Reduce Health Care Expenditures Research Articles

Public transport use and health status in later life: Which relationship?

In many developed countries, ageing trends have called for mobility policies oriented to active travels for older adults, preventing some diseases. As a result, in the transport and health literature, the elderly's psycho-physical health is growingly recognized as linked to the accessibility to local public transport (LPT) and its usage frequency. Using data drawn from a survey by the National Institute of Statistics (ISTAT) on the Italian citizens' daily life, this paper investigates the relationship between health dimensions of the sub-sample of people aged over 60 years in Italy and their use of LPT, considered as a more active and sustainable means with respect to car. By applying a recursive mixed-process approach and controlling for LPT service availability and parking issues, the findings highlight that (i) taking public transport services or driving cars more frequently is associated with higher levels of psychological and self-perceived health; (ii) especially for people over 65 years old, the use of LPT at least once a week is linked to better physical conditions. From a policy perspective, the insights of this study are two-fold. First, improving the accessibility to welfare and activity spaces by using LPT is likely to increase ageing people's mental health and their social inclusion. Second, stimulating the LPT usage might be a primary way to effectively promote physical health, to prevent ageing-related diseases, and to help reducing healthcare expenditures connected to the lack of active mobility in later life.

A Targeted "Top 100" High-Risk Care Management Program Improves Adherence to Best Practices.

Care management programs for high-risk patients have yielded inconsistent results in reducing health care expenditures. We reviewed the most successful programs and identified 5 best practice areas: (1) in-person patient meetings; (2) direct care manager/physician interaction; (3) provide transitional care services; (4) educate patients; and (5) provide medication review. We measured adherence to the best practices at baseline and at 6 and 9 months into the program for the highest-risk patients. The program increased adherence from baseline to each best practice area. Program enrollment increased at the 6-month follow-up but fell at the 9-month follow-up.

Effect of BMI on health care expenditures stratified by COPD GOLD severity grades: Results from the LQ-DMP study

Chronic Obstructive Pulmonary Disease (COPD) is characterized by persistent respiratory symptoms and airflow limitation, which is progressive and not fully reversible. In patients with COPD, body mass index (BMI) is an important parameter associated with health outcomes, e.g. mortality and health-related quality of life. However, so far no study evaluated the association of BMI and health care expenditures across different COPD severity grades.We used claims data and documentation data of a Disease Management Program (DMP) from a statutory health insurance fund (AOK Bayern). Patients were excluded if they had less than 4 observations in the 8 years observational period. Generalized additive mixed models with smooth functions were used to evaluate the association between BMI and health care expenditures, stratified by severity of COPD, indicated by GOLD grades 1–4.We included 30,682 patients with overall 188,725 observations. In GOLD grades 1–3 we found an u-shaped relation of BMI and expenditures, where patients with a BMI of 30 or slightly above had the lowest and underweight and obese patients had the highest health care expenditures. Contrarily, in GOLD grade 4 we found an almost linear decline of health care expenditures with increasing BMI.In terms of expenditures, the often reported obesity paradox in patients with COPD was clearly reflected in GOLD grade 4, while in all other severity grades underweight as well as severely obese patients caused the highest health care expenditures. Reduction of obesity may thus reduce health care expenditures in GOLD grades 1–3.

Optimization of Health Transformation Plan by Drug Utilization Review Strategy in a Pediatric Teaching Hospital

Background: Health transformation planwas implemented in 2014 in Iran with the aim of reducing healthcare expenditures. Transformation plans always have a financial impact on healthcare expenditures because of potential to increase the utilization. Drug utilization review is one of the effective solutions to explore consumption and improve rational use. This study aimed to evaluate the medicine utilization after health transformation with implementation of an evidence-based protocol in a tertiary hospital. Materials and Methods: This is a before-after study which was conducted in a tertiary children’s hospital with 400 beds in Iran. At first, costly medications were identified by ABC analysis in drug and therapeutic committee meetings of the hospital. Increased use of these medications was measured after the implementation of the health transformation plan. Then, the pattern of prescription, its appropriateness and impact of protocol implementation on the health expenditures reduction and rational use was evaluated. Results: Initial estimation of the usage showed that before protocol implementation, in six-month, albumin, pantoprazole, and Apotel® increased by 31.9%, 22.6%, and 21.9%, respectively following the health transformation plan. Medical records of 6,554 patients were evaluated for target medications. The frequency of inappropriate prescription reduced significantly from the first to the second phase for albumin (65.5%-35.8%, P=0.001), pantoprazole (58.9%-22%, p <0.001), and Apotel® (66%-17%, p <0.001), respectively. Health expenditures also reduced significantly for albumin (P=0.003), pantoprazole (P=0.001) and acetaminophen (p <0.001), respectively. Conclusion Timely implementation of medication prescription protocols can provide health benefits to patients and cost savings to the health service provider that could lead the health transformation plan to reach the aim of reduction in health expenditures with rational use.

The medical costs of low leisure-time physical activity among working-age adults: Gender and minority status matter

This study analyzes the direct medical costs of low physical activity by race/ethnicity and gender. Average health expenditures based on physical activity status for Black non-Hispanics (NH), Asian NHs, and Hispanics were compared to White NHs. Data from the National Health Interview Survey were merged with the Medical Expenditure Panel Survey for years 2000–2010 and 2001–2011, respectively, and weights were applied to ensure generalizability to the larger US population. The sample was restricted to non-pregnant adults between the ages of 25 and 64, with a final sample size of 44,953. The multivariate estimates reveal statistically significant lower annual health care expenditures among physically active men and women in five out of eight racial/ethnic groups relative to their inactive counterparts: on average, for men, $1041 less is spent among White NHs, $905 less is spent for Black NHs and $876 less is spent for Asian NHs. Among women, medical expenditures were $956 per year less among active White non-Hispanics relative to their inactive counterparts, and $815 per year among Hispanics. Essentially, the average reduction in health care expenditures is relatively consistent for five out of the eight groups. The absence of any reduction in average health care expenditures for three of the groups, however, suggests that there may be environmental factors at play for certain groups that mitigate the impact of physical activity on health expenditures.

S0385 Implementation of a Deprescribing Tool to Reduce Inappropriate Proton Pump Inhibitor Use

INTRODUCTION: Recent perceptions of inappropriate PPI use have led to an increased interest in deprescribing; however, evaluation of different PPI deprescribing methods have been inconsistent. Inappropriate use of a PPI usually occurs either in the absence of an absolute indication or for non-absolute indications without considering or attempting PPI cessation. The purpose of this project was to study the effectiveness of a deprescribing algorithm to reduce inappropriate use of PPIs in an outpatient gastroenterology clinic. METHODS: This project recruited adult patients seen in the outpatient gastroenterology clinic that were on PPI therapy for more than 8 weeks. Patient’s eligible for study completed an initial GerdQ and were contacted at 2-week and 4-week post intervention for follow up. The primary outcome measure was symptom control, defined as a change in positive predictor GerdQ difference of ≤ 2 at 4 weeks. Baseline variables were assessed with descriptive statistics for analysis and project evaluation. RESULTS: The baseline (week 0) mean GerdQ (1.6 ± 2.09762) was marginally increased at week 2 (1.6667 ± 2.19306) and remained stable at week 4 (1.6667 ± 2.25726). A paired-samples t tests was calculated to compare the mean GerdQ score at baseline to the mean change in GerdQ score at 4 weeks. A significant change from baseline to week 4 was found (t(14) = 2.860, P < 0.05). Of the 15 participants, 13 (87%) had a score change ≤2. CONCLUSION: Overall, most participants (87%) had a statistically significant stability in their GerdQ scores at 4 weeks after having their PPIs deprescribed. These results are considerably higher than the predetermined goal of at least 25% participants with symptom control used to evaluate project effectiveness. It has been widely accepted in the medical community that PPIs are often prescribed inappropriately. The appeal for evidence-based guidelines has been expressed among many medical practitioners to improve their deprescribing capabilities. The potential reduction in health care expenditures, adverse effects, and pill burden strengthens the need to deprescribe PPIs used inappropriately. Results from this study will hopefully encourage clinicians to routinely evaluate use of ongoing medications and deprescribe where appropriate.Figure 1.: PPI deprescribing algorithm. Please note that participants were monitored at 2 and 4 weeks rather than 4 and 12 weeks. Reprinted with permission.Table 1.: GerdQ tool used to measure clinical data at baseline (Week 0), Week 2, and Week 4Table 2.: Comparison of outcome measures assessed by GerdQ score at baseline (week 0), week 2, and week 4. (a) Total of difference in GerdQ scores. Negative values indicate increase in positive predictors in GERD symptoms while positive values indicate decrease in positive predictors in GERD symptoms

Factors associated with the costs of hospitalization after esophagectomy: a retrospective observational study at a three-tertiary cancer hospital in China.

BackgroundEsophageal cancer represents a major health threat in China. Esophagectomy is the standard treatment for respectable esophageal cancer. This study aimed to investigate the costs of hospitalization in esophageal cancer patients undergoing esophagectomy, and to analyze the factors influencing these costs.MethodsA retrospective observational study which enrolled 196 patients who underwent esophagectomy from September, 2018, to April, 2019, in the Affiliated Cancer Hospital of Zhengzhou University were conductedResultsThe median inpatient cost was ￥72,772 (range, ￥49,796–128,771). Materials accounted for 39.7% of the direct medical costs, which was the highest proportion for any of the cost components. Minimally invasive esophagectomy (MIE, OR: 0.031; 95% CI: 0.005–0.209), cardiopathy comorbidity (OR: 0.344; 95% CI: 0.136–0.872), and anastomotic leak (OR: 0.012; 95% CI: 0.001–0.131) were risk factors for higher cost, while early oral feeding (OR: 3.979; 95% CI: 1.430–11.067) was a protective factor.ConclusionsUnderstanding the factors associated with high hospitalization costs will help to reduce healthcare expenditure. By controlling complications and promoting early oral feeding, the economic burden on esophagectomy patients can be relieved. Further research based on a longitudinal design is needed to investigate the full costs of hospitalization associated with esophageal cancer.

The additive impact of multiple psychosocial protective factors on selected health outcomes among older adults

Our objective was to investigate the additive properties of five psychosocial protective factors: purpose-in-life, resilience, optimism, internal locus of control and social connections. Self-reported psychological (depression, stress) and physical (health status, functionality) health outcomes and measured healthcare utilization and expenditures were included. The study sample was identified from adults age ≥65 who completed a health survey during May-June 2019 (N = 3,577). Each of the five protective factors was dichotomized as high/low (1/0) and counted with equal weighting. The protective factors were additive such that significant improvements in psychological and physical health outcomes were evident across factor subgroups: as the number of factors increased, health outcomes improved. The magnitude of the improvements was greatest between 0 and 1 factor. In addition, a significant linear trend for reduced healthcare expenditures ($1,356 reduction per factor added) was evident. Interventions promoting at least one protective factor would be beneficial for older adult populations.

Economic impact of clinical decision support interventions based on electronic health records

BackgroundUnnecessary healthcare utilization, non-adherence to current clinical guidelines, or insufficient personalized care are perpetual challenges and remain potential major cost-drivers for healthcare systems around the world. Implementing decision support systems into clinical care is promised to improve quality of care and thereby yield substantial effects on reducing healthcare expenditure. In this article, we evaluate the economic impact of clinical decision support (CDS) interventions based on electronic health records (EHR).MethodsWe searched for studies published after 2014 using MEDLINE, CENTRAL, WEB OF SCIENCE, EBSCO, and TUFTS CEA registry databases that encompass an economic evaluation or consider cost outcome measures of EHR based CDS interventions. Thereupon, we identified best practice application areas and categorized the investigated interventions according to an existing taxonomy of front-end CDS tools.Results and discussionTwenty-seven studies are investigated in this review. Of those, twenty-two studies indicate a reduction of healthcare expenditure after implementing an EHR based CDS system, especially towards prevalent application areas, such as unnecessary laboratory testing, duplicate order entry, efficient transfusion practice, or reduction of antibiotic prescriptions. On the contrary, order facilitators and undiscovered malfunctions revealed to be threats and could lead to new cost drivers in healthcare. While high upfront and maintenance costs of CDS systems are a worldwide implementation barrier, most studies do not consider implementation cost. Finally, four included economic evaluation studies report mixed monetary outcome results and thus highlight the importance of further high-quality economic evaluations for these CDS systems.ConclusionCurrent research studies lack consideration of comparative cost-outcome metrics as well as detailed cost components in their analyses. Nonetheless, the positive economic impact of EHR based CDS interventions is highly promising, especially with regard to reducing waste in healthcare.

Case Management Models and Continuing Care: A Literature Review across nations, settings, approaches, and assessments

Older adults accessing continuing care often have multiple chronic conditions. Research suggests that case management is a promising approach to reduce health care expenditure and improve patient outcomes. To optimize healthcare delivery, an examination of existing case management models and their effectiveness is essential. This literature review was conducted using Joanna Briggs Institute (JBI) methods to explore case management models for older adults accessing continuing care services. Searches were conducted in PubMed and CINAHL from 2010 to 2018. A total of 37 articles were included in this review. Approaches to case management are diverse with respect to composition of care providers, method of care provision, and location of care. Findings from 27 quantitative studies demonstrated that nurse-led and interdisciplinary team case management models that include home visits can effectively reduce hospital admission/readmission while lowering costs. Mixed results were found on the impact of case management on patient satisfaction, ED visits, quality of life, length of stay, self-efficacy, social integration and caregiver burden. Among 10 qualitative studies, 3 facilitators for quality case management were identified that include receiving care at home, building trusting relationships, and improving self-efficacy. Based on these findings, we conclude that nurse-led and interdisciplinary team case management can effectively reduce hospital admission of frail older adults while lowering costs, particularly within home care settings.

Value-Based Care: An Executive Briefing

In today’s challenging health care environment, the paradigm shift from volume to value requires nurse leaders to develop enhanced skills to transform health care in 2020. Key drivers for success include: igniting innovation and change; embracing data and analytics; and launching new care delivery models that soar beyond organizational boundaries. Value-based care is here to stay, and nursing must be the catalyst for change. Equipped with new skills and the knowledge of CMS Pay for Performance programs, nurse leaders will design the future health care landscape.

Automation, Monitoring, and Standardization of Cell Product Manufacturing.

Although regenerative medicine products are at the forefront of scientific research, technological innovation, and clinical translation, their reproducibility and large-scale production are compromised by automation, monitoring, and standardization issues. To overcome these limitations, new technologies at software (e.g., algorithms and artificial intelligence models, combined with imaging software and machine learning techniques) and hardware (e.g., automated liquid handling, automated cell expansion bioreactor systems, automated colony-forming unit counting and characterization units, and scalable cell culture plates) level are under intense investigation. Automation, monitoring and standardization should be considered at the early stages of the developmental cycle of cell products to deliver more robust and effective therapies and treatment plans to the bedside, reducing healthcare expenditure and improving services and patient care.

Estimation of total cardiovascular risk using the 2019 WHO CVD prediction charts and comparison of population-level costs based on alternative drug therapy guidelines: a population-based study of adults in Bangladesh

ObjectiveThe objective of this study was to estimate the population distribution of 10-year cardiovascular disease (CVD) risk among Bangladeshi adults aged 40 years and above, using the 2019 WHO CVD...

Policy recommendations for a sustainable biosimilars market: lessons from Europe

Approximately 25% of all new medicines approved in recent years and in development today are biologicals. The complexity of biologicals, the investment needed to meet ever more stringent regulatory and payer requirements, combined with the needs of an ageing population, mean the cost of these medicines and the burden on governments and insurance companies is growing. However, the introduction of biosimilars has broadened treatment choices for physicians and their patients and, by increasing competition, reduced healthcare expenditures. The biosimilar market in Europe is the largest in the world, representing approximately 60% of the global biosimilar market and growing consistently year on year. As of October 2019, 54 biosimilars of 15 originator biological medicines have marketing authorization in Europe. European countries, with their large biosimilar markets and diverse healthcare systems, serve as valuable examples of different approaches to biosimilar policy. Several studies, research papers and position statements have been published on such policies. These findings, along with real-world policy and procurement examples from European countries, provide an opportunity for other countries to learn from. This paper will review the different approaches to biosimilar policy across the European continent, highlighting principles which can be applied to develop an efficient and sustainable biosimilar market.

Machine Learning for Identifying Medication-Associated Acute Kidney Injury

One of the prominent problems in clinical medicine is medication-induced acute kidney injury (AKI). Avoiding this problem can prevent patient harm and reduce healthcare expenditures. Several researches have been conducted to identify AKI-associated medications using statistical, data mining, and machine learning techniques. However, these studies are limited to assessing the impact of known nephrotoxic medications and do not comprehensively explore the relationship between medication combinations and AKI. In this paper, we present a population-based retrospective cohort study that employs automated data analysis techniques to identify medications and medication combinations that are associated with a higher risk of AKI. By integrating multivariable logistic regression, frequent itemset mining, and stratified analysis, this study is designed to explore the complex relationships between medications and AKI in such a way that has never been attempted before. Through an analysis of prescription records of one million older patients stored in the healthcare administrative dataset at ICES (an independent, non-profit, world-leading research organization that uses population-based health and social data to produce knowledge on a broad range of healthcare issues), we identified 55 AKI-associated medications among 595 distinct medications and 78 AKI-associated medication combinations among 7748 frequent medication combinations. In addition, through a stratified analysis, we identified 37 cases where a particular medication was associated with increasing the risk of AKI when used with another medication. We have shown that our results are consistent with previous studies through consultation with a nephrologist and an electronic literature search. This research demonstrates how automated analysis techniques can be used to accomplish data-driven tasks using massive clinical datasets.

Governance of mental healthcare: Fragmented accountability.

Within international healthcare systems the neglect of mental health and challenge in shifting from institutional to community care have been recurrent themes. In analysing the challenges, we focus on the case study of Canada by exploring the manner in which health law and policy evolved to inhibit community-based mental healthcare, and compare the resulting funding landscape from an international perspective. The historical institutionalist analysis draws on the literature and healthcare finance data. As a spending statute, the Canada Health Act defines the terms on which the federal government finances publicly insured provincial healthcare. Despite the goal to support physical and mental well-being by removing financial barriers to access health services, exclusion of community care offered by non-physicians (such as psychotherapy) from the terms of the Act inhibited its fulfilment. Diminished federal transfers deepened the disincentive for provinces to establish community care: mental health declined from 11 to 7 percent of provincial healthcare spending from 1979 to 2014. Governance oversight was passed to provinces whose competing demands on diminished resources limited their capacity to extend care. Accountability was found fragmented as neither government stepped-in to ensure the continuum of care, even as federal transfers were restored and evidence of cost-effectiveness grew. Although American and Canadian funding patterns are similar, other OECD countries invest between 13 and 18 percent of healthcare expenditures on mental health. Lessons from the Canadian case are the manner in which its federal structure and intergovernmental dynamics shaped health policy, and the importance of ensuring representation from a range of perspectives in policy development. Federal financial incentives were also found to profoundly impact the expansion of community-based mental healthcare. Evidence shows that public insurance for community supports would reduce healthcare expenditures and employer productivity loss, resulting in savings of $255 billion over 30 years.

The Association between Frailty and Healthcare Expenditure among Chinese Older Adults

ObjectivesThe purpose of this study was to examine whether frailty could explain variability in healthcare expenditure beyond multimorbidity and disability among Chinese older adults. DesignCross-sectional. Setting and ParticipantsParticipants were 5300 community-dwelling adults age at least 60 years from the China Health and Retirement Longitudinal Study. MethodsFrailty was identified by the physical frailty phenotype approach that has been created and validated among Chinese older adults. Five criteria were used: slowness, weakness, exhaustion, inactivity, and shrinking. Persons were classified as “nonfrail” (0 criteria), “prefrail” (1‒2 criteria), or “frail” (3‒5 criteria). Healthcare expenditure was measured based on participants’ self-report and was classified into 3 types: outpatient expenditure, inpatient expenditure, and self-treatment expenditure. The association of frailty and healthcare expenditure was analyzed using a 2-part regression model to account for excessive zero expenditures. ResultsFrailty was associated with higher odds of incurring outpatient, inpatient, and self-treatment expenditure. Among persons with non-zero expenditure, prefrail and frail persons, on average, had US $30.62 [95% confidence interval (CI) 8.41, 52.82] and US $60.60 (95% CI 5.84, 115.36) higher outpatient expenditure than the nonfrail, adjusting for sociodemographics, multimorbidity, and disability. After adjustment for all covariates, prefrail persons, on average, had US $3.34 (95% CI 0.54, 6.13) higher self-treatment expenditure than the nonfrail. Conclusions and ImplicationsFrailty is an independent predictor of higher healthcare expenditure among older adults. These findings suggest that timely screening and recognition of frailty are important to reduce healthcare expenditure among older adults.

Safety, Feasibility and Economic Impact of Same-Day Discharge Following Atrial Fibrillation Ablation

The widely accepted model for atrial fibrillation (AF) ablation involves overnight hospital stay post-procedure. Day case AF ablation has been carried out at Royal Papworth Hospital (RPH) since early 2017. We evaluated the feasibility, safety and efficacy of day case AF ablation at RPH. This was a retrospective, single-centre study of consecutive AF ablations at RPH between March 2017 and April 2018. Demographic, procedural and outcome data were analysed. Over the study period, 452 AF ablations were performed in 448 patients. One hundred and twenty-nine (129) (28.5%) were planned day cases; of these 128 were discharged on the same day. Two hundred and eighty-three (283) procedures resulted in at least one night admission. There was no significant difference in age or sex between the groups. Of note, day case procedures were significantly shorter, more likely to commence in the morning and less likely to require general anaesthetic than overnight stays. Patients listed as day cases also had less far to travel. The overall complication rate was 3.3%, with no significant difference between groups. Follow-up data was available for 448 cases (99.1%). Procedural success rates were comparable between groups. The overall cost saving attributable to providing AF ablation as a day case was £67,200 over the 13-month period. Day case AF ablation is efficacious and associated with a low event rate, even without strict standardisation of patient selection or procedural protocols, in a high-volume centre. Substantial reduction in health care expenditure can be achieved with more widespread implementation of outpatient AF ablation.

Syringe services programs and real-world research: An overview for pharmacists

ObjectiveTo review key arguments supporting and criticizing syringe services programs (SSPs). Data sourcesPeer-reviewed literature and publicly available documents. SummaryPharmacy organizations—including the American Pharmacists Association and the American Society of Health-System Pharmacists—have stated that pharmacists should support programs that supply sterile injection materials to persons who use injection drugs. SSPs may include needle exchanges or other programs that meet these aims. Pharmacists should know that observational public health research demonstrates that SSPs can lower the transmission of blood-borne illnesses, improve linkage to care for substance use disorders, reduce health care expenditures, and reduce drug overdoses. Concerns about SSPs and increases in syringe litter or crime have not been borne out by research. Despite these findings and the positions of professional organizations, contemporary research suggests that pharmacists may be reluctant to support SSPs and other programs that would increase supply of sterile injection supplies to their communities. ConclusionThe review of evidence in this commentary should help pharmacists better understand the evidence in favor of SSPs, the potential criticisms of SSPs, and the reasons that their profession is moving to support these programs.

Medication Therapy Management: Current Challenges.

Medication therapy management (MTM) services have evolved as a means for pharmacists and other providers to assist patients and caregivers in improving therapeutic outcomes and reducing health care expenditures. More than a decade has passed since the Medicare Modernization Act of 2003 provided pharmacists with the opportunity to deliver MTM services to Medicare beneficiaries. MTM continues to offer pharmacists the opportunity to use their knowledge; yet, pharmacists have reported challenges with service delivery. Identifying the challenges that affect MTM services in pharmacy practice is necessary in order to seek improvement to MTM delivery. This narrative review explores the current challenges pharmacists face with MTM delivery, summarizes potential solutions for addressing challenges, and seeks to incite further debate, service reconfiguration, and ultimately service improvement of pharmacist-provided MTM services.