Inpatient Expenditures Research Articles

Trends in health care expenditure in U.S. adults with diabetes: 2002-2011.

OBJECTIVEDirect medical cost of diabetes in the U.S. has been estimated to be 2.3 times higher relative to individuals without diabetes. This study examines trends in health care expenditures by expenditure category in U.S. adults with diabetes between 2002 and 2011.RESEARCH DESIGN AND METHODSWe analyzed 10 years of data representing a weighted population of 189,013,514 U.S. adults aged ≥18 years from the Medical Expenditure Panel Survey. We used a novel two-part model to estimate adjusted mean and incremental medical expenditures by diabetes status, while adjusting for demographics, comorbidities, and time.RESULTSRelative to individuals without diabetes ($5,058 [95% CI 4,949–5,166]), individuals with diabetes ($12,180 [11,775–12,586]) had more than double the unadjusted mean direct expenditures over the 10-year period. After adjustment for confounders, individuals with diabetes had $2,558 (2,266–2,849) significantly higher direct incremental expenditures compared with those without diabetes. For individuals with diabetes, inpatient expenditures rose initially from $4,014 in 2002/2003 to $4,183 in 2004/2005 and then decreased continuously to $3,443 in 2010/2011, while rising steadily for individuals without diabetes. The estimated unadjusted total direct expenditures for individuals with diabetes were $218.6 billion/year and adjusted total incremental expenditures were approximately $46 billion/year.CONCLUSIONSOur findings show that compared with individuals without diabetes, individuals with diabetes had significantly higher health expenditures from 2002 to 2011 and the bulk of the expenditures came from hospital inpatient and prescription expenditures.

Health care expenditures associated with depression in adults with cancer.

The rates of depression in adults with cancer have been reported as high as 38%-58%. How depression affects overall health care expenditures in individuals with cancer is an under-researched area. To estimate excess average total health care expenditures associated with depression in adults with cancer by comparing those with and without depression after controlling for demographic, socioeconomic, access to care, and other health status variables. Cross-sectional data on 4,766 adult survivors of cancer from 2006-2009 of the nationally representative household survey, Medical Expenditure Panel Survey (MEPS), were used. The patients were older than 21 years. Cancer and depression were identified from the patients' medical conditions files. Dependent variables consisted of total, inpatient, outpatient, emergency department, prescription drugs, and other expenditures. Ordinary least square (OLS) on logged dollars and generalized linear models with log-link function were performed. All analyses (SAS 9.3 and STATA12) accounted for the complex survey design of the MEPS. Overall, 14% of individuals with cancer reported having depression. In those with cancer and depression, the average annual health care expenditures were $18,401 compared with $12,091 in those without depression. After adjusting for demographic, socioeconomic, access to care, and other health status variables, those with depression had about 31.7% greater total expenditures compared with those without depression. Total, outpatient, and prescription expenditures were higher in individuals with depression than in those without depression. Individuals with cancer and depression were significantly more likely to use emergency departments (adjusted odds ratio, 1.46) compared with their counterparts without depression. Cancer patients who died during the reporting year were excluded. The financial burden of depression may have been underestimated because the costs of end-of-life care are high. The burden for each cancer type was not analyzed because of the small sample size. In adults with cancer, those with depression had higher health care utilization and expenditures compared with those without depression. One author was partially supported by the National Institute of General Medical Sciences, U54GM104942.

Tertiary paediatric hospital admissions in children and young people with cerebral palsy.

Many previous studies that have investigated hospital admissions in children and young people with cerebral palsy lack information on cerebral palsy severity and complexity. Consequently, little is known about factors associated with the frequency and type of hospital admissions in this population. This study used hospital admission data available for all children and young people known to a population-based cerebral palsy register to describe the patterns of use of tertiary paediatric hospital services over a 5-year period. This was a retrospective cohort analysis of routinely collected admission data from the two tertiary paediatric hospitals in the Australian state of Victoria. Data on admissions of individuals born between 1993 and 2008 registered on the Victorian Cerebral Palsy Register were analysed (n = 2183). Between 2008 and 2012, 53% of the cohort (n = 1160) had at least one same-day admission, and 46% (n = 996) had one or more multi-day admissions. Those with a moderate to severe motor impairment and those with a co-diagnosis of epilepsy had more admissions, and for multi-day admissions, longer lengths of stay, P < 0.05. Across all severity levels, respiratory and musculoskeletal diseases were the most frequently reported reasons for medical and surgical admissions, respectively. All-cause readmission rates for urgent multi-day stays within 7, 30 and 365 days of an index admission were 10%, 23% and 63%, respectively. The reasons for hospital admissions reported here reflect the range of comorbidities experienced by children and young people with cerebral palsy. This study highlights priority areas for prevention, early diagnosis and medical management in this group. Improved primary and secondary prevention measures may decrease non-elective hospital admissions and readmissions in this group and reduce paediatric inpatient resource use and healthcare expenditure attributable to cerebral palsy.

Inpatient Treatment Patterns and Health Care Expenditures for Hepatocellular Carcinoma among the Population with Urban Basic Health Insurance in China

ObjectiveTo identify inpatient treatment patterns and health care expenditures for hepatocellular carcinoma (HCC) among the population with urban basic health insurance (BHI) in China. MethodsHospitalizations for patients 18 years or older with discharge diagnosis of HCC from 2008 to 2011 and enrolled in the Chinese BHI plan were identified from the Chinese Health Insurance Research Association database. Treatment approaches and hospital expenditures were assessed for the full sample, and according to city level and hospital tier. Analyses were extrapolated to the national urban BHI population. ResultsA total of 3679 HCC hospitalizations were identified in the period 2008 to 2011, representing 615,359 hospitalizations among the urban BHI population. More than two-thirds of the patients received active treatment during hospitalization (68%, N = 418,394), most commonly with traditional Chinese medicine (51%) and/or transarterial intervention therapy (21%). Cases from larger level 1 cities and larger tier 3 hospitals reported greater use of active treatments (81% and 83%, respectively) than did those from smaller level 3 cities (46%) or tier 1 hospitals (56%). Hospital expenditures were higher in level 1 cities (mean [95% confidence interval] Chinese currency renminbi [¥] 17,119 [¥16,292–¥17,946]; US $2,506 [$2,385–$2,628]) than in level 3 cities (mean [95% confidence interval] ¥7,870 [¥5,775–¥9,964]; $1,152 [$846–$1,459]). ConclusionsMost patients with HCC received active treatment during hospitalization in China. There were substantial disparities, however, in the use of HCC treatments across different economic regions, and nearly a third received only palliative care. With the recent launch of health care reform, this study provides valuable insights into current resource use and costs for HCC in China to help prioritize areas of improvement.

PHS131 - Out-of-pocket Healthcare Expenditures among patients with Chronic obstructive Pulmonary disease

To describe out-of-pocket (OOP) expenditures for hospitalizations, ambulatory care visits and prescription medications and to determine if there is the difference in OOP expenditures by insurance status among subjects with Chronic Obstructive Pulmonary Disease (COPD). Data for this study were drawn from the 2012 Medical Expenditure Panel Survey (MEPS). The sample included adults (≥18 years) with a COPD diagnosis (ICD-9 codes 491, 492, and 496) who received COPD services at least once in 2012. The dependent variable was annual OOP expenditures and the independent variable was health insurance type (private, public, or no insurance). Descriptive statistics and inferential tests were conducted using SAS ProcSurvey for complex sampling design. Study subjects’ (N=587 unweighted; N=5,982,925 weighted) total mean±SE OOP COPD expenditures were $236.2±45.1 per person. Subjects with no insurance had total OOP expenditures ($621.3±385.9) that were 2.8 to 4.0 times higher than those who were privately ($221.4±22.6) or publicly ($156.9±22.9) insured. Inpatient expenditures (N=31 unweighted; N=332,414 weighted) were significantly higher for subjects with no insurance ($4,631.7±0), and lower for subjects with private ($186.9±1.9) and public insurance ($105.6±4.7). Ambulatory care visit (N=385 unweighted; N=3,831,325 weighted) OOP expenditures for subjects with no insurance ($77.9±14.0) were over 2 times higher than OOP expenditures for those privately or publicly insured ($35.0±5.3; $28.2±5.6, respectively). Of those who had prescription expenditures (N=468 unweighted; N=4,906,191 weighted), patients with private and those with no insurance paid similar OOP amounts ($222.1±24.8; $224.8±61.4, respectively), while those with public insurance had lower OOP expenditures ($162.5±24.4). When compared to subjects with private or public insurance, those with no insurance had higher OOP expenditures for COPD-related total, inpatient and ambulatory care services and lower OOP expenditures for prescriptions. Increasing the use of appropriate COPD medications among the uninsured may result in cost-savings due to reduced hospitalizations.

Pradigastat Did Not Increase Fecal Bile Acids in Patients with Familial Chylomicronemia Syndrome After 52 Weeks

Lead Author’s Financial Disclosures: Dr. Becker has received a grant from Amgen Inc. Study Funding: This study was funded by Amgen Inc. Background/Synopsis: While many studies have examined cost of MI or stroke, few have compared the cost of initial and recurrent events. This study provides information about how treatment intensity may change based on event type and provides more accurate costs for economic models. In the elderly Medicare population, a recurrent stroke costs more than initial stroke; however, the cost of a recurrent myocardial infarction (MI) is lower than the initial MI. Objective/Purpose: This analysis will describe health expenditures following initial and recurrent MI or stroke among elderly Medicare beneficiaries. Methods: We used Medicare claims data to identify beneficiaries who were hospitalized between Jan. 1, 2006 and Dec. 31, 2011 with MI or stroke. For each patient, we identified the first MI or stroke hospitalization meeting our case-definition, which requires a primary diagnosis (or procedure codes) of MI or stroke and no hospitalizations for any cardiovascular events during the prior 18 months. We also limited our analysis to beneficiaries who were $65 and who were continuously enrolled in fee-for-service Medicare during the 18 months prior to their index hospitalization and the 90 days following their index event. We identified mean unadjusted inpatient and outpatient medical expenditures in the 90-day period following index and recurrent MI and stroke hospitalizations. Outpatient drug expenditures were not captured. To identify recurrent MI or stroke hospitalizations, we require a minimum of 30 days between the index discharge date and the admission date for a hospitalization with the same diagnosis. Events occurring within 30 days were assumed to be part of the initial event. Results: As shown in the table below, average expenditures in the 90-day period following index MI and stroke hospitalizations are similar. In contrast, the average expenditures of recurrent hospitalizations are higher than initial hospitalizations for stroke but are lower for MI. Conclusions: Whereas the mean expenditures for index MI and stroke hospitalizations are similar, the average costs of recurrent hospitalizations are higher for stroke patients. These patterns may be explained by increased treatment intensity during index MI hospitalizations relative to recurrent hospitalizations and increased treatment intensity in the recurrent events for stroke patients. These estimates can be used to more accurately assess cost-effectiveness of interventions that reduce cardiovascular events in an elderly Medicare population.

Recent trends in placenta accreta in the United States and its impact on maternal–fetal morbidity and healthcare-associated costs, 1998–2011

Objective: To describe the prevalence, trends, adverse maternal-fetal morbidities and healthcare costs associated with placenta accreta (PA) in the United States (US) between 1998 and 2011.Methods: A retrospective, cross-sectional analysis of inpatient hospital discharges was conducted using the National Inpatient Sample (NIS). We used International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) codes to identify both cases of PA and of selected comorbidities. Survey logistic regression was used to assess the association between PA and various maternal–fetal outcomes. Joinpoint regression modeling was used to estimate annual percent changes (APCs) in PA prevalence during the study period.Results: The prevalence of PA from 1998 to 2011 was 3.7 per 1000 delivery-related discharges. After adjusting for known or suspected confounders, PA conferred between a 20% to over a 19-fold increased odds of experiencing an adverse outcome. This resulted in a higher mean, per-hospitalization, cost of inpatient care after adjustment for inflation ($5561 versus $4989), translating into over $115 million dollars in additional inpatient expenditures relative to non-PA affected deliveries from 2001 to 2011.Conclusions: This study updates recent trends in the prevalence of PA, which is valuable to clinicians and policymakers as they formulate targeted strategies to address factors related to PA.

Health care utilization and expenditures of persons with diabetes comorbid with anxiety disorder: a national population-based cohort study

ObjectiveThe aim of this study was to investigate and compare health care utilization and expenditures between persons with diabetes comorbid with and without anxiety disorder in Taiwan. MethodsHealth care utilization and expenditures among persons with diabetes with and without comorbid anxiety disorder in the period 2000–2004 were examined using the Taiwan's National Health Insurance claims data. Health care utilization included outpatient visits and use of hospital inpatient services, while expenditures included outpatient, inpatient and total medical expenditures. General estimation equation (GEE) models were used to analyze the factors associated with outpatient visits and expenditures, and multiple logistic regression analysis was applied to identify factors associated with hospitalization. ResultsIn the study period, the average number of annual outpatient visits was 43.11–50.37 and 29.82–31.42 for persons with diabetes comorbid with anxiety disorder and for those without anxiety disorder, respectively. The average annual total expenditure was NT$74,875–92,781 and NT$63,764–81,667, respectively. Controlling for covariates, the GEE models revealed that age and time were associated with outpatient visits. Income and time factor were associated with total expenditure. ConclusionsHealth care utilization and expenditures for persons with diabetes with comorbid anxiety disorder are significantly higher than those without anxiety disorder. The factors associated with health care utilization and expenditures are age, income and time.

The choice of reoperation after primary surgeries for uterine prolapse: A nationwide study

Abstract Objective Our previous study described the increasing adoption of uterine-preserving procedures in the surgical approach for uterine prolapse. In this follow-up study, we further explored the reoperation rate and variables for the choice of surgeries after primary uterine prolapse surgery, based on the nationwide claim data in Taiwan. Materials and methods The data of this study was obtained from the Inpatient Expenditures by Admission files of the National Health Insurance Research Database (NHIRD). Women who received primary and repeat surgeries, either hysteropexy or hysterectomy, were identified between 1997 and 2010; and followed up to 2010 or till the event of reoperation. We analyzed the variables including the primary surgical type, concomitant stress urinary incontinence (SUI) surgery, patient age, surgeon age, and hospital accreditation level. Results Among the total 36,609 women, a higher reoperation rate was noted in the hysteropexy group (156/4095) (3.81%) than in the hysterectomy group (116/32,514) (0.36%); the adjusted odds ratio (OR) was 11.70 [95% confidence interval (CI): 8.86–15.43]. It was lower in patients with concomitant SUI surgery; older patients (aged ≥ 60 years and 40–69 years vs. Conclusion Our study offers a population-based nationwide observation that hysteropexy correlates with a higher reoperation rate, as compared with hysterectomy; but it is still as high as 30% in the surgical choice of the failed hysteropexy group.

Systemic opioid elimination after implantation of an intrathecal drug delivery system significantly reduced health-care expenditures.

To compare health-care expenditures over a 12-month horizon for chronic pain patients with implanted intrathecal drug delivery systems (IDDS) who eliminated or continued systemic opioids postimplant. Claims data from commercial and Medicare databases were searched for patients who had an IDDS, used systemic opioids before implant, and had 12 months pre- and 13 months postimplant continuous medical and pharmacy coverage. The number and characteristics of patients who eliminated or continued systemic opioids were determined at four times postimplant: 30 days (allowing a systemic opioid washout period), 120 days, 150 days, and 210 days. Multivariable models evaluated the effect of eliminating opioids on health-care expenditures at each of those times. Three hundred eighty-nine patients met inclusion criteria, and 51% completely eliminated systemic opioids (12% within the 30-day washout and an additional 39% by the end of the one-year horizon). Systemic opioid elimination within 120 to 210 days postimplant was associated with a reduction of $3,388 to $4,465 in inpatient and outpatient expenditures, and $4,689 to $5,571 in inpatient, outpatient, and drug expenditures. Fifty-one percent of patients completely eliminated systemic opioids in the year after IDDS implant. This elimination resulted in a 10% to 17% reduction in yearly inpatient, outpatient, and drug expenditures.

Health policy for the poor: An exploration on the take-up of means-tested health benefits in Turkey

Recent healthcare reform in Turkey aims at achieving universal coverage with the introduction of General Health Insurance (GHI). As part of GHI, the state assumes the provision of health insurance coverage to those unable to afford the public health insurance premiums conditional on a means-testing procedure where the official threshold is set as one-third of the gross minimum wage. This article aims at exploring in Turkey the prevalence of non-take up of means-tested health insurance for the poor and the consequent financial burdens for those poor segments outside the coverage. Based upon Statistics of Income and Living Conditions micro data, the non-take-up rate is estimated to be around 44%, where the prevalence of non-take-up is lower yet still high, i.e. around 30%, for households with very low incomes as well as those with elderly or ill members. The results from a separate health expenditure survey on urban poor, which is specifically designed and implemented by the authors, reveal that poor households without health insurance coverage are faced with significant out-of-pocket expenditures. About 5% of those households without coverage were found to have inpatient expenditures that exceeded 20% of their annual disposable household income. Also, among the households without coverage but with at least one inpatient visit over the last two years, the median expenditure was reported as high as 8% of the annual household income as opposed to 0% median value for those with GHI. The results highlight that a large proportion of poor population still lacks public health insurance despite the overarching aim of universal coverage.

How effective is health coaching in reducing health services expenditures?

Health coaching interventions aim to identify high-risk enrollees and encourage them to play a more proactive role in improving their health, improve their ability to navigate the health care system, and reduce costs. Evaluate the effect of health coaching on inpatient, emergency room, outpatient, and prescription drug expenditures. Quasiexperimental pre-post design. Health coaching participants were identified over the 2-year time period 2009-2010. Propensity scores facilitated matching eligible participants and nonparticipating controls on a one-to-one basis using nearest kernel techniques. Difference in differences logistic and generalized linear models addressed the impact of health coaching on the probability of incurring costs and levels of inpatient, emergency room, outpatient, and prescription drug expenditures, respectively. Administrative claims data were used to analyze health services expenditures preparticipation and post health coaching participation time periods. Of the 6940 health coaching participants, 1161 participated for at least 4 weeks and had a minimum of 6 months of claims data preparticipation and postparticipation. Although the probability of incurring costs and expenditure levels for emergency room services were not affected, the probability of incurring inpatient expenditures and levels of outpatient and total costs for health coaching participants fell significantly from preparticipation to postparticipation relative to controls. Estimated outpatient and total cost savings were $286 and $412 per person per month, respectively. Health coaching led to significant reductions in outpatient and total expenditures for high-risk plan enrollees. Future studies analyzing both health outcomes and claims data are needed to assess the cost-effectiveness of health coaching in specific populations.

Change in medical spending attributable to diabetes: national data from 1987 to 2011.

Diabetes care has changed substantially in the past 2 decades. We examined the change in medical spending and use related to diabetes between 1987 and 2011. Using the 1987 National Medical Expenditure Survey and the Medical Expenditure Panel Surveys in 2000-2001 and 2010-2011, we compared per person medical expenditures and uses among adults ≥ 18 years of age with or without diabetes at the three time points. Types of medical services included inpatient care, emergency room (ER) visits, outpatient visits, prescription drugs, and others. We also examined the changes in unit cost, defined by the expenditure per encounter for medical services. The excess medical spending attributed to diabetes was $2,588 (95% CI, $2,265 to $3,104), $4,205 ($3,746 to $4,920), and $5,378 ($5,129 to $5,688) per person, respectively, in 1987, 2000-2001, and 2010-2011. Of the $2,790 increase, prescription medication accounted for 55%; inpatient visits accounted for 24%; outpatient visits accounted for 15%; and ER visits and other medical spending accounted for 6%. The growth in prescription medication spending was due to the increase in both the volume of use and unit cost, whereas the increase in outpatient expenditure was almost entirely driven by more visits. In contrast, the increase in inpatient and ER expenditures was caused by the rise of unit costs. In the past 2 decades, managing diabetes has become more expensive, mostly due to the higher spending on drugs. Further studies are needed to assess the cost-effectiveness of increased spending on drugs.

The costs and benefits of reducing racial-ethnic disparities in mental health care.

Previous studies have found that timely mental health treatment can result in savings in both mental health and general medical care expenditures. This study examined whether reducing racial-ethnic disparities in mental health care offsets costs of care. Data were from a subsample of 6,206 individuals with probable mental illness from the 2004-2010 Medical Expenditure Panel Survey (MEPS). First, disparities in mental health treatment were analyzed. Second, two-year panel data were used to determine the offset of year 1 mental health outpatient and pharmacy treatment on year 2 mental and general medical expenditures. Third, savings were estimated by combining results from steps 1 and 2. Compared with whites, blacks and Latinos with year 1 outpatient mental health care spent less on inpatient and emergency general medical care in year 2. Latinos receiving mental health care in year 1 spent less than others on inpatient general medical care in year 2. Latinos taking psychotropic drugs in year 1 showed reductions in inpatient general medical care. Reducing racial-ethnic disparities in mental health care and in psychotropic drug use led to savings in acute medical care expenditures. Savings in acute care expenditures resulting from eliminating disparities in racial-ethnic mental health care access were greater than costs in some but not all areas of acute mental health and general medical care. For blacks and Latinos, the potential savings from eliminating disparities in inpatient general medical expenditures are substantial (as much as $1 billion nationwide), suggesting that financial and equity considerations can be aligned when planning disparity reduction programs.

The cost of newly diagnosed breast cancer in Lithuania, 2011

Background and objectiveAlthough the cost of treating women with breast cancer (BC) is an important component for cost saving and effectiveness in relation to the benefits of BC treatment interventions, there is limited information on the direct cost reported for BC in Lithuania. Therefore the aim of this study was to evaluate annual direct medical cost for newly diagnosed BC in Lithuania in the year 2011. Materials and methodsThe retrospective incidence-based top-down direct cost analysis was used. From January 1 to December 31, 2011 incident cases of BC (N=1142) registered by the National Health Insurance Fund, the stage determined by Lithuanian Cancer Registry were included in the study. ResultsThe total average direct cost of BC amounted per patient was 2580 (95% CI 2444–2752)EUR in 2011. The main cost driver per BC patients was the inpatient hospital stay, respectively 1655 (95% CI 1478–2334)EUR. The average outpatient cost for one BC patient was 564 (95% CI 547–898)EUR. The dominant proportion of inpatient expenditures was assigned to BC surgery and chemotherapy treatment. The BC direct medical cost increased according to the diagnosed stage of diseases from 2409 (95% CI 2196–2621)EUR in stage 1 to 3688 (95% CI 2703–4672)EUR in stage 4. The direct medical cost was inversely proportional to age. ConclusionsThe direct BC medical cost estimates provided by this analysis can be used to determine priorities for the future research on BC treatment interventions.

The effect of the National Essential Medicines Policy on health expenditures and service delivery in Chinese township health centres: evidence from a longitudinal study

ObjectivesThe government of China has introduced a National Essential Medicines Policy (NEMP) in the new round of health system reform. The objective of this paper is to analyse whether the...

Chronic pain and health care spending: an analysis of longitudinal data from the Medical Expenditure Panel Survey.

To estimate average incremental health care expenditures associated with chronic pain by health care service category, expanding on prior research that focused on specific pain conditions instead of general pain, excluded low levels of pain, or did not incorporate pain duration. Medical Expenditure Panel Survey (MEPS) data (2008-2011; N = 26,671). Differences in annual expenditures for adults at different levels of pain that interferes with normal work, as measured by the SF-12, were estimated using recycled predictions from two-part logit-generalized linear regression models. "A little bit" of chronic pain-related interference was associated with a $2,498 increase in total adjusted expenditures over no pain interference (p < .0001) and a $1,008 increase over nonchronic pain interference (p = .0001). Moderate and severe chronic pain-related interference was associated with a $3,707 and $5,804 increase in expenditures over no pain interference and a $2,218 and $4,315 increase over nonchronic interference, respectively (p < .0001). Expenditure increases were most pronounced for inpatient and hospital outpatient expenditures compared to other types of health care expenditures. Chronic pain limitations are associated with higher health care expenditures. Results underscore the substantial cost of pain to the health care system.

Multidisciplinary Predialysis Education Reduced the Inpatient and Total Medical Costs of the First 6 Months of Dialysis in Incident Hemodialysis Patients

BackgroundThe multidisciplinary pre-dialysis education (MPE) retards renal progression, reduce incidence of dialysis and mortality of CKD patients. However, the financial benefit of this intervention on patients starting hemodialysis has not yet been evaluated in prospective and randomized trial.MethodsWe studied the medical expenditure and utilization incurred in the first 6 months of dialysis initiation in 425 incident hemodialysis patients who were randomized into MPE and non-MPE groups before reaching end-stage renal disease. The content of the MPE was standardized in accordance with the National Kidney Foundation Dialysis Outcomes Quality Initiative guidelines.ResultsThe mean age of study patients was 63.8±13.2 years, and 221 (49.7%) of them were men. The mean serum creatinine level and estimated glomerular filtration rate was 6.1±4.0 mg/dL and 7.6±2.9 mL⋅min−1⋅1.73 m−2, respectively, at dialysis initiation. MPE patients tended to have lower total medical cost in the first 6 months after hemodialysis initiation (9147.6±0.1 USD/patient vs. 11190.6±0.1 USD/patient, p = 0.003), fewer in numbers [0 (1) vs. 1 (2), p<0.001] and length of hospitalization [0 (15) vs. 8 (27) days, p<0.001], and also lower inpatient cost [0 (2617.4) vs. 1559,4 (5019.6) USD/patient, p<0.001] than non-MPE patients, principally owing to reduced cardiovascular hospitalization and vascular access–related surgeries. The decreased inpatient and total medical cost associated with MPE were independent of patients' demographic characteristics, concomitant disease, baseline biochemistry and use of double-lumen catheter at initiation of hemodialysis.ConclusionsParticipation of multidisciplinary education in pre-dialysis period was independently associated with reduction in the inpatient and total medical expenditures of the first 6 months post-dialysis owing to decreased inpatient service utilization secondary to cardiovascular causes and vascular access–related surgeries.Trial RegistrationClinicalTrials.gov NCT00644046

Inpatient expenditures on alcohol-attributed diseases and alcohol tax policy: a nationwide analysis in Taiwan from 1996 to 2010

ObjectivesTo assess the two opposing effects of alcohol tax policy interventions (tax rate increase in 2002 and decrease in 2009) on hospitalization in monetary terms of alcohol-attributed diseases (AADs) in Taiwan. Study designAn interrupted time-series analysis. MethodsAdmissions data from 1996 to 2010 were retrieved from the National Health Insurance Research Database claims file and analysed in this study. Data for 430,388 males and 34,874 females aged 15 or above who were admitted due to an AAD were collected. An interrupted time-series analysis examining the effects of the implementation of alcohol tax policy on quarterly adjusted hospital inpatient charges (HICs) for AADs was employed. ResultsThe study showed significant (p < 0.001) changes in the adjusted HICs for AADs in 2002. Quarterly HICs showed an abrupt 14.8% decline (i.e., a 1.3 million US dollar reduction) after the first tax policy was implemented. No change in quarterly HICs for AADs was found after the alcohol tax increase. The total cost of treating these AAD inpatients over the course of the 15-year period was 640.9 million US dollars. Each inpatient with an AAD costs an average of $900-$2000 depending on the patient's sex and age with the cost increasing gradually after the two tax interventions. More than 80% of the HICs were attributed to alcoholic liver diseases. Psychoses accounted for 6%–18% of the total HICs. Alcohol abuse and alcohol poisoning accounted for less than 2% of the total HICs. ConclusionsThis study provides evidence that alcohol taxation has resulted in an immediate reduction of medical expenditures related to AADs. The policy of increasing alcohol tax rates may have favourable influences on health care resources related to treating AADs.

Could clinical pathways improve the quality of care in patients with gastrointestinal cancer? A meta-analysis.

This meta-analysis was performed to assess the implementation effects of clinical pathways in patients with gastrointestinal cancer. A comprehensive search was conducted in the Cochrane Library, PubMed, EMBASE, Web of Science and Chinese Biomedical Literature Database (from inception to May 2014). Selection of studies, assessing risk of bias and extracting data were performed by two reviewers independently. Outcomes were analyzed by fixed-effects and random-effects model meta-analysis and reported as mean difference (MD), standardized mean difference (SMD) and odds ratio (OR) with 95% confidence intervals (CI). The Jadad methodological approach was used to assess the quality of included studies and the meta-analysis was conducted with RevMan 5.1 software. Nine citations (eight trials) involving 642 patients were included. The aggregate results showed that a shorter average length of stay [MD = -4.0; 95% CI (-5.1, -2.8); P < 0.00001] was observed with the clinical pathways as compared with the usual care. A reduction in inpatient expenditure [SMD = -1.5; 95% CI (-2.3, -0.7); P = 0.0001] was also associated with clinical pathways, along with higher patient satisfaction [OR = 4.9; 95% CI (2.2, 10.6); P < 0.0001]. Clinical pathways could improve the quality of care in patients with gastrointestinal cancer, as evidenced by a significant reduction in average length of stay, a decrease in inpatient expenditure and an improvement in patient satisfaction. Therefore, indicators and mechanisms within clinical pathways should be a focus in the future.