Greater Healthcare Costs Research Articles

Adapting Physical Activity Interventions to Prevent Obesity in Culturally Diverse Populations

As the United States debates major health reform issues, reversing the obesity epidemic needs to be at the forefront of the discussion. The serious health and economic implications associated with obesity threaten our workforce and burden our health care system. An estimated $117 billion is spent each year to cover the medical and indirect costs of obesity, including lost productivity. The direct health care costs of childhood obesity alone are estimated at $14 billion annually. If we fail to change the policies and environments that contribute to this epidemic, our next generation can expect even higher rates of obesity, greater health care costs, and a health care system less capable of meeting its needs. In the United States, two-thirds of adults and nearly onethird of our youth are overweight or obese. And while the prevalence of obesity has increased in all segments of our population, rates are significantly higher among AfricanAmericans, Native Americans, and Latinos. Research shows that many lower-income, culturally diverse communities have limited access to safe places to walk, bike, and play and that residents have poorer health outcomes. Physical inactivity is a major contributor to the development of obesity, and there is a great need to promote physical activity and support other healthy choices among the populations who are at greatest risk. Thus, efforts to combat obesity must test and implement economically feasible solutions that address the specific needs of these most vulnerable populations. By sharing results about what’s working to promote healthy changes in these populations, we can more rapidly establish the best practices that can inform action in communities across the country. Over the past few decades, we have learned that interventions designed solely to promote positive attitudes and increase health knowledge are insufficient to achieve longterm or sustainable behavior change. The socio-ecological model for behavior change suggests that effective community interventions must include environmental and policy solutions as key components if children and families are going to adopt healthy lifestyles. We cannot expect adults or kids to get regular physical activity or maintain a nutritious diet if they do not have convenient access to safe places to be active and affordable healthy foods. This commentary and the commentary by Kumanyika and Yancey focus on two systematic reviews of physical activity interventions: one conducted in African-American populations by Whitt-Glover and Kumanyika and one conducted in Native American populations by Teufel-Shone et al. These papers were commissioned by the Robert Wood Johnson Foundation (RWJF) to address the lack of published information concerning effective interventions that focus on physical inactivity and obesity among these populations. The literature reviews also examine how physical activity interventions can best be adapted to the cultural needs and values of each population; explore the impact of such interventions on obesity; and offer recommendations for future research. Both reviews show that there have been relatively few highquality studies within each target population. Furthermore, of the interventions that were implemented in either AfricanAmerican or Native American populations, there appeared to be little evidence of systematically adapting the original intervention to the cultural needs, values, and resources of the population studied. Addressing the policy and environmental factors that support sustainable long-term behavior changes was a challenge for all of the interventions, regardless of the specific population that was targeted. Initial findings from the literature reviews were presented at a 2-day meeting, Equal Rights to Health—Moving Forward Together, which was sponsored by RWJF in December 2003. Dr David Satcher, former United States Surgeon General, chaired the meeting, where representatives from research, practice, and media shared ideas and developed recommendations for preventing childhood obesity in the most affected communities. More than 50 experts who had worked with African-American, Latino, Native American, and rural populations participated in discussions about community-based programs, the evidence base regarding culturally diverse interventions, and the role of the media and communications in preventing childhood obesity. During the meeting, discussions revealed that many interventions designed to address obesity had not been widely translated into ‘‘real-world’’ practice, and had not been rigorously applied to culturally diverse populations that are most at risk for obesity. In some cases, the research-based programs were moderately effective, but communities lacked the resources required to implement and sustain the interventions. Many community organizations were unaware Copyright E 2009 by American Journal of Health Promotion, Inc. 0890-1171/09/$5.00 + 0 Terry L. Bazzarre, PhD, recently retired from his position as senior program officer at the Robert Wood Johnson Foundation (RWJF). While at RWJF, he oversaw the Foundation’s support for the literature reviews and Equal Rights to Health meeting described in this commentary.

LATE Preterm Birth

Late preterm infants are those born between 34 and 36 6/7 completed weeks' gestation. In the last decade, late preterm infants have become the fastest growing subset of preterm infants and now account for 74% of all preterm births. They are at greater risk for feeding problems, dehydration, hypothermia, jaundice, and hypoglycemia and are more likely to be readmitted to the hospital in the first weeks after birth and accrue greater healthcare costs as a result. Despite the alarming growth of this population and the acknowledgment of increased risk in the literature, there is limited information available to the clinical nurse and few evidence-based guidelines to direct the care of these infants specifically. This article describes what is known to date about this issue and what nurses need to do to appropriately care for late preterm infants.

The pharmacology of oversedation in mechanically ventilated adults

To review pharmacological-related factors that affect the incidence of oversedation in mechanically ventilated adults. Recent epidemiologic studies have identified a high frequency of oversedation in the ICU that is attributable, in part, to a number of pharmacokinetic, pharmacogenetic, and pharmacodynamic factors. New evidence suggests that the administration of benzodiazepines, even when dosed intermittently, will lead to more oversedation than either propofol or dexmedetomidine and is associated with greater healthcare costs. Based on this data, clinicians should limit the use of benzodiazepines to those patients with anxiety, seizures, alcohol withdrawal, or in whom a deeper level of sedation or therapeutic paralysis is required. Recognition of these new advances will help liberate patients from mechanical ventilation sooner, without compromising patient comfort.

The importance of distant metastases in hormone-sensitive breast cancer

Breast cancer is a leading cause of cancer death in women worldwide. Survival from breast cancer is improving, but distant metastases remain the most common type of breast cancer recurrence, resulting in more than 40,000 deaths per year in the USA alone. Distant metastases are associated with the poorest outcomes when compared with loco-regional or contralateral recurrences and are also associated with greater health care costs and diminished quality of life. The risk of distant metastases increases with larger primary tumor size, lymph node positive cancer, higher tumor grade, and prior loco-regional recurrence. Yet, even patients with minimal risk factors may develop distant metastases. Thus, reducing the development of such relapses is an important goal in adjuvant therapy. As the development of distant metastases has been consistently associated with eventual mortality from breast cancer, a reduction in distant metastases may serve as a better surrogate marker for overall survival and provide earlier results from clinical trials testing new types of adjuvant therapy.

Healthcare Costs and Clinical Sequelae Associated with Constipation in a Managed Care Population

Purpose: In addition to a high cost burden, patients with constipation are likely to suffer from a high incidence of gastrointestinal (GI)-related clinical sequelae. We examine changes in health care costs and sequelae in patients with constipation before and after initial diagnosis compared to matched controls. Methods: The i3 Innovus LabRx database was retrospectively analyzed. Patients diagnosed with constipation (ICD-9 564.0×) between 1/1/03 and 12/31/05 were identified (N = 48,585) and demographically matched in a 1:2 ratio with controls (N = 97,170). An index date for the constipation group was defined as the date 3 months prior to the first observed constipation diagnosis. For controls, the index date corresponded to that of their respective match in the constipation group. Per patient charges for medical services and prescriptions, and rates of GI-related sequelae were assessed over 12 months prior to and following the index date. Results: Total health care charges per patient with constipation were $9,305 pre-index compared to $17,799 in the post-index period (+$8,494; P < 0.0001). Total charges for controls were $5,967 pre-index and $7,151 post-index (+$1,183; P < 0.0001). After controlling for comorbidities, prevalence of cancer, opioid use, and Charlson Score between the pre- and post-index periods via linear regression, total charges per patient with constipation remained substantially higher (+$3,664; P < 0.0001) post-index vs. pre-index. Charges for controls remained $701 higher post-index (P < 0.0001). Logistic regression showed that patients with constipation had a substantially and significantly (P < 0.0001) greater likelihood of intestinal impaction (odds ratio [OR]= 6.6), anal fissures (OR = 5.0), hemorrhoids (OR = 4.2), volvulus (OR = 10.3), intestinal obstruction (OR = 4.1), and rectal ulcers (OR = 4.8) during the post-index period compared to pre-index. Overall, patients with constipation were 4.5 times more likely to have any clinical sequelae post-index (OR = 4.5; P < 0.0001), while no significant change was found among controls. Conclusion: Persons with constipation have greater health care costs and GI-related sequelae post-index period compared to pre-index. Demographically similar patients without constipation have a lower prevalence of these sequelae with no pre- to post-index change. Increased prevalence of these sequelae may contribute to the total cost burden of constipation. Current standards of care may not be sufficient to reduce this burden.

Impact of Crohnʼs Disease Severity on Healthcare Costs and Utilization

Purpose: We quantified the impact of disease severity on healthcare utilization and cost in patients (pts) with Crohn's disease (CD) compared with nonCD controls.Table: Annualized Mean healthcare Utilization and CostsMethods: Patients from PharMetrics, a US claims database (Jan 2000–June 2005), were included with ≥3 distinct claims with a CD diagnosis or ≥2 claims including ≥1 diagnosis by a gastroenterologist. Cases were matched (1:1) to controls by age, gender, region, enrollment year, length of enrollment, and health plan. A treatment algorithm defined disease severity as: remission (R); mild disease (M); severe disease drug-responsive (SDRS); severe disease drug-dependent (SDD); severe disease drug-refractory (SDRF). Differences in annualized utilization (mean number of outpatient care visits, gastrointestinal [GI] procedures, and hospitalizations per 100 pt-years) and payor-related costs (2005 US$/pt-year) were analyzed using Wilcoxon signed-rank tests. Results: The analysis included 2972 pts with CD (54% female). Main drivers for outpatient care were GI procedures and physician visits. Most severe disease required more outpatient care. Hospitalization and GI procedures were the highest costs in the CD group; in the SDRF group, GI procedure costs were substantially higher than for all other severity groups. Conclusion: More severe disease was associated with greater healthcare costs, with hospitalization as the main cost. Regardless of severity, all CD pts had higher utilization and costs compared with controls. Costs were comparatively high in the remission group, indicating a high demand for healthcare services despite no/low medication use. This research was funded by UCB.

A brief pain management program compared with physical therapy for low back pain: Results from an economic analysis alongside a randomized clinical trial

Guidelines for the management of acute low back pain in primary care recommend early intervention to address psychosocial risk factors associated with long-term disability. We assessed the cost utility and cost effectiveness of a brief pain management program (BPM) targeting psychosocial factors compared with physical therapy (PT) for primary care patients with low back pain of <12 weeks' duration. A total of 402 patients were randomly assigned to BPM or PT. We adopted a health care perspective, examining the direct health care costs of low back pain. Outcome measures were quality-adjusted life years (QALYs) and 12-month change scores on the Roland and Morris disability questionnaire. Resource use data related to back pain were collected at 12-month followup. Cost effectiveness was expressed as incremental ratios, with uncertainty assessed using cost-effectiveness planes and acceptability curves. There were no statistically significant differences in mean health care costs or outcomes between treatments. PT had marginally greater effectiveness at 12 months, albeit with greater health care costs (BPM 142 pounds, PT 195 pounds). The incremental cost-per-QALY ratio was 2,362 pounds. If the UK National Health Service were willing to pay 10,000 pound per additional QALY, there is only a 17% chance that BPM provides the best value for money. PT is a cost-effective primary care management strategy for low back pain. However, the absence of a clinically superior treatment program raises the possibility that BPM could provide an additional primary care approach, administered in fewer sessions, allowing patient and doctor preferences to be considered.

The Excess Medical Cost And Health Problems of Family Members of Persons Diagnosed With Alcohol or Drug Problems

Having a family member with substance use problems affects family functioning, which may lead to increased medical problems and increased health care utilization and costs in the other family members. We sought to estimate the excess medical costs and prevalence of diagnosed health conditions of family members of persons with an alcohol or drug diagnosis (AOD) compared with the family members of similar persons without an AOD. Using a large health plan's administrative databases, we identified persons who received an AOD between 2001 and 2004 and a similar group of persons with no AOD during that time. Using a hierarchical linear mixed model, we compared the cost and utilization of the family members of the AOD and non-AOD patients in the 2 years prior to the AOD patient's first AOD. Using logistic regression, we determined whether the family members of patients with AODs were more likely than comparison family members to be diagnosed with medical conditions. Family members of patients with AODs had greater health care costs than comparison family members in the second year before the index date (490 dollars) and in the year before the index date (433 dollars). This was the case for both adult and child family members. They also were more likely to be diagnosed with many medical conditions, especially substance abuse and depression. Family members of patients with AODs have greater health care costs and are more likely to be diagnosed with a number of medical conditions than family members of similar persons without an AOD.

Diversity of bla-type genes in extended-spectrum β-lactamase-producing Klebsiella pneumoniae isolated during 2003 — 2004 at Pretoria Academic Hospital

Multidrug resistance is emerging in many Gram-negative bacteria like Klebsiella pneumoniae, an important cause of nosocomial infections. Increasing production of extended-spectrum beta-lactamases (ESBLs) in this species has become a growing concern, due to associations with longer duration of hospital stay and greater healthcare costs. A few studies have investigated ESBL production in bacterial isolates collected in Africa but only one included K. pnenmoniae. The aim of this study was to determine the prevalence of the s-lactamases TEM, SHV and CTX-M detected in K. pneumoniae isolated from patients with nosocomial infections at Pretoria Academic Hospital. Fifty K. pneumoniae isolates obtained from blood cultures reported to be resistant to one or more oxyimino-cephalosporins were examined Detection of sequences coding for blaTEM'blaSHVand blaCTX-M were performed wuth genomic DNA extracted from all isolates. Polymerase chain reaction (PCR) amplification of target DNA was performed and the resulting gel-el...

The Economic Implications of Glaucoma

Glaucoma is a common ophthalmic condition, often associated with elevated intraocular pressure (IOP). It affects >2 million people in the US, and the incidence is expected to exceed 3 million by 2020. However, relatively little is known about the cost of glaucoma compared with costs for other eye conditions. This comprehensive report reviews published literature on costs and cost effectiveness of treatments for glaucoma. Cost-of-illness studies in glaucoma focus on direct medical costs and generally exclude indirect costs. In general, increased costs are associated with increased severity or lack of control over IOP and the distribution of costs (e.g. medication vs procedures) varies with severity. A large number of studies have evaluated the cost of glaucoma medications, assessing the number of drops per bottle and associated cost per drop or per treatment dose. These studies have limited usefulness as they generally evaluate unit medication costs without including differential effectiveness or adverse effects associated with various therapies, and thus provide only one component of real-world costs for glaucoma. Broader comparative cost studies, mainly adopting a cost-minimisation approach, have evaluated the impact of differing treatments and management strategies on all types of medical care resource utilisation and associated costs, but a variety of metrics for success makes interpretation challenging. Studies have generally found beta2-adrenoceptor antagonists to be associated with greater healthcare costs than newer therapies. Among newer treatments such as prostaglandin analogues, no specific treatment has demonstrated a clear cost advantage over other treatments. A number of studies have modelled hypothetical cohorts of glaucoma patients through courses of therapy, projecting costs, outcomes and cost effectiveness. A majority of these cost-effectiveness models compare one of the newer prostaglandin analogues with older medications or with one another. Existing studies suggest that bimatoprost may be more cost effective than other agents. However, the effectiveness outcomes used in these studies vary, including achieving IOP thresholds, IOP-controlled days, percent reduction in IOP and QALYs. Methods used to determine costs also vary substantially between studies. Future evaluations of the burden of glaucoma need to consider the issues of comparability between, and generalisability of, study results. Differences in methods have created barriers to understanding the cost of glaucoma and comparing costs or cost effectiveness between studies. Furthermore, future studies should also consider direct costs of glaucoma generally not covered by health insurance as well as indirect costs of glaucoma. As new screening technologies for early detection of individuals at elevated risk of glaucoma are now in use, more complete estimates of the cost of glaucoma are critical for issues of resource allocation and health policy.

CHAPTER 3

CHAPTER 3

Utilization of care in haemophilia: a resource-based method for cost analysis from the Haemophilia Utilization Group Study (HUGS).

The Haemophilia Utilization Group Study (HUGS) was created 10 years ago to examine the annual utilization and cost of haemophilia-related healthcare services. Retrospective chart reviews for 336 patients with haemophilia A receiving treatment in one of five comprehensive haemophilia treatment centres (HTCs) during 1995 were completed through interview of the provider. This method provided adequate collection of data from patient charts without the abstractor having direct access to patient health information. Utilization data were used to impute the costs of different components of care (e.g. physician visits, factor VIII concentrate, emergency room, hospitalization). The total annual cost of care was 139,102 dollars (SD $304,033). Factor VIII concentrate costs comprised the largest proportion of these costs; mean factor VIII concentrate use was 128,517 units per patient per year. Unbilled physician utilization accounted for 7.8% of the mean total physician costs per annum, while mean allied healthcare costs accounted for 33.5% of the total annual allied healthcare costs per patient. In the ordinary least-squares regression model, higher costs were associated with severe factor VIII deficiency, arthropathy, more comorbid conditions, an inhibitor to factor VIII concentrate, infusing through a port and prophylaxis. Although factor VIII concentrate is the most costly component, the treatment of haemophilia uses many healthcare resources. HUGS has demonstrated that patient clinical characteristics and physician practices predominantly drive the costs of haemophilia care. Specifically, patients with more severe arthropathy had greater healthcare costs. As future funding decisions are made, it is important to provide for all components of care.

Determinants of delayed nephrologist referral in patients with chronic kidney disease

Late referral to nephrologists of patients with chronic kidney disease (CKD) is a major public health problem because it is prevalent and associated with increased morbidity, mortality, and greater healthcare costs. To identify factors associated with delayed nephrologist referral (first nephrologist visit < 90 days before the onset of renal replacement therapy), we identified a cohort of patients with preexisting CKD that progressed to end-stage renal failure. We developed a logistic regression model to measure the association of specific demographic and clinical covariates with delayed nephrologist referral. Delayed referral was highly associated with older age (P < 0.001), race other than white or black (P = 0.002), and the absence of certain comorbidities: hypertension (P < 0.001), coronary artery disease (P < 0.001), malignancy (P = 0.005), and diabetes (P = 0.02). Associations of late referral with male sex (P = 0.07) and lower socioeconomic status (P = 0.09) were of borderline significance. Patients who were predominantly cared for by a general internist were more likely to be referred late to a nephrologist compared with those cared for by a family or primary care practitioner (P = 0.002) or another subspecialist (P = 0.019). These findings suggest that several factors increase the risk that patients with CKD will have the first nephrologist consultation excessively late in the course of their disease. Although timely access to nephrologist services is important for all patients with advanced CKD, this is of particular concern in older patients, those in certain minority populations, and those in whom the absence of comorbidity may provide a false sense of true risk status. © 2001 by the National Kidney Foundation, Inc.

A Guide for Assessing Caregiver Needs: Determining a Health History Database for Family Caregivers

The complex issue of combining caregiving and employment requires an awareness on the part of primary care providers of the health and social impact these responsibilities have on clients. Failure to consider the psychosocial and health-related consequences of caregiving for individuals with dual roles could result in greater health care costs, jeopardize the health of the caregiver, and place the care recipient at risk of institutionalization. The purpose of this article is to offer a guide that can be used as part of a comprehensive health history to assess the caregiving situation and provide a database on which to establish a plan of action. The caregiver assessment guide can be inserted in the client's health record and periodically reviewed during primary care visits.

Resolved: that a fifth year of dental education be a requirement. Remarks for the negative

Those representing the affirmative side of the issue have failed to provide convincing evidence supporting the necessity of a required fifth year of dental education. The mechanism is already in place for additional education and experience through expanding general practice residency programs for students desiring additional experience. A required fifth year would increase the cost of dental education for all students at a time of diminishing resources and would undoubtedly result in greater health care costs for the public. The overcrowded curriculum can be addressed successfully and far more economically by restructuring the present predental/dental curriculum continuum instead of adding a required fifth year. In conclusion, the negative side asserts that there are more practical, less expensive, and more feasible ways to address the issues confronting dental education today than by adding a mandatory year to the education process.