Greater Medical Costs Research Articles

FACTORS ASSOCIATED WITH THE INCIDENCE OF COGNITIVE IMPAIRMENT IN OLDER COSTA RICAN ADULTS

Abstract Cognitive impairment is a critical global public health problem that contributes to lower quality of life and greater medical costs. Despite the growing number of older adults in Costa Rica, few studies have examined cognitive impairment in this population. We drew data on participants (60 years+) with no cognitive impairment (Score of >=12 on MMSE) from wave 1 of the Costa Rican Longevity and Healthy Aging Study (CRELES; n=2,827). Guided by the diathesis-stress-model, we used logistic regression to determine social and health predictors of cognitive impairment incidence (Score < 12 of on MMSE) 2 years later (wave 2). Incidence of cognitive impairment was 5.8% (95% CI, 5.0-7.0). Formal school education (elementary: OR=0.32; 95% CI, 0.17-0.60; high school or more: OR=0.11; 95% CI, 0.02-0.60) and being married or living as married (OR=0.52; 95% CI, 0.28-0.96) were identified as protective against cognitive impairment. Greater age (OR=1.09; 95% CI, 1.06-1.13), consuming more than 400g of carbohydrates per day (OR=2.20; 95% CI, 1.22-3.91), and more challenges with Instrumental Activities of Daily Living (OR=1.70; 95% CI, 1.23-2.28) increased odds of developing cognitive impairment. Common predictors including biological sex, residential zone, smoking, income, bad health perception, depression, and cortisol (ug/dl) were not associated with the onset of cognitive impairment at wave 2. We consider that contextual (e.g., healthcare infrastructure), cultural factors (e.g., familism), as well as diet may help shape predictors and their effects on cognitive functioning. Researchers and practitioners should collaborate on implementation of culturally appropriate and contextually feasible interventions that address predictors of cognitive impairment.

In-hospital Outcomes and Arrhythmia Burden in Patients with Obstructive Sleep Apnea and Heart Failure with Preserved Ejection Fraction.

Patients with obstructive sleep apnea (OSA) have an increased risk for arrhythmias compared to patients without OSA. However, data quantifying the risk of inpatient complications in patients with heart failure with preserved ejection fraction (HFpEF) are lacking. We sought to compare inpatient outcomes and the occurrence of arrhythmias in patients with HFpEF with and without OSA, respectively. Furthermore, we compared the prevalence of arrhythmias with nocturnal continuous positive airway pressure (CPAP) therapy. We performed a retrospective study using the National Inpatient Sample from 2016–2018 to identify patients with HFpEF with and without OSA. Propensity score matching, adjusting for age, gender, race, hospital characteristics, income, and comorbidities, was used to select matched samples between both groups. From 2016–2018, 127,773 hospitalizations with HFpEF were identified; among these patients, 20% had OSA. Nocturnal CPAP was utilized in 9% of these patients. Patients with OSA had a higher mortality rate, a longer duration of hospitalization, and greater medical costs. In addition, OSA was associated with higher incidence rates of atrial fibrillation, atrial flutter, premature depolarization, sick sinus syndrome, ventricular tachycardia, and atrioventricular block. Nocturnal CPAP was not associated with a lower arrhythmia incidence; however, there was a non-significant trend toward a lower cardiac arrest incidence. In conclusion, OSA in patients with HFpEF was associated with greater mortality, longer hospitalization stays, and higher medical costs relative to findings in patients without OSA. Furthermore, OSA was associated with tachyarrhythmias and bradyarrhythmias in HFpEF patients. Nocturnal CPAP was only utilized in 9% of patients, with no difference in arrhythmogenesis.

Health services utilization and cost of abusive head trauma in Taiwan: A population-based retrospective matched cohort study

BackgroundAbusive head trauma (AHT) is a serious health problem that results the highest mortality among children who are maltreated. Many AHT survivors suffer from long-term sequelae and require medical treatment. However, the knowledge of AHT-attributable health services utilization and costs at national level are limited. ObjectiveTo estimate health services utilization and costs attributable to AHT among children aged 0–4 years in Taiwan. Participants and settingSixty-three fatal and 664 survival AHT cases were identified using Taiwan national population database between 2003 and 2015. A total of 2656 non-AHT children were exactly 4:1 matched to the survival cases based on their birth year, gender, the calendar year of the index date, insured location, and health insurance premium (social economic status indicator). MethodsHealth services utilization and costs were calculated on an annual basis for 3 years after the index date. AHT-attributable health services utilization and costs during 3-year follow-up period was evaluated by regression models. ResultsAHT diagnosis was positively associated with inpatient admissions, length of stay, emergency room (ER) visits, and outpatient visits. AHT-attributable medical costs were 1.64–17.27 times, 1.25–5.22 times, and 1.77–2.36 times greater for inpatient, ER, and outpatient during 3-year period than matched controls, respectively. Fatal AHT cases had higher inpatient utilization and greater medical costs than AHT survivors. ConclusionsChildren with AHT had greater health services utilization and higher costs for years. Strategies to reduce the burden of AHT on health care system are imperative.

Cumulative effect of loneliness and social isolation on health outcomes among older adults

Objectives Loneliness and social isolation are described similarly yet are distinct constructs. Numerous studies have examined each construct separately; however, less effort has been dedicated to exploring the impacts in combination. This study sought to describe the cumulative effects on late-life health outcomes. Method Survey data collected in 2018–2019 of a randomly sampled population of US older adults, age 65+, were utilized (N = 6,994). Survey measures included loneliness and social isolation using the UCLA-3 Loneliness Scale and Social Network Index. Participants were grouped into four categories based on overlap. Groups were lonely only, socially isolated only, both lonely and socially isolated, or neither. Bivariate and adjusted associations were examined. Results Among participants (mean age = 76.5 years), 9.8% (n = 684) were considered lonely only, 20.6% (n = 1,439) socially isolated only, 9.1% (n = 639) both lonely and socially isolated, and 60.5% (n = 4,232) neither. Those considered both lonely and socially isolated were more likely to be older, female, less healthy, depressed, with lower quality of life and greater medical costs in bivariate analyses. In adjusted results, participants who were both lonely and socially isolated had significantly higher rates of ER visits and marginally higher medical costs. Conclusion Results demonstrate cumulative effects of these constructs among older adults. Findings not only fill a gap in research exploring the impacts of loneliness and social isolation later in life, but also confirm the need for approaches targeting older adults who are both lonely and socially isolated. As the COVID-19 pandemic continues, this priority will continue to be urgent for older adults.

Influence of Osteoporosis Following Spine Surgery on Reoperation, Readmission, and Economic Costs: An 8-Year Nationwide Population-Based Study in Korea

To evaluate the relationship between prevalence of osteoporosis and risk factors, medical costs, reoperation, and readmission in patients after spine surgery. Patients >50 years old with thoracic or lumbar spine diseases who underwent spine surgery between 2005 and 2008 were selected from the Korean National Health Insurance Service databases for analysis. There were 147,676 patients selected, who were divided into 2 groups (osteoporosis and non-osteoporosis) and followed for 8 years. Multiple logistic regressions were performed to examine the effect of osteoporosis following spine surgery. Patients with osteoporosis showed significant increases in readmission rates (odds ratio= 1.26, P < 0.001). Osteoporosis was found to be significantly associated with longer hospital stays and increased medical costs regardless of the cause of spine disease. For readmission, there was a 62-day difference in hospitalization time and U.S. dollars $2040 difference in medical costs between the osteoporosis group and non-osteoporosis group. Total medical costs of the osteoporosis group were about U.S. dollars $310 million more than total medical costs of the non-osteoporosis group. Osteoporosis increased the risk of reoperation in fusion surgery, particularly in the first 3 months postoperatively (odds ratio= 1.34, P < 0.001). Osteoporosis was significantly associated with higher readmission rates, longer hospitalization, and greater medical costs during the 8-year follow-up. It also increased the risk of reoperation in fusion surgery. Proper management of osteoporosis is essential before spine surgery, particularly fusion surgery, to help reduce patients' socioeconomic burden and produce more satisfactory surgical outcomes.

The influence of prior opioid use on healthcare utilization and recurrence rates for non-surgical patients seeking initial care for patellofemoral pain.

Prior opioid use can influence outcomes for patients with musculoskeletal disorders. The purpose of this study was to compare downstream medical utilization-based outcomes (costs, visits, recurrent episodes) after an initial diagnosis of patellofemoral pain based on pre-injury utilization of opioids. A total of 85,7880 consecutive patients were followed for a full 12months before and 24months after an initial diagnosis of patellofemoral pain (January 2009 to December 2013). Data were sourced from the Military Health System Data Repository, a single-payer closed government system. Opioid prescription fills were identified, and medical visits and costs were calculated for all knee-related medical care, to include recurrence rates in the 2-year surveillance period. A relatively small number of individuals filled an opioid prescription in the year prior (n = 1746; 2.0%); however, these individuals had almost twice the mean costs of knee-related medical care ($1557 versus %802) and medical visits (8.4 versus 4.0). Patients with prior opioid use were more likely to have at least 1 recurrent episode of knee pain (relative risk 1.58, 95% CI 1.51, 1.65) with a higher mean number of episodes of knee pain (1.5 vs 1.8). The use of opioids with higher risk of misuse or dependency (Schedule II or III) resulted in greater medical costs (for any reason) and recurrent episodes of knee pain compared to the use of opioids in a lower risk category (Schedule IV). Prior opioid utilization was associated with a greater number of recurrent episodes of knee pain and higher downstream medical costs compared with individuals without prior opioid use. For individuals with prior opioid utilization, opioids with higher risk of misuse or dependency (Schedule II or III) resulted in greater medical costs (for any reason) and recurrent episodes compared to the use of lower-risk opioids (Schedule IV). Key Points • Patients with prior opioid use had much greater knee-related medical costs compared to patients without prior opioid use. • Patients with prior opioid use were more likely to have additional episodes of knee pain in the following 2years compared to patients without prior opioid use. • Prior opioid use has predicted higher costs and poor outcomes after surgery, but this is the first study to confirm similar findings in non-surgical patients.

Beta-lactam allergy in the paediatric population.

Beta-lactam allergy is commonly diagnosed in paediatric patients, but over 90% of individuals reporting this allergy are able to tolerate the medications prescribed after evaluation by an allergist. Beta-lactam allergy labels are associated with negative clinical and administrative outcomes, including use of less desirable alternative antibiotics, longer hospitalizations, increasing antibiotic-resistant infections, and greater medical costs. Also, children with true IgE-mediated allergy to penicillin medications are often advised to avoid all beta-lactam antibiotics, including cephalosporins, which is likely unnecessary in greater than 97% of those reporting penicillin allergies. Most patients can be safely treated with penicillin or amoxicillin if they do not have a history compatible with IgE-mediated or systemic, delayed reactions such as Stevens-Johnson syndrome (SJS), serum sickness-like reactions, drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, or acute generalized exanthematous pustulosis (AGEP). Guidance is provided on how to stratify risk of beta-lactam allergy, and on test dosing and monitoring in the outpatient setting for patients deemed low risk. Guidance for patients at higher risk of beta-lactam allergy includes criteria for appropriate referral to allergists and the use of alternative antimicrobials, such as cephalosporins, while awaiting specialist assessment.

Persistence with Basal-Bolus Insulin Therapy in Patients with Type 2 Diabetes Mellitus and Effect on Clinical and Economic Outcomes: A Retrospective Claims Database Study.

Persistence with multiple daily insulin injections (MDI) may be challenging for patients with type 2 diabetes (T2DM). However, limited information is available regarding the effect of persistence with MDI on outcomes. To evaluate persistence with basal and bolus insulin therapy and assess its relationship with clinical and economic outcomes in a real-world setting. This retrospective matched cohort study used 2012-2015 data from multiple U.S. commercial health plans (IBM MarketScan). Patients with T2DM aged 18-64 years with ≥ 2 basal and ≥ 2 bolus insulin claims during a 12-month period were eligible for inclusion if they had 18 months of continuous health plan enrollment (6-month baseline and 12-month post-index). Persistence during 12 months post-index was defined using 2 methods: (a) method 1, ≤ 90-day gaps in both basal and bolus insulin claims and (b) method 2, ≥ 1 basal and ≥ 1 bolus insulin claim every quarter (every 90 days) for 4 consecutive quarters after index bolus claim. Propensity score matching was used to match persistent and nonpersistent method 2 cohorts. Mean per-patient all-cause and diabetes-related medical costs (2015 U.S. dollars, excluding outpatient drugs) and health care resource use (HCRU) were calculated. For patients with hemoglobin A1c (A1c) values during baseline and post-index months 10-12, treatment success was defined as (a) A1c decrease from baseline of ≥ 1% and/or (b) baseline A1c ≥ 7% with post-index A1c < 7%. Baseline characteristics of matched cohorts were compared using standardized mean differences (SMDs). Outcome variables were compared using t-tests, chi-square tests, and generalized linear models. Characteristics of 12,882 eligible patients and 12-month persistence rates were similar as defined by method 1 (22.4%) and method 2 (21.1%). After matching, the method 2 cohorts included 2,723 and 8,169 persistent and nonpersistent patients, respectively, with well-balanced baseline characteristics (mean age 53 years; 58% men; all SMDs < 0.1). All-cause annual medical costs were lower for the persistent cohort (mean $13,499 vs. $17,362; P < 0.0001), as were annual diabetes-related costs (mean $6,392 vs. $8,376; P < 0.0001). In persistent versus nonpersistent cohorts, 11% versus 15% of patients, respectively, experienced ≥ 1 hospitalization; 21% versus 24%, respectively, had ≥ 1 ED visit; 9% versus 12%, respectively, experienced ≥ 1 diabetes-related hospitalization; and 13% versus 15%, respectively, had ≥ 1 diabetes-related ED visit (P ≤ 0.005 for all). Mean baseline A1c was similar in persistent and nonpersistent cohorts (9.7% vs. 9.6%, respectively; P = 0.63). Persistence with MDI was associated with greater mean reduction in A1c (-1.3% vs. -0.8%, respectively; P = 0.006) and greater percentages of patients achieving treatment success (55% vs. 39%, respectively, for nonpersistent; P = 0.009). Poor persistence with basal-bolus insulin therapy over 12 months of follow-up was prevalent and was associated with greater medical costs, greater HCRU, and poorer glycemic control than for patients who were persistent. Interventions are needed to improve persistence with insulin therapy and aid patients with T2DM to achieve glycemic control. Funding for this study was provided by Becton, Dickinson and Company (BD). All authors except Edelman are employees and stockholders of BD. Edelman reports board membership at Senseonics and participation in advisory board/speakers bureau at Lilly USA, MannKind, Novo Nordisk, Sanofi-Aventis U.S., Merck, and AstraZeneca, all unrelated to this study. A poster for this study was presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2018; April 23-26, 2018; Boston MA.

Lumbar Dorsal Root Ganglion Block as a Prognostic Tool Before Pulsed Radiofrequency: A Randomized, Prospective, and Comparative Study on Cost-Effectiveness.

In the study, we discuss the predictive value and cost-effectiveness of dorsal root ganglion (DRG) blocks before using dorsal root ganglion pulsed radiofrequency (DRG-PRF) in the treatment of low back pain. The study comprised 60 patients with low back pain who were randomly assigned into 2 groups. Patients in group 1 were screened using DRG block before DRG-PRF treatment for responders. Patients in group 2 underwent DRG-PRF treatment without DRG block. Successful outcome was defined as patient satisfaction, improvement in numerical rating scale, and medication use reduction. In group 1 (n= 30), 24 patients demonstrated good response to DRG block, and 20 patients had successful outcome at 6 months after DRG-PRF therapy. In group 2 (n= 30), 25 of the patients had successful outcome at 6 months after DRG-PRF therapy. The mean medical costs were NT$ 19,245 and NT$ 16,375 for each successful case in groups 1 and 2, respectively. In this comparative cost-effectiveness study, the application of diagnostic DRG blocks before DRG-PRF did not have a significant impact on patient satisfaction, pain index score, or pain medication reduction. Furthermore, the application of diagnostic DRG blocks resulted in overall greater medical costs. These findings suggest that DRG-PRF without screening by DRG block is more cost-effective and less invasive.

Fibromyalgia and the Prediction of Two‐Year Changes in Functional Status in Rheumatoid Arthritis Patients

Previous cross-sectional studies have shown that rheumatoid arthritis (RA) patients with fibromyalgia (FM) have higher disease activity, greater medical costs, and worse quality of life compared to RA patients without FM. We determined the impact of FM on 2-year changes in the functional status of RA patients in a prospective study. Subjects included participants in the Brigham Rheumatoid Arthritis Sequential Study who were enrolled in a substudy of the effects of pain in RA. Subjects completed questionnaires, including the Multi-Dimensional Health Assessment Questionnaire (MDHAQ) and Polysymptomatic Distress (PSD) scale, semiannually, and underwent physical examination and laboratory tests yearly. Of the 156 included RA subjects, 16.7% had FM, while 83.3% did not. In a multivariable linear regression model adjusted for age, sex, race, baseline MDHAQ score, disease duration, rheumatoid factor/cyclic citrullinated peptide antibody seropositivity, disease activity, and psychological distress, RA patients with FM had a 0.14 greater 2-year increase in MDHAQ score than RA patients without FM (P = 0.021). In secondary analyses examining the association between continuous PSD scale score and change in MDHAQ, higher PSD scale scores were significantly associated with greater 2-year increases in MDHAQ score (β coefficient 0.013, P = 0.011). Both the presence of FM and increasing number of FM symptoms predicted worsening of functional status among individuals with RA. Among individuals with RA and FM, the magnitude of the difference in changes in MDHAQ was 4- to 7-fold higher than typical changes in MDHAQ score among individuals with established RA.

The readmission rate and medical cost of patients with schizophrenia after first hospitalization — A 10-year follow-up population-based study

BackgroundHospital readmissions caused by relapse in patients with schizophrenia are associated with prognosis. Identifying individuals at high risk of readmission and providing interventions to lower the readmission rate are important. MethodsPatients with schizophrenia who were hospitalized for the first time were recruited from the National Health Insurance Research Database from 2001 to 2010 (n=808, mean age 28.9years) and compared with matched controls. Data on the demographics, cost, and utilization of medical resources of patients who were readmitted were compared with non-readmitted patients. The readmission time curve was analyzed by the Kaplan–Meier method. Result570 (70.5%) patients were readmitted within 10years; the median time between admissions was 1.9years, and 25% of subjects were readmitted within 4months of the first hospitalization. There were no significant differences in age, gender, or length of hospitalization between the readmission and non-readmission groups. Taking into account all psychiatric medical services, the readmission group had a significantly higher mean frequency of care and a greater medical cost than the non-readmission group and matched controls. However, there were no significant differences with regard to non-psychiatric medical services. ConclusionSchizophrenia has a high rate of readmission and high medical cost in naturalistic settings. In addition to the traditional hospital-based treatment model for patients with schizophrenia, the development of an effective intervention program is important, especially in the early years of the disease.

Asthma Control and Cost in Latin America

ObjectiveFew patients with asthma have disease that is well-controlled, particularly in Latin American countries. The purpose of this study was to investigate whether partly controlled and uncontrolled asthma are associated with increased costs for asthma-related medications and health care utilization compared with well-controlled asthma in five Latin American countries. MethodsUsing the Global Initiative for Asthma guidelines, we classified respondents from the Latin American Asthma Insights and Management survey into those with well-controlled, partly controlled, and uncontrolled asthma and compared the utilization of health care services and costs among these groups. ResultsMost respondents to our survey (93%) had asthma that was classified as partly controlled or uncontrolled. Across all countries, patients whose asthma was partly controlled or uncontrolled had greater use of asthma-related medications and medical services than did patients whose asthma was well-controlled. After adjusting for age, sex, and country of residence, total costs for asthma-related medications and health care were greater in patients whose asthma was classified as partly controlled and uncontrolled. ConclusionsOur findings indicate that patients with asthma that are not well-controlled used more health care resources and had greater medical costs in Latin America.

Asthma control, cost and race: results from a national survey

Objective: Although interventions have been shown to alleviate symptoms in most patients suffering from asthma, only one-third of asthma patients have disease that is well-controlled. The purpose of this study is to investigate whether partly and uncontrolled asthmas are associated with increased costs for asthma-related healthcare utilization compared to well-controlled asthma and to determine whether these associations differed across racial groups. Methods: We classified respondents from the Asthma Insights and Management survey into those with well-, partly and uncontrolled asthma and compared utilization of healthcare services and costs among these groups, as well as between whites and non-whites. Results: Respondents categorized as having asthma that was not well-controlled reported lower income levels, higher rates of unemployment and more trouble paying for healthcare; similar results were found in analyses stratified by race. Patients whose asthma was partly or uncontrolled had greater use of asthma-related medications and medical services compared to patients whose asthma was well-controlled. Total unadjusted and adjusted costs were greater in patients whose asthma was classified as partly and uncontrolled. Similar results were found in analyses stratified on race. Across all levels of asthma control, non-whites had higher rates of utilization of emergency rooms and urgent care facilities and had greater rates of hospitalizations compared to whites. Conclusions: Our findings indicate that patients with asthma that is not well-controlled utilized more healthcare resources and had greater medical costs, despite lacking of health insurance which may suggest less access to care.

Abstract 12: Evaluation of Medical Costs Associated with Use of Novel Oral Anticoagulants Compared with Warfarin Among Nonvalvular Atrial Fibrillation Patients with Moderate and High Stroke Risk

Background: Nonvalvular atrial fibrillation (NVAF) is a sustained cardiac rhythm disturbance, which increases stroke risk up to 5-fold and affects more than 5 million Americans. Warfarin is efficacious for reducing stroke risk among NVAF patients, but its use is complicated by it having a narrow therapeutic range, significant drug-drug interactions, and an increased risk of major bleeding. The ARISTOTLE, RE-LY, and ROCKET-AF clinical trials demonstrated the novel oral anticoagulants (NOACs), apixaban, dabigatran, and rivaroxaban, respectively are efficacious for stroke prevention among NVAF patients. This study evaluated medical costs of clinical events associated with the use of individual NOACs relative to that of warfarin among NVAF patients with moderate and high stroke risk. Methods: Rates for primary and secondary efficacy and safety outcomes (i.e. clinical events) per year among NVAF patients with CHADS 2 =2 and ≥ 3 were obtained or estimated from the 3 NOAC clinical trials. One year incremental costs among patients with clinical events from a US payer perspective were obtained from the literature and inflation adjusted to 2010 costs. Differences in medical costs for clinical events associated with use of individual NOACs instead of warfarin were then estimated. Results: For NVAF patients with moderate stroke risk (CHADS 2 =2), the overall differences in medical costs for clinical events relative to warfarin were $298, $143, and +$117 per patient year for apixaban, dabigatran (150 mg), and rivaroxaban, respectively (negative numbers=cost reduction). For NVAF patients with high stroke risk (CHADS 2 ≥ 3) the overall differences in medical costs for clinical events relative to warfarin were $697, $2, and $100 for apixaban, dabigatran (150 mg), and rivaroxaban, respectively. Conclusions: Of the three NOACs, apixaban demonstrated greater medical cost reductions relative to warfarin among NVAF patients at moderate and high stroke risk. The medical cost reduction associated with apixaban use instead of warfarin was greater for NVAF patients at higher stroke risk vs. those at moderate stroke risk and was driven primarily by higher absolute reductions in clinical event rates for major bleeding, stroke and systemic embolism.

Patient Characteristics and Medical Care Costs Associated With Hypertriglyceridemia

Hypertriglyceridemia is a lipid abnormality prevalent in 1/3 of the United States adult population. Our objective was to describe the independent contribution of hypertriglyceridemia to medical care costs. Using an observational cohort of 108,324 members of Kaiser Permanente Northwest, we analyzed the electronic medical records of those patients aged ≥18 years who had triglyceride (TG) measurements in 2008 and had been members of Kaiser Permanente Northwest for the entire year. After assigning patients to TG categories of <150, 150 to 199, 200 to 499, and ≥500 mg/dl, we compared the annual direct medical costs. To isolate the independent contribution of the TG levels, we adjusted the costs for age, gender, body mass index, blood pressure, smoking history, low-density lipoprotein and high-density lipoprotein cholesterol, and health conditions such as cardiovascular disease, diabetes, and renal disease. Of the 108,324 study subjects, 64.1% had normal TG levels (<150 mg/dl), 16.4% had borderline high levels (150 to 199 mg/dl), 18.0% had high TG levels (200 to 499 mg/dl), and 1.5% had very high TG levels (≥500 mg/dl). After adjustment, the patients with TG levels ≥500 mg/dl (severe hypertriglyceridemia) had significantly greater mean total costs ($8,567, 99% confidence interval $7,034 to $10,100) than those with levels <150 mg/dl ($6,186, 99% confidence interval $6,058 to $6,314), 150 to 199 mg/dl ($6,449, 99% confidence interval $6,196 to $6,702), or 200 to 499 mg/dl ($6,376, 99% confidence interval $6,118 to $6,634). The differences were driven by both outpatient and pharmaceutical costs. The inpatient costs were also greater for those with TG levels ≥500 mg/dl, but the difference did not reach statistical significance. In conclusion, severe hypertriglyceridemia was associated with 33% to 38% greater medical costs per annum, independent of resource-intensive conditions such as cardiovascular disease, heart failure, hypertension, and diabetes.

Costs Associated With Changes in Antidepressant Treatment in a Managed Care Population With Major Depressive Disorder

Costs Associated With Changes in Antidepressant Treatment in a Managed Care Population With Major Depressive Disorder

Medication Adherence After Myocardial Infarction: A Long Way Left To Go

Medication Adherence After Myocardial Infarction: A Long Way Left To Go

The Cost of Pediatric Stroke Care and Rehabilitation

There is little data regarding the cost of pediatric stroke care or the elements that contribute to these costs. We examined costs for poststroke care during the first year after diagnosis and compared these costs with the volume of the cerebral infarct and the level of neurological and functional outcome. We identified 39 children who sustained nontraumatic ischemic or hemorrhagic strokes and confirmed the diagnoses by review of medical and radiology records. Medical costs were tabulated for the year after the diagnosis of stroke. Cerebral infarct volumes were measured from MRI or CT scans. Neurological outcome was assessed by telephone with a modification of the Pediatric Stroke Outcome Measure (PSOM), and functional outcomes were assessed with a standardized quality-of-life measure. The median cost for poststroke care during the year after diagnosis was $42,338 for the entire group. The cost for stroke care was higher for hemorrhagic stroke than for ischemic stroke. Cost had a significant positive correlation with neurological impairment. The modified PSOM score positively correlated with impairments of physical, emotional, social, and school function. The cost of stroke care may be one measure of stroke severity, with more extensive strokes resulting in greater medical costs. In addition, stroke appears to impair children's social ability along with their neurological function.

Primary care involvement and outcomes of care in patients with a workers' compensation claim for back pain.

A retrospective case series of primary care patients receiving Workers' Compensation (WC) for back pain. To describe the extent of primary care provider (PCP) involvement in work-related low back pain (WRLBP), and whether PCP involvement is a significant determinant of patterns of care or outcomes. In general, WRLBP has inferior outcomes compared with nonoccupational LBP. Although it has been suggested that better outcomes are achieved when care for WRLBP involves specialists such as occupational medicine physicians rather than a PCP, limited evidence supports this claim. Adult patients were identified by electronic records from four hospital-affiliated PCP practices in fiscal years 1996 to 1998. Those with a WRLBP claim filed during the same time period were identified by searching a WC claims database. Medical records were reviewed to assess past medical history, the extent of prior PCP contacts for any visits before and for visits 2 years after the reported onset of the WRLBP claim, and detailed information on visits for this condition. Disability outcomes (total costs and days of work disability) were obtained from the WC database. Among 68,710 individuals with a PCP practice visit, 118 with a WRLBP claim were identified. The final study sample included 87 patients with a WRLBP claim and at least 1 documented PCP practice visit during the study period. Seventy-eight percent of patients saw the PCP at least once in the 2 years after the claim onset date, but only 34 patients (39%) visited the PCP for their WRLBP, and 20 (23%) had more than 1 visit. Although almost all patients with a PCP visit for WRLBP saw a physician (not the PCP in 79% of cases) within a week of the claim onset date, the median number of days between the onset date and the first WRLBP visit to the PCP was 47.5. Patients with a prior history of back problems were more likely to have a PCP visit for WRLBP (odds ratio 2.9, 95% confidence interval 1.1-7.7). Patients with PCP visits for WRLBP had higher total and medical costs than those without PCP visits, but a similar number of paid disability days. After controlling for other potential predictors, involvement of the PCP was not a significant predictor of the total cost of the WRLBP claim. Many individuals with a WC claim do not have a stable PCP relationship around the onset of their WRLBP episode. Those with PCP relationships uncommonly involve the PCP in their WRLBP, and if they do, it is usually later in the course because of persistent or recurrent symptoms. Disability outcomes appear to be similar regardless of whether a PCP was involved. However, PCP involvement is associated with greater medical costs, which may reflect confounding based on duration of symptoms rather than the nature of the care provided. Additional research is needed to understand how different patterns of care for patients with a WRLBP claim relate to outcomes and how these patients compare with individuals without such a claim, as well as the factors that lead patients to involve their PCP or not.

Outcome of surgery for thoracic outlet syndrome in Washington state workers’ compensation

To determine the predictors of outcome of thoracic outlet syndrome (TOS) surgery in a population-based cohort of injured workers. All injured workers in the Washington State Workers' Compensation system who received TOS surgery during 1986 to 1991 were identified by computerized bill payment records and validated by medical record review (n = 158). The main outcome measure was work disability status 1 year after surgery. Additional functional status and quality of life outcomes were determined by telephone survey an average of 4.8 years after operation. A sample of workers with a TOS diagnosis who did not receive surgery during 1987 to 1989 were identified as a comparison group (n = 95). Sixty percent of workers were still work disabled 1 year after surgery. The strongest predictors of remaining disabled were the amount of work disability before surgery (OR = 1.85; 95% CI, 1.51 to 2.28), longer time between injury and TOS diagnosis (OR = 1.34; 95% CI, 1.09 to 1.64), and older age at injury (OR = 1.07; 95% CI, 1.00 to 1.13). There was no relationship between type of surgery, presence of any provocative tests, or experience of surgeon and work disability outcome. In follow-up surveys an average of 4.8 years after surgery, 72.5% of workers still reported they were "limited a lot" in vigorous activities. Compared with a nonsurgical sample of TOS patients, those receiving surgery had 50% greater medical costs and were three to four times more likely to be work disabled. The outcome of TOS surgery among injured workers is worse than has generally been reported. The nonspecific neurogenic TOS diagnosis, the complexity of workers' compensation cases, and the adverse event profile are likely substantial contributors to the worse outcomes reported here. Well-designed prospective studies and randomized trials are required to elucidate any role of TOS surgery in nonspecific TOS.