Medical Care Expenditures Research Articles

Application of clinical pathway in nursing management

Objective To study the application value of the clinical pathway in nursing management.Methods 300 patients before and 300 patients after the application of clinical pathway in nursing management were selected.Patients' satisfaction degree with the nursing,length of hospital stay,and medical expenses were contrasted between the two groups.Results Patients' satisfaction degree with the nursing was significantly increased,the hospitalization time was significantly reduced,and the medical care expenditure was significantly reduced after application of clinical pathway in nursing management.Conclusions The application of the clinical pathway in nursing management can increase patients' satisfaction,reduce the hospitalization time and medical care expenditure. Key words: Clinical pathway; Nursing management; Value

The Effect of Participation in a Fitness Rewards Program on Medical Care Expenditures in an Employee Population

In 2008, the University of Minnesota began offering the Fitness Rewards Program (FRP) that provides a monthly credit toward fitness center dues for individuals who exercise at a participating facility at least 8 times per month. This study evaluates whether participation in the FRP is associated with a decrease in medical spending. Using a difference-in-differences approach, we estimate multivariate regression models of average monthly medical expenditures for 2006 through 2008. We find positive benefits from reduced medical spending among highly persistent FRP exercisers. However, the results are sensitive to the inclusion or exclusion of individuals who had very high medical expenditures in any year. Offering exercise-focused wellness initiatives may have economic benefits for employers, but further research is needed to understand the sensitivity of results to the inclusion of outliers.

C-reactive protein (CRP) is a predictor of high medical-care expenditures in a community-based elderly population aged 70 years and over: The Tsurugaya project

Because CRP is a strong independent predictor of various diseases, it was hypothesized that CRP may be a useful predictor or treatment target for medical-care expenditures. The aim of this study was to investigate the relationship between CRP and medical-care expenditures in a community-dwelling elderly population. This prospective cohort study was conducted including 925 Japanese subjects aged ≥70 years. A high-sensitivity CRP assay was used by applying the nephelometric method. Hospitalizations, outpatient visits, and expenditures were ascertained through computerized linkage with claims lodged between August 2002 and March 2008 with the Miyagi National Health Insurance (NHI) Association. Since medical-care expenditures were not normally distributed, the category of high medical-care expenditures (>75th percentile of medical-care expenditures: inpatient expenditures >$494/month; outpatient expenditure >$522/month; total expenditures >$1103/month) was used to examine the relation of CRP levels with medical-care expenditures. Multiple logistic regression analysis was used to examine the relationship between CRP cutoff points (low concentrations: <1.0mg/L; intermediate concentrations: 1.0–3.0mg/L; or high concentrations: ≥3.0mg/L) and medical-care expenditures during 6 year-follow up period. After adjustment for potential confounding factors, a positive association of CRP with hospitalization, and total expenditures (p for trend=0.03 and 0.02, respectively) was found. An elevated baseline CRP level is an independent predictor of increases in prospective medical-care expenditures among community-dwelling elderly. Further study is required to clarify whether reducing CRP by intervention is a cost-effective measure.

Severe Hypoglycemia in Patients with Diabetes

Strict glycemic control decreases the incidence and progression of diabetic vascular complications [1]. For this reason, recent guidelines recommend tighter glycemic control in patients with diabetes. However, although HbA1c reached the target range, strict glycemic control resulted in an increase in the rate of severe hypoglycemia [2,3]. In addition, severe hypoglycemia can discourage patients in the efforts to lower their blood glucose to the target range. Thus, severe hypoglycemia is a major barrier to optimizing glycemic control in diabetic patients. Therefore, the prevention of hypoglycemic events and the early detection of patients at high risk for hypoglycemia have important clinical implications in patients with diabetes. Severe hypoglycemia can be defined as hypoglycemia episodes requiring the assistance of another person to actively administer glucose or hospitalization or medical care in an emergency department [4]. Although the total incidence of severe hypoglycemic episodes reported by different studies varies markedly, hypoglycemic events are generally more frequent in patients with type 1 than type 2 diabetes [5,6]. Hypoglycemia awareness, insulin use, and preservation of beta cell function through counterregulatory hormone response may all contribute to the difference in the incidence of hypoglycemia between type 1 and type 2 diabetes [7]. The incidence of severe hypoglycemia in Korea has increased considerably during the last decade as estimated from severe hypoglycemic episodes occurring in subjects attending emergency rooms and patients treated by emergency medical services [8]. According to previous studies, severe hypoglycemia has several predictive risk factors such as age, duration of diabetes, duration of insulin treatment, hypoglycemic events occurring in the preceding months, peripheral neuropathy, and, in particular, impaired kidney function [6,9,10]. Ha et al. [11] analyzed the retrospective data, of 320 hypoglycemic patients with type 2 diabetes who had attended an emergency room from January 1, 2006 to December 31, 2009. They found that patients with type 2 diabetes who experienced severe hypoglycemia were elderly, took multiple medications, and had impaired kidney function. Glycemic control was near the goal set by recent guidelines (HbA1c <7.0%), which suggested that strict glucose control may affect the development of severe hypoglycemia. Poor oral intake or a missed meal (73.4%) was the major cause of hypoglycemia. Taken together, if diabetic patients whose blood glucose is strictly controlled complain of poor eating habits, especially in aged or chronic kidney disease patients, health care providers should focus on the cause and seek a solution to the problem more actively in order to prevent the development of severe hypoglycemia. This paper presents an approach to severe hypoglycemia from the viewpoint of medical cost. As the prevalence of diabetes and the incidence of diabetic complications increases, the associated medical costs will also increase dramatically [12]. Thus, severe hypoglycemia should be considered not only in terms of its physical aspects, but also in terms of its indirect social costs such as increased in medical care expenditures and decreased work productivity. The results of this study suggest that severe hypoglycemia increases healthcare costs. Compared to earlier studies [5,6], the population of this study was older and had more impaired renal function. In addition, there was a possibility that the incidence of severe hypoglycemia was underestimated since the hypoglycemia episodes considered were limited to patients visiting hospitals or seeking emergency care, and nearly 90% of patients were over 60 years old. In addition, since aged patients have many factors that can affect severe hypoglycemia, such as combined medication, impaired kidney and cognitive function, further multivariable analyses are needed to the evaluate risk factors for severe hypoglycemia. In conclusion, the incidence of severe hypoglycemia is steadily increasing in patients with type 2 diabetes, and this increase is associated with direct and indirect socio-economic burdens. Healthcare providers should be aware that these events occur primarily in the elderly and sometimes are accompanied by potentially fatal symptoms like unconsciousness. Nevertheless, hypoglycemia is fully preventable with intensive diabetic education, clinical attention to high-risk patients, and individualization of the glycemic control target.

Impact of blunted perception of dyspnea on medical care use and expenditure, and mortality in elderly people.

Dyspnea is an alarming symptom responsible for millions of patient visits each year. Poor perception of dyspnea might be reasonably attributed to an inappropriately low level of fear and inadequate earlier medical treatment for both patients and physicians, resulting in subsequent intensive care. This study was conducted to evaluate medical care use and cost, and mortality according to the perception of dyspnea in community-dwelling elderly people. We analyzed baseline data from a community-based Comprehensive Geriatric Assessment in 2002. The perception of dyspnea in 479 Japanese community-dwelling elderly people with normal lung function was measured in August 2002. The sensation of dyspnea during breathing with a linear inspiratory resistance of 10, 20, and 30 cmH2O/L/s was rated using the Borg scale. According to the perception of dyspnea, we divided the elderly into tertiles and compared all hospitalizations, out-patient visits, costs, and death through computerized linkage with National Health Insurance beneficiaries claims history files between August 2002 and March 2008. In-patient hospitalization days and medical care costs significantly increased with the blunted perception of dyspnea, resulting in an increase in total medical-costs with blunted perception of dyspnea. With low perception group as reference, the hazard ratios of all-cause mortality were 0.65 (95% CI 0.23–1.89) for intermediate perception group and 0.31 (0.10–0.97) for high perception group, indicating the mortality rate also significantly increased with the blunted perception of dyspnea after multivariates adjustment (p = 0.04). The blunted perception of dyspnea is related to hospitalization, large medical costs, and all-cause mortality in community-dwelling elderly people. These findings provide a rational for preventing serious illness with careful monitoring of objective conditions in the elderly.

Medical Home Access and Health Care Use and Expenditures Among Children With Special Health Care Needs

To test associations between having a medical home and health services use and expenditures among US children with special health care needs (CSHCN). Cross-sectional analysis. The 2003-2008 Medical Expenditure Panel Surveys. A total of 9816 CSHCN up to 17 years, including 1056 with a functional or sensory limitation and 8760 without a limitation. Parent or caregiver report of CSHCN having a medical home. We examined CSHCN's annual use of outpatient, inpatient, emergency department, and dental visits, and annual outpatient, inpatient, emergency department, prescription medication, dental, and other health care expenditures. CSHCN with a medical home had 14% more dental visits compared with CSHCN without a medical home (incidence rate ratio [IRR], 1.14; 95% CI, 1.03-1.25); this finding is significant for CSHCN without limitations but not for those with limitations. The medical home was associated with greater odds of incurring total, outpatient, prescription medication, and dental expenditures (odds ratio range, 1.25-1.92). Among CSHCN with a limitation, children with a medical home had lower annual inpatient expenditures compared with those without a medical home (mean, -$968; 95% CI, -$121 to -$1928), and among CSHCN without a limitation, children with a medical home had higher annual prescription medication expenditures compared with those without a medical home (mean, $87; 95% CI, $22-$153). There were few differences in annual health services use and expenditures between CSHCN with and without a medical home. However, the medical home may be associated with lower inpatient expenditures and higher prescription medication expenditures within subgroups of CSHCN.

Hypertension and Heart Failure

Heart failure brings with it personal suffering and disability, lost productivity, and a growing burden on an already excessive US per capita medical care expenditure. As America's baby-boom generation advances in age, we anticipate that the population band of people >65 years of age will swell significantly (Figure 1). Indeed, Census Bureau projections estimate that this number will rise from the current 40 million to 88 million by 2050. This census projection is especially worrisome when juxtaposed to a graph of the age of first heart failure events in a community population where the median age for incident heart failure was 80 years (Figure 2).1 Are we facing a tsunami of heart failure? You do the math. Is there reason for hope in the face of a tidal wave? Perhaps. A half-century of epidemiology has taught us much about the risk factors for heart failure, and clinical trials have provided evidence-based approaches to reduce the impact of those risk factors. Figure 1. Estimated future US population ≥65 years of age. The left axis is in millions of persons and the right axis is the percentage of the total US population. Data obtained from US Census Bureau (http://www.census.gov/). Figure 2. Age distribution of incident heart failure cases in a community population. From Senni et al.1 Article see p 1811 Age may be the paramount risk factor for heart failure, but superimposed on age are modifiable antecedent clinical conditions: hypertension, atherosclerotic cardiovascular disease, diabetes mellitus, and obesity.1–4 Framingham data show a lifetime risk for the development of heart failure of 20% in men and women.2 Population-attributable risk estimates take into account the magnitude of a risk factor's impact and its prevalence.3,4 Attributable risk estimates will vary, therefore, depending on the risk factor definition, the age …

How do health insurance loading fees vary by group size?: implications for Healthcare reform

The health insurance loading fee represents the portion of the premium above the expected amount of medical care expenditures paid by the insurance company. The size of the loading fees and how they vary by employer group size have important implications for health policy given the recent passage of the Patient Protection and Affordable Care Act. Despite their policy relevance, there is surprisingly little empirical evidence on the magnitude and the determinants of health insurance loading fees. This paper provides estimates of the loading fees by firm size using data from the confidential Medical Expenditure Panel Survey Household Component-Insurance Component Linked File. Overall, we find an inverse relationship between employer group size and loading fees. Firms of up to 100 employees face similar loading fees of approximately 34%. Loads decline with firm size and are estimated to be on average 15% for firms with more than 100 employees, but less than 10,000 employees, and 4% for firms with more than 10,000 workers.

Health care policy in Poland and in selected European Union countries: Attempts at reducing fast increasing medical care costs

The objective of the paper is the discussion of the health care systems in selected countries. The paper presents the four basic models of health service, i.e. the Bismarck’s model, the Beveridge’s model, the residual model and the Siemaszko’s model. In the following part, the paper presents information on the deficit in the health care service in Poland, as well as the defi­cit in selected European countries, that is in Germany, in the United Kingdom, in France, Italy or the Netherlands It has been emphasised that a battle is currently waged throughout Europe about reducing expenses for health care services without any radical limitation in the scope of the public health care benefits. The shortage of financial funds and ever increasing expenditures for medical care put in a difficult situation not only physicians, but also patients. The subject matter of the analysis is indication of the possibilities of reducing excessive costs of the public health care services, but without severe reducing of the scope of public health care benefits. It has been emphasised that real changes may occur from development of privatisation in the competitors. The summary presents expenditures for health care in the years 1999-2008 in selected European countries as % of GDP.

The individual and program impacts of eliminating Medicaid dental benefits in the Oregon Health Plan.

We determined how elimination of dental benefits among adult Medicaid beneficiaries in Oregon affected their access to dental care, Medicaid expenditures, and use of medical settings for dental services. We used a natural experimental design using Medicaid claims data (n = 22 833) before and after Medicaid dental benefits were eliminated in Oregon in 2003 and survey data for continuously enrolled Oregon Health Plan enrollees (n = 718) covering 3 years after benefit cuts. Claims analysis showed that, compared with enrollees who retained dental benefits, those who lost benefits had large increases in dental-related emergency department use (101.7%; P < .001) and expenditures (98.8%; P < .001) and in all ambulatory medical care use (77.0%; P < .01) and expenditures (114.5%; P < .01). Survey results indicated that enrollees who lost dental benefits had nearly 3 times the odds (odds ratio = 2.863; P = .001) of unmet dental need, and only one third the odds (odds ratio = 0.340; P = .001) of getting annual dental checkups relative to those retaining benefits. Combined evidence from both analyses suggested that the elimination of dental benefits resulted in significant unmet dental health care needs, which led to increased use of medical settings for dental problems.

How CER Could Pay for Itself — Insights from Vertebral Fracture Treatments

Two procedures for treating osteoporotic vertebral fracture have been widely adopted, but their efficacy is now in doubt. Their story suggests ways in which comparative-effectiveness research (CER) may influence medical practice and health care expenditures.

Estimating the Economic Burden of Racial Health Inequalities in the United States

The primary hypothesis of this study is that racial/ethnic disparities in health and health care impose costs on numerous aspects of society, both direct health care costs and indirect costs such as loss of productivity. The authors conducted three sets of analysis, assessing: (1) direct medical costs and (2) indirect costs, using data from the Medical Expenditure Panel Survey (2002-2006) to estimate the potential cost savings of eliminating health disparities for racial/ethnic minorities and the productivity loss associated with health inequalities for racial/ethnic minorities, respectively; and (3) costs of premature death, using data from the National Vital Statistics Reports (2003-2006). They estimate that eliminating health disparities for minorities would have reduced direct medical care expenditures by about $230 billion and indirect costs associated with illness and premature death by more than $1 trillion for the years 2003-2006 (in 2008 inflation-adjusted dollars). We should address health disparities because such inequities are inconsistent with the values of our society and addressing them is the right thing to do, but this analysis shows that social justice can also be cost effective.

A comparison of disease‐specific medical expenditures in Japan using the principal diagnosis method and the proportional distribution method

There are technical limitations to handling all the information mentioned in health insurance claims (HICs) in Japan. Therefore, conventional methods for estimating disease-specific medical expenditures assume that all medical care expenditures in a given HIC are spent on only one principal diagnosis even when the HIC contains multiple diagnoses. To estimate the disease-specific medical expenditures that consider all diagnosis on a given HIC. Data were obtained from 169 622 outpatient HICs in May 2006 from health insurance provided by the employer. We compared the estimated disease-specific medical expenditures of the conventional method with a proportional distribution method (PDM), which considers all diagnoses on the HICs. For diabetes mellitus and other diseases of the digestive system, the proportion of principal diagnoses among total diagnoses was 52.4% (4849/9251) and 19.6% (2614/13331), respectively. In addition, the ratio of the estimated disease-specific medical expenditures between the conventional method and the PDM method was 1.49 for diabetes mellitus and 0.64 for other diseases of the digestive system. The estimation of disease-specific medical expenditures using the conventional method may therefore have overestimated the expenditures on the disease category typically selected as the principal diagnosis and underestimated the expenditures on the disease category less likely to be selected as the principal diagnosis. The conventional method for estimation of disease-specific medical expenditures should be improved by utilizing all the diagnoses information on HICs.

Broadening the Focus: The Need to Address the Social Determinants of Health

ditures rose by 5.7%. 2 Annual per capita medical care expenditures in the U.S. are higher than those in any other nation, and if current trends continue medical care costs in the U.S. will reach more than 19% of the Gross Domestic Product by 2019. Although recent reforms should help many Americans obtain and keep coverage, the costs of medical care and insurance remain out of reach for many households. These costs also affect employers, threatening the bottom line of many American businesses and deterring job creation. Medical care spending at the local, state, and federal level limits government investments in other crucial areas including infrastructure and education. The rising costs of providing care to aging baby-boomers and the growing number of obese Americans will further strain public and private budgets. Despite spending more on medical care than any other

Informing the uninformed: How drug advertising affects check-up visits

Direct-to-consumer drug advertising has recently become an important and controversial component of drug marketing. In this paper we examine one of the claimed benefits of drug advertising: encouraging the undiagnosed to seek out medical treatment. We measure how advertising affects an undiagnosed individual's decision to visit a physician for a check-up using detailed person-level panel data on more than 30,000 individuals from the Medical Care Expenditure Panel Survey. We find drug advertising is an important determinant of an individual's decision to get a check-up and that this effect of drug advertising appears to differ by demographic group. While the differences between demographic groups are not statistically different, our point estimates suggest that Blacks and the highly educated are the most responsive to drug advertising.

2010 in Review.

2010 in Review.

The Economic Burden of Late Entry Into Medical Care for Patients With HIV Infection

A large proportion of people with human immunodeficiency virus (HIV) infection enter care late in the HIV disease course. Late entry can increase expenditures for care. To estimate direct medical care expenditures for HIV patients as a function of disease status at initial presentation to care. Late entry is defined as initial CD4 test result ≤ 200 cells/mm3, intermediate entry as initial CD4 counts >200, and ≤ 500 cells/mm3; and early entry as initial CD4 count >500. The study included 8348 patients who received HIV primary care and who were newly enrolled between 2000 and 2006 at one of 10 HIV clinics participating in the HIV Research Network. We reviewed medical record data from 2000 to 2007. We estimated costs per outpatient visit and inpatient day, and monthly medication costs (antiretroviral and opportunistic illness prophylaxis). We multiplied unit costs by utilization measures to estimate expenditures for inpatient days, outpatient visits, HIV medications, and laboratory tests. We analyzed the association between cumulative expenditures and initial CD4 count, stratified by years in care. Late entrants comprised 43.1% of new patients. The number of years receiving care after enrollment did not differ significantly across initial CD4 groups. Mean cumulative treatment expenditures ranged from $27,275 to $61,615 higher for late than early presenters. After 7 to 8 years in care, the difference was still substantial. Patients who enter medical care late in their HIV disease have substantially higher direct medical treatment expenditures than those who enter at earlier stages. Successful efforts to link patients with medical care earlier in the disease course may yield cost savings.

Longitudinal direct medical costs associated with constipation in women

Although direct medical costs for constipation-related medical visits are thought to be high, to date, there have been no studies examining longitudinal resource utilisation in adults with constipation. To estimate the incremental direct medical costs associated with constipation in women. This is a nested case-control study. The study population consisted of all mothers of 5718 children in the population-based birth cohort born during 1976-1982 in a community. The cases presented to the medical facilities with constipation. The controls were randomly selected and matched to cases in a 2:1 ratio. Direct medical costs for constipated women and controls were collected for the years 1987-2002. We identified 168 women with a diagnosis of constipation. The total direct medical costs over the 15-year period for constipated subjects were more than double those of controls [$63 591 (95% CI: 49 786-81 396) vs. $24 529 (95% CI: 20 667-29 260)]. The overall out-patient costs for constipated women were $38 897 (95% CI: 31 381-48 253) compared to $15 110 (95% CI: 12 904-17 781) for controls. The median of annual out-patient visits for constipated women was 0.16 compared to 0.11 for controls. Women with constipation have significantly higher medical care utilisation and expenditures compared with women without constipation.

Potential National and State Medical Care Savings From Primary Disease Prevention

We estimated national and state-level potential medical care cost savings achievable through modest reductions in the prevalence of several diseases associated with the same lifestyle-related risk factors. Using Medical Expenditure Panel Survey Household Component data (2003-2005), we estimated the effects on medical spending over time of reductions in the prevalence of diabetes, hypertension, and related conditions amenable to primary prevention by comparing simulated counterfactual morbidity and medical care expenditures to actual disease and expenditure patterns. We produced state-level estimates of spending by using multivariate reweighting techniques. Nationally, we estimated that reducing diabetes and hypertension prevalence by 5% would save approximately $9 billion annually in the near term. With resulting reductions in comorbidities and selected related conditions, savings could rise to approximately $24.7 billion annually in the medium term. Returns were greatest in absolute terms for private payers, but greatest in percentage terms for public payers. State savings varied with demographic makeup and prevailing morbidity. Well-designed interventions that achieve improvements in lifestyle-related risk factors could result in sufficient savings in the short and medium term to substantially offset intervention costs.

Food Insecurity and Out‐of‐Pocket Medical Expenditures: Competing Basic Needs?

Resource‐constrained families face difficult choices when attempting to meet their basic needs and enhance their health and wellness. This research investigated the relationship between a family’s efforts to access enough food and pay their medical bills through an examination of data from the Survey of Income and Program Participation. The data provided information on out‐of‐pocket medical expenditures and responses to an abbreviated version of the U.S. Department of Agriculture food insecurity module for nearly 50,000 people in more than 16,000 U.S. families. A two‐stage probit‐least squares procedure accounted for the endogeneity of food and medical care expenditures, providing insight into the decisions that families make when allocating resources to food and medical care. The results indicated that the probability of experiencing food insecurity increased as out‐of‐pocket medical expenditures increased. Notably, there was no evidence for the reverse relationship—food security status did not affect medical expenditures. The results suggest that programs that seek to help families reduce out‐of‐pocket medical costs may indirectly improve access to food and nutrition.