Lower Total Care Costs Research Articles

Exploring the Impact of Device Sourcing on Real-World Adherence and Cost Implications of Continuous Glucose Monitoring in Patients With Diabetes: Retrospective Claims Analysis.

Insurance benefit design influences whether individuals with diabetes who require a continuous glucose monitor (CGM) to provide real-time feedback on their blood glucose levels can obtain the CGM device from either a pharmacy or a durable medical equipment supplier. The impact of the acquisition channel on device adherence and health care costs has not been systematically evaluated. This study aims to compare the adherence rates for patients new to CGM therapy and the costs of care for individuals who obtained CGM devices from a pharmacy versus acquisition through a durable medical equipment supplier using retrospective claims analysis. Using the Mariner commercial claims database, individuals aged >18 years with documented diabetes and an initial CGM claim during the first quarter of 2021 (2021 Q1, index date) were identified. Patients had to maintain uninterrupted enrollment for a duration of 15 months but file no CGM claim during the 6 months preceding the index date. We used direct matching to establish comparable pharmacy and durable medical equipment cohorts. Outcomes included quarterly adherence, reinitiation, and costs for the period from 2021 Q1 to the third quarter of 2022 (2022 Q3). Between-cohort differences in adherence rates and reinitiation rates were analyzed using z tests, and cost differences were analyzed using 2-tailed t tests. Direct matching was used to establish comparable pharmacy and durable medical equipment cohorts. A total of 2356 patients were identified, with 1178 in the pharmacy cohort and 1178 in the durable medical equipment cohorts. Although adherence declined over time in both cohorts, the durable medical equipment cohort exhibited significantly superior adherence compared to the pharmacy cohort at 6 months (pharmacy n=615, 52% and durable medical equipment n=761, 65%; P<.001), 9 months (pharmacy n=579, 49% and durable medical equipment cohorts n=714, 61%; P<.001), and 12 months (pharmacy 48% and durable medical equipment n=714, 59%; P<.001). Mean annual total medical costs for adherent patients in the pharmacy cohort were 53% higher than the durable medical equipment cohort (pharmacy US $10,635 and durable medical equipment US $6967; P<.001). In nonadherent patients, the durable medical equipment cohort exhibited a significantly higher rate of therapy reinitiation during the period compared to the pharmacy cohort (pharmacy 61/613, 10% and durable medical equipment 108/485, 22%; P<.001). The results from this real-world claims analysis demonstrate that, in a matched set, individuals who received their CGM through a durable medical equipment supplier were more adherent to their device. For individuals who experienced a lapse in therapy, those whose supplies were provided through the durable medical equipment channel were more likely to resume use after an interruption than those who received their supplies from a pharmacy. In the matched cohort analysis, those who received their CGM equipment through a durable medical equipment supplier demonstrated a lower total cost of care.

Care management improves total cost of care for patients with dementia.

To examine a 12-month dementia care management program's effect on health care cost, utilization, and overall return on investment in a Medicare managed care population. Pre-post analysis of participants (n = 121) enrolled in Ochsner's Care Ecosystem program from 2019 through 2021 compared with propensity-matched controls (n = 121). The primary outcome comparison was total cost of care. Secondary outcomes included components of total cost of care (eg, inpatient, outpatient, emergency department [ED] costs), health care utilization (eg, number of ED visits), and differences in Hierarchical Condition Category (HCC) risk scores. Difference-in-differences analyses were conducted from baseline through 12 months comparing various financial metrics and utilization between groups. Care Ecosystem participants had significantly lower total cost of care at 12 months, mean savings of $475.80 per member per month compared with controls. Care Ecosystem participants had fewer ED, outpatient, and professional visits. HCC risk scores were also better relative to matched controls. A collaborative dementia care program demonstrated significant financial benefit in a managed Medicare population.

Abstract 12085: Emergency Heart Failure Mortality Risk Grade (EHMRG) Score Quintiles Correlate With Short and Long-Term Healthcare Costs

Introduction: The use of the EHMRG model in the emergency department (ED) has been demonstrated to improve outcomes for patients presenting with acute heart failure (HF). It is unknown if the EHMRG model also correlates with healthcare costs, which has not been examined in other HF risk models. Hypothesis: We hypothesized that patients with higher EHMRG risk scores, i.e., sicker, would have higher costs of care in short-term (30-day) and longer-term (up to 2 year) time horizons. Methods: We examined direct costs of care from a health payer perspective using the original EHMRG derivation cohort of 11,857 patients hospitalized with acute HF in Ontario, Canada (from 2004) and linking to population-based case-costing databases. Costs were stratified by the quintiles of the EHMRG risk score (Q1 = lowest risk, Q5 = highest risk). Costs (in 2021 Canadian dollars) were categorized into hospital, physician, drug, home care, long term care (LTC), and other costs. Results: Patients in the lowest EHMRG risk quintile (Q1), compared to higher quintiles (Q2-Q5) had lower total cost of care in both the short-term ($8,113 vs $9,442, $10,557, $12,078 and $15,005, p &lt;0.001) and long-term ($46,661 vs $55,904, $58,904, $63,286 and $64,229, p&lt;0.001). This positive correlation between EHMRG risk quintile and cost of care was also observed for hospital costs ($26,388 [Q1] vs $35,659 [Q5], p&lt;.0001) and LTC costs ($1,236 [Q1] vs $6,316 [Q5], p&lt;.0001) at all time intervals, including at 2 years shown here. Physician costs and drug costs were positively correlated with EHMRG risk quintiles at 30 days (physician: $1,241 [Q1] vs $1,762 [Q5], p&lt;0.0001; drug: $219 [Q1] vs $282 [Q5], p&lt;.0001), and negatively correlated at 2 years (physician: $7,943 [Q1] vs $7,175 [Q5], p&lt;.0001; drug: $4,539 [Q1] vs $4,377 [Q5], p&lt;.0001). There was an increasing trend of costs irrespective of the formulation of the EHMRG risk score as 7-day risk quintile, 30-day risk quintile, or 30-day risk tertile. Conclusion: The EHMRG7 risk score was positively correlated with healthcare costs from 30 days to 2 years after initial ED presentation. This novel correlational study demonstrated that in the absence of an associated intervention, higher mortality risk in HF patients portends higher costs in short and long-term follow-up.

Care Ecosystem Collaborative Model and Health Care Costs in Medicare Beneficiaries With Dementia

Collaborative dementia care programs are effective in addressing the needs of patients with dementia and their caregivers. However, attempts to consider effects on health care spending have been limited, leaving a critical gap in the conversation around value-based dementia care. To determine the effect of participation in collaborative dementia care on total Medicare reimbursement costs compared with usual care. This was a prespecified secondary analysis of the Care Ecosystem trial, a 12-month, single-blind, parallel-group randomized clinical trial conducted from March 2015 to March 2018 at 2 academic medical centers in California and Nebraska. Participants were patients with dementia who were living in the community, aged 45 years or older, and had a primary caregiver and Medicare fee-for-service coverage for the duration of the trial. Telehealth dementia care program that entailed assignment to an unlicensed dementia care guide who provided caregiver support, standardized education, and connection to licensed dementia care specialists. Primary outcome was the sum of all Medicare claim payments during study enrollment, excluding Part D (drugs). Of the 780 patients in the Care Ecosystem trial, 460 (59.0%) were eligible for and included in this analysis. Patients had a median (IQR) age of 78 (72-84) years, and 256 (55.7%) identified as female. Participation in collaborative dementia care reduced the total cost of care by $3290 from 1 to 6 months postenrollment (95% CI, -$6149 to -$431; P = .02) and by $3027 from 7 to 12 months postenrollment (95% CI, -$5899 to -$154; P = .04), corresponding overall to a mean monthly cost reduction of $526 across 12 months. An evaluation of baseline predictors of greater cost reduction identified trends for recent emergency department visit (-$5944; 95% CI, -$10 336 to -$1553; interaction P = .07) and caregiver depression (-$6556; 95% CI, -$11 059 to -$2052; interaction P = .05). In this secondary analysis of a randomized clinical trial among Medicare beneficiaries with dementia, the Care Ecosystem model was associated with lower total cost of care compared with usual care. Collaborative dementia care programs are a cost-effective, high-value model for dementia care. ClinicalTrials.gov Identifier: NCT02213458.

EE79 Biomarker Testing in Rheumatoid Arthritis Leads to Lower Total Cost of Care

Rheumatoid arthritis (RA) affects less than 1% of the US population but contributes to $22.3 billion in total annual healthcare costs.1 Biomarker tests are used to diagnose and monitor RA. This study was conducted to determine the effects of biomarker testing on healthcare costs.

Financial burden associated with discordance to intravenous iron therapies in US patients with iron deficiency anemia.

BACKGROUND: Iron deficiency anemia (IDA) affects approximately 5 million people in the United States and has a significant impact on human health. Intravenous (IV) iron is indicated for treatment of IDA when oral iron is not effective or not tolerated. Several IV iron products are available, including oldergeneration and newer-generation products. Newer agents have certain benefits, including the ability to administer high iron doses in fewer infusions; despite the benefits, some payors require failure on older iron products before use of newer iron products in prior authorization processes. IV iron replacement regimens requiring multiple infusions may lead to patients not receiving recommended IV iron treatment per label; potential costs of this discordance may outweigh the difference in price between the older and newer products. OBJECTIVE: To quantify the burden of discordance to IV iron therapy and associated economic consequences. METHODS: This is a retrospective study using administrative claims data between January 2016 and December 2019 from adult patients who are enrolled in a commercial insurance program with a regional health plan. A course of IV iron therapy is defined as all infusions that occur within 6 weeks of the initial infusion. Discordance to therapy is defined as having received less than 1,000 mg of iron over a course of therapy. RESULTS: There were 24,736 patients included in the study. Baseline demographics were similar between the patients who received older- vs newer-generation products and patients who were concordant vs discordant. Discordance to IV iron therapy overall was 33%. Patients who received newer-generation products were less discordant to therapy (16%) than patients who received older-generation products (55%). In general, patients who received newer-generation products had a lower total cost of care than patients who received older-generation products. CONCLUSIONS: Discordance to the older-generation products was significantly higher than that to the newer-generation products. Patients who were concordant to therapy and on a newer-generation product had the lowest total cost of care, suggesting that overall cost of care is not necessarily proportional to the purchase price of the chosen IV iron replacement therapy. Optimizing concordance to IV iron therapy may lead to lower total cost of care in the IDA population. DISCLOSURES: Magellan Rx Management received funding for this study from Pharmacosmos Therapeutics Inc. AESARA contributed to study design and data analysis. Magellan Rx Management contributed to the study design, data analysis, and interpretation of results. Pharmacosmos Therapeutics Inc. participated in the study design and interpretation of results.

Short-term and Long-term Outcomes in Patients with Early-stage Cervical Cancer, Comparing Clinical and Adjuvant Therapy between Laparoscopic and Open Radical Hysterectomy: A Systematic Review and Meta-analysis

BACKGROUND: Cervical cancer represents one of the most common gynecological malignancies worldwide and the standard treatment has been radical abdominal hysterectomy (RAH). Recent surgical developments can be done through minimally invasive surgery (MIS) using laparoscopic radical hysterectomy (LRH), but the data regarding LRH are still conflicting. AIM: Therefore, we undertook a systematic review and meta-analysis comparing the short-term and long-term outcomes of laparoscopic versus RAH in women with early-stage cervical cancer. METHODS: A systematic search was performed within PubMed, Cochrane, Science Direct, and Google Scholar databases to research the outcome of LRH versus RAH in early-stage cervical cancer. Two reviewers independently reviewed titles, abstracts, and full article text to identify studies meeting inclusion and exclusion criteria. If there any discrepancies, it will be resolved by discussion. The Newcastle–Ottawa scale (NOS) was used to assess the risk of bias of non-randomized studies in this analysis. We used Review Manager 5.4 to calculate the result of 95% CI for the outcomes, odds ratio (OR), and mean differences (MD). The endpoints of interest are short-term, during operation, early post-operation, and long-term outcomes. RESULT: The initial search identified 3.030 citations after a comprehensive review of the final 35 observational studies included, involving 6.919 early-stage cervical cancer patients. Pooled analysis showed that LRH had better intraoperative outcomes, estimated blood loss (EBL) significantly lower LRH (MD = 145.88 [95% CI: 132.84–158.92; p &lt; 0.0001; I2 = 94%]), lesser intraoperative urinary tract injury (OR = 0.91), and vascular injury (OR = 0.76) but was not significant, number of pelvic lymph nodes resected tended to be higher in RAH with MD = 3.63 (95% CI: 3.10–4.15; p &lt; 0.0001; I2 = 95%), shorter bowel recovery time post-operative (MD = 0.05 [95% CI: 0.34–0.66; p &lt; 0.001]). Uniquely, the duration of surgery was not significantly different but still shorter in LRH with MD = 0.73. Long-term outcome was not significantly different for LRH from survival (OR = 1.17) and recurrence (OR = 0.83). LRH had shorter length of stay post-operative (MD = 13.23 [95% CI: 12.98–13.47; p &lt; 0.001; I2 = 100%]) and tend to use significantly fewer adjunctive chemotherapy treatments (OR = 1.84 [95% CI: 1.38–2.45; p &lt; 0.001; I2 = 73%]), the same was seen in radiotherapy treatment (OR = 1.27 [95% CI: 1.03–1.58; p = 0.03; I2 = 68%]). DISCUSSION: The result demonstrated that for the long-term outcome, there was no significant difference between the two techniques. In general, LRH is considered to be associated with better recovery, smaller scar, and faster back to normal life than ARH. Some comparative studies have reported that survival outcome and perioperative complications after LRH are comparable to those after ARH. However, some study found that MIS was associated with a higher risk of death than open surgery for patients with tumor size ≥2 cm (HR 1.66, 95% CI: 1.19–2.30) and had significantly worse progression-free survival than those in the open surgery group with tumor size &gt;2 cm and ≤4 cm (p = 0.044). This may be because of the use of uterine manipulator or because the difference approaches in handling the vaginal margin. Thus, avoiding tumor spillage and diminishing tumor handling during MIS may be beneficial. A Korean study demonstrated that LRH was associated with a lower total cost of care within 6-month postoperatively than RAH. It appeared that using laparoscopic approach was the least expensive approach from a societal perspective followed by robotic and then abdominal hysterectomy. CONCLUSION: This systematic review and meta-analysis of observational studies found that among patients who underwent radical hysterectomy for early-stage cervical cancer, LRH had a better outcome in intraoperative, faster post-operative recovery time, and less need for adjunctive therapy.

The cost-effectiveness of a nursing home-based transitional care unit for increasing the potential for independent living in the community among hospitalized older adults

Objective In Canada, a persistent barrier to achieving healthcare system efficiency has been patient days accumulated by individuals with an alternate level of care (ALC) designation. Transitional care units (TCUs) may address the capacity pressures associated with ALC. We sought to assess the cost-effectiveness of a nursing home (NH) based TCU leveraging existing infrastructure to support a hospitalized older adult’s transition to independent living at home. Methods This case-control study included frail, older adults who received care within a function-focused TCU following a hospitalization between 1 March 2018 and 30 June 2019. TCU patients were propensity score matched to hospitalized ALC patients (“usual care”). The primary outcome was days without requiring institutional care six months following discharge, defined as institutional-free days. This was calculated by excluding all days in hospitals, rehabilitation facilities, complex continuing care facilities and NHs. Using the total direct cost of care up to discharge from TCU or hospital, the incremental cost-effectiveness ratio was calculated. Results TCU patients spent, on average, 162.0 days institution-free (95% CI: 156.3–167.6d) within six months days post-discharge, while usual care patients spent 140.6 days institution-free (95% CI: 132.3–148.8d). TCU recipients had a lower total cost of care, by CAN$1,106 (95% CI: $–6,129–$10,319), due to the reduced hospital length of stay (mean [SD] 15.6d [13.3d] for TCU patients and 28.6d [67.4d] days for usual care). TCU was deemed the more cost-effective model of care. Limitations The main limitation was the potential inclusion of patients not eligible for SAFE in our usual group. To minimize this selection bias, we expanded the geographical pool of ALC patients to patients with SAFE admission potential in other area hospitals. Conclusions Through rehabilitative and restorative care, TCUs can reduce hospital length of stay, increase potential for independent living, and reduce risk for subsequent institutionalization.

Total cost of care differences in National Comprehensive Cancer Center (NCCN) concordant and non-concordant breast cancer patients.

e18833 Background: National Comprehensive Cancer Network (NCCN) treatment guideline non-concordance for breast cancer treatment has higher total costs. However, a significant knowledge gap exists regarding which cost components increase in non-concordant therapies. The purpose of this study is to evaluate the total cost of care (TCOC) and cost components for breast cancer patients who received NCCNconcordant versus non-concordant therapies. Methods: This is a retrospective study of patients throughout the United States with breast cancer at a large national Medicaid, Medicare, and commercial insurer from January 1, 2019, to December 31, 2020. NCCN regimen concordance was identified from pharmacy and medical claims and defined as concordant if the entire prescribed treatment regimen matched an NCCNregimen (Level 1 and 2a); patients not receiving an NCCN recommended regimen were deemed to be non-concordant. TCOC and its cost components were contrasted on a matched population of concordant and non-concordant patients with a ratio of 2:1. To eliminate possible selection bias and differences in baseline characteristics that could affect cost, propensity scores were developed using logistic regression and used to match patients on age, comorbidity, socioeconomic status (SES) index and treatment type (chemotherapy and radiation). Results: A total of 315 patients with breast cancer were matched. Beginning with and including the first treatment and for up to 180 days after, the TCOC in the concordant group was significantly less across all lines of business (p &lt; 0.05). A reduction of 25%, 28% and 43% (a difference of $5,872, $6,946 and $3,542) in TCOC per member per month (PMPM) was observed in commercial fully insured (CFI), commercial self-insured (CSI) and Medicare patients, respectively. Provider administered chemotherapy spend was also significantly lower (p &lt; 0.05) in the concordant group, a reduction of 34%, 50% and 43% (a difference of $3,615, $6,788 and $1,879) in CFI, CSI and Medicare patients, respectively. Outpatient spend was 28% lower (a difference of $4,268, p = 0.08) in CFI patients and significantly lower (p &lt; 0.05) with reductions of 29% and 40% ($5,396 and $1,988) in CSI and Medicare patients, respectively. There were no significant differences in Inpatient and Emergency Room spend across all lines of business (p &gt; 0.05). Conclusions: In this study, there is a correlation between breast cancer patients on NCCN concordant therapies and a lower TCOC. The savings due to medical spend highlight the importance of evidence-based guidelines in treatment determinations. Further evaluation will be needed to determine cost changes in hospitalizations and emergency room visits.

Value-based care outcomes in pancreatic cancer patients with and without access to registered dietitians: A retrospective cohort study of patients enrolled in the Oncology Care Model.

e16249 Background: Patients with pancreatic cancer face many nutrition-related concerns, although few guidelines exist to direct clinical nutrition services in this population. Examining quality outcomes for patients in clinics with and without access to a Registered Dietitians (RD’s) can help examine the contributions of RD’s in this area. Methods: A retrospective cohort design was used to compare Total Cost of Care (TCOC), hospital admissions and Length of Stay (LOS), and Emergency Department (ED) and Observation visits for patients with pancreatic cancer who were enrolled in the Oncology Care Model (OCM) during Performance Periods (PP) 1-6 (July 1, 2016–June 30, 2019). Patient deaths during the initial episode of care were also examined. Patients from a geographically concentrated metropolitan hub were divided into cohorts based on clinic access to an RD. Each patient’s initial six-month OCM episode of care was used for analysis. Results: Of the 389 OCM patients identified with pancreatic cancer from PP1-6, 203 were treated at 10 clinics with an RD and 186 in 17 clinics without an RD. In the RD cohort, 43.3% of patients were admitted to the hospital with an average LOS of 8.9 days. By contrast, 52.2% of patients in the non-RD cohort were admitted to the hospital with an average LOS of 10.0 days. TCOC for the 6-month episode was lower in the RD cohort at $37,185 versus the non-RD cohort at $40,907. During the initial 6-month episode of care, 37% of patients in the non-RD cohort died during the initial 6-month episode vs only 28% in the RD cohort. A higher percentage of patients in the RD cohort (35%) had ED or Observation visits, compared with the non- RD cohort (32%). Conclusions: Amongst OCM patients with pancreatic cancers, treatment at a clinic with an RD was associated with lower TCOC, reduced LOS for patients that were admitted to the hospital, and lower percentage of deaths in the first 6-month episode of care. The percentage of patients with ED and Observational visits was slightly higher in the cohort that had access to an RD. This analysis shows the potential benefit of RD services in an outpatient setting and justifies further study. Future multilevel modeling will evaluate the statistical significance of these results.[Table: see text]

Examining value-based care outcomes in gastric and esophageal patients with and without access to registered dietitians: A retrospective cohort study of patients enrolled in the oncology care model.

264 Background: Patients with gastric and esophageal cancers are at high risk for malnutrition. Appropriate nutrition care provided by a registered dietitian (RD) as part of a multidisciplinary care team is supported by evidenced-based guidelines and clinical studies focused on surgical outcomes. However, Medicare does not routinely cover outpatient RD services for oncology patients which limits access to this care. Examining quality outcomes for patients in clinics with and without access to a RD can help define the value of this service. Methods: We used a retrospective cohort design to analyze Total Cost of Care (TCOC), hospital admissions and Length of Stay (LOS), and Emergency Department (ED) and Observation visits for patients with gastric and esophageal cancer who were enrolled in the Oncology Care Model (OCM) during Performance Periods (PP) 1-6 (July 1, 2016 – June 30, 2019). We divided patients from a geographically concentrated metropolitan hub into cohorts based on clinic access to a RD. Each patient’s initial OCM episode of care was used for analysis. Results: We identified 253 OCM patients with gastric or esophageal cancer from PP1-6. Of these, 109 were treated at 9 clinics with an RD and 144 in 16 clinics without a RD. In the RD cohort 42.2% of patients were admitted to the hospital with a LOS of 6.8 days. In the non-RD cohort 45.8% of patients were admitted to the hospital with a LOS of 9.4 days. TCOC for the 6-month episode was lower in the RD cohort at $ 39,033 vs the non-RD cohort at $49,359. There were 0.56 ED and observation visits per patient in the RD cohort and 0.8 ED and observation visits per patient in the cohort without a RD. Conclusions: Amongst OCM patients with gastric and esophageal cancers, treatment at a clinic with a RD was associated with lower TCOC, reduced LOS for patients that were admitted to the hospital and fewer ED and observational visits. This analysis shows the potential benefit of RD services in an outpatient setting and justifies further study. Future prospective studies will need to evaluate which interventions are most impactful.[Table: see text]

Abstract 12926: The Impact of Thoracic Aortic Aneurysm versus Dissection on Postoperative Outcomes After Thoracic Endovascular Aortic Repair

Introduction: As thoracic endovascular aortic repair (TEVAR) is the standard of care for complicated Type B aortic dissection (TBAD) and descending thoracic aortic (DTA) aneurysm, it is critical to understand its outcomes and utilization. Hypothesis: Nationwide postoperative complications, admission costs, and 30- and 90-day readmissions after TEVAR are between TBAD and aneurysm. Methods: Codes from the International Classification of Diseases (ICD) 9 and 10 identified patients with a primary procedure code for TEVAR from 2010-2017 in the Nationwide Readmissions Database (with trend weights to generate national estimates). After ICD codes identified patients with thoracic or thoracoabdominal aortic dissection as well as aortic aneurysm, the two groups were compared. Mixed model logistic regression identified variables associated with readmission, treating individual hospital as a random effect. Results: An estimated 6594 patients underwent non-elective TEVAR, of which 4649 (70.5%) had TBAD and 1945 (29.5%) had aneurysm of the DTA. Patients with aneurysms were more likely to be older, be women, have cardiovascular disease, and have chronic pulmonary disease than patients with TBAD. In-hospital mortality was lower for aneurysm (5.7% vs. 10.9%, p&lt;0.001) than TBAD. For patients with aneurysm, there was less stroke (4.6% vs. 7.1%), paraplegia (2.2% vs. 3.9%), acute kidney injury (18.2% vs. 34.5%), and mesenteric ischemia (2.0% vs. 5.8%) than TBAD. Patients with aneurysm had lower total cost of care during their index admission (48.0 vs. 65.2 x $1000) than TBAD. The proportion of 30-day and 90-day readmissions were similar across each group, with overall 30-day readmission being 23.6%, while 90-day readmission was 38.2%. On multivariable adjustment, aneurysm was not associated with increased odds of 30-day readmission (OR 1.02, 95% CI: 0.84, 1.25, p=0.820) or 90-day readmission (OR 0.97, 95% CI: 0.80, 1.19, p=0.780) compared to TBAD. Conclusions: While TBAD was associated with worse in-hospital mortality and higher incidence of complications, aortic disease was not associated with an increased odds of readmission through 90 days. However, the incidence of early readmission was substantial for patients undergoing non-elective TEVAR.

Professional agency vs consumer directed care workers: Outcomes in managed care.

Direct care workers are a major part of the long-term services and supports (LTSS) needed to address the health of individuals and accounted for $112 billion in United States spending in 2015. Direct care workers are hired within professional agency models (PAMs) or consumer-directed models (CDMs) where workers (including family) are contracted by the individual to obtain services. We sought to identify differences in cost and utilisation outcomes between PAM and CDM participants. Data were obtained from the University of Pittsburgh Medical Center (UPMC) Insurance Services Division from the participants enrolled in UPMC Community HealthChoices in Pennsylvania during 2018. A retrospective, observational cohort study design was performed using claims data. Utilisation outcomes were assessed using multivariate logistic regression and cost outcomes by linear regression. The 3,232 participants met the inclusion criteria. Of these, 69% (N=2,217) were in a PAM, 23% (N=752) were in a CDM, and 8% (N=263) used a combination of services. PAM groups were older (mean 62.4years vs 54.1years), more likely to be women (69.0% vs 62.8%), and had more healthcare needs. Hospital utilisation was the same among groups. However, total cost was lower in CDM groups due to differences in LTSS costs between CDM and PAM services. Among dually eligible Medicare and Medicaid beneficiaries receiving LTSS, there are significant differences in age, gender, race and health needs. While hospital utilisation was not different between groups, CDM groups had lower total costs of care compared to PAM. These findings have implications for families, policymakers and insurers in helping to govern community LTSS while supporting member autonomy.

Impact of Earlier Vs. Later Monitoring on Disease Progression and Economic Outcomes Among Patients with Chronic Myeloid Leukemia in the Real-World Setting

Introduction: The National Comprehensive Cancer Network recommends monitoring of patients with chronic myeloid leukemia (CML) beginning at diagnosis. Such testing is necessary for optimal treatment selection, however, patients are often not monitored until later in the course of disease or when clinical symptoms present. In this study, we evaluated the impact of molecular monitoring earlier in the course of disease as compared to later monitoring with the aim to determine a potential association between timing of monitoring and CML disease progression and healthcare resource utilization in a real-world setting in the US.Methods: Patients (≥ 18 years of age) with ≥1 inpatient or ≥2 distinct outpatient (≥30 days apart) diagnoses for CML, January 01, 2006 through June 30, 2016, were identified from the MarketScan® databases. Patients were defined as having disease progression based on the presence of treatments for advanced phase and blast crisis CML. A case control study design was used; cases were defined as patients with disease progression and patients not captured as having progression were identified as controls. Among cases, the index date was defined as the first date of treatment for CML progression and among controls, the index date was a randomly selected date (using simple random sampling) after the first CML diagnosis. Patients were required to have 24 months of continuous medical and prescription insurance coverage prior to the index date (baseline period). Patients were also required to have ≥1 CML monitoring test in the baseline period. Patients with earlier monitoring were identified as those with ≥1 monitoring test during the 7-24 months prior to the index date (Figure); patients with later monitoring were identified as those with ≥1 monitoring test only during the last 6 months prior to the index date and not during the 7-24 months prior to the index date (Figure). Patient demographics and clinical characteristics were evaluated during the baseline period. All-cause healthcare resource utilization and associated costs were evaluated per patient per month (PPPM) during the baseline period and a variable length follow-up period lasting ≥1 day and up to 1 year. Multivariate generalized linear modeling (GLM) was used to evaluate differences in all-cause healthcare costs between the earlier vs. later monitoring cohorts. Multivariate logistic regression was used to evaluate the association between monitoring status and progression.Results: A total of 2,730 CML patients were identified, among which 60% (n=1,633) received earlier monitoring and 40% (n=1,097) received later monitoring only. The two groups were similar in terms of mean age and gender: 56 years vs. 57 years and 56% vs 57% females among patients with earlier vs. later monitoring, respectively. The mean Charlson Comorbidity Index score was lower among patients with earlier vs. later monitoring (3.15 vs. 3.41, p=0.0001), which indicates that patients with earlier monitoring were healthier. The three most frequently observed comorbid conditions of cardiovascular disease, gastrointestinal disease and lipid abnormalities were present in 67%, 62% and 44%, respectively, of patients with earlier monitoring vs. 71%, 66% and 52% of patients with later monitoring. Evidence of progression was present in 8.9% of patients with earlier monitoring, vs. 9.3% of patients with later monitoring. After the multivariable regression model was used to adjust for patient characteristics, patients with earlier vs. later monitoring were shown to be associated with a lower likelihood of CML progression (odds ratio: 0.715, confidence interval (CI) [0.530 - 0.964]; p=0.0280), during the follow-up period. After adjusting for covariates, the mean all-cause healthcare costs (PPPM) for inpatient (hospitalization), outpatient medical service, total (inpatient + outpatient) medical service, outpatient pharmacy and total healthcare were lower for patients with earlier monitoring as compared to those with later monitoring (Table).Conclusion: Patients who are monitored earlier in the course of their disease may have better outcomes and lower total cost of care, as evidenced by the lower likelihood of CML progression and lower healthcare resource utilization in this group as compared to patients with later monitoring only. [Display omitted] DisclosuresJabbour:Bristol-Myers Squibb: Consultancy. Siegartel:Bristol-Myers Squibb: Employment. Lin:Novosys Health: Employment; Bristol-Myers Squibb: Consultancy. Lingohr-Smith:Novosys Health: Employment. Menges:Novosys Health: Employment. Makenbaeva:Bristol-Myers Squibb: Employment.

Comparing Precision Machine Learning With Consumer, Quality, and Volume Metrics for Ranking Orthopedic Surgery Hospitals: Retrospective Study

BackgroundPatients’ choices of providers when undergoing elective surgeries significantly impact both perioperative outcomes and costs. There exist a variety of approaches that are available to patients for evaluating between different hospital choices.ObjectiveThis paper aims to compare differences in outcomes and costs between hospitals ranked using popular internet-based consumer ratings, quality stars, reputation rankings, average volumes, average outcomes, and precision machine learning–based rankings for hospital settings performing hip replacements in a large metropolitan area.MethodsRetrospective data from 4192 hip replacement surgeries among Medicare beneficiaries in 2018 in a the Chicago metropolitan area were analyzed for variations in outcomes (90-day postprocedure hospitalizations and emergency department visits) and costs (90-day total cost of care) between hospitals ranked through multiple approaches: internet-based consumer ratings, quality stars, reputation rankings, average yearly surgical volume, average outcome rates, and machine learning–based rankings. The average rates of outcomes and costs were compared between the patients who underwent surgery at a hospital using each ranking approach in unadjusted and propensity-based adjusted comparisons.ResultsOnly a minority of patients (1159/4192, 27.6% to 2078/4192, 49.6%) were found to be matched to higher-ranked hospitals for each of the different approaches. Of the approaches considered, hip replacements at hospitals that were more highly ranked by consumer ratings, quality stars, and machine learning were all consistently associated with improvements in outcomes and costs in both adjusted and unadjusted analyses. The improvement was greatest across all metrics and analyses for machine learning–based rankings.ConclusionsThere may be a substantive opportunity to increase the number of patients matched to appropriate hospitals across a broad variety of ranking approaches. Elective hip replacement surgeries performed at hospitals where patients were matched based on patient-specific machine learning were associated with better outcomes and lower total costs of care.

Robotic minor hepatectomy: optimizing outcomes and cost of care

BackgroundThe advantages of robotic liver surgery are strongest for minor resections, where incision size drives recovery time, but cost remains a concern. We hypothesized that patients who underwent robotic minor liver resections would have superior peri-operative outcomes resulting in decreased cost. MethodsWe queried the medical record and cost data for patients who underwent open or robotic minor (1–2 segment) liver resection from 1/2016–8/2019. Financial data were normalized to Medicare reimbursements. ResultsThere were 87 patients who underwent minor liver resections (robotic n = 46, open n = 41). Specimen size (173 ± 203 vs 257 ± 481 cm3), surgical duration (233 ± 87 vs 227 ± 83 min), estimated blood loss (187 ± 236 vs 194 ± 165 mL), and margin status (89% vs 93% R0) were similar for robotic and open resections respectively, yet complications (3/46, 7% vs 10/41, 24%, p = 0.02) and length of stay (2.2 ± 2.2 vs 6.2 ± 2.9, p < 0.001) were significantly lower for patients who underwent robotic resection. These factors contributed to minor robotic liver resections costing $534 less than open resections ($3597 ± 1823 vs $4131 ± 1532, p = 0.03). ConclusionPatients undergoing robotic minor hepatectomy had superior peri-operative outcomes resulting in lower total cost of care when compared to open minor hepatectomy. Financial considerations should not adversely influence selection of a robotic approach for minor hepatectomy.

Total cost of lung cancer care associated with broad panel versus narrow panel sequencing.

7077 Background: Many lung cancer patients are diagnosed late with advanced or metastatic disease. Targeted therapies can improve quality of life and increase the chances of progression-free survival versus conventional treatments. An understanding that there may be more than one driver mutation associated with a specific lung tumor is crucial for the timing and delivery of the most effective line of therapy. Broad panel sequencing (BPS) minimizes tissue use and enables personalized treatment that decreases the use of ineffective agents and unwarranted side effects, in addition to opening pathways to early clinical trials. However, many payors do not reimburse for BPS. The objective of this study was to determine if BPS leads to lower total cost of care versus narrow panel sequencing (NPS). Methods: We identified new lung cancer patients who completed BPS (Current Procedural Terminology (CPT) code 81455, 51+ genomic test) or NPS (CPT code 81445, 5-50 genomic test) using medical claims from January 1, 2018, to March 31, 2019. We defined total cost of care as allowed costs paid for medical and pharmacy claims across a six-month time period from the first gene sequencing panel. We also compared the allowed costs of BPS and NPS. A Student’s t-test was used to compare differences and results are presented as mean +/- standard deviation. Results: From January 2018 to March 2019, we identified 45 patients who underwent BPS sequencing and 399 patients who underwent NPS. The average BPS cost was $1,977 +/- $2,713 versus the average NPS lab cost $719 +/- $1,087, p &lt; 0.0001. The average 6-month per member per month (PMPM) total cost was $11,535 +/- $9,168 among those who underwent BPS compared to $20,039 +/-19,642 in those who underwent NPS. This difference of $8,504 was statistically significant, p = 0.0022. Conclusions: BPS has been shown to optimize treatments in patients with lung cancer. These initial results of claims suggest that while lung cancer patients undergoing BPS have higher total sequencing costs than those undergoing NPS, BPS significantly reduces overall total cost of lung cancer care. Identifying the broader genomic landscape of a patient’s tumor earlier will empower oncology providers and lung cancer patients with information to make timely, precise treatment decisions that are ultimately more cost effective.

PDB126 COMPARATIVE HEALTHCARE COSTS AND MEDICATION BURDEN IN REAL-WORLD PATIENTS AUGMENTING METFORMIN MONOTHERAPY WITH EMPAGLIFLOZIN FROM THE EMPAGLIFLOZIN COMPARATIVE EFFECTIVENESS AND SAFETY (EMPRISE) STUDY

To assess healthcare costs and medication burden among metformin monotherapy users initiating empagliflozin vs. dipeptidyl peptidase-4 inhibitor (DPP4i) in Medicare and 2 US commercial claims datasets from 08/2014 to 09/2016. We identified a 1:1 propensity-score (PS)-matched cohort of type 2 diabetes (T2D) patients ≥18 years on metformin monotherapy starting either empagliflozin or DPP4i, controlling for ≥140 baseline covariates including clinical, healthcare resource utilization, and cost-related covariates, measured during the 1 year before add-on treatment initiation. We evaluated total (inpatient, outpatient and pharmacy) cost and medication burden among empagliflozin vs. DDP4i initiators during the follow-up period. We identified a total of 2,928 1:1 PS-matched pairs from the three datasets, with well-balanced baseline characteristics, as measured by absolute standardized differences (aSD)<0.1. Mean age was 57 years, 45% were female, and mean HbA1C was 8.2%. Baseline mean total ($8,698 vs $8,980, aSD=0.01), inpatient ($1,265 vs $1,369, aSD=0.01), outpatient ($5,161 vs $5,222, aSD=0.00), and pharmacy ($2,239 vs $2,362, aSD=0.02) costs were balanced among empagliflozin vs DPP4i initiators, as well as mean number of distinct medication prescriptions. During follow-up (mean 168 days), the PMPY total costs tended to be lower among empagliflozin vs. DDP4i initiators ($13,547 vs $14,902; Diff=-$1,355, 95%CI: -3,922, 991), as were inpatient ($1,502 vs $2,140 PMPY; Diff=-$638, 95%CI: -1,864, 484) and outpatient ($5,570 vs $6,300 PMPY; Diff=-$730, 95%CI: -2,500, 643) costs. Pharmacy costs ($6,442 vs $ 6,416 PMPY; Diff=$26, 95%CI: -914, 795) were not significantly different between the two groups. CV-related medical costs also tended to be lower (Diff=-$242, 95%CI: -1,641, 902) in empagliflozin initiators. The number of distinct medication prescriptions was similar (15.5 PMPY in both groups; Incidence rate ratio=1.01; 95% CI: 0.99,1.03). Results showed trend towards lower total cost of care, driven by medical costs, and similar medication burden among metformin monotherapy users initiating empagliflozin vs DPP4i.

Impact of earlier versus later monitoring on disease progression and healthcare costs among patients with chronic myeloid leukemia in the United States

We evaluated the impact of molecular monitoring earlier as compared to later in the course of chronic myeloid leukemia (CML) on disease progression and healthcare costs in the real-world setting in the US. Patients with a diagnosis of CML were identified from the MarketScan claims databases (1 January 2006 to 30 June 2016). Multivariable regression analyses were used to control for differences in patient cohorts with earlier versus later monitoring. Of the 2730 CML patients in the study population, 60% (n = 1633) received earlier monitoring and 40% (n = 1097) received later monitoring only. After adjusting for differences in patient characteristics, patients with earlier monitoring had a lower likelihood of CML progression during the follow-up period (odds ratio: 0.72, confidence interval: 0.53–0.96; p = .03) and lower total healthcare costs ($6794 versus $9782 per-patient-per-month, p < .001) than patients with later monitoring. Patients who are monitored earlier in the course of CML may have better outcomes and lower total costs of care.

Outpatient Complex Case Management: Health System-Tailored Risk Stratification Taxonomy to Identify High-Cost, High-Need Patients.

U.S. health systems, incentivized by financial penalties, are designing programs such as case management to reduce service utilization among high-cost, high-need populations. The major challenge is identifying patients for whom targeted programs are most effective for achieving desired outcomes. To evaluate a health system's outpatient complex case management (OPCM) for Medicare beneficiaries for patients overall and for high-risk patients using system-tailored taxonomy, and examine whether OPCM lowers service utilization and healthcare costs. Retrospective case-control study using Medicare data collected between 2012 and 2016 for Ochsner Health System. Super-utilizers defined as Medicare patients with at least two hospital/ED encounters within 180days of the index date including the index event. Outpatient complex case management. Propensity score-adjusted multivariable logistic regression analysis was conducted for primary outcomes (90-day hospital readmission; 90-day ED re-visit). A difference-in-difference analysis was conducted to examine changes in per membership per month (PMPM) costs based on OPCM exposure. Among 18,882 patients, 1197 (6.3%) were identified as "high-risk" and 470 (2.5%) were OPCM participants with median enrollment of 49days. High-risk OPCM cases compared to high-risk controls had lower odds of 90-day hospital readmissions (0.81 [0.40-1.61], non-significant) and lower odds of 90-day ED re-visits (0.50 [0.32-0.79]). Non-high-risk OPCM cases compared to non-high-risk controls had lower odds of 90-day hospital readmissions (0.20 [0.11-0.36]) and 90-day ED re-visits (0.66 [0.47-0.94]). Among OPCM cases, high-risk patients compared to non-high-risk patients had greater odds of 90-day hospital readmissions (4.44 [1.87-10.54]); however, there was no difference in 90-day ED re-visits (0.99 [0.58-1.68]). Overall, OPCM cases had lower total cost of care compared to controls (PMPM mean [SD]: - $1037.71 [188.18]). Use of risk stratification taxonomy for super-utilizers can identify patients most likely to benefit from case management. Future studies must further examine which OPCM components drive improvements in select outcome for specific populations.