Higher Health Resource Utilization Research Articles

Prevalence and outcomes of atrial fibrillation in patients suffering prostate cancer: a national analysis in the United States.

Although the adverse effects of atrial fibrillation (AF) on cancers have been well reported, the relationship between the AF and the adverse outcomes in prostate cancer (PC) remains inconclusive. This study aimed to explore the prevalence of AF and evaluate the relationship between AF and clinical outcomes in PC patients. Patients diagnosed with PC between 2008 and 2017 were identified from the National Inpatient Sample database. The trends in AF prevalence were compared among PC patients and their subgroups. Multivariable regression models were used to assess the associations between AF and in-hospital mortality, length of hospital stay, total cost, and other clinical outcomes. 256,239 PC hospitalizations were identified; 41,356 (83.8%) had no AF and 214,883 (16.2%) had AF. AF prevalence increased from 14.0% in 2008 to 20.1% in 2017 (P < .001). In-hospital mortality in PC inpatients with AF increased from 5.1% in 2008 to 8.1% in 2017 (P < .001). AF was associated with adverse clinical outcomes, such as in-hospital mortality, congestive heart failure, pulmonary circulation disorders, renal failure, fluid and electrolyte disorders, cardiogenic shock, higher total cost, and longer length of hospital stay. The prevalence of AF among inpatients with PC increased from 2008 to 2017. AF was associated with poor prognosis and higher health resource utilization. Better management strategies for patients with comorbid PC and AF, particularly in older individuals, are required.

Health care utilization after enrollment in an outpatient structured clinical program for children with medical complexity

Abstract Objectives Although children with medical complexity (CMC) with high health resource utilization use outpatient structured clinical programs (SCP) to optimize their health, little is known about variation in trends of their health service use shortly after enrollment. We measured these trends and assessed the utility of patient characteristics to predict them. Methods Retrospective analysis of 506 CMC newly enrolled in an outpatient, academic SCP. We measured outpatient and inpatient health service use for the first 6 months following enrollment. Using cluster analysis, we categorized CMC with similar trends by health service. We assessed patient demographic (e.g., age) and clinical [type and number of complex chronic conditions (CCC)] characteristics with the cluster categories. Results Most (90.3%) CMC enrolled had ≥1 CCCs; 53.8% had ≥3 CCCs. For all CMC, outpatient specialty visits, phone calls, and hospitalizations (not involving ICU) decreased significantly over the first 6 months after enrollment. For example, the hospitalization rate decreased from 9.7% to 4.5% in the 1st and 6th months, respectively, (P &amp;lt; 0.001). Cluster analysis revealed four categories of hospitalization trends, 6 months after enrollment: 72.9% of CMC had no hospital use; 16.0% had increased then decreased use; 8.3% had decreased use; and 2.8% had increased use. No patient and clinical characteristics clearly distinguished which hospitalization trend CMC experienced. Conclusions Although the overall population of CMC experienced decreased outpatient and inpatient health services utilization over time, this decrease was not uniformly experienced. Fundamental patient demographic and clinical characteristics did not predict health service trends.

Limited access to liver transplantation and TIPS despite high mortality, healthcare resource use and costs of cirrhosis in Germany.

Data on number of patients with cirrhosis in Germany are limited. We therefore aimed to estimate prevalence, comorbidities, mortality, utilization of healthcare resources and costs of patients with cirrhosis and incidence of decompensation of cirrhosis in Germany. This longitudinal observational study was based on an anonymized representative claims database including 4.9 million persons insured by a statutory health insurance (SHI) between 2015-2020. Patients with decompensated and compensated cirrhosis were selected via diagnostic ICD codes and followed for 2 years. Prevalence of cirrhosis in 2015 was 250/100 000, resulting in 201 747 (95% CI: 197 540-206 040) patients extrapolated to the German population. Out of all patients with compensated cirrhosis in 2015 who did not deceased, 16.0% developed a decompensation within 3 years. Overall, 978 patients (Ø-age: 68 years; 60% male) were included in the decompensated, and 5135 patients (Ø-age: 66 years; 59% male) in the compensated cirrhosis cohort. Patients with decompensated cirrhosis had a higher burden of comorbidities (Charlson Comorbidity Index 7.3 vs. 4.4) and 3 times higher costs per quarter (7172 € vs. 2213 €) than patients with compensated cirrhosis. 1-year mortality after decompensation was 51% compared to 8% in compensated cirrhosis. Of note, only few patients with decompensated cirrhosis received a liver transplantation or transjugular intrahepatic portosystemic shunts (TIPS) (1% and 5%). Patients with cirrhosis have a high healthcare burden in especially decompensated stage. Accordingly, 1-year mortality of decompensated cirrhosis in Germany is high. Despite high health resource utilization, only few patients have access to liver transplantation or TIPS.

Characteristics and Management of Patients with Refractory or Unexplained Chronic Cough in Outpatient Hospital Clinics in Spain: A Retrospective Multicenter Study

PurposeChronic cough (cough that persists for ≥ 8 weeks) can cause a range of physical symptoms and psychosocial effects that significantly impair patients’ quality of life. Refractory chronic cough (RCC) and unexplained chronic cough (UCC) are challenging to diagnose and manage, with substantial economic implications for healthcare systems.MethodsThis retrospective multicenter non-interventional study aimed to characterize the profile and health resource consumption of patients with RCC or UCC who attended outpatient clinics at Spanish hospitals. Data were collected from medical records of patients with RCC or UCC for up to 3 years before study inclusion.ResultsThe patient cohort (n = 196) was representative of the chronic cough population (77.6% female, mean age 58.5 years). Two-thirds of patients (n = 126) had RCC. The most frequently visited doctors were pulmonologists (93.4% of patients) and primary care physicians (78.6%), with a mean of 5 visits per patient over three years’ observation. The most common diagnostic tests were chest x-ray (83.7%) and spirometry with bronchodilation (77.0%). The most commonly prescribed treatments were proton pump inhibitors (79.6%) and respiratory medications (87.8%). Antibiotics were prescribed empirically to 56 (28.6%) patients. Differences between RCC or UCC groups related mainly to approaches used to manage cough-associated conditions (gastroesophageal reflux disease, asthma) in patients with RCC.ConclusionRCC and UCC are responsible for high health resource utilization in Spanish hospitals. Specific treatments targeting the pathological processes driving chronic cough may provide opportunities to reduce the associated burden for patients and healthcare systems.

71 Barriers to providing optimal care to children with medical complexity in the emergency department: A physicians' perspective

Abstract Background Children with medical complexity (CMC) are a subset of the pediatric population with chronic medical conditions requiring specialized care and high health resource utilization. Due to the nature of their underlying diseases, along with the medical devices that they are reliant on, they account for a large proportion of annual pediatric emergency department (ED) visits in tertiary centres and about one third of the children admitted. ED physicians are often the first to interact with CMC patients and thus the quality of care they provide influences the hospital course of those patients. Objectives To determine and explore the barriers that ED physicians face when providing care to CMC in the ED and identify potential areas of improvement in care provided in the ED. Design/Methods Semi-structured personal interviews were conducted virtually with 20 pediatric emergency medicine physicians and fellows. Each participant was asked the same set of questions and given extra time to elaborate. Interviews were transcribed verbatim and manual coding was conducted to identify commonalities across the interviews. Results We identified four major themes and 12 sub-themes as barriers to optimal care of CMC in the ED. Major themes included time, training, medico-legal concerns, and care plans. The two most commonly identified barriers were time required to care for CMC patients, identified by 90% (n=18) of the participants, and limited exposure during fellowship training, identified by 80% (n=16) of the participants. Only 20% (n=4) identified medico-legal challenges as a unique barrier when managing CMC. All the participants (n=20) emphasized the importance of a care plan, a detailed document given to caregivers of CMC by the primary care team with details about their medical condition, and if not available, 85% (n=17) indicated that it will affect the efficiency and quality of care provided. Even if a care plan is available, 50% (n=10) of the participants would still contact the complex care team for further management recommendations. Conclusion Care plan accessibility and time restraint in the ED are major barriers faced by PEM physicians in the ED when caring for CMC. Additional training during fellowship in complex care medicine and providing patients with an updated care plan are two interventions suggested to optimize care of CMC in the ED.

MO187: Healthcare Costs based on Risk of Progression in Patients with Chronic Kidney Disease

Abstract BACKGROUND AND AIMS Nephrologists follow patients with chronic kidney disease (CKD) stage G3 and G4 as a homogeneous group with the assumption that everyone had similar rates of progression with scheduled visits and lab investigations based on the stage of the disease. We now recognize that not all patients progress at similar rates to kidney failure and treatment and follow-up needs vary. The Kidney Failure Risk Equation (KFRE) identifies patients at different risks of progression to kidney failure (low, medium and high risk) in each stage of the disease. Previous studies had looked at resource utilization of patients based on the stage of the CKD. The purpose of our analysis was to examine resource utilization and associated costs based on the risk of progression by KFRE in the setting of a universal healthcare system. METHOD We conducted a retrospective cohort study of adults with CKD G3 and G4 enrolled in multidisciplinary CKD clinics in the province of Saskatchewan, Canada. Data was collected from January 2004 through December 2012 and patients were followed for 5 years. The predicted risk of kidney failure for each patient was calculated using the 8-variable KFRE. The equation used clinical and routine laboratory data, to stratify patients into three risk categories (low, medium and high risk) of progression. We compared the number and cost of hospital admissions, physician visits and prescription drugs by risk within G3 and G4. Negative binomial regression and generalized linear model were used to compare healthcare utilization and cost between the groups respectively (α = 0.05). RESULTS A total of 1003 adults with CKD G3 and G4 were included in the study. In patients with stage G3 CKD, 311 (59%), 150 (28%) and 68 (13%) were in low, medium and high-risk categories, respectively. Amongst patients with CKD stage G4, 275 (58%), 86 (18%) and 113 (24%) were in similar categories respectively. The cost of hospital admissions, physician visits and drug dispensations in stage G4 high risk in comparison to low risk over the 5-year study period was CAD $89 265 versus $48 374 (P = .008), $23 423 versus $11 231 (P &amp;lt; .001) and $21 853 versus $16 757 (P = .01), respectively. In stage G3, the cost of hospital admissions was CAD $55 944 versus $36 740 (P = 0.10), physician visits $13 414 versus $10 370 (P = .08) and prescription drugs $20 394 versus $14 902 (P = .02) in high-risk patients in comparison to low-risk patients (Figure 1). CONCLUSION In patients followed in multidisciplinary clinics with CKD stages G3 and G4, the cost of hospital admissions, physician visits and prescription drugs were higher in high-risk patients compared to patients in low-risk category. In our study, the KFRE, designed to predict the risk of progression to dialysis in patients with CKD, also assisted in identifying patients with higher health resource utilization and healthcare costs compared to those with lower health resource use. We additionally suggest that patients who are in medium and high-risk categories be followed in multidisciplinary clinics rather than individual physician offices to delay the trajectory of decline to kidney failure.

Prevalence and health care costs of mitochondrial disease in Ontario, Canada: A population-based cohort study.

BackgroundMitochondrial disease prevalence has been estimated at 1 in 4000 in the United States, and 1 in 5000 worldwide. Prevalence in Canada has not been established, though multi-linked health administrative data resources present a unique opportunity to establish robust population-based estimates in a single-payer health system. This study used administrative data for the Ontario, Canada population between April 1988 and March 2019 to measure mitochondrial disease prevalence and describe patient characteristics and health care costs.Results3069 unique individuals were hospitalized with mitochondrial disease in Ontario and eligible for the study cohort, representing a period prevalence of 2.51 per 10,000 or 1 in 3989. First hospitalization was most common between ages 0–9 or 50–69. The mitochondrial disease population experiences a high need for health care and incurred high costs (mean = CAD$24,023 in 12 months before first hospitalization) within the single-payer Ontario health care system.ConclusionsThis study provides needed insight into mitochondrial disease in Canada, and demonstrates the high health burden on patients. The methodology used can be adapted across jurisdictions with similar routine collection of health data, such as in other Canadian provinces. Future work should seek to validate this approach via record linkage of existing disease cohorts in Ontario, and identify specific comorbidities with mitochondrial disease that may contribute to high health resource utilization.

PIN35 Prevalence of COVID-19 vs. Seasonal Influenza: A Population-Based National Survey of US Adults

Objectives: To estimate the prevalence of diagnosed/undiagnosed/misdiagnosed COVID-19 (COVID) vs. seasonal influenza (flu) in the US during the 2019-2020 influenza season. Methods: Prevalence of COVID/flu was determined from a nationally representative e-survey of a random adult sample. Additionally, demography, comorbidity, concomitant medications, and health-resource utilization (HRU) were evaluated. Undiagnosed (i.e., symptomatic/no diagnostic testing) or misdiagnosed (i.e., symptomatic/testing negative) COVID/flu was identified from responses to COVID-specific 8-symptom checklist (CSC) derived from a 25-symptom questionnaire. Based on testing or CSC status, respondents were grouped into “neither”, “dual diagnosis”, “COVID-only” and “flu-only” cohorts. Diagnosed COVID or flu was estimated from the positive tests. Overall COVID or flu rates were estimated as a sum of diagnosed, undiagnosed, or misdiagnosed for each. Results: Of the 1,123 respondents (mean age=39.1 years), 21.5% (242/1123) reported COVID/flu symptoms. Amongst respondents who underwent testing (143/1123), 22.4% (32/143) tested positive for COVID and flu (dual-diagnosis) concurrently, 7.0% (10/143) for COVID-only and 30.8% (44/143) for flu-only. Overall, 40.9% respondents had undiagnosed COVID/flu (99/242);8.7% (21/242) and 32.2% (78/242) had undiagnosed COVID-only and flu-only, respectively. Of 39.8% misdiagnosed respondents (57/143), 23.0% (33/143) and 16.8% (24/143) had misdiagnosed COVID-only and flu-only, respectively. Overall, COVID and flu rates were 8.5% (96/1123) and 15.9% (178/1123), respectively. Seventy-five percent diagnosed with COVID (32/42) were also flu-positive (dual-diagnosis). Sensitivity of CSC was 97.6% (41/42 that tested COVID-positive would identify as COVID with only CSC). Compared to neither cohort (n=881), the dual-diagnosis cohort (n=32) had significantly higher comorbidities and concomitant medications followed by COVID-only (n=64) and flu-only (n=146) cohorts. Dual-diagnosis cohort had higher HRU;with greater hospital-stays, ICU-stays, and ventilator-use, as well as longer hospital and ICU length-of-stays. Conclusions: These study findings demonstrate that the prevalence of COVID was half the rates of flu and 75% COVID-positive respondents were also flu-positive (dual-diagnosis). Dual-diagnosis cohort had highest HRU and comorbidity rates.

Burden of Psoriasis in Catalonia: Epidemiology, Associated Comorbidities, Health Care Utilization, and Sick Leave

Background and objectivesEpidemiologic and disease burden data are essential for disease control and optimal health care resource planning. The aims of this study were to estimate the epidemiologic burden of psoriasis and evaluate associated comorbidities, health care utilization, and sick leave. Material and methodsWe collected data from the 2016 Catalan Health Survey (ESCA), the Catalan Registry of Morbidity and Utilization of Health Care Services (MUSSCAT) (2016), and the database of the Catalan Medical Evaluations Institute (ICAM) (2012–2016). ResultsThe prevalence of psoriasis in Catalonia according to 2016 ESCA data is approximately 1.8%.The MUSSCAT registry data indicate that the incidence has remained stable in recent years. The most common comorbidities associated with psoriasis are hypertension (35%) and diabetes (15%). Forty percent of patients with psoriasis have a moderate to high risk for death or high health resource utilization. Annual use of resources by psoriasis patients is high: they make a mean of 8.7 primary care visits, 2.8 outpatient visits, 0.5 emergency and day hospital visits, 0.2 mental health visits, and use 6.1 medications.Sick leave due to psoriasis or psoriatic arthritis accounted for 0.04% of all cases. ConclusionsThe prevalence of psoriasis in Catalonia is high at 1.8%. The disease burden is also high, both in terms of comorbidities and health care utilization.

Carga de la psoriasis en Cataluña: datos epidemiológicos, comorbilidades asociadas, uso de recursos sanitarios e incapacidad laboral

Background and objectivesEpidemiologic and disease burden data are essential for disease control and optimal health care resource planning. The aims of this study were to estimate the epidemiologic burden of psoriasis and evaluate associated comorbidities, health care utilization, and sick leave. Material and methodsWe collected data from the 2016 Catalan Health Survey (ESCA), the Catalan Registry of Morbidity and Utilization of Health Care Services (MUSSCAT) (2016), and the database of the Catalan Medical Evaluations Institute (ICAM) (2012–2016). ResultsThe prevalence of psoriasis in Catalonia according to 2016 ESCA data is approximately 1.8%.The MUSSCAT registry data indicate that the incidence has remained stable in recent years. The most common comorbidities associated with psoriasis are hypertension (35%) and diabetes (15%). Forty percent of patients with psoriasis have a moderate to high risk for death or high health resource utilization. Annual use of resources by psoriasis patients is high: they make a mean of 8.7 primary care visits, 2.8 outpatient visits, 0.5 emergency and day hospital visits, 0.2 mental health visits, and use 6.1 medications.Sick leave due to psoriasis or psoriatic arthritis accounted for 0.04% of all cases. ConclusionsThe prevalence of psoriasis in Catalonia is high at 1.8%. The disease burden is also high, both in terms of comorbidities and health care utilization.

Atrial fibrillation in hospitalized patients with end-stage liver disease: temporal trends in prevalence and outcomes.

End-stage liver disease (ESLD) happens due to the development and progression of chronic liver disease. This study aims to investigate the temporal trend, patient characteristics and outcomes of atrial fibrillation (AF) in hospitalized ESLD patients across the United States. Nationwide Inpatient Sample from 2003 to 2014 was utilized to retrospectively study the weighted prevalence of AF in hospitalized ESLD patients. Multivariable regression models were used to assess the association between AF with clinical factors, in-hospital mortality, length of stay (LOS) and cost. 639345 hospitalizations associated with ESLD were identified, of which 47710 (7.48%) were diagnosed with AF. The prevalence of AF increased from 5.73% in 2003 to 9.75% in 2014 in ESLD and varied by age, race, income, insurance type and hospital characteristics. Factors associated with AF included advancing age, male, white race, high income and urban teaching hospital. AF presence was associated with significant higher in-hospital mortality (odds ratio, 1.40; 95% confidence interval, 1.35-1.45), 21% longer LOS and 22% higher cost. In addition, a significant decreasing trend in in-hospital mortality was observed (from 16.70% to 10.63% in patients with AF and from 10.74% to 7.50% in patients without AF). The prevalence of AF in hospitalized ESLD patients has continued to increase from 2003 through 2014. AF is associated with poor prognosis and higher health resource utilization. Innovative anticoagulation strategies through improved collaboration between cardiologists and hepatologists are required for better management of hospitalized ESLD patients comorbid with AF.

Migraine-related healthcare resource use in the emergency department setting: a panel-based chart review in France, Germany, Italy, and Spain

Objective: Migraine is a common, disabling condition typically characterized by severe headache, nausea, and/or light and sound sensitivity. This study assessed migraine-related health resource utilization (HRU) occurring in the emergency room/accident & emergency department (ER/A&E) setting among European patients with 4 or more migraine days per month.Methods: Patient-level clinical and HRU data were collected via chart extraction by ER/A&E physicians in France, Germany, Italy, and Spain. Eligible patients had 4 or more migraine days in the month prior to a migraine-related ER/A&E visit and a history of migraine, among other criteria. The index date for each patient was defined as the date of an ER/A&E visit for migraine on or after January 1, 2013. Physician and ER/A&E characteristics, patient and disease characteristics, treatment history, migraine-medication used, and migraine-related HRU (i.e. procedures) during the ER/A&E visit were assessed. Descriptive analyses were conducted in the pooled population, and a sensitivity analysis was performed by country.Results: A total of 467 eligible patient’s charts (120 in France, 120 in Germany, 107 in Italy, and 120 in Spain) were provided by 136 physicians (36 in France, 36 in Germany, 28 in Italy, and 36 in Spain). On average, patients spent nearly 8 hours in the ER/A&E. Approximately 82% of patients received a blood test, 62% received an electrocardiography, and 46% received a cranial computerized tomography scan. Despite the majority of patients already using acute or prophylactic treatment upon visiting the ER/A&E, almost all patients were administered or prescribed migraine treatment during the visit. Approximately 21% of patients were admitted to the hospital, and over half of patients were referred to a neurologist or headache specialist.Conclusions: European patients who had four or more migraine days in the month prior to a migraine-related ER/A&E visit had high HRU associated with the visit.

PMU82 EFFECT OF CARBAPENEM RESISTANCE ON TOTAL HOSPITALIZATION COSTS AMONG INPATIENTS WITH PSEUDOMONAS AERUGINOSA: A MULTICENTER STUDY IN CHINA

Pseudomonas aeruginosa is one of the most common hospital-acquired gram-negative bacteria, and carbapenems are often first choice to treat resistant infection with gram-negative bacteria. During 2005 and 2014 in China, the resistance level was around 30% for carbapenem resistant P. aeruginosa (CRPA), which is associated with higher health resource utilization. This study aimed to compare differences in the hospitalization costs between inpatients with CRPA and carbapenem-susceptible P. aeruginosa (CSPA) in four hospitals in China. This is a retrospective and multicenter study. All inpatients who detected clinical culture positive for P. aeruginosa between 2013 and 2015 were included. We selected inpatients with the first episode of P. aeruginosa and classified them into CRPA or CSPA group based on antibiotic susceptibility testing. Univariate and a generalized linear model were conducted to explore the factors associated with total hospitalization cost (THC). A total of 6483 inpatients with P. aeruginosa were included (2317 CRPA; 4166 CSPA). The mean differences in THC, medication cost, antibiotic cost, diagnostic cost, treatment cost, and material cost were ¥33231, ¥16984, ¥2178, ¥2916, ¥7295, and ¥2836, respectively, between CRPA and CSPA group. Compared with CSPA cases, CRPA cases were associated with longer length of stay before first culturing (9.32 vs 6.19, <0.000), longer intensive care unit stays (1.92 vs 1.39, <0.000), and higher mortality rate (6.30% vs 3.19%, <0.000). In the generalized linear model, there remained a significantly independent association between carbapenem resistance and THC. Our study highlights the heavy financial burden imposed by P. aeruginosa and carbapenem resistance on the Chinese healthcare system, and provides information that should take increased efforts to decrease the development of CRPA and their economic burden.

Serological, genetic and clinical associations with increased health‐care resource utilization in inflammatory bowel disease

Inflammatory bowel diseases (IBD) are associated with significant morbidity and economic burden. The variable course of IBD creates a need for predictors of clinical outcomes and health resource utilization (HRU) to guide treatment decisions. We aimed to identify clinical, serological or genetic markers associated with inpatient resource utilization in patients with ulcerative colitis (UC) and Crohn's disease (CD). Patients with IBD with available genetic and serological data who had at least one emergency department visit or hospitalization in a 3-year period were included. The primary outcome measure was HRU, as measured by the All Patient Refined Diagnosis Related Group classification system. Univariate and multivariate linear and logistic regression models were used to identify the associations with HRU. Altogether 858 (562 CD and 296 UC) patients were included. Anti-CBir1 seropositivity (P = 0.002, effect size [ES]: 0.762, 95% confidence interval [CI] 0.512-1.012) and low socioeconomic status (P = 0.005, ES: 1.620 [95% CI 1.091-2.149]) were independently associated with a high HRU. CD diagnosis (P = 0.006, ES: -0.701 [95% CI -0.959 to -0.443]) was independently associated with a low inpatient HRU. In patients with IBD who required at least one emergency department visit or hospitalization, anti-CBir1 antibody status may be a useful biomarker of HRU when formulating management strategies to reduce disease complications and resource utilization.

Association of anti-cyclic citrullinated protein antibodies, erosions, and rheumatoid factor with disease activity and work productivity: A patient registry study.

To evaluate associations between the presence of anti-cyclic citrullinated protein antibodies (anti-CCP) and rheumatoid factor (RF) and other outcomes, including joint erosions and both clinical and economic endpoints, in patients with rheumatoid arthritis (RA). Data from the Brigham and Women's Hospital Rheumatoid Arthritis Sequential Study (BRASS), a prospective registry of adult RA patients with established or recent-onset RA, were analyzed. Logistic regression models were constructed to test associations between anti-CCP/RF seropositivity and erosive disease and the presence of anti-CCP/RF seropositivity plus erosive disease and (1) RA severity; (2) hospitalizations; (3) durable medical equipment (DME) use; and (4) worker productivity (e.g., employment status). Covariates in these models included patient age, gender, race, body mass index (BMI), number of comorbidities, and treatment. Among 1309 registrants, those who were positive (vs. negative) for anti-CCP were 2.72 times more likely to have erosions (OR = 2.72; 95% CI: 1.77-4.18; P < 0.001). Individuals positive (vs. negative) for RF were 36% more likely to have erosions (95% CI: 0.88-2.08; P = 0.162). Patients with anti-CCP seropositivity and erosions were significantly more likely to: (1) have higher disease activity as measured by the Disease Activity Score in 28 joints C-reactive protein (DAS28-CRP ≥ 2.6); (2) be hospitalized; (3) use DME; and (4) be unemployed, disabled, or long-term disabled. For the first time in a "real-world" setting including patients with both recent-onset and chronic RA, this study demonstrated that the combination of anti-CCP seropositivity and erosions were significantly associated with more adverse clinical and health-economic consequences, including a lower probability of low disease activity and higher health resource utilization, despite use of biologic disease-modifying antirheumatic drugs by many patients. This dual presentation may signal a need for more intensive therapies, even when observed in patients with chronic, as well as recent-onset, RA. Trial registration [Brigham and Women's Hospital (BWH) Rheumatoid Arthritis Sequential Study; Registry URL: https://clinicaltrials.gov/ct2/show/NCT01793103; ClinicalTrials.gov Identifier NCT01793103].

Health resource utilization and costs during the first 90days following robot-assisted hysterectomy.

To compare health resource utilization, costs and readmission rates between robot-assisted and non-robot-assisted hysterectomy during the 90days following surgery. The study used 2008-2012 Truven Health MarketScan data. All patients admitted as inpatients with a CPT code for hysterectomy between January 2008 and September 2012 were identified and the first hysterectomy-related admission in each patient was included. Patients were categorized based on the route of their hysterectomy and the use of laparoscopy as: total abdominal hysterectomy, vaginal hysterectomy (VH), laparoscopy-assisted supracervical hysterectomy, laparoscopy-assisted vaginal hysterectomy' and total laparoscopic hysterectomy (TLH). Hospitalization costs, including hospital, physician, pharmacy and facility costs, were calculated for the index admissions and for the 90-day follow-up periods. Health resource utilization was determined in terms of inpatient readmissions, outpatient visits, and emergency room visits, RESULTS: There were 302,923 hysterectomies performed over 5years for benign indications in the inpatient setting (55% abdominal, 17% vaginal, and 28% laparoscopic). Concurrent use of robot assistance steadily increased and was reported in 50% of TLH procedures in 2012. The rates of readmission overall were 4.9% for robot-assisted procedures and 4.3% for procedures without robot assistance (OR 0.89, CI 0.82-0.97). Readmission rates were lowest for VH (3.2%) and highest for TLH (5.6%). Following robot-assisted hysterectomy and VH, 8.3% and 4.6% of patients, respectively, had more than ten outpatient visits in the 90-day follow-up period. The average total cost for 90days was $16,820 for robot-assisted hysterectomy and $13,031 for procedures without robot assistance. Of the additional costs for robot-assisted surgery, 25% were incurred in the 90-day follow-up period. The study using private insurance data found that robot-assisted hysterectomy was associated with higher health resource utilization and costs than other minimally invasive approaches. Given the high costs associated with robot-assisted hysterectomy, it is important to understand the specific indications for this approach and to identify the patients who may benefit.

Depression in epilepsy, migraine, and multiple sclerosis: Epidemiology and how to screen for it.

To provide an overview of the epidemiology of depression in chronic neurologic conditions that can affect individuals throughout the lifespan (epilepsy, migraine, multiple sclerosis [MS]) and examine depression screening tools for adults with these conditions. Depression is common in neurologic conditions and can be associated with lower quality of life, higher health resource utilization, and poor adherence to treatment. It affects around 20%-30% of those with epilepsy, migraine, and MS, and evidence for a bidirectional association exists for each of these conditions. Depression screening tools generally perform well in neurologic conditions, but are not without limitations. Depression is a major contributor to poor outcomes in epilepsy, migraine, and MS. Although psychiatric resources are scarce globally, this is no reason to ignore depression in neurologic conditions. Depression screening tools are available in neurology and should be considered in clinical practice.

Effect of Smoking Status on Health Care Costs In Patients With Type 2 Diabetes: A Retrospective Nested Case-Control Economic Study In Routine Clinical Practice

PDB38 EffEct of Smoking StatuS on HEaltH carE coStS in PatiEntS WitH tyPE 2 DiaBEtES: a rEtroSPEctivE nEStED caSE-control Economic StuDy in routinE clinical PracticE Sicras Mainar A.1, Rejas Gutierrez J.2, Navarro Artieda R.3, Ibanez Nolla J.4, De Lossada Juste A.5 1Badalona Serveis Assistencials SA, Badalona (Barcelona), Spain, 2Pfizer S.L.U., Alcobendas/ Madrid, Spain, 3Hospital Germans Trias i Pujol, Badalona (Barcelona), Spain, 4Badalona Serveis Assistencials, Badalona, Spain, 5Pfizer, S.L.U, Alcobendas/Madrid, Spain Objectives: Smoking in diabetics is associated with a worse prognosis and vascular complications. The available evidence on health care resources utilization and associated costs in diabetics who smoke is limited or nonexistent. Thus, the objective was to compare health care resource utilization and costs according to smoking status in patients with type 2 diabetes in clinical practice. MethOds: A retrospective cohort nested case-control study was designed. Cases were current smokers, while two types of controls (former smokers and never smokers) were matched, two controls per case, for age, sex, duration of diabetes, and burden of comorbidity using data from electronic medical records. Non-institutionalized diabetics, both genders, age > 18 years, seen consecutively over a 5-year period before the index date were enrolled. Perspective of both the National Health System and the Society were chosen and costs of health care resource utilization and loss of productivity due to sick leaves were compared among groups using a linear general model with covariates. Results: A total of 2,490 records were analyzed: 498 from cases, 996 from former smokers, and 996 from never smokers. Mean age was 63.4 years (64.9% male). Smokers had higher HbA1c (7.4% vs. 7.2% and 7.2%, respectively, p = 0.013) and a lower degree of metabolic control (49.2 % vs. 54.7% and 55.8%, p = 0.036). Smokers had higher average annual costs (€ 3,583) than former smokers (€ 2,885) and never smokers (€ 2,183), p< 0.001. Mean annual health care cost saving per patient was associated with elapsed time of quitting smoking from € 950 in subjects quitting smoking 2-year to € 1173 5-year or more, p< 0.05. cOnclusiOns: Diabetic smoker patients had lower metabolic control, higher health resource utilization, and more sick leave, resulting in higher health care costs and lost productivity compared with both former and never diabetic smokers. Health care cost-savings was associated with elapsed time from quitting smoking.

Utilization and costs of home care for patients withcolorectal cancer: a population-based study.

The utilization and costs of home care services provided for people with colorectal cancer is not well-known. We conducted an analysis to determine the utilization and costs of such services associated with each stage of colorectal cancer among patients in the province of Ontario. We included cases of colorectal cancer diagnosed in Ontario between Jan. 1, 2005, and Dec. 31, 2009. Data were extracted from the Ontario Cancer Registry and linked to data from a home care administrative database. The types of services used were stratified by stage of disease and by phase of care (initial phase = 180 d after diagnosis, terminal phase = 180 d before death, continuing phase = interval between initial and terminal phases). Overall utilization rates and costs were determined, and regression analysis was used to examine associated factors. A total of 36195 patients had colorectal cancer diagnosed during the study period; the median age was 71 (interquartile range 61-79) years. Home care services were provided to 24641 patients (68.1%). The number of services per patient-year was 27.5, at a cost of $2180 per patient-year. The number of services provided per patient-year increased with increasing disease severity at diagnosis (15.5 at stage I, 25.5 at stage II, 32.5 at stage III and 62.5 at stage IV; 22.6 for unstaged disease). The cost of services per patient-year also increased with disease severity at diagnosis ($1170 at stage I, $1995 at stage II, $2727 at stage III and $5541 at stage IV). Publicly funded home care services and associated costs decreased with increasing income group, but they increased among patients who had a history of high health resource utilization. The mean 30-day cost of home care services decreased from the initial phase of care ($323) to the continuing phase ($160) but increased during the terminal phase ($616). More than two-thirds of the patients with colorectal cancer in this study used home care services. Those who received home care services used about 2 services per month in a one-year period, at a cost of about $2000 per year. This information can aid policy-makers in future decisions regarding resource allocations.

Effect of Smoking Status on Healthcare Costs and Resource Utilization in Patients with Type 2 Diabetes in Routine Clinical Practice: A Retrospective Nested Case-Control Economic Study

Aim: To compare healthcare resource utilization and costs according to smoking status in patients with type 2 diabetes in clinical practice. Methods: A retrospective cohort nested case-control study was designed. Cases were current smokers, while 2 types of controls (former smokers and never smokers) were matched (2 controls per case) for age, sex, duration of diabetes and burden of comorbidity using data from medical records. Noninstitutionalized diabetics of both genders, aged >18 years and seen consecutively over a 5-year period before the index date, were enrolled. Analysis compared healthcare resource utilization, loss of productivity due to sick leave and corresponding costs. Results: In total, 2,490 medical records were analyzed, i.e. 498 cases, 996 former smokers and 996 never smokers. Mean age was 63.4 years (64.9% male). Smokers had higher glycosylated hemoglobin levels (7.4 vs. 7.2 and 7.2%, respectively; p = 0.013) and a lower degree of metabolic control (49.2 vs. 54.7 and 55.8%; p = 0.036). Smokers had higher average annual costs (EUR 3,583) than former smokers (EUR 2,885; p < 0.001) and never smokers (EUR 2,183; p < 0.001). Conclusions: Diabetic smoker patients had lower metabolic control, higher health resource utilization and more sick leave, resulting in higher healthcare costs and lost productivity compared with both former and never smoker diabetics.