Higher Total Healthcare Costs Research Articles

Telehealth Expansion and Medicare Beneficiaries’ Care Quality and Access

Understanding the association of telehealth use with health care outcomes is fundamental to determining whether telehealth waivers implemented during the COVID-19 public health emergency should be made permanent. The current literature has yielded inconclusive findings owing to its focus on select states, practices, or health care systems. To estimate the association of telehealth use with outcomes for all Medicare fee-for-service (FFS) beneficiaries by comparing hospital service areas (HSAs) with different levels of telehealth use. This US population-based, retrospective cohort study was conducted from July 2022 to April 2023. Participants included Medicare claims of beneficiaries attributed to HSAs with FFS enrollment in Parts A and B. Low, medium, or high tercile of telehealth use created by ranking HSAs according to the number of telehealth visits per 1000 beneficiaries. The primary outcomes were quality (ambulatory care-sensitive [ACS] hospitalizations and emergency department [ED] visits per 1000 FFS beneficiaries), access to care (clinician encounters per FFS beneficiary), and cost (total cost of care for Part A and/or B services per FFS Medicare beneficiary) determined with a difference-in-difference analysis. In this cohort study of claims from approximately 30 million Medicare beneficiaries (mean [SD] age in 2019, 71.04 [1.67] years; mean [SD] percentage female in 2019, 53.83% [2.14%]) within 3436 HSAs, between the second half of 2019 and the second half of 2021, mean ACS hospitalizations and ED visits declined sharply, mean clinician encounters per beneficiary declined slightly, and mean total cost of care per beneficiary per semester increased slightly. Compared with the low group, the high group had more ACS hospitalizations (1.63 additional hospitalizations per 1000 beneficiaries; 95% CI, 1.03-2.22 hospitalizations), more clinician encounters (0.30 additional encounters per beneficiary per semester; 95% CI, 0.23-0.38 encounters), and higher total cost of care ($164.99 higher cost per beneficiary per semester; 95% CI, $101.03-$228.96). There was no statistically significant difference in ACS ED visits between the low and high groups. In this cohort study of Medicare beneficiaries across all 3436 HSAs, high levels of telehealth use were associated with more clinician encounters, more ACS hospitalizations, and higher total health care costs. COVID-19 cases were still high during the period of study, which suggests that these findings partially reflect a higher capacity for providing health services in HSAs with higher telehealth intensity than other HSAs.

Outcomes following robotic assisted total knee arthroplasty compared to conventional total knee arthroplasty.

This study elaborates on previous research to compare length of stay, complication rates, and total cost between patients undergoing robotic assisted total knee arthroplasty (rTKA) and conventional total knee arthroplasty (cTKA). We hypothesized that patients undergoing rTKA would have reduced length of stay, lower complication rates, improved perioperative outcomes, and higher total healthcare costs than those undergoing cTKA. Data were collected from the National Inpatient Sample Database Healthcare Cost and Utilization Project between the years 2016-2019. Patients undergoing rTKA and cTKA were identified under International Classification of Diseases, 10th revision codes (ICD-10-CM/PCS). Length of stay, specific complications, and total costs were examined at time point. SPSS (v 27.0 8, IBM Corp. Armonk, NY) was utilized to compare demographic and analytical statistics between rTKA and cTKA. rTKA and cTKA were compared both before and after propensity matching. 17,249 rTKA (3.09%) and 541,122 cTKA (96.91%) were included. Compared to cTKA patients, rTKA patients had reduced average length of stay of 1.91 days (p < 0.001), higher average total cost of $67133.34 (p < 0.001), reduced periprosthetic infection (OR = 0.027, p < 0.001), periprosthetic dislocation (OR = 0.117, p < 0.001), periprosthetic mechanical complication (OR = 0.315, p < 0.001), pulmonary embolism (OR = 0.358, p < 0.001), transfusion (OR = 0.366, p < 0.001), pneumonia (OR = 0.468, p = 0.002), deep vein thrombosis (OR = 0.479, p = 0.001), and blood loss anemia (OR = 0.728, p < 0.001). These differences remained statistically significant even after propensity matching. This study supports our hypothesis that rTKA is associated with fewer complications, but higher average total cost than cTKA. Our study shows that rTKA can be safely performed in older and sicker patients. Future studies assessing the impacts of these findings on patient reported outcomes would provide further insight into the benefits of rTKA. Furthermore, identifying patient specific factors that place them at risk for increased complications with cTKA as opposed to rTKA could provide surgeons insight on the method of TKA that maximizes patient outcomes while minimizing healthcare cost.

Rural-Urban Health Care Cost Differences Among Latinx Adults With and Without Dementia in the United States.

To compare rural-urban health care costs among Latinx adults ages 51+ and examine variations by dementia status. Data are from the Health and Retirement Study (2006-2018 waves; n = 15,567). We inflation-adjusted all health care costs using the 2021 consumer price index. Geographic context and dementia status were the main exposure variables. We applied multivariate two-part generalized linear models and adjusted for sociodemographic and health characteristics. Rural residents had higher total health care costs, regardless of dementia status. Total health care costs were $850 higher in rural ($2,640) compared to urban ($1,789) areas (p < .001). Out-of-pocket costs were $870 higher in rural ($2,677) compared to urban ($1,806) areas (p < .001). Dementia status was not an effect modifier. Health care costs are disproportionately higher among Latinx rural, relative to urban, residents. Addressing health care costs among Latinx rural residents is a public health priority.

Association of Personal Wealth Indicators and Health Care Costs in Persons With Alzheimer's Disease

ObjectivesThere is paucity of studies on the relationship between personal wealth and health care costs among persons with dementia, and earlier studies on other indicators of socioeconomic position have assessed costs after dementia diagnosis only. We investigated how different indicators of personal wealth (disposable income, supplementary income, assets subject to taxation, taxes and tax-like payments, and liabilities) are associated with health care costs in persons with Alzheimer's disease (AD) before and after AD diagnosis. DesignRegister-based nationwide cohort study of persons with AD. Setting and ParticipantsCohort of 70,531 people who received a clinically verified AD diagnosis in Finland between 2005 and 2011 and were community-dwelling at time of diagnosis. MethodsData on income indicators were obtained from Statistics Finland. Data on medication costs and hospital care costs for the 12-month period from 5 years before to 2 years after AD diagnosis were obtained from national registers. Associations of wealth indicators with costs were investigated with multivariate mixed-effect negative binomial regression. ResultsAfter adjustment for age, region, sex, marital status, comorbidities, expensive medications, use of psychotropic and antidementia medication, and highest occupational class before AD, people with higher levels of personal wealth indicators were more likely to have higher total health care costs along the whole follow-up period. The incidence rate ratios (IRRs), 95% CI for highest quintile vs lowest quintile were 1.17, 1.15−1.19 for disposable income, 1.10, 1.08−1.12 for taxable income, 1.18, 1.16−1.19 for supplementary income, 1.07, 1.06−1.09 for taxes, and 1.05, 1.04−1.07 for taxable wealth. Conclusions and ImplicationsOur observation on the association between income/wealth indicators and health care costs in a country with a strong public health care system call for more effective measures in targeting health inequalities in the aging population. Although the different indicators were not completely interchangeable, associations of different indicators were toward the same direction.

Outcomes and cost analysis of patients with dementia in the intensive care unit: a population-based cohort study

BackgroundDementia is a neurological syndrome affecting the growing elderly population. While patients with dementia are known to require significant hospital resources, little is known regarding the outcomes and costs of patients admitted to the intensive care unit (ICU) with dementia.MethodsWe conducted a population-based retrospective cohort study of patients with dementia admitted to the ICU in Ontario, Canada from 2016 to 2019. We described the characteristics and outcomes of these patients alongside those with dementia admitted to non-ICU hospital settings. The primary outcome was hospital mortality but we also assessed length of stay (LOS), discharge disposition, and costs.ResultsAmong 114,844 patients with dementia, 11,341 (9.9%) were admitted to the ICU. ICU patients were younger, more comorbid, and had less cognitive impairment (81.8 years, 22.8% had ≥ 3 comorbidities, 47.5% with moderate-severe dementia), compared to those in non-ICU settings (84.2 years, 15.0% had ≥ 3 comorbidities, 54.1% with moderate-severe dementia). Total mean LOS for patients in the ICU group was nearly 20 days, compared to nearly 14 days for the acute care group. Mortality in hospital was nearly three-fold greater in the ICU group compared to non-ICU group (22.2% vs. 8.8%). Total healthcare costs were increased for patients admitted to ICU vs. those in the non-ICU group ($67,201 vs. $54,080).ConclusionsWe find that patients with dementia admitted to the ICU have longer length of stay, higher in-hospital mortality, and higher total healthcare costs. As our study is primarily descriptive, future studies should investigate comprehensive goals of care planning, severity of illness, preventable costs, and optimizing quality of life in this high risk and vulnerable population.

Oncology hospitalist impact on hospice utilization.

Unplanned hospitalizations among patients with advanced cancer are often sentinel events prompting goals of care discussions and hospice transitions. Late referrals to hospice, especially those at the end of life, are associated with decreased quality of life and higher total health care costs. Inpatient management of patients with solid tumor malignancies is increasingly shifting from oncologists to oncology hospitalists. However, little is known about the impact of oncology hospitalists on the timing of transition to hospice. To compare hospice discharge rate and time to hospice discharge on an inpatient oncology service led by internal medicine-trained hospitalists and a service led by oncologists. At Smilow Cancer Hospital, internal medicine-trained hospitalists were integrated into one of two inpatient medical oncology services allowing comparison between the new, hospitalist-led service (HS) and the traditional, oncologist-led service (TS). Discharges from July 26, 2021, through January 31, 2022, were identified from the electronic medical record. The odds ratio for discharge disposition by team was calculated by logistic regression using a multinomial distribution. Adjusted length of stay before discharge was assessed using multivariable linear regression. The HS discharged 47/400 (11.8%) patients to inpatient hospice, whereas the TS service discharged 18/313 (5.8%), yielding an adjusted odds ratio of 1.94 (95% CI, 1.07-3.51; p=.03). Adjusted average length of stay before inpatient hospice disposition was 6.83days (95% CI, 4.22-11.06) for the HS and 16.29days (95% CI, 7.73-34.29) for the TS (p=.003). Oncology hospitalists improve hospice utilization and time to inpatient hospice referral on an inpatient medical oncology service. Patients with advanced cancer are often admitted to the hospital near the end of life. These patients generally have a poor chance of long-term survival and may prefer comfort-focused care with hospice. In this study, oncology hospitalists discharged a higher proportion of patients to inpatient hospice with less time spent in the hospital before discharge.

Treatment patterns, health care resource utilization, and costs associated with use of atypical antipsychotics as first vs subsequent adjunctive treatment in major depressive disorder.

BACKGROUND: Major depressive disorder (MDD) is a highly prevalent mental health condition associated with substantial economic burden. Inadequate response to first-line antidepressant monotherapy is common, with most patients requiring 1 or more changes in their treatment regimen. Adjunctive treatment with atypical antipsychotics (AAs) is a guideline-recommended treatment option in patients with inadequate response. However, patients often cycle through multiple treatments before receiving adjunctive AAs, and the economic impact of this delay is unknown. OBJECTIVE: To describe adjunctive treatment patterns among patients with MDD and compare health care resource utilization (HCRU) and costs between patients whose first adjunctive therapy included an AA and those who received an AA after other adjunctive treatments. METHODS: The Merative MarketScan Commercial Database (January 1, 2014, to June 30, 2019) was used to identify patients with administrative claims meeting the following inclusion criteria: adults with newly diagnosed MDD (first observed MDD diagnosis = index diagnosis date); continuous health insurance for at least 6 months pre-index and at least 3 months post-index; and initiation of MDD treatment within 60 days post-index. Lines of therapy (LOTs), HCRU, and costs were analyzed in patients who received AA adjunctive therapy, including those who initiated AAs as the first adjunctive treatment and those who initiated AAs as subsequent adjunctive treatment. RESULTS: Of 508,830 patients meeting inclusion criteria, 121,060 (24%) received adjunctive treatment and 20,797 (4%) received an AA as adjunctive therapy. Mean time to adjunctive therapy initiation was approximately 7.3 months for AA adjunctive therapy. Patients who initiated an AA as their first adjunctive therapy compared with patients who initiated an AA as their subsequent adjunctive therapy had fewer LOTs on average (0.9 LOTs vs 3.9 LOTs) and shorter time between index diagnosis date and initiation of an AA (5 months vs 12 months). Subsequent AA initiators had significantly greater HCRU than first AA initiators (driven primarily by outpatient visits) and incurred significantly higher total health care costs, with mean all-cause and mental health-related health care cost differences per patient per year of $2,441 and $1,762, respectively (both P < 0.05). CONCLUSIONS: Less than 5% of patients in this study received an adjunctive AA as part of their MDD treatment regimen, suggesting underutilization of this recommended therapeutic approach. Patients who received an AA as their first adjunctive treatment regimen had lower HCRU and health care costs than subsequent AA initiators. Along with published evidence of clinical benefits, this potential impact on economic burden should be considered when making treatment choices for patients with inadequate response to antidepressants.

Prevalence and impact of antipsychotic discontinuation among commercially-insured patients with bipolar disorder

BackgroundAntipsychotic discontinuation is common among patients with bipolar disorder, especially when psychotic symptoms are remitted. This analysis describes the prevalence, predictors, and economic impact of antipsychotic discontinuation among patients with bipolar disorder.MethodsA retrospective, observational study was conducted using administrative claims data in the IBM MarketScan Commercial Database. Patients with ≥1 claim with a diagnosis for bipolar disorder (manic or mixed) and newly-initiating antipsychotic therapy between 1 January 2011 and 30 June 2016 were included. Baseline characteristics were assessed in the 12 months prior to the initiation. Outcomes were assessed during a 24-month follow-up. Discontinuation of antipsychotic therapy was utilized as a predictor of healthcare costs in models adjusted for baseline characteristics. Using limited set of variables in the claims database, predictors of discontinuation were also assessed.ResultsA total of 18,259 commercially-insured patients were identified as initiators of antipsychotics. Common comorbidities among the cohorts included major depressive disorder and dyslipidemia. Discontinuation was very common among these patients (85%). Major depressive disorder, drug abuse, and other substance abuse/dependency were predictive of discontinuation. Controlling for differences in baseline characteristics, discontinuation was associated with 33% higher inpatient and emergency visit costs (p <.001) among those using these services, and 24% higher total healthcare costs (p <.001) for the overall cohort.ConclusionsMost patients with bipolar mania or mixed states discontinue antipsychotic treatment in less than 2 years. Antipsychotic discontinuation contributes to excess healthcare costs. Future research focusing on the reasons for discontinuation and tailoring disease management based on comorbidities may inform adherence improvement initiatives.

The Increased Clinical and Economic Burden of Hyperkalemia in Medicare Patients Admitted to Long-Term Care Settings.

Older patients are at increased risk for hyperkalemia (HK). This study describes the prevalence, recurrence, and clinical and economic burden of HK in Medicare patients admitted to a long-term care (LTC) setting. Retrospective cohort study using 100% Medicare Fee-for-Service (FFS) claims identified patients aged≥65years with index admission between 2017 and 2019 to a LTC setting (skilled nursing, home health, inpatient rehabilitation, or long-term acute care). Beneficiaries were required to have 12months continuous medical and pharmacy coverage prior to index LTC admission and≥30days after LTC discharge (follow-up). Patient characteristics, healthcare resource utilization, and costs were assessed. HK was defined as ICD-10 diagnosis code E87.5 in any claim position or Medicare Part D fill for oral potassium binder. Of 4,562,231 patients with a LTC stay, the prevalence of HK was 14.7% over the full study period (pre-index, index stay, and follow-up). Excluding those with HK only during the follow-up period resulted in 4,081,103 patients. Of these, 290,567 (7.1%) had HK and 3,790,536 (92.9%) did not have HK during or within 14days prior to index LTC stay. The HK recurrence rate during index stay and follow-up was 48.3%. Unmatched HK versus non-HK patients were more often male (43.0% vs. 35.4%), Black (13.5% vs. 8.0%), dual eligible for Medicaid (34.2% vs. 25.0%), with higher mean Charlson Comorbidity Index scores (6.2 vs. 3.9) (all p<0.0001). After propensity matching, HK patients were 2.2times more likely to be hospitalized, with higher mortality (30.8% vs. 21.5%) and higher total healthcare costs during both index stay (US$26,520 vs. $18,021; p<0.0011) and follow-up ($57,948 vs. $41,744 (p<0.0011) versus matched non-HK patients. Prevalence and recurrence of HK was high among LTC patients, and HK was associated with significantly greater clinical and economic burden during and post-LTC.

Multiple Comorbidities, Psychiatric Disorders, Healthcare Resource Utilization and Costs Among Adults with Essential Tremor: A Retrospective Observational Study in a Large US Commercially Insured and Medicare Advantage Population.

Background: Essential tremor (ET), the most common movement disorder, often impairs patients’ ability to perform activities of daily living, mental health, and quality of life.Objectives: To assess comorbidities, psychiatric disorders, healthcare resource utilization (HCRU), and costs among patients with ET compared with patients without ET.Methods: This retrospective observational study was conducted using a large US administrative claims database. Patients with ET were identified during the study period (1/1/2017–12/31/2019). The earliest claim date with ET diagnosis was identified as the index date. An index date was assigned randomly for each non-ET patient. Patients had to be at least 22 years old and be enrolled in the health plan for at least 6 months before and at least 12 months after the index date. Patients with and those without ET were matched 1:1 on age, gender, payer type, and first 3 digits of their ZIP code. Comorbidities were assessed using data within 6 months prior to the index date. Psychiatric disorders, HCRU, and costs were examined using data within 12 months after the index date.Results: The mean (SD) age of ET patients (n = 5286) was 70.8 (11.8) years, 49.1% were female, and 82.9% were Medicare Advantage members. In the 12 months following the index date, 26.0% of patients had no insurance claims for ET-related pharmacotherapy or invasive therapies. Patients with ET had a higher number of comorbidities than non-ET patients (5.3 [3.2] vs 4.0 [3.3]); a higher prevalence of psychiatric disorders (depression: 25.6% vs 15.3%; adjusted odds ratio (AOR) [95% CI], 1.56 [1.41-1.73]; anxiety: 27.7% vs 15.5%, AOR: 1.78 [1.61-1.96]); and higher total healthcare costs: $17 560 [$39 972] vs $13 237 [$27 098], adjusted cost ratio [95% CI]: 1.11 [1.06-1.16]; all P<.0001.Discussion: Highly prevalent multiple comorbidities and psychiatric disorders should be considered in the context of clinical decision-making to optimize ET management.Conclusions: This study represents the largest observational study to report ET disease and economic burdens in a real-world setting. The data demonstrate increased comorbidity, mental health, and healthcare cost burdens among ET patients compared with matched non-ET patients. These findings underscore the need for innovative care for this complex population.

Multiple Comorbidities, Psychiatric Disorders, Healthcare Resource Utilization and Costs Among Adults with Essential Tremor: A Retrospective Observational Study in a Large US Commercially Insured and Medicare Advantage Population

Background: Essential tremor (ET), the most common movement disorder, often impairs patients’ ability to perform activities of daily living, mental health, and quality of life. Objectives: To assess comorbidities, psychiatric disorders, healthcare resource utilization (HCRU), and costs among patients with ET compared with patients without ET. Methods: This retrospective observational study was conducted using a large US administrative claims database. Patients with ET were identified during the study period (1/1/2017–12/31/2019). The earliest claim date with ET diagnosis was identified as the index date. An index date was assigned randomly for each non-ET patient. Patients had to be at least 22 years old and be enrolled in the health plan for at least 6 months before and at least 12 months after the index date. Patients with and those without ET were matched 1:1 on age, gender, payer type, and first 3 digits of their ZIP code. Comorbidities were assessed using data within 6 months prior to the index date. Psychiatric disorders, HCRU, and costs were examined using data within 12 months after the index date. Results: The mean (SD) age of ET patients (n = 5286) was 70.8 (11.8) years, 49.1% were female, and 82.9% were Medicare Advantage members. In the 12 months following the index date, 26.0% of patients had no insurance claims for ET-related pharmacotherapy or invasive therapies. Patients with ET had a higher number of comorbidities than non-ET patients (5.3 [3.2] vs 4.0 [3.3]); a higher prevalence of psychiatric disorders (depression: 25.6% vs 15.3%; adjusted odds ratio (AOR) [95% CI], 1.56 [1.41-1.73]; anxiety: 27.7% vs 15.5%, AOR: 1.78 [1.61-1.96]); and higher total healthcare costs: $17 560 [$39 972] vs $13 237 [$27 098], adjusted cost ratio [95% CI]: 1.11 [1.06-1.16]; all P&lt;.0001. Discussion: Highly prevalent multiple comorbidities and psychiatric disorders should be considered in the context of clinical decision-making to optimize ET management. Conclusions: This study represents the largest observational study to report ET disease and economic burdens in a real-world setting. The data demonstrate increased comorbidity, mental health, and healthcare cost burdens among ET patients compared with matched non-ET patients. These findings underscore the need for innovative care for this complex population.

PD17-02 COST IMPLICATIONS OF INFECTIOUS COMPLICATIONS FOLLOWING PROSTATE BIOPSIES IN THE UNITED STATES

You have accessJournal of UrologyCME1 May 2022PD17-02 COST IMPLICATIONS OF INFECTIOUS COMPLICATIONS FOLLOWING PROSTATE BIOPSIES IN THE UNITED STATES Sharon White, Eric Ballon-Landa, Michael Bronsert, Boris Gershman, Peter Clark, Granville Lloyd, Jeffrey Morrison, Rodrigo Rodrigues-Pessoa, Marc Smaldone, Anessa Sax-Bolder, and Simon Kim Sharon WhiteSharon White More articles by this author , Eric Ballon-LandaEric Ballon-Landa More articles by this author , Michael BronsertMichael Bronsert More articles by this author , Boris GershmanBoris Gershman More articles by this author , Peter ClarkPeter Clark More articles by this author , Granville LloydGranville Lloyd More articles by this author , Jeffrey MorrisonJeffrey Morrison More articles by this author , Rodrigo Rodrigues-PessoaRodrigo Rodrigues-Pessoa More articles by this author , Marc SmaldoneMarc Smaldone More articles by this author , Anessa Sax-BolderAnessa Sax-Bolder More articles by this author , and Simon KimSimon Kim More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002555.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Infectious complications following transrectal ultrasound prostate biopsies (TRUS-PB) represent a growing burden in the U.S. Understanding the health care costs attributable to these adverse outcomes following this common urologic procedure is essential but remains largely unknown. Herein, we describe the economic burden attributable to post TRUS-PB infectious complications from a population-based cohort of privately-insured patients. METHODS: From 2010 to 2015, we identified all patients who underwent an incident TRUS PB from MarketScan. Health care costs and patient out-of-pocket costs due to infectious complications requiring hospital admission and emergency room (ER) visits within 30 days of the TRUS-PB represented the primary outcome. Multivariable analyses were used to identify patient characteristics associated with higher health care and out-of-pocket costs. RESULTS: Overall, 193,490 patients underwent TRUS-PB and the mean age was 57.6 years (SD: 5.0). The rates of infectious complications requiring ER visits and hospital admissions were 0.4 and 1.2 per 100 prostate biopsies. Compared to patients who did not experience any infectious complications, patient admitted to hospital within 30 days had higher health care costs ($14,057 vs. $625; p < 0.001) and out-of-pocket costs ($80 vs. $9; p<.0001). Similarly, patients who required ER visits also had higher total health care costs compared to those who did not experience infectious complications ($141 vs. $4; p<.0001). Higher aggregate health care costs ($14,198 vs. $629; p<.0001) and out-of-pockets costs ($89 vs. $18; p<.0001) were observed for patients who sustained infectious complications. The total health care cost for infections was $38,234,689 On multivariable analyses, patients who had Elixhauser index defined comorbidities had total health care costs (p<0.001). CONCLUSIONS: Infectious complications following TRUS-PB are associated with significant economic burden to the health care system and patients. Efforts to reduce post TRUS-PB infectious complications can significantly improve value-based health care delivery. Source of Funding: This study was supported by the Schramm Foundation © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e336 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sharon White More articles by this author Eric Ballon-Landa More articles by this author Michael Bronsert More articles by this author Boris Gershman More articles by this author Peter Clark More articles by this author Granville Lloyd More articles by this author Jeffrey Morrison More articles by this author Rodrigo Rodrigues-Pessoa More articles by this author Marc Smaldone More articles by this author Anessa Sax-Bolder More articles by this author Simon Kim More articles by this author Expand All Advertisement PDF DownloadLoading ...

Association of Body Compartment Shrinkage with Subsequent Health Care Utilization in Older Men

With demographic aging, many older adults require home medical care. Although home-based primary care is promoted in the United States and Japan, there is insufficient evidence about it. We aimed to study the characteristics and prognoses of long-term home care patients. We prospectively registered 151 patients, estimated to receive physician home visits for more than six months, in a clinic in Chiba, Japan, in 2020. The mean (±SD) age was 83.9±10.0 years and ranged from 31 to 102 years. Most patients were men (60.3%) and aged 65 years or above (95.3%). We investigated clinical information, the Edmonton Symptom Assessment System Revised Japanese version (ESAS-r-J), Dementia Assessment Sheet in Community-based Integrated Care System 21 items (DASC-21), EuroQOL 5 dimensions 5-level (EQ-5D-5L) every six months, and the incidence of hospital admission, death, and patient transportation by ambulance. The most frequent diagnoses were dementia (31.1%), bone and articular diseases (17.2%), cerebrovascular diseases (11.9%), organ failure (9.3%), and neurological diseases (9.3%). Most patients (78.2%) showed more than 30 points on the DASC-21, suggesting cognitive impairment. Worse wellbeing, drowsiness, tiredness, anxiety, depression, and pain were the most prevalent symptoms. EQ-5D-5L index values were distributed around–0-0.2 and 0.4-0.7. During the first three months of physician home visits, 21.9% of patients had hospital admissions, 12.5% of them died, and 11.7% required hospital transportation by an ambulance. In this study, most long-term home care patients suffered from cognitive impairment. In addition to receiving care for daily life, these patients require intensive medical management.

Characteristics and resource utilization of high-cost users in the intensive care unit: a population-based cohort study

BackgroundHealthcare expenditure within the intensive care unit (ICU) is costly. A cost reduction strategy may be to target patients accounting for a disproportionate amount of healthcare spending, or high-cost users. This study aims to describe high-cost users in the ICU, including health outcomes and cost patterns.MethodsWe conducted a population-based retrospective cohort study of patients with ICU admissions in Ontario from 2011 to 2018. Patients with total healthcare costs in the year following ICU admission (including the admission itself) in the upper 10th percentile were defined as high-cost users. We compared characteristics and outcomes including length of stay, mortality, disposition, and costs between groups.ResultsAmong 370,061 patients included, 37,006 were high-cost users. High-cost users were 64.2 years old, 58.3% male, and had more comorbidities (41.2% had ≥3) when likened to non-high cost users (66.1 years old, 57.2% male, 27.9% had ≥3 comorbidities). ICU length of stay was four times greater for high-cost users compared to non-high cost users (22.4 days, 95% confidence interval [CI] 22.0–22.7 days vs. 5.56 days, 95% CI 5.54–5.57 days). High-cost users had lower in-hospital mortality (10.0% vs.14.2%), but increased dispositioning outside of home (77.4% vs. 42.2%) compared to non-high-cost users. Total healthcare costs were five-fold higher for high-cost users ($238,231, 95% CI $237,020–$239,442) compared to non-high-cost users ($45,155, 95% CI $45,046–$45,264). High-cost users accounted for 37.0% of total healthcare costs.ConclusionHigh-cost users have increased length of stay, lower in-hospital mortality, and higher total healthcare costs when compared to non-high-cost users. Further studies into cost patterns and predictors of high-cost users are necessary to identify methods of decreasing healthcare expenditure.

Incremental Healthcare Utilization and Cost Burden of Comorbid Insomnia in Alzheimer’s Disease Patients

Background:Insomnia is associated with worsened clinical outcomes among Alzheimer’s disease dementia (AD) patients, increased caregiver burden, and healthcare utilization.Objective:This study aimed to characterize the incremental healthcare burden of insomnia in AD using real-world data.Methods:A retrospective observational study was conducted on AD patients selected from the IBM® MarketScan Commercial and Medicare Supplemental Databases. AD patients with claims-based evidence of insomnia were direct matched to a non-insomnia cohort based on demographic factors. Healthcare utilization and associated costs were assessed for a 12-month follow-up period.Results:A total of 3,500 insomnia AD patients and 9,884 non-insomnia AD patients were analyzed. The insomnia cohort had a higher comorbidity burden at baseline (mean score on Charlson Comorbidity Index 2.5 versus 2.2, p < 0.001) and higher proportions of patients with baseline diagnoses for other conditions including depression: 40%, insomnia cohort versus 25%, non-insomnia (p < 0.001). AD patients with insomnia were more likely to have a claim for inpatient hospitalizations (39.8%versus 32.3%), emergency room services (56.4%versus 48.0%), and skilled-nursing services (42.6%versus 31.9%) (all p < 0.05). Mean total annual healthcare costs during the 12-month follow-up period were significantly higher among AD patients with insomnia as compared to those without. (Mean costs: $37,356 versus $27,990, p < 0.001).Conclusion:AD patients with comorbid insomnia are more likely to use higher-cost healthcare services such as inpatient hospitalization, and skilled nursing, and have higher total healthcare costs. This real-world analysis provides evidence that AD disease management should consider proper treatment of comorbid insomnia due to the incremental burden and cost implications.

PMH54 Impact of Bipolar Disorder Treatment Discontinuation on Healthcare Utilization and Costs in the Real-World Setting

To describe the real-world antipsychotic (AP) treatment discontinuation patterns and the association between treatment discontinuation and healthcare costs among bipolar disorder patients. A retrospective observational study was conducted using administrative claims data the IBM® MarketScan Commercial Database. Patients with at least 1 medical claim with a diagnosis of bipolar disorder (manic or mixed sub-type) and newly initiating AP therapy between 1/1/11-6/30/16 were included. Baseline patient characteristics were assessed in the 12 months prior to the AP initiation. Total healthcare costs and healthcare utilization were assessed during a 24-month follow-up. Discontinuation of index AP therapy, defined as a gap of at least 60 days without the medication on-hand, was utilized as a predictor of healthcare costs and utilization outcomes in generalized linear and logistic regression models adjusted for baseline characteristics. Predictors of discontinuation were also assessed via logistic regression. A total of 18,259 bipolar disorder patients were identified as new initiators of APs. The cohort was 61% female and had an average age of 39 years. The most commonly initiated AP was quetiapine (33.6%), followed by aripiprazole (29.3%). A total of 15,460 patients (85%) discontinued their index regimen. Patients with baseline substance use disorders, depression, and other anxiety disorders were significantly more likely to discontinue. More than half of the cohort utilized emergency room services (53%) and 33% had at least one inpatient admission during the follow-up. The median total healthcare costs were $24,861 during the 24-month follow-up. Controlling for differences in baseline characteristics, discontinuation of AP therapy was associated with 24% higher total healthcare costs (Cost ratio: 1.24; p<0.001) and 33% higher inpatient+ER costs (1.33; p<0.001). Discontinuation of AP therapy among bipolar disorder patients is high and contributes to excess healthcare costs and high-cost services. Future research focusing on the reasons for discontinuation may inform medication adherence initiatives.

Association of Frailty with Healthcare Costs Using Claims Data in Korean Older Adults Aged 66.

To explore the association of frailty and its eight components with claims-based healthcare costs among South Korean older adults aged 66 from 2009 to 2012. A cross-sectional design. Data were obtained from administrative claims, Regular Biennial General and Cancer Screening Examinations, and the 66-year Lifetime Transitional Period Health Examination. South Korean older adults aged 66 (N = 818,337). Frailty was measured using eight components (i.e., hospital admission, self-assessed health status, polypharmacy, weight loss, depressed mood, incontinence, visual and auditory problems, and performance on the Timed Up and Go test). Healthcare costs included those associated with inpatient and outpatient care and pharmaceuticals. Multiple Tobit regression was used to assess the association between frailty and healthcare costs before and after propensity score matching. The mean annual total healthcare cost was $1,403.24 in robust participants, $2,364.78 in pre-frail participants, and $3,655.13 in frail participants. Among participants after propensity score matching, total healthcare costs were higher by $959.58 in the pre-frail (P < 0.001) and by $2,249.70 in the frail group (P < 0.001) compared to the robust group. The presence of each of the eight frailty components was significantly associated with higher total healthcare costs. By comparing the variables of interest using claims data, our study showed that frailty and each of its eight symptoms was associated with increased healthcare costs. This provides evidence of the need for identifying and managing frailty to reduce healthcare costs among South Korean older adults.

Risk Factors Associated with 90-Day Readmissions Following Occipitocervical Fusion—A Nationwide Readmissions Database Study

Occipitocervical fusion (OCF) procedures are increasing due to an aging population and the prevalence of trauma, rheumatoid arthritis, and tumors. Reoperation rates and readmission risk factors for cervical fusions have been established, but in relation to OCF they have not been explored. This study investigates the patterns of readmissions and complications following OCF using a national database. The 2016 U.S. Nationwide Readmissions Database was used for sample collection. Adults (>18 years) who underwent OCF were identified using the 2016 ICD-10 coding system, and we examined the readmission rates (30-day and 90-day) and reoperation rates. Between January and September 2016, a total of 477 patients underwent OCF; the 30-day and 90-day readmission rates were 10.4% and 22.4%, respectively. The 90-day reoperation rate related to the index surgery was 5.7%. Mean age (68.58 years) was significantly greater in the readmitted group versus nonreadmitted group (61.76 years) (P < 0.001). The readmitted group had a significantly higher Charlson Comorbidity Index and Elixhauser Comorbidity Index (5.00 and 2.41, respectively) than the nonreadmitted group (3.25 and 1.15, respectively; P < 0.001). Nonelective OCF showed a higher readmission rate (29.18%) versus elective OCF (12.23%) (P < 0.001). Medicare and Medicaid patients showed the highest rates of readmission (27.27% and 20.41%, respectively). Readmitted patients had higher total health care costs. Nonelective OCF was found to have a readmission rate of almost 2½× that of elective OCF. Understanding risk factors associated with OCF will help with operative planning and patient optimization.

Burden of Heavy Menstrual Bleeding Associated with Uterine Fibroids: A Retrospective Analysis of a U.S. Medicaid Population

Study Objective Assess healthcare costs in Medicaid women diagnosed with uterine fibroids (UF) and/or heavy menstrual bleeding (HMB). Design Retrospective claims analysis. Study period: January 1, 2007 - December 31, 2017. Setting IBM® MarketScan® Multi-State Medicaid Database. Patients or Participants Women age 18-51 years were grouped into four cohorts based upon diagnosis: (a) UF only (ICD-9 218.x or ICD-10 D25.x), (b) HMB only (ICD-9 626.2 or 627.0, or ICD-10 N92.0, N92.1 or N92.4), (c) UF+HMB, and (d) controls. Cohorts were matched based upon age, race, insurance type, and Charlson Comorbidity Index. Patient and treatments characteristics at baseline (1 year pre diagnosis) and follow-up (1 year post diagnosis) were examined descriptively, differences in follow-up costs were examined using analysis of variance. Interventions N/A. Measurements and Main Results After matching, study population included 16,691 women in each cohort, with mean age of 38 years and 54% black. In the matched cohorts, a higher percentage of women with UF+HMB were diagnosed with anemia at baseline (31%), compared to women with UF only (14%) or HMB only (19%). During follow-up, 41% of the UF+HMB cohort were treated surgically, compared to 14% of women with UF only and 15% with HMB only. Among women treated surgically, 74%, 83%, and 44% of the UF+HMB, UF only, and HMB only cohorts, respectively, had a hysterectomy. Mean all-cause total healthcare costs in the UF+HMB cohort ($11,310) were significantly higher compared to costs for all other cohorts ($9,400 UF only; $9,308 HMB only; $7,255 controls; all P Conclusion Women enrolled in Medicaid and diagnosed with UF+HMB are more frequently treated surgically and have significantly higher total healthcare costs compared to women with UF only, HMB only, or controls.

Health care utilization and cost associated with switching biologics within the first year of biologic treatment initiation among patients with ankylosing spondylitis.

Costs associated with biologic switching and discontinuation can be high in chronic inflammatory diseases. Inappropriate use of medications may have cost implications for both payers and patients. Understanding of biologic utilization and switching rates is lacking among patients with ankylosing spondylitis (AS). To compare direct costs of treatment switchers, nonswitchers, and discontinuers among patients with AS who newly initiated a biologic. Patients aged ≥ 18 years with an AS diagnosis and ≥ 1 pharmacy claim for an FDA-approved subcutaneous biologic for AS between January 1, 2016, and December 31, 2016 (identification period) were identified from the Truven Health MarketScan Databases. At the time of biologic initiation (index date), eligible patients were continuously enrolled with medical and pharmacy claims for ≥ 1 year before (baseline period) and ≥ 1 year after the index date (follow-up period). Patients with AS were categorized into 3 mutually exclusive groups of nonswitchers (patients who remained on their index biologic), switchers (patients who had a prescription for a biologic therapy other than their index biologic), and discontinuers (patients who had gaps in prescription claims [> 120 days]) based on their biologic utilization pattern during the 1-year follow-up period. Health care costs (inflated to year 2017 costs) during follow-up were described across the 3 groups separately and by disease. Adjusted health care resource utilization and costs during 1-year follow-up were estimated, controlling for age, sex, fulltime work status, and Charlson Comorbidity Index (Deyo's modification) during the baseline period. A total of 791 patients with AS who were newly initiating a biologic were categorized as switchers (15.4%), nonswitchers (53.1%), and discontinuers (31.5%). Switchers and discontinuers had higher all-cause health care utilization than nonswitchers during the 1-year follow-up period. Switchers had higher mean total health care costs than nonswitchers ($71,280 vs. $66,573) due to increased medical ($13,897 vs. $12,043) and pharmacy costs ($57,384 vs. $54,530). Discontinuers had the lowest total health care costs ($41,179) but had the highest medical costs ($19,079). Adjusted analyses for covariates confirmed similar trends as the unadjusted analysis, where discontinuers had significantly lower total health care and pharmacy costs but had higher medical costs (with increased emergency department and outpatient visits) than nonswitchers (all P < 0.001). Switchers had increased outpatient visits and costs versus nonswitchers in the adjusted analysis (P < 0.001); small sample sizes in the switcher group may have limited the ability to detect significant trends in the adjusted analysis. Biologic switching resulted in higher total health care costs than remaining on the same biologic in patients with AS. These findings highlight the clinical and economic impact of discontinuing or switching biologic therapies in patients with AS, which may inform treatment and/or formulary decision making. This study was sponsored by Novartis Pharmaceuticals (East Hanover, NJ). Yi, Dai, and Park are employed by Novartis. Piao was an employee of KMK Consulting, supporting Novartis at the time of this study; Zheng is an employee of KMK Consulting and works as a consultant for Novartis. Portions of this work were presented at the 2019 AMCP Managed Care and Specialty Pharmacy Annual Meeting; March 25-28, 2019; San Diego, CA; and AMCP Nexus 2019; October 29-November 1, 2019; National Harbor, MD.