significantly higher overall total and hospital/facility payments associated with endoscopic compared with microscopic procedures (both P<0.001); there were no significant differences in physician payments or out-of-pocket expenses between techniques. There were also significant within-region cost differences in overall total, hospital/facility, and physician payments in both techniques as well as in out-of-pocket expenses associated with microsurgery. There were no significant regional differences in out-of-pocket expenses associated with endoscopic surgery. Our results show significant geographic cost disparities associated with TPS. Understanding factors behind disparate costs is important for developing cost containment strategies.