High Healthcare Related Costs Research Articles

Unraveling the Mechanisms of Valvular Heart Disease to Identify Medical Therapy Targets: A Scientific Statement From the American Heart Association.

Valvular heart disease is a common cause of morbidity and mortality worldwide and has no effective medical therapy. Severe disease is managed with valve replacement procedures, which entail high health care-related costs and postprocedural morbidity and mortality. Robust ongoing research programs have elucidated many important molecular pathways contributing to primary valvular heart disease. However, there remain several key challenges inherent in translating research on valvular heart disease to viable molecular targets that can progress through the clinical trials pathway and effectively prevent or modify the course of these common conditions. In this scientific statement, we review the basic cellular structures of the human heart valves and discuss how these structures change in primary valvular heart disease. We focus on the most common primary valvular heart diseases, including calcific aortic stenosis, bicuspid aortic valves, mitral valve prolapse, and rheumatic heart disease, and outline the fundamental molecular discoveries contributing to each. We further outline potential therapeutic molecular targets for primary valvular heart disease and discuss key knowledge gaps that might serve as future research priorities.

Predictors of hospital length of stay and long-term care facility placement in aneurysmal subarachnoid hemorrhage

BackgroundAneurysmal subarachnoid hemorrhage (aSAH) is frequently associated with complications, extended hospital length of stay (LOS) and high health care related costs. We sought to determine predictors for hospital LOS and discharge disposition to a long-term care facility (LTCF) in aSAH patients. MethodsWe performed a retrospective study of a prospectively collected cohort of consecutive patients with aSAH admitted to an academic referral center from 2016 to 2021. Multiple linear regression was performed to identify predictors for hospital LOS. We then created a 10-point scoring system to predict discharge disposition to a LTCF. ResultsIn a cohort of 318 patients with confirmed aSAH, mean age was 57 years (SD 13.7), 61% were female and 70% were white. Hospital LOS was longer for survivors (median 19 days, IQR 14–25) than for non-survivors (median 5 days, IQR 2–8; p < 0.001). Main predictors for longer LOS for this cohort were ventriculoperitoneal shunt (VPS) requirement (p < 0.001), delayed cerebral ischemia (p = 0.026), and pneumonia (p = 0.014). The strongest predictor for LTCF disposition was age older than 60 years (OR 1.14, 95% CI 1.07–1.21; p < 0.001). LTCF score had high accuracy in predicting discharge disposition to a LTCF (area under the curve [AUC] 0.83; 95% CI 0.75–0.91). Forty-one percent of patients who were discharged to a LTCF had significant functional recovery at 3 months post-discharge. ConclusionsVPS requirement and aSAH related complications were associated with longer hospital LOS compared to other factors. LTCF score has high accuracy in predicting discharge disposition to a LTCF.

Peer mentorship to improve outcomes in patients on hemodialysis (PEER-HD): a randomized controlled trial protocol

BackgroundPatients receiving in-center hemodialysis experience disproportionate morbidity and incur high healthcare-related costs. Much of this cost stems from potentially avoidable hospitalizations. Peer mentorship has been used effectively to improve outcomes for patients with complex chronic diseases. We propose testing the efficacy of peer mentorship on hospitalization rates among patients receiving hemodialysis.MethodsThis is a multicenter parallel group randomized controlled pragmatic trial of patients treated at hemodialysis facilities in Bronx, NY and Nashville, TN. The study has two phases. Phase 1 will enroll and train 16 hemodialysis patients (10 in Bronx, NY and 6 in Nashville TN) to be mentors using a program focused on enhancing self-efficacy, dialysis self-management and autonomy-supportive communication skills. Phase 2 will enroll 200 high risk adults receiving hemodialysis (140 in Bronx, NY and 60 in Nashville, TN), half of whom will be randomized to intervention and half to usual care. Intervention participants are assigned to weekly telephone calls with trained mentors (see Phase 1) for a 3-month period.The primary outcome of Phase 1 will be engagement of mentors with training and change in knowledge scores and autonomy skills from pre- to post-training. The primary outcome of Phase 2 will be the composite count of ED visits and hospitalizations at the end of study follow-up in patient participants assigned to intervention as compared to those assigned to usual care. Secondary outcomes for Phase 2 include the change over the trial period in validated survey scores measuring perception of social support and self-efficacy, and dialysis adherence metrics, among intervention participants as compared to usual care participants.DiscussionThe PEER-HD study will test the feasibility and efficacy of a pragmatic peer-mentorship program designed for patients receiving hemodialysis on ED visit and hospitalization rates. If effective, peer-mentorship holds promise as a scalable patient-centered intervention to decrease hospital resource utilization, and by extension morbidity and cost, for patients receiving maintenance in-center hemodialysis.Trial registrationClinicaltrials.gov identifier: NCT03595748; 7/23/2018.Trial sponsorNational Institutes of Diabetes, Digestive and Kidney Disease (NIDDK) 5R18DK118471.FundingFunding for this study was provided by the National Institutes of Diabetes, Digestive and Kidney Disease: R18DK118471.Study statusThis is an ongoing study and not complete. We are still collecting data for observational follow-up on participants.Related articlesNo related articles for this study have been submitted to any journal.The study sponsor and funders had no role in the design, analysis or interpretation of this data. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

A Practical Clinical Protocol for Monitoring Patients with Severe Uncontrolled Chronic Rhinosinusitis with Nasal Polyposis Treated with Biologics.

Objectives:Chronic rhinosinusitis with nasal polyposis (CRSwNP) is a pathological condition which leads to high healthcare-related costs and low quality of life for patients. The introduction of new biological therapies (monoclonal antibodies, MAbs) in CRSwNP patients has allowed new therapeutic options for non-responders to conventional therapies and Dupilumab represents the first approved biological agent. The aim of this paper is to provide a practical clinical multidisciplinary protocol which might help clinicians involved in this field to monitor the clinical outcomes.Methods:Our centre of Rhinology and Rhino-Allergology has developed a dedicated collection form to observe the outcomes of patients treated with Dupilumab. Our research started from the indications given in EPOS 2020 as main reference. We then implemented these references in an electronic database trying to apply Evidence Based Medicine (EBM) in current clinical practice.Results:The result consists of three parts: an anamnestic collection data, a clinician reported outcome and two patient reported outcomes (PROMs) questionnaire, the visual analogue scale (VAS) and the Sino-Nasal Outcome Test-22 (SNOT-22). The tables we propose should provide an adequate correlation with the patients’ adherence to therapy and their treatment outcomes. Such periodical evaluation (after a month, after 3 months, after 6 months and at one year) should quickly allow to monitor if the patient is correctly assuming the therapy and the eventual objective improvements.Conclusions:We propose a practical monitoring protocol formulated to analyse both objective and subjective aspects of patients with severe uncontrolled CRSwNP treated with MAbs, thus helping to define in future a better comparison between the clinical results of different institutes.

Heart failure hospitalization in adult patients with congenital heart disease: risk factors for repeated admissions

Abstract Background Heart failure hospitalizations in adult patients with congenital heart disease (ACHD) are increasing and are associated with higher healthcare-related costs. We aimed to evaluate factors that are associated with repeated heart failure hospitalizations and whether heart failure hospitalizations are related to adverse outcome in ACHD patients with heart failure (ACHD-HF). Methods Out of 3995 patients under active follow-up in our institution (last visit &amp;gt;2010), 256 patients (mean age 49.5±16.7 years) had ACHD-HF and were included in the study. Medical records were reviewed, including heart failure hospitalization prior and after study inclusion. A combined endpoint of death, ventricular assist device and transplantation was defined. Results Overall, 136 ACHD-HF patients (53%) had a prior heart failure hospitalization. Over a mean follow-up of 2.5±2.3 years, 44 patients (17%) had repeated heart failure hospitalizations. Of these, 31 patients (12%) had 1; 9 patients (4%) 2 and 4 patients (2%) 3 repeated heart failure hospitalizations. Patients with repeated heart failure hospitalizations had higher NYHA class (p=0.031), were more likely to have end-organ dysfunction (p=0.025) and more likely to have a prior heart failure hospitalization (p&amp;lt;0.001). In multivariable Cox regression analysis, only end-organ dysfunction (HR 2.431 95% CI 1.516–43.896 p&amp;lt;0.001) was related to repeated hospitalization. Seventy patients (27%) reached the combined endpoint of death, VAD or transplantation (event-rate 11% per year). Repeated heart failure hospitalizations was not related to the combined endpoint in Cox regression analysis. Conclusions Heart failure hospitalizations are frequent in ACHD-HF. End-organ dysfunction appears to be a strong determinant of repeated heart failure hospitalizations. Event-rate is high in patients with ACHD-HF, but repeated heart failure hospitalizations were not related to outcome in this short-term follow-up study. Funding Acknowledgement Type of funding sources: None. Table 1.1Table 1.2

Demographic and Clinical Outcomes of Brazilian Patients With Stage III or IV Non-Small-Cell Lung Cancer: Real-World Evidence Study on the Basis of Deterministic Linkage Approach.

PURPOSENon–small-cell lung cancer (NSCLC) is the most common type of lung cancer and accounts for 80%-90% of the cases. In Brazil, between 2018 and 2019, lung cancer was ranked as the second most frequent cancer among men and the fourth among women. The primary objectives were to describe the journey and survival rates of patients with advanced NSCLC treated in the Brazilian private health care system (HCS).MATERIALS AND METHODSA retrospective cohort study was based on the search in administrative databases to analyze the Brazilian private HCS. Patients with advanced NSCLC diagnosed between 2011 and 2016 were included. The data on demographics, cancer-related information, treatment-related information, and resources used were collected. Survival analyses were performed using the semiparametric Kaplan-Meier method to assess mortality by NSCLC stage, with NSCLC diagnosis as the index date.RESULTSA total of 5,016 patients were included. Most patients were between 60 and 69 years old (33.6%) and had completed elementary school (52.2%). There was a greater proportion of men (58.1% v 41.9%), and the majority of patients had stage IV NSCLC (67%). It took an average of 31 days, from the first consultation, to have diagnosis. In 44% of the cases, a clinical oncologist was the first specialist in the HCS that the patient was referred to. After the diagnosis, the median time to start of treatment was 35 days. Chemotherapy alone was the most common treatment regimen (32%). The median overall survival was 11.5 months and 6 months for stage II and IV NSCLC, respectively.CONCLUSIONThis study provides contemporary data on stage III and IV NSCLC in private health care in Brazil, which has shown a high rate of metastatic disease diagnoses, high health care–related costs, and low survival rates.

Hypofractionated Radiation for Benign Meningiomas and Vestibular Schwannomas

Meningiomas and vestibular schwannomas are generally benign tumors which can be treated with definitive radiation therapy. Both radiosurgery and fractionated intensity-modulated radiotherapy (IMRT) are effective, with radiation schedule guided by tumor characteristics and location. While fractionated IMRT yields favorable tumor control, daily treatments for 5-6 weeks can be burdensome for patients and can be associated with high healthcare-related costs. Thus, hypofractionated radiation may be a reasonable alternative. Here we review the results of patients with benign meningiomas or vestibular schwannomas treated at our institution with hypofractionated IMRT. Following IRB approval, patients treated at our institution from 2008 to 2018 with a primary diagnosis of either meningioma or vestibular schwannoma and who received 30 Gy in 10 fractions were retrospectively reviewed. These patients were offered hypofractionated radiation due to their advanced age, multiple medical comorbidities, or inability to travel to our center for six weeks of treatment. Patient and tumor characteristics as well as follow-up documentation were retrospectively reviewed. Tumor progression was determined by review of patient imaging as well as provider notation. From years 2008 to 2018, 70 patients were treated for meningioma or vestibular schwannoma with 30 Gy in 10 fractions. Median patient age was 73 years (range 43-92 years). At median follow-up of 3.2 years, we observed a local control rate of 97.1%. Two patients (2.9%) had disease progression, which occurred at 9.6 and 6.6 years after treatment. One patient developed asymptomatic radiographic changes consistent with radiation necrosis which resolved without intervention. All patients completed the prescribed course without interruption. In this cohort, the mean tumor size was 18.9 cc (range 3.4-245.5 cc) and tumor volume was not associated with recurrence risk. Hypofractionated radiation with 30 Gy in 10 fractions is an effective, convenient, and well tolerated schedule for patients with benign meningiomas or vestibular schwannomas. This treatment schedule appeared to provide durable control for a wide range of tumor volumes and should be considered for those patients with limited life expectancy or those unable to receive a conventionally fractionated radiotherapy course.

A Pilot Study of a Text Messaging Intervention to Modify Illness and Medication Beliefs Among Patients Diagnosed with Inflammatory Bowel Disease

Intentional and unintentional medication non-adherence is a particular challenge for patients with inflammatory bowel disease (IBD). Non-adherence can affect patients’ quality of life, which can result in unfavorable treatment outcomes, more hospitalizations, and higher healthcare-related costs. The purpose of this study was to assess whether a tailored text message intervention designed to modify illness and medication adherence beliefs in patients with IBD would increase treatment compliance and change patients’ illness perceptions and medication concerns. This pilot study utilized a pre-test-post-test non-randomized design. A sample of 32 IBD patients was recruited within the UK. Participants’ medication beliefs and illness perception scores determined the set of tailored daily text messages, which were sent to patients over duration of 12 weeks. Medication adherence increased post-intervention, as “forgetting to take medication” decreased while “never” forgetting to take medication increased over time. A significant increase in treatment control and coherence and a decreased level of concern surrounding their condition was evident. Participants’ level of concern towards their medications changed during the 12 weeks, with a baseline mean concern score of 3.08 (.57) in comparison to the 12 weeks mean concern score of 2.89 (.59), which is statistically different, t (31) = 2.16, p < .038, r = .36 (medium effect). Sixty-six percent of participants from the baseline were aware of the necessity of their medication: “without my medication I would become ill.” The results have direct implications for improving medication adherence and changing illness and medication beliefs. This study validated the benefits of text messages and highlighted the importance of addressing these beliefs in order to understand the reasons for non-adherence fully.

Morbidity and Health Care Costs After Early Term Birth.

Early term birth is associated with increased need for hospital care during the early postnatal period. The objective of this study was to assess the morbidity and health care-related costs during the first 3 years of life in children born early term. Data come from a population-based birth cohort study in the municipalities of Helsinki, Espoo, and Vantaa, Finland using data from the national medical birth register and outpatient, inpatient, and primary care registers. All surviving infants born in 2006-08 (n = 29 970) were included. The main outcome measures were morbidities, based on ICD-10 codes recorded during inpatient and outpatient hospital visits, and health care costs, based on all care received, including well child visits (specialised care, primary care, private care, and medications). 7.0% of children born full term had at least one of the studied morbidities by 3 years of age. This percentage was significantly higher in children born early term: 8.6% (adjusted odds ratio 1.2, 95% confidence interval (CI) 1.1, 1.4). The increased morbidity of children born early term was attributed to obstructive airway diseases and ophthalmological and motor problems. Health care-related costs during the first 3 years of life were 4813€ (95% CI 4385, 5241) per child in the early term group, higher than for full term children 4047€ (95% CI 3884, 4210). Infants born early term have increased morbidity and higher health care-related costs during early childhood than full term infants. Early term birth seems to be associated with a health disadvantage.

Quantifying the relationship between increased disability and health care resource utilization, quality of life, work productivity, health care costs in patients with multiple sclerosis in the US

BackgroundMultiple sclerosis (MS) is a chronic progressive condition affecting the central nervous system. Progression of MS results in increased level of disability and most patients will eventually experience some degree of functional impairment and impaired mobility. Costs and burdens escalate as MS disability increases. However, there is a lack of recent data on the impact of MS disability on the cost and burden among patients in the US.MethodsData for this study were drawn from a real world, cross-sectional survey undertaken between 2013 and 2014. Neurologists completed detailed patient report forms (PRF) for the most recent consulting patients with MS (age >18 years). Patient’s perceptions of their diagnosis and health-related quality of life (HRQoL) were collected through a patient self-completion questionnaire (PSC). Regression analysis was used to evaluate the relationship between disability (determined by latest Expanded Disability Status Scale [EDSS] score) and current relapse and health care resource utilization, health care costs, HRQoL and work productivity.ResultsPRF data were collected for 715 patients (335 also completed a PSC). Patients with higher disability scores (EDSS 3–5 and >5 vs <3 points) and current relapse (vs no current relapse) reported significantly greater health resource utilization for physician visits (p < 0.05) and hospitalizations (p < 0.05) in the preceding 12 months. In addition, they had poorer HRQoL (p < 0.05), were significantly more likely to be unemployed (p < 0.05) and to have had to stop working due to MS (p < 0.05). They also incurred significantly higher health care related costs, including costs for physician consultations, hospitalizations and therapy (p < 0.05). The total costs of care were $51,825, $57,889 and $67,116 for EDSS < 3, EDSS 3–5 and EDSS > 5 groups, respectively; $51,692 and $58,648 for non-relapse and relapse groups, respectively.ConclusionsFor MS patients in the US, health resource utilization and healthcare care costs increase with progression of disability. As the disability worsens, patients also exhibit diminished HRQoL and lower work productivity. There is a need for treatments that slow down or delay disability progression among MS patients.

Choosing wisely in Allergology: a Slow Medicine approach to the discipline promoted by the Italian Society of Allergy, Asthma and Clinical Immunology (SIAAIC).

BackgroundOne of the main problem health care systems are facis is the mis-use and over-use of medical resources (including useless exams, surgical interventions, medical treatments, screening procedures…) which may lead to high health care related costs without increased patients’ benefit and possible harm to the patients themselves. The “Choosing wisely” campaign, in Italy denominated “Doing more does not mean doing better”, tries to educate doctors and citizens at a correct use of medical resources.Methodsthe Italian Society of Allergy, Asthma and Clinical Immunology (SIAAIC) adhered to the “Doing more does not mean doing better” campaing and made a list of the 5 allergological procedures with the highest evidence of inappropriateness.Resultsthe 5 recommendations were: “Do not perform allergy tests for drugs (including anhestetics) and/or foods when there are neither clinical history nor symptoms suggestive of hypersensitivity reactions”; “Do not perform the so-called “food intolerance tests” (apart from those which are validated for suspect celiac disease or lactose enzymatic intolerance)”; “Do not perform serological allergy tests (i.e.: total IgE, specific IgE, ISAC) as first-line tests or as “screening” assays”; “Do not treat patients sensitized to allergens or aptens if there is not a clear correlation between exposure to that specific allergen/apten and symptoms suggestive of allergic reaction”; “Do not diagnose asthma without having performed lung function tests”.ConclusionsAn important role scientific societies should play is to advise on correct diagnostic and therapeutical pathways. For this reason SIAAIC decided to adhere to the Slow Medicine Italy campaign “Doing more does not mean doing better” with the aim of warning the scientific community and the citizens/patients about some allergological procedures, which, when performed in the wrong clinical setting, may be not only useless, but unnecessarily expensive and even harmful for patients’ health.